<unk>  is one of the least researched and most poorly understood<unk> s in the DSM. There is little systematic epidemiologic information on<unk> , its course is not well established and it appears difficult to diagnose accurately. There is a lack of clarity about the presentation of attachment<unk> s over the age of five years and difficulty in distinguishing between aspects of attachment<unk> s, disorganized attachment or the consequences of maltreatment. According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who exhibit signs of<unk>  need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of<unk>  may also be found in other psychiatric<unk> s and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation. Their practice parameter states that the assessment of<unk>  requires evidence directly obtained from serial observations of the child interacting with his or her primary caregivers and history (as available) of the child's patterns of attachment behavior with these caregivers. It also requires observations of the child's behavior with unfamiliar adults and a comprehensive history of the child's early caregiving environment including, for example, pediatricians, teachers, or caseworkers. In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers or psychiatric nurses. In the UK, the British Association for Adoption and Fostering (BAAF) advise that only a psychiatrist can diagnose an attachment<unk>  and that any assessment must include a comprehensive evaluation of the child's individual and family history. According to the AACAP Practice Parameter (2005) the question of whether attachment<unk> s can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of<unk>  change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence. Assessments of<unk>  past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior. Criteria ICD-10 describes<unk>  of childhood, known as<unk> , and disinhibited attachment<unk> , less well known as DAD. DSM-IV-TR also describes<unk>  of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as<unk> . 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); * the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental<unk> ; * onset before five years of age (there is no age specified before five years of age at which<unk>  cannot be diagnosed); * 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<unk> . For this reason, part of the 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). 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). 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: * 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<unk> . The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring. 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<unk>  and can coexist in the same child. 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. 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<unk> s of attachment. , the American Psychiatric Association has proposed to redefine<unk>  into two distinct<unk> s in the DSM-V. Corresponding with the inhibited type, one<unk>  will be reclassified as<unk>  of Infancy and Early Childhood. In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement<unk>  now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed<unk> s, 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. Differential diagnosis The diagnostic complexities of<unk>  mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. Several other<unk> s, such as conduct<unk> s, oppositional defiant<unk> , anxiety<unk> s, post traumatic stress<unk>  and social phobia share many symptoms and are often comorbid with or confused with<unk> , leading to over and under diagnosis.<unk>  can also be confused with neuropsychiatric<unk> s such as autism, pervasive developmental<unk> , childhood schizophrenia and some genetic syndromes. Infants with this<unk>  can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. Autistic children are likely to be of normal size and weight and often exhibit a degree of intellectual disability. They are unlikely to improve upon being removed from the home. Alternative diagnosis In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10. Many children are being diagnosed with<unk>  because of behavioral problems that are outside the criteria. There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment<unk>  whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment<unk> s. However, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing<unk> s. The Randolph Attachment<unk>  Questionnaire or<unk> Q is one of the better known of these checklists and is used by attachment therapists and others. The checklist includes 93 discrete behaviours, many of which either overlap with other<unk> s, like conduct<unk>  and oppositional defiant<unk> , or are not related to attachment difficulties. Critics assert that it is unvalidated and lacks specificity.
Reactive attachment disorder
Autism
Externalizing disorder
Immature personality disorder
Disinhibited attachment disorder
Internalizing disorder
Spectrum disorder
Haltlose personality disorder