Disinhibited social engagement disorder (DSED) is an attachment disorder. It may make it difficult for children to form deep, meaningful connections to others. It’s one of two attachment disorders that affect children younger than 18 years — the other condition is reactive attachment disorder (RAD). Both DSED and RAD are seen in children with a history of trauma or neglect. DSED requires treatment and won’t go away on its own.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), children must have at least two of the following symptoms to be diagnosed with DSED:
- intense excitement or a lack of inhibition over meeting or interacting with strangers or unfamiliar adults
- behaviors with strangers that are overly friendly, talkative, or physical and not age-appropriate or culturally acceptable
- willingness or desire to leave a safe place or situation with a stranger
- lack of desire or interest in checking in with a trusted adult prior to leaving a safe place, or in a situation that seems foreign, strange, or threatening
Children with DSED are at an increased risk of harm from others because of their willingness to connect with strangers. They have trouble forming loving connections with other children and adults.
DSED can be caused by one or more factors. Cases typically include the absence of a solid, long-term caregiver. A caregiver is someone who:
- meets the child’s needs
- spends time teaching the child
- feeds, shelters, and provides emotional support for the child
Some children diagnosed with DSED come from institutionalized settings with a high caregiver-to-child ratio, such as orphanages. Kids in foster care who are shuttled between households repeatedly or who never get adopted may also have DSED.
Childhood trauma, extreme abuse, or neglect also put kids at risk if the child doesn’t have a caring adult to make the experiences less traumatic.
Situations that may increase a child’s risk are:
- the death of one or both parents
- being raised by an absentee parent or one with a history of substance abuse
- early sexual abuse
Getting a diagnosis
Distinguishing from normal behavior
Not every child who is eager to make contact with strangers has DSED. Typically developing toddlers hit milestones based on independence and physical separation from parents. These children may explore away from their caregivers and gravitate towards others. Some children have naturally outgoing personalities and may approach other adults in an overly enthusiastic way.
In both instances, you may observe your child looking for you and making sure you’re nearby as they explore the world of other people. It’s the bond children have with their caregivers and the knowledge that there is someone committed to keeping them safe that allows for this type of exploration. In this way, typical outgoing kids differ from those with DSED.
When to see a doctor
Talk to your child’s pediatrician or school counselor if they regularly:
- show no healthy fear of strangers
- have no inhibition about leaving a safe place
- connect with strangers
Diagnosis is usually made by a mental health professional, such as a therapist or psychiatrist. The doctor will do comprehensive psychiatric assessment over several visits. These visits may take place in one or more locations. The doctor will ask you and the child questions to assess the child’s:
- emotional development
- mental state
- current functioning
- medical history
- life history
Based on the child’s age, the doctor may use toys, such as stuffed animals, puppets, or paper and crayons, as communication props.
If the child is diagnosed with DSED, the doctor will create a highly-individualized treatment plan. The plan will be geared towards healing the child’s trauma and supporting their ability to form meaningful, close relationships with others.
Treatment for DSED usually includes the child’s entire family unit. Talk therapy may occur individually and in groups. Psychotherapeutic treatments meant to put the child at ease may include play therapy and art therapy.
The adults who care for the child will be given tools to help them improve everyday interactions and help the child feel cared for and safe. The caregiver’s learning how to help the child feel secure is necessary for healthy attachments to form.
Improvements may be seen gradually or quickly, depending on the child’s age and situation. Even if improvement seems fast, remember that there is no quick fix. Children often regress in behavior and show suppressed feelings of anger or other emotions. It’s important to consistently implement treatment tools while also maintaining a therapeutic, caring relationship.
DSED is a serious condition, but recovery is possible with treatment. This condition will not improve on its own. Long-term, consistent treatment, a caring relationship, and the desire to provide the child with a stable, safe environment, are key.
Q&A: Childcare providers and DSED
Q: Do daycare or high student-to-teacher ratio classrooms increase the risk of DSED?
A: There is no research that would suggest that this is an issue. Recall that these disorders involve how the child bonds with the caregiver. While the child may be uneasy in situations with strangers involved in daycare and school, if the child has developed a good bond with their primary caregiver, then that is the bond that gives the child the sense of security they need. While being in a daycare or going off to school may be stressful for the child, they will soon learn that the caregiver does go away at times, but returns and remains a constant support of nurturance. — Timothy J. Legg, PhD, CRNP