Disinhibited Social Engagement Disorder

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Most children are naturally cautious with adults they don't know. For the most part, a fear of unfamiliar people is healthy and helpful. However, some children do not have this fear.

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. This uninhibited friendliness toward people they don’t know can become a serious safety problem for children if the disorder is left untreated.

Signs of Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder was originally considered to be a subtype of another attachment disorder called reactive attachment disorder. However, in the fifth edition of the Diagnostic and Statistical Manual (DSM-5), disinhibited social engagement disorder was categorized as a separate diagnosis.

To meet the diagnostic 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 behaviors:

  • Overly familiar verbal or physical behavior that is not consistent with culturally sanctioned and appropriate social boundaries
  • Diminished or absent checking back with an adult caregiver after venturing away, even in unfamiliar settings
  • Willingness to go off with an unfamiliar adult with minimal or no hesitation

It should also be noted that a child will only meet the criteria for disinhibited social engagement disorder if the behaviors do not stem from impulse control problems, which are common in other disorders.

For example, a child with ADHD may run off at the playground and forget to check that their parent is nearby. A child with disinhibited social engagement disorder will wander off without giving their parent a second thought because they don’t feel the need to ensure their caregiver is around.

In addition to meeting the diagnostic criteria behaviorally, a child must have 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 limited the child's opportunities to form stable attachments
  • Rearing in unusual settings that limited the child's opportunities to form selective attachments (e.g. an institution with high child-to-caregiver ratios)

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

Disinhibited social engagement disorder stems from neglect and therefore may co-occur with other related conditions, such as cognitive and language delays or malnutrition.

No Preference for Caregivers

Most children seek contact with their primary caregivers, especially when they are in need of comfort. For example, a child who falls off a swing and skins their knee will likely look for the parent or caregiver who brought them to the playground to soothe them and tend to the wound.

If a child with disinhibited social engagement disorder falls at the park, they may reach out to a complete stranger for emotional support. They might tell a random passerby that they're hurt or even sit on a stranger's lap on a park bench and cry.

The child's uninhibited behavior can be confusing and unnerving for caregivers. Any adults involved may find it difficult to understand why a child interacts with unfamiliar adults without a moment's hesitation.

Difficulty Knowing Who Is Trustworthy

Young children aren’t good at identifying predators, but most are cautious about people they don't know. Most kids are able to make judgments about whether a stranger looks kind or mean based on an individual's face. Research has found that children make initial assessments about an individual’s trustworthiness based on that person's appearance.

For a child with disinhibited social engagement, difficulties with facial recognition may contribute to their willingness to talk to and engage with strangers. Research using brain imaging has shown that children with the disorder cannot discriminate between a person who looks kind and safe and someone who looks mean and untrustworthy.

Craving Kindness

Kids with disinhibited social engagement disorder crave kindness from others. Since they can’t specifically identify a safe person, they may show affection toward anyone who gives them attention—including someone who is unsafe.

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

A child with disinhibited social engagement disorder also indiscriminately seeks physical affection. For example, they may hug a passerby at the grocery store or sit on a stranger's lap in a waiting room.

Changes Over Time

The nature of disinhibited social engagement disorder behaviors can change and evolve as a child gets older. Toddlers with the disorder often begin showing a lack of fear toward unfamiliar adults, such as by holding hands with a stranger or sitting on the lap of a person they have only just met.

During the preschool years, children with disinhibited social engagement disorder will also begin exhibiting attention-seeking behavior, such as by making loud noises on the playground to get unfamiliar adults to look at them.

By middle childhood, children often show verbal and physical overfamiliarity as well as inauthentic expression of emotions. A preteen may laugh when others laugh or appear sad to manipulate a social situation (rather than out of genuine emotion).

Among peers, they may be overly familiar if not forward. For example, they might say, “I want to go to your house,” when meeting a new classmate for the first time.

Adolescents with disinhibited social engagement disorder are likely to have problems with peers, parents, teachers, and coaches. They tend to develop superficial relationships with others, struggle with conflict, and continue to demonstrate indiscriminate behavior toward adults.

Researchers are studying the long-term outcomes for children with disinhibited social engagement disorder, particularly whether its effects extend to adulthood.

Causes and Contributing Factors

Disinhibited social engagement disorder is caused by neglect during infancy. But there is often misunderstanding about what constitutes neglect and what contributes to the development of attachment disorders in children.

Neglect during infancy interferes with bonding and attachment. This impairs a child's ability to develop trusting relationships with caregivers and often persists into adult life.

Infants learn to trust their caregivers when these individuals consistently respond to their needs. For example, a baby who gets fed in response to their hungry cries will learn that they can count on their parent for nourishment.

Contrary to common myths, the disorder isn't caused by being placed in daycare, and a child won't develop it as a result of being placed in their crib when they are crying.

Children who are neglected may not bond with their caregivers. If a crying baby is constantly ignored, they learn that the people around them are unreliable, if not totally unavailable. 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.

While the consequences can be severe, it's important to know that not all neglected children develop disinhibited social engagement disorder. In fact, many children will grow up to have healthy relationships with no lasting attachment issues.

A Concern for Foster and Adoptive Parents

Disinhibited social engagement disorder stems from neglect that occurs during the first few months of life. The American Psychiatric Association (APA) states that the disorder almost always develops by the age of two.

However, disinhibited social engagement disorder may not become apparent until long after the neglect issues have been resolved. Foster parents, grandparents, and other caregivers who are raising children who experienced neglect as infants should know that children may still be at risk for developing attachment issues even if they are no longer being neglected.

Prevalence

Disinhibited social engagement disorder is thought to be fairly rare. Children who have been raised in institutions (such as an orphanage) and those who have had multiple foster care placements are at the highest risk for developing the condition.

Many children with a history of abuse or neglect do not develop attachment disorders, but studies suggest that around 20% of children in high-risk populations develop disinhibited social engagement disorder.

Risks and Consequences

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

A four-year-old with the disorder might wander off with a stranger at the mall or a nine-year-old might enter a neighbor’s home without thinking twice about the safety or potential consequences of these actions.

Caregivers raising a child with disinhibited social engagement disorder must keep constant watch to ensure the child doesn’t enter a harmful situation. They may need to frequently intervene to prevent the child from interacting with strangers.

Children with attachment disorders struggle to develop healthy relationships with teachers, coaches, daycare providers, and peers. Their behavior can be alarming enough to the people around them, such as a classmate's family, that it precludes social activities (particularly when people are not familiar with the disorder).

Treatment

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 is not likely to improve.

Once consistent care has been established, treatment can begin to help strengthen the bond between a child who has experienced neglect and a primary caregiver.

Attachment disorders don’t tend to get better on their own. Professional treatment typically consists of therapy with both the child and caregivers and treatment plans are individualized to meet a child’s unique needs and symptoms.

If you are concerned that a child in your care may have an attachment disorder, talk to your pediatrician. They can refer your child to a mental health professional for a comprehensive assessment.

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