Posted: November 9th, 2022

SOCW 6090 Trauma and Comorbidity Discussion

Discussion 2: Trauma and Comorbidity

It is not uncommon for people who experience trauma to use substances to moderate psychological or emotional pain. Trauma can easily add to the strain that people already feel. In this Discussion, you diagnose and plan treatment for the case of Bae.

To prepare: Review the Learning Resources on trauma treatment, including additional resources from the optional resources/media or from the Suggested Further Reading document. Then read the case provided by your instructor for this week’s Discussion.

·

· Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.

· Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.

· Identify the first area of focus you would address as client’s social worker, and explain your specific treatment recommendations. Support your recommendations with research.

· Explain how you would manage client’s diverse needs, including his co-occurring disorders.

· Describe a treatment plan for client, including how you would Assessment his treatment.

Support your post with specific references to the resources. Be sure to provide full APA citations for your references.
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SOCW 6090 Trauma and Comorbidity Discussion

Discussion 2: Trauma and Comorbidity
It is not uncommon for people who experience trauma to use substances to moderate psychological or emotional pain. Trauma can easily add to the strain that people already feel. In this Discussion, you diagnose and plan treatment for a case provided by your instructor (case of Neville find attached). SOCW 6090 Trauma and Comorbidity Discussion

To prepare: Review the Learning Resources on trauma treatment, including additional resources from the optional resources/media or from the Suggested Further Reading document. Then read the case provided by your instructor for this week’s Discussion.

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BY DAY 5
Post a 3- to 5-minute recorded video response in which you address the following (do the transcript):

Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention). Keep in mind a diagnosis covers the most recent 12 months.
Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.
Identify the first area of focus you would address as client’s social worker, and explain your specific treatment recommendations. Support your recommendations with research.
Explain how you would manage client’s diverse needs, including his co-occurring disorders.
Describe a treatment plan for client, including how you would Assessment his treatment.
REQUIRED READINGS

American Psychiatric Association. (2013s). Trauma- and stressor-related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm07

American Psychiatric Association. (2013g). Dissociative disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm08

Powers, A., Fani, N., Cross, D., Ressler, K. J., & Bradley, B. (2016). Childhood trauma, PTSD, and psychosis: Findings from a highly traumatized, minority sample. Child Abuse & Neglect, 58, 111–118.

Schnyder, U., Ehlers, A., Elbert, T., Foa, E. B., Gersons, B. P. R., Resick, P. A., … Cloitre, M. (2015). Psychotherapies for PTSD: What do they have in common? European Journal of Psychotraumatology, 6(1), 281–286. doi:10.3402/ejpt.v6.28186

Smith, J. C., Hyman, S. M., Andres-Hyman, R. C., Ruiz, J. J., & Davidson, L. (2016). Applying recovery principles to the treatment of trauma. Professional Psychology: Research and Practice, 47(5), 347–355. doi:10.1037/pro0000105

REQUIRED MEDIA
U.S. Department of Veterans Affairs. (2017). PE—Prolonged exposure: A safe place. Retrieved from https://www.ptsd.va.gov/apps/AboutFace/therapies/pe.html
Note: On this page, watch the following videos about veteran Frederick M. Gantt’s experience with prolonged exposure therapy for PTSD.

“I had to make a decision”
“What am I running from?”
“I could see it in color”
“The Middle Eastern restaurant”
“I’m in a safe place” SOCW 6090 Trauma and Comorbidity Discussion

OPTIONAL RESOURCES

American Psychiatric Association. (2013m). Other conditions that may be a focus of clinical attention. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.VandZcodes

Goral, A., Lahad, M., & Aharonson-Daniel, L. (2017). Differences in posttraumatic stress characteristics by duration of exposure to trauma. Psychiatry Research, 258, 101–107. doi:10.1016/j.psychres.2017.09.079

Maercker, A., & Hecker, T. (2016). Broadening perspectives on trauma and recovery: A socio-interpersonal view of PTSD. European Journal of Psychotraumatology, 7(1), 1–9. doi:10.3402/ejpt.v7.29303

McHugh, R. K., Gratz, K. L., & Tull, M. T. (2017). The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders. Comprehensive Psychiatry, 78, 107–114. doi:10.1016/j.comppsych.2017.07.011

van der Kolk, B., & Najavits, L. M. (2013). Interview: What is PTSD really? Surprises, twists of history, and the politics of diagnosis and treatment. Journal of Clinical Psychology, 69(5), 516–522. doi:10.1002/jclp.21992

Document: Suggested Further Reading for SOCW 6090 (PDF)
Note: This is the same document introduced in Week 1.

OPTIONAL MEDIA
University at Buffalo School of Social Work (Producer). (2014b). Episode 141— Tara Hughes: Disaster mental health: An emerging social work practice [Audio podcast]. Retrieved from http://www.insocialwork.org/episode.asp?ep=141

University at Buffalo School of Social Work (Producer). (2015). Episode 180—Dr. Howard Lipke: HEArt for veterans: Identifying the hidden emotion [Audio podcast]. Retrieved from http://www.insocialwork.org/episode.asp?ep=180

american_psychiatric_association.__2013m_..docx
goral__a.__lahad__m.____aharonson_daniel__l.__2017_..docx
week_9_the_case_of_neville.pdf
diagnostic_and_statistical_m
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Diagnostic and statistical manual of mental disorders: Dsm-5.
Trauma- and Stressor-Related Disorders

Trauma- and stressor-related disorders include disorders in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion. These include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders. Placement of this chapter reflects the close relationship between these diagnoses and disorders in the surrounding chapters on anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders. SOCW 6090 Trauma and Comorbidity Discussion

Psychological distress following exposure to a traumatic or stressful event is quite variable. In some cases, symptoms can be well understood within an anxiety- or fear-based context. It is clear, however, that many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or fear-based symptoms, the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms. Because of these variable expressions of clinical distress following exposure to catastrophic or aversive events, the aforementioned disorders have been grouped under a separate category: trauma- and stressor-related disorders. Furthermore, it is not uncommon for the clinical picture to include some combination of the above symptoms (with or without anxiety- or fear-based symptoms). Such a heterogeneous picture has long been recognized in adjustment disorders, as well. Social neglect—that is, the absence of adequate caregiving during childhood—is a diagnostic requirement of both reactive attachment disorder and disinhibited social engagement disorder. Although the two disorders share a common etiology, the former is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while the latter is marked by disinhibition and externalizing behavior.

Reactive Attachment Disorder

Diagnostic Criteria 313.89 (F94.1)

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.

A persistent social and 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.

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 (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).

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).

The criteria are not met for autism spectrum disorder.

The disturbance is evident before age 5 years.

The child has a developmental age of at least 9 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.

Diagnostic Features

Reactive attachment disorder is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. Children with reactive attachment disorder are believed to have the capacity to form selective attachments. However, because of limited opportunities during early development, they fail to show the behavioral manifestations of selective attachments. That is, when distressed, they show no consistent effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore, when distressed, children with this disorder do not respond more than minimally to comforting efforts of caregivers. Thus, the disorder is associated with the absence of expected comfort seeking and response to comforting behaviors. As such, children with reactive attachment disorder show diminished or absent expression of positive emotions during routine interactions with caregivers. In addition, their emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained. A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments. For this reason, the child must have a developmental age of at least 9 months.

Associated Features Supporting Diagnosis

Because of the shared etiological association with social neglect, reactive attachment disorder often co-occurs with developmental delays, especially in delays in cognition and language. Other associated features include stereotypies and other signs of severe neglect (e.g., malnutrition or signs of poor care) Smyke et al. 2002; Zeanah et al. 2005.

Prevalence

The prevalence of reactive attachment disorder is unknown, but the disorder is seen relatively rarely in clinical settings. The disorder has been found in young children exposed to severe neglect before being placed in foster care or raised in institutions. However, even in populations of severely neglected children, the disorder is uncommon, occurring in less than 10% of such children Gleason et al. 2011.

Development and Course

Conditions of social neglect are often present in the first months of life in children diagnosed with reactive attachment disorder, even before the disorder is diagnosed. The clinical features of the disorder manifest in a similar fashion between the ages of 9 months and 5 years Gleason et al. 2011; Oosterman and Schuengel 2007; Tizard and Rees 1975; Zeanah et al. 2004. That is, signs of absent-to-minimal attachment behaviors and associated emotionally aberrant behaviors are evident in children throughout this age range, although differing cognitive and motor abilities may affect how these behaviors are expressed. Without remediation and recovery through normative caregiving environments, it appears that signs of the disorder may persist, at least for several years Gleason et al. 2011.

It is unclear whether reactive attachment disorder occurs in older children and, if so, how it differs from its presentation in young children. Because of this, the diagnosis should be made with caution in children older than 5 years. SOCW 6090 Trauma and Comorbidity Discussion

Risk and Prognostic Factors

Environmental. Serious social neglect is a diagnostic requirement for reactive attachment disorder and is also the only known risk factor for the disorder. However, the majority of severely neglected children do not develop the disorder. Prognosis appears to depend on the quality of the caregiving environment following serious neglect Gleason et al. 2011; Smyke et al. 2012.

Culture-Related Diagnostic Issues

Similar attachment behaviors have been described in young children in many different cultures around the world. However, caution should be exercised in making the diagnosis of reactive attachment disorder in cultures in which attachment has not been studied.

Functional Consequences of Reactive Attachment Disorder

Reactive attachment disorder significantly impairs young children’s abilities to relate interpersonally to adults or peers and is associated with functional impairment across many domains of early childhood Gleason et al. 2011.

Differential Diagnosis

Autism spectrum disorder. Aberrant social behaviors manifest in young children with reactive attachment disorder, but they also are key features of autism spectrum disorder. Specifically, young children with either condition can manifest dampened expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. As a result, reactive attachment disorder must be differentiated from autism spectrum disorder. These two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors. Children with reactive attachment disorder have experienced a history of severe social neglect, although it is not always possible to obtain detailed histories about the precise nature of their experiences, especially in initial Assessments. Children with autistic spectrum disorder will only rarely have a history of social neglect. The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder. These clinical features manifest as excessive adherence to rituals and routines; restricted, fixated interests; and unusual sensory reactions. However, it is important to note that children with either condition can exhibit stereotypic behaviors such as rocking or flapping. Children with either disorder also may exhibit a range of intellectual functioning, but only children with autistic spectrum disorder exhibit selective impairments in social communicative behaviors, such as intentional communication (i.e., impairment in communication that is deliberate, goal-directed, and aimed at influencing the behavior of the recipient). Children with reactive attachment disorder show social communicative functioning comparable to their overall level of intellectual functioning. Finally, children with autistic spectrum disorder regularly show attachment behavior typical for their developmental level. In contrast, children with reactive attachment disorder do so only rarely or inconsistently, if at all.

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Intellectual disability (intellectual developmental disorder). Developmental delays often accompany reactive attachment disorder, but they should not be confused with the disorder. Children with intellectual disability should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotion regulation difficulties evident in children with reactive attachment disorder. In addition, developmentally delayed children who have reached a cognitive age of 7–9 months should demonstrate selective attachments regardless of their chronological age. In contrast, children with reactive attachment disorder show lack of preferred attachment despite having attained a developmental age of at least 9 months.

Depressive disorders. Depression in young children is also associated with reductions in positive affect. There is limited evidence, however, to suggest that children with depressive disorders have impairments in attachment. That is, young children who have been diagnosed with depressive disorders still should seek and respond to comforting efforts by caregivers.
rauma and Comorbidity

Trauma and Comorbidity
Substances are commonly used by trauma survivors to manage psychological or emotional suffering. Trauma can potentially exacerbate existing stress. You will diagnose and plan therapy for an instructor-provided case (case of Neville find attached). Talk 6090 Trauma and Comorbidity

Prep: Review the trauma therapy learning resources, including optional resources/media and Suggested Further Reading. Then read your instructor’s case for this week’s Discussion.

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Post a 3- to 5-minute video response addressing the following (transcribe):

Give the client the entire DSM-5 diagnosis. Remember to include the disorder’s name, ICD-10-CM code, specifiers, severity, and Z codes (other conditions that may be a focus of clinical attention). Remember that a diagnosis is valid for 12 months.
Explain the diagnosis by comparing the case’s symptoms to the diagnostic criteria.
Your first emphasis as a client’s social worker should be identified, with specific therapy recommendations. Research your suggestions.
Distinguish how you would manage the client’s co-occurring disorders.
Describe your client’s treatment plan, including how you would evaluate it.
READINGS

A.P.A. (2013s). PTSD and other traumatic stress disorders DSM-IV-TR (5th ed.). Author, 9780890425596.dsm07

A.P.A. (2013g). Psychiatric issues. DSM-IV-TR (5th ed.). Author, 9780890425596.dsm08

Powers, A., N. Fani, D. Cross, K. J. Ressler, & B. (2016). Findings from a highly traumatized minority sample. 58, 111–118.

(U. Schnyder et al.) M. (2015). What do PTSD psychotherapies have in common? 6(1), 281–286. doi:10.3402/ejpt.v6.28186

Smith, J. C., et al (2016). Trauma therapy using recovery concepts. 347–355. doi:10.1037/pro0000105

NEEDED MEDIA
Veterans Affairs Department (2017). Long-term exposure (PE): Ptsd Veterans Affairs App (AboutFace) Therapy (PE)
Watch the films on this page about PTSD veteran Frederick M. Gantt’s experience with PET.

“I had to choose”
“What am I fleeing?”
“It was in color”
A Middle Eastern eatery
“I’m safe” Talk 6090 Trauma and Comorbidity

OTHER RESOURCES

A.P.A. (2013m). Aspects of clinical care that may include DSM-IV-TR (5th ed.). Author. 9780890425596.VandZcodes

Aharonson-Daniel, L., & M. Lahad (2017). Posttraumatic stress symptoms differ depending on trauma exposure time. 258, 101–107. doi:10.1016/j.psychres.2017.09.079

Maercker, A., & T. (2016). A socio-interpersonal understanding of PTSD. European Journal of Psychotraumatology, 7(1), 1–9.

McHugh, R. K., et al (2017). Anxiety sensitivity and trauma reactivity in treatment-seeking adults with drug use disorders. 78, 107–114. doi:10.1016/j.comppsych.2017.07.011

B. van der Kolk et al (2013). What is PTSD in reality? Reversals of fortune, and the politics of diagnosis and therapy 69(5), 516–522. doi:10.1002/jclp.21992

Further Reading for SOCW 6090 (PDF)
This is the same document as Week 1.

OTHER MEDIA
Buffalo School of Social Work (Producer). (2014b). Tara Hughes: Disaster mental health: An emergent social work approach www.insocialwork.org/episode/ep=141

UB School of Social Work (Producer) (2015). Listen to Episode 180—Dr. Howard Lipke: HEART for vets: Identifying concealed emotion. www.insocialwork.org/episode.asp?EP=180

american psychiatric association. 2013m ..docx
goral a. lahad m. aharonson daniel l. 2017 ..docx week 9 the case of neville.pdf diagnostic and statistical m
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Trauma- and Stressor-Related Disorders (DSM-5)

Exposure to a traumatic or stressful incident is a diagnostic criteria for trauma- and stressor-related disorders. Among them are reactive attachment disorder, disinhibited social engagement disorder, PTSD, ASD, and adjustment disorders. The proximity of this chapter to chapters on anxiety disorders, OCD and associated disorders, and dissociative disorders illustrates the tight link between these diagnoses and disorders. Talk 6090 Trauma and Comorbidity

Psychological suffering after a traumatic or stressful incident varies widely. Symptoms can sometimes be interpreted within an anxiety or fear setting. It is apparent that many people who have been exposed to a traumatic or stressful incident exhibit anhedonic and dysphoric symptoms, externalizing furious and violent symptoms, or dissociative symptoms. The aforementioned disorders have been placed under a different category: trauma- and stressor-related disorders. It is also usual for the clinical picture to have a mix of the above symptoms (with or without anxiety- or fear-based symptoms). A similar image has long been recognized in adjustment disorders. Social neglect is a need for both reactive attachment disorder and disinhibited social engagement disorder. A shared etiology, the former manifests as an internalizing condition with depressed symptoms and withdrawal, whereas the latter manifests as disinhibition and externalization.

Comorbidity

Conditions associated with neglect, including cognitive delays, language delays, and stereotypies, often co-occur with reactive attachment disorder. Medical conditions, such as severe malnutrition, may accompany signs of the disorder. Depressive symptoms also may co-occur with reactive attachment disorder. SOCW 6090 Trauma and Comorbidity Discussion

References

Gleason MM, Fox NA, Drury S, et al: The validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. J Am Acad Child Adolesc Psychiatry 50(3):216–231, 2011 21334562

Oosterman M, Schuengel C: Autonomic reactivity of children to separation and reunion with foster parents. J Am Acad Child Adolesc Psychiatry 46(9):1196–1203, 2007 17712243

Smyke AT, Dumitrescu A, Zeanah CH: Attachment disturbances in young children, I: the continuum of caretaking casualty. J Am Acad Child Adolesc Psychiatry 41(8):972–982, 2002 12162633

Smyke AT, Zeanah CH, Gleason MM, et al: A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. Am J Psychiatry 169(5):508–514, 2012 22764361

Tizard B, Rees J: The effect of early institutional rearing on the behaviour problems and affectional relationships of four-year-old children. J Child Psychol Psychiatry 16(1):61–73, 1975 1123417

Zeanah CH, Scheeringa M, Boris NW, et al: Reactive attachment disorder in maltreated toddlers. Child Abuse Negl 28(8):877–888, 2004 15350771

Zeanah CH, Smyke AT, Koga S, et al: Attachment in institutionalized and community children in Romania. Child Dev 76(5):1015–1028, 2005 16149999

Disinhibited Social Engagement Disorder

Diagnostic Criteria 313.89 (F94.2)

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).

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.

The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.

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 (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).

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 pathogenic care in Criterion C).

The child has a developmental age of at least 9 months.

Specify if:

Persistent: The disorder has been present for more than 12 months.

Specify current severity:

Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Diagnostic Features

The essential feature of disinhibited social engagement disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers (Criterion A). This overly familiar behavior violates the social boundaries of the culture. A diagnosis of disinhibited social engagement disorder should not be made before children are developmentally able to form selective attachments. For this reason, the child must have a developmental age of at least 9 months.

Associated Features Supporting Diagnosis

Because of the shared etiological association with social neglect, disinhibited social engagement disorder may co-occur with developmental delays, especially cognitive and language delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor care. However, signs of the disorder often persist even after these other signs of neglect are no longer present Chisholm 1998; O’Connor and Rutter 2000. Therefore, it is not uncommon for children with the disorder to present with no current signs of neglect Boris et al. 2004; Rutter et al. 2009. Moreover, the condition can present in children who show no signs of disordered attachment Gleason et al. 2011; O’Connor et al. 2003. Thus, disinhibited social engagement disorder may be seen in children with a history of neglect who lack attachments or whose attachments to their caregivers range from disturbed to secure. SOCW 6090 Trauma and Comorbidity Discussion

Prevalence

The prevalence of disinhibited social attachment disorder is unknown. Nevertheless, the disorder appears to be rare, occurring in a minority of children, even those who have been severely neglected and subsequently placed in foster care or raised in institutions. In such high-risk populations, the condition occurs in only about 20% of children Gleason et al. 2011. The condition is seen rarely in other clinical settings.

Development and Course

Conditions of social neglect are often present in the first months of life in children diagnosed with disinhibited social engagement disorder, even before the disorder is diagnosed Zeanah et al. 2005. However, there is no evidence that neglect beginning after age 2 years is associated with manifestations of the disorder Wolkind 1974. If neglect occurs early and signs of the disorder appear, clinical features of the disorder are moderately stable over time, particularly if conditions of neglect persist Gleason et al. 2011. Indiscriminate social behavior and lack of reticence with unfamiliar adults in toddlerhood are accompanied by attention-seeking behaviors in preschoolers Tizard and Hodges 1978; Tizard and Rees 1975; Zeanah et al. 2005. When the disorder persists into middle childhood, clinical features manifest as verbal and physical overfamiliarity as well as inauthentic expression of emotions Gleason et al. 2011; Rutter et al. 2009. These signs appear particularly apparent when the child interacts with adults. Peer relationships are most affected in adolescence, with both indiscriminate behavior and conflicts apparent Hodges and Tizard 1989. The disorder has not been described in adults.

Disinhibited social engagement disorder has been described from the second year of life through adolescence. There are some differences in manifestations of the disorder from early childhood through adolescence. At the youngest ages, across many cultures, children show reticence when interacting with strangers van Ijzendoorn and Sagi-Schwartz 2009. Young children with the disorder fail to show reticence to approach, engage with, and even accompany adults. In preschool children, verbal and social intrusiveness appear most prominent, often accompanied by attention-seeking behavior Tizard and Rees 1975; Zeanah et al. 2002; Zeanah et al. 2005. Verbal and physical overfamiliarity continue through middle childhood, accompanied by inauthentic expressions of emotion. In adolescence, indiscriminate behavior extends to peers. Relative to healthy adolescents, adolescents with the disorder have more “superficial” peer relationships and more peer conflicts. Adult manifestations of the disorder are unknown.

Risk and Prognostic Factors

Environmental. Serious social neglect is a diagnostic requirement for disinhibited social engagement disorder and is also the only known risk factor for the disorder. However, the majority of severely neglected children do not develop the disorder. Neurobiological vulnerability may differentiate neglected children who do and do not develop the disorder Drury et al. 2012. However, no clear link with any specific neurobiological factors has been established. The disorder has not been identified in children who experience social neglect only after age 2 years. Prognosis is only modestly associated with quality of the caregiving environment following serious neglect Gleason et al. 2011; Smyke et al. 2012. In many cases, the disorder persists, even in children whose caregiving environment becomes markedly improved.

Course modifiers. Caregiving quality seems to moderate the course of disinhibited social engagement disorder. Nevertheless, even after placement in normative caregiving environments, some children show persistent signs of the disorder, at least through adolescence Hodges and Tizard 1989; Rutter et al. 2007.

Functional Consequences of Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder significantly impairs young children’s abilities to relate interpersonally to adults and peers Gleason et al. 2011; Hodges and Tizard 1989.

Differential Diagnosis

Attention-deficit/hyperactivity disorder. Because of social impulsivity that sometimes accompanies attention-deficit/hyperactivity disorder (ADHD), it is necessary to differentiate the two disorders. Children with disinhibited social engagement disorder may be distinguished from those with ADHD because the former do not show difficulties with attention or hyperactivity.

Comorbidity

Limited research has examined the issue of disorders comorbid with disinhibited social engagement disorder. Conditions associated with neglect, including cognitive delays, language delays, and stereotypies, may co-occur with disinhibited social engagement disorder. In addition, children may be diagnosed with ADHD and disinhibited social engagement disorder concurrently.

References

Boris NW, Hinshaw-Fuselier SS, Smyke AT, et al: Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples. J Am Acad Child Adolesc Psychiatry 43(5):568–577, 2004 15100563

Chisholm K: A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Dev 69(4):1092–1106, 1998 9768488

Drury SS, Gleason MM, Theall KP, et al: Genetic sensitivity to the caregiving context: the influence of 5httlpr and BDNF val66met on indiscriminate social behavior. Physiol Behav 106(5):728–735, 2012 22133521

Gleason MM, Fox NA, Drury S, et al: Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. J Am Acad Child Adolesc Psychiatry 50(3):216–231, 2011 21334562

Hodges J, Tizard B: Social and family relationships of ex-institutional adolescents. J Child Psychol Psychiatry 30(1):77–97, 1989 2925822

O’Connor TG, Rutter M: Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up. English and Romanian Adoptees Study Team. J Am Acad Child Adolesc Psychiatry 39(6):703–712, 2000 10846304

O’Connor TG, Marvin RS, Rutter M, et al: Child-parent attachment following early institutional deprivation. Dev Psychopathol 15(1):19–38, 2003 12848433

Rutter M, Colvert E, Kreppner J, et al: Early adolescent outcomes for institutionally-deprived and non-deprived adoptees, I: disinhibited attachment. J Child Psychol Psychiatry 48(1):17–30, 2007 17244267

Rutter M, Kreppner J, Sonuga-Barke E: Emanuel Miller Lecture: Attachment insecurity, disinhibited attachment, and attachment disorders: where do research findings leave the concepts? J Child Psychol Psychiatry 50(5):529–543, 2009 19298474

Smyke AT, Zeanah CH, Gleason MM, et al: A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. Am J Psychiatry 169(5):508–514, 2012 22764361

Tizard B, Hodges J: The effect of early institutional rearing on the development of eight year old children. J Child Psychol Psychiatry 19(2):99–118, 1978 670339

Tizard B, Rees J: The effect of early institutional rearing on the behaviour problems and affectional relationships of four-year-old children. J Child Psychol Psychiatry 16(1):61–73, 1975 1123417

van IJzendoorn MH, Sagi-Schwartz A: Cross-cultural patterns of attachment: universal and contextual dimensions, in Handbook of Attachment. Edited by Cassidy J, Shavers P. New York, Guilford, 2009, pp 880–905

Wolkind SN: The components of “affectionless psychopathy” in institutionalized children. J Child Psychol Psychiatry 15(3):215–220, 1974 4218238

Zeanah CH, Smyke AT, Dumitrescu A: Attachment disturbances in young children, II: indiscriminate behavior and institutional care. J Am Acad Child Adolesc Psychiatry 41(8):983–989, 2002 12162634

Zeanah CH, Smyke AT, Koga S, et al: Attachment in institutionalized and community children in Romania. Child Dev 76(5):1015–1028, 2005 16149999

Posttraumatic Stress Disorder

Diagnostic Criteria 309.81 (F43.10)

Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

Directly experiencing the traumatic event(s).

Witnessing, in person, the event(s) as it occurred to others.

Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

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