Attachment Disorders in the DSM 5 TR | Symptoms and Diagnosis

Hey there everybody, and welcome to today's presentation on reactive and disinhibited engagement attachment disorders. I'm your host, Dr. Donnellice Snipes. In this presentation, we're going to define the criteria for the diagnosis of reactive attachment Disorder and disinhibited social engagement disorder in the DSM 5 TR, as well as talk about what we currently know regarding treatment strategies. Let's start with Reactive Attachment Disorder. That's the one that a lot of people are more familiar with. Reactive attachment disorder is characterized by pervasive, inhibited, withdrawn behavior toward caregivers as evidenced by rarely or minimally seeking or responding to comfort. Both of those have to be there. They have to rarely seek comfort and rarely respond respond to comfort. The second criteria is ongoing social and emotional problems as evidenced by two or the minimal social and emotional responsiveness to others. So instead of seeking solace, seeking comfort from caregivers, this means just interacting with others in a social and emotionally responsive way, including peers, limited positive affect or episodes of unexplained anger, depression or anxiety, even during non threatening interactions with adult caregivers. Additionally, the child must have experienced inadequate care as evidenced by one of the social neglect including not having basic needs for safety, love and stability. Stimulation Met Now I have basic needs bolded and italicized for a reason. What are basic needs for each individual child? May vary. A child, for example, who is neuroatypical may have very different needs than a child who is neurotypical. And the parents may not understand the different needs, especially in the infant, before they're able to articulate what their needs are. So the social neglect may not always be the result of a neglectful caregiver. It could be the result of an unaware caregiver about what the basic needs are. So we really want to explore this concept of basic needs when we're talking about diagnosis. Basic needs for love wow. Some children are characterized by more high needs and others are easier going. And I don't really like those terms. But some children need more assistance with emotional regulation than others do. And caregivers may not be equipped. They may not know how to respond to that. So again, the child's basic needs for love and responsiveness may not be met. And the third one is stimulation. And again, we really want to look at the differences between children. What one child needs for stimulation may be way more than what another child needs and what the average child needs. And another term I don't like, forced stimulation may be super overstimulating for someone who's neuroatypical or who has undiagnosed adhd. So we really want to be aware of those things anyhow. Limited opportunities to develop secure attachments due to frequent changes of primary caregivers. Now, in people diagnosed with reactive attachment disorder, this is most often the criteria that is met. They may meet all three, but a lot of times when we're looking at the prevalence of reactive attachment disorder and when we get to differential diagnosis, you might start to understand why it is not as common as you might think, but it is very common, relatively speaking, in children that are involved in child welfare, children that are in the foster system if they are frequently changing. Primary caregivers going from living with their biological caregivers to a foster home, to another foster home, to another foster home, back to their primary caregivers and, and then start the cycle again. That can be very confusing and very unsettling for the child. And they may just kind of wall off and say, you know what? I can't, I can't trust you to be there. I can't trust you to meet my needs consistently because tomorrow it could be somebody else. So I am not going to connect with you. Or growing up in unusual environments with severely limited opportunities to form a selective attachment. The examples that the DSM 5 TR gave were in reference to large group homes, for example, where there's a high child to caregiver ratio. However, we also look at situations like very large families. Now, they're not the norm in the United States, but they can happen in which the ratio of child to caregiver is 8 to 1 or more. And in that situation, it's important to recognize that there are many situations in large families in which the children get their needs met. So we don't want to assume that it's just as soon as the ratio changes in group homes. Why did I choose that number 8 to 1? Because in group homes most of the time the ratio of child to caregiver is limited to guess what? Eight to one. So those are important things. Now, one of the things that's unique in group homes is that there really isn't a primary caregiver, so to speak. There's somebody on duty 24 hours a day, they may have a primary counselor, but that person doesn't really serve or fit the same role as a primary caregiver you would think of in terms of a family. So we're really looking at an environment in which there's a high child to caregiver ratio and it is a non traditional caregiver arrangement. So to speak. So remember, they only have to have one of these social neglect, limited opportunities to develop secure attachments or unusual environments with limited opportunities to form selective attachments. The diagnosis goes on that inadequate care is responsible for the disturbed behavior. So you have to see the inadequate care and then the behavior happening, not the behavior, and then the parent just going, I don't know what to do. And then the care quality deteriorating, for example, or the behavior being exhibited and then the child being moved to a residential treatment facility. It needs to be the opposite way. Inadequate care needs to have precipitated the behavior. The criteria is not met for autism spectrum disorders and it will be important to differentially diagnose this because there are a lot of similarities between reactive attachment disorder and autism spectrum disorders. However, people with autism spectrum disorders have not experienced that neglectful environment and they have had potentially opportunities to form meaningful connections, but that has just not been something they've been able to do. For reactive attachment disorder, symptoms must be present before the age of 4, 5, and the developmental age of the person must be at least nine months old. So if you have somebody who has severe intellectual disabilities, even if they are chronologically six or seven, if their developmental age is not at least nine months old, then the criteria for reactive attachment disorder would not be fully met. I do want you to consider though, when you look at the data, and I use that term extraordinarily loosely, because there's very little data on the incidence and prevalence of reactive attachment disorder in the general population, whether you look at the DSM or you look in PubMed, the studies that have been done have largely been done in residential treatment centers. So getting accurate estimates of the prevalence is a little bit more difficult. However, I still think that the rough estimate of less than 10% of children in child welfare will develop reactive attachment disorder may be very low. And this is not. This is my opinion here, but I want you to follow me. I want you to thank. Think about this. Children who are in child welfare may enter child welfare when they're five or six years old. And we may not know what happened before that period of time. We may not have a good indication of how long that abuse or neglect was going on. The symptoms, remember we're talking about the symptoms. We may not know whether that child was exhibiting those reactive attachment or avoidant symptoms prior to age 5 because we may not have a good medical history. The child may not have gone to the doctor, or the child may have gone to the doctor, but they just went to random clinics here and there and they don't have any real set medical records. We can't count on the caregiver, the biological caregiver, to be a reliable historian because they may be. During the time that they had the child in their custody, they may have been so overwhelmed with their mental illness or their addiction that they aren't able to actually give an accurate, clear headed report of what was going on. So my estimation, or my guess is that the amount of reactive attachment disorder in children is actually higher than what is showing on the books, so to speak. That's just my thought. And if you work in child welfare, if you work with foster kids, I would encourage you to think about, when you're looking at your caseload, how common are attachment problems now, and I'm getting ahead of myself. We will talk about this some later. But it's important to recognize that even if something doesn't rise to the level of reactive attachment disorder or disinhibited social engagement disorder, doesn't mean it's not a problem. Lack of ability to form secure attachments is going to have reciprocal problems for the child later in life. So on the polar opposite end of the spectrum is disinhibited social engagement disorder. The child frequently approaches and interacts with unfamiliar adults, as evidenced by two of the following. Lack of caution in interacting with unfamiliar adults. We want to be careful in applying this diagnostic criteria and I'll give you an example. When my son was a toddler, one of my husband's partners came over. He was in law enforcement and he was partnered with another detective. And that detective came over and my son had heard about this person, you know, over the, over dinner and everything. So she was familiar to him. Now, they'd never actually met in person, but when they did meet, he ran over and gave her a big hug. And she was like completely freaked out about that because she was like, does he do this to everybody? Or so it is important to get the entire picture. Yes. Shawn had never met this person in person before, but he had heard so much about her and he knew her name. So when she came in and we introduced them, he felt like they knew each other. So this to him was not an unfamiliar adult. So we do want to be explore a little bit. But interacting with unfamiliar adults would be more like a child walking up to a complete stranger on the playground, somebody adult stranger that they've never met before, that they'd never seen before. It's not Tommy's mom that's been on the bench every week since you started going to the Playground, you know, that person is a little bit more familiar to the child. And, and it's Tommy's mom, even though they've never met. So we do want to watch how we apply that criteria. And, or, and, or the child is overly familiar, uses overly familiar verbal or physical behavior that's not culturally or age appropriate. So they may get hugs. You know, things that are overly familiar. They may use terms that are overly familiar, like calling somebody by their first name or addressing an adult in a much more familiar way than would be considered appropriate. Lack of checking in with their adult caregiver, even in unfamiliar situations. And think about children that you've known that have had reasonable attachment. In unfamiliar situations, they will often check back in. Just make sure that the caregiver is still there. Go to the playground and they're playing. They may not actively come back over to you, but a lot of times they will scan and periodically check to make sure that you're there. And it's important to notice if children are just completely detached and oblivious to the caregiver in unfamiliar situations. And there's little hesitation at leaving with unfamiliar people. So, for example, at the playground, a child might walk up to a stranger or even somebody who they kind of sort of know and be like, take me to the bathroom. Or the stranger may say, hey, I've got, you know, candy in my car, or whatever. I know that's a cliche, but. And the child with disinhibited social engagement disorder would likely go with them. So it is important to explore and evaluate whether the child is just being impulsive. Ooh, candy sounds really good. Or if they have a habit of doing this and going up to strangers and engaging in disinhibited behavior. Behaviors are socially disinhibited, not simply impulsive. And the DSM5TR does not really define the difference. However, as I mentioned, impulsive would be the kid sees something, hears something, is tempted by something, and is like, oh, I want to have that now. I mean, we all know what impulsivity is. I want to go pet the doggie. I want to have some candy. I want to go check out this slide. Whatever the case may be, socially disinhibited is going up to adults without provocation or even with minimal provocation, and not being intimidated, not being scared, not being wary at all. It's just like, hey, you're another person. What are we gonna do? The child has experienced insufficient care, as evidenced by, and this is the same as for reactive attachment disorder, social neglect, including not having basic needs Met for safety, love and stimulation. Limited opportunities to form secure attachments due to changes of primary caregivers or or growing up in environments that severely limit opportunities to form selective attachments. The care in criterion C is presumed to be responsible for the disturbed behavior in criterion A. So the neglect is presumed to be responsible for the behavior. We want to see the behavior following the neglect. So and if the child exhibits this behavior, this disinhibited behavior, and then the caregiver corrects that behavior and the child doesn't do it anymore, that's not disinhibited social engagement. That's just a kid pushing boundaries or being curious and not understanding sometimes. So we definitely want to see the neglect first, then the behavior as a reaction. Now, interestingly, in disinhibited social engagement disorder, and I looked over the criteria multiple times, the child has to have a developmental age of at least nine months, but no age requirement for the first presentation. Remember, in reactive attachment disorder, the symptoms need to begin before the age of five. With disinhibited social engagement disorder, not so much. They do have to have a developmental age of at least nine months. So let's think about what that means. Think about a 9 month old. 9 month old are not talking yet. 9 month olds may crawl, but a lot of times a 9 month old is not going to just randomly crawl over to strangers. Now if there was another a toy next to them or another child next to them, they might. But observe children. If you don't typically work with children, especially really young children, observe them in their natural habitat, if you will. Sometimes there are play areas at malls, for example, and you can observe children interacting with one another. Additional features Reactive attachment disorder often co occurs with developmental delays, especially delays in cognition and language. I think this is interesting. Why might this be? Are the developmental delays causing the reactive attachment disorder? Or does the neglect that precipitates the behavior or also contribute to delays in cognition and language? We know that stress, prenatal stress, as well as postpartum stress for the infant, you know, stress in infancy and toddlerhood contribute to potentially hpa. Axis dysregulation can cause brain changes as a result of that stress, which may impair cognitive abilities and potentially language in some. We also have to remember that language doesn't develop in isolation and children who are in neglectful environments may not have the cognitive and social stimulation to develop language to learn words. Now they may be parked in front of a TV so they're hearing lots of words. But this isn't always the case. Interestingly. Now, one of the reasons they put out this new DSM 5 TR was to highlight differences or whether the particular disorder was associated with higher levels of suicidality. It wasn't even mentioned this, this diagnostic set was not even addressed. Sex and gender related issues were also not even addressed. Now, I don't know whether that's because we don't know because there's no research. I didn't find a lot of research on it. And that's another thing that I find very puzzling because there, over the past 20 years, there's been such a flurry of attention to attachment that one would think that we would have a better picture of the prevalence of reactive attachment disorder and disinhibited social engagement disorder, but we don't. It's also important to recognize that reactive attachment disorder and disinhibited social engagement disorder. Reactive attachment has to begin before age 5, but it doesn't have an endpoint. So you can have somebody who is an adolescent or an adult who still is symptomatic for one of these attachment disorders. Differential diagnosis. Now, the DSM in reactive attachment disorder did specifically say you have to rule out autism spectrum disorders. Children with autism spectrum disorder or reactive attachment disorder can have reduced expression of positive emotions, cognitive and language delays and impairments in social reciprocity. So remember back when we were talking about that, I said there's a lot of overlap in the symptoms. What you don't see is the neglect. What you don't see is the inhospitable environments in children with autism spectrum disorders without reactive attachment disorder. So you need to rule out asd. Now, it didn't indicate whether you could have comorbid diagnoses if there was a neglectful environment. If the child did meet all the criteria for reactive attachment disorder, could they also have a diagnosis of autism spectrum disorder? Because ASD symptoms also begin but before the age of 5 in most children. So I'm not sure about that. But it is important to effectively diagnose because the treatment for autism spectrum disorders is far different than the treatment for reactive attachment disorder. Depression was really the only other thing that the DSM 5TR mentioned for, for differential diagnosis. And when we think of depression, children who are depressed may withdraw and may have anhedonia or the inability to express or feel positive emotions. They may have delays in language development because they've been withdrawn. Because they've been depressed again, this may happen, but we didn't have the neglectful environment. We didn't have the changing of caregivers. Now Three more that I thought were really important and there are others, like anxiety I didn't even mention here. Social anxiety, for example. Now, social anxiety, it's not on the slides, but I'll mention it anyway. If the child has social anxiety disorder or an anxiety disorder, they may have a resistance to engaging with other people in some situations. However, a lot of times, most of the time in these situations, again, the neglect didn't occur and they are able to be comforted by their caregiver. When we see separation anxiety, when we see children with high levels of social anxiety starting school, most of the time their caregiver is the home base that they return to. So that is not indicative of reactive attachment disorder. Back to the slide. Three more that I think are important to differentially diagnose that were not specifically mentioned in the tr. Schizoid personality disorder, detachment from social relationships and restricted range of emotional expression. Now remember, personality disorders can't be diagnosed until later in life. However, remember I said people can have reactive attachment disorder. Yeah. Reactive attachment disorder and not get treatment, still have be symptomatic for it later in life. They can still be symptomatic for it in late adolescence. So it is possible that somebody may present with as having schizoid personality disorder with detachment from social relationships and a restricted range of emotional expression. Difficulty being, not wanting to be comforted. So we do want to look at these and then we want to evaluate was there a neglectful environment? Might they have met the criteria for reactive attachment disorder? The treatment will likely be somewhat different. But if they have, if they have untreated reactive attachment disorder versus schizoid personality disorder. Another personality disorder is avoidant. People who have avoidant personality disorder exhibit social inhibition, feelings of inadequacy and hypersensitivity to criticism. Now, we don't see those in reactive attachment disorder. They tend. Those are not criteria that are brought up when we talk about reactive attachment disorder. Now, they may co occur. But it's important to recognize that personality disorders are characterized by behaviors that are pervasive throughout multiple areas of a person's life and have persisted since at least middle childhood or early adolescence. So we want to look at that and we want to say, hey, why might this be? Could reactive attachment disorder something that happens in childhood and impacts the way an infant, a toddler, a, you know, elementary school kid perceives the world? Is that going to impact the way they interact with anyone and anything henceforth? Yeah, it most certainly is. So it is important before we start slapping diagnoses of personality Disorders on people that we rule out reactive attachment disorder, we rule out trauma, and finally, fetal alcohol spectrum disorders. Now in the DSM 5TR, this is still back in the conditions for further study. And it's called something like prenatal neurodevelopmental disorder or something. But if you look in the, in PubMed, if you look in the World Health Organization literature, or if you just Google fetal alcohol spectrum disorders, that is what we're talking about here. We're talking about brain damage that occurs to a fetus as the result of a pregnant person consuming alcohol. Okay, so that's a whole different presentation in and of itself. But what I want to highlight for you, and we don't talk about FASDs nearly enough, what I want to highlight for you is that people with FASDs, now it's a spectrum, just like autism spectrum disorders. It's on a spectrum from mild to severe. They may exhibit hypersensitivity to touch, just like somebody who has reactive attachment disorder may not want to be touched, or somebody with autism spectrum disorder may be hypersensitive to touch. People with FASDs also may have this. People with FASDs may exhibit depression and withdrawal, and that can come off as not wanting to engage with others. Remember, the DSM5TR did say we needed to differentially diagnose it from depression. Now, FASDs can also masquerade, if you will, or be misdiagnosed as Disinhibited Social Engagement disorder. People with FASDs, especially further along on the spectrum, may have a lack of a fear of strangers, and they may be easily convinced to leave places they are gullible. They can be manipulated into doing pretty much anything by a bad actor. People with FASDs cannot anticipate consequences and they don't learn from consequences, especially when it gets further along the spectrum. So when they experience something once, okay, that really sucks, they can be in the exact same situation three months later and do it again. Because they don't connect the dots. They don't remember, oh, when this happened before and I did this, bad things happened. So here we are again. Don't want to make that same mistake. That doesn't happen for a lot of people with FASDs. And, and it is important to recognize that that's one of the reasons when you look at, in the criminal justice system, a lot of times there is a exceptionally high number of people with FASDs involved in criminal justice because they don't learn from their mistakes. But when you look at their criminal record, they typically are committing the same kind of offenses, they're not escalating. They just continue to keep committing the same type of offenses and keep getting caught. The takeaway from that is the treatment is going to be very different if the person has an FASD versus disinhibited social engagement disorder or reactive attachment disorder because cognitively they have, they have differences from people who don't have FASDs and they may also have some neuroatypical qualities that also need to be addressed. Treatment targets and I spent several hours pouring through PubMed looking for information about current best practices for working with people with reactive attachment disorder or disinhibited social engagement disorder. And I came up with very little. There are a mishmash of approaches. Family therapy and parent child interaction therapy tend to rise to the highest level. Interestingly, they didn't really highlight trauma informed cognitive behavioral therapy or any trauma informed therapy in the treatment strategies for these two disorders. So I thought that was interesting. But what I did glean from the symptoms that are present with somebody with one of these disorders and or from the research were a variety of treatment targets. So somebody with attachment issues, you know, we're just going to broaden it. Even if they don't rise to meet the full criteria of reactive attachment disorder or disinhibited social engagement. People who have difficulty forming emotional attachments could be because past attachments resulted in pain or abandonment. Areas that we could or strategies we could use to help them would be to help them figure out how to create safety and security. If you're working with a seven year old, that's going to be very different and that's probably going to involve a lot of family therapy than if you're working with a 27 year old or even a 17 year old. But it's going to be important. They're going to likely have difficulty forming emotional attachments, trusting other people until they feel safe and secure. They're not going to want to tear down those walls. They're not going to want to be vulnerable. So that's really important. Addressing trauma is going to be huge. If a child grew up in a neglectful environment, which is a main criteria for both of these disorders, they experience trauma and it will be important for them to process that trauma, Whether, depending on the age, whether it be through trauma focused cognitive behavioral therapy, EMDR or some other method, play therapy, art therapy, whatever approach is most appropriate for that child to meet that child's needs. Trauma strips people's sense of safety and personal empowerment. So they're not going to feel completely safe. And until they've addressed that trauma, until they have addressed all of the ways that that trauma has imprinted on them cognitively, emotionally and physically, it's going to be important to help them develop interpersonal skills. The person with reactive attachment has difficulty connecting with others and interacting socially and emotionally. The person with disinhibited social engagement has, has very loose boundaries, if they have any boundaries at all. So they may overshare, they may be too familiar. So it's going to be important to help the individual develop culturally appropriate, age appropriate interpersonal skills and encourage assertive communication, helping the person learn how to have those boundaries identify these are my boundaries, these are your boundaries. And how to assert what they need, what they want. As a 7 year old or as a 17 year old. Everybody has the right to be able to identify their needs, to ask to get their needs met, to try to get their needs met. And we want to help the child learn how to do that in ways that are assertive. They're not destructive, they're not self destructive. Children with attachment disorders are often seen as unpredictable. Comes from the DSM Recognize behavior as communication. If Tommy acted one way in this situation Tuesday, and in the same situation, he reacted differently on Thursday. What was different? Linehan encourages people to do backward chaining, work backwards and figure out what was different. It may not be that situation itself. Maybe the situation is exactly the same, but it could be the vulnerabilities. Maybe on Tuesday Tommy was well rested and well fed and everything else. And on Thursday he didn't sleep well and he hadn't eaten but a couple of bites of his breakfast. So he was hungry and tired and cranky and more emotionally reactive. I believe in large part, if we get curious, we are able to understand some of the behaviors and if we are mindful in our approach, the behavior seems a lot less unpredictable. We are able to say, oh, you know, Tommy woke up three times last night, it's going to be a rough day today. You know, it's predictable. We may not exactly know how it's going to come out, but it may be more predictable. And we can learn for each individual child. How do I mitigate this vulnerability? You can't prevent vulnerabilities all the time. But okay, how do I make the best out of this bad situation? Explore triggers and vulnerabilities. Now remember, vulnerabilities are things that make people more likely to respond with intense distress at situations than they ordinarily would. Being overtired, being hungry, being sick, being in pain, being overwhelmed, over stimulated in a strange situation. Those are all vulnerabilities, okay? Triggers are potential things in the environment that may set the person off. It may remind them of a traumatic experience in the past, and it triggers that memory, which triggers the fear response. So triggers make that distressful response happen. And we may want to be curious about what exactly was the trigger in this situation. When people experience trauma, their brain naturally becomes more aware and encodes more of the stimuli involved in that situation in order to help them better predict and prepare for that situation in the future. So there can be some things that seem relatively benign to you in a particular situation that might actually trigger that child. It could be a particular sound, the smell of somebody's deodorant or perfume, or who knows? But it's curious. And a lot of times when, especially with older children, when they are able to get into their wise mind, they may be able to think back to what was it that triggered my response? Younger children may not be able to, and that's where the caregiver is going to be, up to them to explore the situation like a scientist and say, what was different here? Why did what happened in this situation at this time that triggered this stress reaction, this fear reaction? And we need to remember that the reaction is one of fear. It's one to protect themselves. Whether they are trying to find somebody to validate them and keep them safe, or they are trying to avoid people that they're afraid are going to hurt them, difficult to console. Most children who've experienced neglect are going to have a dysregulated HPA axis. They are going to go from what I call flat to furious. They're going to be kind of apathetic, blase, not expressing a lot of positive emotion. But when they do get upset, they go from 0 to 250 like that. And that is that HPA axis responding with, with a tsunami of stress hormones. Therefore, HPA axis recovery is going to be important, helping the child calm down their stress response system. And that can come through breathing exercises, vagus nerve massage, good nutrition, regulating circadian rhythms. There's a lot of ways to, to help reset and rebalance the systems in the body that are responsible for regulating that threat response system. Distress tolerance and de escalation skills are also helpful. And even as young as four or five children can start to learn distress tolerance skills. They can learn that, okay, this really uncomfortable, I don't like this feeling right now, but it's not going to consume me. They can learn that they can sit with it and it's not going to overpower them. And they can also learn strategies to de escalate to trigger the relaxation response so they can get into their wise mind and figure out, okay, what do I do next? Difficult to discipline. We want to recognize how discipline may be related to past trauma. Many children that were in neglectful environments may have been party to or victims of spontaneous rages by their caregiver. And they may not understand. They may have done something 17 times and nobody said anything. And the 18th time they got violently punished for it. We don't know. But we do want to recognize what discipline means to that child. What does it mean when even your disciplined nonverbals. I know my mom, she used to have disciplined nonverbals and I knew when I saw that look that I was in big doo doo. And we want to recognize that children who grew up in neglectful or abusive environments are hypervigilant to those nonverbals. So they may already be in fight or flight mode by the time you even start to open your mouth because they saw it in your body language as soon as you walked in. And they are already trying to protect themselves. We want to recognize dichotomous thinking in young children and dichotomous schema in older children. Dichotomous is all or none. I'm all good, I'm all bad. I'm loved. I'm not loved, I'm safe, I'm unsafe. There's no middle ground. And children that are exposed to neglect are going to develop that all or nothing schema that I'm unsafe. People can never be trusted. I can never be happy. All of those polar types of thinking and those schema, until they are evaluated, will kind of go on unchecked. Those are ingrained and help the person predict the future and predict what's going to happen and interact with the environment henceforth until they stop and go, hmm, Is this thought process, is this schema still accurate? Most of us don't do that. We were never taught to regularly check our thought processes. So that can be helpful in treatment to evaluate the dichotomy of their thinking and encourage caregivers to discipline the behavior, not the child. Start out with compassion, start out with care. Start out with positive things about the child. You know, I can see that you're having a really tough day today. And then talk about the behavior. Not you're a bad child or you're a bad boy, but it was a bad choice, but also making sure ahead of time to reinforce the Notion that you are loved and you are safe. In this environment, people who've been exposed to trauma become hyper vigilant. Help them figure out how to create safety and help them develop grounding activities. So they are regularly checking in. They're regularly mindful and checking the situation and able to say in this situation at this time am I safe? When they get up in the morning, in this situation at this time am I safe? When they sit down in the classroom when, when they get to school, in this situation at this time am I safe? That can help them start reprogramming their threat response system and noticing when they are safe instead of only noticing all of the potential threats. People who've been exposed to trauma or neglect have a strong desire to control their environment and make their own decisions. Well, other people couldn't be counted on, so yeah, it makes sense. It's important to try to provide children and people with a voice and choice whenever possible. And for children who have really big difficulty with changes in routine, you were going to grandma's house, but now you've got to go do something else. That can feel overwhelming for them. And it's important to warn them about changes in routine. And finally, we do want to target if we're dealing with a juvenile parental frustration, burnout and dysregulation. By the time the child comes to therapy, the caregivers may already be frustrated and burned out. Or if you're working with a child and their adoptive parents, the adoptive parents may not be at a point of burnout yet, but we need to help them prevent that. We need to help them understand what's going on and develop the tools and the support that they need in order to cope with this situation. Until the child can develop a sense of safety and security and all these other tools that they will need in order to have a happier healthier life. Behavioral management training or parent child interaction training has been shown to be the most effective treatment for disinhibited social engagement disorder. And parent child interaction training in this particular instance focuses on improving the quality of interactions between the child and the caregivers and enhancing communication of expectations and consequences. The prevalence of reactive attachment disorder or disinhibited social engagement disorder according to the DSM 5TR, is less than 10%. Even in neglected children, however, there's a significant positive association between attachment related issues. Even if it doesn't rise to the level of meeting one of these two attachment disorders, there's a significant positive association between attachment related issues and non suicidal self injury. Borderline personality disorder, depression, addiction, and anxiety. Treatment for attachment issues usually requires family and or couples based therapy in addition to individual treatment for the identified patient.