Disinhibited Social Engagement Disorder (DSED)

What is disinhibited social engagement disorder (DSED)?

Disinhibited social engagement disorder (DSED) is an attachment disorder in which a child displays indiscriminate friendliness—a lack of appropriate social boundaries—with strangers. A child with DSED has no hesitation in talking with strangers or seeking physical comfort, such as hugs, from a person who isn’t their parent or caregiver. They may even wander off with a person they just met.

Of course, all children have different temperaments. While some kids are shy and cling to their parents, others are chatty and show more independence. However, it is possible for a child to be too open and willing to engage with unfamiliar adults—and even put themselves in serious danger.

Some children with DSED have preferred attachments, meaning they'll turn to their parent for comfort, but they still show a lack of restraint in approaching strangers. In other cases, a child with DSED may show no preference in attachment, so they're just as likely to turn to a stranger for attention as they are their own parents.

If your child has DSED, their lack of social discretion can be a constant source of stress. You may be afraid to take them out in public because they might engage with a dangerous stranger. Or worried they’ll make others uncomfortable by being overly talkative, attention seeking, or intrusive. Since some personality disorders are rooted in attachment issues, you may also fear that DSED will lead to relationship difficulties as your child grows older.

As an attachment disorder, DSED forms early in life. However, this doesn’t mean that your child is “broken” or unable to develop healthy social boundaries. With your patient efforts, you can repair attachment issues and enable your young one to enjoy a physically safe and emotionally secure childhood.

DSED vs. RAD

A child with reactive attachment disorder (RAD) has difficulty managing their emotions and connecting with others, including their parents. They may be withdrawn and hypervigilant yet unwilling to seek comfort. They might even act with indifference or aggression when you attempt to hold or cuddle them.

Children with RAD tend to be less outgoing and emotionally expressive than children with DSED. However, like DSED, RAD is rooted in early traumatic experiences that impact attachment, such as emotional neglect. At one point, DSED was considered a subtype of RAD. However, experts now see them as distinct conditions.

[Read: Attachment Issues in Children]

Causes and risk factors

DSED can be caused by disruptions in early attachment—the deep emotional connection formed between an infant and their primary caretaker. If a parent is absent, abusive, neglectful, or unwilling or unable to offer emotional support, for example, it can impact attachment. Traumatic events, such as the death of a parent, can lead to the child being shuffled through multiple caregivers and also affect attachment.

Research shows that time spent in institutional care, such as orphanages, can increase the risk of a child developing DSED. In these situations, the child has less of an opportunity to form a solid, consistent attachment to a specific caregiver. Early placement into a stable family environment can be effective in reducing DSED symptoms.

It’s important to note that many children who receive inadequate caregiving don't develop DSED. So, other factors, such as genetics, may also play a role in the development of the disorder.

Role of a child’s attachment style

An attachment style is the result of a child’s earliest experiences with a primary caregiver. If the caregiver made the child feel safe and understood, they’re likely to develop a secure attachment style.

If the caregiver couldn’t provide consistent comfort or was unresponsive to the child's needs, they’re more likely to develop one of three types of insecure attachment: ambivalent, avoidant-dismissive attachment, or disorganized attachment. Attachment styles can have a lasting impact on a person’s relationships throughout life.

[Read: How Attachment Styles Affect Adult Relationships]

Children with DSED may have a lack of attachments or insecure attachments. But, surprisingly, even children with a secure attachment can show signs of DSED. It's possible that a parent was responsive to the child, but that attachment was later disrupted in some way. The child then goes on to develop indiscriminate friendliness, and a lack of wariness around strangers.

Signs and symptoms of DSED

DSED is rare in the general population. However, some research shows that roughly 20 percent of post-institutionalized children—children with a history of being in foster care or orphanage care—show some degree of DSED.

Signs of DSED tend to show up within the first two years of life, and it can be easy to mistake symptoms with a naturally friendly disposition. One key difference is that a child with DSED tends to ignore boundaries to a degree that can be dangerous or socially inappropriate.

Here are some symptoms to look for:

No wariness of strangers. Your child may be fearless or overly eager when interacting with unfamiliar adults. They might try to hold a stranger’s hand, for example, hug them, or sit on their lap. They might even do this when you’re present and available to offer comfort. Their inability to acknowledge personal space can be uncomfortable for strangers and dangerous for the child.

Asking personal questions. If the child is old enough to talk, they might ask strangers questions that are intrusive or cause embarrassment.

Wandering away without checking back. Your child might seem comfortable venturing away in unfamiliar settings, such as a mall or theme park, without looking for you. They may also go off with a beckoning stranger.

Shallow social connections. Your child might try to hug peers who they're not actually familiar with or treat strangers the same way they treat a best friend. In older children, DSED may present as a pattern of shallow, short friendships. For example, an older child might be quick to describe someone they just met as a “best friend.”

Attention-seeking behavior. Your child may go out of their way to get attention from peers and adults, maybe even resorting to aggressive behavior. When they don’t get the attention they’re seeking, they may get upset or act out.

Early warning signs

If your child is too young to walk or talk, you can still identify early signs of DSED. Around 12 months of age, their curiosity and fearlessness toward strangers can show up in nonverbal cues:

• They may constantly reach out their arms to new people to indicate they want to be held.
• Get fussy when a stranger tries to return them to your arms.
• Accept toys and food from strangers without hesitation.
• Show a lack of concern over your absence when you leave the room.

Other signs that may also indicate an attachment disorder include difficulty gaining weight, severe colic. defiant or detached behavior, and a resistance to being comforted.

Diagnosis

To be diagnosed with DSED, your child must be at least nine months old, which is when signs of attachment to a specific parent or caregiver tend to develop.

During an evaluation, a medical professional will conduct a psychological assessment and observe the child's behavior. They might take notes on how your child interacts with you, for example, and how they react when you leave and return to the room. They'll also ask questions about your child's upbringing to determine if the behavior is the result of circumstances that would impact caregiver attachment, such as neglect.

Comorbid conditions

Although they are two distinct conditions, signs of DSED and ADHD may overlap and the conditions can co-occur. One difference between the two disorders is that DSED involves impulsivity in social situations. A child with ADHD, on the other hand, may demonstrate impulsivity in the way they generally think and behave, even outside of social situations.

Post-traumatic stress disorder (PTSD) can also co-occur with DSED. Both conditions can have roots in traumatic experiences or neglect.

Taking care of a child with DSED

The consistent presence of an emotionally available parent can help reduce symptoms of DSED, especially if the child has insecure attachments or no attachments.

[Read: What is Secure Attachment and Bonding?]

Not only will you need to be around to comfort the child, but you’ll need to set, communicate, and enforce rules to keep them safe as well. The following tips can help:

Tip 1: Be a consistent source of stability and structure

By consistently meeting your child’s needs—for things like food, attention, affection, and praise—you can build trust and strengthen your bond.

Although it's important to be sensitive to your child's wants and needs, you're also responsible for imposing limits. A child with DSED will benefit from guidance and structure. They need to know when it’s time to clean up their play area, for example, take a bath, or eat dinner. When your child sees you as the person who sets the rules, you’ll also become the person they center their attention on.

The importance of being present

Even the most dedicated parents can’t always be fully focused on their children. Every day comes with many other demands that require your attention. However, it’s important to set aside time to be completely tuned in to your child’s needs.

At these times, put away possible distractions, such as your phone, and give the child your undivided attention as you play or do chores together. By staying in the moment, you’ll also help establish an emotional connection and build a secure attachment bond.

Tip 2: Emphasize social boundaries and norms

If your child is old enough to understand, explain to them that strangers are people they don't know. Rather than pose all strangers as threats, explain that some strangers, such as teachers and police officers, are safe to approach.

Aim to establish social rules, such as:

• “Keep one hand on me whenever we're in a crowd.”
• “Ask for my permission before talking to strangers.”
• “Stay more than an arm's length away from strangers.”
• “Don’t take items from strangers.”

Rehearse the rules. Practice social boundaries with your child in a safe environment. For example, you can quiz them on how far they should remain from strangers. Be patient and expect them to have a hard time sticking to the boundaries. Rather than take it as a personal slight or sign of disrespect, understand that it’s the disorder making things more difficult. One 2014 study showed that children with DSED have difficulty evaluating the trustworthiness of strangers’ faces, which impairs their ability to make social judgments.

Be calm but firm. It’s easy to lose your temper when your child strays from your side or fails to recognize another person’s personal space. However, it’s important to respond in a level-headed way. Angry outbursts will only serve to scare your child and diminish trust. When you do act in anger, be quick to apologize and acknowledge your mistake.

[Read: Anger Management]

Tip 3: Take safety precautions

Rather than assume your child will follow your rules, take proactive measures to keep them safe.

• Dress your child in bright clothing or an outfit that you can easily identify. If they wander off, you'll be able to spot them in a crowd or describe them to other people who can assist in your search. If you have difficulty remembering what your child is wearing, take a picture of them with your phone before leaving home.
• Teach your child to memorize your phone number and address. If they wander away from you, they'll be able to give another adult enough information to ensure you're reunited.
• Equip your child with identifying items if they’re too young to recite your name and phone number. An identifying item could be as simple as a necklace or bracelet with your phone number on it. Or you could attach a clothing label to their jacket with your information on it.

Tip 4: Take care of your own well-being

Raising a child with DSED can be emotionally challenging. Every time you leave the house with your child, you may be filled with anxiety. Will they wander off or get lost in a crowd? Will they strike up a long, awkward conversation with a stranger or attempt to grab someone’s hand? Will they act out to get attention from their peers?

To maintain a healthy perspective during these situations, it’s important to practice self-care. This is especially important on the days you feel discouraged and frustrated.

Temper your expectations. Although the symptoms of an attachment disorder can be diminished and overcome, healing doesn't take place overnight. You may notice progress one day, only to feel your child is regressing a week later. When you experience setbacks, try to view them as learning experiences. Remember to celebrate signs of success and praise your child for good behavior.

Find ways to unwind. Try to incorporate stress-reducing activities into your daily schedule, such as meditation. Following a healthy lifestyle can also help you manage stress, so try to get enough sleep at night, eat a balanced diet, and exercise regularly. Supportive friends and family members can also play a big role in improving your mood, whether they allow you to vent your frustrations or offer to babysit while you take a break.

Seek support. Search for a local or online support group for parents of children with attachment disorders. General parenting classes may also introduce you to child safety ideas.

Professional treatment

Treatment for attachment disorders should involve professional guidance from a pediatrician or therapist. The earlier you turn to a child development expert, the earlier they can recommend a personalized treatment plan to address your child’s DSED.

The treatment plan might involve a combination of the following approaches:

Parenting skills classes. These classes will focus on attachment disorders and help ensure you’re able to provide a stable living environment and appropriate emotional support for your child. An expert can also offer you guidance on keeping your child safe in public.

Play therapy. This form of therapy can help your child learn appropriate boundaries when interacting with others. For example, the child might be asked to act out social situations with dolls or other toys.

Family therapy. These sessions can include therapist-guided activities that involve both you and your child, with the goal of strengthening the attachment bond. A therapist might walk you through strategies for responding to your child's attention-seeking behavior, or setting effective consequences for breaking social boundaries.

[Read: Finding a Therapist Who Can Help You Heal]

Individual psychological counseling. A therapist might meet separately with you to offer guidance on how you can be more sensitive to your child’s needs and manage your own stress.

If you’re parenting an adopted or foster child with DSED, their unusual attachment might be confusing and sometimes even hurtful. But know that progress is possible through a combination of professional treatment and your own at-home efforts. Your patience, watchful eye, and emotional availability can lead to positive changes in your child’s life—and your own.