What is Disinhibited Social Engagement Disorder?
Disinhibited social engagement disorder (DSED) is a mental health-related issue in which a child doesn’t form healthy emotional bonds or relationships with caregivers, guardians, or parents. Instead of forming typically close bonds with parents or caregivers, the child treats strangers with an atypical lack of fear, shyness, or inhibition.
DSED is most common in children who have experienced neglect or abuse in early childhood. The disorder is especially common in children who have come from an unstable home environment and have been placed in foster care or some other institutional setting.
DSED is considered an attachment disorder similar to reactive attachment disorder (RAD). Although DSED and RAD have similar features and may stem from similar causes, children with RAD typically do not have an unusual openness toward strangers.
Symptoms of DSED
DSED symptoms usually begin early in childhood, even sometimes in infancy. Common symptoms include:
- Showing little or no fear or inhibition when meeting adult strangers
- No shyness when meeting new people
- Inappropriate shows of affection to strangers (e.g., hugging or kissing)
- Not needing or seeking permission from caregivers to approach strangers
- No fear or anxiety when leaving caregivers with strangers
What Causes Disinhibited Social Engagement Disorder?
The cause of DSED is not yet known. Many different factors in a child’s life may increase the risk of DSED, but not every child exposed to those situations develops the disorder. Scientists don’t yet understand why some children experience DSED and others don’t. However, it is clear that certain risk factors significantly increase the chance that a given child will experience DSED.
Risk factors include:
- Experiencing neglect or abuse (physical, emotional, or sexual)
- Experiencing food insecurity or dangerous situations at home
- Experiencing trauma or violence
- Having parents who struggle with mental health issues or substance abuse
- Having parents who engage in criminal activity
- Being separated from parents or caregivers
- Frequently changing caregivers or foster homes
- Living in a group home or other institution
Is Disinhibited Social Engagement Disorder Hereditary?
Some scientists believe that there is a genetic component to attachments disorders like DSED. However, no specific gene or genes have yet been associated with DSED. Some children may have a genetic predisposition that puts them at increased risk for developing the disorder, which is then triggered by external circumstances.
How Is Disinhibited Social Engagement Disorder Detected?
Sometimes symptoms of DSED may appear very early in childhood. Warning signs of DSED in very young children may include:
- No fear or hesitation in approaching strangers
- Eagerness to talk to or express affection toward strangers
- No anxiety when required to leave caregivers and go with strangers
- Not looking to caregivers for cues about how to react to strangers
How Is Disinhibited Social Engagement Disorder Diagnosed?
Diagnosis of DSED begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that DSED or another mental health issue is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.
Diagnostic steps may include:
- A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The results of the psychological assessments will be compared to the diagnostic criteria for DSED in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for DSED include:
- The child exhibits a pattern of behavior in which they inappropriately approach or interact with adult strangers.
- The behavior is social and not the result of impulsivity, as in attention-deficit/hyperactivity disorder (ADHD).
- The child has experienced negative circumstances that are presumed to have caused the symptoms.
- The child is at least nine months old.
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Is Disinhibited Social Engagement Disorder Treated?
There is no cure for DSED. However, early intervention may help control the disorder’s symptoms. Psychotherapy is the most common course of treatment, and treatment options typically include both the child and their caregivers.
Types of therapy commonly used to treat DSED include:
- Play therapy
- Art therapy
- Family therapy
- Parent training
- Social skills training
How Does Disinhibited Social Engagement Disorder Progress?
DSED is considered a childhood disorder, and symptoms usually improve or resolve by adolescence. There is little evidence that DSED continues into adulthood. However, long-term research on children with DSED is sparse, and its potential effects after childhood are still largely unknown.
While the long-term impact of DSED is unclear, the disorder presents dangers in childhood. Because children with DSED lack appropriate inhibition in their interactions with strangers, they are at risk of inadvertently entering into dangerous situations. Caregivers should monitor the child’s interactions with unknown adults.
How Is Disinhibited Social Engagement Disorder Prevented?
Scientists are unsure whether DSED is preventable, but it seems certain that providing a child with a caring, supportive, safe environment during their early development is likely to reduce the child’s risk.
Disinhibited Social Engagement Disorder Caregiver Tips
Caregivers can help to reduce the risk of DSED by following some simple guidelines as they care for children:
- Provide a consistent, reliable, emotionally supportive relationship with the child.
- Consistently meet the child’s basic needs for food, shelter, hygiene, medical care, and other essentials.
- Give the child your consistent attention.
- Set limits, and be consistent with rules.
Many people with DSED also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with DSED:
Disinhibited Social Engagement Disorder Brain Science
Some scientists suspect that abuse or neglect during specific critical periods of a child’s development could lead to structural changes in the child’s brain. However, it’s unclear exactly how these changes could be responsible for DSED symptoms.
One study used magnetic resonance imaging (MRI) to examine the brains of children with attachment disorders. The study found several potentially significant associations between the children’s brain development and their past traumas, including:
- Children with attachment disorders showed smaller than typical brain volume in a rear part of the brain called the visual cortex.
- Children exposed to abuse or neglect between the ages of 5 and 7 showed the most significant decreases in visual cortex volume.
- The more different types of mistreatment experienced by the child, the greater the effects on the brain.
- Children who experienced neglect showed more reduction in brain volume than those who experienced other types of mistreatment.
Disinhibited Social Engagement Disorder Research
Title: Promoting Infant Mental Health in Foster Care
Principal investigator: Susan J. Spieker, PhD
University of Washington
Infants who enter foster care are at risk of developing multiple social and emotional problems later in life. These behavioral issues often result in foster children being placed with multiple different families during their childhoods. In turn, unstable family life can lead to serious conduct disorders and mental health problems. The infants’ loss of their first attachment relationship heightens the risk of developing these problems, even if the quality of care was poor prior to removal. Infants’ reactions to this loss, combined with other vulnerabilities, complicate the development of new secure attachments to their foster care families. Garnering a secure attachment relationship between foster parents and foster infants may reduce the infant’s risk of developing problematic mental health and conduct issues. PFR is a family therapy intervention focused on aiding foster care parents to cultivate secure attachments with their foster infants. This study will evaluate the effectiveness of the PFR program versus an EES program in promoting attachment security and infant well-being, preventing emotional and behavioral problems, countering developmental delay, and reducing placement instability in young foster care children.
Participants in this single-blind study will be randomly assigned to receive either PFR or EES. Both interventions will be administered by a trained staff member of a community agency. Participants assigned to PFR will receive ten weekly home visits that will focus on promoting the development of a secure attachment between foster parents and infants. EES will consist of three monthly home visits, during which infants will be assessed and referred for additional care if necessary. EES participants will not receive any training. Outcomes will be assessed at 1, 6, and 12 months post-intervention for all participants.
Title: Promoting Caregiver-child Attachment and Recovery Through Early Intervention (pCARE): A Pilot Randomized Control Trial (pCARE)
Principal investigator: Elizabeth Peacock-Chambers, MD, MSc
Baystate Medical Center
The purpose of this study is to use the existing infrastructure and therapeutic relationships developed by Early Intervention, a national system of child development programs, to make an evidence-based intervention for parents with substance use disorder, Mothering from the Inside Out, more readily accessible to postpartum women with substance use disorder. This study will assess the feasibility, acceptability, and preliminary outcomes of the intervention in a pilot randomized controlled trial. Researchers will also identify key implementation domains that impact successful delivery. They hypothesize that the intervention will be feasible and acceptable to the study participants.
Title: Effectiveness of a Parent Training Program for Parents of Children Adopted Internationally
Principal Investigator: Mary Dozier, PhD
University of Delaware
Children adopted internationally by parents in the United States often experience institutional care before adoption. Early institutional care may lead to inattention, deficits in inhibitory control, and insecure attachments in children. Many of these problems persist even after the child is adopted. This study will test the effectiveness of a parent training program called Attachment and Biobehavioral Catch-up for Children Adopted Internationally (ABC-I). This program is designed to enhance children’s ability to regulate their attention, behavior, and physiology and develop secure, organized attachments to their parents.
Participation in this study will begin when the child participant is between 12 and 20 months old, and it will end when the child is four years old. Participants, who will include parents and their adopted child, will meet with the study researchers three times before receiving the training program intervention, twice in their home and once at the research site. During these visits, the background and medical history of the child participant will be reviewed. Participants will then be randomly assigned to receive 1 of 2 parent training programs: ABC-I or Developmental Education for Families (DEF). Both programs will involve ten weekly sessions, each lasting 60 to 90 minutes and occurring in the parents’ homes. The DEF training program will focus on enhancing the intellectual and language development of the child participant, but it will not train parents to pay attention to and interpret their children’s cues. The ABC-I training program will involve videotaping parents while they interact with their children, reviewing the videotapes, discussing strategies for interacting with children, and completing homework assignments.
Participants will undergo assessments before and after the training programs and during follow-up visits when each child turns 2, 3, and 4 years old. Assessments will be made of sensitivity in parents and inattention, inhibitory control, attachment quality, and cortisol production in children. Parent sensitivity will be measured by observing parent-child interactions and coding them according to a pre-existing scale. Child inattention and inhibitory control will be measured by observing each child’s behaviors on various structured tasks, such as watching a video with a distracter present or being told to wait to open a wrapped gift. Attachment will be measured through observation of child behavior and through parent ratings and diaries. Cortisol production will be measured through a saliva sample collected via a cotton swab. When children are four years old, they will also be evaluated for diagnosable behavioral disorders. For a subset of children, cheek swabs will be collected at age 5-6 to assess telomere length.