a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disor— der (PTSD), acute stress disorder, and adjustment disorders. Placement of this chapter reﬂects the close relationship between these diagnoses and disorders in the surrounding chapters on anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders.
Psychological distress following exposure to a traumatic or stressful event is quite vari- able. In some cases, symptoms can be well understood within an anxiety- or fear-based context. It is clear, however, that many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symp- toms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms. Because of these variable expressions of clinical distress following exposure to catastrophic or aversive events, the aforementioned disorders have been grouped under a separate category: trauma- and stressor—related disorders. Furthermore, it is not uncommon for the clinical pic- ture to include some combination of the above symptoms (with or without anxiety- or fear-based symptoms). Such a heterogeneous picture has long been recognized in adjust- ment disorders, as well. Social neglect—that is, the absence of adequate caregiving during childhood—is a diagnostic requirement of both reactive attachment disorder and disin- hibited social engagement disorder. Although the two disorders share a common etiology, the former is expressed as an internalizing disorder with depressive symptoms and with- drawn behavior, while the latter is marked by disinhibition and externalizing behavior.
Diagnostic Criteria 313.89 (F94.1)
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregiv- ers, manifested by both of the following: 1. The child rarely or minimally seeks comfort when distressed.
2. 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: 1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable at- tachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective at- tachments (e.g., institutions with high chiId-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Cri- terion 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 it:
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as severe when a child exhibits all symp- toms of the disorder, with each symptom manifesting at relatively high levels.