Condition

Disinhibited Social Engagement Disorder

Editors: Lucy Ogbu-Nwobodo MD, MS, MAS; Esther Jolanda van Zuuren MD; Alexander Rae-Grant MD, FRCPC, FAAN

Overview and Recommendations
Background Information
History and Physical
Diagnosis
Management
Complications and Prognosis
Prevention and Screening
Guidelines and Resources
Patient Information
References
Related Content

Next Section >

Background Information

Description

disinhibited social engagement disorder (DSED) is a trauma- and stress-related disorder affecting young children with a history of severely insufficient caregiving, and is characterized by aberrant behavior patterns demonstrating lack of hesitation in interactions with unfamiliar adults ^1
,2
characteristic traits of DSED include^1
,2
- reduced or absent reticence when approaching strangers
- overly familiar verbal or physical behavior
- diminished or absent checking in with caregiver after venturing away (even in unfamiliar settings)
- willingness to "go off with" an unfamiliar adult with minimal or no hesitation
DSED may occur and persist in children^1
,2
- without attachment
- with aberrant attachment
- with healthy attachments to subsequent foster or adoptive parents

Also Called

disinhibited social behavior (key feature of disinhibited social engagement disorder) is sometimes also referred to as
- disinhibited attachment
- indiscriminate friendliness
- over-friendliness
- Reference - Clin Child Fam Psychol Rev 2013 Jun;16(2):101

Types

diagnosis by Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) separates disinhibited social engagement disorder (DSED) and reactive attachment disorder (RAD) into distinct conditions¹
- previous versions of DSM considered DSED the "disinhibited" subtype of RAD, while what is currently RAD in DSM-5 was considered the "withdrawn/inhibited" subtype of RAD
- both disorders arise in children with early experiences that limit their ability to form selective attachments including social neglect, frequent changes in caregivers, or deprivation that may occur in institutional settings
- rationale of DSED and RAD separation in DSM-5
  - both disorders have distinct presentations (though some children present with symptoms from both disorders), response to treatment, associated conditions, and prognoses
  - unlike RAD (which remits with formation of healthy attachment to adoptive or foster parent), DSED may be present in children without attachment, with aberrant attachment, or with healthy attachments to subsequent caregivers; diagnosis of DSED as an attachment disorder has been questioned due to irrelevance of attachment behaviors to caregiver
- mixed-type attachment disorder refers to an attachment disorder with symptoms of both RAD and DSED
specifiers
- DSED is "persistent" if present for ≥ 12 months
- DSED is "severe" if child exhibits all symptoms listed in first criterion with each symptom at relatively high levels
- Reference - California Evidence-Based Clearinghouse for Child Welfare (CEBC)

Epidemiology

Who Is Most Affected

young children with history of institutional rearing, particularly those adopted into another country from which they were born (J Child Psychol Psychiatry 2011 Aug;52(8):819)

Incidence/Prevalence

DynaMed Commentary

Population-based epidemiological studies have not been conducted to accurately estimate incidence or prevalence of disinhibited social engagement disorder based on the Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (DSM-5) criteria. Estimates below are from smaller cohort studies and many use the DSM-IV definition of reactive attachment disorder (RAD) disinhibited subtype that encompasses disinhibited social engagement disorder (DSED) which is considered a distinct disorder in DSM-5.

exact prevalence estimates unknown due to lack of epidemiological studies on DSED, but the condition is generally reported in < 20% of children with history of severe neglect subsequently placed in foster care or raised in institutions¹
STUDY SUMMARY
disinhibited attachment disorder reported in 2% of community-based survey of children aged 1-5 years in Romania
CROSS-SECTIONAL STUDY: Eur Child Adolesc Psychiatry 2011 Oct;20(10):527
based on cross-sectional study

1,003 children aged 1-5 years in Bucharest, Romania were screened for psychiatric disorders in pediatrician waiting room with Child Behavior Checklist (CBCL)

305 children and their primary caregivers who screened positive were evaluated with DSM-IV diagnostic criteria with Preschool Age Psychiatric Assessment (PAPA)

13 children had DSM-IV disinhibited reactive attachment disorder; weighted prevalence was 2% (95% CI 1.1%-4.3%)

Reference - Eur Child Adolesc Psychiatry 2011 Oct;20(10):527
prevalence in at-risk populations
- STUDY SUMMARY
  reactive attachment disorder disinhibited subtype prevalence reported to range from 17% to 18% in children aged 2-4 years residing in institutions in Romania
  RANDOMIZED TRIAL: J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216
  based on cohort analysis of data from Bucharest Early Intervention Project (BEIP) quasi-randomized trial
  
  136 children residing in institutions in Bucharest, Romania aged 6-30 months were assessed for attachment disorders and randomized to remaining in institutional care vs. foster care and followed until age 54 months
  
  overall rates of DSM-IV RAD disinhibited subtype (DSM-5 DSED diagnosis)
  31.8% of children at baseline
  
  17.9% of children at age 30 months
  
  18% of children at age 42 months
  
  17.6% of children at age 54 months
  
  Reference - J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216, editorial can be found in J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):210
- STUDY SUMMARY
  12%-19% of children aged 2-7 years in foster care reported to have disinhibited subtype reactive attachment disorder
  COHORT STUDY: Child Adolesc Psychiatry Ment Health 2014 Jul 15;8:21
  based on analysis of data from 2 cohort studies
  
  126 children aged 2-7 years in foster care in 2 cohort studies in the Netherlands were evaluated for DSM-IV RAD with Disturbances of Attachment Interview (DAI)
  61 children were in regular foster care and were assessed for RAD at study initiation, and were evaluated for internalizing and externalizing problems 3 weeks after initial interview
  
  65 children were newly placed in treatment-based foster care (involving behavioral interventions and trauma therapy) and were assessed for RAD at 3 months after placement (to allow attachments to form), and for internalizing and externalizing problems at 6 weeks after placement
  
  50 children in regular foster care (82%) and 34 children in treatment-oriented foster care (52%) had no RAD symptoms
  
  presence of RAD symptoms
  disinhibited subtype (DSM-5 RAD) found in 7 children in regular foster care (12%) and 12 children in treatment-based foster care (19%)
  
  mixed-symptoms RAD subtype found in 2 children in regular foster care (3%) and 10 children in treatment foster care (15%)
  
  Reference - Child Adolesc Psychiatry Ment Health 2014 Jul 15;8:21
- STUDY SUMMARY
  21% of adolescents aged 12-17 years receiving Intensive Youth Justice Services in Scotland reported to have DSED
  CROSS-SECTIONAL STUDY: Child Abuse Negl 2017 Mar;65:77
  Pediatrics Psychiatric_Disorders21% of adolescents aged 12-17 years receiving Intensive Youth Justice Services in Scotland reported to have disinhibited social engagement disorder (Child Abuse Negl 2017 Mar)06/21/2017 09:37:00 AM28126657
  based on cross-sectional study
  
  29 adolescent adolescents aged 12-17 years with history of receiving Intensive Services in Scotland were assessed for DSM-5 reactive attachment disorder (RAD), DSED, and psychopathology with diagnostic interviews of self-report, 29 caregivers, and 20 teachers
  
  25 adolescents (86%) had history of ≥ 1 form of maltreatment, and 3 adolescents (10%) were suspected of having experienced ≥ 1 form of maltreatment (suspected abuse without proof)
  
  15 adolescents (52%) had attachment disorder or borderline attachment disorder
  6 adolescents (21%) had DSED and 3 adolescents (10%) had RAD
  
  3 adolescents had mixed attachment disorder (symptoms of both RAD and DSED) (10%), and 3 adolescents (10%) had borderline attachment disorder
  
  Reference - Child Abuse Negl 2017 Mar;65:77

Risk Factors

risk of disinhibited social engagement disorder (DSED) is increased with experience of seriously adverse, neglectful caregiving environments in early childhood^1
,2
,3
- many children raised in institutions are reported to develop insecure or disorganized attachment styles, but most do not develop attachment disorders
- children in some countries are at risk for DSED due to poor quality and quantity of care from understaffing of children's homes/orphanages due to socio-economic conditions
- in Western industrialized countries early environmental risk factors usually involve parental mental illness such as addiction, familial disintegration, teenage parenthood, poverty, or transgenerational traumatization
- DSED has also been reported in children without history of institutional rearing and/or social neglect, though both are considered risk factors for indiscriminate social behavior
- STUDY SUMMARY
  institutionalization appears associated with disinhibited social engagement behaviors
  COHORT STUDY: J Child Psychol Psychiatry 2016 Oct;57(10):1126
  based on prospective cohort study
  
  68 postinstitutionalized children were assessed for disinhibited social engagement behaviors during first 2 years postadoption and for DSED at age 5 years
  
  52 children without history of institutionalization or adoption recruited from general population were also assessed
  
  disinhibited social engagement (DSE) was assessed at 4 intervals by clinical observation of 10-minute stranger interactions and verbal and physical intimacy throughout 2-hour lab visit, DSE scores were categorized as physical, nonphysical, and composite scores
  
  DSED was assessed with Disturbances of Attachment Interview (DAI) and semi-structured clinical interview; presence of 4 main DSED symptoms were scored from 0 (no symptoms) to 2 (high levels of all symptoms) and cutoff for DSED diagnosis was score ≥ 1 (indicates ≥ 2 symptoms)
  
  compared to controls, prior institutionalization associated with increased DSE
  composite score at first assessment, and evaluations 3 and 4 (p < 0.01 for each)
  
  physical score at first assessment (p < 0.001) and all other evaluations (p < 0.05 each)
  
  Reference - J Child Psychol Psychiatry 2016 Oct;57(10):1126
genetic factors
- due to presentation similarity between DSED and Williams syndrome (see Differential diagnosis section), it is hypothesized specific polymorphisms on region 7q11.23 plus deprivation in first year of life may be a pathway to DSED development²
  - STUDY SUMMARY
    homozygous s/s genotype of serotonin transporter gene (5-HTTLPR) plus institutional rearing reported to be associated with increased indiscriminate behavior
    CASE-CONTROL STUDY: Physiol Behav 2015 Dec 1;152(Pt A):85
    based on case-control study
    
    85 children aged 3-6 years residing in institutions and 135 home-reared age-matched children were evaluated for indiscriminate friendliness with DAI and for polymorphisms of serotonin transporter (5-HTTLPR) and val66met Brain-Derived Neurotrophic Factor (BDNF)
    
    DAI score range is 0-6, with higher scores indicating increased indiscriminate friendliness; 5-HTTLPR polymorphisms include 2 short alleles (s/s), 1 short and 1 long allele (s/l), and 2 long alleles (l/l)
    
    20 children in institutionalized group and 21 children in home-reared group had s/s 5-HTTLPR genotype
    
    mean DAI scores comparing institutionalized vs. home-reared group (estimated from figure)
    1 vs. 1 point in children with l/s and l/l genotypes (no significant difference)
    
    2 vs. 0.5 points in children with s/s genotype (no p value reported; effect size 0.81, 95% CI 0.17-1.44)
    
    no significant differences in indiscriminate behavior scores among BDNF polymorphisms
    
    Reference - Physiol Behav 2015 Dec 1;152(Pt A):85
evidence for effect of caregiving quality on DSED or disinhibited attachment is mixed²
- STUDY SUMMARY
  quality of caregiving appears associated with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) reactive attachment disorder (RAD)
  RANDOMIZED TRIAL: J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216
  based on cohort analysis of data from Bucharest Early Intervention Project (BEIP) quasi-randomized trial
  
  136 children aged 6 months to 2 years residing in institutions in Bucharest, Romania were assessed for DSM-IV RAD with DAI at baseline and yearly until age 4 years and also for current caregiving quality at baseline and yearly until age 3 years
  
  caregiving quality was evaluated with adapted Observational Record of the Caregiving Environment (ORCE), which consists of taped 1.5 hour session of interaction between child and primary caregiver rated on 5 measures: sensitivity, stimulation of development, positive regard for child, flat affect, and detachment (each rated from 1 [not at all characteristic] to 4 [highly characteristic]; scoring on flat affect and detachment items are reversed)
  
  RAD withdrawn subtype was present in mean 3.4% of children throughout ages 0-4 years, and socially disinhibited type in mean 21.3% of children throughout ages 0-4 years
  
  concurrent quality of caregiving associated with
  RAD socially disinhibited subtype at age 3 years (p ≤ 0.05), but not at baseline or age 2 years
  
  RAD withdrawn subtype at all time points (p ≤ 0.01 each)
  
  Reference - J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216, editorial can be found in J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):210
- STUDY SUMMARY
  higher levels of positive caregiving might be associated with increased levels of indiscriminate friendliness in institutionally reared children, but not in family reared children
  COHORT STUDY: J Child Psychol Psychiatry 2010 Dec;51(12):1368
  based on cohort study
  
  64 children in Ukraine aged 3-6 years (29 children were institutionally reared, 35 were family reared) had physical, cognitive, and social domains and HIV status assessed and quality of caregiving evaluated
  13 children had HIV infection and were institutionally reared; 16 children were institutionally reared without HIV infection
  
  16 children had HIV infection and were family reared; and 19 children were family reared without HIV infection
  
  primary caregivers were evaluated with Emotional Availability Scales (EAS) and with clinical observations of taped interactions of play with child; attachment and indiscriminate friendliness of child were evaluated with Strange Situation Procedure and with semi-structured caregiver-report interview
  
  comparing institutionally reared children vs. family reared children (no p values reported)
  secure attachments style in 28% vs. 51%
  
  attachment style was unclassifiable in 13.5% vs. 0%
  
  higher levels of indiscriminate friendliness associated with
  institutional care (p < 0.05)
  
  positive caregiving in institutional environments (p < 0.01); positive caregiving in family rearing environments was not associated with increased indiscriminate friendliness
  
  Reference - J Child Psychol Psychiatry 2010 Dec;51(12):1368
- STUDY SUMMARY
  higher levels of maternal sensitivity may be associated with decreased levels of indiscriminate friendliness in female infants adopted from China
  COHORT STUDY: Dev Psychopathol 2012 Feb;24(1):49
  based on cohort study
  
  92 female infants aged 11-16 months at adoption from China (50 postinstitutionalized and 42 formerly fostered) and their maternal caregivers were assessed for caregiving quality, infant responsiveness, and attachment style at 2-6 months postadoption
  
  maternal sensitivity and child responsiveness were evaluated with EAS, and attachment style was assessed with Strange Situation Procedure and parent-report of indiscriminate friendliness
  
  increased maternal sensitivity associated with lower levels of indiscriminate friendliness (p < 0.05)
  
  Reference - Dev Psychopathol 2012 Feb;24(1):49
STUDY SUMMARY
increasingly older age at adoption might be associated with increased likelihood of disinhibited attachment disorder, but evidence is mixed
SYSTEMATIC REVIEW: Clin Child Fam Psychol Rev 2013 Jun;16(2):101
based on systematic review without meta-analysis

systematic review of 15 studies (6 independent cohorts) evaluated age at adoption from institution and presence of DSED and RAD

7 studies reported increasingly older age at adoption significantly associated with demonstrating disinhibited social behavior in 742 children

2 studies found "mixed results"
1 study with 111 children found significant associations between age at adoption and persistence of disinhibited behavior over time, and in age 6-42 months at adoption group, but no significant association overall

1 study with 68 children found age at adoption significantly associated with disinhibited attachment disorder, but not inhibited attachment disorder

7 studies found no significant association between age at adoption and disinhibited attachment in 294 children

Reference - Clin Child Fam Psychol Rev 2013 Jun;16(2):101

Associated Conditions

severe caregiving adversity early in life is required for diagnosis of disinhibited social engagement disorder (DSED), and is also a risk factor for many other conditions; early deprivation or neglect also associated with^1
,2
,3
- developmental and cognitive delays
- psychological disorders or behavioral aberrations; data is limited but disorders commonly associated with DSED include
  - attention deficit hyperactivity disorder (ADHD)
  - posttraumatic stress disorder (PTSD)
    - suspect comorbid PTSD if
      - hyper-vigilance or irritability is present in infant, toddler, or preschool child
      - repetitive play with recurrent catastrophic themes is present in preschool child
    - see also Posttraumatic stress disorder (PTSD)
  - "quasi-autism"
    - has been reported in some children adopted out of institutions with severely deprived environments
    - characterized by meeting full clinical criteria for autism at age 4 years, but not meeting criteria at age 6 years
    - at age 6 years, children were reported to still exhibit odd relatedness including some indiscriminate behavior and peculiar interests, but demonstrated more flexible communication abilities than is typical of autism
    - some children reported to have quasi-autism were reported to show indiscriminate behavior similar to DSED at school-age and adolescence
high levels of cognitive comorbidities reported in older children and adolescents with attachment disorder diagnosis including¹
- intellectual disabilities
- language problems
- learning difficulties
attachment styles found in cross-sectional study of 14 children with definite reactive attachment disorder (RAD) or suspected or borderline RAD (majority with disinhibited subtype now Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5} disinhibited social engagement disorder diagnosis) from a cohort of 1,600 children aged 6-8 years residing in low-socioeconomic urban sector of United Kingdom, compared to reported normative values on Manchester Child Attachment Story Task (MCAST)
- secure attachment in 8 children (57%) compared to expected normative proportion of 65%
- insecure-disorganized in 4 children (30%) compared to expected normative proportion of 12% (estimated from figure)
- insecure-avoidant attachment in 1 child (7%) compared to expected normative proportion of 8% (estimated from figure)
- insecure-ambivalent attachment in 1 child (7%) compared to expected normative proportion of 8% (estimated from figure)
- Reference - ScientificWorldJournal 2013;2013:818157
STUDY SUMMARY
RAD disinhibited subtype appears associated with below average social skills and IQ, and increased likelihood of developmental problems and comorbid disorders
CROSS-SECTIONAL STUDY: ScientificWorldJournal 2013;2013:818157
based on cross-sectional study

1,600 children aged 6-8 years residing in low-socioeconomic urban sector of United Kingdom were screened for signs of DSM-IV RAD and comorbidities by interview and parent- and teacher-report; those with suspected RAD were evaluated for diagnosis

RAD included withdrawn/inhibited subtype (DSM-5 RAD) and disinhibited subtype (DSM-5 DSED)

direct assessment of past neglect or trauma was not obtained due to concerns of parental dropout, but indirect assessment was obtained with posttraumatic section of Development and Well-Being Assessment (DAWBA) (examples of maltreatment included physical abuse and witnessing domestic violence)

13 children had definite RAD (12 with disinhibited subtype) and 9 children had suspected or borderline RAD, of these children
55% were in foster or kinship care, remaining 45% thought to be living with birth parents

45% had below average social skills on Social Skills Improvement System (SSIS) compared to normative scores in American children

78% had abnormally high risk of development problems on parent-report Strengths and Difficulties Questionnaire (12% of children in normative United Kingdom sample had abnormally high risk) (estimated from figure)

all mean scores on Wechsler Intelligence Scale for Children (WISC IV) subscales (range 82-87) and overall (79.4) were below average (100 points)

85% of children had likely comorbid ICD-10 or DSM-IV disorder on DAWBA, of these (some overlap)
11 children had likely attention deficit hyperactivity disorder

6 had likely oppositional defiant disorder

6 had likely conduct disorder

4 had likely posttraumatic stress disorder

3 had likely autism spectrum disorder

3 had likely specific phobia

1 had likely tic disorder

Reference - ScientificWorldJournal 2013;2013:818157
STUDY SUMMARY
RAD disinhibited subtype appears associated with social problems and functional impairment in children residing in institutions in Romania
RANDOMIZED TRIAL: J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216
based on cohort analysis of data from Bucharest Early Intervention Project (BEIP) quasi-randomized trial

136 children residing in institutions in Bucharest, Romania aged 6-30 months were assessed for attachment disorders and randomized to remaining in institutional care vs. foster care and followed until age 54 months

overall rates of DSM-IV RAD disinhibited subtype (DSM-5 DSED) were 31.8% at baseline, 17.9% at age 30 months, 18% at age 42 months, and 17.6% at age 54 months

RAD disinhibited subtype associated with decreased social emotional competence on Infant Toddler Social Emotional Assessment (p ≤ 0.01) and increased functional impairment on Preschool Age Psychiatric Assessment (p ≤ 0.01)

Reference - J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216, editorial can be found in J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):210
STUDY SUMMARY
disinhibited attachment associated with problems in ≥ 1 other domain of functioning at age 11 years in adopted children
COHORT STUDY: J Child Psychol Psychiatry 2007 Jan;48(1):17
based on English and Romanian Adoption (ERA) cohort study

143 children adopted into families in United Kingdom with history of institutional care in Romania between 1990 and 1992, 20 children adopted from Romania without history of institutional care, and 52 children adopted from within the United Kingdom were followed until age 11 years; of children adopted from Romanian institutions
45 were adopted at < 6 months old

98 were adopted at age 6-42 months

children were assessed for disinhibited attachment at ages 4, 6, and 11 years by parent-report and clinical observation of behavior; disinhibited behavior was assessed with 3 items scored 0-2 (score range 0-6)
items included definite lack of differentiation in social response to adults, clear indication child would go off with a stranger, and definite lack of checking back with parent after anxiety-provoking situations

mild disinhibited attachment defined as score 1-3, and marked disinhibited attachment defined as score ≥ 4

at ages 6 or 11 years 40 children (28%) had marked disinhibition, 55 children (38.5%) had mild disinhibition, and 45 children (31.5%) had no disinhibition

rates of ≥ 1 problem in cognitive development, "quasi-autism", peer relationships, behavior, or emotional issues at age 11 years in (p < 0.01 for difference between groups)
37% of children without disinhibition at age 6 or 11 years

55.1% of children with mild disinhibition at age 6 or 11 years

75% of children with marked disinhibition at age 6 or 11 years

Reference - J Child Psychol Psychiatry 2007 Jan;48(1):17, correction in J Child Psychol Psychiatry 2007 Aug;48(8):848
STUDY SUMMARY
attachment disorder symptoms appear associated with hyperactivity, peer problems, and emotional symptoms in adolescent offenders aged 12-17 years
CROSS-SECTIONAL STUDY: Child Abuse Negl 2017 Mar;65:77
based on cross-sectional study

29 adolescents aged 12-17 years with history of receiving Intensive Youth Justice Services in Scotland were assessed for DSM-5 RAD, DSED, and psychopathology with diagnostic interviews of self-report, 29 caregivers, and 20 teachers

mental health problems were evaluated with carer-report Strengths and Difficulties Questionnaire (C-SDQ)

25 adolescents (86%) had history of ≥ 1 form of maltreatment, and 3 adolescents (10%) were suspected of having experienced ≥ 1 form of maltreatment (suspected abuse without proof)

15 adolescents (52%) had attachment disorder or borderline attachment disorder; 6 adolescents (21%) had DSED based on DSM-5 criteria

comparing adolescents with attachment disorder vs. those without, proportion with probable other mental health problems on C-SDQ (no p values reported)
emotional difficulties in 60% vs. 36%

conduct problems in 100% vs. 71%

hyperactivity in 67% vs. 21%

peer problems in 87% vs. 71%

Reference - Child Abuse Negl 2017 Mar;65:77
STUDY SUMMARY
RAD disinhibited type appears associated with signs of ADHD and impaired social competence in children with history of institutional rearing in Romania
RANDOMIZED TRIAL: J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216
based on cohort analysis of data from BEIP quasi-randomized trial

136 children residing in institutions in Bucharest, Romania aged 6-30 months were assessed for attachment disorders and randomized to remaining in institutional care vs. foster care and followed until age 54 months

overall rates of RAD disinhibited subtype (DSM-5 DSED) were 31.8% at baseline, 17.9% at age 30 months, 18% at age 42 months, and 17.6% at age 54 months

DSM-IV RAD disinhibited subtype associated with
signs of ADHD on Preschool Age Psychiatric Assessment (PAPA) at age 4 years (54 months), though only 4 of 16 children (25%) with definite disinhibited RAD met full criteria for ADHD (not significant)

impaired social competence at age 30 months and 42 months (p ≤ 0.01 each) on Infant Toddler Social Emotional Assessment (ITSEA) in analysis controlling for ADHD signs and IQ

overall functional impairment at age 4 years (54 months) (p ≤ 0.01) on PAPA assessment in analysis controlling for ADHD sings and IQ

Reference - J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):216, editorial can be found in J Am Acad Child Adolesc Psychiatry 2011 Mar;50(3):210
STUDY SUMMARY
impairment in pragmatic language skills reported to be associated with RAD disinhibited or mixed subtypes
CASE-CONTROL STUDY: Eur Child Adolesc Psychiatry 2012 May;21(5):267
based on case-control study

35 children aged 5-8 years with DSM-IV RAD disinhibited or mixed subtype, 52 children with autism spectrum disorder (ASD), and 39 typically developing children were assessed for pragmatic language functioning with Children Communication Checklist (CCC) and autistic symptomatology

all children had verbal IQ estimates in normal range

CCC questionnaire consists of 70 items within 7 subscales: speech (items include "seldom makes errors producing speech sounds"), syntax ("speech is mostly 2-3 word phrases"), inappropriate initiation ("talks to anyone and everyone"), coherence, stereotype language ("makes frequent use of expressions such as 'by the way' or 'actually'"), use of context ("may say things that are tactless or socially inappropriate"), rapport, social relationships, and interests ("has ≥ 1 overriding specific interest")

compared to typically developing group, both RAD and ASD groups had significantly more abnormal CCC subscales scores in all domains excepting those of speech, syntax, and rapport

compared to ASD group, RAD group had significantly more abnormal scores on CCC subscales of use of context (p = 0.005), rapport (p < 0.001), and social relationships (p = 0.006)

Reference - Eur Child Adolesc Psychiatry 2012 May;21(5):267
STUDY SUMMARY
comorbidity of RAD with DSED appears associated with callous-unemotional traits and conduct disorder
COHORT STUDY: Res Dev Disabil 2017 Apr;63:28
Pediatrics Psychiatric_Disorderscomorbidity of reactive attachment disorder with disinhibited social engagement disorder appears associated with callous-unemotional traits and conduct disorder (Res Dev Disabil 2017 Apr)06/21/2017 09:38:00 AM28254669
based on cohort study

1,828 children aged 4-17 years (mean age 10 years) with RAD and/or DSED, ASD, or ADHD were assessed for psychiatric comorbidities
15 children had RAD with DSED, and 5 children had DSED only; of these 20 children
16 children had been removed from their biological families because of severe abuse and/or neglect, and 4 children had been adopted from orphanages in Russia or China; all children had been removed at mean age 4 years and were diagnosed at mean age 6 years (range 0.5-16 years)

at study initiation, 75% were residing in adoptive homes, 15% were in foster care, and 10% were residing with their biological fathers (after removal from mothers)

933 children had ASD, and 895 children had ADHD

comparing children with RAD and DSED vs. those with DSED alone
callous-unemotional traits present in 100% vs. 0%, p < 0.001

conduct disorder in 73.3% vs. 0%, p = 0.008

no significant difference in diagnoses of oppositional defiant disorder, ASD, ADHD, anxiety, or depression

Reference - Res Dev Disabil 2017 Apr;63:28
STUDY SUMMARY
DSED with or without RAD may co-occur with autism spectrum disorder
COHORT STUDY: Clin Child Psychol Psychiatry 2017 Oct;22(4):620
based on cohort study

486 children aged 4-17 years with ASD without RAD or DSED and 20 age- and IQ-matched children with RAD/DSED were evaluated for autism spectrum disorder with Checklist for Autism Spectrum Disorder (CASD) (cutoff score for autism diagnosis is ≥ 15 points)

of 20 children with DSED/RAD
25% diagnosed with DSED only, 75% met criteria for both RAD and DSED

comorbidities included ADHD (14 children), oppositional defiant disorder (3 children), mood disorder not otherwise specified (3 children), posttraumatic stress disorder (3 children), and anxiety disorder (3 children); 2 children RAD/DSED without comorbid disorder

13 children with RAD/DSED (65%) met criteria for autism spectrum disorder

Reference - Clin Child Psychol Psychiatry 2017 Oct;22(4):620

Etiology and Pathogenesis

Causes

disinhibited social engagement disorder is classified as "trauma and stress-related disorder" that occurs in young children due to severely insufficient caregiving^1
,2
,3
situations that limit a child's ability to form selective attachment may include^1
,3
- social neglect or deprivation
- frequent changes of primary caregivers (as in foster care)
- deprivation that may occur in institutional settings

Pathogenesis

disinhibited social engagement disorder (DSED) develops as a result of social neglect or deprivation in first years of life and early childhood^1
,2
typical bonding and attachment process begins in first few years of life and results in normal patterns of behavioral organization¹
- in infancy, behavior develops to seek close physical proximity to preferred caregiver for comfort, support, nurturance, or protection
- between ages 2 and 7 months, infants interact with variety of social partners and may be able to be soothed by unfamiliar caregivers in addition to familiar caregivers
- at ages 7-9 months "selective or preferred" attachment develops, with development of stranger wariness and protestation if separated from familiar caregivers
  - infants favor caregivers with whom they have significant amounts of interaction
  - typically there is a hierarchy of caregiver preference, and there is reported to be a limit to capacity to attach to large numbers of caregivers because actual physical contact and regular interaction appears necessary for bonds to form
  - in institutions with many caregivers working irregular shifts, many children are reported to have little to no preference for attachment figures
- preferred attachments can develop at any age after 7-9 months, if sufficient interaction is provided
- at age 12 months, assessment of attachment quality can be assessed with Strange Situation Procedure (see Clinical observations of attachment section)
neurobiological abnormalities in children with early deprivation in functional imaging studies include^1
,2
- reductions of gray and white matter volumes, corresponding with reduced electrical activity in higher frequencies and increased electrical activity in lower frequencies
- disruptions in connectivity between amygdala and prefrontal cortex
- STUDY SUMMARY
  adopted children with history of institutionalization reported to not show discrimination between images of mother and stranger's faces in amygdala activation, and to show significantly higher activation compared to controls when viewing stranger's faces
  CASE-CONTROL STUDY: Biol Psychiatry 2013 Dec 1;74(11):853
  based on case-control study
  
  33 youths aged 4-17 years with history of institutional rearing and 34 controls were evaluated for amygdala response to mother and age- and ethnicity-matched stranger's faces with functional magnetic resonance imaging
  
  youths with history of institutionalization were all adopted by parents in United States via foreign adoption (75% were from Eastern Europe, 24% were from East and South Asia)
  
  youths with history of institutionalization were significantly more indiscriminately friendly compared to controls by parent report (p < 0.05)
  
  no significant difference in amygdala activation
  comparing reactions of controls vs. youths with history of institutionalization to mother's faces
  
  comparing mother vs. stranger's faces in youths with history of institutionalization
  
  significantly higher amygdala activation when reacting to
  stranger's faces compared to mother's faces in controls (p < 0.05)
  
  stranger's faces comparing controls vs. youths with history of institutionalization (p < 0.05)
  
  compared to controls, youths with history of institutionalization exhibited significantly less amygdala habituation in later scan sessions (p < 0.025)
  
  older age at adoption nonsignificantly associated with increased indiscriminate friendliness by parental report (p < 0.07) and significantly decreased amygdala discrimination between mother and stranger (p < 0.05) in youths with history of institutionalization
  
  Reference - Biol Psychiatry 2013 Dec 1;74(11):853, editorial can be found in Biol Psychiatry 2013 Dec 1;74(11):788

Next Section >

Published by EBSCO Information Services. Copyright © 2025, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

DynaMed Levels of Evidence

Quickly find and determine the quality of the evidence.

DynaMed provides easy-to-interpret Level of Evidence labels so users can quickly find and determine the quality of the best available evidence. Evidence may be labeled in one of three levels:

1Level 1 (likely reliable) Evidence

Representing research results addressing clinical outcomes and meeting an extensive set of quality criteria which minimizes bias.

There are two types of conclusions which can earn a Level 1 label: levels of evidence for conclusions derived from individual studies and levels of evidence for conclusions regarding a body of evidence.

2Level 2 (mid-level) Evidence

Representing research results addressing clinical outcomes, and using some method of scientific investigation, but not meeting the quality criteria to achieve Level 1 evidence labeling.

3Level 3 (lacking direct) Evidence

Representing reports that are not based on scientific analysis of clinical outcomes. Examples include case series, case reports, expert opinion, and conclusions extrapolated indirectly from scientific studies.

Grades of Recommendation

Guideline producers are now frequently using classification approaches for their evidence and recommendations, and these classifications are recognized and requested by guideline users. When summarizing guideline recommendations for DynaMed users, the DynaMed Editors are using the guideline-specific classifications and providing guideline classification approach when this is done.

Download the full version of Levels of Evidence

Condition

Disinhibited Social Engagement Disorder

Background Information

Description

Also Called

Types

Epidemiology

Who Is Most Affected

Incidence/Prevalence

Details

Details

Details

Details

Risk Factors

Details

Details

Details

Details

Details

Details

Associated Conditions

Details

Details

Details

Details

Details

Details

Details

Details

Etiology and Pathogenesis

Causes

Pathogenesis

Details

DynaMed Levels of Evidence

Quickly find and determine the quality of the evidence.

1Level 1 (likely reliable) Evidence

2Level 2 (mid-level) Evidence

3Level 3 (lacking direct) Evidence

Grades of Recommendation