Reactive Attachment Disorder and Disinhibited Social Engagement Disorder: Meta-Analyses of Proportions

Maltreated children are at risk of exhibiting attachment disorders: The reactive attachment disorder (RAD) and the disinhibited social engagement disorder (DSED). Determining overall proportions for these disorders, however, is difficult. Assessment methods have varied across studies and over time due to a shift in diagnostic criteria from the Diagnostic and Statistical Manual of mental disorders - 4th Edition (DSM-IV) to the DSM-5. This study examines the overall proportion of RAD-DSED combined (34 studies with 47 independent samples, 8994 participants), RAD (16 studies with 19 independent samples, 1,924 participants), and DSED (16 studies with 21 independent samples, 2,018 participants). Inclusion criteria were all empirical English studies reporting on at least one RAD or DSED classification/diagnosis in children 9 months to 18 years old. Moderators included child age and sex, sample type, measure type, nosological system type, year of publication, study geographical region, and study quality. Random-effects meta-analyses with logit transformation of event proportions were conducted. Publication bias was not tested, given that symmetry assumptions do not apply to proportion data. Results set the overall proportions of attachment disorders in at-risk samples (RAD-DSED combined) at 18.4% [13.4%, 24.9%], 9.6% for RAD [6.6%, 13.7%], and 20.1% for DSED [12.2%, 24.7%]. Some RAD-DSED combined, RAD, and DSED proportions varied according to types of measures, nosological systems, and geographical region of study. Results indicate a decline in RAD proportions since the advent of the DSM-5 in 2013 (from 8.4% [6.5%, 10.9%] to 4.6% [1.4%, 5.6%]), and the DSM-5 algorithm for RAD is markedly more restrictive than that of the Research Diagnosis Criteria (RDC).