Editing Reactive attachment disorder (section)

===Criteria===
ICD-10 describes reactive attachment disorder of childhood, known as RAD, and [[disinhibited attachment disorder]], less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:
* markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers);<ref name=DSMIV />
* the disturbance is not accounted for solely by [[Child development|developmental]] delay and does not meet the criteria for [[pervasive developmental disorder]];
* onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed);<ref name=DSMIV>{{cite book|title=Diagnostic and Statistical Manual of Mental Disorders: Text Revision|url=https://archive.org/details/diagnosticstatis0ed4unse_y1p2|url-access=registration|year=2000|publisher=American Psychiatric Association|isbn=978-0-89042-025-6|pages=[https://archive.org/details/diagnosticstatis0ed4unse_y1p2/page/943 943]}}</ref>
* a history of significant neglect;
* an implicit lack of identifiable, preferred attachment figure.

ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of "[[pathogenic]] care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the [[medical diagnosis|diagnosis]] is the child's history of care rather than observation of symptoms.

In DSM-IV-TR the ''inhibited'' form is described as 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", hypervigilance while keeping an impassive and still demeanour).<ref name= "DSM">{{cite book |title= Diagnostic and Statistical Manual of Mental Disorders |edition=4th ed., text revision ([[DSM-IV-TR]]) |author= American Psychiatric Association |year=2000 |isbn=978-0-89042-025-6 |chapter=Diagnostic criteria for 313.89 Reactive attachment disorder of infancy or early childhood  |publisher= AMERICAN PSYCHIATRIC PRESS INC (DC) |location= United States}}
</ref> Such infants do not seek or accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The ''disinhibited'' form shows 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).<ref name ="DSM"/> There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.

The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:
* [[Child abuse|abuse]], ([[Psychological abuse|psychological]] or physical), in addition to neglect;
* associated emotional disturbance;
* poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
* evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).

The first of these is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder.

The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring.<ref>Prior &amp; Glaser (2006), pp. 220–21.</ref> ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child.<ref name="Zeanah et al. (2004)"/> The question of whether there are two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision.<ref name="WHO1992">World Health Organisation (1992) ''International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10)''. Geneva: World health Organization.</ref> One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment.<ref>{{cite journal | author = Zilberstein K | year = 2006 | title = Clarifying core characteristics of attachment disorders | journal = [[American Journal of Orthopsychiatry]] | volume = 76 | issue = 1| pages = 55–64 | doi=10.1037/0002-9432.76.1.55| pmid = 16569127 | s2cid = 25416390 }}</ref>

{{as of|2010}}, the American Psychiatric Association has proposed to redefine RAD into two distinct disorders in the DSM-V.<ref name=DSM-V>Proposed Revision Reactive Attachment Disorder, ''American Psychiatric Association'' (2012). Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=120</ref> Corresponding with the inhibited type, one disorder will be reclassified as ''Reactive Attachment Disorder of Infancy and Early Childhood''.<ref name=DSMIV />

In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver.<ref name=DSM-V />