WEBVTT 1 00:00:24.800 --> 00:00:28.760 Hi folks, welcome back. This is part two of our 2 00:00:29.120 --> 00:00:33.439 long ass episode on attachment disorders. Hopefully you had a 3 00:00:33.520 --> 00:00:36.039 chance to listen to part one first. You really need 4 00:00:36.079 --> 00:00:39.560 to listen to part one or this is probably going 5 00:00:39.640 --> 00:00:41.920 to be very confusing. What do you think, doctor Shi. 6 00:00:41.840 --> 00:00:45.399 Though, Yeah, it is certainly your prerequisite episode to listen 7 00:00:45.479 --> 00:00:49.600 to for this one. And this is getting super interesting. 8 00:00:49.679 --> 00:00:52.679 I mean, we laid the foundation with attachment styles and 9 00:00:52.759 --> 00:00:56.520 attachment theory. Now we're going to get into the disorders 10 00:00:56.520 --> 00:00:58.759 that are out there and then just kind of follow 11 00:00:58.799 --> 00:00:59.719 this rabbit hole where it's. 12 00:00:59.640 --> 00:01:01.799 Taken us exactly. And one of the things that might 13 00:01:01.840 --> 00:01:04.280 be interesting to think about for our listeners or maybe 14 00:01:04.280 --> 00:01:07.239 even discuss when we have a chance to do a 15 00:01:07.280 --> 00:01:10.760 live stream is the idea of these actual disorders and 16 00:01:10.879 --> 00:01:14.000 how they might apply to the examples we gave in 17 00:01:14.079 --> 00:01:19.079 yesterday's episode. So let's graduate from insecure attachment styles to 18 00:01:19.239 --> 00:01:22.120 attachment disorders, or rather we're going to take a look 19 00:01:22.159 --> 00:01:26.680 backwards at where disorders form. And there are only two 20 00:01:26.920 --> 00:01:30.920 officially that are included in the Diagnostic and Statistical Manual 21 00:01:31.359 --> 00:01:37.359 that is reactive attachment disorder and disinhibited social engagement disorder. 22 00:01:42.040 --> 00:01:46.359 So let's first look at reactive attachment disorder. This is 23 00:01:46.599 --> 00:01:52.280 a whole different level of disordered attachment. Reactive attachment disorder 24 00:01:52.439 --> 00:01:55.640 is a rare but serious condition where an infant or 25 00:01:55.680 --> 00:01:59.760 young child struggles to form healthy bonds with the parents 26 00:01:59.879 --> 00:02:05.200 or caregivers. Reactive attachment disorder usually starts in infancy, and 27 00:02:05.239 --> 00:02:09.599 there's little research on signs and symptoms of anything beyond 28 00:02:10.400 --> 00:02:14.400 really early childhood. It actually remains unclear whether it even 29 00:02:14.520 --> 00:02:19.039 occurs in children older than five, So this diagnosis is 30 00:02:19.319 --> 00:02:23.360 made pretty early on. Reactive attachment disorder can happen when 31 00:02:23.360 --> 00:02:26.960 the child's basic needs for comfort, affection, and nurturing aren't 32 00:02:27.000 --> 00:02:30.960 met and stable loving relationships with others just aren't developed. 33 00:02:31.080 --> 00:02:32.960 And I think, in a sense that's really putting it 34 00:02:33.000 --> 00:02:34.960 too lightly. Sometimes they talk about it like that in 35 00:02:35.000 --> 00:02:37.680 the literature. Generally this is going to be due to 36 00:02:37.800 --> 00:02:42.479 high levels of neglect, abuse, or frequent changes in caregivers. 37 00:02:42.879 --> 00:02:47.000 The combination and severity of these factors directly impacts the 38 00:02:47.080 --> 00:02:52.000 child's inability to form healthy emotional bonds. However, most children 39 00:02:52.039 --> 00:02:55.800 who are severely neglected don't go on to develop reactive 40 00:02:55.800 --> 00:03:00.439 attachment disorder. Remember we're still taking into account that humans 41 00:03:00.800 --> 00:03:04.000 and even children and babies are incredibly resilient, so children 42 00:03:04.080 --> 00:03:08.479 with reactive attachment disorder often show emotionally distant behaviors towards 43 00:03:08.520 --> 00:03:13.120 their caregivers and have difficulty managing their emotions. This can 44 00:03:13.159 --> 00:03:16.919 sometimes appear as aggression or violence, and to cope, they 45 00:03:17.000 --> 00:03:20.879 might even pull away from interactions with their caregivers, rarely 46 00:03:20.879 --> 00:03:24.639 seeking comfort when upset and showing little to no response 47 00:03:24.759 --> 00:03:28.639 when comfort is actually offered. Basically, the behaviors of the 48 00:03:28.719 --> 00:03:32.719 children fall into two categories. The first is social and 49 00:03:32.759 --> 00:03:38.879 emotional disturbances, so this is unexplained irritability, sadness, or fearfulness 50 00:03:39.080 --> 00:03:43.199 during non threatening interactions with caregivers, and then the other 51 00:03:43.319 --> 00:03:47.400 is aggressive or violent behaviors. Some children, even this young 52 00:03:47.800 --> 00:03:53.759 with reactive attachment disorder may display aggression towards their peers, animals, 53 00:03:53.960 --> 00:03:58.039 or even themselves, often as a result of unmet emotional 54 00:03:58.120 --> 00:04:01.960 needs and in a of course at this age to 55 00:04:02.039 --> 00:04:06.840 process really complex emotions. With proper treatment, children with reactive 56 00:04:06.840 --> 00:04:11.280 attachment disorder can learn to build healthier and more stable relationships. 57 00:04:11.960 --> 00:04:15.639 Treatment often focuses on creating a safe, nurturing environment and 58 00:04:15.759 --> 00:04:20.040 encouraging positive interactions between the child and caregivers. Counseling and 59 00:04:20.199 --> 00:04:22.800 education for parents or caregivers can also play a really 60 00:04:22.959 --> 00:04:26.639 key role in supporting the child's development and is absolutely key. 61 00:04:26.800 --> 00:04:30.279 So children who grew up in Romanian orphanages often had 62 00:04:30.319 --> 00:04:33.720 trouble adapting to their new lives after being adopted, and 63 00:04:34.079 --> 00:04:38.199 MRI studies found that these children had smaller brains than 64 00:04:38.279 --> 00:04:42.639 average children. So just like a footnote to show how 65 00:04:42.680 --> 00:04:43.519 impactful this. 66 00:04:43.439 --> 00:04:46.959 Can be, right for those of you who aren't familiar 67 00:04:47.000 --> 00:04:50.680 with that particular reference, it's one of those really difficult 68 00:04:50.959 --> 00:04:55.000 examples of we got a lot of research information from 69 00:04:55.040 --> 00:04:58.959 an absolutely horrific event. And this was without going into 70 00:04:58.959 --> 00:05:01.480 the whole history of why there were so many children 71 00:05:01.480 --> 00:05:04.439 in Romanian orphanages, because that's a whole other story. What 72 00:05:04.600 --> 00:05:08.240 happened was is that these infants and toddlers were placed 73 00:05:08.240 --> 00:05:12.199 in environments where there wasn't enough staff to pay attention 74 00:05:12.240 --> 00:05:16.519 to them at all. So infants were basically wrapped and swaddling, 75 00:05:16.920 --> 00:05:20.399 They were fed, they were kept warm, their diapers were changed, 76 00:05:20.720 --> 00:05:23.920 but there was no body contact and there was no attention, 77 00:05:24.000 --> 00:05:27.959 and there was also very very little stimulation. So the 78 00:05:28.040 --> 00:05:31.120 kids as adults, I mean now, historically we have figured 79 00:05:31.120 --> 00:05:35.000 out that there's a lot of developmental issues. I mean, 80 00:05:35.079 --> 00:05:39.480 it's interesting because the nurture informed the nature as it were, 81 00:05:39.639 --> 00:05:45.160 basically a lack of stimulation actually caused these individuals to 82 00:05:45.279 --> 00:05:50.360 have noticeably smaller brains than average for children at that 83 00:05:51.160 --> 00:05:54.240 physiological developmental stage. So again, if you want to go 84 00:05:54.279 --> 00:05:58.319 down a crazy, crazy but fascinating research hole, just go 85 00:05:58.360 --> 00:06:01.959 to the Wikipedia page four Romanian orphans and read on that. 86 00:06:02.000 --> 00:06:05.519 It's fascinating. Now, the good news is that there are 87 00:06:05.720 --> 00:06:09.600 some evidence based interventions for rad But while I'm just 88 00:06:09.720 --> 00:06:12.319 going to quickly in a bit rattle off a few 89 00:06:12.319 --> 00:06:15.199 of them, I want to be really clear about treatment. 90 00:06:15.240 --> 00:06:18.560 And this is for anybody that's out there that is 91 00:06:18.759 --> 00:06:22.800 the parent to special needs children, to people who have 92 00:06:22.959 --> 00:06:26.399 relatives that are parents the special needs children, or somebody 93 00:06:26.399 --> 00:06:30.120 that's witnessing a mountdown in public, of which you may 94 00:06:30.160 --> 00:06:33.120 not have any idea of what's going on. This is 95 00:06:33.279 --> 00:06:37.399 not a walk in the park. None of these treatment 96 00:06:37.519 --> 00:06:40.439 modalities is a magic wand to fix it. It's a 97 00:06:40.480 --> 00:06:43.360 slog at least the ones that I've witnessed. Although I 98 00:06:43.360 --> 00:06:46.800 have seen really really fantastic outcomes, it's not easy for 99 00:06:46.879 --> 00:06:52.600 the parents, and being such a stressful experience for both 100 00:06:52.639 --> 00:06:55.720 the parent and the child has to be understood that 101 00:06:55.920 --> 00:06:59.680 it requires a total buy in from parents or caregivers. 102 00:06:59.720 --> 00:07:03.160 Both parents and clinicians are going to face really unique 103 00:07:03.240 --> 00:07:06.240 challenges because they have to navigate a very complex and 104 00:07:06.279 --> 00:07:10.560 emotionally charged process of healing. And as we've discussed so far, 105 00:07:10.879 --> 00:07:15.120 RAD is rooted in early trauma, neglect or inconsistent caregiving, 106 00:07:15.519 --> 00:07:18.319 and it leaves the children with deeply rooted trust issues 107 00:07:18.319 --> 00:07:24.240 and difficulties informing even understanding healthy relationships. The treatments are 108 00:07:24.240 --> 00:07:28.680 not about bandaging a wound, it is about demolation of 109 00:07:28.759 --> 00:07:32.240 some faulty emotional foundation work. So parents that are trying 110 00:07:32.279 --> 00:07:35.120 to help the child with RAD are often caught in 111 00:07:35.199 --> 00:07:39.439 a tsunami of emotional ups and downs, a literal emotional 112 00:07:39.519 --> 00:07:42.399 roller coaster, if you'll be patient with my massacring of 113 00:07:42.480 --> 00:07:46.079 etymology and metaphors. At the same time, kids with RAD 114 00:07:46.120 --> 00:07:50.399 can push caregivers away while simultaneously needing them desperately, so 115 00:07:50.639 --> 00:07:53.600 it's a confusing push pull dynamic for the kids. That's 116 00:07:53.639 --> 00:07:56.319 just exhausting for everyone, and it's not in common for 117 00:07:56.360 --> 00:07:58.759 parents to feel rejected or blamed for behaviors that they 118 00:07:58.759 --> 00:08:02.439 can't control or fix overnight, and sometimes the pushing away 119 00:08:02.519 --> 00:08:06.160 of any attempts at healing is a misfiring of defense 120 00:08:06.199 --> 00:08:10.560 mechanisms that individuals engage in because chaos has become the 121 00:08:10.600 --> 00:08:17.519 baseline for the kids. Techniques like attachment based parenting require consistency, patience, 122 00:08:17.560 --> 00:08:23.720 and empathy even when a child exhibits rad behaviors like lying, stealing, aggression, 123 00:08:23.920 --> 00:08:27.600 and the child's resistance to closeness that stems from early 124 00:08:27.680 --> 00:08:31.600 trauma can make parents feel like they're pouring love into 125 00:08:31.680 --> 00:08:33.519 a bucket that has a hole in it, right, so 126 00:08:33.759 --> 00:08:36.879 they need to manage daily life like school work, and 127 00:08:36.960 --> 00:08:39.600 it's easy to see why the burnout becomes a real concern. 128 00:08:39.679 --> 00:08:42.080 And in saying rejected or blamed, I don't want to 129 00:08:42.200 --> 00:08:46.159 minimize the impact that all this has on a harried 130 00:08:46.279 --> 00:08:48.879 and exhausted parent. The parent is trying to follow a 131 00:08:48.960 --> 00:08:54.360 prescribed treatment protocol, manage their kids explosive or angry damaging behaviors, 132 00:08:54.720 --> 00:08:58.840 and then manage their own adult reactivity to it. That's 133 00:08:59.000 --> 00:09:03.840 so much, and that's like something that an outsider cannot 134 00:09:03.879 --> 00:09:06.799 see or understand, Like if you're seeing you know it's 135 00:09:06.840 --> 00:09:09.919 just so easy to throw off judgment on how kids 136 00:09:09.960 --> 00:09:12.919 are being parented in your view when you just see 137 00:09:12.919 --> 00:09:15.519 something happening at Target or Costco, or in a parking 138 00:09:15.559 --> 00:09:17.960 lot or a restaurant or on a plane or something. 139 00:09:18.039 --> 00:09:20.679 Right, Yeah, I also want to say, I mean Scott 140 00:09:20.759 --> 00:09:23.559 is talking about how difficult this is. He doesn't think 141 00:09:23.600 --> 00:09:26.399 it's RAD. He's using the acronym if we hadn't used 142 00:09:26.440 --> 00:09:29.159 it before for reactive attachment disorder. 143 00:09:29.320 --> 00:09:33.399 Oh sorry, yeah, yeah, yeah, yeah, that's the acronym for it. 144 00:09:33.440 --> 00:09:36.279 And instead of like us kind of garbling our words, 145 00:09:36.360 --> 00:09:40.600 it is known as RAD. So clinicians working with RAD 146 00:09:40.600 --> 00:09:43.840 face their own set of challenges, and that, of course 147 00:09:44.120 --> 00:09:47.039 makes sense because every child's experience of trauma is going 148 00:09:47.080 --> 00:09:49.720 to be unique to them, meaning that there can't be 149 00:09:50.080 --> 00:09:53.120 a one size fits all treatment. It just doesn't work 150 00:09:53.159 --> 00:09:56.440 that way. And our culture really loves the idea of 151 00:09:56.480 --> 00:10:00.679 a single easiest pie, magic wand treatment, just it doesn't 152 00:10:00.679 --> 00:10:06.240 work like that. Modalities like diadic development, psycotherapy, trauma focused CBT, 153 00:10:06.600 --> 00:10:11.039 which is cognitive behavioral therapy or attachment and behavioral catchup 154 00:10:11.159 --> 00:10:15.120 can offer templates and frameworks, but carrying them out requires 155 00:10:15.159 --> 00:10:17.720 a good bit of flexibility and creativity to meet that 156 00:10:17.799 --> 00:10:22.080 particular kid's needs. As an additional challenge, RAD often comes 157 00:10:22.080 --> 00:10:25.720 with a side order of other behavioral or emotional challenges 158 00:10:25.799 --> 00:10:30.879 like ADHD, generalized anxiety disorder, or even conduct disorders, making 159 00:10:31.000 --> 00:10:36.240 diagnosis and treatment a really layered puzzle. As we've referred 160 00:10:36.240 --> 00:10:39.480 to in the past, Diagnosing children is a challenge, and 161 00:10:39.639 --> 00:10:42.639 it should be a challenge because quick diagnoses of children, 162 00:10:42.679 --> 00:10:44.759 at least to me, is just always a sign of 163 00:10:44.759 --> 00:10:48.320 a clinician phoning it in. Clinicians have to tread carefully 164 00:10:48.320 --> 00:10:51.120 with parents, ensuring that they feel supported but not blamed, 165 00:10:51.200 --> 00:10:55.519 as unresolved feelings of guilt or frustration can create roadblocks 166 00:10:55.759 --> 00:10:59.120 in the treatment process. All of these approaches demand long 167 00:10:59.240 --> 00:11:01.879 term commitment, and that can be tough for families juggling 168 00:11:01.919 --> 00:11:05.720 other responsibilities or dealing with financial strain. And the reality 169 00:11:05.840 --> 00:11:09.000 is is like, we're incredibly lucky here in southern California, 170 00:11:09.120 --> 00:11:12.720 Like we have so many resources within our schools even 171 00:11:12.840 --> 00:11:15.039 to help with these types of things, and there are 172 00:11:15.200 --> 00:11:18.360 areas of our country that don't have anything like this 173 00:11:18.559 --> 00:11:21.159 at all, and parents struggle. There's also the idea of 174 00:11:21.159 --> 00:11:27.200 cultural challenges that stem from class from socioeconomic status from 175 00:11:27.320 --> 00:11:29.240 age and such. I can't tell you the number of 176 00:11:29.279 --> 00:11:32.200 times that I've had to have really tough conversations with 177 00:11:32.279 --> 00:11:36.720 parents who refuse to accept diagnoses, and then those that 178 00:11:36.759 --> 00:11:39.799 get caught up in diatribes that begin with well, back 179 00:11:39.840 --> 00:11:41.919 in my day, we didn't have any of this nonsense, 180 00:11:42.000 --> 00:11:44.120 we didn't have all this autism stuff, we didn't have 181 00:11:44.159 --> 00:11:46.480 all this reactive attachment to sort. You know, they just 182 00:11:46.519 --> 00:11:49.360 want to kind of have a very closed view of it. 183 00:11:49.440 --> 00:11:53.080 But most of these treatment modalities require parents to be 184 00:11:53.279 --> 00:11:56.840 active participants, and of course that is going to feel 185 00:11:56.919 --> 00:12:01.639 uncomfortable if trust between parent and child is already shaky 186 00:12:02.080 --> 00:12:05.960 from the precipitating behaviors. So building a therapeutic alliance with 187 00:12:06.000 --> 00:12:08.720 a child who struggles to trust can take time, and 188 00:12:08.840 --> 00:12:12.519 lots of it. The progress can be slow, like glacially slow, 189 00:12:13.159 --> 00:12:17.120 and it can also be nonlinear or recursive, and that 190 00:12:17.159 --> 00:12:21.679 can leave exhausted parents and clinicians questioning whether or not 191 00:12:21.759 --> 00:12:25.759 their efforts are working. Patience is the key in one 192 00:12:25.759 --> 00:12:28.120 of the many challenges. So now that I've expanded on 193 00:12:28.159 --> 00:12:32.200 the challenges, there are really really great success stories out there. 194 00:12:32.320 --> 00:12:37.080 Amazing breakthroughs happen when a child starts seeking comfort, making 195 00:12:37.159 --> 00:12:40.879 eye contact, or expressing affection, it's a game changer. So 196 00:12:40.919 --> 00:12:43.440 healing from rad is a marathon, it's not a sprint. 197 00:12:43.480 --> 00:12:45.679 And while the journey is going to be really tough, 198 00:12:46.039 --> 00:12:50.919 the possibility of success will literally alter the path of 199 00:12:51.000 --> 00:12:54.000 the kid's life and that is well worth it. So 200 00:12:54.360 --> 00:12:58.039 just without going too far into it, Like diadic developmental therapy, 201 00:12:58.519 --> 00:13:02.200 it focuses on enhancing the relationship between the caregiver and 202 00:13:02.240 --> 00:13:06.559 the child and you know, fostering that sort of nurturing 203 00:13:06.679 --> 00:13:10.200 environment that may not have been there initially, and that 204 00:13:10.360 --> 00:13:14.440 focuses on the importance of creating positive interactions. Diadic development, 205 00:13:14.480 --> 00:13:17.559 I think is also the one where there are periods, 206 00:13:17.639 --> 00:13:21.120 especially in older children, where the kid has to sit 207 00:13:21.240 --> 00:13:24.279 between the parents hours a day, Like if we're going 208 00:13:24.360 --> 00:13:27.279 to eat dinner, if we're going to watch television, you're 209 00:13:27.320 --> 00:13:30.240 sitting between us so that actually our bodies are touching, 210 00:13:30.759 --> 00:13:33.399 which is very fascinating, right, Like I'm sure some people 211 00:13:33.399 --> 00:13:36.440 would have like an absolute terrible reaction to that, like, oh, 212 00:13:36.679 --> 00:13:38.840 what a terrible idea. But what you're doing is you're 213 00:13:38.960 --> 00:13:43.240 rewiring a person to understand that there's trust and safety 214 00:13:43.279 --> 00:13:46.279 in the containment of the relationship. It's fascinating stuff. 215 00:13:46.279 --> 00:13:49.159 And with all of these, I mean sometimes we're defaulting 216 00:13:49.200 --> 00:13:52.240 to the term parent, and often that is not the case, 217 00:13:52.240 --> 00:13:54.960 that it's a biological parents, right, because these children are 218 00:13:54.960 --> 00:13:57.960 not still with caregivers who are the ones who have 219 00:13:58.639 --> 00:14:02.799 really significantly abused them. So these can be foster parents, 220 00:14:03.039 --> 00:14:06.480 adopted parents, other caregivers who are now doing all of 221 00:14:06.480 --> 00:14:10.360 this rewiring with the child that they are caring for. 222 00:14:14.399 --> 00:14:18.360 Right. Another one is attachment and biobehavioral catchup, and that 223 00:14:18.559 --> 00:14:21.919 again it's going to help the caregivers provide nurturing care 224 00:14:22.480 --> 00:14:25.399 even when the child doesn't ask for it, and it 225 00:14:25.480 --> 00:14:29.279 focuses on the kid having more self regulation skills. Then 226 00:14:29.320 --> 00:14:33.120 there's parent child interaction therapy. This one is absolutely fascinating 227 00:14:33.120 --> 00:14:36.799 to watch. At my master's level training center, we had 228 00:14:37.039 --> 00:14:41.159 two way mirror sessions where we would watch people being 229 00:14:41.240 --> 00:14:45.000 given instruction on how to interact with their kids. Now 230 00:14:45.080 --> 00:14:47.840 ours was done with an old timy phone, which sounds 231 00:14:48.159 --> 00:14:52.240 incredibly archaic, I know, but there are really incredible videos 232 00:14:52.320 --> 00:14:56.679 online on YouTube of people engaging in parent child interaction 233 00:14:56.799 --> 00:15:01.200 therapy where parents have like a bluetooth microphone in their ear, 234 00:15:01.600 --> 00:15:05.720 and there's a clinician outside the mirror coaching them on 235 00:15:05.879 --> 00:15:09.120 how to give their kids praise. And this one is 236 00:15:09.159 --> 00:15:12.960 actually done with the parents who basically, because of their 237 00:15:13.000 --> 00:15:17.480 own upbringing, really didn't have any parenting skills. Sure, and 238 00:15:17.720 --> 00:15:22.200 the transformation that happens is unbelievable. Like you just see 239 00:15:22.639 --> 00:15:26.320 the kids break into these huge smiles when they get 240 00:15:26.360 --> 00:15:30.440 a compliment and immediately just launch themselves physically at their 241 00:15:30.480 --> 00:15:33.679 parents for a hug. The parents are just they're emotional 242 00:15:33.679 --> 00:15:36.799 in the interviews afterwards because they're sharing, you know, now 243 00:15:36.799 --> 00:15:39.000 I see how powerful this was. I wish I had 244 00:15:39.039 --> 00:15:41.159 had this, but I definitely want to have this, you know, 245 00:15:41.240 --> 00:15:45.120 for my child. Then there's also trauma focused cognitive behavioral therapy, 246 00:15:45.120 --> 00:15:48.360 and this one is really important and different from the 247 00:15:48.360 --> 00:15:52.320 other ones because it's looking through that window of children 248 00:15:52.399 --> 00:15:57.480 who have experienced trauma, and it integrates trauma sensitive interventions 249 00:15:58.000 --> 00:16:01.480 with cognitive behavioral techniques are at the level the child 250 00:16:01.480 --> 00:16:04.720 can understand, and the idea there is to reduce trauma 251 00:16:04.799 --> 00:16:08.159 related symptoms. So if you reduce the symptoms, then you 252 00:16:08.159 --> 00:16:10.720 can go do the foundational work. So many other things 253 00:16:10.840 --> 00:16:13.320 involved here. You have to have an assessment that is 254 00:16:14.399 --> 00:16:18.039 really comprehensive. It can't be a fifteen minute interview by 255 00:16:18.120 --> 00:16:22.080 telehealth with a nurse practitioner who has no background in this, 256 00:16:22.399 --> 00:16:24.799 like you just you can't have that. You have to 257 00:16:24.799 --> 00:16:28.919 have caregiver involvement, like you've pointed out so beautifully, It's 258 00:16:29.080 --> 00:16:32.720 not necessarily going to be the biological parents. It may 259 00:16:32.919 --> 00:16:36.559 maybe the biological parents have realized that what they were 260 00:16:36.600 --> 00:16:39.240 doing was neglectful or abusive and they're being allowed back 261 00:16:39.240 --> 00:16:42.399 into the process. That's always great. Our studies show as 262 00:16:42.440 --> 00:16:45.919 much as we have a reaction to or you know what, 263 00:16:46.000 --> 00:16:49.039 I won't even generalize it to other people. My bias, 264 00:16:49.840 --> 00:16:52.720 which is incorrect. I have an incorrect bias that I 265 00:16:52.759 --> 00:16:56.679 am sharing. My incorrect bias is to say, take the 266 00:16:56.759 --> 00:16:59.039 kid out of that environment, get them out, get them out, 267 00:16:59.080 --> 00:17:01.240 don't let them back in. Maybe that's because of my 268 00:17:01.320 --> 00:17:04.960 own avoidant attachment style. That could be it, because the 269 00:17:05.079 --> 00:17:10.279 studies show that generally speaking, children will do better in 270 00:17:10.319 --> 00:17:16.519 their biological environment if the offending behaviors, if the aberran 271 00:17:16.799 --> 00:17:22.079 or the unhealthy toxic behaviors can be modified, and we 272 00:17:22.200 --> 00:17:25.519 have to hold hope right that they can. If we 273 00:17:25.559 --> 00:17:25.839 can do. 274 00:17:25.839 --> 00:17:26.680 People can do better. 275 00:17:27.119 --> 00:17:32.200 Ye better, skill can do better. So caregiver involvements so important, 276 00:17:32.319 --> 00:17:35.200 and then we have to be really careful of falling 277 00:17:35.240 --> 00:17:38.440 into the habit of coercive therapies. This might sound obvious 278 00:17:38.480 --> 00:17:42.680 at first, but therapies that are labeled as coercive do exist. 279 00:17:43.480 --> 00:17:48.039 So controversial treatments that lack empirical support, like holding therapy, 280 00:17:48.160 --> 00:17:50.880 are not recommended and can be harmful. Do you know 281 00:17:50.880 --> 00:17:52.160 what holding therapy is? 282 00:17:52.559 --> 00:17:54.160 I do want you explain it. 283 00:17:54.319 --> 00:17:58.799 Holding therapy involves a person, usually a parent, holding their 284 00:17:59.200 --> 00:18:04.000 ASD child tightly in a way that ensures eye contact 285 00:18:04.000 --> 00:18:07.680 between them, and allegedly the aim of that was to 286 00:18:07.839 --> 00:18:12.920 deliberately provoke distress in the child until the child needs 287 00:18:12.920 --> 00:18:17.680 and accepts comfort. It's kind of weird to think that 288 00:18:17.759 --> 00:18:21.279 this was actually an approach. I know, it's like today 289 00:18:21.319 --> 00:18:22.000 from what we know. 290 00:18:22.319 --> 00:18:27.039 It's like, let's take learned helplessness and hold this child 291 00:18:27.119 --> 00:18:30.160 down until they just sort of give in to it. Right, Yeah, 292 00:18:30.200 --> 00:18:32.599 I mean, with anything, right, interventions really need to be 293 00:18:32.680 --> 00:18:36.000 evidence based, and even more so in this case, holding 294 00:18:36.039 --> 00:18:40.559 therapy is not evidence based clearly, and the interventions need 295 00:18:40.599 --> 00:18:44.039 to focus on creating that supportive and empathic environment for 296 00:18:44.079 --> 00:18:47.240 the child. If you're interested in looking up more information, 297 00:18:47.400 --> 00:18:50.680 the legitimate sources we suggest are the American Academy of 298 00:18:50.759 --> 00:18:54.559 Child and Adolescent Psychiatry, the Mayo Clinic, and the Journal 299 00:18:54.680 --> 00:18:58.400 of the American Academy of Child and Adolescent Psychiatry. This 300 00:18:58.519 --> 00:19:01.039 episode is just makes me so grateful for the work 301 00:19:01.160 --> 00:19:04.240 that people who specialize in child psychology and psychiatry do, 302 00:19:04.880 --> 00:19:09.240 because man, what a really tough road some of these 303 00:19:09.400 --> 00:19:11.720 can be. And I say it all the time, there's 304 00:19:11.759 --> 00:19:14.799 a mental health professional cutout for every type of work 305 00:19:14.799 --> 00:19:17.480 there is, and I'm just so grateful for those that 306 00:19:17.559 --> 00:19:20.000 are drawn towards this type of work. The prognosis on 307 00:19:20.079 --> 00:19:24.359 RAD indicates that with early and appropriate intervention, children with 308 00:19:24.480 --> 00:19:28.400 this disorder can develop healthier attachment patterns and improve their 309 00:19:28.400 --> 00:19:33.799 emotional and social functioning. However, without treatment, RAD can lead 310 00:19:33.880 --> 00:19:38.359 to persistent relational difficulties and an increased risk of mental 311 00:19:38.400 --> 00:19:41.920 health issues later in life, as well as the acting out, 312 00:19:42.160 --> 00:19:47.559 violent or severe behaviors that we've highlighted already. So again, 313 00:19:47.680 --> 00:19:52.759 treatment and early early identification and then intervention so important. 314 00:19:52.839 --> 00:19:57.799 Research shows that attachment disorders in juvenile's behavior generally falls 315 00:19:57.880 --> 00:20:02.160 into three categories. So typically we look at antisocial conduct, 316 00:20:02.519 --> 00:20:06.119 which is like lying, stealing, manipulation. We look at aggression, 317 00:20:06.400 --> 00:20:09.799 both verbal and physical aggression are common, especially when children 318 00:20:09.839 --> 00:20:12.480 feel threatened or abandoned. And then we look at emotional 319 00:20:12.480 --> 00:20:16.880 and dysregulation. Are there extreme outbursts, what's their impulsivity, like 320 00:20:17.400 --> 00:20:20.920 the difficulty of forming friendships because of the emotions that 321 00:20:20.920 --> 00:20:23.440 go along with that. So let's quickly examine a couple 322 00:20:23.519 --> 00:20:28.359 of real life cases based on behavioral patterns commonly associated 323 00:20:28.400 --> 00:20:32.640 with attachment related issues. So not all disorders necessarily, but 324 00:20:32.680 --> 00:20:37.359 at the very least insecure attachment styles, or perhaps there 325 00:20:37.359 --> 00:20:41.839 are some suspected attachment disorder going on here. So first 326 00:20:41.839 --> 00:20:44.519 one is the case of Mary Bell from nineteen sixty 327 00:20:44.519 --> 00:20:47.599 eight out of England. At age ten, Mary Bell was 328 00:20:47.599 --> 00:20:51.880 convicted of the manslaughter of two boys age three and four. 329 00:20:52.559 --> 00:20:57.079 The murders involved asphyxiation and acts of mutilation. So in 330 00:20:57.200 --> 00:21:01.799 terms of Mary's attachment background, she grew up in an 331 00:21:01.839 --> 00:21:05.599 abusive household where she experienced neglect and was exposed to 332 00:21:05.720 --> 00:21:10.319 violence and exploitation. Her mother was reportedly physically and emotionally abusive, 333 00:21:10.519 --> 00:21:16.640 contributing to severe attachment disruptions, and then behaviorally, Mary exhibited 334 00:21:16.759 --> 00:21:22.000 a lack of empathy. She showed greater impulsivity and an 335 00:21:22.039 --> 00:21:26.559 inability to form meaningful social bonds, which are all hallmarks 336 00:21:26.640 --> 00:21:27.920 of disorganized attachment. 337 00:21:28.039 --> 00:21:30.640 One of the things that's really fascinating about the case 338 00:21:30.680 --> 00:21:32.799 of Mary Bell, that maybe at some point we'll be 339 00:21:32.799 --> 00:21:37.119 able to expand on, is that after she had committed 340 00:21:37.160 --> 00:21:40.960 these crimes, she went to the home of the parents 341 00:21:41.000 --> 00:21:46.880 of one of the boys and just very innocently asked 342 00:21:46.920 --> 00:21:51.799 where they were, asked about what had happened, knowing that 343 00:21:51.839 --> 00:21:55.160 these parents were distraught, knowing that she had killed them, 344 00:21:55.359 --> 00:22:00.880 because she was basically getting stimulation from this act of cruelty. 345 00:22:01.599 --> 00:22:06.279 So was that learned behavior from the emotional and physical 346 00:22:06.279 --> 00:22:09.319 abuse that she experienced. It's hard to tell at this point, 347 00:22:09.319 --> 00:22:12.119 but it is very interesting and very uncommon. You don't 348 00:22:12.119 --> 00:22:17.240 see that type of abject cruelty in children. Eric Smith 349 00:22:17.480 --> 00:22:21.440 nineteen ninety three, USA. At age thirteen, Eric lured a 350 00:22:21.480 --> 00:22:23.400 four year old boy into the woods and killed him 351 00:22:23.440 --> 00:22:28.680 by strangulation and blunt forced trauma. Smith reportedly endured bullying 352 00:22:28.720 --> 00:22:31.880 and emotional neglect, and this may have contributed to feelings 353 00:22:31.880 --> 00:22:35.480 of alienation and anger. The home environment in which he 354 00:22:35.559 --> 00:22:39.759 resided may have aggravated his difficulties in forming secure attachments. 355 00:22:40.240 --> 00:22:42.920 And then the noted behavioral traits that we have access 356 00:22:42.960 --> 00:22:48.400 to are indicated as isolation, anger, and really an inability 357 00:22:48.440 --> 00:22:51.799 to connect with his peers, And all these three definitely 358 00:22:51.799 --> 00:22:55.599 would be indicative of attachment disturbances, all right. So the 359 00:22:55.680 --> 00:23:01.960 other diagnosable disorder under attachment disorders is inhibited social engagement disorder. 360 00:23:02.480 --> 00:23:05.799 It's also diagnosed in childhood. In this case, the child 361 00:23:05.920 --> 00:23:09.599 lacks appropriate nurturing and affection from parents for any number 362 00:23:09.599 --> 00:23:14.359 of reasons, emotionally unavailable parents to just full on intentional neglect. 363 00:23:14.839 --> 00:23:17.240 As a result of these unfulfilled needs, the child is 364 00:23:17.319 --> 00:23:20.559 not closely bonded to parents and is as comfortable with 365 00:23:20.599 --> 00:23:24.799 strangers as they are with their primary caregivers. That could 366 00:23:24.839 --> 00:23:27.960 be maybe seen as an advantage, but we could also 367 00:23:28.000 --> 00:23:32.160 see how that could absolutely be problematic. Right. It's not 368 00:23:32.440 --> 00:23:36.519 good to immediately trust everybody in your environment as a child. 369 00:23:37.000 --> 00:23:40.000 The symptoms can look like this. No fear of adult 370 00:23:40.000 --> 00:23:43.400 strangers and no shyness when meeting new people for the 371 00:23:43.440 --> 00:23:47.559 first time. Behavior that is overly friendly or talkative to strangers, 372 00:23:47.599 --> 00:23:51.960 including hugging or cuddling of unknown adults. Another way to 373 00:23:52.000 --> 00:23:54.559 look at this is that there's no hesitation around strangers. 374 00:23:55.119 --> 00:23:59.200 Even when departing with an unfamiliar person. This individual does 375 00:23:59.240 --> 00:24:03.160 not look to parents or their caregivers for permission to 376 00:24:03.359 --> 00:24:07.640 approach strangers. So it's like this defense mechanism that we 377 00:24:07.720 --> 00:24:12.160 just assume is normal in children just doesn't exist at all, 378 00:24:12.519 --> 00:24:16.599 And you can see already in this description how it 379 00:24:16.640 --> 00:24:20.400 can be problematic. Symptoms like this can continue into the 380 00:24:20.400 --> 00:24:23.000 teenage years, where clearly that can get you in a 381 00:24:23.000 --> 00:24:26.400 lot of trouble, especially as a young woman, right but 382 00:24:26.559 --> 00:24:30.680 the condition is not known necessarily to last into adulthood. 383 00:24:31.119 --> 00:24:33.960 There are some similarities with RAD in terms of the 384 00:24:33.960 --> 00:24:38.079 etiology of the disorder, but the child with RAD is 385 00:24:38.200 --> 00:24:41.440 not necessarily friendly with unknown people. And as far as 386 00:24:41.559 --> 00:24:44.559 risk goes, infants and young children between the ages of 387 00:24:44.599 --> 00:24:48.559 six months and two years are more at risk of 388 00:24:48.599 --> 00:24:53.599 developing d SD if they've been institutionalized. And as far 389 00:24:53.680 --> 00:24:56.359 as risk goes, infants and young children between the ages 390 00:24:56.400 --> 00:24:58.880 of six months and two years are at more risk 391 00:24:59.000 --> 00:25:03.680 of developing DSA if they've been institutionalized, for instance, after 392 00:25:03.720 --> 00:25:06.759 being abandoned or left in orphanages after the loss of 393 00:25:06.759 --> 00:25:10.759 birth parents, or if they spend time in changing or 394 00:25:10.799 --> 00:25:14.480 inconsistent family environs like foster care. I think it's really 395 00:25:14.519 --> 00:25:17.160 important for us to note that although most of the 396 00:25:17.200 --> 00:25:20.319 research has been done with children who were in foster care, 397 00:25:20.359 --> 00:25:24.880 by no means do most children in these situations end 398 00:25:24.960 --> 00:25:29.279 up experiencing DSED. The data shows that about one quarter 399 00:25:29.400 --> 00:25:33.599 of young children in foster care developed this disorder, So 400 00:25:33.920 --> 00:25:36.519 it's higher than it should be. It's higher than we 401 00:25:36.599 --> 00:25:39.640