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

Abstract

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.

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

“…Even so, the RAD symptoms of ambivalence and lack of emotional sensitivity were also seen in the DSED profile, and hypervigilance and negative reunion responses were equally frequent in both profiles. This is consonant with the high correlation found between symptoms of DSED and the RAD B criteria in foster-placed adolescents [8] and may reflect that such potential effects of relational trauma and inadequate developmental support are not specific to RAD but may also co-exist with DSED behaviour in adolescence. Replications are needed (also in young children) before considering possible implications of the RAD/DSED criteria.…”

“…These considerations taken together, adolescents in Norwegian RYC may therefore be considered at increased risk of early adversity compared to foster children in Norway, and the comparability of prevalence rates for these two groups indicates the unlikelihood of RAD/ DSED being over-diagnosed in this study. The preponderance of girls with DSED was surprising, as it is undescribed in previous research in adolescence [6,8,9]. Possible explanations include rater bias, such as primary contacts being more concerned by indiscriminate behaviour in girls than boys, or sample bias, such as gender differences in types and frequencies of adverse experiences [33].…”

“…Although this could be questioned, it is arguably a methodological strength because one of the key questions is whether RAD and DSED, as seen in young children and defined by DSM, also exist in adolescents. After the completion of data collection in the current study, an instrument -the RAD and DSED assessment interview (RADA) [8] was developed by a different research group specifically to assess DSM-5-defined RAD and DSED in adolescents. Critically, there is substantial overlap between RADA and the measurement of RAD/ DSED as per PAPA, lending support to the age relevance of the items used in the current study.…”

“…Further, most existing research examines young children, and the question of whether RAD and DSED diagnoses should be reserved for the youngest or whether they also apply to older children and adolescents has been raised [1,2,5]. Although there is growing evidence that RAD and DSED symptoms may persist into adolescence and early adulthood [5][6][7][8][9], controversy remains regarding their diagnostic classification. Whereas some denominate RAD and DSED as valid diagnostic constructs in adolescence, others question whether symptoms of RAD and DSED may then be better conceptualized as more common psychiatric disorders [2,10].…”

“…This distinction between RAD and DSED is well founded in young children [3,25,27] and is evident in school-aged children [11,28]. Although less studied in adolescence, confirmatory factor analysis (CFA) has revealed a clear distinction between RAD and DSED in foster care adolescents [8]. Therefore, we hypothesize that symptoms of RAD and DSED in adolescents living in residential youth care (RYC) will form two definite clusters, assessed both with a dimensional factor analytic approach and a categorical/typological latent profile approach.…”