• Diminished or no expression of positive emotions during routine interactions with caregivers
• Unexplained negative emotions, such as fear, sadness, or irritability

Criterion A. A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, manifested by both of the following: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.

Criterion B. A persistent social and emotional disturbance characterized by at least 2 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 non-threatening interactions with adult caregivers.

Criterion C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 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 attachments (e.g. frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g. institutions with high child-to-caregiver ratios).

Criterion D. The care in Criterion C is presumed to be responsible for the disturbed behaviour in Criterion A (e.g. the disturbances in Criterion A began following the lack of adequate care in Criterion C).

Criterion E. The criteria are not met for autism spectrum disorder.

Criterion F. The disturbance is evident before age 5 years.

Criterion G. The child has a developmental age of at least 9 months.

Specifiers:

• Persistent (present for more than 12 months)
• Severe (all symptom criteria are met and manifested at relatively high levels)