Disinhibited Social Engagement Disorder

Kids should have a healthy fear of strangers

Grandfather and grandson sharing a tablet-pc

Kids should naturally have a healthy fear of unfamiliar people. Most of them are a bit cautious with adults they don't know. But children with disinhibited social engagement disorder aren’t afraid of strangers.

In fact, they are so comfortable around unfamiliar people that they wouldn’t think twice about climbing into a stranger’s car or accepting an invitation to a stranger’s home. Their friendliness toward people they don’t know can become a serious safety problem if the disorder is left untreated.

No Preference for Caregivers Over Strangers

Most children seek comfort and contact with their primary caregivers. A healthy 4-year-old who falls at the playground and skins his knee will likely look for Mom, Dad, or the caregiver who brought him to the playground to help him care for his wound.

But a child with disinhibited social engagement disorder may reach out to a complete stranger for emotional support. He may tell a random passerby he’s injured and ask for help or he may sit on a stranger’s lap and begin to cry.

This can be very confusing and distressing for a caregiver. Why would a child interact with unfamiliar adults without a moment's hesitation?

Signs of Disinhibited Engagement Disorder

Disinhibited social engagement disorder was initially a subtype of reactive attachment disorder. But, the fifth edition of the Diagnostic and Statistical Manual made disinhibited social engagement disorder a completely separate diagnosis.

In order to meet the criteria for disinhibited social engagement disorder, a child must exhibit a pattern of behavior that involves approaching and interacting with unfamiliar adults as well as 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 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

A child will only meet the criteria for disinhibited social engagement disorder if those behaviors don’t stem from an impulse control problem. So while a child with ADHD may run off at the playground and forget to make sure Mom is around, a child with disinhibited social engagement disorder will wander off without giving Mom a second thought because he doesn’t feel the need to ensure she’s around.

Additionally, a child will only meet the criteria for disinhibited social engagement disorder if he’s also experienced a history of neglect as evidenced by one of the following:

  • Social neglect including the 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
  • Rearing in unusual settings that limit opportunities to form selective attachments, such as an institution with high child-to-caregiver ratios

If a child exhibits the behavior for more than 12 months, the disorder is considered persistent. It may also be described as severe when a child exhibits the symptoms at relatively high levels.

Because disinhibited social engagement disorder stems from neglect, it may occur alongside other disorders such as cognitive and language delays or malnutrition.

Difficulty Distinguishing Who Is Trustworthy

Young children aren’t good at identifying predators. But, most of them do remain cautious about people they don't know.

Researchers have found that children make initial assessments about an individual’s trustworthiness based on a person's appearance. They're able to make some judgments about whether a stranger looks kind or mean based on an individual's face.

But brain imaging studies have found that kids with disinhibited social engagement disorder can’t discriminate between someone who looks kind and safe from someone who looks mean and untrustworthy.

Their difficulties with facial recognition may contribute to their willingness to talk to strangers or engage with unfamiliar people since they assume everyone is nice.

They Crave Kindness From Anyone

Kids with disinhibited social engagement disorder crave kindness from others. Since they can’t identify who may be a safe person and who isn’t, they may show affection toward anyone who gives them attention.

It’s not unusual for a child to hug a stranger in the grocery store or strike up a conversation about personal issues with an unfamiliar adult at the playground. They may even sit down with another family at the park as if they were invited to the picnic.

They often seek physical affection from strangers too. A child with disinhibited social engagement disorder is likely to hug a passerby in the store or sit on the lap of a stranger in a waiting room.

Contributing Factors

Disinhibited social engagement disorder isn't caused by being placed in daycare. And a child won't develop it because her mother placed her in her crib sometimes when she was crying.

Children only develop disinhibited social engagement disorder if they suffered serious neglect as infants.

Neglect during infancy interferes with bonding and attachment. And that impairs their ability to develop trusting relationships with caregivers later in life as well.

Infants learn to trust their caregivers when their caregivers respond to their needs. A crying baby who gets fed learns she can count on her mother. Or a crying baby who gets picked up and cuddled learns that her father is there for her.

When kids are neglected, they may not bond with their caregivers. A crying baby who is chronically ignored may come to believe that no one is there for her. Or a baby who is left unattended most of the time with little social engagement may not form any type of relationship with a caregiver. Consequently, that child may be at risk of an attachment disorder.

But, not all neglected children develop disinhibited social engagement disorder. Many of them go on to form healthy relationships without serious attachment issues.

Foster Parents and Adoptive Parents Should Be on the Lookout

Disinhibited social engagement disorder stems from neglect during the first few months of life. There is no evidence that neglect beginning after the age of 2 contributes to the disorder.

So foster parents, grandparents, adoptive parents, or other caregivers who begin raising a child months or even years after birth may recognize the symptoms. Just because a child is no longer neglected doesn’t mean he isn’t at risk for developing an attachment issue.

The disorder may not become apparent until long after the neglect issues have been resolved. So a foster parent raising an 8-year-old may notice signs of the disorder. Or, a child who was adopted from an orphanage may exhibit signs around the age of 5.

How Disinhibited Social Engagement Disorder Changes Over the Years

Toddlers often begin showing a lack of fear toward unfamiliar adults. They may hold hands with a stranger or sit on the lap of a person they just met.

During the preschool years, children with disinhibited social engagement disorder continue to be overly comfortable with strangers but they also begin exhibiting attention-seeking behavior. So a 4-year-old may make loud noises at the playground just to get unfamiliar adults to look at him.

During middle childhood, children often show verbal and physical overfamiliarity as well as inauthentic expression of emotions. So a 9-year-old child may laugh when others laugh or she may appear sad to manipulate the situation, rather than out of genuine emotion. She may also say things like, “I want to go to your house,” as soon as she meets someone new.

Adolescents with disinhibited social engagement disorder are likely to have problems with their peers. They tend to develop superficial relationships with others and they often struggle with conflict. They continue to have indiscriminate behavior toward adults.

How Common Is Disinhibited Social Engagement Disorder?

Disinhibited social engagement disorder is fairly rare. Children who have been raised in institutions like an orphanage, or those who have resided in multiple foster care placements, are at the highest risk for developing the condition.

Studies have found that about 20 percent of children in high-risk populations develop disinhibited social engagement disorder. Many children who have a history of abuse or neglect don’t develop any type of attachment disorder.

Risks and Consequences

It’s important for kids to have a healthy fear of strangers and potentially harmful people. So raising a child with disinhibited social engagement disorder can be quite confusing and terrifying for caregivers.

A 4-year-old might wander off with a stranger in the grocery store or a 9-year-old might enter a neighbor’s home without thinking twice about potential safety issues.

Caregivers who are raising a child with disinhibited social engagement disorder must keep constant watch to ensure a child doesn’t put himself in a harmful situation. They may need to intervene often to prevent a child from interacting with people he doesn’t know.

Kids with attachment disorder struggle to develop healthy relationships with teachers, coaches, daycare providers, peers, and others. Their behavior is likely to be alarming to families or other parents who aren’t familiar with the disorder.

At this time, there is little research about the long-term effects of disinhibited social engagement disorder. It isn't clear how it might impact an individual during adulthood.

Treatment for Disinhibited Social Engagement Disorder

It’s important for children with attachment disorders to receive consistent care from stable caregivers. A child who continues to move from foster home to foster home or one who continues to be institutionalized isn’t likely to improve.

But once consistent care has been established, treatment can begin to help strengthen the bond between a child and a primary caregiver.

Attachment disorders don’t tend to get better on their own. So it’s important to seek professional treatment. Treatment typically consists of therapy that involves both the child and the caregivers. Treatment plans are individualized, however, based on a child’s unique needs and symptoms.

If you suspect a child in your care may have an attachment disorder, talk to your child's pediatrician. Your child will likely be referred to a mental health professional for a comprehensive assessment.

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