Disinhibited social engagement disorder

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Disinhibited social engagement disorder
Other namesDisinhibited Attachment Disorder
Specialty Psychiatry

Disinhibited Social Engagement Disorder (DSED), or Disinhibited Attachment Disorder, is an attachment disorder in which a child has little to no fear of unfamiliar adults and may actively approach them. It can significantly impair young children's abilities to relate with adults and peers, according to the Diagnostic and Statistical Manual of Mental Disorders, [1] as well as put them in dangerous and potentially unsafe conditions. Common examples of this include sitting on a person's lap of which they do not know or leaving with a stranger.

Contents

DSED is exclusively a childhood disorder and is usually not diagnosed before the age of nine months or until after age five if symptoms do not appear. There is no current research showing that signs of DSED continue after twelve years of age. Infants and young children are at risk of developing DSED if they receive inconsistent or insufficient care from a primary caregiver.

Signs and symptoms

The most common symptom is unusual interaction with strangers. A child with DSED shows no sign of fear or discomfort when talking to, touching, or accompanying an adult stranger. [1] They can be categorized by the following:

The attachment style associated with DSED is disorganized attachment. This attachment style is a combination of anxious and avoidant attachment and participants often have a need for closeness, fear of rejection, and contradictory mental states and behaviors. Disorganized attachment is common amongst children living in institutions such as foster care. Children living in these institutions have an increased risk of having DSED. [3] Which is common in those who experience neglect from caregivers at an early age making it a common occurrence in children with DSED.

DSED can cause symptoms commonly associated with attention deficit hyperactivity disorder (ADHD) It can be comorbid with cognitive, language and speech delay. [4] Additionally, children who are socially disinhibited despite not undergoing the trauma to become so should not be diagnosed with DSED. The child's behavior can be explained with other disorders such as Williams syndrome which often has similar symptoms to DSED. [5]

Risk factors

DSED is a result of inconsistent or absent primary caregivers in the first few years of childhood. [6] Children who are institutionalized may receive inconsistent care or become isolated during hospitalization. Parental issues such as mental health problems, depression, personality disorder, absence, poverty, teen parenting, or substance abuse interfere with attachment. [7]

Diagnosis

The ICD-10 definition is: "A particular pattern of abnormal social functioning that arises during the first five years of life and that tends to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused attachment behavior, attention-seeking and indiscriminately friendly behavior, poorly modulated peer interactions; depending on circumstances, there may also be associated emotional or behavioral disturbance." [8]

Differential diagnosis can be attention deficit hyperactivity disorder. [4]

Treatment

Two effective treatment approaches are play therapy or expressive therapy which help form attachment through multi-sensory means. Some therapy can be nonverbal. [9]

Play Therapy: This is a therapy in which children use toys to “play” and interact with the environment in efforts to work through their problems and understand the world around them. In this therapy children can decide the outcome of situations giving them a sense of control. This is for children ages three to eleven and it can also be used as a means to diagnose a child. Also this type of therapy can be directed in attempts to better understand and diagnose the child. This is a psychodynamic and cognitive behavior therapy. [10]

Prognosis

Over time the nature of the behaviors of a child with disinhibited social engagement disorder can evolve during their preschool, middle school, and adolescence years. With this being said, most of the symptoms exhibited by children significantly lessen to the point of almost no detection after approximately twelve years of age.

Pre School: In this early stage DSED is exhibited by a need for attention such as being overly boisterous at the playground in attempts to get the attention of unfamiliar adults

Middle School: There are two main identifiers of DSED in this stage including physical and verbal overfamiliarity of inauthentic emotions and being overly forward. This can be seen as appearing sad in front of others in efforts to manipulate a social situation or being overly insistent upon going over a classmate's house when they first meet them.

Adolescent: Amongst this stage children with DSED are likely to develop problems amongst both their peers and other authoritative figures such as parents and coaches. With that being said “They [also] tend to develop superficial relationships with others, struggle with conflict, and continue to demonstrate indiscriminate behavior toward adults.” [2]

Epidemiology

The exact prevalence is unknown. In high-risk individuals, the prevalence rate is 20%. [11]

History

Disinhibited Social Engagement Disorder (DSM-5 313.89 (F94.2)) is the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) name formerly listed as a sub-type of Reactive Attachment Disorder (RAD) called Disinhibited Attachment Disorder (DAD).

The American Psychiatric Association considers "...Disinhibited Social Engagement Disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments. The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders." [12]

Research

This study was an attempt to solidify the current research that Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are separate dimensions of psychology. In this study a sample of school aged foster children were tested and their foster parents, and social workers completed questionnaires to better understand the children and to pinpoint signs of DSED. Amongst completion it was evident that DSED was indeed its own separate dimension of psychology. [13]

See also

Related Research Articles

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Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from unavailability of normal socializing care and attention from primary caregiving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers between three months and three years of age, frequent change or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts resulting in a lack of basic trust. A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.

Reactive attachment disorder (RAD) is described in clinical literature as a severe disorder that can affect children, although these issues do occasionally persist into adulthood. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited attachment disorder".

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Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness." This behavior is usually targeted toward peers, parents, teachers, and other authority figures, including law enforcement officials. Unlike conduct disorder (CD), those with ODD do not generally show patterns of aggression towards random people, violence against animals, destruction of property, theft, or deceit. One-half of children with ODD also fulfill the diagnostic criteria for ADHD.

<span class="mw-page-title-main">Complex post-traumatic stress disorder</span> Psychological disorder

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<span class="mw-page-title-main">Stranger anxiety</span> Stranger anxiety is a form of distress that children feel when exposed to strangers.

Stranger anxiety is a form of distress that children experience when exposed to strangers. Stranger anxiety and stranger fear are two interchangeable terms. Stranger anxiety is a typical part of the developmental sequence that most children experience. It can occur even if the child is with a caregiver or another person they trust. It peaks from six to 12 months but may recur afterwards until the age of 24 months. As a child gets older, stranger anxiety can be a problem as they begin to socialize. Children may become hesitant to play with unfamiliar children. Foster children are especially at risk, particularly if they experienced neglect early in their life.

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

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Disinhibited attachment disorder (DAD) according to the International Classification of Diseases (ICD-10), is defined as:

Charles H. Zeanah Jr. is a child and adolescent psychiatrist who is a member of the council (Board) of the American Academy of Child and Adolescent Psychiatry (AACAP).

Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder.

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Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

Adult Attachment Disorder (AAD) develops in adults as the result of an attachment disorder, or Reactive Attachment Disorder, that goes untreated in childhood. It begins with children who were not allowed proper relationships with parents or guardians early in their youth, or were abused by an adult in their developmental stages in life. According to attachment theory, causes and symptoms of the disorder are rooted in human relationships over the course of one's lifetime, and how these relationships developed and functioned. Symptoms typically focus around neglect, dysfunction, abuse, and trust issues in all forms of their relationships. These symptoms are similar to those of other attachment disorders, but focus more on relationships later in life rather than those in earlier years. To be considered to have AAD, you must demonstrate at least 2-3 of its symptoms. These symptoms include: impulsiveness, desire for control, lack of trust, lack of responsibility, and addiction. While the DSM-5 does not recognize it as an official disorder, Adult Attachment disorder is currently being studied by several groups and treatment is being developed. Some of these studies suggest splitting AAD into two groups, avoidance and anxious/ambivalent. More recent and advanced medical practice advocates for four categorisations;

References

  1. 1 2 Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing quoted in The Theravive website
  2. 1 2 Humphreys KL, Nelson CA, Fox NA, Zeanah CH (May 2017). "Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care". Development and Psychopathology. 29 (2): 675–684. doi:10.1017/S0954579417000256. PMC   5777580 . PMID   28401844.
  3. ↑ Zeanah CH, Gleason MM (March 2015). "Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment". Journal of Child Psychology and Psychiatry, and Allied Disciplines. 56 (3): 207–222. doi:10.1111/jcpp.12347. PMC   4342270 . PMID   25359236.
  4. 1 2 Langtiw CL. "Fostering connections: Responding to Reactive Attachment" (PDF). The Chicago School of Professional Psychology. Archived from the original (PDF) on 2021-05-18. Retrieved 2018-03-18.
  5. ↑ "Module 4 -Disinhibited Social Engagement Disorder and Reactive Attachment – Behavioral Disorders of Childhood". opentext.wsu.edu. Retrieved 2022-04-04.
  6. ↑ Guyon-Harris KL, Humphreys KL, Miron D, Gleason MM, Nelson CA, Fox NA, Zeanah CH (October 2019). "Disinhibited Social Engagement Disorder in Early Childhood Predicts Reduced Competence in Early Adolescence". Journal of Abnormal Child Psychology. 47 (10): 1735–1745. doi:10.1007/s10802-019-00547-0. PMC   6717530 . PMID   31119469.
  7. ↑ Ogundele, Michael O (2018-02-08). "Behavioural and emotional disorders in childhood: A brief overview for paediatricians". World Journal of Clinical Pediatrics. 7 (1): 9–26. doi: 10.5409/wjcp.v7.i1.9 . ISSN   2219-2808. PMC   5803568 . PMID   29456928.
  8. ↑ International statistical classification of diseases and related health problems (10th revision, 2nd ed.). Geneva: World Health Organization. 2004. ISBN   9789241546492.
  9. ↑ Steffen H (May 26, 2006). Integrative Expressive Therapy: A program development for children (Ph.D. thesis). The Chicago School of Professional Psychology.
  10. ↑ "Disinhibited Social Engagement Disorder". disinhibitedsocialengagementdisorder.com. Retrieved 2021-11-09.
  11. ↑ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
  12. ↑ Highlights of Changes from DSM-IV-TR to DSM-5 Archived October 19, 2013, at the Wayback Machine
  13. ↑ Lehmann S, Breivik K, Heiervang ER, Havik T, Havik OE (April 2016). "Reactive Attachment Disorder and Disinhibited Social Engagement Disorder in School-Aged Foster Children--A Confirmatory Approach to Dimensional Measures". Journal of Abnormal Child Psychology. 44 (3): 445–457. doi:10.1007/s10802-015-0045-4. PMC   4785216 . PMID   26126635.
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