What is Disinhibited Social Engagement Disorder?

July 16, 2021

Disinhibited social engagement disorder is classified as an attachment disorder. A young child or adolescent who struggles with disinhibited social engagement disorder may find it challenging to form meaningful, deep connections to others, including parents and caregivers. It is one of two attachment disorders that affect children younger than 18 years of age. The other condition being reactive attachment disorder. Both conditions are seen in children and adolescents with a history of childhood trauma or neglect. Disinhibited social engagement disorder is not a mental health condition that will go away on its own and requires comprehensive treatment at a treatment center like Hillcrest with treatment providers skilled in addressing the unique needs of child and adolescent mental health.

What Causes Disinhibited Social Engagement Disorder

Several factors are believed to lead to disinhibited social engagement disorder in children and adolescents. Some of the more common causes center around the absence of a long-term solid caregiver presence. A caregiver is defined as someone who spends time teaching the child and meets their basic needs (food, shelter, emotional support). Some children diagnosed with disinhibited social engagement disorder have a background in the foster care system or orphanages. In these instances, children struggle with a high caregiver-to-child ratio or struggle with moving from home to home throughout their childhood. Also, some children who are not adopted out of the foster care system may have an increased likelihood of developing disinhibited social engagement disorder.

Another potential set of causes relates to childhood trauma. This can come in the form of traumatic experiences, abuse, or childhood neglect. In these situations, neglect can lead to an increased risk of disinhibited social engagement disorder because children lack a caring adult to make experiences less traumatic. Examples of traumatic experiences that can increase the risk for disinhibited social engagement disorder may include sexual abuse, absentee parents, parents with a history of substance abuse, or the loss (death) of one or both parents at an early age.

How to Recognize Disinhibited Social Engagement Disorder

The Diagnostic and Statistical Manual of Mental Disorders (5th Edition) or DSM-5 indicates disinhibited social engagement disorder is (typically) recognized by the presence of specific symptoms. For a mental health provider to reach a diagnosis for disinhibited social engagement disorder, your child or adolescent must present two or more of the following symptoms related to social behaviors.

  • Acting overly friendly, talkative, or physical with strangers. This behavior can also include behaviors that are not age-appropriate, socially, or culturally acceptable.
  • Exhibiting a willingness or desire to leave a safe place (such as home, restaurant, or other settings) or situation with a stranger.
  • Strong excitement or lack of inhibition over meeting and interacting with strangers or adults who are unfamiliar to the child.
  • Notable lack of desire or interest in checking in with a trusted adult prior to leaving a safe space or a situation that seems foreign, strange, or threatening.

How is Disinhibited Social Engagement Disorder Diagnosed

It is important to note that not all children who are excited to talk to or socialize with strangers have or could have disinhibited social engagement disorder. As many toddlers grow and develop, they hit healthy developmental milestones characterized by independence and physical separation from parents or caregivers. Some children may seek to explore their surroundings and environment away from known adults and gravitate towards other adults in the area. Also, some children are naturally more “outgoing” than others and can seem overly enthusiastic when interacting with strangers.

In most cases, these children will still look to ensure their parent or caretaker is nearby and accessible. Children in these instances still want to know someone is there to protect them and keep them safe should there be potential for harm. This is the primary difference between “typical” toddler and adolescent growth and development and a child who may meet the diagnostic criteria for disinhibited social engagement disorder. Suppose you notice your child has limited or no inhibitions about leaving a safe place (either alone or with a stranger), does not have what is considered a healthy fear or concern about strangers, or regularly connects with strangers. In that case, it is important to reach out to their primary care provider.

As previously mentioned, a diagnosis of disinhibited social engagement disorder requires the presence of at least two of the above symptom patterns. In most cases, a primary care provider will refer you to a mental health professional such as a psychiatrist or a therapist at Hillcrest specialized in treating adolescent mental health conditions. During a series of appointments with a mental health professional, they will work with your child to complete a comprehensive psychiatric assessment. This occurs over several visits to one or more locations. As part of the comprehensive assessment, the mental health professional will as questions to assess your child’s mental state, current functioning, medical history, life history, and emotional development. Depending on your child’s age, they may utilize tools including toys, stuffed animals, paper, crayons, play dough, communication props, or puppets.

If your child meets the diagnostic criteria for disinhibited social engagement disorder, your provider will work with your family to create a highly individualized, evidence-based treatment plan that addresses your child’s specific treatment needs. The goal of the treatment plan will be to heal any underlying trauma and improve your child’s ability to form close and meaningful relationships with others.

How is Disinhibited Social Engagement Disorder Different from Reactive Attachment Disorder?

Both disinhibited social engagement disorder and reactive attachment disorder are childhood attachment disorders often rooted in unsupported or inadequate care environments. Children with disinhibited social engagement disorder typically externalize the effects of ineffective caregiving, whereas children with reactive attachment disorder internalize the impact. Children who struggle with disinhibited social engagement disorder may be attached to a caregiver. However, they also can be equally (if not more) comfortable with strangers and the idea of seeking solace and comfort in strangers.

Reactive attachment disorder differs from disinhibited social engagement disorder in one key way. Where children with disinhibited social engagement disorder will show signs of attachment, children with reactive attachment disorder do not show signs of attachment to anyone, including their primary caregiver. They will not seek comfort for stressful experiences, and when comfort is offered, they will not respond. Additionally, disinhibited social engagement disorder symptoms may continue even in the presence of adequate care; however, symptoms of reactive attachment disorder typically resolve with access to a healthy caretaking environment and attachment figure.

Disinhibited Social Engagement Disorder Statistics

Research indicates a strong link between inadequate caregiving environments or environments of childhood trauma and the development of disinhibited social engagement disorder. Recent statistics show as many as 22% of children who have experienced trauma as part of the foster care system and 20% of children who have been institutionalized or in an orphanage go on to develop disinhibited social engagement disorder. Additionally, 49% of children adopted out of home between the ages of six and eleven have a disinhibited social engagement disorder diagnosis, and 1.4% of attachment disorders are seen in school-aged children with inadequate home environments where basic needs are often unmet.

Co-Occurring Disorders and Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder presents during a child’s formative years (generally between birth and age eight). This is a period of significant social, emotional, physical, and cognitive development. Substantial portions of a child’s development during this time relate to how they experience and respond to their environment and surroundings. Inadequate caregiving during this time can lead to struggles with development and cognitive delays. Some studies indicate the inadequate caregiving that often leads to disinhibited social engagement disorder can also lead to hyperactivity and behavioral aggression in toddlers entering kindergarten.  It is important to note, although some symptoms of disinhibited social engagement disorder are similar to attention-deficit hyperactivity disorder, the two diagnoses are not the same.

How is Disinhibited Social Engagement Disorder Treated?

A comprehensive treatment program for disinhibited social engagement disorder often includes the child and their entire family unit. Therapy sessions often include talk therapy and other forms of family therapy. These sessions may consist of group and individual therapy sessions and will use treatment models and methods designed to put the child at ease with the process. Common examples include play therapy and art therapy.

Adults and family members who act as primary caretakers will learn and practice tools to help improve interactions within the family unit. These tools are designed to help the child struggling with disinhibited social engagement disorder feel cared for and safe as part of the family unit. It is essential for caregivers to learn how to help foster these emotions, as security and safety are vital elements of healthy attachment formation.

Depending on the child (their age, developmental stage, and other unique characteristics), improvements may be quick or gradual. It is important to remember that there is no immediate “cure” for disinhibited social engagement disorder, and healing takes time, persistence, and patience. It is not uncommon for children to regress in behavior or show emotions such as anger, suppressed feelings, or other emotions that appear new. It is essential to continue using the tools learned during therapy while maintaining a caring and supportive relationship.

Although disinhibited social engagement disorder is a serious condition, it is possible to recovery with comprehensive, evidence-based treatment. Disinhibited social engagement disorder will not “go away” on its own. Healing for both the child and their family requires long-term, consistent treatment and the desire to continually provide the child with a stable and safe environment. If you are concerned about your child and would like to learn more about disinhibited social engagement disorder and our youth-focused programs at Hillcrest, contact our admissions team today. Let our highly-skilled, caring, and compassionate treatment team help your family take the first steps on the journey to healing and recovery.