Disinhibited social engagement disorder

Disinhibited social engagement disorder is a reactive attachment disorder newly introduced in the DSM-5. It is commonly confused with ADHD and is caused by childhood neglect or maltreatment. Children with disinhibited social engagement disorder interact with strangers in a way like they interact with parents or parental figures. In other words, they do not discriminate between parents and strangers (American Psychiatric Association [APA], 2013a).

The disorder is causes by severe neglect at a young age, likely before the age of 2 (APA, 2013a). Disinhibited social engagement disorder has no relationship with depressed mood or the quality of care giving (improved quality of care giving results in only marginal improvements) (Zeanah, 2010).

Disinhibited social engagement disorder was previously a subtype of reactive attachment disorder (RAD), referred to as indiscriminately social/disinhibited type or indiscriminately social RAD (Zeanah, 2010). It was separated from reactive attachment disorder with the release of the DSM-5 in 2013 because the two disorders differ in important ways (APA, 2013b, p. 9). See reactive attachment disorder for more information.

The American Psychiatric Association states that "both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments." (APA, 2013b, p. 9) Both disorders are readily identifiable in maltreated children and some young children who have been raised in institutions, although disinhibited social engagement disorder may have a biological cause in some cases (e.g., Williams Syndrome) (Zeanah, 2010).

Unlike both disinhibited social engagement disorder and reactive attachment disorder, ADHD (a disorder that can be confused with disinhibited social engagement disorder) can develop when no maltreatment or neglect occurs (Follan, 2011). For example, ADHD there is a strong evidence of a genetic link whereas dishibited social engagement disorder can result from being raised in conditions of extreme adversity, such as being raised from infancy in an institution. (Zeanah, 2010).

Differences between Disinhibited social engagement disorder and ADHD
Both disorders include indiscriminate friendliness, but there are some differences. It has been suggested that this may be an attempt to control a situation that is unpredictable to the child. It may also be a way to win the approval of an adult the child deems most important in his/her life. This opposed to ADHD, where indiscriminate friendliness may just be a result of impulsivity (Follan, 2011).

ADHD

 * a brain disorder and a common mental health problem
 * affects both adults and children
 * children may squirm and fidget or daydream a lot, have difficulty following instructions, appear to not listen when being spoken to, are not able to stay seated, talk too much or interrupt, or are easily distracted
 * hyperactivity is more significant in some children than others (APA, 2009)

Disinhibited social engagement disorder
It appears that this disorder can be distinguished from ADHD with these four symptoms, which occur far less or not at all in ADHD:
 * Cuddliness with strangers
 * Seeking comfort from strangers
 * Unpredictable responses when reunited with a caregiver
 * Frozen watchfulness (sitting as if frozen) (Follan, 2011)

Other than that, important differences are that this disorder only occurs in children, most notably during early childhood although it seems like it can persist into middle childhood and adolescence (Zeanah, 2010). It is categorized as a trauma and stressor-related disorder (APA, 2013b).

DSM-5 diagnostic criteria
The criteria for the DSM-5 manual are:

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
 * 1) Reduced or absent reticence in approaching and interacting with unfamiliar adults.
 * 2) Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
 * 3) Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
 * 4) Willingness to go off with an unfamiliar adult with minimal or no hesitation.

B. The behaviors in Criterion A are not limited to impulsivity (as in ADHD|attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:


 * 1) Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
 * 2) Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
 * 3) Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least 9 months (APA, 2013a).

In common with other childhood psychiatric diagnoses, information from a variety of sources should be considered, including parental report, teacher questionnaires and clinician observation (Follan, 2011).

The DSM-IV criteria were altered after criticism that they focused on socially abhorrent behavior rather than reflecting attachment disorder behaviors (Zeanah, 2010).

ICD-10 Diagnostic Criteria
The ICD-10 manual states this disorder starts before a child reaches the age of five years (World Health Organization, 1990), and probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. It is characterized by persistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and vary depending on the environment. For example:
 * Fearfulness and hypervigilance (very jumpy/easy startled)
 * Poor social interaction with peers
 * Aggression towards self and others
 * Misery

The definition of "Disinhibited attachment disorder of childhood" in the ICD-10:

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 behaviour, attention-seeking and indiscriminately friendly behaviour, poorly modulated peer interactions; depending on circumstances there may also be associated emotional or behavioural disturbance (World Health Organization, 1990).