Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types

Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, 1440 Canal Street, New Orleans, LA 70112, USA.
Journal of the American Academy of Child and Adolescent Psychiatry (Impact Factor: 7.26). 03/2011; 50(3):216-231.e3. DOI: 10.1016/j.jaac.2010.12.012
Source: PubMed


This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).
As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time.
As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time.
Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.

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Available from: Charles H Zeanah, Oct 06, 2015
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    • "Similarly, signs of DSED in the same study were concurrently associated with lack of socialemotional competence at 30 and 42 months and with functional impairment at 54 months. Signs of DSED at 42 months predicted impairment at 54 months, but signs at 22 months and 30 months did not (Gleason et al., 2011). The peer relational abnormalities in adolescents in the Tizard study also reflect functional impairment associated with indiscriminate behavior (Hodges & Tizard, 1989). "
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    ABSTRACT: Background Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions.Methods We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms ‘reactive attachment disorder,’ ‘attachment disorder,’ ‘indiscriminate behavior,’ ‘indiscriminate friendliness,’ ‘indiscriminate socially disinhibited reactive attachment disorder,’ ‘disinhibited social engagement disorder,’ and ‘disinhibited social behavior.’ We also contacted investigators who have published on these topics.FindingsA growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries.Conclusions Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.
    Journal of Child Psychology and Psychiatry 10/2014; 56(3). DOI:10.1111/jcpp.12347 · 6.46 Impact Factor
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    • "In contrast with hypotheses based on attachment theory and developmental attachment research (e.g., Verschueren et al., 2012), indiscriminately friendly children reported a more positive global self-concept and more relational trust than controls. Though unexpected, given the pathogenic attachment history assumed to be characteristic of indiscriminate friendliness, the higher level of trust is in line with (clinical) observations of indiscriminately friendly children's oversociable behaviors toward interaction partners (Gleason et al., 2011; Rutter et al., 2007). Moreover, it adds to the small-scale qualitative study of Bennett and colleagues (2009), as children who show more indiscriminate friendliness not only appeared to consider trust as an important factor in social relationships, but also were more likely to report trust-related appraisals. "
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    ABSTRACT: Objective: Despite increasing research on indiscriminate friendliness in children, almost no research exists on social-cognitive deficits that are supposed to underlie indiscriminately friendly behavior. In this study, we compared indiscriminately friendly children with controls regarding their perceptions of self, reliability trust in significant others, and perceptions of the teacher-child relationship. Method: Children's perceptions were compared in two samples: a sample of 33 likely cases for disinhibited reactive attachment disorder (RAD) from special education for children with emotional and behavioral disorders (75.76% boys, Mage=8.52, 96.9% Caucasian, 33.3% and 45.5% of their mothers completed primary or secondary education, respectively) was matched on sex, age, and socio-economic status with a sample of 33 controls from general education. Children participated individually in several interviews assessing global and social self-concept, reliability trust in significant others, teacher-child relationship perceptions, and vocabulary. Parents and teachers completed a screening questionnaire for RAD and the Strengths and Difficulties Questionnaire. Results: Likely disinhibited RAD-cases showed more indiscriminate friendliness and more problem behavior in general according to their parents and teachers than controls. Furthermore, likely RAD-cases reported a more positive global self-concept, more reliability trust in significant others, and more dependency in the teacher-child relationship than controls. Conclusions: The results are in line with clinical observations of indiscriminately friendly children and findings in clinical samples of maltreated or attachment disrupted children but contrast hypotheses from developmental attachment research. Further research is needed to explain the more positive perceptions of indiscriminately friendly children.
    Research in Developmental Disabilities 07/2014; 35(11):2802-2811. DOI:10.1016/j.ridd.2014.07.004 · 3.40 Impact Factor
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    • "The inhibited subtype identifies children who have no preferred caregiver, rarely seek comfort in times of stress, show a minimum of positive affection, and/or experience difficulties in the regulation of their emotions. Inhibited symptoms are reported in children that lack selective attachment and symptoms tend to represent disturbances in attachment [3,4]. It has been suggested that the inhibited subtype comprises internalizing behaviors, but the only study that reported correlations between inhibition and internalizing problems was based on a limited number of children [4]. "
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    ABSTRACT: Background Previous DSM-versions recognized an inhibited and a disinhibited subtype of the Reactive Attachment Disorder (RAD). The current DSM-5 distinguishes two different disorders, instead of two subtypes of RAD. This study examined whether a split-up of the subtypes is valid. Method In 126 foster children, attachment disorder symptoms were assessed with the Disturbances of Attachment Interview. Forms of pathogenic care were identified based on dossier analyses. Associations between symptoms of attachment disorder with internalizing and externalizing problems (Child Behavior Checklist and Teacher Report Form) were examined. Results Omnibus tests showed no significant association between type of symptoms and type of pathogenic care. Exploratory analyses did reveal an univariate association between disinhibited symptoms and history of physical abuse. Disinhibited symptoms were associated with more internalizing and externalizing problems (d’s < 0.50). Conclusion The distinction of inhibited and disinhibited subtypes of RAD seems valid regarding their emotional and behavioral correlations. Whereas inhibited symptoms lack a correlation, disinhibited symptoms seem to have an externalizing and internalizing correlation. Trial registration NTR1747
    Child and Adolescent Psychiatry and Mental Health 07/2014; 8(1):21. DOI:10.1186/1753-2000-8-21
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