A quick and reliable waiting room checklist for symptoms of disinhibited social engagement disorder

Background: Disinhibited social engagement disorder (DSED) is a psychosocial disorder, associated with child neglect, characterised by indiscriminate friendliness towards strangers. Some behavioural overlap between DSED and autism spectrum disorder (ASD) – a neurodevelopmental condition whose core symptoms include impaired communication – has been observed. Since DSED is associated with a maltreatment history and ASD is not, differential diagnosis is important. We aimed to establish norms and reference ranges for a clinic waiting room checklist (WRO) for the observation of DSED symptoms, and to examine its discrimination between DSED and ASD. Methods: Norms are provided for the WRO based on 56 children aged 5–12 with DSED and 151 typically developing controls, for whom a reference range is also provided. We modified the WRO based on both quantitative examination of discrimination between DSED and ASD ( n = 16) and qualitative observations of typically developing children ( n = 7), children with DSED ( n = 5) and ASD ( n = 6). Results: A WRO score >6 may indicate the need for a multi-informant assessment for DSED. In a waiting room, children from both atypical groups (ASD and DSED) were more likely to approach strangers than controls; however, while children with DSED symptoms appeared to take control of the social aspects of the situation, children with ASD followed a non-social agenda, with the stranger appearing irrelevant. Conclusion: The WRO is an efficient tool that, along with information from parents and teacher, can contribute to clinical decision-making regarding children who have difficulties with social relationships.

A girl without stranger danger

Disinhibited social engagement disorder (DSED) is a rare disorder of childhood affecting a small number of children who experience extreme neglect or abuse in early childhood such as institutional rearing. The characteristic feature of DSED is disinhibited, socially indiscriminate social behavior that begins prior to the age of five years. Children with DSED exhibit reduced reticence in approaching unfamiliar adults, overly familiar behavior, lack of checking back with their caregiver after venturing away, and willingness to leave with an unfamiliar adult. The assessment includes a psychiatric evaluation and observation of how the child interacts with their caregiver and unfamiliar adults. There are no medication treatments for DSED; however, psychiatric comorbidities may benefit from psychopharmacology. The cornerstone of treatment for DSED is providing the child with an emotionally available attachment figure. It may be necessary to limit the child’s exposure to strangers for several months to reduce socially indiscriminate behaviors.

Reactive attachment disorder and disinhibited social engagement disorder in adolescence: co-occurring psychopathology and psychosocial problems

Insufficient care is associated with most psychiatric disorders and psychosocial problems, and is part of the etiology of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). To minimize the risk of misdiagnosis, and aid treatment and care, clinicians need to know to which degree RAD and DSED co-occur with other psychopathology and psychosocial problems, a topic little researched in adolescence. In a national study of all adolescents (N = 381; 67% consent; 12–20 years old; 58% girls) in Norwegian residential youth care, the Child and Adolescent Psychiatric Assessment interview yielded information about psychiatric diagnoses and psychosocial problems categorized as present/absent, and the Child Behavior Check List questionnaire was applied for dimensional measures of psychopathology. Most adolescents with a RAD or DSED diagnosis had several cooccurring psychiatric disorders and psychosocial problems. Prevalence rates of both emotional and behavioral disorders were high in adolescent RAD and DSED, as were rates of suicidality, self-harm, victimization from bullying, contact with police, risky sexual behavior and alcohol or drug misuse. Although categorical measures of co-occurring disorders and psychosocial problems revealed few and weak associations with RAD and DSED, dimensional measures uncovered associations between both emotional and behavioral problems and RAD/DSED symptom loads, as well as DSED diagnosis. Given the high degree of comorbidity, adolescents with RAD or DSED—or symptoms thereof—should be assessed for co-occurring psychopathology and related psychosocial problems. Treatment plans should be adjusted accordingly.

Which biopsychosocial view of mental illness?

Biopsychosocial theories of mental illness claim that biological, psychological, and social factors are all central to every mental illness. This general approach cannot be assessed or employed properly without specifying the precise relation between mental illnesses and these three levels of understanding. This chapter distinguishes disjunctive, causal, explanatory, therapeutic (or treatment), and constitutive (or definitional) versions of biopsychosocial theories. However, all of these claims are uncontroversial and not distinctive of the biopsychosocial approach, except the constitutive claim. That constitutive claim is inaccurate, because almost all mental illnesses are and should be defined by their psychological symptoms instead of their biological or social causes. These lessons are applied to case studies of post-traumatic stress disorder, disinhibited social engagement disorder, obsessive–compulsive disorder, and scrupulosity.

Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence

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.

Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview

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.