As a result, reactive attachment disorder must be differentiated from autism spectrum dis- order. These two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors. Children with reactive attachment disorder have experienced a history of severe social neglect, although it is not always pos— sible to obtain detailed histories about the precise nature of their experiences, especially in initial evaluations. Children with autistic spectrum disorder will only rarely have a history of social neglect. The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder. These clinical features manifest as excessive adherence to rituals and routines; restricted, fixated interests; and unusual sensory reactions. However, it is important to note that children with either con- dition can exhibit stereotypic behaviors such as rocking or ﬂapping. Children with either disorder also may exhibit a range of intellectual functioning, but only children with autis- tic spectrum disorder exhibit selective impairments in social communicative behaviors, such as intentional communication (i.e., impairment in communication that is deliberate, goal-directed, and aimed at inﬂuencing the behavior of the recipient). Children with reac— tive attachment disorder show social communicative functioning comparable to their overall level of intellectual functioning. Finally, children with autistic spectrum disorder regularly show attachment behavior typical for their developmental level. In contrast, children with reactive attachment disorder do so only rarely or inconsistently, if at all.
Intellectual disability (intellectual developmental disorder). Developmental delays of- ten accompany reactive attachment disorder, but they should not be confused with the disorder. Children with intellectual disability should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotion regulation difficulties evident in children with reactive attach- ment disorder. In addition, developmentally delayed children who have reached a cogni- tive age of 7—9 months should demonstrate selective attachments regardless of their chronological age. In contrast, children with reactive attachment disorder show lack of preferred attachment despite having attained a developmental age of at least 9 months.
Depressive disorders. Depression in young children is also associated with reductions in positive affect. There is limited evidence, however, to suggest that children with depres— sive disorders have impairments in attachment. That is, young children who have been di- agnosed with depressive disorders still should seek and respond to comforting efforts by caregivers.
Conditions associated with neglect, including cognitive delays, language delays, and ste- reotypies, often co-occur with reactive attachment disorder. Medical conditions, such as severe malnutrition, may accompany signs of the disorder. Depressive symptoms also may co-occur with reactive attachment disorder.
Diagnostic Criteria 313.89 (F94.2)
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: 1. Reduced or absent reticence in approaching and interacting with untamiliar adults.
2. Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate 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 behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyper- activity disorder) but include socially disinhiblted behavior.
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).