266 Trauma- and Stressor-Related Disorders
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 child-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 if:
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.
Diagnostic Features
Reactive attachment disorder of infancy or early childhood is characterized by a pattern of
markedly disturbed and develo pmentally inappropriate attachment behaviors, in which a
child rarely or minimally turns preferentially to an attachment figure  for comfort, support,
protection, and nurturance. The essential featur e is absent or grossly underdeveloped at-
tachment between the child and putative caregiving adults. Children with reactive attach-
ment disorder are believed to have the capa city to form selective attachments. However,
because of limited opportunitie s during early development, they  fail to show the behavioral
manifestations of select ive attachments. That is, when di stressed, they show no consistent
effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore,