Reactive Attachment Disorder and Disinhibited Social Engagement Disorder: Diverging Responses to Neglect
This post is for Kelly Godwin
Reactive Attachment Disorder and Disinhibited Social Engagement Disorder: Diverging Responses to Neglect
While childhood trauma can consist of physical, sexual, and emotional abuse, one of the most common reports received by child protective services is neglect. Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are the result of this maltreatment and can prove to be a long-term detriment to the social, emotional, and intellectual development of affected children. (Kroupina, et al. 2018). Children diagnosed with either of these attachment disorders did not have their basic emotional needs met in early life, but the symptoms of the disorders are very different. (Kroupina, et al. 2018).
The delineation between social inhibition (RAD) and social disinhibition (DSED) is a fairly recent development, as before they were viewed under the umbrella of attachment disorders in the DSM-IV but were reclassified with these differences in mind upon the release of the DSM-V. (Kliewer-Neumann, et al. 2018). RAD is observed as social inhibition and occurs when a child’s need for stimulation, comfort and soothing are not met. (Humphries, et al. 2017). This results in a failure to seek or respond to comfort, hypervigilance, becoming emotionally withdrawn and indifference to caregivers. (Kliewer-Neumann, et al. 2018). (Kroupina, et al. 2018). In contrast, children with DSED experience similar forms of neglect, but instead exhibit signs of being extremely social, overly friendly, and fail to acknowledge normal social boundaries. (Kroupina, et al. 2018). Children with either RAD or DSED may exhibit symptoms of inattentiveness and hyperactivity which may affect academic achievement. (Humphreys, et al. 2017).
These attachment disorders fall on spectrum, meaning these disorders share multiple linked conditions with diverse symptoms and degrees of severity. Great strides have been made in diagnosing attachment disorders in the last 20 years as clinicians use situational observation and interviews or questionnaires. (Kliewer-Neumann, et al. 2018). Observations used to test for attachment behavior are based in having the infant or child interact with a stranger to see if the child is responsive to the stranger or caregiver, and in cases of older children, whether the child will willingly go off with a stranger. (Kliewer-Neumann, et al. 2018). The interview most often used is the Disturbance of Attachment Interview which asks caregivers about their observations of specific behaviors exhibited by the child and frequency to determine if the child shows either inhibited or disinhibited characteristics. (Kroupina, et al. 2018).
Because neglect is one of the most reported forms of child maltreatment, foster children tend to show observable signs of these disorders, however being placed with responsive caregivers can help resolve the issues related to RAD and DSED. (Kliewer-Neumann, et al. 2018). The positive impact of responsive caregivers is especially effective when maintained over an extended period and if the duration of neglect is shorter. (Kroupina, et al. 2018). Children with DSED exhibited improved signs of recovery if placed with effective caregivers at a younger age. (Humphreys, et al. 2017). Children coming from high-risk environments such as lengthy hospitalization, institutionalization, and foster care environments where placement is not consistent need to be referred to well-trained clinicians to help them avoid the long-term effects of RAD and DSED. (Kroupina, et al. 2018). (Humphreys, et al. 2017). In all cases, the most important means to address signs of attachment disorders is to ensure the child has a caregiver who is responsive to the child’s emotional needs as early as possible. (Humphreys, et al. 2017). Children exhibit a natural resilience and can develop secure attachments when put in healthy environments. (Humphreys, et al. 2017).
Works Cited:
Humphreys, K., Nelson, C., Fox, N., & Zeanah, C. (2017). Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care. Development and Psychopathology, 29(2), 675-684. doi:10.1017/S095457941700025
Kliewer-Neumann, J.D., Zimmermann, J., Bovenschen, I. et al. (2018). Assessment of attachment disorder symptoms in foster children: comparing diagnostic assessment tools. Child Adolesc Psychiatry Ment Health 12, 43 (2018). https://doi.org/10.1186/s13034-018-0250-3
Kroupina, M., Ng, R., Dahl, C., Nakitendi, A., Ellison, K. C.. (2018). Identifying Reactive Attachment Disorder and Disinhibited Social Engagement Disorder in a Sample of High Risk Children. (https://bettercarenetwork.org/sites/default/files/RAD%20and%20DSED.pdf)