TABLE 1.
Study details.
| Authors/Date | Study design | Investigative focus of study | Participants (n, age range, recruitment) | Measures (related to social functioning only | Outcomes (pertaining to social relationships/social function only) | CCAT score |
|---|---|---|---|---|---|---|
| 1. Social competence | ||||||
| Millward et al. (2006) | Quantitative cross sectional | Investigate symptoms of DSEDRAD in children and related outcomes | 82 families of children in foster care, residential care or special education schools, (age range 4–16 years). | Strengths and difficulties questionnaire (SDQ) via parent report. | Children with DSEDRAD symptoms were likely to score highly on all sub‐scales of the SDQ and significantly more poorly than controls. | 29 Moderate |
| Control group: 125 families from local nurseries and schools and 231 families recruited from local general practices, within a similar socio‐economic status, (age range 5–16 years), matched on age and gender. | ||||||
| DSEDRAD symptomology established via the standardised reactive attachment disorders questionnaire (caregiver report). | ||||||
| Pritchett et al. (2013) | Quantitative | To describe the characteristic of children with DSEDRAD | 22 children (6–8 years old) with definite or suspected DSEDRAD from population screening of 1600 children. | Strengths and difficulties questionnaire (SDQ), completed by care givers and teachers. | SDQ: 75% of children with definite or suspected DSEDRAD scored within the abnormal range. | 28 Moderate |
| Symptoms of DSEDRAD were identified via triangulation of standardised measures of caregiver report (relationships problems questionnaire, child and adolescent psychiatric assessment ‐RAD and development and wellbeing assessment) and child observation (waiting room observation). Diagnoses were made using DSM‐IV criteria by clinicians in the research team. | Social skills improvement system which assesses social skills, problem behaviours and academic competence. | SSIS: 10/22 children scored below average, compared to american norms. | ||||
| Giltaij et al. (2016) | Quantitative cross sectional | Tested whether children with RAD or DSED had lower adaptive functioning (which included socialisation) than peers without RAD or DSED. | Total sample of 55 children with intellectual disabilities, mean age 10 years, mean IQ 72.1. | Vineland screener 0–12. | Vineland: DSED & mixed DSED/RAD group scored significantly lower than peers for socialisation. | 28 Moderate |
| 1/55 had DSED symptoms; 6/55 children mixed RAD/DSED. Comparison group, n = 45/55. | The developmental behaviour checklist (DBC) | DBC parent: Mixed DSED/RAD & DSED only group more disruptive and anti‐social behaviour than peers. DBC teacher: More emotional disturbance in children, without DSED or mixed DSED/RAD. | ||||
| DSED & RAD symptoms were based on the list of behavioural signs of disturbed attachment in young children following observation of parent‐child interactions. | ||||||
| Guyon‐Harris, Humphreys, Fox, et al. (2019) | Quantitative, prospective cohort study | Investigated the association between symptoms of DSED in early childhood and social competency in adolescence, across multiple domains. | 136 Romanian children from the bucharest early intervention project (BEIP). | The authors created a composite of competent functioning based on 7 domains (family relationships, peer relationships, academic performance, physical health, mental health, substance use and risky behaviour); information was gathered via items from the following standardised measures: | Children with more symptoms of DSED were significantly less likely to meet threshold for social competency at age 12 years. | 34 High |
| Caregiver reports examined at 4 time points (30, 42 and 54 months and 12 years). | The social skills rating system. | Children who received an early diagnosis of DSED (before 54 months) were significantly less likely to be classified as socially competent. | ||||
| DSED symptoms were investigated via the standardised disturbances of attachment interview at all 4 time points, and stranger at the door observation (age 54 months only) | MacArthur health and behaviour questionnaire (HBQ). | Social competence at 12 years: ‘Never’ group (no DSED symptoms at any time): 58% were socially competent. | ||||
| Youth risk behaviour survey. | ‘Early’ group (DSED diagnosis before 54 months): 28% of children were socially competent. ‘Late’ group (DSED symptoms at 12 years only): 33% were socially competent. 'Persistent’ group: (DSED symptoms at all time points): 0% were socially competent. | |||||
| 2. Peer relationships | ||||||
| Bennet et al. (2009) | Qualitative | Social experiences of disinhibited children. | 8 indiscriminate friendly children (aged 9–14 years, mean 11.5 years), with suspected/confirmed maltreatment history, recruited from clinical services and voluntary organisation for adoptive parents. | Semi‐structured interview with indiscriminate friendliness social scenarios (IPA analysis). | IPA themes: 1. difficulty with concepts of friendships. 2. Exclusion from peer friendships. 3. Need for trust in relationships. 4. parental attempts to instil stranger danger and 5. Kindness as a response from others (seeking kindness and acceptance). | 32 High |
| DSED symptoms were assessed using the standardised relationship problems questionnaire. | ||||||
| Raaska et al. (2012) | Quantitative cross sectional | Bullying or victimisation in DSEDRAD | 364 international adoptees in Finland, ages 9–15 years (mean, 11.6 years) and comparison data of 146,767 children was derived from a large data set collected from Finnish schools. | Five to fifteen questionnaire | Children with mild DSEDRAD more likely to report victimisation. Children with severe DSEDRAD more likely to be both victims and bullies. | 29 moderate |
| Assessments conducted via postal survey (response‐rate 49.4%) | Olweus bully/Victim questionnaire (OBVQ). | Lack of social skills was associated with victimization but not independently from bullying. | ||||
| Symptoms of DSEDRAD were measured via FINADO questionnaire, designed for use within the study. | ||||||
| Kay and Green (2013) | Quantitative cross sectional | Assess DSED behaviours and associated functional impairment.in non‐institutionalised adolescents exposed to early maltreatment or neglect. | 153 adolescents, at high risk of placement breakdown, referred by social workers, were assessed. The mean age was 174 months. | Health of the nation outcome scales for children and adolescents (HoNOSCA). | High risk group: Demonstrated significantly higher total and scale DAWBA‐RAD scores than the low risk group. | 34 High |
| Control group was a low risk community sample in a deprived area, recruited via schools and local youth clubs and mean age was 168 months. | The disinhibited indiscriminate scale (DAWBA‐RAD) was a significant predictor of impaired peer relationships on the HoNOSCA. The superficial relationships item showed the most association with functional impairment. | |||||
| DSED symptoms measured via the standardised development and wellbeing assessment—reactive attachment disorder (DAWBA‐RAD). | ||||||
| Guyon‐Harris, Humphreys, Fox, et al. (2019) | Quantitative cross sectional | Examine associations between signs of DSED and RAD and social functioning in early adolescence. | Post institutionalised children, randomised into a high quality foster care intervention (n = 55) compared to post‐institutionalised children in care as usual (n = 55) and 50 never institutionalised children from the local community. Participants assessed at 12 years. | Peer conflict scale (PCS). | Symptoms of DSED (and not RAD) were associated with greater caregiver perceptions of the child being victimised and were perceived to have greater conflicts in peer relationships. | 35 High |
| Signs of DSED or RAD were measured using the standardised disturbances of attachment interview‐ early adolescence. | MacArthur health and behaviour questionnaire (HBQ). | DSED (and RAD) associated with lower social competency, independent of placement disruption or time in institutional care. | ||||
| Seim et al. (2022) | Quantitative cross sectional | To assess possible co‐occurrence of psychopathology and/or psycho‐social problems in children with DSED, or RAD. | A total sample of 381 adolescents (mean age, 16.7, range 12–20 years) in a group residential setting were assessed and 31 presented with DSED. | Psycho‐social difficulties were assessed via the child behaviour checklist for ages 12–18 years, | Children with DSED had significantly greater number of associated psycho‐social problems than children without DSED, (mean 4.04) and were more likely to be bullied. | High 32 |
| DSED was assessed using the preschool age psychiatric assessment (PAPA) (caregiver report) due to lack of available age appropriate measure and then DSM‐5 criteria applied stringently to determine if symptoms met diagnostic criteria. | In addition, the child and adolescent psychiatric assessment was utilised to assess for ‘exposure to bullying’ (and other psychiatric problems, not relevant to this review). | |||||
| 3. Self‐esteem/Self‐concept | ||||||
| Vervoort et al. (2014) | Cross sectional quantitative | To compare indiscriminately friendly children with controls regarding their perceptions of self, reliability trust in significant others and perceptions of child‐teacher relationship. | 33 likely cases for disinhibited reactive attachment disorder (d‐RAD, DSM‐IV) from special education for children with emotional and behavioural disorders (mean age, 8.52) and 33 controls from general education (mean age, 8.42) (matched by age, sex and socio‐economic status). | Self‐description Questionnaire‐I (SDQ‐I) and the following 2 scales were used: | Perceptions of self‐concept were higher in the d‐RAD group than those of the control. The d‐RAD group also reported more trust in the reliability of significant others but greater conflict with their teachers, despite dependency on the teacher‐child relationship. | 28 moderate |
| DSED symptoms were assessed using the standardised relationship problems questionnaire | The general‐self scale and the peer relations scale. Three domains are assessed: Cognitive competence, physical competence and peer acceptance. | |||||
| Vacaru et al. (2018) | Quantitative cross sectional | To investigate possible associations between disturbed attachment, (DSED & RAD) and self‐concept. | Thirty‐three institutionalised children (Mean age, 9.75, range 4–12 years) participated along with staff working at the institute (caregivers, social workers and teachers). | Self‐concept was assessed via the validated measure, the pictorial scale of perceived competence and social acceptance in young children. | DSED, and RAD, were generally associated with negative perceptions of self‐competence, but self‐perceptions of physical competence were higher than the teachers' perception of their physical competence. | High 33 |
| DSED was assessed via the disturbances of attachment interview (caregiver report) and the behavioural signs of disturbed attachment (observational measure) | ||||||
| Seim et al. (2021) | Cross sectional quantitative | Investigate whether global and domain‐specific self‐esteem among adolescents living in group residential care differs between those with a RAD diagnosis, a DSED diagnosis, or neither RAD nor DSED diagnoses, and with adolescents in the general population. | 306 individuals living in youth residential care in Norway, (mean age, 16.8 years, range, 12–20 years) of which 26 met diagnostic criteria for DSED and 28 RAD. | Self‐perception profile for adolescents (SPPA) measuring global self‐worth and domain‐specific elements of scholastic competence, social acceptance, athletic competence, physical appearance, romantic appeal, and close friends. | Children with DSED demonstrated lower self‐esteem regarding social acceptance compared to both children with RAD and the environmental control, as well as the ‘typical development’ group | 37 High |
| DSED/RAD symptoms were assessed via preschool age psychiatric assessment (PAPA) (caregiver report) due to lack of available age appropriate measure and then DSM‐5 criteria applied stringently to determine if symptoms met diagnostic criteria. | ||||||
| 4. Social interaction | ||||||
| Groark et al. (2011) | Quantitative cross sectional | Assessed caregiver characteristics and child‐caregiver interactions in Latin american institutions. | 3 institutions with 120 children, many of whom were indiscriminately friendly, were included. Age range, from birth to 7 years old (wards had average 8–23 children with some larger). | The caregiver—‐child social/Emotional/Relationship rating scale (CCSERRS): Designed for purposes of measuring child‐carer interactions in institutions. | CCSERRS: Low levels of carer responsiveness and availability to the child were rated, although interactions were more positive during free play and physical caring. Children demonstrated poor responsiveness/anticipation, child directed behaviours and relationship with the caregiver. | 27 moderate |
| Children's problem behaviour scale (CPBS). | CPBS: High levels of indiscriminate friendliness, non‐compliance, provocative interpersonal behaviour and aggression, but little stereotyped self‐stimulation or withdrawn behaviours. | |||||
| Sadiq et al. (2012) | Cross sectional quantitative | Pragmatic language deficits in children with DSEDRAD compared to children with ASD and typically developing children. | 35 children with DSEDRAD (mean age, 6.7, range, 5–8 years); 52 children with autism (mean age, 6.4, range, 5–8 years) and 39 with typical development (TD) (mean age, 6.5, range 5–8 years) verbal IQ was within ‘normal’ range for all 3 groups. | Children's communication checklist (CCC). | CCC: The DSEDRAD and autism groups performed significantly more poorly on all sub‐scales except syntax and speech. | 28 Moderate |
| DSEDRAD group recruited from clinical and social work services, the TD group recruited via their general practitioners, during a previous study. The autism group were recruited from a specialist tier 4 clinic. | The DSEDRAD group performed most poorly in domains use of language in context, rapport and social relationships. | |||||
| Only the DSEDRAD group differed from the TD group on rapport. | ||||||
| Davidson et al. (2023) | Mixed method cross sectional | To determine the outcomes of children with autism, in comparison to children with DSED, on standardised autism measures and a socially challenging behavioural observational assessment called live. | 10 children with autism (no maltreatment history), 8 children with confirmed symptoms of DSED who were either caregiver referred or referred by local mental health service, and 10 typically developing children who were caregiver referred (age range, 5–11 years and groups were matched by age). | Diagnostic interview for social and communication disorders (DISCO): | Disco: Almost all the children with DSED met core criteria for autism on the parent interview. | 30 High |
| DSED symptoms were confirmed via caregiver reports using standardised relationship problems questionnaire and reactive attachment disorder and disinhibited social engagement disorder assessment interview and via observation using the standardised waiting room observation. | Autism diagnostic observational Schedule‐2 (ADOS‐2) | ADOS‐2: 62.5% of children with DSED did not meet diagnostic criteria for autism. But false positive outcomes were found in 3 cases of DSED, who had additional moderate to severe symptoms of ADHD. | ||||
| Live assessment: An unstructured dynamic assessment (2 assessors) designed to increase unpredictability and greater social challenge. | LIVE: The DSED group were more able than children with autism to engage in complex humour, their play was more creative and spontaneous, and children with DSED tended to involve the assessors, even if their interactions were not entirely appropriate. | |||||
| Controlling and/or obsessive behaviours and lack of empathy were noted in both groups. | ||||||
| Sheaffer, Golden, and Averett (2009) | Cross sectional quantitative | Decoding of emotions from facial expressions and paralanguage (intonation patterns) in DSEDRAD | 17 children with DSEDRAD 15 children in foster care, without DSEDRAD recruited by social services, private clinicians and university psychology department; 31 typically developing children recruited via an afterschool organisation and university psychology department (age range 5–19 years). | Diagnostic analysis of nonverbal accuracy (DANVA2): 2 sub‐tests relating to facial expressions, 1 sub‐test relating to child paralanguage and 1 to adult paralanguage. | No significant differences found between groups regarding ability to decode emotions from facial expressions or paralanguage. | 26 Moderate |
Abbreviations: CCAT, Crowe Critical Appraisal Tool; DSED, Disinhibited Social Engagement Disorder; IQ, intelligence quotient; RAD, Reactive Attachment Disorder.