Disinhibited social engagement disorder (DSED) is a behavioral disorder that occurs in young children.

It
is an attachment disorder that makes it hard for children to form an emotional bond with others. But you
may notice that children with DSED can easily talk to strangers and mingle with them. It is an attachment
condition characterized by difficulty forming emotional bonds with others and a lack of inhibition around
strangers. The condition tends to occur in young children who have experienced neglect, trauma,
abandonment, or abuse.

Most children are naturally cautious with adults they don't know. For the most part, a fear of unfamiliar
people is healthy and helpful. However, children with disinhibited social engagement disorder do not
have this fear. Kids who have DSED aren’t afraid of strangers in fact, they are so comfortable around
unfamiliar people that they wouldn’t think twice about climbing into a stranger’s car or accepting an
invitation to a stranger’s home. This uninhibited friendliness can become a serious safety problem if the
disorder is left untreated.

Symptoms of Disinhibited Social Engagement Disorder

Common symptoms of disinhibited social engagement disorder include

 Excessively familiar physical and verbal behavior toward unfamiliar adults

 Lack of checking in with parents or caregivers
 Lack of social boundaries
 Minimal inhibition around strangers
 Willingness to go with strangers with little or no hesitation

Characteristics of Disinhibited Social Engagement Disorder

Children with DSED may display certain characteristics. Here are three to consider.

No Preference for Caregivers

Most children seek contact with their primary caregivers, especially when they are in need of comfort.
For example, a child who falls off a swing and skins their knee will likely look for the parent or caregiver
who brought them to the playground to soothe them and tend to the wound.
If a child with disinhibited social engagement disorder falls at the park, they may reach out to a complete
stranger for emotional support. They might tell a random passerby that they're hurt or even sit on a
stranger's lap on a park bench and cry.

The child's uninhibited behavior can be confusing and unnerving for caregivers. Any adults involved may
find it difficult to understand why a child interacts with unfamiliar adults without a moment's hesitation.

Difficulty Knowing Who Is Trustworthy

Young children aren’t good at identifying predators, but most are cautious about people they don't know.
Most kids are able to make judgments about whether a stranger looks kind or mean based on an
individual's face. Research has found that children make initial assessments about an individual’s
trustworthiness based on that person's appearance

For a child with disinhibited social engagement, difficulties with facial recognition may contribute to their
willingness to talk to and engage with strangers. Research using brain imaging has shown that children
with the disorder cannot discriminate between a person who looks kind and safe and someone who looks
mean and untrustworthy.4

Craving Kindness

Kids with disinhibited social engagement disorder crave kindness from others. Since they can’t
specifically identify a safe person, they may show affection toward anyone who gives them attention—
including someone who is unsafe. It’s not unusual for a child with the disorder to hug a stranger in the
grocery store or strike up a highly personal conversation with an unfamiliar adult at the playground. They
may even sit down with another family at the park as if they had been invited to the picnic. A child with
disinhibited social engagement disorder indiscriminately seeks physical affection. For example, they may
sit on a stranger's lap in a waiting room.

Disinhibited Social Engagement Disorder Behaviors by Age

Disinhibited social engagement disorder behaviors can change and evolve as a child gets older

Toddlers

Toddlers with the disorder often begin showing a lack of fear toward unfamiliar adults, such as holding
hands with a stranger or sitting on the lap of a person they have only just met.
Preschoolers
During the preschool years, children with DSED will also begin exhibiting attention-seeking behavior,
such as making loud noises on the playground to get unfamiliar adults to look at them.

School-Age Children

By middle childhood, children often show verbal and physical overfamiliarity and inauthentic expression
of emotions. A preteen may laugh when others laugh or appear sad to manipulate a social situation (rather
than out of genuine emotion). Among peers, they may be overly familiar if not forward. For example,
they might say, “I want to go to your house,” when meeting a new classmate for the first time.

Teens

Adolescents with disinhibited social engagement disorder are likely to have problems with peers, parents,
teachers, and coaches. They tend to develop superficial relationships with others, struggle with conflict,
and continue to demonstrate indiscriminate behavior toward adults.

Adults

While research in this area is limited, some studies have found that children with DSED may experience
more cognitive impairment in young adulthood, along with more emotional symptoms. 8

Diagnosis of Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder was originally considered to be a subtype of another attachment
disorder called reactive attachment disorder. However, in the fifth edition of the Diagnostic and
Statistical Manual (DSM-5), disinhibited social engagement disorder was categorized as a separate
diagnosis.9

To meet the diagnostic criteria for disinhibited social engagement disorder, a child must exhibit a pattern
of behavior that involves approaching and interacting with unfamiliar adults as well as at least two of the
following behaviors:2

 Overly familiar verbal or physical behavior that is not consistent with culturally sanctioned and
appropriate social boundaries
  Reduced or absent reticence to approach and interact 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

In addition to meeting the diagnostic criteria behaviorally, a child must have a history of neglect as
evidenced by one of the following:

 Social neglect, including the persistent lack of having basic emotional needs for comfort,
stimulation, and affection met by caregiving adults
 Repeated changes in primary caregivers that limited the child's opportunities to form stable
attachments
 Rearing in unusual settings that limited the child's opportunities to form selective attachments
(e.g. an institution with high child-to-caregiver ratios)

If a child exhibits the behavior for more than 12 months, the disorder is considered persistent. The
disorder is described as severe when a child exhibits all of the symptoms at relatively high levels.

Disinhibited Social Engagement Disorder vs. Other Disorders

Disinhibited social engagement disorder is similar to reactive attachment disorder (RAD) and attention-
deficit hyperactivity disorder (ADHD). Here's how they compare.

DSED vs. RAD

In RAD, children have difficulty forming emotional attachments with their parents or caregivers. They
often struggle to show affection, have problems controlling their emotions, and fear interacting with
others. Kids with DSED, on the other hand, are overly affectionate toward others. While they are
outgoing and friendly, they struggle to form meaningful connections with other people.

DSED vs. ADHD

A child only meets the criteria for disinhibited social engagement disorder if their behaviors do not stem
from impulse control problems, which are common in other disorders. For example, a child
with ADHD may run off at the playground and forget to check that their parent is nearby. A child with
disinhibited social engagement disorder will wander off without giving their parent a second thought
because they don’t feel the need to ensure their caregiver is around. Disinhibited social engagement
disorder stems from neglect and therefore may co-occur with other related conditions, such as cognitive
and language delays or malnutrition.

Causes of Disinhibited Social Engagement Disorder

Disinhibited social engagement disorder is caused by neglect during infancy. But there is often
misunderstanding about what constitutes neglect and what contributes to the development of attachment
disorders in children. Neglect during infancy interferes with bonding and attachment. This impairs a
child's ability to develop trusting relationships with caregivers and often persists into adult life. Infants
learn to trust their caregivers when these individuals consistently respond to their needs. For example, a
baby who gets fed in response to their hungry cries will learn that they can count on their parent for
nourishment.

Contrary to common myths, attachment problems aren't caused by spending time in daycare, and a child
won't develop them as a result of being placed in their crib when they are crying. Children who are
neglected may not bond with their caregivers. If a crying baby is constantly ignored, they learn that the
people around them are unreliable, if not totally unavailable. A baby who is left unattended most of the
time with little social engagement may not form any type of relationship with a caregiver. Consequently,
that child may be at risk of an attachment disorder. While the consequences can be severe, it's important
to know that not all neglected children develop disinhibited social engagement disorder. In fact, many
children will grow up to have healthy relationships with no lasting attachment issues.

A Concern for Foster and Adoptive Parents

Disinhibited social engagement disorder stems from neglect that occurs during the first few months of
life. The disorder almost always develops by the age of two. However, disinhibited social engagement
disorder may not become apparent until long after the neglect issues have been resolved. Foster parents,
grandparents, and other caregivers who are raising children who experienced neglect as infants should
know that children may still be at risk for developing attachment issues even if they are no longer being
neglected.
Prevalence of Disinhibited Social Engagement Disorder

How common is DSED? Disinhibited social engagement disorder is thought to be fairly rare. Children
who have been raised in institutions (such as orphanages) and those who have had multiple foster care
placement are at the highest risk for developing the condition. Many children with a history of abuse or
neglect do not develop attachment disorders, but studies suggest that around 20% of children in high-risk
populations develop disinhibited social engagement disorder.1

Risks of Disinhibited Social Engagement Disorder

It’s important for kids to have a healthy fear of strangers and potentially harmful people. Raising a child
with disinhibited social engagement disorder can be quite confusing and terrifying for caregivers. A four-
year-old with the disorder might wander off with a stranger at the mall or a nine-year-old might enter a
neighbor’s home without thinking twice about the safety or potential consequences of these actions.

Caregivers raising a child with disinhibited social engagement disorder must keep constant watch to
ensure the child doesn’t enter a harmful situation. They may need to frequently intervene to prevent the
child from interacting with strangers. Children with attachment disorders struggle to develop healthy
relationships with teachers, coaches, daycare providers, and peers. 6 Their behavior can be alarming
enough to the people around them, such as a classmate's family, that it precludes social activities
(particularly when people are not familiar with the disorder).

Treatment for Disinhibited Social Engagement Disorder

It’s important for children with attachment disorders to receive consistent care from stable caregivers. A
child who continues to move from foster home to foster home or one who continues to be institutionalized
is not likely to improve. Once consistent care has been established, treatment can begin to help strengthen
the bond between a child who has experienced neglect and a primary caregiver.

Attachment disorders don’t tend to get better on their own. Professional treatment typically consists of
therapy with both the child and caregivers, with treatment plans individualized to meet a child’s unique
needs and symptoms.
 Coping With Disinhibited Social Engagement Disorder

There are steps that parents and caregivers can take to help children with DSED form bonds and manage
their behaviors.

 Provide stability: If a child has been diagnosed with disinhibited social engagement disorder, it's
essential to provide them with stable, reliable, and consistent care.
 Set expectations and rules: In addition to having expectations for behavior, it is important to let
children know what they can expect. Clearly explaining rules and consequences can provide
children with a greater sense of consistency and establish boundaries.
 Develop routines: Foster consistency by having household routines that you follow every day.
Helping kids know what to expect and then sticking with it can help develop a sense of trust in
caregivers.

If a child exhibits symptoms of disinhibited social engagement disorder, caregivers need to seek advice
and treatment from a professional. Offering consistent care can help, but specific interventions are needed
to address the attachment issues and behavioral problems that interfere with a child's ability to form
relationships.

Reference
1. Gleason MM, Fox NA, Drury S, et al. Validity of evidence-derived criteria for reactive attachment
disorder: Indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. J Am Acad
Child Adolesc Psychiatry. 2011;50(3):216-231.e3. doi:10.1016/j.jaac.2010.12.012
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.).
American Psychiatric Association.
3. Harris PL, Corriveau KH. Young children's selective trust in informants. Philos Trans R Soc Lond B Biol
Sci. 2011;366(1567):1179–1187. doi:10.1098/rstb.2010.0321
4. Miellet S, Caldara R, Gillberg C, Raju M, Minnis H. Disinhibited reactive attachment disorder symptoms
impair social judgements from faces. Psychiatry Res. 2014;215(3):747-52.
doi:10.1016/j.psychres.2014.01.004
5. Kennedy M, Kreppner J, Knights N, et al. Adult disinhibited social engagement in adoptees exposed to
extreme institutional deprivation: Examination of its clinical status and functional impact. Br J
Psychiatry. 2017;211(5):289-295. doi:10.1192/bjp.bp.117.200618
6. Guyon-Harris KL, Humphreys KL, Fox NA, Nelson CA, Zeanah CH. Course of disinhibited social
engagement disorder from early childhood to early adolescence. J Am Acad Child Adolesc
Psychiatry. 2018;57(5):329-335.e2. doi:10.1016/j.jaac.2018.02.009
7. Guyon-Harris KL, Humphreys KL, Miron D, et al. Disinhibited social engagement disorder in early
childhood predicts reduced competence in early adolescence. J Abnorm Child
Psychol. 2019;47(10):1735-1745. doi:10.1007/s10802-019-00547-0
8. Sonuga-Barke E, Kennedy M, Kumsta R, et al. Child-to-adult neurodevelopmental and mental health
trajectories after early life deprivation: the young adult follow-up of the longitudinal English and
Romanian Adoptees study. The Lancet. 2017;389(10078):15-21. doi:10.1016/S0140-6736(17)30045-4
9. Lehmann S, Breivik K, Heiervang ER, Havik T, Havik OE. Reactive attachment disorder and disinhibited
social engagement disorder in school-aged foster children--a confirmatory approach to dimensional
measures. J Abnorm Child Psychol. 2016;44(3):445–457. doi:10.1007/s10802-015-0045-4
10. Zeanah CH, Gleason MM. Annual research review: Attachment disorders in early childhood--clinical
presentation, causes, correlates, and treatment. J Child Psychol Psychiatry. 2015;56(3):207-222.
doi:10.1111/jcpp.12347
11. von Klitzing K, Döhnert M, Kroll M, Grube M. Mental disorders in early childhood. Dtsch Arztebl Int.
2015;112(21-22):375–386. doi:10.3238/arztebl.2015.0375
12. Scheper FY, Groot CRM, de Vries ALC, Doreleijers TAH, Jansen LMC, Schuengel C. Course of
disinhibited social engagement behavior in clinically referred home-reared preschool children. J Child
Psychol Psychiatry. 2019;60(5):555-565. doi:10.1111/jcpp.12994
13. Zeanah CH, Chesher T, Boris NW. Practice parameter for the assessment and treatment of children and
adolescents with reactive attachment disorder and disinhibited social engagement disorder. J Am Acad
Child Adolesc Psychiatry. 2016;55(11):990-1003. doi:10.1016/j.jaac.2016.08.004
14. American Academy of Child and Adolescent Psychiatry. Facts for Families: Attachment Disorders.