Reactive Attachment Disorder

    Reactive Attachment Disorder
    The newest guide to diagnosing mental disorders is the DSM-5, classifies this as a Stressor-related disorder which can only be caused by social neglect during childhood (meaning a lack of adequate caregiving). Disinhibited Social Engagement Disorder is similar to Reactive Attachment Disorder but presents with externalizing behavior and a lack of inhibitions in behavior, rather the internalizing, withdrawn behavior and depressive symptoms present in Reactive Attachment Disorder. [2]:265 It is also recognized as an emotional disorder which begins during childhood. [1], [2]
    Reactive Attachment Disorder DSM-5 Diagnostic Criteria
    Code 313.89
    "A. consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
    • The child rarely or minimally seeks comfort when distressed.
    • The child rarely or minimally responds to comfort when distressed.
    B. A persistent social and emotional disturbance characterized by at least two of the following:
    • Minimal social and emotional responsiveness to others.
    • Limited positive affect.
    • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interaction with adult caregivers.
    C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
    • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
    • Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care.)
    • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g. institutions with child-to-caregiver-ratios.)
    D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C.)

    E. The criteria are not met for autism spectrum disorder.

    F. The disturbance is evident before age 5 years.

    G. The child has a developmental age of at least 9 months.

    Specify if: Persistent: The order has been present for more than 12 months.
    Specify current severity: Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels." [2]:265-266

    ICD Diagnostic Criteria

    The most recent approved version of the International Classification of Diseases, the diagnostic guide published by the World Health Organization is the ICD-10, published in 1992.[2] The draft ICD-11 criteria for Reactive Attachment Disorder gives this description:

    ICD 11 draft - Reactive Attachment Disorder
    Code 7B24
    "Reactive attachment disorder is characterized by grossly abnormal attachment behaviours in early childhood, occurring in the context of a history of grossly inadequate child care (e.g., severe neglect, maltreatment, institutional deprivation). Even when an adequate primary caregiver is newly available, the child does not turn to the primary caregiver for comfort, support and nurture, rarely displays security-seeking behaviours towards any adult, and does not respond when comfort is offered. Reactive attachment disorder can only be diagnosed in children, and features of the disorder develop within the first 5 years of life. However, the disorder cannot be diagnosed before the age of 1 year (or a mental age of less than 9 months), when the capacity for selective attachments may not be fully developed, or in the context of Autism spectrum disorder."

    Exclusion: Asperger syndrome, disinhibited attachment disorder of childhood, maltreatment syndromes, normal variation in pattern of selective attachment, sexual or physical abuse in childhood (which results in psychosocial problems)
    Alternative terms include childhood reactive attachment disorder, reactive attachment disorder of childhood, and reactive attachment disorder of early childhood [3] Last updated December 2014.
    ICD 10 Diagnostic Criteria - Reactive attachment disorder of childhood
    Code F94.1
    "Starts in the first five years of life and is characterized by persistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling." [1]

    It may occur alongside an associated failure to thrive, or growth retardation.
    Exclusion: Asperger syndrome, disinhibited attachment disorder of childhood, maltreatment syndromes, normal variation in pattern of selective attachment, sexual or physical abuse in childhood (which results in psychosocial problems)

    See also Disinhibited Social Engagement Disorder.
    1. World Health Organization. (2010) ICD-10 Version: 2010. Retrieved December 7, 2014, from
    2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. ISBN 0890425558.
    3. World Health Organization. (December 7, 2014). ICD-11 Beta Draft (Joint Linearization for Mortality and Morbidity Statistics).
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