Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED)

Reactive Attachment Disorder & Disinhibited Social Engagement Disorder

Jane F. Gilgun, Ph.D., LICSW

School of Social Work

University of Minnesota, Twin Cities, USA

Topics

Reactive Attachment Disorder (RAD)

Disinhibited Social Engagement Disorder (DSED)

“disturbances in the regulation of affect/emotion are the core deficits underlying symptomatology related to traumatic responses or attachment disturbances” (Hinshaw-Fuselier et al., 1999, p. 56).

Disorganized Attachment,RAD & DSED

Result from complex traumaTwo or more traumatic events that go

unattended

These children have issues with AttachmentExecutive function Self-regulation

Neurological changes in brain—synapses encode schemas/inner working models

Children with These Issues

Can do well when parents Are emotionally availableGive love and set clear rulesAffirm behaviors they want children to repeatGive minimal attention to children’s difficult

behaviorsEnsure safety


Can do well whenThey do not also have fetal alcohol effects,

autism, and other co-occurring conditionsParents deal well with their own issues

Have good executive function and self-regulationCan manage own traumas wellHave emotional and instrumental support

Parent support groupsSpend time with others who have common

interests

hParents require a great deal of support


Can do well whenOther people are fair, consistent, loving, and clear

in their expectationsExtended family membersNeighborsOther childrenTeachersYouth workersAnyone else who has contact with the children

hParents require a great deal of support

Reactive Attachment Disorder

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:The child rarely or minimally seeks comfort

when distressed.The child rarely or minimally responds to

comfort when distressed.


B. A persistent social or emotional disturbance characterized by at least two of the following:Minimal social and emotional

responsiveness to othersLimited positive affect


B. A persistent social or emotional disturbance characterized by at least two of the following:Minimal social and emotional responsiveness

to othersLimited positive affectEpisodes of unexplained irritability, sadness, or

fearfulness that are evident even during nonthreatening interactions with adult caregivers.


C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:Social neglect or deprivation in the form of

persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults


Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)

Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)


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

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

F. The disturbance is evident before age 5 years.


G. The child has a developmental age of at least nine months.Specify if persistent: The disorder has been

present for more than 12 months.Specify current severity: Reactive Attachment

Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Disinhibited Social Engagement Disorder

(DSED0A. A pattern of behavior in which a child

actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: Reduced or absent reticence in approaching and

interacting with unfamiliar adults. Overly familiar verbal or physical behavior (that is

not consistent with culturally .

Disinhibited Social Engagement Disorder (DSED)A. A pattern of behavior in which a child

actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: Reduced or absent reticence in approaching

and interacting with unfamiliar adults. Overly familiar verbal or physical behavior

(that is not consistent with culturally sanctioned and with age-appropriate social boundaries).


Diminished or absent checking back with adult caregiver after venturing away, even

in unfamiliar settings. Willingness to go off with an unfamiliar adult with minimal

or no hesitation.

B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD) but include socially disinhibited behavior.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.

Repeated changes of primary caregivers that limit opportunities to form stable attachments.


Disinhibited Social

Engagement Disorder (DSED)Rearing in unusual settings that severely limit

opportunities to form selective attachments .

The care in Criterion C presumed to be responsible for disturbed behavior in Criterion A.

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

RAD & DSEDDefining feature: “pathogenic care”

Not all children who receive “pathogenic care” have RAD

RAD is notMental retardationAutism Fetal alcohol effectsADHDConduct DisorderOppositional Defiant Disorder

“disturbances in the regulation of affect/emotion are the core deficits underlying symptomatology related to traumatic responses or attachment disturbances” (Hinshaw-Fuselier et al., 1999, p. 56).

Emotion Regulation

Emotion Regulation: Capacities to modulate emotional responses in a range of situations

Teach parents and children methods of self-regulation

References American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Gilgun, Jane F. (2011). The NEATS: A Child and Family Assessment. Amazon.

Heller, Sherryl Scott, Neil W. Boris, Sarah Hinshaw Fuselier, Timoty Page, Nina Koren-Karie, & Devi Miron (2006). Reactive attachment disorder in maltreated twins follow-up: From 18 months to 8 years. Attachment & Human Development, 8(1), 63-86.

Hinshaw-Fuselier, S., Boris, N. W., & Zeanah, C. Z. (1999). Reactive attachment disorder in maltreated twins. Infant Mental Health Journal, 20, 42 – 59.

Education

Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED)