Children with disinhibited social engagement disorder show reduced reticence with strangers, do not check back with their caregiver after venturing away, and may willingly leave with an unfamiliar adult. The recent DSM-5 has moved away from an attachment framework to understand disinhibited social engagement behavior (DSEB) due to studies indicating its presence in previously institutionalized children even after these children are adopted and show a selective, more secure attachment with their substitute caregiver (e.g. Chisholm et al., 1998). This meta-analysis aims to clarify the size of the associations between DSEB and attachment insecurity or disorganization. It also examines whether studies effect sizes differ according to various moderators (e.g., child age, type of attachment and DSEB measures). The results (k = 24) showed that the associations between DSEB and attachment insecurity (d = 0.48) or attachment disorganization (d = 0.47) were of small magnitude. There were no publication biases. As for moderator analyses on both attachment insecurity and disorganization, the effect sizes in studies using DSEB observational measures (respectively d = 0.63 and 0.57) were of moderate magnitude and stronger than those in studies not using an observational component (respectively d = 0.28 and 0.32). Given these small-to-moderate associations, attachment can be considered a relationship process associated with DSEB, and attachment-informed interventions could be potential tools to reduce DSEB in children. Nevertheless, given the sizable unshared portion of variance between DSEB and child attachment, future studies should examine other variables related to caregiving and noncaregiving contexts to further understand DSEB.
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Ainsworth, M. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: a psychological study of the strange situation. Oxford, England: Erlbaum.
Allen, B. (2011). The use and abuse of attachment theory in clinical practice with maltreated children, part I: Diagnosis and assessment. Trauma, Violence, & Abuse, 12(1), 3–12.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5e ed.). Washington, DC: Author.
Borenstein, M., Hedges, L. V., Higgins, J. P., & Rothstein, H. R. (2009). Introduction to Meta-Analysis. United States: Wyley.
Boris N.W., Hinshaw-Fuselier S.S., & Smyke A.T. (2004) Comparing criteria for attachment disorders: Establishing reliability and validity in high-risk samples. Journal of the American academy of child & adolescent psychiatry,43, 568–577.
Bruce, J., Tarullo, A. R., & Gunnar, M. R. (2009). Dishinhibited social behaviour among internationally adopted children. Development and Psychopathology, 21, 157–171. https://doi.org/10.1017/S0954579409000108
Chisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Development, 69, 1092–1106.
Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.
Cyr, C., Euser, E., & Bakermans-Kranenburg, & M.J., & van IJzendoorn, M.H. (2010). Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses. Development and Psychopathology, 22, 87–208.
De Schipper, J. C., Oosterman, M., & Schuengel, C. (2012). Temperament, disordered attachment, and parental sensitivity in foster care: differential findings on attachment security for shy children. Attachment & Human Development, 14, 349–365. https://doi.org/10.1080/14616734.2012.691651
*Delbarre, M. (2017). Comportements d’attachement et de désinhibition sociale d’enfants consultant en pédopsychiatrie : lien avec des caractéristiques maternelles. (Doctoral dissertation, Université du Québec à Trois-Rivières, Canada). Retrieved from https://papyrus.bib.umontreal.ca/xmlui/bitstream/handle/1866/20485/Delbarre_Marthe_2017_memoire.pdf?sequence=6
*Dobrova-Krol, N. A., Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., & Juffer, F. (2010). The importance of quality of care: Effects of perinatal HIV infection and early institutional rearing on preschoolers attachment and indiscriminate friendliness. Journal of Child Psychology and Psychiatry, 51, 1368–1376. https://doi.org/10.1111/j.1469-7610.2010.02243.x
Duval, S., & Tweedie, R. (2000). A nonparametric “trim and fill” method of accounting for publication bias in meta-analysis. Journal of the American Statistical Association, 95, 89–98.
Friedman, N.P., Miyake, A., Young, S.E., DeFries, J.C., Corley, R.P., Hewitt, J.K. (2008). Individual differences in executive functions are almost entirely genetic in origin. Journal of Experimental Psychology: General, 137, 201–225. https://doi.org/10.1037/0096-34184.108.40.206
Gleason, M. M., Fox, N. A., & Drury, S. (2011). Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionall withdrawn/inhibited types. Journal of the American academy of child & adolescent psychiatry, 50(3), 216–231.
Guyon-Harris, K. L., Humphreys, K. L., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2018). Course of disinhibited social engagement disorder from early childhood to early adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 57, 329-335. https://doi.org/10.1016/j.jaac.2018.02.009
Hong, Q.N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M-P, Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, M-C., Vedel, I. (2018) Mixed Methods Appraisal Tool. Retrieved from http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf
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, 675–684. https://doi.org/10.1017/S0954579417000256
Israel, H., & Richter, R. R. (2011). A guide to understanding meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 41, 496–504. https://doi.org/10.2519/jospt.2011.3333
*Kočovská, E., Puckering, C., Follan, M., Smillie, M., Gorski, C., Barnes, J., Wilson, P., Young, D., Lidstone, E., Pritchett, R., Hockaday, H., & Minnis, H. (2012). Neurodevelopmental problems in maltreated children referred with indiscriminate friendliness. Research in Developmental Disabilities, 33, 1560–1565. https://doi.org/10.1016/j.ridd.2012.02.016
Lalande, C., Cyr, C., Dubois-Comtois, K., Losier, V., Paquette, D., & Emery, J. (2012). Les comportements d’attachement indiscriminé chez les enfants de mères adolescentes: étiologie et facteurs de risque. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. https://doi.org/10.1037/a0027426
*Lanctôt, A.S. (2017). Évaluation multiple de l’attachement auprès d’enfants victimes de maltraitance et placés en famille d’accueil. (Doctoral dissertation, Université du Québec à Trois-Rivières, Trois-Rivières, Canada). Retrieved from http://depot-e.uqtr.ca/8047/1/031624601.pdf
Lehmann, S., Monette, S., Egger, H., Breivik, K., Young, D., Davidson, C., & Minnis, H. (2020). Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview. Assessment, 27, 749-765. https://doi.org/10.1177/1073191118797422
Lyons‐Ruth, K. (2015). Commentary: Should we move away from an attachment framework for understanding disinhibited social engagement disorder (DSED)? A commentary on Zeanah and Gleason (2015). Journal of Child Psychology and Psychiatry, 56(3), 223–227. https://doi.org/10.1111/jcpp.12373
Lyons-Ruth, K., Bureau, J.-F., Riley, C. D., & Atlas-Corbett, A. F. (2009). Socially indiscriminate attachment behaviour in the Strange Situation: Convergent and discriminant validity in relation to caregiving risk, later behaviour problems, and attachment insecurity. Development and Psychopathology, 21, 355–372. https://doi.org/10.1017/S0954579409000376
McGoron, L., Gleason, M. M., Smyke, A. T., Drury, S. S., Nelson, C. A., Gregas, M. C., et al. (2012). Recovering from early deprivation: attachment mediates effects of caregiving on psychopathology. Journal of the American academy of child & adolescent psychiatry, 51, 683–693.
McLaughlin, A., Espie, C., & Minnis, H. (2010). Development of a brief waiting room observation for behaviours typical of reactive attachment disorder. Child and Adolescent Mental Health, 15, 73–79 https://doi.org/10.1111/j.1475-3588.2009.00549.x
Minnis, H., Green, J., O’Connor, T. G., Liew, A., Glaser, D., Taylor, E., et al. (2009). An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children. Journal of Child Psychology and Psychiatry, 50, 931–942. https://doi.org/10.1111/j.1469-7610.2009.02075.x
Minnis, H., Rabe-Hesketh, S., & Wolkind, S. (2002). Development of a brief: clinically relevant, scale for measuring attachment disorders. International Journal of Methods in Psychiatric Research, 11, 90–98.
Minnis, H., Reekie, J., Young, D., O’Connor, T., Ronald, A., Gray, A., & Plomin, R. (2007). Genetic, environmental and gender influences on attachment disorder behaviours. British Journal of Psychiatry, 190, 490–495. https://doi.org/10.1192/bjp.bp.105.019745
Moher, D., Liberati, A., Tetzlaff, J., Altman, DG., The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Medicine, 6, e1000097. https://doi.org/10.1371/journal.pmed.1000097
Monette, S., Terradas, M. M., Yan Boudreault, M., Carrier, A., Ruest-Bélanger, A., Robert, A., Archambault, M., Cyr, C., & Couture, S. (2018). Troubles de l’attachement: Validation d’un questionnaire basé sur le DSM-5 [Attachment disorders: Validation of a questionnaire based on DSM-5 criteria], 511–532. https://doi.org/10.3917/enf2.184.0511
Monette, S., Cyr, C., Terradas, M., Couture, S. Minnis, H., Lehmann, S. (2020, in press). Development and validation of a measure of attachment disorders based on DSM-5 criteria: the Early TRAuma-related Disorders Questionnaire (ETRADQ). Asssessment.
O’Connor, T. G., Marvin, R. S., Rutter, M., Olrick, J. T., Britner, P. A., & The English and Romanian (ERA) Study Team. (2003). Child-parent attachment following early institutional deprivation. Development and Psychopathology, 15, 19–38. https://doi.org/10.1017/S0954579403000026
Pears, K. C., Bruce, J., Fisher, P. A., & Kim, H. K. (2010). Indiscriminate friendliness in maltreated foster children. Child Maltreatment, 15, 64–75. https://doi.org/10.1177/1077559509337891
Pritchett, R., Pritchett, J., Marshall, E., Davidson, C., & Minnis, H. (2013). Reactive attachment disorder in the general population: a hidden essence disorder. Scientific World Journal. https://doi.org/10.1155/2013/818157
Pritchett, R., Rochat, T. J., Tomlinson, M., & Minnis, H. (2013). Risk factors for vulnerable youth in urban townships in South Africa: The potential contribution of reactive attachment disorder. Vulnerable Children and Youth Studies, 8, 310–320. https://doi.org/10.1080/17450128.2012.756569
Riley, C., Atlas-Corbett, A., & Lyons-Ruth, K. (2005). Rating of Infant-Stranger Engagement (RISE) coding system. Unpublished Manuscript, Psychiatry Department, Harvard Medical School, Cambridge, USA.
Rutter, M., Colvert, E., Kreppner, J., Beckett, C., Castle, J., Groothues, C., et al. (2007). Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: disinhibited attachment. Journal of Child Psychology and Psychiatry, 48, 17–30. https://doi.org/10.1111/j.1469-7610.2006.01688.x
Schoemaker, N. K., Vermeer, H. J., Juffer, F., Spies, R., van Ee, E., Maras, A., & Alink, L. R. A. (2020). Indiscriminate friendliness in foster children: Associations with attachment security, foster parents’ sensitivity, and child inhibitory control. Developmental Child Welfare, 2, 92–109. https://doi.org/10.1177/2516103220940325
*Schröder, M., Lüdtke, J., Fux, E., Izat, Y., Bolten, M., Gloger-Tippelt, G., Suess, G. J., & Schmid, M. (2019). Attachment disorder and attachment theory—Two sides of one medal or two different coins? Comprehensive Psychiatry, 95.
Smyke, A. T., & Zeanah, C. H. (1999). Disturbances of attachment interview. Unpublished manuscript.
Smyke, A. T., Zeanah, C. H., Fox, N. A., Nelson, C. A., & Guthrie, D. (2010). Placement in foster care enhances quality of attachment among young institutionalized children. Child Development, 81, 212–223. https://doi.org/10.1111/j.1467-8624.2009.01390.x
Tarabulsy, G. M., Pearson, J., Vaillancourt-Morel, M.-P., Bussières, E.-L., Madigan, S., Lemelin, J.-P., Duchesneau, A.-A., Hatier, D.-E., & Royer, F. (2014). Meta-analytic findings of the relation between maternal prenatal stress and anxiety and child cognitive outcome. Journal of Developmental and Behavioral Pediatrics, 35(1), 38–43. https://doi.org/10.1097/DBP.0000000000000003
Thompson, S. G., & Higgins, J. P. T. (2002). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine, 21, 1559–1573. https://doi.org/10.1002/sim.1187
*Van den Dries, L., Juffer, F., van Ijzendoorn, M. H., Bakermans-Kranenburg, M. J., & Alink, L. R. A. (2012). Infants’ responsiveness, attachment, and indiscriminate friendliness after international adoption from institutions or foster care in China: Application of Emotional Availability Scales to adoptive families. Development and Psychopathology, 24(1), 49–64. https://doi.org/10.1017/S0954579411000654
Van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2003). Attachment disorders and disorganized attachment: Similar and different. Attachment & Human Development, 5, 313–320. https://doi.org/10.1080/14616730310001593938
Van IJzendoorn, M. H., Palacios, J., Sonuga‐Barke, E. J. S., Gunnar, M. R., Vorria, P., McCall, R. B., Le Mare, L., Bakermans‐Kranenburg, M. J., Dobrova‐Krol, N. A., & Juffer, F. (2011). Children without permanent parents: Research, practice, and policy: I. Children in institutional care: Delayed development and resilience. Monographs of the Society for Research in Child Development, 76, 8–30. https://doi.org/10.1111/j.1540-5834.2011.00626.x
Waters, E. & Deane, K. (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behaviour in infancy and early childhood. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research. Monographs of the Society for Research in Child Development, 50 (Serial No. 209), 41–65.
Zeanah, C. H., Chesher, T., Boris, N. W., & American Academy of Child and Adolescent Psychiatry Committee on Quality Issues. (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, 990–1003. https://doi.org/10.1016/j.jaac.2016.08.004
Zeanah, C. H., & Gleason, M. M. (2015). Commentary: A response to Lyons-Ruth (2015). Journal of Child Psychology and Psychiatry, 56, 227.
Zephyr, L., Cyr, C., Monette, S., Langlois, V., Cyr-Desautels, L., & Archambault, M. (2020). Disinhibited social engagement behaviors in young maltreated children: dysfunctional behavior of biological parents and child attachment. Child Abuse & Neglect. https://doi.org/10.1016/j.chiabu.2020.104791
This study has obtained the financial support of a scholarship to the first author from the Fonds de recherche du Québec — Société et culture (FRQSC) and the Social Sciences and Humanities Research Council of Canada. Financial support was also provided to the second author by the Canada Research Chairs Program (SSHRC).
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Zephyr, L., Cyr, C., Monette, S. et al. Meta-Analyses of the Associations Between Disinhibited Social Engagement Behaviors and Child Attachment Insecurity or Disorganization. Res Child Adolesc Psychopathol (2021). https://doi.org/10.1007/s10802-021-00777-1
- Child attachment
- Disinhibited social engagement disorder