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Reactive attachment disorder matters because it results specifically from grossly inadequate early care, and its inhibited pattern sits at the opposite end of a spectrum from the overfamiliar pattern of disinhibited social engagement disorder. It is diagnosed as a pattern of inhibited, emotionally withdrawn behaviour toward caregivers, with limited positive affect, arising from a documented history of insufficient care, such as severe neglect or repeated changes of caregiver. For example, imagine a toddler adopted from an institution where he received minimal individual attention, who now rarely seeks comfort from his new parents even when hurt or frightened. In practice, that documented history of grossly inadequate care is a required part of the diagnosis, not just the behaviour itself.

Features include rarely seeking or responding to comfort when distressed, minimal social and emotional responsiveness, and limited positive affect, all emerging before age five, in the context of a clear history of inadequate care. Disinhibited social engagement disorder arises from the same inadequate care history but produces the opposite behavioural pattern: indiscriminate, overly familiar approach toward unfamiliar adults, with reduced normal wariness of strangers. Picture a child from the same institutional background who instead runs up to and readily hugs any unfamiliar adult in the clinic waiting room. In practice, these opposite presentations, withdrawn versus overfamiliar, come from the same care-deprivation history but need to be told apart carefully.

• Which finding best separates reactive attachment disorder from autism spectrum disorder?
• Which developmental requirement must be met before reactive attachment disorder can be diagnosed?
• Where should treatment for reactive attachment disorder be directed?

• Disinhibited social engagement disorder, indiscriminate overfamiliarity with strangers, unlike reactive attachment disorder's inhibited withdrawal from caregivers, though both share a similar care-deprivation history.
• Autism spectrum disorder, reduced social responsiveness plus restricted, repetitive behaviours, unlike reactive attachment disorder, which requires a documented history of inadequate care and lacks repetitive behaviours.
• Normal shyness, does not require a history of grossly inadequate care, unlike reactive attachment disorder, where that care history is essential to diagnosis.
• Reactive attachment disorder, symptoms emerge before age five, unlike conditions with no requirement for a documented adverse caregiving history.

• Reduced eye contact is seen in both and is not discriminating.
• Speech delay is common in autism but does not distinguish the two.
• Social difficulty occurs in both conditions and cannot separate them.
• Solitary play occurs in both conditions.
• No intelligence threshold is required.

• Extract the defining phenomenology, duration, severity and functional-impact clues.
• Match the pattern to the most specific diagnostic or assessment construct.
• Actively test the closest look-alike against the missing or contradictory clue.
• Choose the precise term rather than a broader category that is merely compatible.