A 4-year-old girl is brought to the office by her adoptive mother due to concerns about her adjustment to preschool. She was placed in foster care at age 2 due to parental substance use disorder and was adopted by her current family 6 months ago. Prenatal history is unknown. At school, the patient does not interact with classmates and prefers to play by herself. She speaks infrequently at home and stays in her room; the mother has discovered that she hoards toys and food under the bed. The mother says, "She doesn't like being hugged or picked up; nothing I do seems to comfort her." The patient can dress herself, copy a triangle, write the letters of her name, and walk down the stairs without aid. Vital signs are within normal limits; weight and height curves are at the 50th and 60th percentiles, respectively. On examination, the patient is sitting quietly, playing with various toys in the room. She interacts with the physician and makes occasional eye contact. Responses are brief and said with little facial expression, but speech is otherwise normal. Physical examination shows no other abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 4-year-old girl is brought to the office by her adoptive mother due to concerns about her adjustment to preschool.  She was placed in foster care at age 2 due to parental substance use disorder and was adopted by her current family 6 months ago.  Prenatal history is unknown.  At school, the patient does not interact with classmates and prefers to play by herself.  She speaks infrequently at home and stays in her room; the mother has discovered that she hoards toys and food under the bed.  The mother says, "She doesn't like being hugged or picked up; nothing I do seems to comfort her."  The patient can dress herself, copy a triangle, write the letters of her name, and walk down the stairs without aid.  Vital signs are within normal limits; weight and height curves are at the 50th and 60th percentiles, respectively.  On examination, the patient is sitting quietly, playing with various toys in the room.  She interacts with the physician and makes occasional eye contact.  Responses are brief and said with little facial expression, but speech is otherwise normal.  Physical examination shows no other abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7f4_9565_bc81_295b96f072ed_MD0003_00 This child's history of early foster care placement due to parental substance use, social withdrawal, lack of positive response to attempts to comfort, and poor emotional responsiveness is consistent with reactive attachment disorder (RAD). RAD may develop in young children when abuse, neglect, prolonged institutionalization, or inconsistent care (eg, frequently moving between foster homes) disrupts the development of a healthy, secure attachment to caregivers. Children with RAD seldom seek comfort and do not respond to attempts to comfort them. Other symptoms include lack of social responsiveness, lack of positive emotions, and episodes of unexpected irritability or sadness in response to nonthreatening encounters. Symptoms of RAD often improve when a child has access to consistent and responsive attachment figures. (Choice A) Adjustment disorder is diagnosed when the response to a stressor is out of proportion to the circumstances and is typically accompanied by either anxiety, depression, and/or a disturbance of conduct. Social disengagement both at school and at home, as well as lack of response to comfort, are not typical. Adjustment disorder should not be diagnosed when symptoms are better explained by another disorder, such as RAD in this patient. (Choice B) Deficits in social and emotional interaction can be seen in both RAD and autism spectrum disorder (ASD). However, this girl interacts with the physician and does not display the restricted interests, stereotyped and repetitive motor mannerisms, and language impairment commonly seen in ASD. Her history of neglect and hoarding, which is common in children who have suffered neglect, makes RAD the more likely diagnosis. (Choice C) Disinhibited social engagement disorder is another possible outcome of severe, early neglect and is characterized by overfamiliarity with unfamiliar adults. Rather than a lack of seeking comfort, these children show a lack of boundaries when approaching adults (eg, sitting on another person's lap, leaving with a stranger). (Choice D) Young children with posttraumatic stress disorder (PTSD) may engage in constricted play, social withdrawal, and avoidance. However, they tend to avoid interactions reminiscent of the abuse, rather than interactions in general. Key features of PTSD include intrusive reexperiencing (eg, nightmares, dissociative flashbacks) and emotional hyperarousal (eg, irritability, aggression, startle response), both of which this girl's mother does not describe. A lack of response to comfort is not typical of PTSD. Educational objective: Early childhood abuse or neglect can result in disrupted attachment to caregivers and difficulty forming healthy relationships. Reactive attachment disorder is characterized by a pattern of emotional and social withdrawal as well as a lack of response to comfort. References: Annual research review: attachment disorders in early childhood-clinical presentation, causes, correlates, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25359236) Impaired neural reward processing in children and adolescents with reactive attachment disorder: a pilot study. (http://www.ncbi.nlm.nih.gov/pubmed/26310381) Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: effects of institutional care history and high-quality foster care. (http://www.ncbi.nlm.nih.gov/pubmed/28401844)

A 4-Year-Old Girl Is Brought to the Office by Her