The proposed revision for Reactive Attachment Disorder includes the division of the two DSM-IV types into two disorders: Reactive Attachment Disorder of Infancy and Early Childhood and Disinhibited Social Engagement Disorder.
Proposed DSM-V Criteria for Reactive Attachment Disorder of Infancy or Early Childhood
A. A pattern of markedly disturbed and developmentally inappropriate attachment behaviors, evident before 5 years of age, in which the child rarely or minimally turns preferentially to a discriminated attachment figure for comfort, support, protection and nurturance. The disorder appears as a consistent pattern of inhibited, emotionally withdrawn behavior in which the child rarely or minimally directs attachment behaviors towards any adult caregivers, as manifest by both of the following:
1) Rarely or minimally seeks comfort when distressed.
2) Rarely or minimally responds to comfort offered when distressed.
B. A persistent social and emotional disturbance characterized by at least 2 of the following:
1) Relative lack of social and emotional responsiveness to others.
2) Limited positive affect.
3) Episodes of unexplained irritability, sadness, or fearfulness which are evident during nonthreatening interactions with adult caregivers.
C. Does not meet the criteria for Autistic Spectrum Disorder.
D. Pathogenic care as evidenced by at least one of the following:
1) Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection (i.e., neglect).
2) Persistent disregard of the child’s basic physical needs.
3) Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care).
4) Rearing in unusual settings such as institutions with high child/caregiver ratios that limit opportunities to form selective attachments.
E. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
F. The child has a developmental age of at least 9 months.
Proposed DSM-V Criteria for Disinhibited Social Engagement Disorder
A. A pattern of behavior in which the child actively approaches and interacts with unfamiliar adults by exhibiting at least 2 of the following:
1) Reduced or absent reticence to approach and interact with unfamiliar adults.
2) Overly familiar behavior (verbal or physical violation of culturally sanctioned social boundaries).
3) Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
4) Willingness to go off with an unfamiliar adult with minimal or no hesitation.
B. The behavior in A. is not limited to impulsivity as in ADHD but includes socially disinhibited behavior.
C. Pathogenic care as evidenced by at least one of the following:
1) Persistent failure to meet the child’s basic emotional needs for comfort, stimulation, and affection (i.e., neglect)
2) Persistent failure to provide for the child’s physical and psychological safety.
3) Persistent harsh punishment or other types of grossly inept parenting.
4) Repeated changes of primary caregiver that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
5) Rearing in unusual settings that limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least 9 months.
Reactive Attachment Disorder of Infancy or Early Childhood
A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):
(1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)
(2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)
B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.
C. Pathogenic care as evidenced by at least one of the following:
(1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection
(2) persistent disregard of the child's basic physical needs
(3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
Specify type:
Inhibited Type: if Criterion A1 predominates in the clinical presentation
Disinhibited Type: if Criterion A2 predominates in the clinical presentation