CAP Grand Rounds: Waking up from a Bad Dream by Dr. Lindsay Riopka Manrique, Feb 18, 2025

追加: 2026-05-12

[00:00:28]e e hello and welcome to our University of Alberta child and Adas and Psychiatry Grand rounds I'm Dr Alice leang and I will be your moderator today uh we're very grateful to be partner with the fomd office of lifelong learning uh otherwise known as L3 uh which provides much of the logistical and Technical supports for us so um our presentation today is on attachment and Trauma waking up from a bad dream walking with families as they heal from trauma but before we proceed I'm just going to do a te a territorial acknowledgment and um uh I'm actually going to use the um more you know common names in this acknowledgement so I don't mango the pronunciation so the University of Alberta its buildings labs and research stations are primarily located on the territory of the cre Blackfoot matey Stony Denny Ira oju Salto lands that are now known as part of treaty 67 and8 and homeland of the matey the University of Alberta respects the sovereignty land lands histories languages knowledge systems and cultures of all First Nations matey and innuit Nations so just a quick reminder to use the chat feature if you have uh questions about technical issues um and if you have uh questions for the speaker to use the Q&A feature um for which you can also upvote the questions uh Dr rova manri has uh uh indicated to us that she actually would be very open uh to uh answering questions um as she presents so definitely um uh if you have a question then uh put in a chat and I'll try to pay attention so that um uh again uh she can answer questions along the way so uh I like to now uh introduce Dr Lindsay Roka manri uh who is a Child and Adolescent psychiatrist uh and also the medical lead of ca's trauma Clinic she provides individual psychiatric care and co- facilitates cassa's trauma and attachment or tag group therapy program uh which is the uh intensive year-long group Therapy Program for kids with uh reactive attachment disorder um Desa and uh developmental trauma disorder and their caregivers um she also is the uh current cast chair of medical staff and so she's one of her own I'm very uh happy and proud that uh she is presenting uh on uh trauma and attachment uh today for us welcome oh you're on mute hi Alice I just wanted to in order to sorry technical difficulty welcome everybody thank you so much for joining us um so at this point Natasha I want to share my presentation yes that's correct okay you me to go ahead and do that um share my screen yeah please just the little green arrow with the share okay forgive me thank you okay yeah we just need you to put into presenter mode yes are we yeah that's perfect wonderful okay welcome everybody so um thank you for that introduction Alice yeah today we're going to talk about childhood trauma and if you work with kids um you're definitely going to run across these cases they may end up being some of the more complicated cases in your your your course um in your case load uh there's often treatment resistance there's often lots of family Strife but if you're not looking for them it's very easy to miss and I know that early on in my career um I diagnosed a lot of OD that in retrospect would have been much more it would have been much more beneficial to the patient if we had called it developmental trauma or um an attachment disorder it would have changed um our approach so I hope that you leave today with um more confidence in how to approach and identify and support these these families okay so um very briefly disclosures as Alice mentioned um I'm an employee of cassa I'm the medical lead of the trauma Clinic there currently and um I received an honorarium for doing a presentation this year at a rural mental health conference um I received support in kind from cassa in preparing this presentation through access to their database of therapy and research materials and um yeah potential conflict of interest as well that I I work exclusively at Cass at this time um and I'll mitigate that by just being clear when I'm talking about cassa programs which I feel it is a very um we are sort of leaders in the field in the region and and um it is good to know about what we're doing there in addition to when we talk about um treatment in general so I think I don't need to go into too much of this I was already mentioned but um I just wanted to outline a little bit about what we do at Casa so in our we have a trauma Clinic there among other clinics and we provide individual care to patients um and in our trauma Clinic we take a dietic and family- based approach so there's lots of support for parents too there's parent Psychotherapy which we're very blessed to have and a parent psychoed group that we call Taps um and then we have this Flagship program called tag um that uh there's an elementary school version tag one and tag two which are um kind of sequential parts of that program and then there's a team tag version um and it's an intensive yearlong program um that we're we're manualized and we're we're looking we're currently expanding into red jar and Calgary so yeah referrals to the trauma clinic or through Central intake or through um a direct referrals are accepted um if there's been six months of stabilization with the therapist in the community so I thought we'd start with a clinical case just to give some context to what you probably have run across these cases yourselves um and this is a very classic case of rad so the name has been changed um it is a bit of an amalgam case but this is not unusual so Jada is seven-year-old girl um is and is globally behind and struggling in terms of development academically behind socially behind prefers to play with younger kids and is at a loss for kids uh her same age does not have friends same AG friends at school um she has a bad reputation because she would go through bags people's bags and steal steal things um and uh and she would rage at times um um and so yeah she had a hard time socially sadly also for these kids their teachers maybe also um struggle to connect with them her teacher didn't know how to motivate Jada with academics um Jada would refuse or sort of escalate she didn't want to do the work and um also the teacher had a hard time connecting with her because J was always in this kind of Frozen um fawning State and was not very genuine spontaneous so Jade is living with um her aunt and uncle her teenage son was apprehended when she was seven um because of this complex trauma that she was experiencing prior to that um it is a story as in many cases it is of transgenerational trauma so her birth mom had childhood trauma went on to develop BPD had an erratic lifestyle poverty addictions domestic violence the dad was not in the picture um we had had this case relatively stable um but then some contact was reintroduced in the forms of letters and that blew blew this case up to the point that the parents were on the feeling like they're on the verge of placement breakdown where their kid is become going to become a a career criminal maybe actually destroy their family when you meet Jade or when I would meet her um she is small stature slight thing but has like the the the aura of like an Savvy adult is guarded is very controlling and anxious in any kind of interview or or meeting um controls the conversation but is there's like not not any Rance to separate from her caregivers she is however super anxious when I would meet alone with her parents probably worried about what was being discussed and would interrupt frequently um you could see her dissociate at times freeze and dissociate when triggered when there was difficult things that came up for her um yes uh and sort of beyond that it's a story of her either fighting or freezing and fawning with stress withdrawing from um others when she's distressed as opposed to seeking them out to co-regulate um and she's struggling with boundaries and we'll explore that in this presentation um and it's sort of how we frame our cases here in trauma clinic but she's deceitful as we mentioned the stealing lying conning manipulating can be quite aggressive has threatened her mother with pruning shears and will sort of tackle people um his struggles with sexual boundaries is very interested in romantic relationships dresss dresses inappropriate for her age um and had vindictively told her C her her aunt that her cousin had propositioned her um and later admitting it wasn't true so sexual boundaries are hard food boundaries are hard overeating or um restricting sneaking foods and then empathy right so the parents were concerned she was lacking in empathy and was quite callous um which she probably was at this point so now sort of with that context we'll jump into our talk um uh as an outline so we'll start with um optimal stress and development um how there is this healthy stress that's necessary to build brains and and um psyches um we'll talk about ear sustained early life toxic stress and how that disrupts attachment we'll talk about how that same toxic stress can result in developmental trauma or complex PTSD um we'll talk about treatment options um sort of the damage has been done now what next steps and um some take- home points and questions but as Alice mentioned it will make the talk a lot more interesting if you guys interrupt and ask questions as we go um that's one hard thing about virtual presentations it's a bit harder to attract people's attention so um a reminder traumatic experiences in childhood are extremely common so research shows about 25 to 65% um interestingly or sadly 80% of that is in relation to their caregivers and of those exposed um only the most vulnerable do develop PTSD so there is this powerful res resilience that most kids have to adverse caregiving environment but still both 3 to 15% of girls and 1 to 6% of boys will develop PTSD um disorganized attachments which are kind of in some ways they're flip kinds of flip um sides of the same coin um when the when the toxic stress is early on in life the the rates are about 5% in the general population 20% in foster care and 40% of those kids in group homes um so early life positive attachment experiences form a Wellspring of regulation for life and there's four key ingredients um the first is proximity that's that physical closeness of um like a baby is e ideally sort of on their caregiver or very close proximity to their caregiver for the first years of their life um the second is specificity forming SEL active attachments hierarchies of attachments is actually extremely important we'll learn about this um the D set and how if you are indiscriminate in your attachments how that can make your life quite difficult um good enough caregiving so um much better than perfect caregiving good enough where we we kind of give for that Circle of security 30% of the time that you're accurately attuned and responsive reflecting back to your your child um which still gives opportunities for ruptures and repairs and recovery and working um through stress together and the fourth is this sensitive period so although there is the concept of earn secure that we'll recover will review um the 0 to threee period including the pre prenatal or intrauterine experience is actually the most sensitive time for these attachment templates to develop um the brain is just um primed to adapt to its environment and if you're an environment of have um abundance and safety and nurturance the Brain can sort of adapt to that and devote lots of resources towards Learning and Development and exploration and regulation but if if it is an environment of scarcity and Terror and stress um then that's how the brain um and the mind adapts okay um so this graphic represents the different attachment Styles I just want to review it quickly um so again this is established this is based on the work of um Mary Mary inworth and then supplemented with man and Solomon who added the disorganized um subtype and uh it's based on that 0 to3 like early life EXP experience it's Rel relatively stable across the lifespan although there is this earn secure um phenomenon as well so we'll maybe focus on secure attachment that's the majority about 55% of the population learn on the left there you'll see safe rules for living I can seek out others for support and comfort when I'm faced with stress this is like emotional armor um if you're lucky enough to have it we can talk about the anxious attachment style so there's the avoidant um attachment where your parent is sort of consistently dismissive um avoids feelings and closeness pretty in a consistent way so the child learns to distrust others and avoid relationships to um to maintain um their relationship with their parent not alienate their parent in ambivalence um you have maybe a preoccupied parent that's not accurately attuned and can be in Rive so there's confused and mixed feelings about relationships um and it results in a child that makes demands and it has a hard time being comforted and then the disorganized attachment that we're going to focus today on where the parent presents an un unresolved um trauma um an untenable conflict to the child um resulting in strange behavior um boundary violations and PT SD symptoms um dissociation reexperiencing um the child is unable to regulate and integrate or process their experience and it's so it's hard for them to move forward in a more directed efficient way so these kids have learned unsafe rules for living in reactive attachment it's I'll just have to deal with this on my own and in dis disinhibited social engagement um anybody will do is the kind of the the philosophy okay so we'll look at diagnosis now um I I just put this up just to review it dsm5 has um reasonable diagnosis that is practical for research purposes but I we don't use it as much clinically in our in our at at uh the trauma Clinic here um a few things to just draw your attention to in Rad or reactive attachment disorder the deficit um the core deficit is disorganized Detachment Behavior so the child appears um detached or uninterested in genuine relationships whereas in disinhibited social engagement um it's social dis disinhibition so they seek out superficial relationships with multiple adults maybe even strangers and they tend to be effectively brighter um and more social than the rad counterparts but both stem from the CDG criteria of insufficient care social neglect multi primary attachments or institutional rearing and um as a sort of a reminder for for everyone and we do come across this as kind of a a challenge in our Clinic technically you're not supposed to diagnose rad if there is autism um with the Spectrum now it's a bit trickier uh but it is because um kids with autism also struggle struggle with interacting with they have a limited interest in their caregivers and um a limited rest reciprocity um but there are sort of other differences in that they'll have those restrictive repetitive um behaviors interests and activities and less deviant Behavior than than kids with a red so now that we looked at the DSM this is actually more the framework that we use and um this is where we talk about boundary violations those unsafe rules for living that we talked about um which is basically this constellation of aberant attachment behaviors um and behavioral abnormalities that you will see in kids who have disorganized attachments and if you do use this framework when you're approaching families and even patients um kids themselves you're just going to have instant Rapport because it Maps perfectly onto like the real life challenges that they face and it also helps reframe all these very difficult behaviors not as character logical flaws or parenting fails but um just part of a part of the medical diagnosis um that they're kid and that they're trying to heal from so um I'll just walk through these so we would start with deceit um so like Jada lying stealing conning manipulating is very common stranger danger that's what's distinguishing rad from the DED um and said these kids would walk off with a stranger it's quite terrifying actually um whereas ideally you would have a child who would be sort of hesitant around new people slow to warm up but would warm up um in rad they they sort of never warm up and are disinterested in close Intimate Relationships personal space either the kids have no personal space at all and give other people no personal space or they have a gigantic personal space bubble and cannot tolerate people being in it toiletting is another boundary violation our kids struggle with even adolescents I have a lot of adolescence who struggle with inesis and Ankle priess um hygiene is the next one um resistance or a total sort of lack of awareness of the need for M managing hygiene lack of interest and need lots of scaffolding um empathy limited empathy and genuine which are related um of course those are learned early on in life nobody's born with empathy through mirroring and and the relationships with caregivers so our kids obviously they they do struggle they can be callous um and um and the genuiness often comes as they heal where they they sort of learn more about who they are because it's being reflected back to them in a more genuine in a more realistic way um Dr R there is a question from uh ah Dr Mark nckl one of our psychologists he's asking are there age ranges for the DED uh it's the exact same well according to the the DSM 5 is the exact same as um rad and I believe it's the kids have to be 9 months old um and the onset has to be prior to five years old is that is that kind of what was being asked yeah so it sounds like that's when you want to be able to diagnose this or or can you diagnose it let's say retroactively in the sense of they might not hit your doorstep until let's say age 11 but then if you go back they would meet criteria for B said as like a youngster that's right yeah exactly yeah most of the time we don't see them out in that window but um the the disruption would be present from from that point it it would it it wouldn't be a disorganized attachment if sort of they were able to work through stress and didn't have a lot of Behavioral concerns until say seven and then all of a sudden it started that's a bit more Su suspicious and you know according to the dsm5 anyways that wouldn't that wouldn't qualify yeah yeah and so actually there's a follow-up question I came from Mark uh who says thank you uh I was wondering about the differential when you have a teen and are wondering about uh borderline personality traits because they probably you know start to you know overlap in terms of some of those uh interpersonal issues boundary violations Etc a very very good question um very so we come across this all the time and it is a bit of a clinical judgment um if if the if the patient and their family are amendable to therapy through like trauma trauma um approach is then it would be preferable to air on the side of diagnosing these things as attachment disorders and complex trauma or developmental trauma but if we're sort of in at a point and it is early adulthood and it's a consistent pattern and they're not able they don't have the capacity or interest to engage in in trauma therapy um or we're not making any progress with trauma therapy then we would settle on a diagnosis of um borderline personality thank you you're welcome very good question thank you so much oh we actually have uh sorry we have another question I think people are starting to really uh think about this uh with uh and this uh looks like Chelsea with stranger uh danger what age should we start to be concerned about this um that's a good question I don't know a specific age it's more of a trend um so These Guys these kids would be outliers um it's not an you know I think there's different in terms of attachment there's different stages right um I have to go back and and review but uh it we will get into comorbidities and also um um possible other diagnoses that could could that could explain that lack of reticence to go off with the stranger it's not always a disorganized attachment um it could be extraversion right could be ad there's different things it could be so it's more like this whole um Spectrum you kind of take the big picture um and you don't worry about any one boundary in in isolation but it does give you a nice sort of map of the troubles they would have if it is rad and they do have that early life trauma um we did talk about yeah sexual behavior food so often this is a big one not understanding when you are hungry or full um overeating Comfort eating often these kids will hoard food in their rooms sometimes they not they will stay up at night and rumage through the house and they can eat they they'll eat um sugar from the cupboard if that's all there is or or a loaf of bread in their room but if their snack foods like that aggression it's kind of obvious towards others towards Wards themselves yeah families just the just the sense of relief when you use this framework to um explore what's going on for their kid it's it's palpable the relief they have um so this is the comorbidity kind of speaks to you know we don't always worry if it's one you know one of those boundaries is there boundary violations we'll start with developmental trauma disorder and disorganized attachment they're there's actually no um solid evidence there hasn't been studied that the correlation from what I could see but um and practically they're very common commonly co-occurring uh especially if the complex trauma occurred those first three years of life um cognitive or learning disorders OB see your resources are diverted towards sort of getting your needs met as opposed to learning and exploring um depression anxiety ADHD sensory processing disorders are very common addictions all the V codes excuse me um yeah this OD conduct disorder whether or not to diagnose that you know I will if if if it's needed for some um purpose but generally we find we would just prefer to diagnose with the attachment disorder and Trauma the cluster be personalities um somebody picked up on very astutely also we watch for that as to when to diagnose and and to use more of like a DBT approach as opposed to a trauma approach and um identity confusion is also very common in kids who haven't had that consistent mirroring and and accurate reflection back to them um dissociative identity disorder even gender dysphoria is something that's elevated in this population um so then the differentials just briefly so with rad we want to make sure there's not just a global developmental delay or language disorder ISM right as mentioned before um severe depression or anxiety could have withdrawal and then with the D said yeah is it just a an ADHD kid an extroverted kid o severe OD or conduct or William syndrome um where there's also extreme um sort of extravision and lack of checking back okay and then we see we do see a lot of um co-occurring fast as well in the population so complex trauma which is related obviously to attachment but we started there it's when it's multiple diverse prolonged interpersonal early life onset and interferes with development and that results in developmental trauma disorder or complex PTSD so the toxic stress we're talking about is like abuse or neglect um but also just chaos and poverty right and the distress that has on families I didn't realize this when I started but even just witnessing domestic violence so the child is not targeted but they witness it it they may as well have experienced that abuse directly because it it has a profound effect on them parental mental health mental illness and addictions um accidents losses medical painful like recurring medical illnesses and interventions also can cause this picture um versus simple trauma which is a discret incident not necessarily early life onset and doesn't interfere with attachment or development we call that more ptst um this is sort of a map of the impact of complex trauma so separate from attachment and there's so much overlap it can be confusing but um this is Vander Coke 5 FS so trauma responses in general most people would start would prefer kind of fighting or fleeing but when that's not an option kids will freeze if they still need to get their needs met they will Fawn which is just being overly accommodating and um sugary sweets or they'll flopping um I've had kids in my office who um they collapse they kind of go into a sleep State and we you know we always end up doing eegs and ruling out seizure disorders but this is a a trauma response that that they're show exhibiting um and then just briefly you could just see all the different ways that trauma comp complex trauma affects uh an individual neurologically those are the dissociative States the hypervigilance that's pretty much Universal for the kids we see there's always on edge always guarded um trouble sleeping flashbacks sensory perceptual flashbacks are a special type where it may even be preverbal but just they have a flash of their body a flash of sort of reexperiencing um that's not a narrative but uh an experience intrusive memories um emotionally so lots of anxiety obviously but also mood liability depression anger um pretty much everybody I see as well is controlling interpersonally makes sense that's a pretty sure far way to get your needs met they also have soci social skills deficits and difficulty maintaining relationships um and our void of obviously reminders of their trauma these internal models are really interesting and helpful to think about as well um especially this sort of centration because so many of our our parents are very distressed that their kids are so like you might call they might call them like narcissistic like they just could they seem to care less about other people they just think about themselves but this is really a manifestation of um sort of how they their working models of how to survive so very egocentric here now approach learned helplessness lack of agency this is why um and lack of predictability both these things combined mean that behavioral approaches generally don't work and they may even be counterproductive so we spend a lot of our time um encouraging parents and schools and things to um be cauti cautious not to overuse behavioral approaches especially if they're not working for the the child sometimes they willon other times it backfires um and then the split impression of self and another as good all good or all bad which is not helpful can be the building block for sort of personality disorders as well okay I just want to check you you Pro presenting very rich information um like I think there was a query whether um you would be um okay with sharing your slides after sure yeah that's fine okay yeah and so we'll just have um uh Natasa you know send it out an email to our uh you know attendees and I think there was a question about flop freeze and fla but it sounds like he did answer that um so if it's still not um super clear then uh we can have a request for the person to ask again thank you okay yes I'd be happy to do that um so I did since we're talking about developmental trauma disorder this is these are the proposed um criteria for the dsm5 it wasn't accepted this was by Vander Coke's team but it it still it Maps just like the boundary violations it Maps very usefully onto what what you would be seeing in kids presenting whereas I find that the DSM pts PTSD um symptoms are are maybe less clinically useful but maybe good still for research and things so it has the criteria the exposure see multiple or chronic exposure to one or more forms of development leerse inpersonal trauma and then the second is the triggered pattern of repeated disregulation in response to cues um so that's things like we call this like time traveling or reenacting regressions um under stress dissociation so different um disregulation when when triggered and uh and then the um the persistent alter altered attributions and expectancy so that's kind of the distorted core beliefs that we we also watch for and and look to modify um through therapy so maybe like yeah just feeling inadequate and unlovable and um not good enough and not able to trust other people and the world and then functional impairment um like over diagnosis I just wanted to make sure we reviewed that um um we'll move on to treatment so um to beware um Alice can you remind me what time I need to finish for questions good question um so uh Natasa said that um ideally we finish at 11:35 uh am and latest 11:40 so if we can end you know in between you know like no later than 11 40 at the latest okay great yeah so we're doing fine um okay yeah treat okay there we go um so uh we uh and sort of the there's a lot of different U modalities that address trauma and across all of them there is this pattern of these three phases um the first phase being stabilization and deepening attachment um and then the second one being processing or mastering the story and then the third phase is like stepping back from therapy and reintegration into the community um of all of them um there's a few core um Concepts our patient in trauma and attachment is the diad of the child and their primary caregiver and maybe even broader than that sometimes the child and their family um and I know in our tag groups the parent is really a co-therapist that we sort of train for the vers have and then have them doing um spending oneon-one time with the kids at home trying to do that stabilization and repair um outside of groups um it's an attachment first approach which is what AAP sort of this kind of the fundamentals of of of treating attachment disorders and traumas attachment first um and that's why I put all those Stars around the first phase um so it's probably the most important and this is a lot of this work is done in the community before they would even come um to the trauma Clinic ideally so that's medical treatment to sort of a bottomup approach to manage um symptoms and help the kids to be more regulated and more Parable and teachable um therapy sports happening in the community um regulation strategies emotional awareness mindfulness communication with their with their parents with in general dietic work um we recommend sensory motor strategies a lot with this population um which is sort of that bottom up as opposed to top down um because it kind of addresses where they're where they're living where to meet them um in their disregulation so things like um you know uh as opposed to kind of lecturing and talking about morals and values um um just spending time being with them maybe using movement silence um food uh music lighting things like that to regulate co-regulate with them and connect and we do a lot of work with the caregivers you can see psychoed um we encourage self-care for our caregivers it's a huge um focus and we provide an encourage them to get their own therapy and their own medication management so that they're in an OP position to to do this hard work with their with healing their kiddos um and we also focus on rest bite for the same reason because it in some cases by the time people come to us it's a stage of burnout it's almost like a postpartum depression like where uh a parent has not had breaks from their their overwhelming kid and they just need they're kind of the system is collapsing they need break so we advocate for rest bite um question is do you um have uh resources that you recommend in terms of um a toolbox for these um sensor motor um regulation strategies and dietic interactions um there's well there's a whole sort of field like sensory motor therapy um so you can there's a lot of things available if somebody has specific interest um or interest and resources they could reach out and we could provide um some things that we have here in our Clinic um but yeah there's you know I think the field of trauma is just booming right now so there's just so much even preparing this present there's just so much out there but that those sensory motor approaches are great and there's lots of um great books you can get about it as well yeah I mean I think part of it is H you know what's age appropriate oh yeah those resources would be great appreciated uh and and maybe if I I I don't know even you can include that in you know when when you share your slides because because if let's say you know you have a 13 or 14 year old and you're doing that type of attachment work versus let's say a five-year-old uh you know some of those sensor motor strategies are uh you know you know are going to look different and uh what's going to be more I guess appropriate and also what the uh P you know youth or child is going to go for I guess yes it it is very individual we do remind people that often the developmental age of kids with trauma and attachment is less than their chronological age so you wouldn't believe like we even doing a group with 11 and 12 year olds and I'm reading children's books to them at the end and people are engaged so um it is a bit of trial and error some kids are not at all interested in engaging and then others are and it's a bit of intuition as well so just remembering instead of doing a lot of talking how can I um help regulate my kiddo's body yeah and I can include something in the slides so um if we do get on and I'd say probably most kids don't progress to processing or mastering their trauma story in their childhood maybe because there's just not enough stability in their family you know or um capacity to do this work um but for those that can yet we use exposure therapy sand trays um guided meditation and we um we hope to help them sort of Master their their narrative create more coherence and realism with their caregivers um help with their split loyalties towards caregivers as all good or all bad um and deepen their attachment and then the third phase which is given equal weight here because it's also very important is stepping away from therapy and allowing families to build confidence managing on their own um build connections to their community and not become sort of Perpetual patients um these are in our tag program sort of another way to frame that same multimodal approaches we have these three goals um an attachment goal a trauma goal and a self-care goal and there's because it is the diet we have a caregiver and a child portion to each goal um sort of the enhancing the caregivers understanding of either attachment or traa trauma and how to parent effectively and sort of the child learning to seek comfort and connection appropriately and having more manageable trauma symptoms and then again a third and equally important goal is self-care so we put a whack of emphasis on helping our parents to um be sort of in as optimized condition as possible through re reiterating um reiterating the importance of self-care and encouraging regular rest bites and breaks from their kids we have another a comment question here so again thanks for all of their information and uh uh from Dr uh Lindy van rer uh asking about kids who uh don't want to engage in treatment like what's the best way to get resources to parents for kids who might not even want to come into appointments but the caregivers are willing yeah that's a you know that's quite a common scenario actually and um we it's a bit we do balance we do care about supporting the parents but in general If the child is very um recalcitrant and not interested in therapy we it would could be potentially harmful to force it so it is a bit of um yeah we want to follow the child's lead and if the child is not wanting to engage then we we would um just support the parents through um we well here here in in cassa um we do have that Taps program which is the parent psychoed group um you can support the parent by doing um encouraging them to do their own therapy kind getting their own supports and um and then working on their attachment with their kiddo to see if um they do develop more interest in processing their their trauma um at a later date if the if the kid is opposed to therapy just in general that's tough if they're open to therapy but don't want to talk about their trauma well then you can work with them right on sort of coping strategies and regulation skills and and this uh you know caps group that you can are mentioning is it possible to refer to uh that group uh like directly this is a good question I think no that the child would have to be the child would have to be amendable to therapy um to to refer to our group um as far as I understand right now okay so even before like the parent um yeah so if it was just a parent but the child doesn't want to engage at all in any kind of assessment or therapy I don't think that would work here so I guess you'd have to improvise you'd have to improvise and from this learnings and from other your your other research and how to teach the parent about um trauma yeah you might need to do it more on an individual basis okay yes thank you um I don't want to talk too much about medication but I thought I would mention it um so yeah often the kiddos that do have complex trauma and attachment disorders they're quite symptomatic and they're quite functionally impaired um they live with a lot of distress so we do use medicines as another tool as a bottomup approach um to help regulate uh their brain stem regulate and and for them to function a little more optimally um so we use a lot of ssris um we use a lot of um guanosine um which is helpful with so often the kids do have this comorbid ADHD can be helpful with but it also helps with um impulsivity and the rages that are not uncommon um we use caution with unopposed stimulants in kids with trauma often will um it's a risk a bit of a risk to just start with a A stimulant for ADHD sometimes we'll do it if the parents understand that risk um in general if there's significant anxiety and ADHD is best to treat the anxiety first and then treat um the ADHD um because yeah it can heighten heighten their symptoms um sleeping we do a lot of work with sleep because our most of our kids have trouble sleeping um and then the only other sort of um medicine that I just wanted to mention here that is sometimes useful and is a bit unlike other fields of Psychiatry is nxone um which is obviously has use in um uh alcohol uh alcohol use disorders and dependence um but there there are some studies that show it can be helpful for dissociation um and uh it is a bit of trial and error uh or like sometimes it works sometimes it doesn't work in our in my clinical experience yeah and in your experience even though it might be like what would be like the range would you expect like 50% or like how often I'd say about 50% but the good news is that there's not um basically I I've never seen anyone have a side effect on it either it works or it doesn't you know assuming they're medically healthy healthy liers and what dosage do you go up to uh for that before you figure it out what working so um oh I think I I start at 25 milligrams um and um once a day and then often we switch to like a twice a day dosing up to a Max say 100 milligrams a day thank you um okay and uh I did want to just review these for people who are interested and want to do more research but there's so many modalities um and there's a tremendous amount of overlap between the different Mo modalities um but here in our our Clinic we we really um refer back to the circle of security a lot most of our therapists are therapy trained sandree therapy trained emotion focused family therapy trained um we use Concepts from poly vagal Theory and some of our therapists are EMDR trained um and then this DDP is um actually Maps probably closest to what we do in tag and that's the development dietic developmental Psychotherapy that I'm going to I will talk a bit more about that in a sec yeah um these are these are other therapies that we we use so it's very multimodal um approaches and but they they generally there's so much overlapping they're not at conflict or at odds with each other the different approaches so there are just like three um clinical Concepts I wanted to share one is the window of Tolerance from Daniel seagull and and this is um a great visual kind of like the circle of security um that helps parents to make sense of how their kids present as this jaal and hide um these these rapid switches and how and how they and how they move through the world um and also just to remind parents that kids with complex trauma their window of Tolerance is generally quite small to begin with and then we can sort of watch and and set goals about expanding it little by little with healthy stress and lots of support so you could see smooth sailing in the middle Zone there um the optimal arousal Zone um where the child seeks soothing can self soothe and is socially engaged so this is kind of the obstal zone and if anyone's interested in poly vagal theapy Theory that's like the ventral vagal activation Zone um and then occasionally your kid who knows what happened it could be something quite random they can be bumped into this hyperarousal Zone which is sympathetic in um nature the fight flight zone and that's just generally kids first line of defense you can get these kids into so much trouble um socially with their caregivers um just navigating through life and then once and then sometimes two kids will just dropped into this hypoarousal Zone as a last defense and that's dorsal vagal activation um and kids would sort of be immobilized low energy effectively flattened maybe dissociated we've had kids uh I've worked with kids who just describe they do a map of their body and feelings and they just dead they just feel dead everywhere um so somebody who's in that state at um Baseline so we have a question here um that it seems like by uh uh J jeda Wilson anyways I they it seems like there's a lot of research on how developmental trauma can build into cluster B presentations is there any research on obsessive compulsive personality presentations because these kids can have I think we've seen obsessive compulsive Tendencies um yeah h i you know I can't that's a very good question I'm not sure if there's research on that I'd say we don't tend to see those kids as much possibly it's not as common at least in the kids that we're seeing in our Clinic it may be among the the kids who are able to sort of function and adapt they they use that as a coping strategy maybe that can work for them a bit more so they don't C like they don't make it to our program um for sure we see kids who are very controlling and um who fixate and are quite rigid and um inflexible so this very I I had not thought about that actually myself thank you um this is that DDP that dietic developmental Psychotherapy we had just mentioned in brief um and this the tag has been around for a while and and um so we actually had to kind of review the evidence and find out what what paradigms really sort of capture the work we're doing here um because it been about 30 years but this this really sort of captures it um it's an attachment to F focused family therapy approach um the parent child is the diad or sorry there's the parent child diad is the patient and um it outlines the core struggles for the child is um the fear of being parented and then limited empathy or this thing inter subjectivity so just not being able to make those serve in return kind of shared social meaning that makes it hard for them with their caregivers as well in general socially and then um the child and parent of unwittingly or or sometimes willingly um triggering each other's narratives and um and the strategies used there so it's it's um a long and slow process and that's what we would you know it's good to prepare families for that there's not a quick fix for complex trauma or attachment disorders it's a long and slow process and it's it's not sort of useful to focus on the discipline or behavioral change first although that's likely to occur over time so like in t we work on creating a safe environment um so we have a safe sort of um relationship with your therapist or or in therapy in general or if you're seeing a patient trying to make the interaction as safe um and predictable uh as possible um lots of parents support in coaching about the sort of the importance of Attunement and reflecting back to their kiddo um co-regulation um which we prescribe in our clinic by like um prescribing daily connecting time so depending on the child's age that might look different but just making a real deliberate attempt to build that attachment and then co-construction of the child's autobiographical narrative um so working on those split loyalties and the black and white thinking and giving the child in a developmentally appropriate way more realistic details of their story and more coherence in the story um that can be very stabilizing so the goal um is a more secure attachment Style even a shift from Rad or DED to an anxious attachment is a profound Improvement um in quality of life so we look to sort of shift to a more secure attachment style and hopefully build an enduring connection with the caregiver resolve the trauma symptoms and reduce the disruptive behaviors so so talking about the um you know the co- regulation and and Attunement so there's a question related to that that um uh that about mentalization based treatment U by Mark nichel uh it seems to align well with uh what you're discussing and that um it can be a great alternative to DBT uh when um maybe there's concern about too much of a behavioral emphasis um so um like have you explored uh mentalization base treatment as part of your program was the question well uh we do do um um mindfulness and meditation as a regular an important therapeutic component of our therapy and and the group therapy too and um yes it's part of the like learning to feel um like discover some awareness of your body when there might be dissociation from your body and um maybe even move towards feeling some safety or comfort in your body and uh and then ultimately we do um can do an imaginary exposures to kids trauma stories um through guided meditation which we do in our in our groups so I I'm not by any means an expert in any of these forms of therapy but familiar with them and um yes that's a wonderful modality that we do use yeah this it sounds like what I'm you know hearing from you is that it it is individualized and that sometimes if let's say you know you know trauma you know specific work isn't as working you might do DBT if maybe you know that's not as fit maybe you know MBT that they can all be part of a um you know coherent you know framework for addressing kids with um uh the trauma and attachment issues um and also is there expected a change in the brain uh evidence through scans I brain scans uh I assume with different um therapies it's a very good question all I I can't answer directly to that um I do know that um there's not nearly enough um sort of comparative research between the different modalities um but uh I believe in general you'll see sort of recovery and growth of the hypothalamus um like you would in recovery from depression um but yeah that I I can speak further to that very good question um okay and then these are the last two concepts I wanted to review um just to share that we find very very helpful um in the neurosequential model of Therapeutics by Bruce Perry is just this inverted pyramid of so much of so in typical development there's lots of energy liberated to from regulation to Social and emotional communication and cognition but for for our kidos the bulk of their energy just goes into survival and regulation um so it's a reminder to our caregivers not to waste their energy um trying to teach their kids complex things when they're disregulated um and we really like this in kind of again in the pyramid the three are from Beacon House of the this um progression from reg regulation first um regulating their and calming their fight flight responses then relating right um so being with connecting whatever your child will tolerate and then third reasoning um so sometimes for kids with quite significant trauma you might not get to that reasoning for some time like maybe maybe it's like there's like months where we're just in sort of containment mode um until we can find more stability for most kids it's going to take a few hours maybe a few days so instead of rushing to the the reasoning we encourage parents to wait okay and well those are just some clinical resour but so these are the take-home points um first that childhood so it should be a time of Innocence but of course we know in our line of work that childhood trauma is quite common and uh making an an accurate diagnosis can be a huge benefit to um a child and their family so um because of course the approach to OD and rad would be very very different um so it's good practice to collect the child's trauma story and so you might sort of just open-endedly ask them some questions about it but then mostly you're connect collecting that from the caregivers um ask about boundary violations and ask about developmental trauma symptoms if there is a history of early life trauma and looking for comorbidities as well um our our patient if you're treating kids with trauma is ideally going to be the the diet or the family um this stabiliz stabilization and attachment first approach is important um and then you may or may not progress to trauma therapy If the child is stable and willing to move on to that stage sometimes we just realistically have to accept that maybe kids are only going to want to process their trauma as adults right sometimes we do see those cases and we have to respect that so we follow the child's lead we recommend therapeutic breaks so if they're not ready to do it now take a break and maybe things will change they can come back um we it's a good to Endeavor to build safety so this safe place I'm sorry I forgot to talk about that um graphic but just being this is for in therapy but as well for the caregivers to coach them to be playful loving accepting curious and empathic um and then as if you're a clinician you're also wearing all these hats like you're putting out fires you're trying to help them expand and build their Village you know by leing with school and um rest bite and and building um encouraging them to reach out to their Village we're a cheerleader and sometimes when it feels like nothing is working um we are there is maybe some benefit in bearing witness right so not leaving this family on their own but bearing witness to the the struggles they're going through and supporting them through it um yeah trauma therapy itself involves exposure and processing of the trauma story to develop more for coherence and realism in the child's narrative it can be very stabilizing and remember vicarious trauma transgenerational trauma um so check in with the parent how they're feeling about parenting this kid and their morale parents will need their own supports I do see a lot of parents who maybe had a fine childhood and they're parenting a child who has R in developmental tra and they are struggling um so they they've they and they have been traumatized in the process of raising their child um and then for yourself as well it can be difficult to um sometimes bear Witness and to work with these the with these um children and families so it's nice to um reframe things and just looking for increments of achieve Improvement and not um remission or or cure um because you're just one person obviously thank you I'm just looking at the time here thank you very much uh for your wonderfully informative and compassionate uh presentation uh we uh I think uh will be sending out the um uh the QR code or link for the evaluation and um uh yeah uh and and if you can fill it out that would be uh great so thank you very much and I think uh people will be connecting with you thank you very welcome