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Introduction: Attachment disorder (AD), including reactive AD and disinhibited social engagement disorder, is a prevalent, yet underdiagnosed disorder in severely maltreated children. Because the condition is associated with significant psychiatric morbidity over the entire lifespan, a valid and economic screening tool to identify children with clinical symptoms of AD is needed to avoid unspecific or ineffective treatment. The present study aimed to assess the effectiveness and efficiency of the German version of the Relationship Problems Questionnaire (RPQ). Methods: With a total of 135 children (mean age = 7.17 years, SD = 1.40, 63% male) from both general (34 children) and high-risk populations (69 in- and outpatients, 32 foster children), we investigated the sensitivity and specificity of the RPQ. AD was diagnosed using a standardized clinical interview (K-DIPS). 35 out of 135 children fulfilled the criteria for AD. Results: The RPQ identified 74% of the children who fulfilled the criteria for AD in the standardized clinical interview. The optimal cut-off score of the RPQ for identifying AD was 4.5 with a moderate sensitivity of 0.74 and specificity of 0.68. Conclusions: The German version of the RPQ proved useful as a diagnostic indicator of clinical symptoms of AD. The tool is economic and suitable for the screening of AD in the general population as well as high-risk populations. We recommend the use of the RPQ in clinical and research settings, adding multi-method approaches after a positive screening.

Background: Co-occurring trauma-related and neurodevelopmental problems are common in maltreated children. In population research and clinical practice, these tend to be considered separately. Overlapping health problems, that is, “multi-morbidity,” in adulthood is associated with increased service burden and costs, but this has not been investigated in childhood. Methods: Using well-validated parent-report questionnaires, we examined the overlap between symptoms of the neurodevelopmental disorder autism (autism spectrum disorder, ASD) and symptoms of the trauma- and stressor-related disorders (reactive attachment disorder [RAD] and disinhibited social engagement disorder [DSED]) in a representative general population sample of over 3,300 children aged 5–6 years of age. We investigated sociodemographic factors, service burden, and costs in association with these problems when considered separately and when co-occurring. Results: Nearly 2% of this population had symptoms suggestive of both ASD and RAD/DSED. High symptom scores for ASD were associated with male gender, (younger) age of mother at birth, and being in a single-parent family, while high symptom scores for RAD/DSED were associated with (younger) age of mother at birth, being in a single-parent family, and the number of accidents reported. Service use costs per likely case of both ASD and RAD/DSED in the preschool years were increased by £348.62 (95% confidence interval 121.04–391.11)—nearly double the costs of ASD alone. Conclusions: There is considerable overlap between symptoms of ASD and RAD/DSED in the general population, indicating that multi-morbidity is already present in childhood and is associated with increased service use and costs even in the preschool years.

Here, we report a study using computer role-play to investigate Disinhibited Social Engagement in 54 typically developing children aged 6, 8 and 10 years. Children completed 22 (theme-matched) vignettes and computerised scenarios that captured the themes of the specific symptoms of Disinhibited Social Engagement Disorder (DSM V, APA, 2013). Our newly created 22 "Paper pencil" vignettes and computer role-play scenarios were used in conjunction with the Strange Stories (O'Hare, Bremner, Nash, Happe & Pettigrew, 2009) and Parents and Teachers completed versions of the Relationship Problems Questionnaire (RPQ: Minnis et al., 2007). Our findings revealed the developmental (age) differences of social vulnerability/indiscriminate friendliness and potential advantages of computermediated role-play in comparison to “paper pencil” tasks. We argue that using a method of children role playing characters gives a better insight into children's true vulnerabilities. We discuss our findings in relation to using this methodology for clinicians and researchers to improve social skills in the most socially vulnerable children.

The fifth edition of the Diagnostic and Statistical Manual ( DSM) categorizes reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) as two separate disorders, and their criteria are revised. For DSED, the core symptoms focus on abnormal social disinhibition, and symptoms regarding lack of selective attachment have been removed. The core symptoms of RAD are the absence of attachment behaviors and emotional dysregulation. In this study, an international team of researchers modified the Child and Adolescent Psychiatric Assessment for RAD to update it from DSM-IV to DSM-5 criteria for RAD and DSED. We renamed the interview the reactive attachment disorder and disinhibited social engagement disorder assessment (RADA). Foster parents of 320 young people aged 11 to 17 years completed the RADA online. Confirmatory factor analysis of RADA items identified good fit for a three-factor model, with one factor comprising DSED items (indiscriminate behaviors with strangers) and two factors comprising RAD items (RAD1: failure to seek/accept comfort, and RAD2: withdrawal/hypervigilance). The three factors showed differential associations with clinical symptoms of emotional and social impairment. Time in foster care was not associated with scores on RAD1, RAD2, or DSED. Higher age was associated with lower scores on DSED, and higher scores on RAD1.

This paper provides a critical response to Jean Mercer’s article published in the Child and Adolescent Social Work Journal (2017, https://doi.org/10.1007/s10560-017-0511-7 ), which reviewed articles published on attachment theory, practice, and research in past decade. Jean Mercer further classified information in two categories of conventional and unconventional. Primarily, the purpose of this paper is to contest this classification. This paper posits that conceptualization underlying both these categories can be linked to core tenets of attachment theory. It further identifies that attachment-related concerns occur on a continuum, and adequate guidance is not available to clinicians to diagnose it as such. At one end of the spectrum are attachment insecurities and at the other end disorders like reactive attachment disorder and disinhibited social engagement disorder. Not acknowledging the spectrum of attachment problems can result in inadequate guidance to clinicians, leading to idiosyncratic diagnosis and treatment. The absence of validated diagnostic assessment methods has further exacerbated this issue. Limited research base for conventional or unconventional approaches has allowed the growth of treatment models with the potential to harm clients. Promoting new thinking, devising validated diagnostic methods, and strengthening evidence-base for treatments for attachment-related problems are the challenges facing the practitioners in the field of child and adolescent mental health, researchers in this field, and watch-guard organizations.

Objective We aimed to investigate the current diagnostic incidence, and medical and psychiatric comorbidities of reactive attachment disorder (RAD) using the National Health Insurance Review and Assessment (HIRA) claims data. Methods To examine the diagnostic incidence, we selected patients who were under 10-year-old and who had at least one medical claim containing a 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for RAD (F94.1 and F94.2) and who had not been diagnosed in the previous 360 days, from 2010 to 2012. In this study, we used the term 'reactive attachment disorder' representing for both RAD per se and Disinhibited social engagement disorder. Comorbid disorders were categorized according to ICD-10. Results Among 14,029,571, the total population under 10-year-old during 2010-2012, incident cases of RAD were 736. The mean diagnostic incidence of RAD was 5.25 per 100,000 annually. Language disorders (F80-84) were the most common psychiatric comorbidities in both boys and girls in age groups 0-3 years and 4-6 years, and attention deficit hyperactivity disorder was the most common in both sex aged 7-9 years. In non-psychiatric comorbidities, diseases of the respiratory system (J00-99) were the commonest in both sex in all age groups, and diseases of the digestive system (K00-99) were the next. Conclusion RAD was very rare in practice and would be disguised as other psychiatric disorders. Children with RAD might have more medical comorbidities than typically developed children.

Objective: A comprehensive approach is needed for diagnosing disordered attachment behavior due to the multifaceted nature of attachment. Differences between various indicators can pose a challenge for deciding on the proper diagnosis. This study assessed the convergence between clinical interview assessment and observation-based clinical diagnosis, and their linkages with inadequate care. Method: Participating children (N = 55) had intelligence quotients (IQs) between 50 and 85 and were referred for psychiatric consultation. Data were obtained by structured review of medical records, the Disturbances of Attachment Interview (DAI), and the Clinical Observation of Attachment (COA) procedure. Results: Of the 18 children identified using the DAI with Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) diagnosis of reactive attachment disorder (RAD) and/or disinhibited social engagement disorder (DSED), only 7 received a clinical DSM-5 diagnosis of RAD and/or DSED. Observed maladaptive attachment behavior in the COA was strongly associated with DAI scores and with clinical diagnosis of DSM-5 RAD and/or DSED. There was a significantly higher prevalence of extremes of insufficient care in children who were classified with RAD by DAI or DSM-5 and/or with DSED by DSM-5 compared to those with no attachment disorder. Conclusions: Using structured observation and record assessment leads to more conservative identification of RAD or DSED than using the DAI.

Two disorders of attachment have been consistently identified in some young children following severe deprivation in early life: reactive attachment disorder and disinhibited social engagement disorder. However, less is known about whether signs of these disorders persist into adolescence. We examined signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years in 111 children who were abandoned at or shortly after birth and subsequently randomized to care as usual or to high-quality foster care, as well as in 50 comparison children who were never institutionalized. Consistent with expectations, those who experienced institutional care in early life had more signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years than children never institutionalized. In addition, using a conservative intent-to-treat approach, those children randomized to foster care had significantly fewer signs of reactive attachment disorder and disinhibited social engagement disorder than those randomized to care as usual. Analyses within the ever institutionalized group revealed no effects of the age of placement into foster care, but number of caregiving disruptions experienced and the percentage of the child's life spent in institutional care were significant predictors of signs of attachment disorders assessed in early adolescence. These findings indicate that adverse caregiving environments in early life have enduring effects on signs of attachment disorders, and provide further evidence that high-quality caregiving interventions are associated with reductions in both reactive attachment disorder and disinhibited social engagement disorder.

Introduction: Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts.We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9. Methods: A total of 135 children aged between 5 and 9 years (M = 7.17 years, SD = 1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development. Results: The prevalence of AR in children with AD was 28.6% for the ‘secure’ form of AR, 17.1% for the ‘insecure-avoidant’ form, 25.7% for the ‘insecure-ambivalent’ form, and 28.6% for the ‘disorganized’ form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills. Conclusions: Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models. Keywords: Attachment theory, Attachment representations (AR), Reactive attachment disorder (RAD), Story stem method, Research Domain Criteria (RDoC)

Background Low self-esteem predicts negative outcomes and mediates the association between childhood adversity and mental health problems in adolescence. Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are presumably caused by early insufficient care, but their association with self-esteem is unknown. Objective Investigate global and domain-specific self-esteem in adolescents with RAD or DSED. Participants and setting All adolescents living in Norwegian residential youth care (RYC) (N = 306; age 12–20) were compared with a sample from the general Norwegian adolescent population (N = 10,480; age 12–20). Methods Self-esteem for scholastic competence (SC), social acceptance (SA), athletic competence (AC), physical appearance (PA), romantic appeal (RA), close friendship (CF), and self-worth (SW) was investigated using the revised version of the Self-Perception Profile for Adolescents. Results Compared to the general population, adolescents with RAD diagnosis had lower SC (mean difference, MD = −0.30, p = .020) and higher CF (MD = 0.25, p = .021), whereas adolescents with DSED diagnosis had lower SC (MD = −0.42, p = .005), SA (MD = −0.40, p = .015), AC (MD = −0.22, p = .038), PA (MD = −0.33, p = .048), and SW (MD = −0.37, p = .013). Compared to adolescents in RYC without RAD/DSED diagnoses, adolescents with DSED diagnoses had lower SA (MD = −0.42, p = .012) and SW (MD = −0.32, p = .037). More RAD symptoms were associated with lower SA (B = −0.051, p = .013), AC (B = −0.048, p = .028), RA (B = −0.053, p = .007), and CF (B = −0.052, p = .005). More DSED symptoms were associated with lower SC (B = −0.125, p = .038). Conclusion Both global and domain-specific self-esteem in adolescents with RAD or DSED should be assessed; developmental support and treatment plans should be adjusted accordingly.

Disinhibited social engagement disorder (DSED), formerly known as reactive attachment disorder–disinhibited type, is a relatively rare condition connected to severe deprivation early in life. DSED ...

Although reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are acknowledged as valid disorders in young children, controversy remains regarding their validity in adolescence. An unresolved question is whether symptoms of RAD and DSED are better conceptualized as other psychiatric disorders at this age. All adolescents (N = 381; 67% consent; 12–20 years old) living in residential youth care in Norway were interviewed to determine the symptoms and diagnosis of RAD/DSED and other common psychiatric disorders using the Child and Adolescent Psychiatric Assessment (CAPA). The construct validity of RAD and DSED, including structural and discriminant validity, was investigated using confirmatory factor analysis and latent profile analysis. Two-factor models distinguishing between symptoms of RAD and DSED and differentiating these symptoms from the symptoms of other psychiatric disorders revealed better fit than one-factor models. Symptoms of RAD and DSED defined two distinct latent groups in a profile analysis. The prevalence of RAD was 9% (95% CI 6–11%), and the prevalence of DSED was 8% (95% CI 5–11%). RAD and DSED are two distinct latent factors not accounted for by other common psychiatric disorders in adolescence. RAD and DSED are not uncommon among adolescents in residential youth care and therefore warrant easy access to qualified health care and prevention in high-risk groups. Electronic supplementary material The online version of this article (10.1007/s00787-019-01456-9) contains supplementary material, which is available to authorized users.

This chapter illustrates how the EBP practice decision-making process is undertaken in work with Sally, a 12-year-old biracial girl whose adoptive parents and adoption social worker are concerned about her lack of turning to her parents for nurture when upset and her indiscriminate interactions with other adults. Sally also has both a potential medical issue and a history of serious neglect. Issues of assessment are addressed, and the six steps of the EBP process are each explored in detail. How EBP is done in practice is examined fully as it applies to the specifics of Sally’s, and her parents’, needs and strengths.

Background In DSM 5, three disorders are related to trauma and/or maltreatment: Post-traumatic Stress Disorder (PTSD), Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) but how these disorders relate to each other and to traumatic events is unknown. Objective We examined 1. Prevalence of Potentially Traumatic Events (PTEs) and poly-victimization for youths in foster care. 2. Associations between single/multiple PTEs and PTSD, DSED, and the two symptom-clusters that constitute RAD: Failure to seek/accept comfort (RAD A), and Low social-emotional responsiveness/ emotion dysregulation (RAD B). Participants, setting and methods Foster youth 11–17 years (N = 303) in Norway completed The Child and Adolescent Trauma Screen. Foster parents completed the RAD and DSED Assessment interview. Results Foster youth reported experiencing, on average, 3.44 PTEs each (range 0–15, SD 3.33), and 52.9 % reported PTSD symptoms at or above clinical cut off. The PTE sum score was associated with the latent factors PTSD (r = .66, p

BACKGROUND: Institutional rearing is associated with increased risk for reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). Disorders of attachment involve disturbances in children’s primary caregiving relationships, and are likely to disturb multiple domains of social functioning. OBJECTIVE: To examine associations between signs of RAD and DSED and social functioning in early adolescence. PARTICIPANTS AND SETTING: Our participants were 110 children with a history of institutional rearing and 50 community comparison adolescents from the Bucharest Early Intervention Project, based in Bucharest, Romania. Participants were assessed at age 12 years (M age in years=12.80, SD=0.71). METHOD: Signs of RAD and DSED were obtained through caregiver report. Reports of social functioning were provided by caregivers and teachers. General and specific domains of social functioning were identified using bi-factor modeling. A general social functioning factor and four specific factors were revealed: peer conflict, caregiver views as victim, teacher views as victim, and social competence. RESULTS: Signs of RAD predicted poorer general social functioning (β=−.36, p

Introduction Trauma- and stressor-related disorders (TSRD) is a new category in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ; American Psychiatric Association, 2013). The specific criterion for inclusion in this diagnostic category is the explicit exposure to a traumatic or stressful event. Several disorders have been incorporated into the TSRD category as individuals exhibit a wide range of reactions following trauma. The disorders in this new category are reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorders (ASD), and adjustment disorders. Of these, adjustment disorder, ASD, and PTSD are the most prevalent. In order to qualify for a diagnosis of PTSD, explicit exposure to the most severe stress (PTSD Criterion A) is required, while criteria for diagnosis of an adjustment disorder requires exposure to the least level of stress. Immediately following exposure to a distressing event, a diagnosis of an adjustment disorder or ASD (providing diagnostic criteria are fulfilled) can be established. However, the criterion for ASD is that a short-term reaction that persists from 3 days to 1 month exists. Should symptoms last longer than a month, a diagnosis of PTSD may apply if specific. For the sake of brevity, this chapter will consider only PTSD and ASD. The development of PTSD may occur following exposure to a traumatic event where severe threat or injury occurred. However, a straightforward trajectory does not always exist. For instance, while most people with ASD also develop PTSD, many with PTSD do not initially display ASD (Bryant et al., 2008). Many develop PTSD more than 6 months post-trauma, a phenomenon known as delayed onset PTSD. McFarlane (2010) argues that a key reason for this is the escalating process of increasing sensitisation, which progresses an over-reactivity to subtle environmental cues associated with the trauma. PTSD can present at any age; however, there are separate diagnostic criteria for children under the age of 6 (Scheeringa, Zeanah, & Cohen, 2011). Events that may precipitate PTSD include violent assault, natural disasters, wars, or accidents; for example, direct exposure to natural disasters such as bush fires in Australia (McFarlane, 1990; Parslow, Jorm, & Christensen, 2006) and earthquakes in New Zealand (NZ; Fergusson et al., 2014). Intimate interpersonal violence has the highest reported risk factor for developing PTSD (Forbes et al., 2014). Cumulative stress can also precipitate PTSD.

A systematic review of reactive attachment disorder (RAD)/disinhibited social engagement disorder (DSED) in adolescence highlighted that young people with the disorder had indiscriminate friendliness with difficulties in establishing and maintaining stable relationships. Most reported experiences of rejection. We were struck by similarities between the above and features of emergence of personality disorders (EPD). This feasibility study aimed to determine best ways of recruiting and retaining vulnerable young people and the proportion of participants with RAD/DSED who might have emerging borderline personality disorder (EBPD). Participants were referred to the study by their treating clinicians from local mental health teams. Results showed strong association between RAD/DSED and EBPD. Participant characteristics showed high levels of out of home placements, early termination of school careers, suicide attempts, quasipsychotic symptoms, and multiagency involvements. They experienced the project as an opportunity to talk about relationships and reported that they would like more of this in usual clinical contacts. They all agreed to be contacted for future studies. Previous studies have shown that early detection and treatment of emergent personality traits can alter trajectory. Future research will continue to explore these trajectories, explore detection of vulnerability factors, and evaluate interventions.

This study aimed to investigate the factor structure and external correlates of the constructs Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The following were addressed: First, do our data support the DSM-5 conceptualization of RAD/DSED as two separate constructs? Second, are RAD and DSED distinct from other well-established dimensions of child psychopathology? Third, what are the external correlates of RAD/DSED in this sample? The study sample included 122 foster children aged 6–10 years. Foster parents completed the Strengths and Difficulties Questionnaire (SDQ), and the RAD/DSED-scale from the Developmental and Well-Being Assessment. Child protection caseworkers completed a questionnaire regarding exposure to maltreatment and placement history. Confirmatory factor analysis (CFA) of the RAD/DSED items identified a good fit for a model with a two-factor structure, which is congruent with the DSM-5 definition of RAD and DSED. A new CFA model, which included the RAD and DSED factors together with the four problem factors of the SDQ (emotional, conduct, hyperactivity-inattention, and peer problems), also demonstrated a good fit with our data. RAD and DSED were associated with the SDQ Impact scale and help seeking behavior. This was partly explained by the SDQ externalizing and peer problem subscales. Our findings lend support for the DSM-5 conceptualization of RAD and DSED as separate dimensions of child psychopathology. Thus, the assessment of RAD and DSED provides information beyond other mental health problems. publishedVersion

Recent research has shown high rates of comorbidity between attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) and difficulties regarding differential diagnosis. Unlike those in Western countries, the Japanese ADHD prevalence rate is lower relative to that of ASD. This inconsistency could have occurred because of cultural diversities among professionals such as physicians. However, little is known about attitudes toward ADHD and ASD in non-Western cultural contexts. We conducted two experiments to identify biases in ASD and ADHD assessment. In Study 1, we examined attitudes toward these disorders in medical doctors and mental health professionals, using a web-based questionnaire. In Study 2, medical doctors and clinical psychologists assessed four fictional cases based on criteria for ADHD, ASD, oppositional defiant disorder, and disinhibited social engagement disorder (DSED). Diagnosis of ASD was considered more difficult relative to that of ADHD. Most participants assessed the fictional DSED case as ASD, rather than DSED or ADHD. The results provide evidence that Japanese professionals are more likely to attribute children's behavioral problems to ASD, relative to other disorders. Therefore, Japanese therapists could be more sensitive to and likely to diagnose ASD, relative to therapists in other countries. These findings suggest that cultural biases could influence clinicians' diagnosis of ADHD and ASD.

Trauma occurs when a subject happens to be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence; historical studies raised much interest on the persistent role of past traumatic experiences on people’s current lives. Confrontation with trauma results in the release of important neurochemical factors, capable of compromising subjective integrative capacity and the ordinary process of neurodevelopment. DSM-5 classifies trauma- and stressor-related disorders in a specific chapter that includes the reactive attachment disorder, the disinhibited social engagement disorder, acute stress disorder, the adjustment disorders, and post-traumatic stress disorder.

This chapter reviews trauma-related and neurodevelopmental disorders from a public health perspective, with a particular attention to the epidemiology of trauma exposure and associated mental health conditions. The epidemiologic literature suggests that over half of children will have experienced one or more traumatic events by adolescence and that low socioeconomic status, prior trauma exposure, and mental health conditions consistently increase risk for exposure. A sizeable minority of trauma-exposed youth go on to develop post-traumatic stress disorder, with female gender, low socioeconomic status, more severe exposure, and events involving interpersonal violence increasing the likelihood of this condition. Other trauma-related disorders, including acute stress disorder, bereavement-related disorder, reactive attachment disorder, and disinhibited social engagement disorder, have been relatively less explored in the epidemiologic literature, and thus their prevalence and risk factors are unknown. Neurodevelopmental disorders, including attention deficit hyperactivity disorder and autism spectrum disorder, share symptoms with trauma- and stressor-related disorders and can complicate differential diagnosis, although few population-based studies address this issue. However, epidemiologic studies suggest that neurodevelopmental disorders, already prevalent among children generally, may be (a) more common among children from disadvantaged backgrounds and those exposed to trauma and (b) are highly comorbid with anxiety, depression, and trauma-related conditions. Public health interventions to prevent and mitigate trauma-related and neurodevelopmental disorders, including primary, secondary, and tertiary prevention efforts, are discussed. However, the full mental health impact of trauma exposure on youth has yet to be appreciated, and further research is needed to explore the extent to which trauma-related disorders co-occur with neurodevelopmental disorders in the general population.

Background Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment. Case presentation A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine. Conclusions The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

We examined the associations between attachment-related symptoms (symptoms of reactive attachment disorder (RAD), symptoms of disinhibited social engagement disorder (DSED), and clinging) and later psychological problems among international adoptees. The study population comprised internationally adopted children (591 boys and 768 girls, 6-15 years) from the ongoing Finnish Adoption (FinAdo) study. Data were gathered with self-administered questionnaires both from adoptive parents and from adoptees aged over 9 years. Attachment-related symptoms were measured using of a short (8-item) questionnaire and later behavioral/emotional problems were assessed using the Child Behavior Checklist (CBCL) and the Five to Fifteen (FTF) scale for attention-deficit/hyperactivity disorder (ADHD) symptoms. RAD and DSED symptom subscales were associated with an increased risk of emotional and behavioral problems and ADHD. Especially the mixed type of attachment-related symptoms was strongly associated with later emotional and behavioral problems.

OBJECTIVE: This study included 54-month-old children with a history of institutional care. Our goal was to: (1) examine differences in indiscriminate social behaviors in children with a history of institutional care compared with home-reared children; (2) test whether foster care reduces indiscriminate social behaviors in a randomized controlled trial; and (3) examine early predictors of indiscriminate behaviors. METHODS: Participants were 58 children with a history of institutional care and 31 never-institutionalized control (NIG) subjects enrolled in a randomized controlled trial of foster care for institutional care, assessed from toddlerhood to 54 months. Indiscriminate social behaviors were measured naturalistically by using the Stranger at the Door procedure. RESULTS: In the Stranger at the Door procedure, children with a history of institutional care left with a stranger at higher rates than NIG subjects (33% vs 3.5%; P < .001). Children in the care as usual group left more than NIG subjects (41.9% vs 3.6%; P ≤ .001). The differences between the foster care group (24.1%) and the care as usual group and between foster care group and NIG were not significant. In a logistic regression, early disorganized attachment behaviors, baseline developmental quotient, and caregiving quality after randomization contributed to variance at 54 months. In the same analysis using only children with a history of institutional care, only disorganized attachment contributed significantly to 54-month indiscriminate social behaviors (Exp[B] = 1.6 [95% confidence interval: 1.1–2.5]). CONCLUSIONS: Observed socially indiscriminate behaviors at 54 months were associated with prolonged exposure to institutional care. Young children raised in conditions of deprivation who fail to develop organized attachments as toddlers are at increased risk for subsequent indiscriminate behaviors.

Disinhibited social engagement disorder (DSED) is one of the most intriguing syndromes in child and adolescent psychiatry but also one of the least understood. We know little about its developmental course in different groups of children, so I was delighted to see the incisive longitudinal work from the Bucharest Early Intervention Study by Guyon-Harris and colleagues.1 My own interest in DSED was sparked back in the early 1990s, when a travel bug had taken me to Guatemala and I had found a job in an orphanage. I was also the family doctor to the surrounding villages, in which children were considerably more materially deprived than their peers in the orphanage who had three meals a day, chlorinated running water, and a reliable school. What the orphanage children did not have was family care-instead they experienced rotating shifts of carers, many of whom were travelers like me, some only there for one or two weeks. Prior to my trip, a senior child psychiatrist had armed me with Bowlby's Attachment and Loss2 and a photocopy of the ICD-10 classification of "disinhibited attachment disorder." My dual role in the orphanage soon made it obvious that the social behavior of many of the institutionalized children was grossly different from that of their family-reared peers. Strangers could not walk into the orphanage until they had peeled off the hands of the small children who had crowded them. In contrast, children in local family homes peeked out from behind their mother's skirts-just as John Bowlby had said they would. Indiscriminate behavior was adaptive in the orphanage setting, because otherwise emotionally neglected children received bursts of attunement from whichever carer was available. The same indiscriminate behavior was, however, highly maladaptive outside the orphanage setting, as children would wander off without checking back and put themselves in danger.

High family risk was tested as an impediment to recovery in children exposed to interparental violence (IPV) participating in community-based intervention. Characteristics of IPV were also explored as moderators for the effect of an IPV-focused intervention over a common factors intervention. Baseline, posttest and follow-up measurements of 155 parents and children (aged 6 to 12 years; 55.5% boys) were fitted in a multilevel model. Outcomes were clinical classifications of internalizing and externalizing problems, and posttraumatic stress symptoms. Tested moderators were child maltreatment, symptoms of disordered attachment, parental psychopathology, parenting stress, poverty, and IPV characteristics. Children without symptoms of disinhibited social engagement disorder, children of parents with high levels of psychopathology, and children of parents with high levels of parenting stress showed strongest recovery. Participation in an IPV-focused intervention was not more effective than in a common factors intervention, irrespective of the nature of the IPV. Based on rate of recovery, participation in community-based group interventions does not need to be contraindicated for children facing high family risk after being exposed to IPV, except for children with symptoms of disinhibited social engagement disorder. (PsycINFO Database Record (c) 2014 APA, all rights reserved). Language: en

The Relationship Problems Questionnaire (RPQ) was developed to screen symptoms of the inhibited and disinhibited subtype of reactive attachment disorder (RAD). This study further examines the psychometric properties of the RPQ in children with severe emotional and behavioural problems by testing its measurement invariance across informants and its convergent validity. Parents and teachers of 152 children [mean age (Mage) = 7.92] from 20 schools for special education filled out the RPQ and the Strengths and Difficulties Questionnaire (SDQ). During a home visit in a subsample of 77 children the Disturbances of Attachment Interview (DAI) was administered to the caregiver and the child was observed using an observational schedule for RAD. Exploratory and confirmatory factor analyses revealed the expected two-factor structure for both parent and teacher RPQ. Configural and metric invariance, but no scalar invariance, were obtained across informants. Both RPQ-subscales had acceptable to good internal consistencies and correlated as expected with similar DAI-subscales. Furthermore, the disinhibited RPQ-scale related with observations of the child's approach to a stranger. Finally, significant associations were found between the RPQ and the SDQ. Overall, the RPQ has good psychometric qualities as a multi-informant instrument for RAD-symptoms in children with severe emotional and behavioural problems. Copyright © 2013 John Wiley & Sons, Ltd.

This chapter provides an overview of a disorder newly defined in DSM-5 (APA, 2013), disinhibited social engagement disorder (DSED). This disorder has been recognized and described by various names since at least the mid-twentieth century and defines a pattern of behavior characterized by the absence of developmentally expected reticence in young children about engaging and interacting socially with unfamiliar adults. These defining behaviors have been identified most readily in young children raised in institutions or in those who have been neglected and placed in foster care.

Background DSM-5 Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are rare, understudied, and controversial disorders. Methods Comorbidity in children diagnosed with RAD or DSED was compared with comorbidity in ADHD and autism to determine if RAD/DSED comorbidity differed from that for the two most common disorders in child psychiatric clinics. Samples included 4–17-year-olds, 20 with RAD and/or DSED, 933 with autism, and 895 with ADHD. Children with RAD/DSED were removed from their neglectful environments at a mean of 4 years and were a mean 10 years when studied. Mothers rated the children on the Pediatric Behavior Scale assessing oppositional behavior, conduct problems, ADHD, anxiety, depression, and other symptoms. Results Five of the 20 children with RAD/DSED had DSED without RAD, 15 had RAD with DSED, and none had RAD without DSED. All children with RAD had callous-unemotional traits (CU) and 73% had conduct disorder (CD). No children with DSED-no RAD had CU or CD. Children with RAD + DSED were considerably more impaired than children with DSED-no RAD, autism, and ADHD. Conclusions Findings are consistent with other studies indicating high CD/CU comorbidity in RAD and extreme rarity of RAD without DSED, findings which are not noted in the DSM-5.

Reactive Attachment Disorder (RAD) remains one of the least evidence-based areas of DSM and ICD nosology. Recent evidence from severely deprived institutional samples has informed review of RAD criteria for DSM-V; however, this data is not necessarily generalizable to expectable child environments in the developed world. We provide the first systematic study of this important syndrome in maltreated non-institutionalized adolescents from a high-income country. 153 high-risk adolescents in English out-of-home Looked After Care (LAC: mean age 174 months, SD 23, 52 % male) and 42 low-risk (LR) community controls (mean age 168 months, SD 18, 38 % male) were assessed for RAD behaviors. Data on maltreatment and care history were collected from social work reports and concurrent psychopathology from caregiver report. Triangulated data sources informed independent researcher ratings of adaptive functioning. LAC adolescents showed high prevalence of RAD behaviors. Factor analysis showed four symptom groups; Disinhibited Indiscriminate, Attention Seeking, Superficial Relationships and Unpredictability. RAD was associated with multiple maltreatment experience, earlier entry to care and increased rates of psychopathology. Superficial Relationships and Attention Seeking factors showed strong independent association with particularly pervasive functional impairment. Disinhibited RAD behaviors are identifiable with high prevalence in non-institutionalized high-risk adolescents. They are strongly associated with psychopathology and functional impairment. Retention of this subtype in DSM-V is supported. Findings on the inhibited subtype in adolescence are less persuasive. RAD behavior is a relevant marker of developmental impairment, has significant clinical implications and is deserving of further study within non-institutionalized risk populations.

The authors examined signs of emotionally withdrawn (inhibited type) and indiscriminately social (disinhibited type) reactive attachment disorder in Romanian children enrolled in a randomized trial of foster care compared with institutional care and in a comparison group of never-institutionalized children.At baseline and when children were ages 30, 42, and 54 months and 8 years, caregivers were interviewed with the Disturbances of Attachment Interview to assess changes in signs of reactive attachment disorder in three groups of children: those receiving care as usual (including continued institutional care) (N=68); those placed in foster care after institutional care (N=68); and those who were never institutionalized (N=72). The impact of gender, ethnicity, and baseline cognitive ability was also examined.On the Disturbances of Attachment Interview, signs of the inhibited type of reactive attachment disorder decreased after placement in foster care, and scores were indistinguishable from those of never-institutionalized children after 30 months. Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group. Early placement in foster care (before age 24 months) was associated with fewer signs of the disinhibited type. Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group and more signs of the disinhibited type in both groups.Signs of the inhibited type of reactive attachment disorder responded quickly to placement in foster care; signs of the disinhibited type showed less robust resolution with foster placement. Lower baseline cognitive ability was linked to signs of reactive attachment disorder.

Objective: To develop a brief standardised observational schedule for Reactive Attachment Disorder (RAD) in school-age children to aid clinician recognition of these behaviours. Design: A new structured observational schedule for symptoms of RAD was developed using unstructured observation of children in a clinic waiting room setting. The measure's ability to discriminate between a sample of children with RAD and a normative sample was established by comparing scores in these two groups. Method: Children aged 5-8 years (n = 77 [38 RAD cases and 39 controls]) were observed with their primary caregiver in a standardised waiting room setting. A structured observational tool was developed that tested the reliability, sensitivity and specificity of each item. Results: The schedule has good internal consistency (0.75). The individual items on the observational schedule were predominantly highly discriminatory between cases and comparisons, showing both reasonable sensitivity and excellent specificity. Certain questions were dropped due to poor discrimination and/or poor inter-rater reliability. Conclusion: The 10-item observational schedule for RAD in school-age children provides a promising tool for assessment, although further research will be required to evaluate its ability to discriminate between RAD and other disorders. © 2009 Association for Child and Adolescent Mental Health.

Objective: To explore attachment narratives in children diagnosed with reactive attachment disorder (RAD). Method: We compared attachment narratives, as measured by the Manchester Child Attachment Story Task, in a group of 33 children with a diagnosis of RAD and 37 comparison children. Results: The relative risk (RR) for children with RAD having an insecure attachment pattern was 2.4 (1.4–4.2) but 30% were rated as securely attached. Within the RAD group, children with a clear history of maltreatment were more likely to be Insecure-Disorganised than children without a clear history of maltreatment. Conclusions: Reactive attachment disorder is not the same as attachment insecurity, and questions remain about how attachment research informs clinical research on attachment disorders.

Indiscriminate friendliness is well documented in children adopted internationally following institutional rearing but is less studied in maltreated foster children. Precursors and correlates of indiscriminate friendliness were examined in 93 preschool-aged maltreated children residing in foster care and 60 age-matched, nonmaltreated children living with their biological parents. Measures included parent reports, official case record data, and standardized laboratory assessments. Foster children exhibited higher levels of indiscriminate friendliness than nonmaltreated children. Inhibitory control was negatively associated with indiscriminate friendliness even after controlling for age and general cognitive ability. Additionally, the foster children who had experienced a greater number of foster caregivers had poorer inhibitory control, which was in turn associated with greater indiscriminate friendliness. The results indicate a greater prevalence of indiscriminate friendliness among foster children and suggest that indiscriminate friendliness is part of a larger pattern of dysregulation associated with inconsistency in caregiving.

Postinstitutionalized children frequently demonstrate persistent socioemotional difficulties. For example, some postinstitutionalized children display an unusual lack of social reserve with unfamiliar adults. This behavior, which has been referred to as indiscriminate friendliness, disinhibited attachment behavior, and disinhibited social behavior, was examined by comparing children internationally adopted from institutional care to children internationally adopted from foster care and children raised by their biological families. Etiological factors and behavioral correlates were also investigated. Both groups of adopted children displayed more disinhibited social behavior than the nonadopted children. Of the etiological factors examined, only the length of time in institutional care was related to disinhibited social behavior. Disinhibited social behavior was not significantly correlated with general cognitive ability, attachment-related behaviors, or basic emotion abilities. However, this behavior was negatively associated with inhibitory control abilities even after controlling for the length of time in institutional care. These results suggest that disinhibited social behavior might reflect underlying deficits in inhibitory control.

We investigate the prevalence, specificity and possible aetiology of Disinhibited Attachment Disorder (DAD) in adopted children without a history of institutional care. Sixty children adopted from UK out-of-home care (AD; mean age 102 months, 45 % male); 26 clinic-referred children with externalizing disorder (ED; mean age 104 months, 77 % male) but no history of maltreatment or disrupted care; and 55 matched low-risk comparison controls (LR; mean age 108 months, 49 % male) were assessed for DAD using a triangulation of parent, teacher, and research observations. Maltreatment history and child psychiatric symptoms were obtained from parent report and child language development was assessed. DAD was identified in 49 % of AD, 4 % of ED and 6 % of LR children. Seventy-two percent of AD children had suffered maltreatment. DAD was not associated with degree of risk exposure, demographics, or language. A significant association with ADHD did not explain variance in DAD prevalence across groups. DAD was significantly more common in children first admitted to out-of-home care between 7 and 24 months, independent of maltreatment severity, age at adoption and number of care placements. Implications for developmental theory, adoption policy and clinical application are discussed. Electronic supplementary material The online version of this article (doi:10.1007/s10802-016-0131-2) contains supplementary material, which is available to authorized users.

Purpose– The purpose of this paper is to describe the mental and intellectual developmental status of children with combined intellectual disabilities, reactive attachment disorder (RAD), and/or disinhibited social engagement disorder (DSED), and to describe the presence of comorbid diagnoses.Design/methodology/approach– The study included 55 children that were referred for psychiatric consultation due to low intellectual functioning (borderline or mild; IQ 50-84). Attachment diagnoses were based on the Clinical Observation of Attachment (COA) procedure. Development was measured with the Dutch version of the Vineland Adaptive Behaviour Scales. Psychopathology was measured with the DISC-IV and AUTI-R. Emotional and behavioural problems were measured with the Dutch version of the Developmental Behaviour Checklist.Findings– Children with and without attachment diagnoses had similar IQs. However, children with disturbed attachment, RAD, and/or DSED had lower levels of adaptive behaviour than those without attachment diagnoses. No comorbidity was associated with autism or ADHD. However, 80 per cent of children with RAD and/or DSED were also diagnosed with ADHD. Parents of children with DSED often reported disruptive anti-social behaviour.Practical implications– Children with RAD and/or DSED may have unused developmental potential. Disturbed attachment should be considered in some cases of ADHD.Originality/value– Findings suggested that diagnostic expertise provided added value for distinguishing disordered attachment in young clients with intellectual disability.

Background Despite current interest in attachment disorder, there is concern about its discrimination from other disorders and an unproven assumption of an environmental aetiology. Aims To test whether behaviours suggestive of attachment disorder are distinct from other childhood behavioural and emotional problems and are solely environmentally determined. Method In a community sample of 13 472 twins, we carried out factor analysis of questionnaire items encompassing behaviours indicative of attachment disorder, conduct problems, hyperactivity and emotional difficulties. We used behavioural genetic model-fitting analysis to explore the contribution of genes and environment. Results Factor analysis showed clear discrimination between behaviours suggestive of attachment disorder, conduct problems, hyperactivity and emotional problems. Behavioural genetics analysis suggested a strong genetic influence to attachment disorder behaviour, with males showing higher heritability. Conclusions Behaviours suggestive of attachment disorder can be differentiated from common childhood emotional and behavioural problems and appear to be strongly genetically influenced, particularly in boys. INTRODUCTION TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES There have been recent attempts to codify behaviours associated with early neglect and institutionalisation (Chisolm et al, 1995; Zeanah et al, 2004) into a psychiatric category. Both DSM–IV and ICD–10 describe reactive attachment disorder, with two subtypes encompassing inhibited and disinhibited behaviour (World Health Organization, 1992; American Psychiatric Association, 1994). Questions remain about the nosology of the syndrome beyond age 5 years (American Academy of Child and Adolescent Psychiatry, 2005), therefore we simply refer to ‘attachment disorder behaviours’. We seek to extend the extant literature by testing two hypotheses: first, that the two subtypes are distinct from one another and from other common behavioural and emotional problems in young children, and second that these behavioural patterns are environmentally mediated. We capitalise on a twin study, a design that provides particular leverage in testing environmental hypotheses.

Attachment disorders, specifically Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are disorders associated with neglect and abuse in which people have significant difficulties relating to others. This study aims to explore Attachment Disorder symptoms and diagnoses in young offenders and factors that may be associated with them such as mental health problems. A cross-sectional design was used with 29 young people who were known to Intensive Services, aged 12-17 (M=16.2, SD=1.3), 29 carers and 20 teachers. They completed measures investigating symptoms of Attachment Disorders and psychopathology. Eighty-six percent of the young people had experienced some form of maltreatment and the rates of an actual or borderline Attachment Disorder was 52%. A positive correlation between Attachment Disorder symptoms and other mental health problems (as rated by carer-report Strengths and Difficulties Questionnaire Total Difficulties Score), accounting for 36% of the variance was found, with a large effect size (rs=0.60). Attachment Disorder symptoms were associated with hyperactivity and peer relationship problems.

The great majority of children living in foster or residential care have been abused and neglected. Mental health problems are common and the nature of these problems may be rooted in early attachment relationships. The carers of 82 children in care in Scotland and 125 children from local schools completed questionnaires on mental health problems including Reactive Attachment Disorder. More than half (53%) of the children in care fulfilled criteria for mental health problems compared with 13% of the control group, and children living in care scored significantly higher for conduct problems, emotional problems (anxiety and depression), hyperactivity, problems with peer relations and Reactive Attachment Disorder. This has important implications for service development for this vulnerable group of children.

To determine whether published subtypes of attachment disorder can be reliably identified by trained clinicians reviewing data from high-risk populations and to investigate the relationship between disorder classification and standardized measures of attachment behavior.Twenty or more children aged 18 to 48 months and their primary caregivers were recruited from three sites: a treatment team for maltreated young children (n = 20), a homeless shelter (n = 25), and Head Start centers (n = 24). All dyads completed a semistructured clinical assessment and laboratory and home-based attachment measures.All but one type of attachment disorder could be identified reliably by clinician raters (kappa range = 0.62-0.74, depending on subtype). Children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups (p.001). As predicted, children without an attachment disorder were more likely to be classified as securely attached than those with an attachment disorder (p =.03); however, children classified as having disorganized attachment were not more likely to receive an attachment disorder diagnosis.Attachment disorders can be reliably diagnosed in young children, though research on refining disorder criteria should precede intervention trials.

This paper provides an overview of the largest longitudinal investigation of institutionalized children less than 2 years old ever conducted. The Bucharest Early Intervention Project is an ongoing randomized controlled trial of foster placement as an alternative to institutionalization in abandoned infants and toddlers being conducted in Bucharest, Romania. In addition to describing the contexts in which this study is imbedded, we also provide an overview of the sample, the measures, and the intervention. We hope that the natural experiment of institutionalization will allow us to examine directly the effects of intervention on early deprivation. We hope it will provide answers to many of the critical questions that developmentalists have asked about the effects of early experience, the timing of deprivation, and the ameliorating effects of early intervention and provide clues to which underlying neurobiological processes are compromised by, and resilient to, dramatic changes in early experience.

Child–parent attachment quality with an adoptive caregiver at age 4 years was examined in a sample of 111 children adopted into the United Kingdom following early severe deprivation in Romania and a comparison group of 52 nondeprived within–United Kingdom adoptees. Findings indicated that, compared with nondeprived adoptees, children who experienced early severe deprivation were less likely to be securely attached and more likely to show atypical patterns of attachment behavior; ordinary forms of insecure attachment were not associated with deprivation. Within the sample of deprived adoptees, there was a dose–response association between duration of deprivation and disturbances in attachment behavior. In addition, a minority of children who experienced severe early deprivation were classified as avoidant, secure, or dependent using conventional classification strategies, despite also exhibiting atypical patterns of attachment behaviors, and this was also more likely among children exposed to prolonged deprivation. The results raise both theoretical and methodological implications for attachment research on very deprived children.

Aberrant social behaviors in young children who experience serious neglect have been described for more than half a century and have been used as the basis for defining disorders of attachment. A broad consensus notes two phenotypes in early childhood—one characterized by socially withdrawn behavior and restricted positive affect and the other by disinhibited social behavior and repeated violations of conventional interpersonal boundaries. Reactive attachment disorder seems to be quite responsive to enhanced caregiving environments, although the indiscriminate behavior of disinhibited social engagement disorder persists in some cases even after affected children receive enhanced caregiving. Keywords: psychopathology; attachment; disinhibited social engagement disorder; indiscriminate behavior; parenting; reactive attachment disorder

Objective: To assess convergence among three different measures of indiscriminate behavior and to assess the relationship of indiscriminate behavior to having an attachment figure and to aggressive behavior among young children living in a Romanian institution. Method: Caregivers in the institution were interviewed with semistructured interviews regarding the behavior of 61 children with special emphasis on indiscriminate behavior. The study was conducted in Bucharest, Romania (1999). Results: Substantial convergence among measures of indiscriminate behavior was demonstrated. Indiscriminate behavior was common whether or not these children had a preferred attachment figure. Indiscriminate behavior was independent of aggressive behavior. Conclusions: Differing explanations for indiscriminate behavior in young children derive from differing interpretations of similar findings rather than different findings with different measures. Indiscriminate behavior was largely independent of aggression in these institutionalized young children. Indiscriminate behavior may represent an independent problem rather than a type of reactive attachment disorder as suggested by DSM-IV criteria. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(8):983‐989. Key Words: reactive attachment disorder, disinhibited attachment disorder, indiscriminate behavior, indiscriminate sociability, indiscriminate friendliness.