Course of Disinhibited Social Engagement Disorder From Early Childhood to Early Adolescence

Previously institutionalized toddlers' social and emotional competence and kindergarten adjustment: Indirect effects through executive function

Longitudinal multimethod data across three time points were examined to explore the associations between previously institutionalized toddlers' (N = 71; 59% female) socioemotional skills (Time Point 1: 18 months to 3-years-old), executive functioning (i.e., attention, working memory, inhibitory control) in the preschool years (Time Point 2: 2-4-years-old), and adjustment in kindergarten (5-6-years-old). Children were from multiple regions (35% Eastern European, 31% Southeast Asian, 25% African, and 9% Latin American), and 90% of adoptive parents were White from the Midwestern United States. Socioemotional competency at Time Point 1 was associated with fewer attention problems and greater inhibitory control at Time Point 2, which were subsequently associated with more observed social competence, greater observed classroom competence, and less teacher-reported teacher-child conflict in kindergarten. Indirect effects from socioemotional competencies in toddlerhood to kindergarten adjustment via executive functioning during the preschool period emerged. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attachment disorder symptoms in foster children: development and associations with attachment security

BACKGROUND

Children in foster care constitute a risk population for developing symptoms of attachment disorders. However, little is known about the longitudinal course of attachment disorders and their association with attachment security in foster children.

METHOD

This longitudinal study assessed attachment disorder symptoms in a sample of foster children (n = 55) aged 12 to 82 months. Foster parents with a newly placed foster child were assessed at three points during the first year of placement. At all assessment points, the Disturbance of Attachment Interview (DAI; Smyke and Zeanah in Disturbances of attachment interview, Tulane University, New Orleans, 1999) and the Attachment Q-sort (AQS; Waters and Deane in Monogr Soc Res Child Dev 50:41-65, 1985 German version as reported (Schölmerich and Leyendecker in Deutsche Übersetzung des attachment behavior Q-Set, revision 3.2. Unpublished manual, Ruhr University Bochum, Bochum, 1999) were used to investigate the interplay between disorder symptoms and attachment security.

RESULTS

The results revealed that the symptoms of attachment disorders decreased. The decrease was more pronounced for the inhibited than for the disinhibited symptoms with marked changes in the first 6 months of placement. There was a noticeable gender difference in the development with boys showing a more pronounced decrease in inhibited attachment disorder symptoms and a stronger increase of attachment security. After 12 months, no significant gender effects were found. Regarding the association between symptoms of attachment disorders and attachment security, a significant negative correlation between the inhibited attachment disorder symptoms and attachment security was found 12 months after placement.

CONCLUSIONS

Attachment disorder symptoms decreased in the stable foster care environment. Thus, foster care seems to be an effective placement option regarding children's attachment development.

A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation

OBJECTIVE

The Bucharest Early Intervention Project is the first randomized controlled trial of foster care as an alternative to institutional care. The authors synthesized data from nearly 20 years of assessments of the trial to determine the overall intervention effect size across time points and developmental domains. The goal was to quantify the overall effect of the foster care intervention on children's outcomes and examine sources of variation in this effect, including domain, age, and sex assigned at birth.

METHODS

An intent-to-treat approach was used to examine the causal effects of the randomized controlled trial for 136 children residing in institutions in Bucharest, Romania (baseline age, 6-31 months) who were randomly assigned to either foster care (N=68) or care as usual (N=68). At ages 30, 42, and 54 months and 8, 12, and 16-18 years, children were assessed for IQ, physical growth, brain electrical activity (EEG), and symptoms of five types of psychopathology.

RESULTS

Participants provided 7,088 observations across follow-up waves. Children assigned to foster care had better cognitive and physical outcomes and less severe psychopathology than did those who received care as usual. The magnitude of these effect sizes remained stable across development. The foster care intervention most influenced IQ and disorders of attachment/social relatedness.

CONCLUSIONS

Young children benefit from placement in families after institutional care. The benefits of foster care for previously institutionalized children were remarkably stable across development.

The Bucharest Early Intervention Project: Adolescent mental health and adaptation following early deprivation

Over the last 20 years, we have learned much about the extent to which early-life deprivation affects the mental health of children and adolescents. This body of evidence comes predominantly from studies of children raised in institutional care. The Bucharest Early Intervention Project (BEIP) is the only randomized controlled trial designed to evaluate whether the transition to family-based foster care early in development can ameliorate the long-term impact of institutional deprivation on psychopathology during vulnerable developmental windows such as adolescence. In this review, we detail the extent to which early deprivation affects mental health during this period, the capacity of family-based care to facilitate recovery from early deprivation, and the mechanisms underpinning these effects spanning social-emotional, cognitive, stress, and neurobiological domains. We end by discussing the implications and directions for the BEIP and other studies of youth raised in institutions.

Changes in Attachment Disorder symptoms in children internationally adopted and in residential care

BACKGROUND

A high incidence of Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) has been reported for children with experiences of trauma and other forms of adversity.

OBJECTIVE

The present study aims to explore symptoms of RAD and DSED in children in two protection alternatives (international adoption and residential care) after experiences of early adversity.

PARTICIPANTS AND SETTING

The participants were 146 children: 40 children adopted into Spanish families from Russia, 49 children in residential care in Spanish institutions (40.8% in long-term foster centers) and 57 community comparison children.

METHODS

The Relationship Problems Questionnaire was used to explore both RAD and DSED. All adoptive parents and institutional caregivers retrospectively reported the problems at time of placement (Wave 0), as well as the symptoms observed at the time of the study, with children aged 4-8 years old (Wave 1). At this stage, the assessment of the community comparison group was added.

RESULTS

Adopted and children in residential care presented high levels of RAD and DSED symptoms at placement. For adoptees, previous experiences of abuse and neglect were marginally associated with the initial presence of RAD symptoms and a significant recovery was observed after an average of three years in their families, with a certain level of longitudinal continuity between initial and later assessments. In children currently placed in long-term residential centers in Spain, DSED symptoms worsened from W0 to W1.

CONCLUSIONS

Adoption appears to be an effective intervention that promotes recovery of RAD and DSED symptomatology after early adversity, whereas institutionalization causes negative effects.

The expected and the unexpected in recovery and development after abuse and neglect: The role of early foster carer commitment on young children's symptoms of attachment disorders and mental health problems over time

BACKGROUND

Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects.

OBJECTIVE

This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment.

PARTICIPANTS & SETTING

144 children, age 0-5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial.

METHODS

Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data.

RESULTS

Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation.

CONCLUSIONS

This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems.

Autonomic reactivity to social rejection, peer difficulties, and the buffering effects of adolescent friendships following early psychosocial deprivation

Autonomic nervous system reactivity has been posited to be a mechanism contributing to social and emotional problems among children exposed to early adversity. Leveraging data from the Bucharest Early Intervention Project, a longitudinal randomized controlled trial of foster care versus institutional care of abandoned children in Romania, we assessed whether altered sympathetic reactivity to peer rejection feedback in early adolescence mediated the relation between early institutional rearing and peer problems in later adolescence. We also assessed whether adolescent friendship quality or randomized placement in foster care early in life moderated these associations. Participants include 68 institutionalized children randomized to care as usual, 68 institutionalized children randomized to foster care, and 135 never-institutionalized children. At age 12, participants reported friendship quality with respect to a best friend and completed a social rejection task while electrocardiogram and impedance cardiography were recorded. Sympathetic nervous system reactivity to rejection feedback was assessed using preejection period (PEP). At ages 12 and 16, peer problems were reported by parents. Mediation analysis revealed that less PEP reactivity to social rejection at age 12 partially mediated the association between early institutionalization and greater peer problems at age 16. Further moderated mediation analysis revealed that this indirect effect was evidenced among previously institutionalized youths with low, but not high, quality friendships. We did not observe foster care intervention effects. These findings suggest that altered sympathetic reactivity to social rejection might be a mechanism linking early institutionalization to social difficulties into adolescence, however, positive adolescent friendships may buffer these effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cortisol Reactivity and Socially Anxious Behavior in Previously Institutionalized Youth

The current study investigated the association between cortisol stress reactivity to a social stressor and observed socially anxious behaviors both concurrently and over time among previously institutionalized (PI) (N = 132; ages 7-17) youth and a comparison non-adopted (NA) sample (N = 176). Cortisol reactivity was captured during the Trier Social Stress Test for Children (TSST-C; Yim et al., 2015) and youths' social anxiety behaviors were coded during the speech portion of the TSST-C. Autoregressive cross-lagged panel models with structured residuals showed that for PI youth, greater cortisol reactivity predicted increases in socially anxious behavior during the TSST-C across three sessions. However, greater cortisol reactivity was negatively associated with concurrent social anxiety behavior. Thus, increases in cortisol reactivity across adolescence may aid in behavioral control in social situations in the short-term but may exacerbate PI youths' socially anxious behavior over time. No significant associations emerged for NA youth.

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.

Growth in self-regulation over the course of adolescence mediates the effects of foster care on psychopathology in post-institutionalized children: a randomized clinical trial

Children reared in institutions experience severe psychosocial deprivation, with lasting consequences for social and emotional development. This study evaluated growth trajectories of self-regulation from ages 8 to 16 among institutionally-reared children randomized to foster care (foster care group; FCG) or to remain in institutional care (care as usual group; CAUG), compared to a never-institutionalized group (NIG). We then tested a developmental pathway by which growth in self-regulation reduces general psychopathology at 16 for FCG versus CAUG. FCG experienced modest growth in self-regulation over adolescence and "caught up" to NIG by age 16. The beneficial effect of foster care on psychopathology operated through growth in self-regulation; part of this effect was further mediated by reduced peer difficulties for FCG. Findings reveal that the effects of foster care on self-regulation emerge over adolescence and that growth in self-regulation is a mechanism by which foster care mitigates the impact of institutionalization on psychopathology.

Self-esteem in adolescents with reactive attachment disorder or disinhibited social engagement disorder

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.

Long-Term Effects of Institutional Care and Enhanced Attachment Relationships on Close Adolescent Friendships

This study examined whether early institutional rearing and attachment security influence the quality and quantity of friendships at age 16 in 138 participants, including children abandoned to institutions in Bucharest, Romania, who were randomized to care as usual (n = 45, 26 female), or foster care (n = 47, 25 female), and a never-institutionalized group (n = 46, 18 female). Adolescents in the foster care group with secure attachment to their foster mothers at 42 months were comparable to never-institutionalized adolescents in having more friends and more positive behaviors with their friend during dyadic interactions, compared to the foster care group with insecure attachment and care as usual group. Interventions targeting early child-caregiver attachment relationships may help foster the ability to build positive friendships in adolescence.

Social communication deficits following early-life deprivation and relation to psychopathology: a randomized clinical trial of foster care

BACKGROUND

Children reared in institutions experience profound deprivation that is linked to impairments in social communication (SC). However, little is known about the long-term consequences of institutional rearing on SC through adolescence, and how SC deficits relate to broad-spectrum psychopathology. It is also unclear whether early removal from deprivation and placement into socially enriched environments remediates these difficulties.

METHODS

Children reared in Romanian institutions from the Bucharest Early Intervention Project were randomly assigned to care as usual or foster care intervention in early childhood. An age- and sex-matched group of never-institutionalized children was also recruited. SC data from 208 children at age 8 and 129 children at 16 were collected using the Social Communication Questionnaire. Psychopathology was assessed as saved factor scores for general (P) and specific internalizing (INT) and externalizing (EXT) problems. We examined (a) whether institutional rearing is associated with continued SC deficits into adolescence; (b) whether early placement into foster care mitigates risk for SC problems; and (c) associations between SC and psychopathology from middle childhood (age 8) to adolescence (age 16).

RESULTS

Findings suggest that: (a) institutionally-reared children have significantly more SC problems than never-institutionalized children at age 16; (b) children placed into foster care early in life have fewer problems with reciprocal social interaction compared to those with prolonged institutional rearing; and (c) deficits in SC at age 8 partially account for the link between institutional rearing and general psychopathology at age 16.

CONCLUSIONS

Early deprivation is associated with impairments in SC that persist into adolescence, with evidence for the remedial benefit of family-based care in the domain of reciprocal social interaction. Moreover, deficits in SC among ever-institutionalized children in middle childhood may increase the risk of broad-spectrum psychopathology in adolescence, thus providing one putative target for early intervention to safeguard against later psychiatric problems.

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.

Early caregiving quality predicts consistency of competent functioning from middle childhood to adolescence following early psychosocial deprivation

Adverse developmental outcomes for some children following institutional care are well established. Removal from institutional care and placement into families can promote recovery. However, little is known about how positive outcomes are sustained across adolescence among children with histories of severe deprivation. The present study examined the caregiving conditions that are associated with attaining and maintaining competent functioning (i.e., outcomes within typical levels) from middle childhood to adolescence following exposure to early institutional care. The participants included children with and without a history of institutional care who had competence assessed at ages 8, 12, and 16 years across seven domains: family relationships, peer relationships, academic performance, physical health, mental health, substance use (ages 12 and 16 years only), and risk-taking behavior. The participants were grouped based on whether they were always versus not always competent and never versus ever competent at ages 8 through 16 years. Adolescents with a history of institutional care were less likely to be consistently competent than those who were family reared. Among those who were exposed to early institutional rearing, maintaining competent functioning from 8 to 16 years was associated with spending less time in institutions and receiving higher-quality caregiving early in life. Ensuring high quality early caregiving may promote competent functioning following early deprivation.

Early Deprivation Revisited: Contemporary Studies of the Impact on Young Children of Institutional Care

There is clear evidence that early deprivation in the form of early institutional care affects children both immediately and long after they are removed from the institution. This article reviews the modern literature on the impact of institutional care from animal models to longitudinal studies in humans. Importantly, we examine the current understanding of neuroendocrine regulation in the context of early deprivation. We discuss the opportunities and limitations of studying the effects of deprivation in previously institutionalized children, review behavioral findings and related neurobiological studies, and address the physical health ramifications of institutional care. Finally, we touch on future directions for both science and intervention.

Friendship and social functioning following early institutional rearing: The role of ADHD symptoms

Early institutional rearing is associated with increased risk for subsequent peer relationship difficulties, but the underlying mechanisms have not been identified. Friendship characteristics, social behaviors with peers, normed assessments of social problems, and social cue use were assessed in 142 children (mean age = 10.06, SD = 2.02; range 7-13 years), of whom 67 were previously institutionalized (PI), and 75 were raised by their biological families. Anxiety and attention-deficit/hyperactivity disorder (ADHD) symptoms, often elevated among PI children, were examined as potential mediators of PI status and baseline social functioning and longitudinal follow-ups (2 and 4 years later). Twenty-seven percent of PI children fell above the Child Behavior Checklist Social Problems cutoff. An examination of specific social behaviors with peers indicated that PI and comparison children did not differ in empathic concern or peer social approach, though parents were more likely to endorse aggression/overarousal as a reason that PI children might struggle with friendships. Comparison children outperformed PI children in computerized testing of social cue use learning. Finally, across these measures, social difficulties exhibited in the PI group were mediated by ADHD symptoms with predicted social problems assessed 4 years later. These findings show that, when PI children struggle with friendships, mechanisms involving attention and behavior regulation are likely contributors.

Disinhibited Social Engagement Disorder in Early Childhood Predicts Reduced Competence in Early Adolescence

Psychosocial deprivation is associated with the development of socially aberrant behaviors, including signs of disinhibited social engagement disorder (DSED). In longitudinal studies, signs of DSED have been shown to decrease over time, especially as children are removed from conditions of deprivation. What is less clear is whether signs of DSED in early childhood are associated with poorer functioning in early adolescence, including among children who no longer manifest signs of DSED at this age. In a sample of 136 Romanian children from the Bucharest Early Intervention Project (BEIP), who were exposed to early psychosocial deprivation in the form of institutional care, we examined caregiver-reported (ages 30, 42, and 54 months and 12 years) and observer-rated (age 54 months) signs of DSED. Competent functioning in early adolescence (age 12 years) was assessed across seven domains (i.e., family relationships, peer relationships, academic performance, physical health, mental health, substance use, and risk-taking behavior). A diagnosis of DSED in early childhood was associated with reduced competence in early adolescence. Furthermore, this association was significant even when signs of DSED diminished by age 12 years. We conclude that signs of DSED in early life are associated with reduced likelihood of competent functioning many years later in adolescence, even if signs of the disorder remit.

Course of disinhibited social engagement behavior in clinically referred home-reared preschool children

BACKGROUND

Evidence supporting clinical relevance and persistence of disinhibited social engagement behavior (DSEB) pertains mostly to children reared in institutions and foster care. This study examined the course of DSEB in clinically referred home-reared children from early into middle childhood, and associations with neglect/emotional maltreatment, effortful control, Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Autism Spectrum Disorder.

METHODS

Disinhibited social engagement behavior was examined in 124 children (82% boys, M = 4.06 years, SD = 0.89), referred for treatment of emotional and behavioral problems, by use of the Disturbances of Attachment Interview (DAI) with biological parents. Neglect and emotional maltreatment were assessed from case records and effortful control by use of the Child Behavior Questionnaire. At follow-up, on average 4 years later, DSEB was examined by use of DAI as well as two observational ratings: the Stranger at the Door procedure (SatD) and a structured home observation of stranger approach. Psychiatric disorders were assessed by means of the Kiddie-Schedule for Affective Disorders and Schizophrenia.

RESULTS

Persistence of parent-reported DSEB was found in 57% (n = 27) of the children with DSEB at baseline (n = 47). Parent-reported DSEB at follow-up was significantly related to DSEB observed in the SatD (rpb  = .31, p = .001) and to observed stranger approach (rs  = .41, p < .001), but only stranger approach was associated with baseline DSEB. The course of DSEB was not related to neglect/emotional maltreatment, nor to the level of effortful control. There was no association between DSEB and Autism Spectrum Disorder, but course of DSEB was associated with Attention Deficit/Hyperactivity Disorder/Oppositional Defiant Disorder at follow-up (χ2  = 13.08, p = .004).

CONCLUSIONS

Although explanations for the onset and course of DSEB in home-reared children remain elusive, findings suggest that DSEB is part of a complex of clinically significant problem behaviors in referred home-reared preschool children.

Signs of attachment disorders and social functioning among early adolescents with a history of institutional care

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=-0.36, p < .01, 95% confidence interval [CI] [-.33, -.09]) and poorer social competence (β=-0.38, p < .01, 95% CI[-0.05, -.01]) above and beyond time spent in institutional care and placement disruptions. Signs of DSED (β=-0.38, p < .001, 95% CI[-0.49, -.16]) along with placement disruptions (β=-0.22, p < .05, 95% CI[-.29, -.01]) predicted poorer general social functioning above and beyond time spent in institutional care. Signs of DSED predicted higher scores on caregiver views as victim (β = 0.29, p < .05, 95% CI[0.02, 0.14]) and lower scores on social competence (β=-0.29, p < .01, 95% CI[-.06, -.01]) above and beyond time spent in institutional care and placement disruptions.

CONCLUSIONS

Attachment disorder signs in early adolescence are problematic for social functioning, although the manifestation of these social difficulties differs based on whether RAD or DSED signs are present.

What Happens to Disinhibited Social Engagement Disorder Over Time?

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.