Etiology: a combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)
It’s called “adjustment”, because the stressor is mild and people just need to adjust.c
Does not meet criteria for another psychiatric illness (e.g., MDD, GAD, PTSD).
Reactive attachment disorder
Etiology & Risk Factors:
Severe early social neglect, emotional deprivation, or institutional rearing (e.g., orphanages).
Frequent caregiver turnover (e.g., multiple foster placements). c
Onset occurs between age 9 months and 5 years.
Clinical Presentation:
Markedly inhibited, emotionally withdrawn behavior: Rarely seeks comfort when distressed and minimally responds to comfort when provided.
Social/emotional disturbance: Minimal social responsiveness, absent/limited positive affect, and unprovoked episodes of irritability, fear, or sadness during nonthreatening interactions.
Physical exam: Signs of neglect, malnutrition, and failure to thrive (FTT) / psychosocial growth failure.
Diagnosis:
Clinical (DSM-5): Requires confirmed history of pathogenic neglect/deprivation + persistent inhibited caregiver attachment.
Exclusion: Must not meet criteria for Autism Spectrum Disorder (ASD).
Workup: Rule out organic causes of FTT, lead toxicity, and non-accidental trauma.
Key Differentials:
Disinhibited Social Engagement Disorder (DSED): Indiscriminate sociability, no stranger anxiety, wanders off with unfamiliar adults (externalizing vs. RAD’s internalizing/withdrawn pattern).
Autism Spectrum Disorder (ASD): Features stereotypies/repetitive behaviors and restricted interests; persists regardless of a supportive environment; does not require early neglect.
Depressive Disorders: Rare in early infancy; typically episodic without requirement for pathogenic early care.
Management:
First-line (Safety & Environment): Notify CPS if ongoing neglect; place child in a safe, stable, and nurturing environment with a consistent primary caregiver.
Psychotherapy: Child-Parent Psychotherapy (CPP) / dyadic therapy to foster attachment security and caregiver responsiveness.
Pharmacotherapy: No approved medications; reserve psychotropics only for diagnosed target comorbidities (e.g., ADHD, anxiety) in older children.
Contraindicated: Coercive holding or “rebirthing” therapies (ineffective, potentially fatal).
Treatment
First-line: psychotherapy with or without adjunctive pharmacotherapy