The course of early disinhibited social engagement among post-institutionalized adopted children

Trauma of separation: the social and emotional impact of institutionalization on children in a post-soviet country

BACKGROUND

In the former Soviet Union (fSU) region, which has the highest rate of institutional care worldwide, 'social orphans' -indigent children who have one or both parents living-are placed in publicly run residential institutions to receive education, food, and shelter. Few studies have focused on understanding the emotional effects of separation and life in an institutional environment on children who grow up with their families.

METHODS

Semi-structured qualitative interviews (N = 47) were conducted with 8- to 16-year-old children with a history of institutional care placement and their parents in Azerbaijan. Semi-structured qualitative interviews were conducted with 8- to 16-year-old children (n = 21) involved in the institutional care system in Azerbaijan and their caregivers (n = 26). Trained interviewers collected narratives about children's experiences prior to being separated from their families while living in an institution, as well as the impact of institutional placement on their emotional well-being. We applied thematic analysis with inductive coding.

RESULTS

Most of the children entered institutions around the school entry age. Prior to entering institutions, children had already experienced disruptions within their family environments and multiple traumatic events, including witnessing domestic violence, parental divorce, and parental substance abuse. Once institutionalized, these children may have had their mental health further impaired by a sense of abandonment, a strictly regimented life, and insufficiencies of freedom, privacy, developmentally stimulating experiences, and, at times, safety.

CONCLUSION

This study illustrates the emotional and behavioral consequences of institutional placement and the need to address accumulated chronic and complex traumatic experiences that occurred before and during institutional placement, which may affect emotion regulation and the familial and social relationships of children who lived in institutions in a post-Soviet country. The study identified mental health issues that could be addressed during the deinstitutionalization and family reintegration process to improve emotional well-being and restore family relationships.

Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) Symptomatology in a High-Risk Clinical Sample

Attachment relationships are broadly considered foundational to child development as such attachment disorders, reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED), pose a severe threat to children's safety and developmental trajectory. This study examined the prevalence of full diagnosis and symptoms of RAD and DSED in a high-risk sample of adopted children (n = 98; mean age: 46.26 months; range: 16.09 months-6.51 years). Consistent with existing literature, a full diagnosis of RAD and DSED was rare, 1% (n = 1) and 8.1% (n = 8), respectively. However, over half of the sample presented with at least one clinically concerning symptom of RAD or DSED. Given the nature of attachment disorders and the level of concern associated with symptoms, these findings emphasize the need for effective mental health screening, sensitivity beyond just a full diagnosis, and early interventions for adopted children.

Neural correlates of face familiarity in institutionalised children and links to attachment disordered behaviour

BACKGROUND

One of the most well-documented sequelae of early maltreatment and institutionalisation is attachment problems, including behaviours under the labels of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). Despite growing evidence of the neurobiological effects of institutionalisation, the neural correlates of these behavioural patterns are largely unknown.

METHODS

The current study examined effects of both institutionalisation in general and attachment disordered behaviour, in particular, on brain-based markers of face processing, in 100 Portuguese children (70 currently institutionalised, 30 continuously raised by their families). Children's neural processing of caregiver's and stranger's faces was assessed with Event-Related Potentials (ERPs).

RESULTS

Compared to children from the community, institutionalised children showed smaller amplitudes in the N170, to both stranger and caregiver faces. Amongst the institutionalised group, living in a setting with a higher children-to-caregivers' ratio was associated with smaller P400 amplitudes. The display of DSED symptoms was associated with a smaller P1 to both faces, as well as a reduced differentiation between faces in P400 amplitudes and smaller P400 to the stranger's face. In contrast, RAD symptoms were not associated with any ERP measures.

CONCLUSIONS

Results replicate previously reported hypoactivation in institutionalised children, in a less-globally deprived setting than past work, indicating that such a pattern is associated with lack of individualised care and increased symptoms of DSED.

Disinhibited social engagement behaviors in young maltreated children: Dysfunctional behavior of biological parents and child attachment

BACKGROUND

Studies on children with disinhibited social engagement behavior (DSEB) and their caregivers have primarily been limited to institution-reared children.

OBJECTIVE

Using a sample of intact parent-child dyads, the current study examined the distinct contributions of dysfunctional (disconnected/extremely insensitive) parental behaviors and type of maltreatment on maltreated children's levels of DSEB. Child time in foster care and quality of attachment to caregiver were taken in account.

PARTICIPANTS

The sample comprised 67 children (1-5 years old) and their biological parent with substantiated maltreatment and recruited through child protective services between the years of 2008 and 2012.

METHODS

Observations of parent-child interactions were collected and child CPS files were consulted.

RESULTS

Results indicate that very few children (4%), in this predominantly neglected sample (79 %), showed high levels of DSEB. Levels of socioeconomic risks, child age, child sex, time in placement, or attachment to caregiver were not significantly related to DSEB. The vast majority of the children developed an insecure attachment to their parent (76 %), especially of the disorganized type (51 %). Finally, beyond neglect, which was no longer associated with DSEB in the final model, we found that the more the parent showed disconnected and extremely insensitive behavior (R² = .10), in particular withdrawn behavior, the more the children exhibited DSEB.

CONCLUSION

Albeit of a small magnitude, we suggest that the quality of parental behavior could play a role in children's development and recovery of DSEB.

Development and Validation of a Measure of Attachment Disorders Based on DSM-5 Criteria: The Early TRAuma-Related Disorders Questionnaire (ETRADQ)

BACKGROUND

A review of the scientific literature showed few valid tools for assessing reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED), two diagnostic entities traditionally grouped under "attachment disorders." The Early TRAuma-related Disorders Questionnaire (ETRADQ), a caregiver report, was developed to assess attachment disorders in school-age children based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth edition criteria. This study sought to validate this instrument.

METHOD

Caregivers of school-age children from the community (n = 578) and caregivers of at-risk children adopted or in out-of-home care (n = 245) completed a sociodemographic questionnaire, the ETRADQ, the Relationship Problem Questionnaire, the RADA (RAD and DSED Assessment) interview, and the Barkley Functional Impairment Scale for Children and Adolescents.

RESULTS

Confirmatory factor analysis of the ETRADQ items supported the expected organization of the measure, that is, two second-order factors and five subfactors: (1) RAD scale (three subscales: Low selective attachment, Low social and emotional responsiveness, Emotional unpredictability) and (2) DSED scale (two subscales: Interactions with unfamiliar adults, Social disinhibition). All scales showed excellent internal consistency, test-retest reliability, convergent validity, and known-group validity.

CONCLUSIONS

Results support the reliability and validity of the ETRADQ.

Early adversity and children's regulatory deficits: Does postadoption parenting facilitate recovery in postinstitutionalized children?

Children reared in orphanages typically experience the lack of stable, reliable caregivers and are at increased risk for deficits in regulatory abilities including difficulties in inhibitory control, attention, and emotion regulation. Although adoption results in a radical shift in caregiving quality, there remains variation in postadoption parenting, yet little research has examined postadoption parenting that may promote recovery in children experiencing early life adversity in the form of institutional care. Participants included 93 postinstitutionalized children adopted between 15 and 36 months of age and 52 nonadopted same-aged peers. Parenting was assessed four times during the first 2 years postadoption (at 2, 8, 16, and 24 months postadoption) and children's regulation was assessed at age 5 (M age = 61.68 months) and during kindergarten (M age = 71.55 months). Multiple parenting dimensions including sensitivity/responsiveness, structure/limit setting, and consistency in routines were examined. Both parental sensitivity and structure moderated the effect of preadoption adversity on children's emotion regulation while greater consistency was associated with better inhibitory control and fewer attention problems. Results support the notion that postadoption parenting during toddlerhood and the early preschool years promotes better regulation skills following early adversity.

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.

Cortisol and Parenting Predict Pathways to Disinhibited Social Engagement and Social Functioning in Previously Institutionalized Children

Previously institutionalized children on average show persistent deficits in physiological and behavioral regulation, as well as a lack of normative reticence towards strangers, or disinhibited social engagement (DSE). Post-adoption parenting, specifically a combination of supportive presence and structure/limit-setting, may protect against DSE over time via better adrenocortical functioning. This study examined the impact of adrenocortical activity and post-adoption parenting on DSE across the first two years post-adoption (age at adoption: 16-36 months) and observed kindergarten social outcomes in previously institutionalized children (n = 94) compared to non-adopted children (n = 52). Path analyses indicated a developmental cascade from institutional care (operationalized as a dichotomous group variable, age at adoption, and months of institutionalization) to blunted adrenocortical activity, increased DSE, and lower kindergarten social competence. Consistent with a permissive parenting style, higher parental support was associated with increased DSE, but only when not accompanied by effective structure/limit-setting. Further, parental structure reduced the association between blunted adrenocortical activity and DSE behaviors.

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.

Affective attunement in peer dyads containing children adopted from institutions

Children who have experienced institutional care early in life tend to show deficits in behavioral and adrenocortical regulation that impact their ability to form friendships and have positive social interactions with peers. Understanding how post-institutionalized children interact with unfamiliar peers and the factors that predict the quality of these interactions may shed light on the processes contributing to the persistent, often increasing social deficits seen in post-institutionalized children. In this study, one child (either post-institutionalized or non-adopted; the "target") interacted with another non-adopted child (the "peer"; N = 58 dyads, M age = 9.65 years) through a series of competitive and cooperative games during which interaction quality and affect of each participant were coded. Three saliva samples were also collected from each participant to measure cortisol production across the session. No group differences in behavior, affect, or cortisol were found. However, non-adopted target children's affect was positively associated with their peers' affect and negatively associated with peers' change in cortisol across the session, while post-institutionalized target children's affect was not associated with their peers' affect or cortisol. Thus, future interventions may want to promote social skills in children exposed to early adversity by focusing on dyadic social contingencies rather than individual behavior.

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.

EARLY MALTREATMENT AND CURRENT QUALITY OF RELATIONAL CARE PREDICT SOCIOEMOTIONAL PROBLEMS AMONG INSTITUTIONALIZED INFANTS AND TODDLERS

The present study is focused on child socioemotional problems 6 months after institutionalization, by considering the putative predictive role of child maltreatment, of developmental functioning at admission and the following months, and of the quality of institutional relational care. Fifty institutionalized infants and toddlers participated in this study. Child developmental functioning (i.e., cognitive, language, and motor development) was assessed at admission to the institution (Wave 0), and 3 (Wave 1) and 6 months (Wave 2) thereafter. The quality of institutional relational care-operationalized in terms of caregivers' sensitivity and cooperation-was measured at Wave 2. Caregivers reported on the presence of disturbed socioemotional behaviors at Wave 2. Child gestational age, birth weight, age, and stunted growth at admission to the institution served as covariates. Results revealed significant associations between socioemotional difficulties and lower levels of motor development at Waves 0 and 1, child maltreatment, and less sensitive caregiving. A logistic regression showed that child maltreatment and caregiver insensitivity were the only significant predictors of disturbed socioemotional functioning by the end of 6 months of institutionalization.

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

OBJECTIVE

Disinhibited social engagement disorder (DSED) is poorly understood beyond early childhood. The course of DSED signs in a sample of children who experienced severe, early deprivation from early childhood to early adolescence was examined using variable-centered (linear mixed modeling) and person-centered (growth mixture modeling) approaches.

METHOD

The study included 124 children with a history of institutional care from a randomized controlled trial of foster care as an alternative to institutional care and 69 community comparison children matched by age and sex. DSED signs were assessed at baseline (mean age 22 months), 30, 42, and 54 months of age, and 8 and 12 years of age using a validated caregiver report of disturbed attachment behavior.

RESULTS

Variable-centered analyses based on intent-to-treat groups indicated that signs of DSED decreased sharply for children randomized to foster care and decreased slightly but remained high for children randomized to care as usual. Person-centered analyses showed 4 profiles (i.e., elevated, persistent modest, early decreasing, and minimal). Elevated and persistent modest courses were associated with greater placement disruptions (F3,99 = 4.29, p = .007, partial eta-squared [η2] = 0.12), older age at placement into foster care (F3,56 = 3.41, p < .05, partial η2 = 0.16), and more time in institutional care (F3,115 = 11.91, p < .001, partial η2 = 0.24) compared with decreasing and minimal courses.

CONCLUSION

Early and sustained placement into families after deprivation is associated with minimal or decreasing signs of DSED across development. Shortening the amount of time children spend in institutions and preserving placements could help decrease signs of DSED into early adolescence in previously institutionalized children.

Adult disinhibited social engagement in adoptees exposed to extreme institutional deprivation: examination of its clinical status and functional impact

BackgroundEarly-life institutional deprivation produces disinhibited social engagement (DSE). Portrayed as a childhood condition, little is known about the persistence of DSE-type behaviours into, presentation during, and their impact on, functioning in adulthood.AimsWe examine these issues in the young adult follow-up of the English and Romanian Adoptees study.MethodA total of 122 of the original 165 Romanian adoptees who had spent up to 43 months as children in Ceauşescu's Romanian orphanages and 42 UK adoptees were assessed for DSE behaviours, neurodevelopmental and mental health problems, and impairment between ages 2 and 25 years.ResultsYoung adult DSE behaviour was strongly associated with early childhood deprivation, with a sixfold increase for those who spent more than 6 months in institutions. However, although DSE overlapped with autism spectrum disorder and attention-deficit hyperactivity disorder symptoms it was not, in itself, related to broader patterns of mental health problems or impairments in daily functioning in young adulthood.ConclusionsDSE behaviour remained a prominent, but largely clinically benign, young adult feature of some adoptees who experienced early deprivation.

Early life adversity during the infant sensitive period for attachment: Programming of behavioral neurobiology of threat processing and social behavior

Animals, including humans, require a highly coordinated and flexible system of social behavior and threat evaluation. However, trauma can disrupt this system, with the amygdala implicated as a mediator of these impairments in behavior. Recent evidence has further highlighted the context of infant trauma as a critical variable in determining its immediate and enduring consequences, with trauma experienced from an attachment figure, such as occurs in cases of caregiver-child maltreatment, as particularly detrimental. This review focuses on the unique role of caregiver presence during early-life trauma in programming deficits in social behavior and threat processing. Using data primarily from rodent models, we describe the interaction between trauma and attachment during a sensitive period in early life, which highlights the role of the caregiver's presence in engagement of attachment brain circuitry and suppressing threat processing by the amygdala. These data suggest that trauma experienced directly from an abusive caregiver and trauma experienced in the presence of caregiver cues produce similar neurobehavioral deficits, which are unique from those resulting from trauma alone. We go on to integrate this information into social experience throughout the lifespan, including consequences for complex scenarios, such as dominance hierarchy formation and maintenance.