The document discusses Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED), highlighting their roots in complex trauma and insufficient care, which affect emotional and social behaviors in children. Key features of RAD include withdrawal from caregivers and emotional disturbances, while DSED is characterized by overly familiar behavior with unfamiliar adults. Supportive parenting and environments play a crucial role in helping affected children manage their symptoms and develop healthier attachments.

1. Reactive Attachment Disorder
& Disinhibited Social
Engagement Disorder
Jane F. Gilgun, Ph.D., LICSW
School of Social Work
University of Minnesota, Twin Cities, USA

2. Topics
Reactive Attachment Disorder (RAD)
Disinhibited Social
Engagement Disorder (DSED)

3. “disturbances in the regulation of
affect/emotion are the core deficits
underlying symptomatology related to
traumatic responses or attachment
disturbances” (Hinshaw-Fuselier et al.,
1999, p. 56).

4. Disorganized Attachment,
RAD & DSED
Result from complex trauma
Two or more traumatic events that go
unattended
These children have issues with
Attachment
Executive function
Self-regulation
Neurological changes in brain—synapses
encode schemas/inner working models

5. Children with These
Issues
Can do well when parents
Are emotionally available
Give love and set clear rules
Affirm behaviors they want children to repeat
Give minimal attention to children’s difficult
behaviors
Ensure safety

6. Children with These
Issues
Can do well when
They do not also have fetal alcohol effects,
autism, and other co-occurring conditions
Parents deal well with their own issues
Have good executive function and self-regulation
Can manage own traumas well
Have emotional and instrumental support
Parent support groups
Spend time with others who have common
interests

7. Children with These
Issues
Can do well when
Other people are fair, consistent, loving, and clear
in their expectations
Extended family members
Neighbors
Other children
Teachers
Youth workers
Anyone else who has contact with the children

8. Reactive Attachment Disorder
A. A consistent pattern of inhibited,
emotionally withdrawn behavior toward
adult caregivers, manifested by both of the
following:
The child rarely or minimally seeks comfort
when distressed.
The child rarely or minimally responds to
comfort when distressed.

9. Reactive Attachment
Disorder
B. A persistent social or emotional
disturbance characterized by at least
two of the following:
Minimal social and emotional
responsiveness to others
Limited positive affect

10. Reactive Attachment
Disorder
B. A persistent social or emotional
disturbance characterized by at least two
of the following:
Minimal social and emotional responsiveness
to others
Limited positive affect
Episodes of unexplained irritability, sadness, or
fearfulness that are evident even during
nonthreatening interactions with adult
caregivers.

11. Reactive Attachment
Disorder
C. The child has experienced a pattern of
extremes of insufficient care as evidenced
by at least one of the following:
Social neglect or deprivation in the form of
persistent lack of having basic emotional needs
for comfort, stimulation, and affection met by
caring adults

12. Reactive Attachment
Disorder
Repeated changes of primary caregivers
that limit opportunities to form stable
attachments (e.g., frequent changes in
foster care)
Rearing in unusual settings that severely
limit opportunities to form selective
attachments (e.g., institutions with high
child to caregiver ratios)

13. Reactive Attachment
Disorder
D. The care in Criterion C is presumed to be
responsible for the disturbed behavior in
Criterion A (e.g., the disturbances in Criterion A
began following the lack of adequate care in
Criterion C).
E. The criteria are not met for autism spectrum
disorder.
F. The disturbance is evident before age 5 years.

14. Reactive Attachment
Disorder
G. The child has a developmental age of at
least nine months.
Specify if persistent: The disorder has been
present for more than 12 months.
Specify current severity: Reactive Attachment
Disorder is specified as severe when a child
exhibits all symptoms of the disorder, with each
symptom manifesting at relatively high levels.

15. Disinhibited Social
Engagement Disorder
(DSED0
A. A pattern of behavior in which a child
actively approaches and interacts with
unfamiliar adults and exhibits at least two of
the following:
Reduced or absent reticence in approaching and
interacting with unfamiliar adults.
Overly familiar verbal or physical behavior (that is
not consistent with culturally
.

16. Disinhibited Social
Engagement Disorder (DSED)
A. A pattern of behavior in which a child
actively approaches and interacts with
unfamiliar adults and exhibits at least two
of the following:
Reduced or absent reticence in approaching
and interacting with unfamiliar adults.
Overly familiar verbal or physical behavior
(that is not consistent with culturally
sanctioned and with age-appropriate social
boundaries).

17. Disinhibited Social
Engagement Disorder (DSED)
Diminished or absent checking back with adult caregiver
after venturing away, even
in unfamiliar settings.
Willingness to go off with an unfamiliar adult with minimal
or no hesitation.
B. The behaviors in Criterion A are not limited to
impulsivity (as in ADHD) but include socially disinhibited
behavior.

18.
C. The child has experienced a pattern of
extremes of insufficient care as evidenced by at least
one of the following:
Social neglect or deprivation in the form of persistent
lack of having basic emotional needs for comfort,
stimulation, and affection met by caregiving adults.
Repeated changes of primary caregivers that limit
opportunities to form stable attachments.
Disinhibited Social
Engagement Disorder (DSED)

19.
Disinhibited Social
Engagement Disorder (DSED)
Rearing in unusual settings that severely limit
opportunities to form selective attachments .
The care in Criterion C presumed to be
responsible for disturbed behavior in Criterion A.
The child has a developmental age of at least 9
months.

20. RAD & DSED
Defining feature: “pathogenic care”
Not all children who receive “pathogenic care” have
RAD
RAD is not
Mental retardation
Autism
Fetal alcohol effects
ADHD
Conduct Disorder
Oppositional Defiant Disorder

21. “disturbances in the regulation of
affect/emotion are the core deficits
underlying symptomatology related to
traumatic responses or attachment
disturbances” (Hinshaw-Fuselier et al., 1999,
p. 56).

22. Emotion Regulation
Emotion Regulation: Capacities to
modulate emotional responses in a
range of situations
Teach parents and children methods of
self-regulation

23. References
 American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC:
Author.
 Gilgun, Jane F. (2011). The NEATS: A Child and Family Assessment.
Amazon.
 Heller, Sherryl Scott, Neil W. Boris, Sarah Hinshaw Fuselier, Timoty
Page, Nina Koren-Karie, & Devi Miron (2006). Reactive attachment
disorder in maltreated twins follow-up: From 18 months to 8 years.
Attachment & Human Development, 8(1), 63-86.
 Hinshaw-Fuselier, S., Boris, N. W., & Zeanah, C. Z. (1999). Reactive
attachment disorder in maltreated twins. Infant Mental Health
Journal, 20, 42 – 59.