A 5-year-old boy is brought to the office by his aunt for evaluation of behavioral concerns. The patient was placed with the aunt 4 months ago due to physical abuse and neglect by his parents. His teacher is concerned that he does not follow directions, rarely participates during group activities, and does not respond to praise. Last week, the patient hit a classmate after being asked to share the book he was reading. The aunt says, "He seems to get upset for no reason at times and usually starts throwing and breaking things. I'm trying my best and want him to know he's loved, but it feels like nothing I do helps." Vital signs are within normal limits; growth curves are tracking adequately and consistently. The patient is sitting on the floor playing with various toys. Physical examination shows no abnormalities. He makes eye contact and answers questions briefly before turning away to play by himself. Affect is indifferent with constricted range. Which of the following is the most likely diagnosis?

Question

A 5-year-old boy is brought to the office by his aunt for evaluation of behavioral concerns.  The patient was placed with the aunt 4 months ago due to physical abuse and neglect by his parents.  His teacher is concerned that he does not follow directions, rarely participates during group activities, and does not respond to praise.  Last week, the patient hit a classmate after being asked to share the book he was reading.  The aunt says, "He seems to get upset for no reason at times and usually starts throwing and breaking things.  I'm trying my best and want him to know he's loved, but it feels like nothing I do helps."  Vital signs are within normal limits; growth curves are tracking adequately and consistently.  The patient is sitting on the floor playing with various toys.  Physical examination shows no abnormalities.  He makes eye contact and answers questions briefly before turning away to play by himself.  Affect is indifferent with constricted range.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d787_f075_bc81_3198ff77ea23_MD0003_00 This child's history of physical abuse and neglect, social withdrawal, lack of response to positive affirmation, and emotional outbursts are consistent with reactive attachment disorder (RAD). RAD arises when the normal developmental process of emotional bonding to a primary caregiver is interrupted by inconsistent or inadequate care (eg, abuse, neglect, frequent moves between foster homes, prolonged institutionalization). Children with RAD often appear socially and emotionally inhibited. They do not seek reassurance or respond to the comfort that most children crave. Other symptoms may include a lack of positive emotions (eg, constricted affect, as in this patient) and episodes of unexpected irritability or aggression in seemingly safe encounters (eg, hitting classmate, throwing objects). Symptoms of RAD can improve with consistent and nurturing caregiving. (Choice A) Although autism spectrum disorder (ASD) also presents with deficits in social and emotional reciprocity, this child does not display the repetitive motor mannerisms or restricted fixated interests required for the diagnosis of ASD. His extensive history of abuse and neglect, coupled with observations of his ability to make eye contact, respond to the physician, and play with a variety of toys, make RAD more likely than ASD. (Choice B) Disinhibited social engagement disorder (DSED) is another possible outcome of severe neglect or abuse. Unlike RAD, where children are emotionally distant, children with DSED display overfamiliarity (even with adults they do not know) and a lack of appropriate boundary setting. (Choice C) It is expected for young children to be anxious or hesitant when moving to a new environment. However, a lack of response to comfort, generalized social disengagement, and aggressive behavior should not be dismissed as normal. Early intervention in RAD can result in significant improvement in behavioral symptoms. (Choice D) Oppositional defiant disorder is characterized by deliberately disobedient and hostile behavior- often vindictive in nature- toward authority figures. It would not explain this child's social withdrawal from both peers and adults, indifference to praise, and lack of response to comfort. Educational objective: Reactive attachment disorder occurs in the context of early abuse or neglect and is characterized by emotional withdrawal and a lack of seeking or responding to comfort from caregivers. Unexplained irritability, fear, or aggression may occur even during safe encounters. References: Reactive attachment disorder and attachment theory from infancy to adolescence: review, integration, and expansion. (http://www.ncbi.nlm.nih.gov/pubmed/30014775)

A 5-Year-Old Boy Is Brought to the Office by His