Disinhibited Social Engagement Disorder (DSED)

Introduction and Clinical Features

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Disinhibited social engagement disorder (DSED) is a prevailing attachment disorder in childhood characterized by indiscriminate sociality with familiar and unfamiliar adults. Children with this attachment disorder are overly friendly and comfortable with strangers. DSED is one of two attachment disorders seen in children—its relative is reactive attachment disorder (RAD) Opens in new window.

Oftentimes children are wary of strangers and seek comfort from their parents or caregivers. However, children with DSED are not in any way wary of strangers and may seek support from unfamiliar people. In toddlers, the disorder typically involves seeking physical closeness and lack of reticence with unfamiliar adults.

Diagnostic Features

The essential diagnostic characteristic of this disorder is seen in children displaying socially and culturally inappropriate overly familiar social behavior with strangers.

According DSM-5’s criteria, the child must be developmentally old enough and capable of forming selective attachments, at least 9 months of age.

Children with DSED actively approach and interact with unfamiliar adults without verbal or physical reticence. They may also fail to check with an adult or caregiver when leaving and may even indiscriminately go with a stranger or unfamiliar adult, without hesitation.

These uninhibited behaviors should not be better accounted for by attention deficit hyperactivity disorder (ADHD Opens in new window), impulsive type, or merely social extroversion. Finally, an environment in which the child was exposed to social neglect or deprivation where basic emotional needs were not met precedes the behaviors.

Alternatively, an environment in which the child experienced frequent caregiver changes (e.g., frequent foster care changes) or resided in an institution in which there was a high child to caregiver ratio, where the emotional and social needs were not met, must have been present. The term persistent is used to specify when a child has exhibited symptoms of the disorder for longer than 12 months.

Assessment Issues

Much as in RAD Opens in new window, DSED is best assessed through interviews of adult caregivers about the child’s typical behavior and direct observation of the child’s behavior.

Indiscriminate social behavior, which forms the essence of the disorder, may be assessed by comparing the child’s behavior to a stranger and to a familiar caregiver, with subsequent questioning.

A detailed history of the child’s caregiving experiences is important in order to establish that deficiencies were sufficient to account for the child’s social abnormalities. Therefore, details of the child’s caregiving history, with attention to neglect, changes in primary caregiving relationships, or significant losses of primary caregivers should be determined.

An important confounding factor that can complicate assessment for DSED in the clinical interview is the presence or absence of selective attachments to a child’s primary caregiver.

Children with a clear diagnosis of DSED may have varying levels of attachment to a primary caregiver with some studies finding not attachment behaviors and some studies finding secure attachments (Zeanah & Gleason, 2015).

Further research is required to understand how security of attachment to a parental figure might affect the development or course of DSED. Structured interviews such as the Disturbances of Attachment Interview Opens in new window (Smyke et al., 2002, Zeanah et al., 2004, Zeanah et al., 2005) or the Preschool Age Psychiatric Assessment Opens in new window (Egger et al., 2006) may be used to inquire systematically about specific signs of the disorder and include diagnostic algorithms that assist with making the diagnosis.

Several standardized observational procedures that allow the clinician to observe the child’s social behaviors with unfamiliar adults have been studied, but only one has been used in clinical settings. (Boris et al., 2004).


While few studies assessing rates of the DSM-5 DSED diagnosis have been performed, research examining rates of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders Opens in new window disinhibited subtype of Reactive Attachment Disorder (RADd) Opens in new window are instructive. In a study of 2 to 5-year-old children recruited from pediatric clinics in Bucharest, Gleason et al. (2011b) found a weighted prevalence of 2% for RADd.

Disinhibited attachment disorder behaviors in 4- to 6-year-olds raised in institutions were seen in nearly 30% of children adopted between 24 and 42 months, in nearly 20% children adopted between 6 and 24 months, and in nearly 5% of children adopted before 6 months (O’Connor et al., 2000). In this same adoptee population, by 11 years old, rates of severe RADd behaviors dropped to 9.9% with higher rates among those adopted after 6 months (Rutter, Colvert, et al., 2007).

A separate population of children institutionalized in Romanian orphanages was studied assessing for rates of attachment disorders over a 54-month period (Gleason et al., 2011a). In this study group, half of subjects were adopted between 12 and 31 months of age and others remained in orphanages.

At the time of initial evaluation (average of 22 months), 30 months, 42 months, and 54 months, rates of RADd were 31.8%, 17.9%, 18% and 17.6%, respectively.

Pritchett, Rochat, Tomlinson, and MIinnis (2013) studied youths in urban townships in South Africa and found a 12.5% incidence of attachment disorders. All the diagnosed youths were male and displayed the disinhibited symptoms of RAD. Minis et al. (2013) conducted a large-scale study of an entire educational sector of a UK city, targeting high-risk youths. All 1,600 of the students were screened for attachment disorders, followed by focused interviews.

Those who screened in after the semistructured focused interview were subsequently evaluated face-to-face to confirm the diagnosis. Through this methodologically rigorous population-based sampling method, the authors determined that 1.4% (95% confidence interval 0.94-2.10) of children in their sample met diagnostic criteria for attachment disorders with RADd far outweighing the inhibited type.

A study of 94 maltreated toddlers from one area of New Orleans evaluated 3 months after placement in foster care found rates of 22% of the ICD-10 diagnosis disinhibited attachment disorder (DAD) (5% disinhibited only and 17% mixed withdrawn and disinhibited type; Zeanah et al., 2004).


In DSED there have been consistent findings of associations with inattention and overactivity that may meet criteria for a separate diagnosis of ADHD Opens in new window.

In a study of institutionalized Romanian adoptees, signs of DSED were associated with ADHD and more modestly associated with signs of disruptive behavior disorders by 54 months (Gleason et al., 2011). This study replicated similar associations found among studies of Romanian adoptees between the ages of 54 and 72 months (Rutter, Kreppner, et al., 2007). This same study by Rutter, Kreppner, et al. (2007) found a significant minority of subjects (9.2%) who demonstrated quasi-autism.

These participants met criteria for autism on the Autism Diagnostic Interview but were differentiated from those with “true” autism by high rates of indiscriminant behavior (such as social approach), superior “spontaneity and flexibility of communication,” and improvement in autism symptoms with adoption out of institutions. This findings is further complicated by the increased prevalence of cognitive and language delays known be seen in populations who experienced severe neglect.


While children may be neglected in the first year of life, the diagnosis of DSED is not made until the child is at least 9 months of age, after the developmental capacity to form selective attachment to caregivers is present.

Prior to that age, it is developmentally expected that young children will show social engagement without discrimination. There is no evidence to date that neglect that begins after the age of 2 years is associated with the disorder (Wolkind, 1974).

Like RAD Opens in new window, among children who remain in an insufficient rearing environment, there is evidence that signs of the disorder are stable over a period of years (Gleason et al., 2011a). However, unlike RAD, signs of DSED can be resistant to change despite normalization of the caregiving environment.

Among children adopted out of Romanian orphanages, some children continued to demonstrate signs of the disorder between ages 6 and 11 years (Rutter, Colvert, et al., 2007) and when assessed again at age 15 years old (Rutter et al., 2010).

Among subjects who improved, the amount of improvement was sometimes modest and took at least 2 years after adoption to be identified. Sometimes signs of DSED were noted to be present even after developing secure attachments to adoptive caregivers (Chisholm, 1998).

Given the sometimes refractory nature of DSED, more is known about the functional impairment of this disorder throughout the child/adolescent life course. In toddlers, the disorder typically involves seeking physical closeness and lack of reticence with unfamiliar adults. In addition, affected children may exhibit separation protest from complete strangers after brief acquaintances. As children move into preschool years, they may display violation of social boundaries and attention-seeking behavior. Increasingly, they may display violation of boundaries with verbally intrusive and inappropriate questions.

This over-familiarity with adults has been shown to shift to indiscriminate behavior with peers (Hodges & Tizard, 1989). Affected individuals are expected to have decreased social/emotional competence, peer relational problems, and higher rates of psychopathology (Rutter et al., 2010). These social deficits may be mediated in part by deficits in theory of mind Opens in new window and misattribution that have been found among those with this diagnosis (Kay & Green, 2016).

Differential Diagnosis

The social impulsivity seen in DSED is also a hallmark of several other disorders such as ADHD Opens in new window, Williams syndrome Opens in new window, and bipolar disorder, which can cause confusion between the several conditions.

Despite this similarity, Gleason et al. (2011a) demonstrated the ability to differentiate DSED from ADHD. Children with ADHD demonstrate more prominent patterns of pervasive inattention or hyperactivity outside of social interactions.

Williams syndrome Opens in new window is a genetic disorder in which affected individuals display many of the socially disinhibited behaviors associated with DSED. People with Williams syndrome can be distinguished by characteristic facial dysmorphology, cardiac and endocrine manifestations, and microdeletion within characteristic regions on chromosome 7 (Pober, 2010).

Finally, social impulsivity seen in DSED must be distinguished from impulsive hyper-social behavior that can be seen in manic or hypomanic states. In bipolar disorder such impulsivity is expected to be episodic with periods that are distinguishable from a patient’s previous functioning and associated with a constellation of associated mood changes (irritability, euphoria), grandiosity/flight of ideas, and decreased need for sleep.

Etiology and Pathophysiology

  1. Social/Environmental Factors

Environmental factors play a central role in the development of DSED and in fact are considered necessary for the diagnosis of the disorder.

Children growing up in neglectful environments have a much higher risk of developing DSED, and the length of time spent in the environment is correlated with symptom persistence.

In a report about the Bucharest Early Intervention Project, children randomly assigned to foster care and placed before 24 months of age showed a reduction in signs of DSED by 42 months as compared to children with more prolonged institutionalization (Smyke et al., 2012), and the intervention effect was still evident at 12 years of age (Humphreys et al., 2017). The English and Romanian Adoptees (ERA) Study Team demonstrated similar time sensitivity with the lowest rates of DSED being seen in those adopted before 6 months (O’Connor et al., 2000).

Similar to RAD Opens in new window, higher severity of neglect (as measured by consistency of caregivers) is linked to increased signs of DSED (Smyke et al., 2002). Pears et al. (2010) found signs of DSED were linked to the number of placement disruptions among children in foster care.

Despite similarities with RAD Opens in new window, symptoms of DSED may be less influenced by improvements in the quality of the caregiving environment after neglect is experienced.

One study of children adopted out of Romanian orphanages found no relationship between caregiving quality and signs of DSED following placement. This finding seems supported by the fact that the ERA Study Team found subjects with persistent signs of DSED even by age 15 years.

However, data in this area is mixed with at least one study showing reductions in indiscriminant behavior among subjects with more sensitive adoptive mothers (Van Den Dries, Juffer, van Ijzendoorn, Bakermans-Kranenburg, & Alink, 2012). It is unknown whether refractory signs of DSED are a function of the disorder or as yet unknown mediating qualities of the caregiving environment.

  1. Genetic Factors

A preliminary study has explored genetic factors in children exposed to deprivation. Drury et al. (2012) showed that children who had the s/s genotype of the serotonin transporter gene variant (5HTTLPR) and the met66 allele of brain derived neurotropic factor (BDNF) showed the lowest levels of indiscriminate behavior among children in foster care but the highest levels among children remaining in institutions. These findings need to be replicated, but they illustrate the kind of approach to vulnerability factors that may lead to delineating individual differences in vulnerability to environmental risk.

  1. Neurobiological Factors

There is an evolving body of research finding neurobiological factors linked to indiscriminant friendliness among study subjects who experienced the extremes of early neglect.

One study of internationally adopted children found that participants with stunted growth had higher rates of disinhibited social behavior and higher evening cortisol levels (Johnson et al., 2011). This study implicates chronic stress (allosteric load) on the body as a mediating factor.

Olsavsky et al. (2013) performed a functional MRI (fMRI) study of amygdala activation in response to presentation of mother versus stranger’s faces in postinstitutionalized (PI) subjects.

Among non-PI participants (controls) there were clear differences in patterns of amygdala activaton when comparing fMRI data upon viewing images of strangers versus images of their mother’s face. PI participants showed less discrimination in amygdala activation between strangers and mothers’ faces, and this lack of variation in amygdala activation was associated with indiscriminant friendliness.

Finally, Tarullo et al. (2011) have proposed a hypo-activation model of institutional rearing where PI and foster care children demonstrate associations between indiscriminant friendliness and EEG patterns suggesting decreased arousal states.

Rutter, Connor, and the ERA Study Team (2004) have theorized the existence of a sensitive period of developmental programming, wherein institutional deprivation during a key window of development may result in attachment disorders via neural damage.

In support of this theory is the Rutter and colleagues’ finding that disordered attachment behaviors were not associated with the consequences of malnutrition, cognitive age, or lead circumference but were associated with institutional deprivation during the early developmental period. Therefore, deprivation itself is proposed to be the etiologic factor in behavior changes thought to have their roots in “biological programming.”

Others have argued that extreme privation may disrupt the establishment of a foundation for neural networks to form in the brain, especially in the right hemisphere (Hardy, 2007).

The right hemisphere is involved in affective experiences and is important for interpreting and conveying emotion. Healthy exchanges between infant and caregiver are proposed as key in this process. Therefore, a child in abusive or neglectful environment during that sensitive period may not correctly develop the skills necessary for interpersonal relationships. Studies involving analyzing children institutionalized later in childhood or adolescence are needed to support these sensitive period theories in the development of disinhibited behavior.

  1. Psychological Factors

Similar to RAD Opens in new window, certain temperaments may increase the risk of developing DSED when subjected to adverse environments, although this is quite challenging to study.

A child with an exuberant temperament may be prone to making impulsive and spontaneous decisions, and, when put under the stresses of a neglectful early environment, this may develop into the disinhibited behaviors of DSED (Zeanah et al., 2004).

Many studies have explored the relationship between externalizing disorders, specifically ADHD and the disinhbited behaviors associated with DSED. Gleason et al. (2011a) confirmed an association between disinhibited behavior and signs of ADHD in the sample of children in the Bucharest Early Intervention Program but still showed that these two disorders typically may not occur together. This may demonstrate an association between disinhibited behavior and poor social inhibitory control independent of an ADHD diagnosis.

Treatment for RAD and DSED

The key intervention for these conditions is ensuring a caregiving environment that is sensitive, responsive, and likely to build a sense of security in the child (Boris, Zeanah, & Zeanah, C. H., & Work Group on Quality Issues, 2005).

Cortisol levels of those children participating in the intervention were lower after the Strange Situation Test Opens in new window compared to the foster care control group. Even more surprising, cortisol levels from the control group that had never been in foster care did not statistically differ from those children in foster care receiving the intervention. Research such as this provides important insight into ways of treating children with attachment disorders.

Currently there are no pharmacologic interventions for attachment disorders unless clinicians identify a separate comorbid condition such as ADHD Opens in new window. Among studies with subjects raised in institutions, the primary intervention is adoption into stable, safe, and emotionally available families.

Studies of the quality of such adoptive families (as measured by the sensitivity and responsiveness of caregivers) have linked such measures to improvement in RAD Opens in new window but less robustly to DSED (Smyke et al., 2012). Such a finding may suggest a threshold effect of caregiving quality, wherein further enhancement does not further reduce signs of DSED.

Therapeutic interventions that may hasten remission of signs of attachment disorders or treat refractory cases have been examined, but guidelines and effectiveness data is limited. Psychoeducation of caregivers is, after ensuring safety of children, the first crucial step in helping families understand the context and proposed meaning behind disordered attachment behaviors.

Such education may help caregivers who feel hurt or rejected by the absence or indiscriminant display of affection. Furthermore, this education can help guide caregivers in how to respond to their child.

For instance, many clinicians advise that a child with RAD Opens in new window or DSED may need an overemphasized emotional response from parents in order to sufficiently establish new attachments and make the connection clear to the child (Lieberman, 2003).

Restricting the child’s contacts to family only, especially in the early months of placement, is often recommended for DSED, although no studies have evaluated this approach. Such restriction is thought to help the children learn to focus comfort and affection seeking to attachment figures. Including the caregiver in therapy is important for treatment success.

A study by Dozier, Stovall, Albud, and Bates (2001) found that maltreated children placed in foster care were more likely to develop secure attachments if their foster mothers were themselves securely attached.

Manualized guidelines for treatments for working with families to foster caregiver sensitivity and emotional availability have been explored with promising results (Bernard et al., 2012) and should especially be considered in treatment refractory cases (Zeanah, Berlin, & Boris, 2011).

Moreover, interventions that address the history of caregivers’ own attachment styles and relationships may play a preventative role for infants at risk for developing attachment disorders (Cicchetti, Rogosch, & Toth, 2006).

Infant-parent psychotherapy and child-parent psychotherapy can be used for the treatment of attachment disorders with modifications geared specifically for families dealing with these disorders.

Working individually with the caregivers or, when appropriate, children on specific strategies to manage maladaptive behaviors can also be helpful in strengthening the child’s attachment (Boris et al., 2005). Interaction guidance therapy is a way to incorporate working with both child and caregiver and involves shaping positive behaviors through suggestion and positive reinforcement during interactions between the child and caregiver.

Basic behavioral or cognitive behavioral therapy (CBT) Opens in new window may also be helpful in DSED to assist the child or teenager in learning socially appropriate behaviors. Research has implicated social cognitive abnormalities in this disorder, which may be particularly well addressed with CBT.

The presence of co-occurring RAD Opens in new window or DSED can reduce the effectiveness of trauma-focused therapies. A randomized controlled trial titled, “It’ My Turn Now” targeted internalizing and externalizing disordered youth exposed to interpersonal violence within a Dutch sample.

Results indicated that RAD and DSED negatively impacted recovery from trauma, such that treatment outcomes for both internalizing and externalizing disorders were slowed in individuals with RAD or DSED compared to individuals without the comorbidities.

The authors hypothesized that youth with attachment disturbance lacked appropriate social engagement necessary to fully benefit from the therapy process, thereby reducing the therapy’s potency (Overbeek, de Schipper, Lamers-Winkelman, & Schuengel, 2014).

A study by Dozier, Peloso, Lewis, Laurenceau, and Levine (2008) examined the Attachment and Biobehavioral Catch-up Opens in new window manualized intervention for children in foster care.

To measure the efficacy of the program, cortisol levels were measured for the interventional group of foster children, a control group of foster children with no intervention program, and a control group of children never in foster care and not receiving any intervention.

The intervention program combined the teaching of self-regulatory capabilities and focused on teaching parents how to be responsive to their child’s emotions, along with attachment security.

    Adapted from: Trauma- and Stressor-Related Disorders, edited by Frederick J. Stoddard, David M. Benedek, Mohammed R. Milad, Robert J. Ursano. References as cited include:
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