Disinhibited Social Engagement Disorder DSM-5 313.89 (F94.2)
DSM-5 Category: Trauma- and Stressor-Related Disorders
Introduction
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines disinhibited social engagement disorder as “a pattern of behavior in which a child actively approaches and interacts with unfamiliar adults.” (American Psychiatric Association, 2013). Disinhibited social engagement disorder is a trauma and stressor-related disorder that develops as a result of severe neglect during the first two years of life. Although any seriously neglected child can show symptoms of disinhibited social engagement disorder, it is most common among children who spend infancy in an institution. Institutionalized children are often cared for inconsistently and do not have the opportunity to develop healthy attachments (McLaughlin, Epsie & Minnis, 2010).
Symptoms of Disinhibited Social Engagement Disorder
The most obvious symptom of disinhibited social engagement disorder is the absence of normal fear or discretion when approaching strangers. The child is unusually comfortable talking to, touching, and leaving a location with an adult stranger. These behaviors are not the result of attention problems or other issues that might be associated with impulsive behavior. The DSM-5 explains that a background of severe social neglect is a diagnostic requirement (American Psychiatric Association, 2013). Because young infants are unable to form selective attachments, disinhibited social engagement disorder is not diagnosed in children younger than nine months old. Development of disinhibited social engagement disorder almost always occurs during the first two years of life (American Psychiatric Association, 2013).
Because neglect is a diagnostic feature of disinhibited social engagement disorder, patients may also present other symptoms of neglect that are not directly related to disinhibited social engagement disorder. For example, a neglected child may present with developmental delays and malnutrition (American Psychiatric Association, 2013). Although developmental disability is not a diagnostic feature of disinhibited social engagement disorder, the disorder is more common in developmentally disabled infants because they are more likely than healthy children to be mistreated or institutionalized (Minnis, Fleming & Cooper, 2010). Children who are removed from abusive or neglectful environments tend to recover physically but still present symptoms of disinhibited social engagement disorder. Therefore, not all children with disinhibited social engagement disorder have physical symptoms (American Psychiatric Association, 2013).
Risk Factors
Disinhibited social engagement disorder is most common in children institutionalized during infancy and early childhood. Still, not all children raised in institutions develop disinhibited social engagement disorder or other attachment disorders. Disinhibited social engagement disorder is specifically related to the quality of attachment. Therefore, children living in institutions with adequate medical care, stimulation and nutrition can develop disinhibited social engagement disorder. In noninstitutionalized children, parental adjustment problems are the most prevalent risk factors. Examples include poverty, teen parenting, substance abuse and mental health issues such as a depression or personality disorder that affect the parent’s ability to form an attachment with the child (Oliveira, et al, 2013).
Social Concerns
According to the DSM-5, “Disinhibited social engagement disorder significantly impairs young children’s abilities to relate interpersonally to adults and peers.” (American Psychiatric Association, 2013). This is because both adults and children are put-off by verbal and behavioral over-familiarity. For example, a child with disinhibited social engagement disorder may sit on the lap of a stranger, which creates a very uncomfortable situation for the adult. Adolescents with disinhibited social engagement disorder extend this familiarity to peers, creating awkward social situations. Caregivers of children with disinhibited social engagement disorder often experience anxiety and fear that the child’s behavior will put him or her in a dangerous situation by behaving too comfortably with strangers. Further, caregivers often feel frustrated that the child is not developing an appropriate attachment (Oliveira, et al, 2013).
Disinhibited Social Engagement Disorder in Adulthood
Disinhibited social engagement disorder is exclusively a disorder of childhood and is not diagnosed after the age of five. Still, children experiencing disinhibited social engagement disorder eventually grow up. Unfortunately, little is known about what happens to these children in adulthood. Few studies have examined adolescents with disinhibited social engagement disorder and no studies to date have examined adults. It is widely believed that symptoms diminish with age, although indiscriminate friendliness may persist. Many experts believe that as developmental milestones are reached, symptoms lessen. Another possibility is that disinhibited social engagement disorder is an adaptive mechanism used to elicit care from potential caregivers. As this need diminishes, so do the symptoms (Minnis, Fleming & Cooper, 2010).
Treatment for Disinhibited Social Engagement Disorder
An integrative approach to psychotherapy is the most effective way to treat disinhibited social engagement disorder. The therapy must facilitate multisensory experiences, communication, social skills, emotional awareness and self-exploration (Malchiodi & Crenshaw, 2013). Establishing rapport between child and therapist is typically easy because, according to the DSM-5, overfriendliness and trust is a key feature of disinhibited social engagement disorder (American Psychiatric Association, 2013). Establishing a relationship, however, is more challenging because children with disinhibited social engagement disorder only develop shallow, superficial attachments. Play therapy and creative arts therapy are two effective approaches to treating disinhibited social engagement disorder (Malchiodi & Crenshaw, 2013)
Because children naturally develop attachments through play, play therapy offers and opportunity to create attachments that did not occur during early infancy. In many cases, the primary caregiver is invited to join the play therapy sessions, so that the new attachment can extend beyond the therapist. Creative arts therapy is another effective approach to treating disinhibited social engagement disorder. Creative arts therapy uses painting, drawing, dance, music and theatrical activities as a means of carrying out psychotherapy. Like play therapy, creative arts therapy is interactive and experiential (Malchiodi & Crenshaw, 2013).
Infants develop healthy attachments to parents and primary caregivers through their five senses. Being held, fed, and talked to, for example, are important components of attachment development. These needs don’t disappear with age. Children, teens, and adults experience relationships through hugging, touching, story-telling, and eating together. Both play therapy and creative arts therapy provide sensory experiences. Both approaches also normalize experiences for children with disinhibited social engagement disorder, because children in all cultures enjoy play and artistic expression. Another benefit to both play therapy and creative arts therapy is that both approaches can be done non-verbally. This is important because young children are not always willing to able to verbally discuss trauma, thoughts, and feelings (Malchiodi & Crenshaw, 2013).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Malchiodi, C.A. & Crenshaw, D.A. (2013). Creative arts and play therapy for attachment problems. New York, New York: Guilford Publications, 2013.
Mclaughlin, A., Espie, C. & Minnis, H. (2010). Development of a brief waiting room observation for behaviours typical of reactive attachment disorder. Child and Adolescent Mental Health, 15 (2): 73-79
Minnis, H., Fleming, G., Cooper, S. (2010). Reactive attachment disorder symptoms in adults with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 23 (4): 398-403
Oliveira, P.S., Soares, I., Martins, C., Silva, J., Marques, S., Baptista, J. & Lyons-Ruth, K. (2012). Indiscriminate behavior observed in the strange situation among institutionalized toddlers: Relations to caregiver report and to early family risk. Infant Mental Health Journal. 33(2): 187-196
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