Introduction

Disinhibited Social Engagement Disorder (DSED) belongs under the umbrella term of attachment disorders and is primarily observed in children. Children with DSED exhibit certain characteristics in their social behavior that generally manifest as excessive familiarity with strangers.¹ In general, measuring social engagement in early childhood serves in the study of mental disorders, such as Autism Spectrum Disorder (ASD),² as well as in the prediction of certain behaviors at later life stages.³ As such, out of the few studies on DSED, most take place during early childhood. Their findings on causation, behavioral traits, assessments, diagnosis, and treatment are summarized below.

Understanding Disinhibited Social Engagement Disorder

Prevalence and demographics

DSED is a relatively new term, which has not been extensively studied yet in regards to reaching safe conclusions in regards to the prevalence of the disorder. DSED is developed during the early stages of a child’s development and manifests quickly during early childhood. Usually, the age of children taking part in research studies regarding DSED ranges from five to eleven years old,^4,5,6 which constitutes a time window when the social behavior of a child can be more easily assessed to yield reliable results.

Cause

So far, there are no links between DSED and inherited genetic factors, while it is considered that the disorder is a result of the conditions of a child’s nurturing environment. The main causes of DSED in children are neglect of the child by its care-giver or negative experiences coming from abusive behaviors, for example. Apart from abuse towards a child,, the minimal care provided to a child by its parents, ranging from a lack of emotional support to neglect of physical needs, can also lead to DSED development. As a result, it stands to reason that many children diagnosed with DSED have been found to be residing in orphanages, where the absence of parents and the disproportionate number of care-givers to children leads to minimal personalized care and unavoidably gives ground for the development of behaviors that manifest in DSED.⁵

Assessment and Diagnosis

Interviews and Observational measures

DSED in children is mainly assessed through interviews of a child’s family and social environment in combination with observations made in a socially controlled environment, where the child may interact with different people, who may be familiar or be  strangers.^5,7 An example of these measures is summarized by Bruce et al. In their study, the child and one parent/care-giver would enter a room where the child was prompted to draw something while the parent would sit at the back of the room and fill a questionnaire relevant to the case. At some point, a stranger would enter the room, who, apart from making the necessary introduction, would not attempt to interact with the child. For a designated amount of time, the stranger would be responsive but not encourage any further interactions with the child, while later on, the stranger would engage more with the child. This way, the child’s intention to interact with the stranger can be effectively assessed.⁶

Criteria

There are two criteria for a child to be diagnosed with DSED. The first one requires the observation of specific behaviours relevant to socializing with strangers in order to answer four questions:

• Is the child excessively friendly with a stranger?
• Does the child attempt to engage in physical contact with the stranger?
• Does the child seek their caregiver’s approval in their social interactions with the stranger?
• Is the child willing to leave with the stranger instead of its caregiver?

If the answer to two out of the four questions is yes, then the first criterion towards DSED diagnosis is met.

The second criterion requires that the child’s social behaviour is ascribed to its social instincts and not an impulsive behaviour in general.⁷

Limitations in Research and Development of Diagnosis Tools

The generation and establishment of diagnosis tools for DSED relies on studies that attest reliability and reproducibility of behavioral measurement methods. As previously noted, a significant number of children diagnosed with DSED have been raised in orphanages. As a result, many case studies in DSED research include that such children ,at the time of the assessment, live under the care of foster parents, meaning that the historical background on how the children were raised and treated by their caregivers up to the point of assessment might be vague. This absence of information may hinder the process of finding the proper indicators of a DSED case when based on the questionnaires filled out by parents or caregivers.

Moreover, in the process of novel diagnosis tools development, all research studies include subjects that serve as normal controls, meaning children without DSED. This way, comparisons between ‘normal’ and ‘DSED’ groups can be made. However, it is unavoidable that children without DSED might have a different quality of life compared to children with DSED, which might have an impact on the cognitive tests performed and, subsequently, the conclusions drawn.⁶

These limitations in research are only one factor that challenges the proper diagnosis of attachment disorders. Another challenge that professionals have to overcome is the relevance of DSED symptoms with that of other disorders.

Distinguishing DSED from other attachment disorders:

Diagnosis of attachment disorders can be sometimes challenging due to the many aspects that govern them. Only in more recent years DSED was distinguished from reactive attachment disorder (RAD) according to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).⁸ RAD may be considered as one side of a coin, while DSED is the other. Even though both disorders are considered to be derived from similar causes,^5,9 RAD, unlike DSED, has been associated with a child’s inability to form emotional bonds and their reluctance to physical contact (e.g. hugs) with all people.⁹ On the other hand, children with DSED may be seen to easily associate with strangers in an over-friendly manner, while they exhibit deficits in their emotional attachment to family members and friends.¹

Common behavioural manifestations in DSED and other disorders of different origins may lead to confusion in the process of diagnosis. Such a disorder is ASD associated with deficits in social behavior similar to that of attachment disorders. However, contrary to DSED, ASD is the result of neurodevelopmental issues derived from genetic causes.^4,10 One study proposes a specific assessement method, called ‘Live Assessment’, as a helpful diagnosis tool to help decipher between DSED and ASD. This type of assessment involves two assessors and the subject child, but no parents/care-givers. The two assessors meet the child in succession, so that the first is the “familiar" one. Then the assessors converse and play with the child in order to measure social interactions, emotions, empathy, creativity, and understanding of social or sensory cues. So, in the end after a long session with the child, the assessors are able to reach a conclusion based on observations made during their interaction with the child. It turned out that the ‘Live Assessment’ test yielded better results in distinguishing between DSED and ASD cases compared to the interviewing methods (interviewing parents/care-givers and/or teachers) or the observation method alone (e.g., placing the child in a room with the parent/care-giver and a stranger).⁴

DSED impact on adolescence

As previously mentioned, DSED is more prominent during early childhood. Despite that, there is evidence that DSED has an impact on later life stages even if the clinical outcomes originally observed and assessed no longer apply. More specifically, children that were diagnosed with DSED may exhibit competence difficulties during early adolescence. Namely, these competency issues are related to their performance in school and their inclination towards risky behavior. Interestingly though, it appears that interactions with family and friends are not affected despite a DSED diagnosis in their earlier years.³

Treatment and Intervention

Unfortunately, studies regarding intervention of DSED are limited. Observations on DSED progression and effectiveness of intervention methods have been reported only on institutionalized children. However, it is encouraging that adoption has a positive effect on social engagement behavior.¹ In addition, it has been reported that intervention may be aided further by proper professional guidance along with the foster parents’ efforts to care for a child with DSED.¹¹

Even though psychological measures are taken into account when assessing DSED, it should be noted that neuroimaging studies have reported significant changes in the brains of children that had been institutionalized or exhibited behaviors relevant to the ones manifested in DSED.¹ This indicates that neurobiological factors may be associated with DSED and could potentially aid in the endeavors of diagnosis and treatment.

Summary

The basis on which DSED is founded is considered to be inadequate caretaking during early childhood, which in turn makes the child careless to interactions with strangers. This behavior constitutes the main factor towards diagnosis of DSED. However, DSED behavioral outcomes may be falsely attributed to other disorders and vice versa, which stresses the need for reliable assessment methods. While there appears to be progress on that front, there are other issues that need to be addressed as well, such as progression and treatment. As DSED manifests only in children, studies of the disorder are limited to a specific age range, and the reports on follow ups of DSED cases are few. Consequently, our knowledge on the progress and effectiveness of intervention methods is limited and further research towards understanding and treating DSED is necessary.