Article topic: Disinhibited social engagement disorder (DSED)
Author name: Batool Fahad Alkasasbeh
Editor Name: Ihda Mahmoud Bani Khalaf, Sadeen Eid.
Reviewer: Ethar Hazaimeh
Keywords: Disinhibited social engagement disorder, Attachment, young children, caregiver
Children with a disinhibited social engagement disorder are known to show a lack of normative reticence with strangers, to be physically or verbally overly familiar, to not check their caregiver after venturing away, or to willingly go off with an unfamiliar adult (2).
It can make it difficult for kids to form relationships with peers and adults, and it can place them in risky and perilous situations like riding on a stranger’s lap or leaving without telling their parents (2).
There is now broad consensus that in early childhood, attachment disorders result from inadequate caregiving environments and encompass two clinical patterns, an emotionally withdrawn/inhibited phenotype and an indiscriminately social/disinhibited phenotype (3).
Using continuous measurements to monitor symptoms and categorically diagnose Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED ) in maltreated children and those who are currently or were formerly institutionalized, some research on attachment disorders in early children has been done (3).
The prevalence of DSED also is not completely clear because the condition has not been subjected to large, community-based studies explicitly designed to estimate prevalence (4). Nevertheless, DSED occurs only in a minority of children who have been severely neglected and subsequently placed in foster care or those raised in institutions. Even in such high-risk populations, the condition occurs in fewer than 20% of children (5–7).
The DSM notes that prevalence is up to 2% in low-income community populations in the United Kingdom (8).
Along with other trauma and stress-related disorders, attachment disorders include the specification of etiology in the criteria. Thus, social neglect is noted as a necessary but not sufficient requirement for the diagnosis to be entertained (9).
There may be one or several causes of DSED. Cases frequently involve the lack of quality, long-term caregiving. Some kids with DSED are from institutionalized environments, such as orphanages. Children in foster care who are frequently moved between homes or who are never adopted may also develop DSED (10).
Studies of children who have been maltreated, and those raised in institutions, have confirmed that indiscriminate behavior, the central feature of the phenotype, is increased compared to that in children who have not experienced such extremes of care (7,11–19).
In a study exploring genetic vulnerability to indiscriminate behavior in children who experienced deprivation, Bakersman-Kranenberg et al. (2011) examined whether the serotonin transporter gene (5HTT) moderated the association between institutional care and both disorganized attachment or indiscriminate behavior among young children raised in Ukranian institutions. They found that the long allele of the genotype protected against the development of disorganized attachment but did not protect against the development of indiscriminate behavior (3).
The DSM-5 Diagnostic criteria
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines disinhibited social engagement disorder as “a pattern of behavior in which a child actively approaches and interacts with unfamiliar adults.” (American Psychiatric Association, 2013) (20).
The DSM-5 gives the following criteria for Disinhibited Social Engagement Disorder (21):
- A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits 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 age-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 little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
- Repeated changes in primary caregivers that limit the ability to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Behavioral features of DSED include an inappropriate approach to unfamiliar adults and lack of wariness toward strangers, and a willingness to wander off with strangers. In DSED, children also demonstrate a lack of appropriate social and physical boundaries, such as interacting with adult strangers in over proximity (experienced by the adult as intrusive) and by actively seeking close physical contact. By the preschool years, verbal boundaries may be violated as the child asks overly intrusive and overly familiar questions of unfamiliar adults (3).
Children with DSED have a history of social neglect, but they are usually effectively brighter and more social than children with RAD. The essence of DSED is socially disinhibited behavior with strangers. Affected children lack restraint around adults whom they do not know, instead approaching and engaging them. They are notably willing to leave caregivers and accompany or “go off” with strangers without hesitation (4).
Workup and Diagnosis
Not all children who are able to interact with strangers have DSED. Children who typically show manifestations of independence and physical separation from parents may explore away from their caregivers and be attracted to others some of them have naturally outgoing personalities and they like to approach other adults in an overly enthusiastic way (10).
A therapist or psychiatrist is usually responsible for making the diagnosis. The doctor will conduct a thorough psychiatric evaluation across multiple appointments that may occur in one or more places (10).
Observations may be largely informal. A psychologist may note several behaviors as they occur, such as how the child approaches the psychologist and interacts with them. If the child immediately runs up to the psychologist and wants the psychologist to hold them, that is notable. If the child gets upset in the room, and they do not seek their caregiver out for comfort, or if they reject the caregiver’s attempts to comfort them, that is important. Also, if the caregiver or psychologist praises the child for doing something well, and the child seems to not react or be impacted by the praise, that is notable (8).
If the child is diagnosed with DSED, the doctor is going to create a highly individualized treatment plan. The plan will be targeted toward healing the child’s trauma and supporting their ability to form meaningful, close relationships with others (10).
Due to significant impairment in caregiving, the relationship and attachment between the child and caregiver are damaged, therapies focus on repairing that relationship or making a bond between the child and a new caregiver if the unpleasant caregiver is no longer involved in the child’s life, It is important to note, nevertheless, that relatively little research particularly looks at how treatments affect these illnesses (8).
A significant goal of therapy is to improve sensitive caregiving from the caregiver. This involves increasing the caregiver’s ability to ‘tune in’ to the child so that they can be particularly responsive and sensitive to the child’s needs. This can be achieved by either working only with the caregiver or working with the caregiver and the child. Treatment is not typically conducted with only the child because that does not allow a clinician to address the core concern appropriately (3).
One of the first things that occur in therapy is trying to understand the relationship between the caregiver and child and provide support to the caregiver (8). The primary objective of the intervention is to help the caregiver and child form an attachment.
In other words, if a caregiver is overwhelmed, frustrated, and defeated, they may not be able to respond consistently and calmly to the child. If they cannot do this, attachment cannot be fostered. Therefore, it is important to acknowledge and support the caregiver’s own emotions and responses (8).
The most common treatment methodologies include relatively stress-free psychotherapies such as expressive therapy or play therapy. These treatments allow your child to interact with a professional, trusted, adult counselor in a way that is comfortable for them. They will guide their treatment by playing naturally or engaging in the arts, all while developing appropriate levels of discretion and attachment (22).
Research has already shown that symptoms of DSED can persist across childhood (15,23), and even into adulthood (24), but the Guyon-Harris et al. study goes deeper:(25) it adds new knowledge by examining different profiles in the course of DSED over time, and takes a closer look at factors that might be associated with reduction or persistence of DSED symptoms (26).
The research reveals that symptoms of DSED can persist throughout childhood and even into adulthood. The study identifies four profiles of DSED development: “minimal” (consistently low symptoms), “persistent modest” (low-to-moderate symptoms persisting over time), “early decreasing” (marked reduction in symptoms in early childhood), and “elevated” (high symptom scores throughout childhood, decreasing somewhat in adolescence) (25).
The findings demonstrate that early placement in foster care from an institutional context leads to a significant reduction in DSED symptoms for many children. However, the persistence of DSED symptoms is associated with longer periods of institutional care, older age at placement into foster families, and a higher number of placement disruptions (25).
In conclusion, Disinhibited Social Engagement Disorder (DSED) is a condition characterized by children showing a lack of reticence with strangers, engaging in overly familiar behaviors, and willingly going off with unfamiliar adults. This disorder can hinder the formation of relationships with peers and adults, placing children at risk of dangerous situations. The prevalence of DSED is not well established, but it is typically observed in a minority of children who have experienced severe neglect or have been raised in institutional environments. The etiology of DSED is complex, involving factors such as social neglect, frequent changes in caregivers, and limited opportunities to form stable attachments. The DSM-5 provides diagnostic criteria for DSED, emphasizing the pattern of socially disinhibited behavior and a history of insufficient care. A diagnosis is typically made through a psychiatric evaluation, considering the child’s behavior and interactions with both caregivers and unfamiliar individuals. Treatment focuses on repairing the relationship between the child and caregiver or establishing a bond with a new caregiver, aiming to improve sensitive caregiving and promote secure attachment. Therapy often involves the caregiver and child, with an emphasis on understanding the caregiver-child relationship and providing support. Common treatment approaches include expressive therapy or play therapy, which allows the child to interact with a trusted adult while developing appropriate boundaries and attachment. The prognosis for children with DSED tends to improve over time, with most symptoms diminishing significantly by the age of twelve.
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