Disinhibited social engagement disorder

Essential (Required) Features:

• A history of grossly insufficient care of a child that may include:
• Persistent disregard for the child’s basic emotional needs for comfort, stimulation, and affection.
• Persistent disregard for the child’s basic physical needs.
• Repeated changes of primary caregivers (e.g., frequent changes in foster care providers).
• Rearing in unusual settings (e.g., institutions) that prevent formation of stable selective attachments.
• Maltreatment.
• A persistent and pervasive pattern of markedly abnormal social behaviours in a child, in which the child displays reduced or absent reticence in approaching and interacting with unfamiliar adults, including one or more of the following:
• Overly familiar behaviour with unfamiliar adults, including verbal or physical violation of socially appropriate physical and verbal boundaries (e.g., seeking comfort from unfamiliar adults, asking age-inappropriate questions to unfamiliar adults).
• Diminished or absent checking back with an adult caregiver after venturing away even in unfamiliar settings.
• A willingness to go off with an unfamiliar adult with minimal or no hesitation.
• The symptoms are evident before the age of 5.
• The child has reached a developmental level by which the capacity to form selective attachments with caregivers normally develops, which typically occurs at a chronological age of 1 year or a developmental age of at least 9 months.
• The disinhibited social engagement behaviour is not better accounted for by another mental disorder (e.g., Attention Deficit Hyperactivity Disorder).

Additional Clinical Features:

• Persistent disregard for the child’s basic needs may meet the definition for neglect: Egregious acts or omissions by a caregiver that deprive a child of needed age-appropriate care and that result, or have reasonable potential to result, in physical or psychological harm. Disinhibited Social Engagement Disorder is associated with persistent neglect rather than isolated incidents.
• Maltreatment is characterized by one or more of the following: 1) non-accidental acts of physical force that result, or have reasonable potential to result, in physical harm or that evoke significant fear; 2) sexual acts involving a child that are intended to provide sexual gratification to an adult; or 3) non-accidental verbal or symbolic acts that results in significant psychological harm. Disinhibited Social Engagement Disorder is typically associated with persistent maltreatment rather than isolated incidents.
• Children with a history of grossly insufficient care are at increased risk for developing Disinhibited Social Engagement Disorder, particularly when it occurs very early (e.g., prior to the age of 2). However, Disinhibited Social Engagement Disorder is rare, and most children with such a history do not develop the disorder.
• In contrast to Reactive Attachment Disorder, symptoms of Disinhibited Social Engagement Disorder tend to be more persistent following the provision of appropriate care, even with the development of selective attachments.
• Children with Disinhibited Social Engagement Disorder related to repetitive maltreatment (e.g., chronic physical or sexual abuse) are at risk for developing co-occurring Post-Traumatic Stress Disorder or Complex Post-Traumatic Stress Disorder.
• General impulsivity is commonly associated with Disinhibited Social Engagement Disorder, particularly among older children, and there is a high rate of co-occurrence with Attention Deficit Hyperactivity Disorder.

Boundary with Normality (Threshold):

• Children vary greatly in their temperamental features, and Disinhibited Social Engagement Disorder should be distinguished from the ebullience associated with an outgoing temperamental style. Distinguishing features of the Disinhibited Social Engagement Disorder are the dysfunctional nature of the behaviour and its association with ¬a history of grossly insufficient care.

Course Features:

• Disinhibited Social Engagement Disorder is moderately stable and symptoms may persist throughout childhood and adolescence. Overly friendly behaviour appears to be relatively resistant to change.
• Individuals with Disinhibited Social Engagement Disorder who lived in institutions for an extended period of time appear to be at greatest risk for persistent symptoms, even after adoption. Early removal from an adverse environment decreases the likelihood that indiscriminate social behaviours will persist.
• In adolescence, individuals with a history of Disinhibited Social Engagement Disorder demonstrate superficial peer relationships (e.g., identification of acquaintances as close friends) and other deficits in social functioning (e.g., increased conflict with peers).
• Evidence-based treatment for maltreated children and adolescents and for enhancing secure attachment is recommended for children and adolescents diagnosed with Disinhibited Social Engagement Disorder. However, only some individuals with Disinhibited Social Engagement Disorder appear to respond to interventions targeting enhancement of caregiving.
• During childhood, Disinhibited Social Engagement Disorder often manifests in violation of socially appropriate physical (e.g., seeking comfort from unfamiliar adults) and verbal boundaries (e.g., asking inappropriate questions to unfamiliar adults).

Developmental Presentations:

• Children and adolescents are at greater risk for Disinhibited Social Engagement Disorder if they have experienced seriously neglectful caregiving and adverse environments, such as institutions, particularly if this occurred prior to the age of 2. However, Disinhibited Social Engagement Disorder is relatively rare and not all children or adolescents with a history of experiencing such environments go on to develop Disinhibited Social Engagement Disorder.
• Individuals with Disinhibited Social Engagement Disorder may or may not have developed selective attachment to caregivers.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Attention Deficit Hyperactivity Disorder: Similar to Disinhibited Social Engagement Disorder, children with Attention Deficit Hyperactivity Disorder may display socially disinhibited behaviour. Disinhibited Social Engagement Disorder is distinguished by specific behaviours with unfamiliar adults and its association with ¬a history of grossly insufficient care. However, children with Disinhibited Social Engagement Disorder do often exhibit inattention, general impulsivity, and hyperactivity. Rates of Attention Deficit Hyperactivity Disorder are elevated among children with Disinhibited Social Engagement Disorder, and both disorders may be diagnosed if all diagnostic requirements for each are met.
• Boundary with Disorders of Intellectual Development: Children with a Disorder of Intellectual Development may exhibit atypical social behaviours. However, these are usually consistent with the child’s general developmental level. Children with Disorders of Intellectual Development are able to form selective attachments to caregivers by the time the child has reached a developmental age of at least 9 months. Disinhibited Social Engagement Disorder should only be diagnosed if it is clear that the characteristic problems in social behaviour are not a result of limitations in intellectual functioning.
• Boundary with Diseases of the Nervous System, Developmental Anomalies and other conditions originating in the perinatal period: Indiscriminate social engagement may be a result of brain damage or a feature of neurological syndromes such as Williams syndrome or foetal alcohol syndrome. These conditions are differentiated from Disinhibited Social Engagement Disorder by confirmatory clinical features and laboratory investigations and typically by the absence of a history of grossly insufficient care.