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Clinical Atlas Prestige · Evidence-first

Psych VivasGeneral adult psychiatry — reactive attachment and disinhibited social engagement

Psych Vivas · General adult psychiatry — reactive attachment and disinhibited social engagement

Reactive attachment and DSED — structured clinical viva

Fellowship viva covering RAD vs DSED, residual transition risk, APSAC red lines, caregiving-first care, and adult residual trajectories after early deprivation.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar in a transition clinic. A 17-year-old leaving foster care has a childhood diagnosis of disinhibited social engagement disorder after institutional care. Residual indiscriminate friendliness continues. He has recent low mood, and carers report he nearly left a train station with a stranger last month. They ask for holding therapy. A youth justice worker asks whether 'RAD' will be his lifelong adult diagnosis. Discuss diagnosis, differentials, risk, management including rejection of coercive therapies, adult residual formulation, and evidence (AACAP, APSAC, BEIP, ERA).

Interpretation

Reveal interpretation

This is a transition-age residual DSED case after extremes of insufficient care, not an inhibited RAD presentation. Core tasks: reproduce DSED criteria and insufficient-care aetiology; separate disorder from insecure style and from ASD/ADHD; manage stranger/absconding risk; refuse holding therapy (APSAC); treat mood comorbidity; and explain that residual early-deprivation burden into adult life (ERA trajectories) does not equal a freestanding lifelong "adult RAD" stamp.[1][2][3][5]

Immediate management. Environmental supervision plan for stranger risk; safety discussion with carers and leaving-care workers; depression risk assessment; multiagency transition plan.[1]

Definitive plan. Caregiver/support-network coaching on boundaries; psychological care for mood and social skills; no medication for attachment itself; if major depression criteria are met, standard SSRI pathway with young-person monitoring; explicit refusal of coercive attachment therapies.[1][2]

Evidence soundbites. AACAP caregiving-first parameter; APSAC safety line; BEIP environment/timing; ERA young-adult residual ND/MH risk for some after early severe deprivation.[1][2][3][4]

Key points

RAD ≠ DSED

Withdrawn comfort failure versus indiscriminate stranger approach after insufficient care.[1][5]

Caregiving first, never coercion

Stable sensitive care and carer coaching; APSAC rejects holding/rebirthing.[1][2]

Adult residual is heterogeneous

ERA shows child-to-adult residual risk for some — formulate residual features; do not invent adult RAD for convenience.[3]

Escalating viva questions

  1. Reproduce DSM-5-TR criteria for RAD and for DSED including developmental age threshold.
  2. How did DSM-5 change the DSM-IV single-disorder framing?
  3. Discriminate DSED from ADHD social impulsivity and from ASD.
  4. What is first-line treatment according to AACAP?
  5. What does APSAC say about holding and rebirthing therapies?
  6. What do BEIP and ERA young-adult follow-up add for general-adult examiners?
  7. How would you answer a court letter requesting certification of "adult RAD"? [1][2][3][4]

References

  1. [1]Zeanah CH, Chesher T, Boris NW; AACAP Committee on Quality Issues Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder J Am Acad Child Adolesc Psychiatry, 2016.PMID 27806867
  2. [2]Chaffin M, Hanson R, Saunders BE, Nichols T, et al. Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems Child Maltreat, 2006.PMID 16382093
  3. [3]Sonuga-Barke EJS, Kennedy M, Kumsta R, Knights N, et al. Child-to-adult neurodevelopmental and mental health trajectories after early life deprivation: the young adult follow-up of the longitudinal English and Romanian Adoptees study Lancet, 2017.PMID 28237264
  4. [4]Nelson CA 3rd, Zeanah CH, Fox NA, Marshall PJ, et al. Cognitive recovery in socially deprived young children: the Bucharest Early Intervention Project Science, 2007.PMID 18096809
  5. [5]Gleason MM, Fox NA, Drury S, Smyke A, 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, 2011.PMID 21334562