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intermediatedisinhibited social engagement disorderreactive attachment disorderattachment disorderschild psychiatryinstitutional care
A 5-year-old boy adopted from an overseas orphanage at age 3 is evaluated for behavioral concerns. His adoptive parents report that he approaches strangers without hesitation, climbs into unfamiliar adults' laps, and has wandered off with a stranger at a grocery store without any distress. He is excessively familiar and affectionate with people he has just met. Despite 2 years in a stable, loving home, he does not preferentially seek comfort from his adoptive parents over unfamiliar adults. He makes good eye contact, engages socially, and shows age-appropriate language skills.
Explanation
Reactive attachment disorder and disinhibited social engagement disorder both arise from pathogenic care (neglect, institutional rearing, frequent caregiver changes) but manifest in opposite ways. RAD presents as inhibited and withdrawn, while DSED presents as disinhibited and indiscriminately social. DSED can persist even after the child is placed in an adequate caregiving environment, whereas RAD symptoms typically improve with stable attachment.
Key Takeaway
Disinhibited social engagement disorder involves indiscriminate sociability with unfamiliar adults following early social neglect, while reactive attachment disorder presents as inhibited and withdrawn behavior. They are opposite responses to the same pathogenic care history.