Disinhibited Social Engagement Disorder (DSED): What It Is, Symptoms, & Treatments

What Are Attachment Disorders?

Attachment disorders are a group of psychological and behavioral disorders that can develop in those who have not formed secure emotional attachments with their primary caregivers during early childhood. These disorders can have significant and lasting effects on social, emotional, and cognitive development.

There are two main types of attachment disorders:¹

• Reactive Attachment Disorder: Reactive attachment disorder (RAD) typically occurs in children who have experienced severe neglect, abuse, or frequent changes in caregivers during their early years. Children with RAD struggle to form meaningful and trusting relationships with others. They often avoid physical or emotional closeness, resist comforting, and exhibit difficulty in regulating their emotions. RAD can lead to problems in social interactions, academic performance, and overall emotional well-being.
• Disinhibited Social Engagement Disorder: DSED is characterized by a lack of fear or hesitation when approaching unfamiliar adults. Children with DSED may not understand or respect social boundaries, making them overly friendly and willing to go off with strangers. This behavior is unusual and not in line with typical cultural norms. Like RAD, DSED often results from early neglect or lack of stable caregiving.

Disinhibited Social Engagement Disorder Symptoms

Symptoms of DSED present during 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

The four main DSED symptoms are:¹

1. Reduced or absent restraint when approaching or interacting with unknown or unfamiliar adults
2. An overly comfortable and familiar exchange with the unknown adults, either through verbal or behavioral interactions
3. Limited interest in checking in with caregiver to gain assurance or allowance for behaviors and actions
4. A willingness to go to new situations or leave current settings with strangers

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. 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.

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.

Outward Signs & Characteristics 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

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 personal questions to strangers that may be inappropriate, uncomfortable, or rude
• Entering people’s personal 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

Disinhibited Social Engagement Disorder in Adults

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

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 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

1. Social neglect or deprivation: The adults were not able to meet the child’s needs related to comfort, attention, or affection
2. 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
3. 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)

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.

The risk factors of DSED that are linked to childhood trauma include:

• 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

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:

• 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
• 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
• 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.

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 include:

• 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.

How Is Disinhibited Social Engagement Disorder Diagnosed?

Diagnosis and treatment of attachment disorders typically involve comprehensive assessments by mental health professionals, and therapeutic interventions such as attachment-based therapy, play therapy, and family therapy. Early intervention and a stable, nurturing environment are essential for helping children with attachment disorders develop secure and healthy relationships.

Common Comorbid Conditions

Children with DSED often have an increased risk of developing comorbid conditions, including:⁶

• ADHD: ADHD commonly co-occurs with attachment disorders. Children may have difficulty focusing, impulsivity, and hyperactivity, which can further complicate their social interactions and academic performance.
• PTSD: Children with attachment disorders often have a history of trauma, neglect, or abuse, which puts them at higher risk for developing PTSD. Traumatic experiences can lead to persistent anxiety, flashbacks, and emotional numbing.
• Developmental disorders: Children with attachment disorders might experience developmental delays, speech and language disorders, or learning disabilities. Early trauma or neglect can impact cognitive and physical development.
• Behavioral disorders: Conduct disorder, oppositional defiant disorder, and other disruptive behavior disorders are frequently comorbid with attachment disorders. Children with attachment issues may display aggressive behavior, defiance, and problems following rules.
• Mood disorders: Depression and anxiety disorders are common in individuals with attachment disorders. The lack of secure attachment can lead to emotional dysregulation, low self-esteem, and persistent feelings of sadness or worry.
• Personality disorders: In some cases, attachment disorders can be associated with the development of personality disorders, especially borderline personality disorder. They may have unstable relationships, self-image, and emotions.

Disinhibited Social Engagement Disorder Treatment

Treatment for disinhibited social engagement disorder is a complicated and uncertain process, as even the best professional treatment cannot 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

Cognitive Behavioral Therapy (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

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.

Caring for Your Child With DSED

Issues between a child and their caregivers are both the cause and effect of DSED.

If you’re caring for a child with DSED, here are some tips:

Be a Source of Continued Structure & Unconditional Support

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.

Focus on the Condition, Don’t Blame the Child

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.

Emphasize Social Norms & Safe Boundaries

It is important to maintain firm, fair, and consistent boundaries. Be firm in your discipline but also fair and consistent. Consistency helps the child understand the consequences of their actions.

Take Safety Precautions

If you have a young child who wanders frequently, consider dressing your child in bright colors and making sure they have your phone number memorized—or they could wear a bracelet with your number on it. Help them develop a safety plan and have safe places and people they can also go to. Work closely with the child’s school and teachers. Advocate for the child’s needs and ensure they receive appropriate support and accommodations.

Take Care of Your Own Well-Being

Caregivers often experience stress and burnout. Don’t hesitate to seek support from therapists, support groups, or friends who understand your situation. It’s okay to take breaks when needed. Respite care can provide temporary relief for caregivers.

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.