Module 4 -Disinhibited Social Engagement Disorder and Reactive Attachment

3rd edition as of August 2022

Module Overview

In Module 4, we will discuss matters related to disinhibited social engagement disorder and reactive attachment disorder to include their clinical presentation, prevalence, comorbidity, etiology, assessment, and treatment options. We will also describe attachment and how its disruption affects the development of the two disorders. Be sure you refer to Modules 1-3 for explanations of key terms (Module 1), an overview of the various models to explain psychopathology (Module 2), and descriptions of the various therapies (Module 3).

Module Outline

• 4.1. Clinical Presentation
• 4.2. Prevalence and Comorbidity
• 4.3. Etiology
• 4.4. Assessment and Treatment

Module Learning Outcomes

• Describe how disinhibited social engagement disorder and reactive attachment disorder present.
• Describe the prevalence of disinhibited social engagement disorder and reactive attachment disorder.
• Describe the etiology of disinhibited social engagement disorder and reactive attachment disorder.
• Describe how disinhibited social engagement disorder and reactive attachment disorder are assessed, diagnosed, and treated.

4.1. Clinical Presentation

Section Learning Objectives

• Describe the presentation and associated features of disinhibited social engagement disorder.
• Describe the presentation and associated features of reactive attachment disorder.
• Describe attachment and the impact attachment disruption has on the development of disinhibited social engagement disorder and reactive attachment disorder.

Although we are covering disinhibited social engagement disorder and reactive attachment disorder under the label of “early childhood disorders,” both are technically trauma-related disorders. The reason we are covering them here is because the disorders emerge due to traumatic experiences during early childhood. They do not spontaneously present in late childhood or adulthood.

4.1.1. Clinical Presentation of Disinhibited Social Engagement Disorder

We will explore disinhibited social engagement disorder in terms of: (1) how the child presents and (2) the history of the child.

Let’s start with how the child presents. These children, unlike children with reactive attachment disorder described below, tend to be overly social and interact with complete strangers. The child may walk up to someone in a store they have never met and hug them or even walk away with them. They may do this without ever hesitating when separating from their caregiver and might not even look to check back with their caregiver.

In terms of the history of the child, these children often experience impaired caregiving, which means that the caregiver does not sufficiently care for the child on a consistent basis.  This could result from a child simply not being attended by their caregivers. Perhaps the parent does not interact with them regularly, or the basic needs of the child are not appropriately cared for, such as food, hygiene, and shelter. The child may be in a setting in which there are not enough caregivers to care for them consistently (e.g., an orphanage in which there are only a few caretakers with several infants), or they may not have had one consistent caregiver (e.g., they moved from one foster care setting to another regularly). These situations interrupt the attachment and security of a developing child. It should be noted that the child will have a developmental age of at least 9 months.

Disinhibited social engagement disorder may co-occur with developmental delays such as cognitive and language delays, stereotypies, and other signs of severe neglect. Signs of the disorder often persist even after these other signs of neglect are absent. As such, it is not uncommon for children with disinhibited social engagement disorder to present with no current signs of neglect. The DSM adds that the condition can present in children who show no signs of disordered attachment. “Thus, disinhibited social engagement disorder may be seen in children with a history of neglect who lack attachments or whose attachments to their caregivers range from disturbed to secure” (APA, 2022, pg. 299).

The functional consequences of disinhibited social engagement disorder include impairment of a young child’s abilities to relate interpersonally to adults and peers. Social functioning and social competence may be impaired and there may be increased risk for peer conflicts and victimization.

4.1.2. Clinical Presentation of Reactive Attachment Disorder

We will discuss reactive attachment disorder in much the same way as disinhibited social engagement disorder starting with how the child presents. Children with this disorder typically present as detached from others or emotionally withdrawn. They do not seek comfort from caregivers or respond to physical touch when distressed. These children typically have low levels of expressed emotions, particularly positive emotion. They may experience unexplained irritability, sadness, and fearfulness.

In terms of the history of the child, similarly to disinhibited social engagement disorder, the child will have experienced a pattern of extremes of insufficient care manifested as one of the following: social neglect or deprivation; repeated changes of primary caregivers that restrict their ability to form stable attachments, and/or rearing in unusual settings that do not allow for the formation of attachments. The clinical features of the disorder manifests between the ages of 9 months and 5 years.

Associated features include developmental delays, especially in cognition and language. Reactive attachment disorder impairs a young child’s ability to relate interpersonally to adults or peers and causes functional impairment across many domains of early childhood.

4.1.3. Attachment

Zeanah, Chesher, Boris, and the AACAP CQI (2016) define attachment as a “biologically driven process that results in organization of behaviors in the young child, especially behavior designed to achieve physical proximity to a preferred caregiver when the child is in need of comfort, support, nurturance, or protection (p. 991).” Attachment begins to develop early in infancy, which is recognizable in an infant as early as 7 to 9 months of age. At this age, infants will often show hesitation around unfamiliar adults and become distressed when separated from their caregiver – this is a sign of attachment. If this does not occur, caregivers may become concerned. A child can form attachments with more than one caregiver, however, they have a maximum number of individuals they can do this with. Although attachment begins to form around 7 to 9 months, attachment can occur after this time. Thus, if a child is removed from an impaired caregiving situation and placed in a situation in which he or she receives sensitive, responsive, and consistent care from a caregiver, they may be able to form an attachment appropriately (Zeanah, et al.,  2016). However, if they have tried to attach to multiple individuals, perhaps their ability to fully attach may be compromised.

Mary Salter Ainsworth created the Strange Situation procedure in 1969 to assess attachment. In this procedure, the child experiences separating and reuniting with their primary caregiver. Strangers are also introduced during this procedure. During all trials and interactions, the infant’s reaction is monitored and recorded (Krapp, 2005). In this procedure, the caregiver, baby, and observer first enter a room, then after 30 seconds, the observer leaves, allowing the caregiver and baby to explore the room together. Next, a stranger enters the room quietly, interacts with the caregiver, and approaches the infant as the caregiver leaves. The caregiver will be absent and the stranger will stay with the infant for three minutes. After three minutes, the caregiver comes back, engages with the child, and the stranger leaves. Next, the caregiver says goodbye to the child and leaves the room again for three minutes. At this point, the baby is alone in the room but observed for behaviors and safety through a one-way mirror. The baby is alone for three minutes before the stranger, but not the caregiver, enters the room. After another three minutes, the caregiver returns and the stranger leaves. During each of these variations, the infant’s behaviors are monitored and recorded. Observers will note things such as whether the child moves close to their caregiver, cling to their caregiver, if they ignore either their caregiver or the stranger, if they avoid or reject contact from an adult, if they look around for their caregiver, or if they vocalize or interact across the room with their caregiver or the stranger. The presence or absence of a combination of these behaviors helps determine the child’s attachment style (Krapp, 2005).

When we talk about attachment, we often talk about different attachment styles (Zeanah, Chesher, Boris, and AACP CQI, 2016). Avoidant or resistant attachment is a risk factor for later psychopathology and negative trajectories, whereas secure attachment is a protective factor. During the Strange Situation procedure, a child that is securely attached is likely to explore a room while the caregiver is present, feeling confident that their caregiver will be there to help or support them, if needed. They are also easily calmed by their caregiver when distressed. A child that is avoidant does not seek their caregiver out or utilize their caregiver for soothing. A resistant attachment style may be represented by a child never moving away from their caregiver to explore the room, or a child that is difficult to sooth. Disorganized attachment typically involves patterns of interactions that are not fully described above or are significantly inconsistent. Attachment is considered either secure, avoidant, resistant, or disorganized (Zeanah, et al., 2016).

4.2. Prevalence and Comorbidity

Section Learning Objectives

• Describe the prevalence of disinhibited social engagement disorder and reactive attachment disorder.
• Describe common disorders that are comorbid with disinhibited social engagement disorder and reactive attachment disorder.

4.2.1. Disinhibited Social Engagement Disorder

     4.2.1.1. Prevalence. The prevalence of disinhibited social engagement disorder is largely unknown (APA, 2022) and considered to be extremely rare. The DSM notes that prevalence is up to 2% in low-income community populations in the United Kingdom.

     4.2.1.2. Differential diagnosis. Disinhibited social engagement disorder must be differentiated from ADHD. Unlike ADHD, children with disinhibited social engagement disorder do not show difficulties with either attention or hyperactivity (APA, 2022).

Additionally, the medical condition of Williams syndrome, caused by a partial chromosomal deletion, may mimic disinhibited social engagement disorder symptoms (Zeanah, et al., 2016). These children struggle with social discrimination and tend to be overly approaching to strangers. However, they display this behavior despite not having a history of neglect/trauma symptoms (Zeanah, et. al, 2016). As such, if a child is socially disinhibited, but has no history of neglect, disinhibited social engagement disorder is not the likely diagnosis. In fact, it may be that the behavior is caused by a more medically-based etiology such as Williams syndrome.

     4.2.1.3. Comorbidity. Cognitive and language delays, autism spectrum disorder, as well as stereotypies are often comorbid with disinhibited social engagement disorder. ADHD and externalizing disorders are often comorbid in younger children and in middle childhood (APA, 2022).

4.2.2 Reactive Attachment Disorder

     4.2.2.1. Prevalence. The prevalence of reactive attachment disorder is largely unknown and considered extremely rare.  Young children exposed to severe neglect often present with reactive attachment disorder before being placed in foster care or institutions. Despite this, the disorder is uncommon and occurs in less than 10% of neglected children, even when severe neglect has occurred (APA, 2022).

     4.2.2.2. Differential diagnosis. Due to the significant deficit in emotional-social reciprocity, autism spectrum disorder must be differentiated from reactive attachment disorder. Whether or not a child was neglected, and the presence or absence of restricted or repetitive behaviors/interests, help differentiate the two disorders (APA, 2022). If a child has no history of severe neglect or abuse, the diagnosis of autism spectrum disorder is more likely than reactive attachment disorder. If the child does not have restricted/repetitive behaviors/interests, the child is not likely to be diagnosed with autism spectrum disorder, and as such, deficits in social/emotional reciprocity are more likely to be explained by reactive attachment disorder, particularly if there is a significant neglect/abuse history.

     4.2.2.3. Comorbidity. Cognitive and language delays, severe malnutrition, as well as stereotypies are often comorbid with reactive attachment disorder. There may be a comorbidity with ADHD, though this is not clearly established.

4.3. Etiology

Section Learning Objectives

• Describe environmental causes of disinhibited social engagement disorder and reactive attachment disorder.
• Clarify if there are any genetic causes of either disorder.

4.3.1. Environmental

     4.3.1.1. General. For both disinhibited social engagement disorder and reactive attachment disorder, severe social neglect and impaired caregiving is the overall cause. These experiences disrupt the attachment process during the critical developmental period for a child. This disruption results in behavioral patterns that are problematic, not only in the short-term, but long-term, particularly if no interventions are implemented.

     4.3.1.2. Causes specific to disinhibited social engagement disorder. Some evidence has been presented suggesting that both blunted reward sensitivity and decreased inhibitory control are associated with indiscriminate social behavior. Multiple placement disruptions, a mother with borderline personality disorder, aberrant caregiving behaviors, and low quality of care are also implicated as causes. It should be noted that the disorder may still persist even if the child’s caregiving environment greatly improves.

4.3.2. Genetics and Disinhibited Social engagement Disorder

Some genetic vulnerabilities involving the brain-derived neurotrophic factor and serotonin transporter genes, combined with history of neglect/caregiving, may result in more significant difficulties with social disinhibition (Zeanah, et al., 2016). For example, a child in a foster-care setting that also has a genetic vulnerability may have more significant symptoms of disinhibited social engagement disorder than a child in the same setting without the genetic vulnerability.

4.4. Assessment and Treatment

Section Learning Objectives

• Describe assessment tools commonly used to diagnose disinhibited social engagement disorder and reactive attachment disorder.
• Describe treatment options for disinhibited social engagement disorder and reactive attachment disorder.

4.4.1.  Assessment

Assessment will include a thorough interview with a caregiver. This caregiver may be the biological parent of the child, or a foster parent, social worker, or other relative. An understanding of, not only the child’s history, such as trauma, access to care and nurturing, etc., but also developmental progress and social interactions, are important. An in-depth exploration of how the child responds to support, calming, and nurturing is needed. Moreover, understanding how the child typically reacts to strangers is imperative. Much of this is gained through interviews. However, observation is also important.

Observations may be largely informal. A psychologist may note several behaviors as they occur, such as how the child approaches the psychologist and interacts with them. If the child immediately runs up to the psychologist and wants the psychologist to hold them, that is notable. If the child gets upset in the room, and they do not seek their caregiver out for comfort, or if they reject the caregiver’s attempts to comfort them, that is important. Also, if the caregiver or psychologist praise the child for doing something well, and the child seems to not react or be impacted by the praise, that is also notable.

The psychologist may also choose to implement a more formal observational assessment. Although the most known and validated observational procedure to assess attachment is the Strange Situation procedure, this is typically only conducted in a research setting, and is less commonly used in clinical settings. However, Zeanah, et al. (2016) developed an informal procedure that can be used to obtain qualitative information that does not result in an objective score, necessarily. The authors note that the safety and appropriateness of the child’s current care, living situation, and caregiver relationship should also be examined.

4.4.2. Treatment

Because it is theorized that, due to significant impairment in caregiving, the relationship and attachment between the child and caregiver is damaged, therapies focus on repairing that relationship or establishing a bond between the child and a new caregiver if the offending caregiver is no longer involved in the child’s life. However, it should be noted that little research directly investigates the impact of therapies on these disorders.

A significant goal of therapy is to improve sensitive caregiving from the caregiver. This involves increasing the caregiver’s ability to ‘tune in’ to the child so that they can be particularly responsive and sensitive to the child’s needs. This can be achieved by either (1) working only with the caregiver or (2) by working with the caregiver and the child. Treatment is not typically conducted with only the child because that does not allow a clinician to appropriately address the core concern – attachment (Zeanah, et al., 2016).

     4.4.2.1. Caregiver only treatment.  One of the first things that may occur in therapy is an attempt to (1) understand the relationship between the caregiver and infant and (2) provide support to the caregiver. To help the child and caregiver attach, which is the primary goal of the intervention, the caregiver must be emotionally ready to do so (Zeanah, et al., 2016). In other words, if a caregiver is overwhelmed, frustrated, and defeated, they may not be able to respond consistently and calmly to the child. If they cannot do this, attachment cannot be fostered. As such, the caregiver’s own feelings and reactions must be acknowledged and supported. The therapist may also ask the caregiver to talk about their relationship with the child so that the therapist can examine the parent-child relationship in detail. This will allow the therapist to identify interactions between the parent and child that can be improved. Once the caregiver is emotionally ready, and the therapist understands the relationship between the child and parent, then work on their attachment can occur. Video review or group therapy may occur as well (Zeanah, et al., 2016).

     4.4.2.2. Child-parent dyad treatment. When working with both the child and the caregiver, focus is on the dyad and the emotional interchanges (Zeanah, et al., 2016). Therapy typically starts by focusing on strengths in the relationship and parenting skills. This allows the parent to trust the therapist, for the therapist to build rapport with the caregiver, and to lower defensiveness and feelings of low efficacy. Following this, coaching the caregiver through moments of disengagement or frustration occurs. This may occur through either child-parent psychotherapy or Attachment and Biobehavioral Catch Up (ABC) videotape review and the clinician shaping the caregiver’s responses. ABC targets not only the attachment but the environment the child lives in. The intervention, in addition to building sensitive caregiving, also works to increase the predictability in the child’s environment and to decrease caregiver behaviors that may distress the child (CEBC, 2018, September).

Module Recap

In this module, we learned about disinhibited social engagement disorder and reactive attachment disorder. We discussed the various behaviors and symptoms of both disorders and how they relate to the various presentations. We also learned about attachment styles and how they related to disinhibited social engagement disorder and reactive attachment disorder. We then discussed the prevalence of these disorders, frequently comorbid disorders, and possible causes. We ended on a discussion of how disinhibited social engagement disorder and reactive attachment disorder are assessed and treated.

In our next module we will discuss another category of disorders that appear in infancy and early childhood – feeding disorders.

3rd edition