We’ll take a closer look in this post at the new companion diagnosis to Reactive Attachment Disorder related to pathologic care in early childhood… Disinhibited Social Engagement Disorder.
Studies of children who have been maltreated or raised in institutions have demonstrated two characteristic patterns of emotional response and behavior in response to pathologic caregiving environments. The first pattern involves emotional withdrawal…kids who lacked a preferred attachment figure, failed to respond to comfort when distressed, demonstrated decreased social and emotional reciprocity, decreased positive affect and unexplained fearfulness or irritability. Their symptoms could be described as internalized. This is the group we discussed in a previous post who will continue to be described as meeting criteria for Reactive Attachment Disorder (RAD). In contrast, the second group was observed to demonstrate indiscriminately social behavior-inappropriately approaching unfamiliar adults and a lack of concern for strangers… in some instances, a willingness to wander away with strangers. They may also exhibit a lack of ability to maintain an appropriate sense of body space, and may also demonstrate disinhibition of behavior.
Research has demonstrated that these two patterns differ in terms of clinical correlates, course, and response to treatment. There was also much greater interrater reliability among clinicians using diagnostic criteria based upon the assumption that the two patterns represented separate and distinct conditions compared to the existing DSM-IV criteria for Reactive Attachment Disorder. As a result, the authors of the DSM-5 chose to establish a separate diagnosis of Disinhibited Social Engagement Disorder (DSED) to distinguish the second group from children with Reactive Attachment Disorder. This new designation corresponds to the condition in the ICD-10 referred to as Disinhibited Attachment Disorder of Childhood. Disinhibited Social Engagement Disorder encompasses the vast majority of children and teens we’ve treated in our practice who in the past were identified with attachment disorders.
Here are the criteria for Disinhibited Social Engagement Disorder in the DSM-5:
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
First, we’ll start by looking at the similarities between kids with DSED and RAD. Both conditions are linked to social deprivation, neglect and pathologic care, and are readily identified among children being raised in institutional settings. Both conditions appear to be relatively stable over time in institutionalized children. But some very key differences exist as well…
- Some kids continue to exhibit symptoms associated with DSED after establishing selective or secure attachments with adoptive or foster parents, while RAD has only been observed in research studies among children who lack attachments.
- DSED appears not to be responsive (or only minimally responsive) to enhanced caregiving, whereas RAD is often very responsive. One study done in Romania comparing foster care to institutionalized care found a significant reduction in signs of RAD among children placed in foster care, but no reduction in the signs of DSED.
- Kids with DSED are often interested in, and willing to interact with unfamiliar adults, while kids with RAD typically demonstrate limited interest in interaction with unfamiliar adults.
- Kids with DSED appear to be at greater risk of developing externalizing disorders (ADHD, Oppositional Defiant Disorder, Conduct Disorder) whereas kids with RAD are more vulnerable to internalizing disorders (depressed mood).
- Kids described with DSED are prone to social and verbal intrusiveness and attention-seeking behavior during childhood, and superficial peer relationships along with enhanced peer conflicts during adolescence. The presentation of RAD in childhood and adolescence is less clear.
- Kids with DSED are more likely to be confused with kids with ADHD, while kids with RAD are more likely to be confused with kids with autism. Lack of capacity for self-regulation in social situations is a key feature of DSED, while a lack of comfort-seeking behavior is characteristic of DSED.
We can anticipate lots of confusion because the vast majority of children presenting for clinical care will meet the diagnostic criteria for DSED as opposed to RAD, since DSED is more likely to persist after kids leave pathologic care and causes more difficulties with interpersonal relationships. DSED is easier to observe across settings, especially in schools. I can certainly understand why the name of the condition was changed…not all kids with DSED lack attachments…but I’m not sure this distinction will be recognized by a majority of clinicians for quite some time.
Updated March 1, 2016
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Key Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!
Church4EveryChild 
Hi there, I would love your help;) We have a 4.5 year old daughter, who was adopted at birth. She has not had any form of trauma/neglect. We did do babywise parenting though, so are quite strict. We live on a farm, and are rural we devoted the first 6 months to her, and getting to know her and bond. We rarely went out, and socialized, but we did have playdates with other kids. She has not attended preschool until this week. We have always fostered independence, and tried to show her that when I leave to get the washing on the line, I will be right back. We have never had any clingyness from her of any type. She has not really been sick, so I am unsure how she would be if she got sick. When it is just us at home she is an angel. However – when we go to Sunday school, before we get there she says ‘you have to go away’ ‘I don’t want you here’ (I thought that it was because we were so strict, she didn’t want me watching) so i have left her, as she was happy, and I thought independent. But she hates it when we return to pick her up, and would rather stay with the other adults, some of whom she has only just meet, and doesn’t even know their names. She has started preschool this week – and the behavior is the same – she runs away when we get there, without saying goodbye, and she tell me she hates me and I am a bad mother, and not to touch her when I pick her up. She displays all of the criteria above for A 1-4. And she stands still and cries/screams when she hurts herself. I am sure she may have attached in some ways – because she is the angle at home when alone, but as soon as another person enters, she ignores us. We had a family reunion, and we lost her at the camp as she ran away from her Auntie, and we found her in a strangers car. I am scared that this will get worse as she gets older. Please help! Is she independent, or does she have this dis-inhibited disorder? What can I do? And what have I done?
Thank you so much,
Toni
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Hi Toni,
Thanks for sharing your experience with our readers.
From your description of some of your daughter’s behaviors, I do think it would be reasonable to seek out the advice of a mental health professional with experience in serving families of adopted kids. You might start by asking for referrals from the agency through which you adopted your daughter. If you have a local adoption support group, they may have suggestions regarding professionals in your area. Many/most of the larger children’s hospitals have adoption clinics that employ or refer to mental health professionals with skill in these situations. Many of our families get subsidies through state or local government to pay for treatment services not covered by insurance.
You’re wise to recognize the challenges of parenting a child who appears to lack age-appropriate stranger anxiety along with the need to seek help.
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Studies have shown that a child receives much from the parents – esp. the mother in stress hormones during pregnancy, as well as trauma (we don’t know what happens in the womb when a mom is physically abused, abuses substances). There are also health issues passed down in the microflora of vaginal births which can upset the digestive system, and thus also the brain function of the child (GAPS Gut and Psychology Syndrome – this is only the beginning of the understanding of this topic). My child, though adopted at 7, exhibits all of the DSED in high levels – had him evaluated by a psychologist. He also has “ring of fire” ADHD (tested with brain wave computer hook up), was evaluated before we got him with the ODD and behavior issues. We homeschool b/c of his violence at school was daily and severe. He learns better at home for a number of reasons – the school was too busy for him visually, noise-wise, and population. At home he gets more patience from his teacher (I care more for him as an individual than the stranger at school) and ability to get up to play every time he finishes an assignment. He did know everyone’s name in the hall by the end of week one in first grade, however, though exceptionally smart, he couldn’t learn academics with all the distractions and his own inability to control himself. Even the school had to admit, after much testing, that he would do better in a one-one teaching situation which they could not provide.
There is a misnomer about socialization: children who do not know how to socialize do not learn how to socialize from others in the same boat. One teacher does not have enough time in her day after keeping peace/discipline in her classroom of 18-30 students AND teach academics to where each child can learn it sufficiently to pass, AND teach socialization skills – which are taught mostly by modeling in very specific situations. Students in a classroom are asked to sit quietly, walk quietly in a line and raise their hand for permission to speak – is that normal socialization? Parents model socialization skills in their interactions with other adults and normal children naturally copy them.
As much as your child probably has the disinhibited social issues and may have difficulties learning them naturally by watching you, she is less likely going to get healthy understanding of socializing from school children who don’t know much more than she does and could very well be influenced in a negative manner from older school children in the same school. For my DSED young man, I continually have to take him aside and tell him what is acceptable and what is not and why. Does it help? In the moment, but not long term. But perhaps, just perhaps, someday he will catch himself because I have repeated the lesson so many times (and we practice by doing “do-overs” – like motor memory for the verbal part of the brain).
Your young lady is probably old enough, too that she has noticed whether or not you have told her, that there is something different between you and her. She might have questions in her head. My guy knew exactly what was happening when he got adopted and he still has questions.
Not knowing anything more, I wonder if she likes the other situations due to lack of discipline? My guy loves to be in control of adults – is extremely good at manipulation of therapists to the point that normal adults are easy targets. He hates that I can catch him at his attempts of deceit. He asked to go back to any one of his foster families or birth family and I asked him why – he said b/c they didn’t discipline him – he doesn’t deserve to be disciplined/corrected. This is a heart issue as well as a brain function issue.
You have a challenging child. There is a place on FB called Beta Beyond Trauma and Attachment.
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I need help finding a place for my granddaughter. Asap please. Thank you
Cathy Burgess
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Hi Cathy,
That’s not part of what our ministry does. You probably need to call Children’s Services in the community where you live if you need that kind of help.
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