3. Hearing in unusual settings that severely limit opportunities to form selective at- tachments (e.g., institutions with high chiId-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible forthe disturbed behavior in Cri- terion 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.
Specify if:
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Disinhibited social engagement disorder is specified as severe when the child exhibits all symptoms of the disorder. with each symptom manifesting at relatively high levels.
The essential feature of disinhibited social engagement disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers (Criterion A). This overly familiar behavior violates the social boundaries of the culture. A diagnosis of disinhibited social engagement disorder should not be made before children are developmentally able to form selective attachments. For this reason, the child must have a developmental age of at least 9 months.
Because of the shared etiological association with social neglect, disinhibited social en- gagement disorder may co-occur with developmental delays, especially cognitive and lan- guage delays, stereotypies, and other signs of severe neglect, such as malnutrition or poor care. However, signs of the disorder often persist even after these other signs of neglect are no longer present. Therefore, it is not uncommon for children with the disorder to present with no current signs of neglect. Moreover, the condition can present in children who show no signs of disordered attachment. Thus, disinhibited social engagement disorder may be seen in children with a history of neglect who lack attachments or whose attach- ments to their caregivers range from disturbed to secure.
The prevalence of disinhibited social attachment disorder is unknown. Nevertheless, the disorder appears to be rare, occurring in a minority of children, even those who have been severely neglected and subsequently placed in foster care or raised in institutions. In such high-risk populations, the condition occurs in only about 20% of children. The condition is seen rarely in other clinical settings.
Conditions of social neglect are often present in the first months of life in children diag- nosed with disinhibited social engagement disorder, even before the disorder is diag- nosed. However, there is no evidence that neglect beginning after age 2 years is associated with manifestations of the disorder. If neglect occurs early and signs of the disorder appear, clinical features of the disorder are moderately stable over time, particularly if conditions of neglect persist. Indiscriminate social behavior and lack of reticence with un- familiar adults in toddlerhood are accompanied by attention-seeking behaviors in pre- schoolers. When the disorder persists into middle childhood, clinical features manifest as verbal and physical overfamiliarity as well as inauthentic expression of emotions. These signs appear particularly apparent when the child interacts with adults. Peer relationships are most affected in adolescence, with both indiscriminate behavior and conﬂicts appar- ent. The disorder has not been described in adults.
Disinhibited social engagement disorder has been described from the second year of life through adolescence. There are some differences in manifestations of the disorder from early childhood through adolescence. At the youngest ages, across many cultures, children show reticence when interacting with strangers. Young children with the disorder fail to show reticence to approach, engage with, and even accompany adults. In preschool children, verbal and social intrusiveness appear most prominent, often accompanied by attention-seeking behavior. Verbal and physical overfamiliarity continue through middle childhood, accompanied by inauthentic expressions of emotion. In adolescence, indis- criminate behavior extends to peers. Relative to healthy adolescents, adolescents with the disorder have more "superficial” peer relationships and more peer conﬂicts. Adult man- ifestations of the disorder are unknown.