DB Replies Assignment

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Disinhibited social engagement disorder

Research Question

Should disinhibited social engagement disorder (DSED) be categorized as an attachment disorder?

The researcher questions whether Disinhibited Social Engagement Disorder (DSED) should continue to be categorized as an attachment disorder since it’s separation from Reactive Attachment Disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th edition (APA, 2013).

hypothesis

Disinhibited social engagement disorder symptoms will decrease with parent-child attachment intervention and will increase attachment security, thus being categorized as an attachment disorder

The researcher hypothesizes that DSED symptoms will decrease with parent involvement and participation in the Circle of Security (COS), which is a parent-child attachment intervention (Powell, Cooper, Hoffman, & Marvin, 2014).

Introduction

Dsed is an attachment disorder that has it’s roots in insufficient care, neglect, deprivation, and limited opportunity to form secure attachments with a caregiver

Children with dsed display socially indiscriminate behavior and have no fear of approaching complete strangers and often struggle to understand socially appropriate boundaries

Dsed is present in 20% of post-institutionalized children, and More studies need to be done to understand dsed in other settings

Dsed and reactive attachment disorder (rad) were separated into two separate diagnoses in the dsm-5

Researchers are questioning if dsed should be categorized as an attachment disorder or a disorder of social relatedness due to symptoms of indiscriminate social behavior that can persist in the presence of a secure attachment

DSED was separated from Reactive Attachment Disorder in the DSM-5 and is now a stand-alone diagnosis. This study aims to contribute to the counseling field by gaining increased understanding of DSED and whether a parent-child attachment intervention will reduce symptoms and increase attachment security, indicating that it should remain an attachment disorder. This study will contribute to the counseling profession by increasing awareness of appropriate treatment of DSED and appropriate classification of the diagnosis, potentially assisting adoptive and foster parents to have increased understanding of DSED behaviors, it’s origins, and potential treatment.

Literature review

Lehmann, S., Monette, S., Egger, H., Breivik, K., Young, D., Davidson, C., & Minnis, H. (2018). Development and examination of the reactive attachment disorder and disinhibited social engagement disorder assessment interview. Assessment, 1073191118797422.

Lehmann et al.(2018) conducted a study to create an effective assessment to measure dsed and rad as separate diagnoses that are both associated with extreme pathogenic care. Lehmann et al. (2018) concluded that due to the updated dsm-5 criteria for dsed, this diagnosis should be considered a disorder of social relatedness and should not be categorized as an attachment disorder at all

Lehmann et al. (2018) helped to form an assessment to measure DSED as a separate diagnosis according to DSM-5 (APA, 2013) criteria and in creating this assessment and reviewing the DSED diagnosis criteria stated in the DSM-5 (APA, 2013), he questioned whether DSED ‘is an attachment disorder at all’ and indicated that further studies need to be done now that DSED is a stand-alone diagnosis and researchers should question whether DSED symptoms are attachment based or if these behaviors can be contributed to other criteria.

Literature review

Humphreys, K. L., Nelson, C. A., Fox, N. A., & Zeanah, C. H. (2017). Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care. Development and psychopathology, 29(2), 675-684.

This study examines the effects of dsed beyond adoption and introduction to a secure attachment. The researchers highlight that indiscriminate behavior (DSED) is one of the most persistent social abnormalities of children with pathogenic caregiving, and indicate that more studies need to be done to understand why rad symptoms desist and dsed symptoms persist after a secure family environment is obtained an what risks are presented beyond early childhood

The researchers in this study examine DSED and RAD beyond adoption and in the context of secure attachments, and note that RAD symptoms desist upon formation of secure attachments and indicate that more studies need to be done to understand why DSED symptoms can persist in a secure attachment if it is considered an attachment disorder. The researchers imply that the counseling field needs increased understanding of DSED and how it should be categorized in future diagnostic manuals.

Research gap

Zeanah, Chesher, & Boris (2016) studied Reactive attachment disorder (RAD) and DSED as separate diagnoses that are both the result of insufficient care. This study highlighted that Rad symptoms diminish or disappear when the child is able to form a healthy attachment with a caregiver, however, DSED symptoms may persist in the presence of a healthy and secure attachment. This causes researchers to question if dsed is an attachment disorder or a disorder of social relatedness

Studies of RAD and DSED as separate disorders have caused researchers to begin questioning if DSED is truly an attachment disorder due to the fact that DSED symptoms are able to persist in the presence of a healthy attachment, while RAD symptoms diminish or disappear in the presence of a attachment. RAD and DSED used to be considered one disorder, however, in the most recent DSM-5 (APA, 2013) they were separated and few studies have been done to understand them as independent diagnoses. Researchers indicate that RAD presents as an attachment disorder, but more studies should be done to understand if DSED should remain an attachment disorder.

Population & Sampling

Sample included children with DSED diagnosis and history of childhood adversity

Random selection and assignment of 16 parent-child dyads into control(n=8) and experimental group(n=8)

Participants selected from the Family Based Mental Health services program (FBMHS), a family therapy program for kids who are at risk for out of home placement

Participants were randomly selected from the FBMHS Therapy Program (n=16) and randomly assigned to a control and experimental group. Inclusion criteria for this study consisted of having a DSED diagnosis, participation in FBMHS, and a history of childhood maltreatment and adversity. According to Knight & Tetrault (2017), a distinguishing feature of a true experimental design is random selection and assignment. Exclusion criteria consisted of increased risk for out of home placement. Participants were informed of the study and screened through a brief phone interview to determine eligibility.

Instrumentation

RADA

(Reactive Attachment Disorder and Disinhibited Social Engagement Disorder assessment)

Instrumentation used in this research was the RADA, which is a caregiver interview that measures social discriminate and indiscriminate behaviors (Lehmann et al., 2018). The RADA is the first updated assessment to measure DSED symptoms that address diagnostic criteria for the DSM-5 (APA, 2013; Lehmann et al., 2018). The RADA can be administered as an online questionnaire or in an interview format, and for this study an in-person caregiver interview format was utilized to administer both pre- and posttest assessments. Questions 1-9 from the DSED scale were used for the pre- and post interviews, and participants were able to state whether each DSED symptom listed in the assessment was 1) absent, 2) present, 3) or considered a big problem for the child. The RADA has intraclass correlation between two independent assessors and excellent inter-rater agreement (.94 for DSED) (Archambault et al., 2019).

procedures

Group Comparison experimental design

In-person RADA interview for pre and posttest assessment to measure DSED

Independent variable:

circle of security 20-week intervention

Dependent variable:

Dsed symptoms

This study used a group comparison research design, a between groups pre-test/posttest experimental design with a control group (CG) and experimental group (EG). DSED was assessed in both groups for baseline scores before the introduction of the independent variable. The EG participated in a 20-week counseling intervention called Circle of Security (COS) (Powell et al., 2014). COS is a 20-week parent-child attachment based intervention program that is designed to increase attachment security between a parent and child (Powell et al., 2014). Previous studies have shown reduced problematic behaviors in the child after the 20-week intervention (Huber, McMahon, & Sweller, 2015). Participants completed the 20-week COS intervention with a licensed professional counselor (LPC) who was trained and certified in the COS model, using COS curriculum (Powell et al., 2014).

Analysis

Dependent samples t-test for paired groups

(to measure difference scores from pre- to posttest)

Independent samples t-test

(to compare means of CG and EG to test null hypothesis)

The RADA was administered again to CG and EG post treatment to measure DSED changes within and between groups in order to test the null hypothesis that there will be no change in DSED symptoms. Jackson (2016) indicates that criteria to use a parametric t-test involve the use interval-ratio data, normally distributed data, as well as the use of random sampling and distribution.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author

Archambault, Maude & Monette, Sebastien & Cyr, Chantal & Lehmann, Stine & Minnis, Helen. (2019). Validation of the RADA (Rad and DSED Assessment): A Semi-Structured interview for Attachment Disorders. 10.13140/RG.2.2.26910.89920.

Jackson, S. L. (2016). Research methods and statistics: A critical thinking approach (5th ed.). Boston, MA: Cengage. ISBN: 9781305257795.

Knight, A., & Tetrault, D. (2017). Research and program evaluation key concepts: A study guide. Kona Publishing & Media Group. ISBN: 9781945628245.

Powell, B., Cooper, G., Hoffman, K., & Marvin, B. (2014). The Circle of Security intervention: enhancing attachment in early parent-child relationships. New York, Ny: Guilford Press.

Zeanah, C. H., Chesher, T., Boris, N. W., Walter, H. J., Bukstein, O. G., Bellonci, C., ... & Hayek, M. (2016). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 55(11), 990-1003.