Disinhibited social engagement disorder (DSED) is a relatively rare mental health condition that typically stems from early childhood neglect or inconsistent caregivers. A child with DSED will appear fearless around new adults, seek attention or comfort from strangers, and often wander off with unfamiliar people. Therapeutic interventions can help, but having consistent, caring adults in the child’s life is the best way to reduce DSED symptoms.
Symptoms of DSED
Symptoms of DSED will be expressed in the varied interactions and instances of communication between the child and any adults in their life. The child with DSED may have limited insight and understanding into the condition, so their ability to verbalize their thoughts and feelings may be minimal. Caring adults will need to observe their actions and behaviors to identify the presence of disinhibition around strangers.1
Like other mental health conditions, DSED follows a set of diagnostic criteria. To be diagnosed with DSED, two of four specific symptoms must be present.
The four symptoms of DSED are:1
- Reduced or absent restraint when approaching or interacting with unknown or unfamiliar adults
- An overly comfortable and familiar exchange with the unknown adults, either through verbal or behavioral interactions
- Limited interest in checking in with caregiver to gain assurance or allowance for behaviors and actions
- A willingness to go to new situations or leave current settings with strangers
Another defining factor of DSED is that the child is at least nine months old. No one under the age of nine months can receive the DSED diagnosis.1 Though there is no upper age limit on the condition, experts rarely observe the disorder into adulthood.
Causes of DSED
Simple impulsivity or spontaneity is not enough to qualify a child with DSED. The child and their disinhibited social interactions cannot be sourced from attention-deficit/hyperactivity disorder (ADHD), autism, or any other mental or physical health condition. Rather, it must stem from the insufficient care they received earlier in life.2
Here are three potential causes of DSED:1
- Social neglect or deprivation: The adults were not able to meet the child’s needs related to comfort, attention, or affection
- Repetitive changes in caregivers: The people primarily responsible for childcare were frequently shifting or being inconsistent, like in the case of everchanging foster care placements
- Being raised in environments with limited access to relationships: Places where the number of children far outweighed the number of adults, so the child could not form a strong attachment (e.g., institutions and residential centers with high child-to-staff ratios)
Signs of DSED
At first, the signs of DSED may be challenging to identify and differentiate from normal childhood behaviors. An adult may benefit from a series of observations to begin noticing patterns of interactions with unfamiliar adults. Initially, a child with DSED may seem outgoing, social, and friendly, which would all be positive qualities, but as time goes on, the observer can note how extreme and atypical the behaviors become.
Potential signs of disinhibited social engagement disorder include:3
- A willingness to have relationships with any adult or peer without regard of the person’s age, status, or safety level
- Cuddliness with strangers
- Seeking comfort from strangers, rather than hoping to be soothed by guardians
- Asking a list of personal questions to strangers that may be inappropriate, uncomfortable, or rude
- Entering people’s person space without their consent and ignoring social cues
- Freely exploring new settings and situations without consulting or checking in with guardians
- Leaving situations with new people or following strangers around
- Displaying behaviors that are demanding or attention-seeking
Examples of DSED
A child with DSED could display some or all of these symptoms at any one time. Alternatively, the child’s symptoms could change and evolve over time to incorporate new signs and symptoms of the condition.
Here are three examples of the ways DSED could manifest:
Example 1
A child with DSED may be walking through a park, notice a stranger’s shoes, and comment that they like the shoes. Alone, this comment is not significant, but then the child could try to enter into a long conversation with the adult and ask them a long list of personal or inappropriate questions, despite no prompting or encouragement.3
Example 2
Another child with DSED could meet a new adult at a party or school function and quickly encroach on the adult’s personal space. After no time knowing each other, the child could ask for hugs, kisses, or sit on the adult’s lap. They could even start cuddling with the adult in an attempt to receive the desired level of comfort that they have been unable to achieve in the past.3
Example 3
A third variation of a child with DSED is one that will quickly leave the security of their guardian to be with strangers or struggles to make healthy peer relationships and will spend time with anyone, regardless of their age, danger, or safety.
Risk Factors of Disinhibited Social Engagement Disorder
Some mental health disorders have causes and risk factors that are confusing or unclear, but with DSED, the roots of the condition are almost always obvious. Disinhibited social engagement disorder stems from childhood neglect, especially neglect that occurs during the first two years of life.1 The actual roots of this neglect are varied and can arrive from multiple sources.
Here are six causes of DSED that are linked to childhood trauma:
- Death of a parent
- Parental divorce or separation
- Incarceration of parents or guardians
- Placement in the foster care system
- Being housed in a residential treatment center
- Limited attention from parents due to substance use, low intellectual functioning, or mental health concerns
Whatever the source of the neglect, children with DSED routinely try to overcompensate for the limited attention, comfort, and connection by forming new bonds with other adults and strangers. Since the children are typically young, they will not have the memory, insight, or understanding to put this need into words, but their behaviors will show how they are desperately looking for love and attention.
An interesting aspect of DSED is that not all children who endure severe neglect during childhood will develop this condition. In fact, the incidence of DSED is so rare that true prevalence rates are difficult to measure.1 Among children who are neglected to the point that residing in foster care or another out-of-home placement is necessary, only about 20% of them will meet criteria for the DSED diagnosis.1 2
DSED vs. Normal Development
Typical childhood behavior will stand in sharp contrast to children with DSED. These children will require no time to appear comfortable and confident in a new setting around new people. For a moment, they may simply appear friendly or outgoing, but the complete lack of social, emotional, and physical boundaries will become obvious over time.
How Does a Child With DSED Develop Over Time?
When someone experiences neglect and high levels of inconsistent caregiving before age two, they have increased risk of DSED. Once symptoms of DSED emerge, they tend to be fairly consistent over time, especially when neglectful conditions persist.1
Younger children and toddlers may express their DSED through overly familiar social interactions with strangers and a lack of hesitation with unknown adults. In preschoolers, the symptoms may shift towards more attention-seeking behaviors. Children from this age group may act in intense or exaggerated ways to gain more concern and affection from adults around them.1
School aged children with DSED will show overfamiliarity with new adults in verbal and physical ways. They could ask inappropriate questions or be quick to sit on their laps or ask for hugs. Rather than expressing emotions in an authentic way, they may use emotional reactions as a way to manipulate others.1
During adolescence, people with DSED will struggle with peer interactions. They tend to have chaotic and inconsistent relationships with other kids their age.1
Experts have not observed symptoms of DSED in adults, but it is unlikely that the condition simply alleviates spontaneously. It’s more likely that the disorder shifts and morphs into other mental health diagnoses more associated with adulthood like depression, anxiety, bipolar disorder, and personality disorders.4
Risks & Consequences of DSED
Based on their inability to discriminate between safe and threatening adults and caregivers, children with DSED may find themselves exposed to a list of dangerous risks and consequences. These risks may not end with childhood and could extend well past adolescence and into adulthood.
Possible risks and consequences of DSED are:
- Increased likelihood of physical, emotional, or sexual abuse
- Higher risk of exploitation and manipulation
- Danger of becoming injured due to wandering off into unsafe situations like walking into traffic, falling, or entering a swimming pool without being able to swim
- Feeling disenfranchised and pessimistic about people and the world, which can lead to mood disorders
- Higher likelihood of experimenting with alcohol and other drugs as a way to connect with peers or self-medicate
DSED seems to create lifelong complications, so the risks and consequences of the condition are endless. Worse, the person with DSED may not identify these situations as risky as they feel compelled to act in these ways.
Treatment of Disinhibited Social Engagement Disorder
Treatment for disinhibited social engagement disorder is a complicated and uncertain process as even the best professional treatment can not undo the symptoms caused by ongoing instability. With a combination of therapeutic interventions and parent training, the child, their guardians, and their treatment team may begin to notice symptoms of DSED improve.
To produce any helpful change with DSED, the first step is ensure that the child has an emotionally available attachment figure. Ideally, this attachment would come from a parent or guardian who is available in the home. Without consistency and stability at home, the treatment of DSED will be severely hindered.2
Medication
At this point, there is no medication recommended or prescribed to children with DSED.2 Some children with DSED may also have ADHD, anxiety, or depressive disorders and could benefit from medications to address these symptoms. By treating these co-occurring conditions, the overall treatment of DSED can improve. Medical professionals like primary care physicians (PCPs), psychiatrists, and nurse practitioners may offer medications to address other mental health disorders.
Therapy
With the limited ability of medications to directly address symptoms of DSED, therapy will be the primary form of treatment. Options like cognitive behavioral therapy (CBT), play therapy, expressive arts therapy, and parent-child interaction therapy (PCIT) will be helpful in reducing symptoms of DSED.
Before any discussion of therapy choices for DSED, it is essential to understand how unhelpful and potentially damaging some treatment styles could be. According to the Journal of the American Academy of Child and Adolescent Psychiatry, children with DSED should never be exposed to these interventions:2
- Therapeutic holding or compression holding
- Rebirthing therapy
- Reattachment therapy
Not only is there no evidence to support the use of these interventions, but these “treatments” have been linked to serious harm, including death.
CBT
CBT is one of the best therapy styles for addressing a wide range of conditions. It should come as no surprise then that it is helpful for DSED as well. Other versions of CBT focus on training the client to understand that thoughts, feelings, and behaviors are all interconnected in their influence.
CBT can also focus on:
- Communication skills
- Relaxation
- Stress reduction
- Mindfulness
- Problem-solving skills
With DSED, much of the CBT treatment will be focused on training the parent or guardian to use behavior management skills. Behavior management training (BMT) helps give the caregiver skills to establish reasonable expectations and boundaries for the child.5
Play Therapy & Expressive Art Therapy
Play therapy and expressive arts therapy allow the young child to communicate their experiences, struggles, and feelings without the use of verbal disclosure. By playing with toys, drawing, creating projects out clay, making music, or writing a poem.
Therapists work to interpret and praise this level of communication. The child benefits from expressing and processing the thoughts that may be unable or unwilling to put into words.
These treatments are especially helpful since the child may not have conscious memory of their neglectful situations. They may only experience thoughts, feelings, and behaviors that they do not fully understand.
Parent-Child Interaction Therapy
Parent-child interaction therapy (PCIT) is a highly-structured treatment protocol that emphasizes the relationship between the child and their caregivers. PCIT involves a therapist observing the interactions between the client and their guardians through a two-way mirror, while giving feedback to the adult through an earpiece.
Through teaching, prompting, and encouragement, the therapist helps the adult shift their relationship with the child towards one based on respect, trust, and support. This move towards a healthier relationship is just what a child with DSED needs the most.5
DSED & Caregivers
Issues between a child and their caregivers are both the cause and effect of DSED. Caregivers dealing with the effects of DSED will endure many frustrations and periods of confusion, but they should always focus on doing their best to remain consistent, stable, caring, patient, and understanding. Without these qualities, the child with DSED will struggle to improve.
Like with other conditions that stem from a form of trauma, it may be challenging to continue seeing the child as the victim as they are consistently breaking the rules by wandering off and spending time with strangers. Caregivers can improve the situation tremendously by focusing on the condition and how the condition significantly impacts the child well after the neglect ends.
Final Thoughts on Disinhibited Social Engagement Disorder
If your child has DSED, you know the struggle that exists for them, but you also see how the condition affects the people around them. Take action as soon as possible to receive treatment for the entire family from a treatment team who is skilled in the rare condition. Progress with DSED may be slow, but it is always possible.
