OTHER
DISORDERS OF INFANCY,
CHILDHOOD, OR ADOLESCENCE
Elective
Mutism
The essential feature of this disorder is
persistent refusal to talk in one or more
major social situations, including school,
despite ability to comprehend spoken language
and to speak. The refusal to talk is not a
symptom of Social Phobia, Major Depression,
or a psychotic disorder, such as
Schizophrenia.
The child with Elective Mutism may
communicate via gestures, by nodding or
shaking the head, or, in some cases, by
monosyllabic or short, monotone utterances.
Most commonly the child will not speak at
school, but will talk normally within the
home. Less commonly the child refuses to
speak in nearly all social situations.
Children with this disorder generally have
normal language skills, though some have
delayed language development and
abnormalities of articulation.
Associated features. Speech
disorders may be present, such as
Developmental Articulation Disorder,
Developmental Expressive or Receptive
Language Disorder, or a physical disorder
that causes abnormalities of articulation.
Excessive shyness, social isolation and
withdrawal, clinging, school refusal,
compulsive traits, negativism, temper
tantrums, or other controlling or
oppositional behavior, particularly at home,
may be observed.
Age at onset. Although onset
is usually before age five, the disturbance
may come to clinical attention only with
entry into school.
Course. In most cases the
disturbance lasts only a few weeks or months;
in a few, it continues for several years.
Impairment. There may be
severe impairment in social and school
functioning.
Complications. School
failure and teasing or scapegoating by peers
are common complications.
Predisposing factors.
Maternal overprotection, Language and Speech
Disorders, Mental Retardation, immigration,
and hospitalization or trauma before age
three may predispose to Elective Mutism.
Prevalence. The disorder is
apparently rare; it is found in fewer than 1
% of child-guidance, clinical, and
school-social-casework referrals
Sex ratio. The disorder is
slightly more common in females than in
males.
Familial pattern. No
information.
Differential diagnosis. In Severe or Profound
Mental Retardation, Pervasive Developmental
Disorder, and Developmental Expressive
Language Disorder, there may be inability to
speak, but not a refusal to do so. Children
in families who have emigrated to a country
of a different language may refuse to speak
the new language. When comprehension of the
new language is adequate but the refusal to
speak persists Elective Mutism should be
diagnosed.
Diagnostic Criteria for Elective
Mutism
A. Persistent refusal to
talk in one or more major social situations
(including at school).
B. Ability to comprehend
spoken language and to speak.
Identity
Disorder
The essential feature of this disorder is
severe subjective distress regarding
inability to integrate aspects of the self
into a relatively coherent and acceptable
sense of self. There is uncertainty about a
variety of issues relating to identity,
including long-term goals, career choice,
friendship patterns, sexual orientation and
behavior, religious identification, moral
value systems, and group loyalties. These
symptoms last at least three months and
result in impairment in social or
occupational (including academic)
functioning. The disturbance does not occur
exclusively during the course of another
mental disorder, such as a Mood Disorder,
Schizophrenia, or Schizophreniform Disorder;
the disturbance is not sufficiently pervasive
and persistent to warrant the diagnosis of
Borderline Personality Disorder.
The uncertainty regarding long-term goals may
be expressed as inability to choose or adopt
a life pattern, for example, one dedicated to
material success, or service to the
community, or even some combination of the
two. Conflict regarding career choice may be
expressed as inability to decide on a career
or as inability to pursue an apparently
chosen occupation. Conflict regarding
friendship patterns may be expressed in an
inability to decide the kinds of people with
whom to be friendly and the degree of
intimacy to permit. Conflict regarding values
and loyalties may include concerns about
religious identification, patterns of sexual
behavior, and moral issues. The person
experiences these conflicts as irreconcilable
aspects of his or her personality and, as a
result, fails to perceive himself or herself
as having a coherent identity. Frequently the
disturbance is epitomized by the person's
asking, 'Who am I?"
Associated features. Mild
anxiety and depression are common and are
usually related to inner preoccupations
rather than external events. Self-doubt and
doubt about the future are usually present,
and take the form of either difficulty in
making choices or impulsive experimentation.
Negative or oppositional patterns are often
chosen in an attempt to establish an
independent identity distinct from family or
other close people. Such attempts may include
transient experimental phases of widely
divergent behavior as the person "tries
on" various roles.
Age at onset. The most
common age at onset is late adolescence, when
people generally become detached from their
family value systems and attempt to establish
independent identities. As value systems
change, this disorder may also appear in
young adulthood, or even in middle age, if a
person begins to question earlier life
decisions.
Course. Frequently there is
a phase with acute onset, which either
resolves over a period of time or becomes
chronic. In other instances the onset is more
gradual. If the disorder begins in
adolescence, it is usually resolved by the
mid-20s. If it becomes chronic, however, the
person may be unable to make a career
commitment, or may fail to form lasting
emotional attachments, with resulting
frequent shifts in jobs, relationships, and
career directions.
Impairment. The degree of
impairment varies. Usually there is some
interference in both occupational (including
academic) and social functioning, with
deterioration in friendships and family
relationships
Complications. Educational
achievement and work performance below that
appropriate to the person's intellectual
ability may result from this disorder
Prevalence. No information.
The disorder is apparently more common now
than several decades ago, perhaps because
today there are more options regarding
values, behavior, and life-styles and more
conflict between adolescent peer values and
parental or societal values.
Predisposing factors, sex ratio, and
familial pattern. No information.
Differential diagnosis. Normal
conflicts associated with maturing, such as
“adolescent turmoil" or
"middle-age crisis," are usually
not associated with severe distress and
impairment in occupational or social
functioning. Nevertheless, if the criteria
are met, the diagnosis of Identity Disorder
should be given regardless of the person's
developmental stage.
In Schizophrenia, Schizophreniform Disorder,
and Mood Disorder, there frequently are
marked disturbances in identity, but these
diagnoses preempt the diagnosis of Identity
Disorder.
In Borderline Personality Disorder, identity
disturbances are only one of several
important areas of disturbance, and there is
often considerable mood disturbance. If the
disturbance is sufficiently pervasive and
persistent to warrant the diagnosis of
Borderline Personality Disorder, then that
diagnosis preempts the diagnosis of Identity
Disorder. What appears initially to be
Identity Disorder may later turn out to have
been an early manifestation of one of the
disorders noted above.
Diagnostic Criteria for Identity
Disorder
A. Severe subjective
distress regarding uncertainty about a
variety of issues relating to identity,
including three or more of the following:
- long-term goals
- career choice
- friendship patterns
- sexual orientation and behavior
- religious identification
- moral value systems
- group loyalties
B. Impairment in social
or occupational (including academic)
functioning as a result of the symptoms in A.
C. Duration of the
disturbance of at least three months.
D. Occurrence not
exclusively during the course of a Mood
Disorder or of a psychotic disorder, such as
Schizophrenia.
E. The disturbance is not
sufficiently pervasive and persistent to
warrant the diagnosis of Borderline
Personality Disorder.
Reactive
Attachment Disorder of
Infancy or Early Childhood
The essential feature of this disorder is
markedly disturbed social relatedness in most
contexts that begins before the age of five
and is not due to Mental Retardation or a
Pervasive Developmental Disorder, such as
Autistic Disorder. The disturbance in social
relatedness is presumed to be due to grossly
pathogenic care that preceded the onset of
the disturbance.
The disturbance may take the form of either
persistent failure to initiate or respond in
an age-expected manner to most social
interactions or (in an older child)
indiscriminate sociability, e.g., excessive
familiarity with relative strangers, as shown
by making requests and displaying affection.
Some severe forms of this disorder, in which
there is lack of weight gain and motor
development, have been called "failure
to thrive or "hospitalism."
Infants with this disorder present with
poorly developed social responsiveness.
Visual tracking of eyes and faces and
responding to the caregiver's voice may not
be established by two months of age;
attention, interest, and gaze reciprocity may
be absent. At four to five months, the infant
may fail to express pleasure by smiling,
participate in playful, simple games with the
caregiver or observer, or attempt vocal and
visual reciprocity (e.g., turn his or her
head toward the side from which the voice of
the caregiver or observer comes). At six to
ten months, the infant may fail to reach out
when he or she is to be picked up, reach
spontaneously for the caregiver, crawl toward
the caregiver, establish visual or vocal
communication with the caregiver, begin to
imitate the caregiver, or display any of the
usual more subtle facial expressions of joy,
coyness, curiosity, surprise, fear, anger, or
attentiveness.
The child often is apathetic; staring, weak
cry, poor muscle tone, weak rooting and
grasping reactions to attempts to feed, and
low spontaneous motility are commonly
observed. Excessive sleep and a rather
generalized lack of interest in the
environment are frequent manifestations of
the disorder.
Often such infants are noticed by a
pediatrician because of failure to thrive
physically Since these infants frequently do
not receive well-baby care, the reason for
the visit to the pediatrician may be a
complicating physical illness, usually
infectious, or an associated feeding problem
(e.g., rumination) or injury. The head
circumference is generally normal, and
failure to gain weight, if present, is
disproportionately greater than the failure
(if any) to gain in length.
The diagnosis of Reactive Attachment Disorder
of Infancy or Early Childhood can be made
only in the presence of clear evidence of
grossly pathogenic care. This frequently
requires either a home visit, observation of
the spontaneous emotional and social
interaction between the caregiver and the
infant during both feeding and non-feeding
periods, or reports from other observers.
Parental reports may not be reliable,
particularly when there is suspected child
abuse The pathogenic care may include
persistent disregard of the child's basic
emotional needs for comfort, stimulation, and
affection. For example, the caregiver may be
overly harsh, or consistently ignore the
child. Some caregivers may persistently
disregard the child's physical needs, failing
to feed the child adequately, or to protect
the child from physical danger or assault
(including sexual abuse). Repeated and
frequent changes of the primary caregiver so
that stable attachments are not possible may
also be an etiologic factor.
It is pathognomonic of this disorder that,
except in cases of extreme neglect with
consequent severe physical complications
(e.g., starvation, dehydration, or other
intercurrent physical complications that can
cause death before therapeutic measures can
take hold), the clinical picture can be
substantially improved by adequate care (Such
care need not be provided by a single person
to be effective; it can include
hospitalization, for example.) Such a
therapeutic response is ultimate confirmation
of the diagnosis.
Associated features. Feeding
disturbances may be present, in particular,
rumination, regurgitation, and vomiting. Such
disturbances may be related to psychosocial
deprivation and may, in turn, be a central
factor in malnutrition. There may be sleep
disturbances, and hypersensitivity to touch
and sound.
Age at onset. By definition,
the age at onset is before age five. Beyond
this age, children do not develop this
clinical picture in response to grossly
pathogenic care. The diagnosis can be made as
early as in the first month of life.
Course, impairment, and
complications. If care remains
grossly inadequate, severe malnutrition,
intercurrent infection, and death can occur.
As noted above, however, the disorder is
reversible with appropriate treatment and
does not recur if affectionate and
developmentally appropriate care is provided,
preferably by a primary caregiver.
Predisposing factors. All
factors that interfere with early emotional
attachment of the child to a primary
caregiver can predispose to this disorder. In
terms of the caregiver, these include: severe
depression, isolation and lack of support
systems, obsessions of infanticide that make
the caregiver stay away from the infant,
impulse-control difficulties, and extreme
deprivation or abuse during the caregiver's
own childhood.
Babies that are “difficult" or very
lethargic may frustrate the caregiver
excessively and discourage appropriate
caregiver behavior. Other factors that
predispose to the disorder are lack of
affectionate body-to-body contact during the
first weeks of life, such as a prolonged
period in an incubator or other early
separations from a caring adult.
Prevalence, sex ratio, and familial
pattern. No information.
Differential diagnosis. The
diagnosis of Reactive Attachment Disorder of
Infancy or Early Childhood is not made if the
disturbance in social relatedness is
attributed to either Mental Retardation or a
Pervasive Developmental Disorder, such as
Autistic Disorder.
Children with a variety of severe neuralgic
abnormalities, such as deafness, blindness,
profound multisensory defects, major central
nervous system disease, or severe chronic
physical illness, may have very specific
needs and few means of satisfying them, and
thus may suffer minor secondary attachment
disturbances However, markedly disturbed
social relatedness is generally not present.
ln psychosocial dwarfism there may also be
apathy, parental neglect, and disappearance
of symptoms with hospitalization. However, in
psychosocial dwarfism there rarely is a
history of grossly pathogenic care.
Diagnostic Criteria for Reactive
Attachment Disorder of Infancy or Early
Childhood
A. Markedly disturbed social
relatedness in most contexts, beginning
before the age of five, as evidenced by
either (1) or (2);
- persistent failure to initiate or
respond to most social interactions
(e.g., in infants, absence of visual
tracking and reciprocal play, lack of
vocal imitation or playfulness,
apathy, little or no spontaneity; at
later ages, lack of or little
curiosity and social interest)
- indiscriminate sociability, e.g.,
excessive familiarity with relative
strangers by making requests and
displaying affection
B. The disturbance in A
is not a symptom of either Mental Retardation
or a Pervasive Developmental Disorder, such
as Autistic Disorder.
C. Grossly pathogenic care,
as evidenced by at least one of the
following:
- persistent disregard of the child's
basic emotional needs for comfort,
stimulation, and affection. Examples:
overly harsh punishment by caregiver;
consistent neglect by caregiver.
- persistent disregard of the child's
basic physical needs, including
nutrition, adequate housing, and
protection from physical danger and
assault (including sexual abuse)
- repeated change of primary caregiver
so that stable attachments are not
possible, e.g., frequent changes in
foster parents
D. There is a presumption
that the care described in C is responsible
for the disturbed behavior in A; this
presumption is warranted if the disturbance
in A began following the pathogenic care in
C.
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