and minimal distractibility. Some proportion of them are probablyborderline in the sense that Pine (1986) has used the term. They possessan amorphous and generally negative sense of self, they have deficient"signal anxiety," and they may show widely fluctuating levels ofbehavior. Furthermore, splitting and projective identification are prom­inent defenses in many of the children with neglectsyndrome. However,they usually do not meet DSM-IIl-R descriptive criteria for borderlinepersonality because they lack identity disturbance and other adult man­ifestations of the condition.

DSM-IV is already in the works. I am proposing this new diagnosisto. fill what I perceive to be a significant gap in our classification ofchildhood disorders. I hope others in our field will respond with com­ments or additions.

GeneWright,M.D.Santa Rosa, California

REFERENCES

Ainsworth, M. D. S. & Wittig, B. A. (1969), Attachment and exploratorybehavior in one-year-olds in a strange situation. In: Determinants ofInfantBehavior-IV, ed. B. H. Foss. London: Methuen, pp. 113-136.

Belsky, J., Rovine, M. & Taylor, D. G. (1984), The Pennsylvania Infantand Family Development Project, III: the origins of individual differ­ences in infant-mother attachment: maternal and infant contributions.ChiidDev., 55:692-705.

Galdston, R. (1979), Disorders of early parenthood: neglect, deprivation,exploitation, and abuse oflittle children. In: Basic Handbook ofChildPsychiatry, ed. J. Noshpetz. New York: Basic Books, Inc., p. 583.

Hodges, J. & Tizard, B. (1989), Social and family relationships ofex-institutional adolescents. J. ChildPsychol. Psychiatry, 30:77-97.

Pine, F. (1986), On the development of the "Borderline Child-to-Be"Am.J. Orthopsychiatry, 56;450-457.

Drs. Shaffer and Volkmar reply:

Among the proposals that the DSM-IV Child and Adolescent DisorderWorking Party are currently reviewing is one for an elaboration of thereactive attachment disorder category. The proposal would resemble theformat adopted by ICD-lO which was influenced by the Hodges andTizard study, quoted by Dr. Wright, and will include two sub-types: oneof which (F.94. 2 disinhibited attachment disorder of childhood) will becharacterized by a relative failure to show selective social attachments,generally clinging behavior in infancy and/or attention seeking, andindiscriminantly friendly behavior in early or middle childhood.

As proposed for DSM-IV, these behaviors will be found in associationwith clear evidence of abuse or neglect, which is consistent with DSM­IIl-R. Additionally, there is the more general issue of how to classifyrelationship problems that is being dealt with by the Working Party andother groups.

We would welcome receiving explicit case history examples from Dr.Wright and/or other interested clinicians.

David Shaffer, F.R.C.P., F.R.C. Psych.Co-Chairman, Child and Adolescent Disorder Work Group

Fred Volkmar, M.D.Chairman, Infant Disorder Sub-Group

To the Editor:

I would like to comment on the diagnostic criteria of three childhooddisorders as described in the DSM-III-R.These disorders are overanxiousdisorder, separation anxiety disorder, and oppositional defiant disorder.

In overanxious disorder, the exclusion criteria are dispersed andrepetiti ve.•• Psychotic disorder' , is listed as an exclusion criterion in bothcriteria "B" and "0" of the disorder. "Mood disorder," on the otherhand, is listed in criterion "B" rather than in criterion "0," where allother exclusion criteria are listed. I would like to propose deleting thelast sentence of the "B" paragraph, namely, " ... In addition, the

J.Am.Acad. Child Adolesc. Psychiatry, 29:5, September1990

LEITERS TO THE EDITOR

disturbance does not occur during the course of a psychotic or a mooddisorder," and I would like to add "mood disorder" to the otherexclusion criteria listed in criterion "0," in case these same criteria areused in the DSM -IV.

In separation anxiety disorder, the text describing this disorder in theDSM-IIl-R specifies the onset as being before the age of 18, and thecourse as characterized by periods of exacerbations and remissions overseveral years. However, the diagnostic criteria are not explicit in de­scribing the course of this disorder. These criteria may be misinterpretedas limiting the disorder to the patients who are under 18. The descriptionof the age of onset as being before the age of 18 (criterion C) and theduration as lasting at least 2 weeks (criterion B) does not allow thediagnosis of this disorder to patients older than 18 years old unless thedisorder has been chronic and uninterrupted over several months oryears. The additional description of the course as characterized byremissions and exacerbations, or the addition of such a statement as:"provided that there was a first episode before the age of 18," mayprevent unnecessary assumption presumption and possible misinterpre­tation.

Also, the DSM-IIl-R description of oppositional defiant disorder(ODD) and of major depressive disorder have contradictory statements.In the former disorder, it is reported that if features of ODD are seen inthe course of depressive disorders, the additional diagnosis of ODD isnot made. However, in the text describing the age-specific features ofadolescent major depression, it is stated that negativistic behavior mayjustify the additional diagnosis of ODD . I believe that such contradictorystatements need to be avoided in order to increase diagnostic homoge­neity. In fact, additional clinical research based on diagnostic homoge­neity may help in resolving such controversial issues.

Michael J. Calache, M.D.Southern Illinois University

Drs. Shaffer and Campbell reply:

Dr. Calache draws attention to a number ofinconsistencies in the rulesthat govern the relationship between different disorders. His points arewell taken and we propose to bring them to the attention of the relevantworking parties and to the editorial group that will be responsible for thefinal assembly of criteria for DSM-IV.

Dr. Rachel Klein, who leads the Child Anxiety Disorder Work Group,comments as follows on the points raised with respect to separationdisorder: .. It is our interpretation that the intent is not to preclude thediagnosis after age 18, providing that it occurred before that age. Ourgroup will review the issue and will suggest that it be dealt with byspecifying that for criterion C, onset of the first episode should be beforethe age of 18."

Observations of this kind are immensely helpful and we will alwaysbe pleased to receive them directly.

David Shaffer, F.R.C.P., F.R.C.Psych.Magda Campbell , M.D.

Co-Chairpersons, DSM-IV Child and Adolescent Work Group

Subtypes of Conduct DisorderTo the Editor:

A possible revision of the disruptive behavior disorders in DSM-IIl-Rwill need to be clinically meaningful for children of different ages andfor boys and girls and will need to have stood the test of replication instudies at different sites.

Dr. R. L. Jenkins (1990) recently made some valuable but alsocontroversial comments in your Journal on the desirability of distin­guishing among subtypes of conductdisorder. His citing of studies showshis empirical orientation, necessary for valid and consistent diagnosis.He also stressed the need to examine possible etiological antecedents and

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