Psychiatry & Psychotherapy Podcast - Disorganized Attachment: Fear Without Solution Part 2

Episode Date: August 8, 2020

Understanding disorganized attachment as medical professionals is important because some patients have experienced trauma, or 2nd generation influences of trauma, which leads to this issue. As we continue to explore disorganized attachment and how we can help patients with this attachment style, it's important to remember that this information provides the foundation for why empathy, connection, and emotion mirroring is vital in psychotherapy and psychiatry. Dr. Puder is joined by Dr. Kuhn for this part 2 episode. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds.

Welcome back to the podcast. This is Disorganized Attachment Part 2. I am here with Annabelle Kuhn, and I'm very excited to continue this conversation with you. So welcome back to the podcast. Thanks. It's great to be back. I'm excited to continue the discussion as well and talk a little bit more about what disorganized attachment is. So one of the big things about why this topic is so important is because it really provides the foundation for why psychotherapy and specifically

psychotherapy emphasizing empathy and connection and mirroring is so important for this for this population and for for patients that come in there's a large amount of patients that will come in with with trauma and disorganized attachment and so hearing them having them feel heard and understood mirroring their emotions understanding their emotions so important and so that that was kind of the summary after the after episode one for me at least in the written portion that we did. Anything you'd like to say about part one or things that kind of stood out? Yeah, I think things that stood out were, I mean, it's a very broad topic. And I think maybe just like talking about how it's like disorganized attachment is defined. And like it's, I think like

some feedback I got from friends was like disorganized attachment can't just be labeled to anybody. it's specific to if kids are undergoing like a certain experiment. And so, yeah, I just wanted to like point that out. Yeah, so you wouldn't just label anyone it. Right. And we kind of left off talking about the sequela later in life. Right, right, like in adolescence. Yeah, we talked about how it's linked to dissociation.

One person told me, you know, well, dissociation comes off. from trauma and people with chronic, you know, early life trauma will have dissociation later on. And I was like, yeah, yeah, that's totally true. And so I think it's also good to point out that although dissociation is one of the main features of people who continue to have more of a disorganized attachment style later on in adolescence adulthood, it's not the only cause of dissociation. And so, you know, childhood trauma of various kinds could cause that and then could also create disorganized attachment. So there's some overlap there.

Right. Let's launch into attention problems. Sure. So attention problems with disorganized attachment is an interesting sub-topic. It was previously thought for quite a while that there was no association between disorganized attachment and ADHD, which is attention deficit hyperactivity disorder. And that was according to an article that was from 1998. But a recent 2019, but a recent 2019 meta-analysis showed that children with disorganized attachment had a lot more attention problems compared to children with organized attachment.

Yeah. And do we know how strong that association is? Yes. It's associated a lot with risk status. So risk was coded when children had clinical problems or suffered maltreatment or abuse if they were adopted or were children of adolescent parents. did parents or parents of, with a previous stillbirth. So the effect size for at-risk disorganized children was 0.35,

and that was greater than the effect size for kids who were not at risk. Okay. So in summary, attention problems might be prevalent among individuals with disorganized attachment, and is important to keep this in mind when evaluating patients who may be experiencing disorganized attachment or maybe experiencing focus issues. So, you know, when we have people who come in with focus issues, it's not always just pure ADHD. There may be other things going on. There may be other things that then when you treat them, the person gets better.

So I've seen a lot of people who, when they have a lot of trauma, they have a lot of those things growing up, they have a hard time focusing in college. and so it's so important to get them the therapy that's needed, right? Yeah. Next big problem. Problems regarding convergence in parent youth reports in adolescent psychopathology. So tell me a little bit about that and what they found there. Sure. So convergence in parent youth reports of adolescent psychopathologies, it's critical for treatment planning.

So basically, like, if the kid and the parent, if their ideas link up, that means that they they have convergence. So according to this 2019 study, compared with organized adolescents, disorganized adolescents had a lower parent-use convergence reports in their internalizing symptoms and higher convergence in reports of their externalizing symptoms. So internalizing symptoms would be like anxiety, sadness, social withdrawal, or fearfulness, and externalizing symptoms would be like overactivity. poor impulse control, aggression, or noncompliance, things like that.

Yeah, so basically if the child was more of the disorganized type, the parent would have less of a clue what's going on internally. Right. They wouldn't understand maybe that the child was anxious or sad or had withdrawal or was fearful. And that shows me that there's that sort of lack of mentalization that's maybe going on from the parent. and communication that's going on from the child.

That's right. And they also talked about how maybe the child is unable to verbalize, like, their own internalizing symptoms. And so it's, it's a number of factors. It's probably, like, related to communication between parent and child, but also, like, the child's inability to form words to describe that, those internalizing symptoms. Okay. The next thing that we found and or looked at was psychopathy and violent behavior.

So we had previously discussed how that, you know, there was some callous on emotional traits at the age of eight. What did we find that happened later in life? So a 2014 study showed that participants who had the highest PCLR, which is the psychopathy checklist revised, People who scored very highly on that also showed indicators of disorganized attachment using the adult attachment interview. Right. So these were 139 Italian offenders who had committed violent crimes, murder, rape, child sexual abuse, armed robbery, assault, causing bodily harm. And they were administered the PCR, which is the gold standard for psychopathy. And what do they find? So they found qualitative analysis was performed on the transcripts of 10 participants

who had the highest PCLR scores. And when appropriate, the coders use the adult attachment interview to score their attachment pattern. And also the attachment style interview, which scored attachment styles, which is another way to characterize attachment. So there were indicators of disorganized and or dual attachment. in seven cases. For example, transcripts showed competitive internal working models of attachment, including both anxious, preoccupied, and avoidant dismissing attitudes, and or unresolved abuse and unresolved loss. So the investigation of attachment experiences in the subsample of the most

severe psychopaths, who showed very high average scores on the items denoting devaluation of attachment bonds further suggested that insecure and disorganized attachment styles are very common among violent offenders and that adverse childhood environments may play a role in the development of psychopathic personalities. Yeah, I think this is important not to say that, you know, all people with disorganized attachment are going to be psychopaths, but showing that the most severe psychopaths fundamentally have some very large overlaps with attachment issues. You know, these are people who are cold callous, who have a multiplicity of relationships, you know, like hundreds of sexual partners.

They don't have, you know, when they look at humans, they don't say, oh, this is someone to have a relationship with. They think this is someone who's kind of like an insect or, you know, like I'm not going to form a connection with this person. So it's interesting that it showed that basically people who have that severe psychopathy also have more of that sort of disorganized attachment style. Yeah. Okay. That was interesting.

Let's talk about what did you find about higher body mass index? So this was something that you found. I wasn't expecting this. Yeah. It was a newer study. It was from 2019. And it showed that attachment disorganized individuals are especially, likely to engage in uncontrolled eating behaviors and are associated with having a higher BMI or

body mass index. So this showed that uncontrolled eating, but not emotional eating or cognitive restraint, significantly mediated a relationship between disorganized attachment and BMI. So it was the uncontrolled eating. Yes. Okay. That was not the emotional eating. Right, the uncontrolled eating and not the emotional eating. Okay. That mediated the relationship between the disorganized attachment and body mass index. Interesting. Okay, let's kind of move on to the genetic, intrinsic basis for disorganized attachment.

So in an earlier episode, I actually quoted an article that was early. And then as we kind of like started to unravel this, I realized there's some. newer studies that show some interesting things. So let's go through a couple of the different genes and talk about how, you know, the research develops, which by the way, in the big debate of, you know, hydroxychloroquine and, you know, like, wait, weren't there some positive studies early on, you know, how do we make sense of the studies that came afterwards, you know, the multiplicity of studies. Right. So this is kind of a good example of how research develops and how, you know, 10 years from now, there may be more evidence to support a different something, right? But we do

our best as researchers to look at the data, look at the most recent data, try to understand, you know, is the most recent data stronger than the previous data and so on. So let's jump into it. seven repeat polymorphisms in DDR4 gene? Sure. So the DDR4 is the gene encoding the dopamine D4 receptor, and it has been under investigation as being related to childhood maladaptive behavior. So a study from the year 2000 said that a particular polymorphism, which is like a mutation, in this DDR4, is associated with disorganized attachment.

But 18 years later in 2018, another study said that this polymorphism is actually associated with less disorganized behavior. Yeah. So contradictory studies. Right. And there is yet another contradictory study related to the genetics. What's that? That has to do with mutations in the 5-H-T-LPR region of the SLC-6A-4 gene, and basically this is a gene that encodes for the serotonin transporter, which is 5HTT.

So 5HT is a key regulator of serotonergic transmission that affects behavior such as food intake, reproduction, cognition, and emotion. And a 2007 study said that a mutation in this gene may be related to disorganized attachment. But a 2016 study said there was no. correlation. Unreal. Who to believe? You know, we initially had about like six pages just on jeans and we just were like, okay, well, I guess there's not much to say there yet. So let's keep going. Great. All right. Is disorganized attachment just someone's temperament was another question we asked ourselves? Like is it just their sort of natural predisposition, right? To

to have a certain way of attachment. Okay. Right. So a 2017 study of 11,000 patients found that temperament is not significantly associated with disorganized attachment. Yep. And an earlier study also said disorganized attachment is not related significantly to gender or temperament. True. Yeah. So I think that's helpful, right? because, you know, is there a link between, you know, this, like, very difficult child and developing

disorganized attachment, right? Do certain, like, highly trait disagreeable children just kind of go that direction? And the answer is that's not what we're seeing. So, like, does that just mean that, like, oh, like, disorganized attachment isn't just who somebody is, meaning it's not just their temperament? I think these two sort of things say it's not their genes for what we can tell, and it's also not sort of some inborn temperament from what we can tell. So it really is a dyad relationship, which is why I think the dyad relationship later,

either in that sort of early childhood, when that changes, when the dyad relationship changes, they'll move out of disorganized attachment, or with someone later in life, a mentor, a therapist, I think that's when they can move out of more of that disorganized attachment. So there's hope. There's hope. I like to think that, yes, there is hope. And there's meaning in what we do. Right.

I was just talking to a resident yesterday, and, you know, they're just starting up first year residency, and, you know, they see these patients that. come in and out of the psychiatric hospital. And, you know, as a first year, that's what you see a lot of the times. You're not doing partial. You're not doing an outpatient. You're mostly seeing sort of inpatient situations. And, you know, there are those patients that it's their 10th visit, and you're like,

what impact am I making? And I told the resident, the problem is, is it. that you don't see the patients who had their 10th visit and then something improved and they ended up seeking outpatient care and they got stabilized and they sought some therapy and they got better or they went through partial and then they had improvement in their ability to regulate their emotions and so they didn't need to go back inpatient again. You only see the ones that continue to sort of come back, which can be, it can be a little bit defeating because our brains weren't wired to remember the ones that graduated and did well because we didn't see that happen.

We're just seeing the handful that are coming back for their 10th visit, and it's like, what impact am I making? So I try to encourage them that, you know, it's incredibly meaningful. One half an hour, one 20 minute session with a patient can make a huge difference. especially if they're being attuned to in a way that's incredibly empathic and supportive. If they're being attuned to, then they won't, then that may be what decreases the shame enough to seek further treatment. I like that. So, okay, what role does the primary caregiver play in terms of the child to display disorganized attachment?

Yeah, so I think this is like an, an, a nice segue from like where we were talking about how it's not genetics and it's not necessarily temperament, but it may be more related to the relationship, like the dyad relationship with the child and the caregiver. So this is like this is where we're going to talk about like what sorts of interactions may cause that. Yeah. So the first one that we're going to discuss is maltreatment by cares. And this is the predisposing factor most likely to be associated with disorganized attachment. the abuse and neglect of a child is far more likely than any other factor to lead to disorganize attachment because that's at the heart of what disorganized attachment means it's the paradox for

the child that is the very person the paradox for the child is that the very person who should be able to protect him or her is also the same is also at the same time the source of danger Yeah, so they don't, it's like they need help, but they also are scared of them. Yeah. And the combined effect size in one study that looked at five different studies, so it was a meta-analysis, showed that maltreatment and disorganized attachment had a combined effect size of 0.4-1. so it did have a moderate effect size in the impact of developing disorganized attachment. Yeah. Yeah.

In maltreating parents, 48% of children were found to be disorganized compared to 14% in low-risk groups. And the percentage rose to 77% when only the Maine and Solomon coding were used. Right. A 2008 study found that 90% of maltreated infants were disorganized compared to 43% of low-income controls. So, yeah. Tell me about this 2010 meta-analysis. It's a little bit more recent than that prior one. Right.

So it produced large effect size and that maltreated children are more likely to be disorganized. The effect size was 2.19. 2.19. That's really significant. So this is the most recent data. And other socioeconomic at-risk children, the effect size was only 0.48. So an effect size of two, that's like literally moving someone to standard deviations from where they would be otherwise. Point five, it's still 0.5 is moderate, but a two effect size is huge. Yeah. So of these 10 studies, only seven studies examined disorganized attachment. The 10 studies, in the meta-analysis. So despite the small set of studies, the estimates of combined effect size reported for attachment security and disorganization of maltreated children show lower 95% confidence boundaries that are still more than 1.5 standard deviations from zero, again, pointing in a large effect sizes. Right. So the chance that it would be less than 1.5, you know, standard deviations or 1.5 effect size units, there's a very, very low chance that it would be less than that. So it's a huge thing to be, to be maltreated.

And that's what this study showed. Yeah, anything else you want to mention on this? Yeah, I just wanted to make a note that maltreatment by CARES is not because. only factor that results in disorganized attachment. And so it's important to keep in mind the other things that may cause it. Yeah. Let's talk about maternal unresolved trauma. Sure. So a consistent relationship has been found between parental unresolved loss in trauma and infant disorganized attachment. Many studies consider disorganized attachment as being a second generation effect of trauma that had been inflicted on the disorganized infant's parent.

Yeah, so there was an effect size of 0.31 when they looked at 10 studies in 1995, where they had 548 participants. And they showed that parents who were classified as unresolved in the adult attachment interviewed showed an overlap with corresponding disorganized infant classification. So I think it's important to look at that effect size is not anywhere near as important as like maltreatment. Yeah. So if you're a mother who's who suffered from trauma and now you're looking at your kid and you're like, oh, no, like I'm like hopelessly, helplessly, you know, damaging them just because I, you know, went through trauma. That's just not the case.

You know, if anything, you probably need encouragement that you're doing awesome. getting therapy can be helpful, but the effect size is 0.3. So it's not as large as if you're like abusing your, if someone was abusing their child. Okay. Yeah. Okay. Tell me what, tell me what, any other studies that you found that looked at this and what did

they find? Yeah, there's, there's quite a few. So how exactly parental unresolved loss might lead to disorganized attachment can be thought of like as the parents' behavior. representing an attempt to defend themselves against re-experiencing like the fear, helplessness and anger associated with the trauma. And that may result in a repeated failure to comfort and soothe their child when the attachment system is activated.

Yeah. So, you know, 62% of adults diagnosed with dissociative disorders had mothers who, who had lost a close relative within two years of the child's birth. Wow. So conceivably adults with dissociative disorders may have had disorganized attachment patterns as infants as a consequence of maternal unresolved attachment classification. You know, so you have these parents who have been through something very hard and then it impacts the child. So parents living with unresolved trauma might behave in a frightening.

or frightened manner toward their child during the strange situation procedure. And then, like, so the caregiver maybe may have this unresolved attachment pattern and thus is unable to protect the child adequately from later threats and may cause the child to feel threatened or display disorganized attachment behaviors. Yeah. So some examples of frightening or frightened parental behavior include the parents' making unpredictable invasions of the infant space, you know, so basically not reading the infant when the infant needs space, moving across the infant's face, throat area, also like bearing

teeth, unusual vocalizations, scary pursuit of the baby, translike or dissociative states that last more than 30 seconds, covering the baby's face with a stuffed toy. Also, they may appear stiff handling the baby as if the baby were an inanimate object or suddenly retreating from the baby as if fearful of being hurt and making guarded postures. So these are some of the things that they witnessed and defined as frightening or, you know, frightened parental behavior. Yeah, that does, that does sound very frightening, just hearing about it. So what is, like, what it means if a parent displays this behavior, many parents, who display this behavior are otherwise sensitive and responsive to the needs of their children,

but they're experiencing this frightening or frightened behavior as a result of having experienced major loss or maltreatment themselves. So this is the first generation effect, and the disorganized attachment pattern in the child can therefore be viewed as the second generation effect of the parent's prior trauma. Yeah. So individuals with socioeconomic factors may be more likely to display frightened or frightening behavior. And we'll discuss that in a later section. Right. So in the handout, we'll also, the blog that goes with this, we'll talk about what it looks like to have that sort of adult attachment interview that's considered unresolved or disorganized. And this kind of increases the risk of disorganized attachment patterns. with their infant? Do you want to mention any of the commonalities of the unresolved disorganized attachment status in adult attachment interview? Yeah, certainly. So there are lapses in the

monitoring of discourse. So there may be like shifts from normal speaking patterns into eulogistic or funeral speech. They give the example of the parents saying things like, she was young, she was lovely and she was torn from us by that most dreaded of diseases, tuberculosis. Or maybe they will fall silent for two minutes in mid-sentence and then continue on an unrelated topic. Or they might give extreme attention to details surrounding a loss or a potentially traumatic experience. It's inappropriate to the context of the conversation. And they give the example of like a 10-minute discussion involving details of a lot. loss, including the time of day, like very specific things, like the furnishings within the room

or the type of car taken to a funeral and, like, clothing worn by each family member. So those are lapses in the monitoring of discourse. Then there's examples of lapses in the monitoring of reasoning. Do you want to touch on those? So the basic idea is that things don't make sense from their narratives of their past. Like there's a, there's a lack of sort of a cohesive narrative. Well, but let's put that in the handout. People can kind of read more about that.

It's really interesting, yeah. Yeah. So, okay, so we talked a little bit about maltreatment as kind of like the big thing. And then we talked about maternal unresolved trauma. And then the third one is parental withdrawal behavior. Yes. So a 2003 study suggests that levels of parental withdrawal is significantly higher in children with disorganized attachment as compared to with children

with organized attachment patterns. So withdrawal is defined as in this study as a lack of response and apparently can be as fear provoking for the child as behavior that is frightening in and of itself, like what we discussed just before. Right. And we, I mean, if you've watched the Stillface experiment, you get it. Right. a mom that's just flat-faced.

Yeah. Spaced out. Can be very, very distressing for the child. And, you know, I see that in couples that I treat as well. It's like the husband or the wife just kind of spaces out. And then the other partner is like, feels really, really upset, you know, or like gets angry that this person is not engaging, not mirroring, not hearing. Yeah.

Tell me, did they also find that this predicted borderline personality disorder, maternal withdrawal? Yeah, so in a 2013 study, they said maternal withdrawal in infancy was a significant predictor of both borderline symptoms and suicidality or self-injury in late adolescence. Yeah. And the effect size on that was 0.45. So moderate effect size. Right. Okay. What about the next sort of big category for, you know, what kind of early diads the infant has that might lead to disorganized attachment is a mother with major depression? What did they find? How strong is that? It's actually a very, it seems like it's a controversial topic as to whether maternal major depressive disorder can lead to disorganized attachment.

many studies say no not at all and other studies say well maybe um so let's talk about what what they say yeah so there's this book that was like understanding disorganized attachment and they tended to think it wasn't linked right right they said that they said that depressed cares may like behave in a way that like does not necessarily lead children to lack an organized strategy to seek and maintain proximity. Like basically, like, it may not. Okay. So they didn't see there was a link between those two. No, that's what they said, yeah. Okay. And then later, or kind of like in our own digging, looking at studies, what did we find? Yeah. So the book that said there's like no clear relationship was published in 2011. And there was also a study from

1999 that agreed with that, that said only 19% of children whose parents were living with depression showed disorganized attachment behaviors. And there were no significant differences compared to the normative 14%. But in contrast to that, other studies, like one study from the year 2000 and one from 2006, suggests that maternal depression may be a factor that results in disorganized behavior. Yeah. So tell me some more details about this, uh, this 2006. study. So the 2006 study says that mothers with MDD, major depressive disorder, have been shown to be less sensitive as a parent, and they exhibit greater negativity and less positive affect when interacting with their kids, and they tend to be poor disciplinarians. And the children of depressed mothers

also have been shown to be at increased risk for developing insecure attachment relationships, because they often have experienced maternal, physical, and psychological unavailability. Yeah. I mean, when I just saw like a depressed mother today and this stuff is going through my mind and I know that if I can effectively treat this mother, bring her out of the depression, the sooner the better. Yeah. You know, when I think of this, I think, you know, attachment patterns change, right?

So if the mother can get out of depression, she can make up for lost time. There can be that attunement, connection. And I also recommend for very depressed mothers, for the family to come around more, for the husband to stay home more. So I feel passionate about it because. And I don't think a lot of people really understand how these things can influence a small child, but they really can. We don't want to leave mothers depressed.

We want to get them out of depression. So the way that I follow it as a psychiatrist is I get them right into therapy, start, you know, maybe Zoloft or something like that. If they're not out of depression in a month or two months, I will highly recommend that they go to like an intensive outpatient program where they can get, you know, three days a week, five days a week, therapy, groups, medication adjustments so they can get out of it. it's a little bit hard initially to get a mother into that just because she wants to be home with her child. If the depression is suicidal and the mother does not want to be with the child, then I go straight to that level of care. I go straight to partial. Okay. So when you suggest like a higher level of care, say for example, like one to two months after like a medication doesn't help, are you doing this with like the intention of, well, of course, like helping the patient,

but also are you like thinking at all about disorganized attachment in the in the kid? I'm thinking of attachment problems in the kid, period. We know that babies who have had depressed mothers react differently to the stillface experiment. Yeah. We know that there is increased in secure attachments, not just disorganized attachments. There's increased rates of avoidant attachment. There's increased rates of, there's decreased rates of secure attachment. So and that 2000 study by Martins kind of showed this.

So yeah, I am thinking about the infant. Yeah. And I watch mothers and how they, you know, interact with the infants when they bring them in. And yeah, so I want to get them into therapy if I can twice a week. And honestly, sometimes I have to bring in the husband or boyfriend or, you know, the partner and be like, hey, this is really important. like this is a this is very important that you carve out some time to give your you know partner a break so that they can get treatment right um so that they can go for a run you know so the the person today make sure the vitamin get vitamin d omega-3s increase the the SSRI and um get exercise

and go to go to therapy and i'll see her back in two weeks if it's in two weeks, she's still in a bad place, then we'll go from there. Okay. So let's talk about depression, although there was a link and it was marginal, it seems like maternal borderline personality disorder is not a small link. It's a big link. Right. And I thought it was interesting that that 2011 book on Understanding Disorganized Attachment, like pretty much brushed over maternal borderline personality disorder. They didn't really talk about it. But, yeah, we did our own research into it. And so according to a 2005 study, 80% of 12-month-old infants who had mothers with borderline

personality disorder were classified as having disorganized attachment. And this was compared to only 27% of 12-month-old infants with mothers without borderline personality disorder. And there was a medium effect size of 0.66. and the group contrast was significant. This is big. Yeah. 80%.

Yeah. That's a huge percent. Right. 80 percent of mothers with borderline per size disorder had infants with disorganized attachment as compared to like 27 percent in this control. Right. That's a big percent.

You know, mothers with borderline per size disorder showed lower levels of availability. for positive engagement, lower ratings of behavior organization and mood states that were stable, lower proportion of interpersonally directed looks that were positive in the strange situation. And so, yeah, less play. Let's play. Yeah. So, you know, this is another group that is, to me, high risk, and that I can.

about when I see them in my clinic, you know, it's like no one with borderline personality disorder asked to have borderline personality disorder, nor do they want to, you know, hurt their child in any way. So they really do benefit from getting the psychotherapy they need and getting the treatment they need. Yeah. And the kid benefits as well. The kid will benefit as well. And it's never too late. So if you're listening to this and you're like, Dr. Puter, I'm borderline per size order. What do I do? It's never too late to get treatment. Okay, so let's jump into kind of another big category of kind of a, you know, what social factors are associated with disorganized attachment. Great. So there is, there's quite a few. So one of them is pre-pregnancy exposure

to alcohol. So, very old study. It's from 1987, and it says that pre-pregnancy exposure to alcohol has been associated with disorganized attachment, and alcohol used during pregnancy increases risk of insecure attachment and later suicidal behavior. Yeah. So, you know, that's an easy win. Don't drink alcohol. You know, and I have, I have patients. who have adopted kids, kids that have fetal alcohol syndrome, kids that there was meth or heroin or fentanyl going on when they were in the womb, those kids are going to be harder. Those kids are going to be harder to raise. They might be, you know, a little bit higher risk to develop certain things.

It's sad. And, you know, my friends who are adopting these kids are saints. And I have all the love in the world for them because they're making an impact in the world. but this is just one example. Okay, let's talk about marital conflict between caregivers. Sure. So according to a 1997 study, marital conflict may play a small role in disorganized attachment behavior. You know, point two, one was the correlation.

So not a huge correlation, but it's there. Okay. What about extensive non-maternal care? Yeah, I thought this study was really interesting. It's from 2014, and it describes that infants who have extensive non-maternal care may be at increased risk for developing disorganized attachment. So it examined two different samples to determine whether there was a maximum threshold of time spent in non-maternal care, and beyond this threshold, does a child have increased risk of developing disorganized attachment patterns? And they actually found that infants with over 60 hours per week in non-maternal care were significantly more likely to have disorganized attachment patterns. Yeah. You know, if the kid is watching 60 hours of television a week, is at some daycare where there's very, very poor, you know, sort of supervision, this is when that kid is going to be at risk. So think about, you know, if you are going to put your child in a daycare, you know, go observe what happens on a normal day in that daycare. You know, read some reviews.

I talk to some parents who have their kids in that daycare. If you have to be away from your kid, you have, and you have to work, you have to work, right? Most people are not working 60 hours a week. There are some people who have to work two jobs. So if that's the case, you know, maybe. sure your child is with someone who's connecting with that child who's raising that child as if it was theirs and do the best you can. Yeah. And I'm saying as I'm thinking about this, I'm thinking, man, there are some kids and, you know, the next one, socioeconomic risk factors, right? Right.

We know that risk factors do increase the rate of disorganized attachment and it's probably because of some of these stressors, like less material care, the television may be on more because, you know, the stresses is higher in the home. You know, okay, let's talk about socioeconomic factors. Yeah, lots of overlapping themes with these risk factors here. So as we discussed earlier, childhood maltreatment is the strongest predictor for disorganized attachment. And it's stronger than socioeconomic risk factors.

And that was according to the same study that also demonstrates that children with five or more socioeconomic risks were not significant. significantly less likely to be disorganized than maltreated children. I think it's really important because even if, you know, there is a low income, there is single parenthood, you know, an adolescent mother, low education, it doesn't, it's still not as strong as maltreatment. Right. Okay.

So walk me through some of the risks of the socioeconomic risks and what the findings were. Sure. So socioeconomic and environmental stressors such as poverty, isolation, racism, these things all affect parental coping. And they may cause the parent to behave in a frightening or frightened manner like we discussed before. And that's important to keep in mind when interpreting claims that higher rates of disorganized attachment classifications exist among children of single mothers and of mothers from minority racial and or ethnic groups who are more likely to be living in poverty. Yeah. So in this one study, CYR 2010, you know, there were significantly more disorganized attachments found in single minority groups compared to single Caucasian mothers. And we looked at that and there was part of me that didn't want to report that. that wanted to just kind of like say yeah let's skip that over that's kind of controversial right um because that's why it's good to to talk about it yeah because i'm i'm white you know and because this

sort of topic is so hot right now but i think the more that i thought about it the more i thought to myself well you know we have to talk about it because this is data that's there and maybe it's data that can help inform some of the changes that we need in our society. Absolutely. Yeah. So tell me about anything that you found about this. I know we did a little bit more digging into what might be going on here, why this might be the case.

So there were significantly more disorganized attachments found in studies with single minority groups in comparison with studies of single Caucasian mothers. So disorganized attachment in studies with single minority mothers had an effect size of 0.86. And this study said that the data on ethnicity shows that most mothers of minority groups were also single. And so they go on to say that being a single mother may limit access to financial or social resources, increase social isolation and maternal stress, and therefore results in inadequate caregiving behavior. and therefore childhood disorganized attachment. You know, you hear stories about mothers working two jobs.

You hear stories about, you know, trauma, you know, racial trauma, right? I think is a big part of this. And we talked about that a little bit in episode one. We talked about, and this is like, this is, this is it right here, guys. This is part of what they're going through, right? It's not that the mothers are more abusive, maltreatment is. still a lot, a lot higher than this. The effect sizes, you know, around two.

This is only 0.6 or point, sorry, 0.86. But at the same time, it's like, okay, how do we build programs to support these mothers? How do we build, you know, like Montessori level, you know, daycares, right? Where it's like an enriching environment, support the mothers, you know, thinking about raising my own kids. we'd go back and forth. I'd take two hours with the kids. My wife would take two hours because it's exhausting. I can't imagine raising the kids alone,

being isolated with the mother, and then all the other difficulties of getting treatment. Like if you do have depression, you know, and you're isolated and your mother and you're single and you just have so much on your plate. So, you know, I think that this is something that I'm not sure I have all the answers for right now, but I want to put it on people's radar is, hey, this is part of the complex issue that we're

talking about when we're talking about race. This is something that can be targeted through psychotherapy, and through programs. And I think that we can make a big difference if we pay more attention to this. So I hope someone listening to this looks at this data, gets excited about utilizing this information to make the world a better place. That's why we're putting it out there not to, yeah. So anything else you wanted to mention on this? I think we covered it.

Okay. We'll put all this details in the blog so you guys can look at it. Yeah. And so, you know, if you're trying to develop any policy or make any recommendations, you know, on a larger scale, you know, these are things that we should look at is how do we decrease disorganized attachment, how do we decrease intergenerational trauma that has gone on for centuries? Empathy goes a long ways. Hearing people goes a long ways. Okay, so in the next section, we'll look at any biomarkers of disorganized attachment.

Real quickly, what did you find with biomarkers? Sure. So, yeah, I think this, what I found here is really interesting. and I'm excited to talk about it. So just in case anyone listening is wondering, a biomarker is defined as a distinct biochemical genetic or molecular characteristic or substance that is an indicator of a particular biological condition or process. So we're going to discuss like biomarkers

as they relate to disorganized attachment. So we'll talk about things like CRP levels, left amygdala volume and cortisol secretion patterns. Okay. Yeah. So. So physiologic stuff. So, you know, I think for this section, we're just going to kind of, we're just

going to kind of highlight some of the big things that we found and not really go into all the studies. But we'll put that in the blog if you guys want to dig into this a little bit more. So CRP, what did we find? Sure. So CRP is at CREactive protein, and it's a marker of inflammation. and so there is, I guess this one study from 2018, found that CPS referred children with disorganized or insecure attachment during infancy

had higher levels of CRP in early childhood than CPS referred children who had secure attachment. Yeah. So there is a link between CRP and early childhood. and also CRP is also associated with the body mass index. Right. Right. Right. They say that elevated CRP in early childhood is associated with increased BMI over time.

What do they find about the left amygdala volume? Yeah. So in 2016, a study demonstrated that the volume of the left amygdala can be predicted by the quality of an infant's attachment pattern at 18 months. So disorganized attachment interactions result in increased left amygdala volume in adulthood, which is associated with dissociation and limbic irritability. Like that word limbic irritability. Yeah.

Which it refers to what? It refers to a variety of somatic symptoms that may stem from increased excitatory neurotransmission following childhood maltreatment. Yeah. So as described earlier, dissociation is like a long-term ramification of disorganized attachment, behavior during infancy. Right. And so the amygdala volume was larger on the left side. And this related to limbic irritability and dissociative symptoms. Right.

Okay, what did we find with respiratory sinus arrhythmia? Sure. So RSA is basically like a marker of someone's vagal tone or parasympathetic nervous system. And a 2013 study said that disorganized infants of depressed mothers have a lower resting RSA. And another study from 2014 says that disorganized infants have a higher reactive RSA, meaning a higher RSA during a stressful interaction. Yeah. That's really interesting. So they have higher CRP, which is like an inflammatory, you know, kind of like acute phase reactant.

They have a larger left amygdala volume. And they have lower resting RSA and higher reactive RSA. You can learn more about RSA if you're curious in the My Polyvagal episode. If you're in that sort of calm connected state, that nucleus and, ambiguous, parasympathetic, you have a good RSA. And so what this shows is that these infants, these infants are not, or these kids are not in sort of that nice rest and relaxation place naturally. Okay. They're more in kind of a fight and flight or dissociated space. And when they get stressed out, the RSA kicks up even higher. I think it's probably trying to

overcompensate to bring that stress response down. Or maybe it's up higher because of it being a lot more stressful. That still face experiment is a whole lot more stressful to a kid that's disorganized attachment. Okay, I'm thinking kind of like highlights of this episode and some of the things that we wanted to kind of point to as like takeaways. Sure. Maltreatment is the biggest cause of disorganized attachment. so a kid that's going through abuse

and socioeconomic factors do create higher levels of disorganized attachment and so we need to be able to come around people, patients who are borderline personality disorder, maybe have depression, you know, have a lot of risk factors like not a lot of resources not a lot of help at home, you know, and those are the people that we can make a big impact,

and we can make an impact for their kids and their connection with their kids, their joy of motherhood, you know. Absolutely. So those are the big things that come to me. And the second thing I want to reemphasize is the power of empathy, the power of connection, right? So if someone does have disorganized attachment, if someone is more on that sort of dissociative spectrum, empathy is so powerful. and sometimes it can be a little bit more difficult for this population because you have to read them a little bit better, right?

Their internal states are not as transparent, you know, they found that kids with disorganized sort of features, the mothers didn't really know what was going on internally. They knew what was going on externally, but not internally. And so this is where I think the microexpression training, the empathy training, the training, the therapeutic alliance can make a huge impact for these types of patients. Do you have any big takeaways you want to share? Yeah, so I think another like a couple of things that we touched on were that there may not be a very strong genetic basis for disorganized attachment. And there are there are quite a few biomarkers that talk about disorganized attachment that we just touched on. Yeah, I think the left amygdala one is is really helpful. Yeah, very interesting.

Yeah, very interesting. And also the higher sort of inflammatory cascade is acute phase reactant. CRP. Yeah. The RSA, it's interesting to have a lower baseline RSA. I think it fits really nicely into what it means to be in a more dissociated state, a more fine-in-flight state. And interestingly, the, you know, a lot of the therapy that we give to people with borderline precise order is that mindfulness, that learning how to breathe, the things that are naturally good for them might be like yoga or coming back into their body, auto-regulating their nervous system through that calm breathing. So I think about that as well.

Right. Well, hey, this was a pleasure. We're going to break this in. We're going to break it into a final component with some of the treatments. Or actually, you know what? I feel like that might be a good thing to just leave in the blog. So if people are interested in, kind of like what are the therapies that are out there that are going to help kids with disorganized attachment, we'll have that. We'll leave that in our resources. It'll be in our resource library. It'll be in our blog. I don't think we're going to have the time to get to that today. But there's some good stuff there. And you did a great job of summarizing that as well. Thanks so much.

Okay. All right. Thank you guys. I appreciate your support. Let me know what you think of this episode. I'll be on social media on Instagram. I'll post something on it. And let me know what you think of the new website design. I recently did a complete overhaul of the website. And it looks totally different.

So if you get a chance to look at that, let me know what you think.