# Disinhibited social engagement disorder

Disinhibited Social Engagement Disorder (DSED), or Disinhibited Attachment Disorder, is an attachment disorder in which a child has little to no fear of unfamiliar adults and may actively approach them. It can significantly impair young children's abilities to relate with adults and peers, according to the Diagnostic and Statistical Manual of Mental Disorders, as well as put them in dangerous and potentially unsafe conditions. Common examples of this include sitting on a person's lap of which they do not know or leaving with a stranger.
DSED is exclusively a childhood disorder and is usually not diagnosed before the age of nine months or until after age five if symptoms do not appear. There is no current research showing that signs of DSED continue after twelve years of age. Infants and young children are at risk of developing DSED if they receive inconsistent or insufficient care from a primary caregiver.

## Signs and symptoms

The most common symptom is unusual interaction with strangers. A child with DSED shows no sign of fear or discomfort when talking to, touching, or accompanying an adult stranger. They can be categorized by the following:
* Overly familiar verbal or physical behavior that is not consistent with culturally sanctioned and appropriate social boundaries or seems out of character for their current age
* Lack of reservation when it comes to approaching and interacting with unfamiliar adults
* 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
The attachment style associated with DSED is disorganized attachment. This attachment style is a combination of anxious and avoidant attachment and participants often have a need for closeness, fear of rejection, and contradictory mental states and behaviors. Disorganized attachment is common amongst children living in institutions such as foster care. Children living in these institutions have an increased risk of having DSED. Which is common in those who experience neglect from caregivers at an early age making it a common occurrence in children with DSED.
DSED can cause symptoms commonly associated with attention deficit hyperactivity disorder (ADHD) It can be comorbid with cognitive, language and speech delay. Additionally, children who are socially disinhibited despite not undergoing the trauma to become so should not be diagnosed with DSED. The child's behavior can be explained with other disorders such as Williams syndrome which often has similar symptoms to DSED.
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## Risk factors

DSED is a result of inconsistent or absent primary caregivers in the first few years of childhood. Children who are institutionalized may receive inconsistent care or become isolated during hospitalization. Parental issues such as mental health problems, depression, personality disorder, absence, poverty, teen parenting, or substance abuse interfere with attachment.

## Diagnosis

The ICD-10 definition is: "A particular pattern of abnormal social functioning that arises during the first five years of life and that tends to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused attachment behavior, attention-seeking and indiscriminately friendly behavior, poorly modulated peer interactions; depending on circumstances, there may also be associated emotional or behavioral disturbance."
Differential diagnosis can be attention deficit hyperactivity disorder.
Adolescents who exhibit symptoms of DSED can often be misdiagnosed due to several contributing factors, such as a history of neglect, an overidentifying or misidentifying of symptoms, and disregarding Comorbid conditions that could account for their symptoms. However, it is essential to mention the intersectionality between contributing factors and DSED and how they influence the symptomatic behavior of children diagnosed with DSES. For example, adolescents diagnosed with DSED and ADHD experience overlapping symptoms that are essential to identify, especially when considering treatment.

## Treatment

Two effective treatment approaches are play therapy or expressive therapy which help form attachment through multi-sensory means. Some therapy can be nonverbal.
Play Therapy: This is a therapy in which children use toys to “play” and interact with the environment in efforts to work through their problems and understand the world around them. In this therapy children can decide the outcome of situations giving them a sense of control. This is for children ages three to eleven and it can also be used as a means to diagnose a child. Also this type of therapy can be directed in attempts to better understand and diagnose the child. This is a psychodynamic and cognitive behavior therapy.

## Prognosis

Over time the nature of the behaviors of a child with disinhibited social engagement disorder can evolve during their preschool, middle school, and adolescence years. With this being said, most of the symptoms exhibited by children significantly lessen to the point of almost no detection after approximately twelve years of age.
Pre School: In this early stage DSED is exhibited by a need for attention such as being overly boisterous at the playground in attempts to get the attention of unfamiliar adults
Middle School: There are two main identifiers of DSED in this stage including physical and verbal overfamiliarity of inauthentic emotions and being overly forward. This can be seen as appearing sad in front of others in efforts to manipulate a social situation or being overly insistent upon going over a classmate's house when they first meet them.
Adolescent: Amongst this stage children with DSED are likely to develop problems amongst both their peers and other authoritative figures such as parents and coaches. With that being said “They [also] tend to develop superficial relationships with others, struggle with conflict, and continue to demonstrate indiscriminate behavior toward adults.”

## Epidemiology

The exact prevalence is unknown. In high-risk individuals, the prevalence rate is 20%.

## History

Disinhibited Social Engagement Disorder (DSM-5 313.89 (F94.2)) is the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) name formerly listed as a sub-type of Reactive Attachment Disorder (RAD) called Disinhibited Attachment Disorder (DAD).
The American Psychiatric Association considers "...Disinhibited Social Engagement Disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments. The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders."

## Research

This study was an attempt to solidify the current research that Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are separate dimensions of psychology. In this study a sample of school aged foster children were tested and their foster parents, and social workers completed questionnaires to better understand the children and to pinpoint signs of DSED. Amongst completion it was evident that DSED was indeed its own separate dimension of psychology.