Disinhibited Social Engagement Disorder

While some children are naturally friendly and occasionally enjoy cheerful interactions with strangers, it may be a problem if the child constantly seeks verbal, physical, and social interactions with adult strangers without caution and hesitation. Find out more about disinhibited social engagement disorder.

Disinhibited Social Engagement Disorder: What does it mean?

Disinhibited social engagement disorder (DSED) is an attachment disorder which results from disruptions in the normative relationship between children and their caregivers. Such disruptions are a result of the absence of adequate social and emotional care during childhood. DSED is one of two types of attachment disorder, the other being reactive attachment disorder (RAD).

Attachment describes the behavioral patterns and emotions observed in a child as a result of their relationships with others, usually their caregivers. Generally, attachment disorders result from negative childhood experiences a child may have had with caregivers. This may occur through loss of the primary caregiver or inability of the caregiver to provide adequate emotional and social support for the child.

Stats: How many suffer from this Disorder?

Disinhibited social engagement disorder is typically a disorder of childhood, affecting children younger than 18 years. The condition typically has an onset occurring before the age of 5 years. In severe cases, the disorder may persist with behavioral and relationship problems continuing in preschool and school years. In more complicated cases, the disorder may progress into adolescence and adulthood.

The disorder has its roots in infancy, with attachment problems in this developmental period being the root of this disorder.

What Causes Disinhibited Social Engagement Disorder?

Although the exact causes of disinhibited social engagement disorder are unknown, several factors may contribute to its development. Some of these factors include:

• Receiving care from multiple caregivers at the same time or sequentially. This makes the child lack a sense of security and permanency associated with long-standing relationships with permanent caregivers.
• Frequent changes in foster care.

Signs and symptoms of Disinhibited Social Engagement Disorder

The most common symptom of this disorder is the absence of normal restraint and discretion when interacting with strangers. Other symptoms include the following:

• Being unusually comfortable talking to an unfamiliar stranger, usually against the normal culture or social norms.
• Willingness to touch or give hugs to adult strangers.
• A tendency to go off with an adult stranger without any hesitation.
• Willingness to approach a stranger for help, comfort, or food.
• Willingness to receive gifts or toys from adult strangers.
• Children with severe conditions may show an excessive appetite or thirst.

Testing: What are the Diagnostic Criteria per the DSM 5

Criteria for the diagnosis of disinhibited social engagement disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), include

• A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following:

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults;
2. Overly familiar verbal or physical behavior (inconsistent with culturally sanctioned and age-appropriate social boundaries)
3. Diminished or absent checking-back with adult caregivers after venturing away, even in unfamiliar settings
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation

• The behaviors described in the first criterion are not limited to impulsivity (as in ADHD) but also include socially disinhibited behavior
• The child has experienced a pattern of extremes of insufficient care, as evidenced by at least 1 of the following:
  1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
  2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (for example, frequent changes in foster care)
  3. Rearing in unusual settings that severely limit opportunities to form selective attachments (for example, institutions with high child-to-caregiver ratios)
• The care described in the third criterion is presumed to be responsible for the disturbed behavior described in the first criterion (for instance, the disturbed behavior began after the inadequate care)
• The child has a developmental age of at least 9 months.

In a child with disinhibited social engagement disorder, if the disorder has been present for longer than 12 months, it is specified as persistent. If the child exhibits all the symptoms of the disorder, with each symptom manifesting at relatively high levels, the disorder is further specified as severe.

Disinhibited Social Engagement and Other Conditions

There are a number of psychological disorders, as well as personality traits, which have some similarities to DSED but can be distinguished clinically.

Disinhibited Social Engagement vs. Extraversion

Extraversion is one of the five core personality traits. Extraversion is characterized by high sociability, talkativeness, and external excitability. Children with strong extraversion usually love to interact with other people. Extraversion is not a disorder, but a component of normal personality and children high in extraversion are typically cheerful, action-oriented, friendly, and enjoy being the center of attention.

Disinhibited Social Engagement vs. Autism Spectrum Disorders

Autism spectrum disorders are a group of developmental disorders characterized by delayed social, communication, intellectual skills, as well as behavior. A key similarity between autism spectrum disorders and DSED is the delayed emotional development. However, children with DSED usually retain age-appropriate intellectual level and language patterns.

This group of disorders includes Asperger’s Disorder, Autistic Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified, and usually result from abnormalities in the biology of the child’s brain. These conditions are typically associated with developmental regression, abnormal interactions with people, abnormal responses to external stimuli, language delays and abnormalities, and repetitive stereotyped behavior. Autism spectrum disorders are not caused by childhood negative experiences with parents or caregivers.

Related Conditions

Another condition related to DSED is reactive attachment disorder, the other form of attachment disorder, also caused by disruptions in the normative bond between a child and a caregiver during early childhood.

The symptoms are typically opposite of those of DSED and include minimal social and emotional interactions with others, reduced expressions of joy, minimal search for comfort when distressed, and multiple episodes of unexplained sadness and irritability.

Disinhibited Social Engagement in Adults/Children

Disinhibited social engagement disorder is exclusively a disorder of childhood and is typically not diagnosed after the age of 5 years. Usually, as the child grows and attains various developmental milestones, the symptoms reduce.

Similarly, experts note that as the child’s needs to elicit care from strangers and potential caregivers wane, the symptoms will also lessen. However, in a few cases, some children may continue to experience these symptoms in their adolescent and adult years.

Example Case of Disinhibited Social Engagement Disorder

Lola is a 5-year-old girl who is brought to the primary care pediatrician by her new foster parent. Lola was said to have been cared for by five foster parents within a space of two years after her mother abandoned her following her cocaine addiction problems. Her new foster parent describes several incidences where Lola becomes excessively cheerful with adult strangers who come to visit, giving them several hugs, and on two occasions following an adult neighbor to visit his friends. These parents express serious concerns over Lola’s overfamiliarity and think that there may be something wrong with her.

How to Deal/Coping with Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder is a serious condition, but full recovery is possible with adequate treatment. Without receiving treatment and building new attachments, children with the disorder have a poor chance of attaining normal emotional development, building strong relationships, and engaging in intimate relationships with members of the opposite sex.

Parents should put the risk factors and complications of the disorder in mind to aid improvement of the child’s symptoms and prevent progression of the symptoms.

Risk factors of disinhibited social engagement disorder include:

• Children that are institutionalized during infancy or early childhood.
• Parental neglect
• Parental maltreatment.
• Teen parenting
• Parents with substance abuse or other mental health issues including personality disorders and depression.
• Childhood emotional trauma such as early sexual abuse.
• Parental loss – from the death of one parent or divorce.
• Caregivers who have experienced attachment disorders.

In the absence of treatment, symptoms may progress and lead to a number of complications which include:

• Exhibition of defiant and uncooperative behavior toward adults
• Children may become exploitative toward other people.
• A great fear of closeness and intimacy
• Transmitting a similar behavioral pattern to their children, when they become parents.
• As a result of the absence of appropriate caring behavior during childhood, children with disinhibited social engagement disorder may develop conduct disorder.
• Attention problems which result in poor school performance

Disinhibited Social Engagement Disorder Treatment

Treatment is essential for a child with this disorder to help them attain normal emotional development and build trusting social relationships. The absence of treatment is generally associated with a poor prognosis. Treatment involves the use of medications, as well as behavioral and psychological therapy. Much of the behavioral and psychological therapy is provided by the child’s primary caregivers in their daily interactions.

Possible Medications for DSED

Although there is no specific medication for treating DSED, some drugs may be used in treating symptoms and associated problems such as hyperactivity, social anxiety, emotional outbursts, and sleep disturbances. These drugs include anxiolytics, mood stabilizers, and sedatives.

Home Remedies to Help DSED

Therapy for children with disinhibited social engagement disorder is largely provided by the caregivers in their day-to-day interactions. One psychological therapy used in the treatment of this disorder is play therapy in which children learn to express their fears, worries, and emotional needs during play sessions. In the context of play also, caregivers will learn to be more sensitive to the needs of the child.

During interactions, caregivers should incorporate security, stability, and sensitivity as key ingredients to help the child develop healthy attachments. These reparative processes require consistency and repetition to allow the child to overcome the scars of attachment disruption and develop trust in the caregiver and other people. This is the sense of security a child needs in the caregiver-child relationship.

Stability refers to building a long-standing attachment with the child. It is not uncommon for children to feel that a new caregiver will disappear or neglect them. Incorporating a sense of stability in the relationship helps a child to understand that their needs can be met by a particular caregiver repeatedly and consistently.

Sensitivity, as a key ingredient of therapy, refers to attentiveness to the needs of the child. Because a child’s emotional development may be delayed by repeated attention disruptions, a new caregiver must be emotionally available and attentive to the needs and desires of the child for them to improve. In a case, for instance, where a naturally independent child develops dependency needs and wants to always be around the caregiver, the caregiver should be sensitive to these dependency needs and meet them.

Living with DSED

It may be challenging living with and grooming a child with DSED. However, active participation of the caregivers is pivotal for the clinical improvement of the child. In addition, new caregivers may require emotional support and therapy to cope with the difficult behaviors the child may exhibit.

A behavioral management program that encourages a positive learning model is essential for improvement of the child’s symptoms. For example, excessive corrective measures such as punishment or abandonment may exacerbate symptoms instead of relieving them.

Insurance Coverage for DSED

Check your insurance plan benefits for coverage of mental or behavioral health services. You may inquire directly through your human resources office for employer-sponsored health coverage for treatment of this condition or contact your health insurance company directly. Also, find out about out-of-pocket costs and deductibles you will pay to access the mental health services under your insurance plan.

How to Find a Therapist

After an initial evaluation, your primary care physician will refer your child to a psychiatrist or child psychologist who will confirm the diagnosis and institute appropriate therapeutic measures. You may also ask friends and family for good therapists, or check through online resources and directory to find the right therapist for you.

What should I be looking for in a Licensed Mental Health Professional (LMHP)?

Qualities you should look for in an LMHP include:

• Good Communication Skills: An effective LMHP should communicate their expert ideas about your child’s symptoms effectively.
• Empathy: You do not want a counselor who would rush through medical facts without considering your emotional needs or those of your child. You need an LMHP that is considerate, patient, calm, and compassionate with you.
• Problem-Solving Skills: Your chosen LMHP must be knowledgeable enough to help you through to a satisfactory resolution of your child’s symptoms. While your resolution of your child’s symptoms is not entirely up to your counselor, they must demonstrate an ample ability to help manage those symptoms effectively.
• Good multicultural Relationship: Your counselor must be able to strike a good patient-therapist relationship with you and your family irrespective of your racial, ethnic, or cultural differences. Therapy must be devoid of such prejudices which may hamper on the effectiveness of treatment.

Questions to ask for Potential Therapist

You should ask a potential therapist the following questions to help you gain more insight into your symptoms and the scope of your treatment options.

• What do you think is causing my child’s symptoms?
• How will the diagnosis be determined?
• Does my child have disinhibited social engagement disorder?
• Is the condition self-limiting or chronic?
• What factors contribute to the problem?
• Does my child require screening for other mental health disorders?
• What are the likely complications of this condition?
• What is the treatment approach you recommend?
• How long will therapy be for, if necessary?
• What medications will my child be on?
• What side effects should I expect from those drugs?
• Should I inform my child’s school teachers about the diagnosis?
• Are there effective strategies to use at home and school to improve my child’s behavior?
• Do you recommend therapy for the caregivers as well?
• Are there any resources or websites you recommend?

Disinhibited Social Engagement Disorder: An Overview

Disinhibited social engagement disorder (DSED) is an attachment disorder of childhood caused by disruptions in a child’s attachment to or negative experiences with the caregiver during early childhood or infancy. Symptoms center on the child’s physical, verbal, and emotional overfamiliarity with adult strangers.

DSED has an onset typically below the age of 5 years and may progress, in some children, to adolescence and adulthood. Treatment of the disorder is largely based on psychological and behavioral modification with the caregiver actively participating, meeting the child’s emotional needs and creating new attachment and relationships.

Resources

https://psychcentral.com/disorders/symptoms-of-disinhibited-social-engagement-disorder/

https://www.theravive.com/therapedia/disinhibited-social-engagement-disorder-dsm–5-313.89-(f94.2)

https://traumadissociation.com/disinhibited

https://emedicine.medscape.com/article/915447-treatment#d9

https://www.healthline.com/health/disinhibited-social-engagement-disorder#symptoms

https://www.medscape.com/viewarticle/761663

https://emedicine.medscape.com/article/912781-overview#a1
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