Disinhibited Social Engagement Disorder

(DSED): What It Is, Symptoms, &

Treatments
Disinhibited social engagement disorder (DSED) is a relatively rare mental health condition
that typically stems from early childhood neglect or inconsistent caregivers. A child with
DSED will appear fearless around new adults, seek attention or comfort from strangers, and
often wander off with unfamiliar people. Therapeutic interventions can help, but having
consistent, caring adults in the child’s life is the best way to reduce DSED symptoms.

Symptoms of DSED
Symptoms of DSED will be expressed in the varied interactions and instances of
communication between the child and any adults in their life. The child with DSED may have
limited insight and understanding into the condition, so their ability to verbalize their
thoughts and feelings may be minimal. Caring adults will need to observe their actions and
behaviors to identify the presence of disinhibition around strangers.1

Like other mental health conditions, DSED follows a set of diagnostic criteria. To be
diagnosed with DSED, two of four specific symptoms must be present.

The four symptoms of DSED are:1

1. Reduced or absent restraint when approaching or interacting with unknown or

unfamiliar adults
2. An overly comfortable and familiar exchange with the unknown adults, either through
verbal or behavioral interactions
3. Limited interest in checking in with caregiver to gain assurance or allowance for
behaviors and actions
4. A willingness to go to new situations or leave current settings with strangers

Another defining factor of DSED is that the child is at least nine months old. No one under
the age of nine months can receive the DSED diagnosis.1 Though there is no upper age limit
on the condition, experts rarely observe the disorder into adulthood.

Causes of DSED
Simple impulsivity or spontaneity is not enough to qualify a child with DSED. The child and
their disinhibited social interactions cannot be sourced from attention-deficit/hyperactivity
disorder (ADHD), autism, or any other mental or physical health condition. Rather, it must
stem from the insufficient care they received earlier in life.2

Here are three potential causes of DSED:1

1. Social neglect or deprivation: The adults were not able to meet the child’s needs
related to comfort, attention, or affection
 2. Repetitive changes in caregivers: The people primarily responsible for childcare
were frequently shifting or being inconsistent, like in the case of everchanging foster
care placements
3. Being raised in environments with limited access to relationships: Places where
the number of children far outweighed the number of adults, so the child could not
form a strong attachment (e.g., institutions and residential centers with high child-to-
staff ratios)

Signs of DSED
At first, the signs of DSED may be challenging to identify and differentiate from normal
childhood behaviors. An adult may benefit from a series of observations to begin noticing
patterns of interactions with unfamiliar adults. Initially, a child with DSED may seem
outgoing, social, and friendly, which would all be positive qualities, but as time goes on, the
observer can note how extreme and atypical the behaviors become.

Potential signs of disinhibited social engagement disorder include:3

 A willingness to have relationships with any adult or peer without regard of the
person’s age, status, or safety level
 Cuddliness with strangers
 Seeking comfort from strangers, rather than hoping to be soothed by guardians
 Asking a list of personal questions to strangers that may be inappropriate,
uncomfortable, or rude
 Entering people’s person space without their consent and ignoring social cues
 Freely exploring new settings and situations without consulting or checking in with
guardians
 Leaving situations with new people or following strangers around
 Displaying behaviors that are demanding or attention-seeking

Examples of DSED
A child with DSED could display some or all of these symptoms at any one time.
Alternatively, the child’s symptoms could change and evolve over time to incorporate new
signs and symptoms of the condition.

Here are three examples of the ways DSED could manifest:

Example 1

A child with DSED may be walking through a park, notice a stranger’s shoes, and comment
that they like the shoes. Alone, this comment is not significant, but then the child could try to
enter into a long conversation with the adult and ask them a long list of personal or
inappropriate questions, despite no prompting or encouragement.3

Example 2

Another child with DSED could meet a new adult at a party or school function and quickly
encroach on the adult’s personal space. After no time knowing each other, the child could ask
for hugs, kisses, or sit on the adult’s lap. They could even start cuddling with the adult in an
attempt to receive the desired level of comfort that they have been unable to achieve in the
past.3

Example 3

A third variation of a child with DSED is one that will quickly leave the security of their
guardian to be with strangers or struggles to make healthy peer relationships and will spend
time with anyone, regardless of their age, danger, or safety.

Risk Factors of Disinhibited Social Engagement Disorder

Some mental health disorders have causes and risk factors that are confusing or unclear, but
with DSED, the roots of the condition are almost always obvious. Disinhibited social
engagement disorder stems from childhood neglect, especially neglect that occurs during the
first two years of life.1 The actual roots of this neglect are varied and can arrive from multiple
sources.

Here are six causes of DSED that are linked to childhood trauma:

1. Death of a parent
2. Parental divorce or separation
3. Incarceration of parents or guardians
4. Placement in the foster care system
5. Being housed in a residential treatment center
6. Limited attention from parents due to substance use, low intellectual functioning, or
mental health concerns

Whatever the source of the neglect, children with DSED routinely try to overcompensate for
the limited attention, comfort, and connection by forming new bonds with other adults and
strangers. Since the children are typically young, they will not have the memory, insight, or
understanding to put this need into words, but their behaviors will show how they are
desperately looking for love and attention.

An interesting aspect of DSED is that not all children who endure severe neglect during
childhood will develop this condition. In fact, the incidence of DSED is so rare that true
prevalence rates are difficult to measure.1 Among children who are neglected to the point that
residing in foster care or another out-of-home placement is necessary, only about 20% of
them will meet criteria for the DSED diagnosis.1 2

DSED vs. Normal Development

Typical childhood behavior will stand in sharp contrast to children with DSED. These
children will require no time to appear comfortable and confident in a new setting around
new people. For a moment, they may simply appear friendly or outgoing, but the complete
lack of social, emotional, and physical boundaries will become obvious over time.

How Does a Child With DSED Develop Over Time?

When someone experiences neglect and high levels of inconsistent caregiving before age
two, they have increased risk of DSED. Once symptoms of DSED emerge, they tend to be
fairly consistent over time, especially when neglectful conditions persist.1

Younger children and toddlers may express their DSED through overly familiar social
interactions with strangers and a lack of hesitation with unknown adults. In preschoolers, the
symptoms may shift towards more attention-seeking behaviors. Children from this age group
may act in intense or exaggerated ways to gain more concern and affection from adults
around them.1

School aged children with DSED will show overfamiliarity with new adults in verbal and
physical ways. They could ask inappropriate questions or be quick to sit on their laps or ask
for hugs. Rather than expressing emotions in an authentic way, they may use emotional
reactions as a way to manipulate others.1

During adolescence, people with DSED will struggle with peer interactions. They tend to
have chaotic and inconsistent relationships with other kids their age.1

Experts have not observed symptoms of DSED in adults, but it is unlikely that the condition
simply alleviates spontaneously. It’s more likely that the disorder shifts and morphs into other
mental health diagnoses more associated with adulthood like depression, anxiety, bipolar
disorder, and personality disorders.4

Risks & Consequences of DSED

Based on their inability to discriminate between safe and threatening adults and caregivers,
children with DSED may find themselves exposed to a list of dangerous risks and
consequences. These risks may not end with childhood and could extend well past
adolescence and into adulthood.

Possible risks and consequences of DSED are:

 Increased likelihood of physical, emotional, or sexual abuse

 Higher risk of exploitation and manipulation
 Danger of becoming injured due to wandering off into unsafe situations like walking
into traffic, falling, or entering a swimming pool without being able to swim
 Feeling disenfranchised and pessimistic about people and the world, which can lead to
mood disorders
 Higher likelihood of experimenting with alcohol and other drugs as a way to connect
with peers or self-medicate

DSED seems to create lifelong complications, so the risks and consequences of the condition
are endless. Worse, the person with DSED may not identify these situations as risky as they
feel compelled to act in these ways.
Treatment of Disinhibited Social Engagement Disorder
Treatment for disinhibited social engagement disorder is a complicated and uncertain process
as even the best professional treatment can not undo the symptoms caused by ongoing
instability. With a combination of therapeutic interventions and parent training, the child,
their guardians, and their treatment team may begin to notice symptoms of DSED improve.

To produce any helpful change with DSED, the first step is ensure that the child has an
emotionally available attachment figure. Ideally, this attachment would come from a parent
or guardian who is available in the home. Without consistency and stability at home, the
treatment of DSED will be severely hindered.2

Medication

At this point, there is no medication recommended or prescribed to children with DSED.2

Some children with DSED may also have ADHD, anxiety, or depressive disorders and could
benefit from medications to address these symptoms. By treating these co-occurring
conditions, the overall treatment of DSED can improve. Medical professionals like primary
care physicians (PCPs), psychiatrists, and nurse practitioners may offer medications to
address other mental health disorders.

Therapy

With the limited ability of medications to directly address symptoms of DSED, therapy will
be the primary form of treatment. Options like cognitive behavioral therapy (CBT), play
therapy, expressive arts therapy, and parent-child interaction therapy (PCIT) will be helpful
in reducing symptoms of DSED.

DSED & Caregivers

Issues between a child and their caregivers are both the cause and effect of DSED. Caregivers
dealing with the effects of DSED will endure many frustrations and periods of confusion, but
they should always focus on doing their best to remain consistent, stable, caring, patient, and
understanding. Without these qualities, the child with DSED will struggle to improve.

Like with other conditions that stem from a form of trauma, it may be challenging to continue
seeing the child as the victim as they are consistently breaking the rules by wandering off and
spending time with strangers. Caregivers can improve the situation tremendously by focusing
on the condition and how the condition significantly impacts the child well after the neglect