Dr. Sharp: [00:00:00] Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
This episode is brought to you by PAR. PAR has recently released the Feifer Assessment of Childhood Trauma or the FACT, the first and only comprehensive instrument measuring how stress and trauma can impact children in a school-based setting. You can learn more or purchase the FACT Teacher Form by visiting parinc.com\fact_teacher.
All right, y’all. Welcome back. Glad to have you as always. And as usual, I have fantastic guests here today. I have two guests, Dr. Akeem Marsh and Dr. Lara Cox. They are co-editors of the book, Not Just Bad Kids, which goes [00:01:00] into plenty of background information, suggestions, ideas around kids who have experienced significant trauma, disruptions to attachment, and the dangers of assigning these kids behavioral diagnoses like oppositional defiant disorder and conduct disorder.
We talk about many things in that world, but we really focus on the downsides of behavioral diagnoses or disruptive behavior diagnoses, in particular. We talk about what trauma looks like, what it does to the brain, how it affects attachment, how that leads to disruptive behavior. We talk about how to connect with these kinds of kids in a clinical setting. We talk about intervention and plenty more. This is a fantastic interview.
So let me tell you [00:02:00] more about them. Dr. Akeem Marsh has dedicated his career to working with children and families of medically underserved communities. He currently serves as the Assistant Medical Director of The Home for Integrated Behavioral Health, Article 31 Mental Health Clinic of the New York Foundling. And as a member of the Verywell Mind Review Board. He holds a faculty appointment as Clinical Assistant Professor of Child and Adolescent Psychiatry at the New York University Grossman School of Medicine.
Akeem previously served for many years as an attending psychiatrist with the Bellevue Juvenile Justice Mental Health Service. He’s board-certified in both general and child and adolescent psychiatry. He got a BS from the Prestigious Sophie Davis School of biomedical education CUNY School of Medicine at The City College of New York and got his medical doctorate from the SUNY Health Science Center at Brooklyn Downstate College of Medicine.
[00:03:00] He completed his residency in general psychiatry and his fellowship in child and adolescent psychiatry at the Zucker School of Medicine at Hofstra/Northwell. And he’s a fellow of the American Psychiatric Association, and a general member of the American Academy of Child and Adolescent Psychiatry. Dr. Marsh also serves as a member of the board of directors of the New York Council on Child and Adolescent Psychiatry and on the editorial board of the organization’s newsletter. This guy’s got a lot going on.Dr. Lara Cox is an attending psychiatrist with the Bellevue Juvenile Justice Mental Health Service, providing clinical care to youth in both secure and non-secure juvenile detention in New York City. She has a dual appointment as a Clinical Assistant Professor in the Department of Child and Adolescent Psychiatry and the division of Forensic Psychiatry at the New York University Grossman School of Medicine. She completed her adult psychiatry residency in addition to her child and [00:04:00] adolescent psychiatry and forensic psychiatry fellowships at NYU.
She is board-certified in general, child and adolescent, and forensic psychiatry. She got her MD and a master’s in clinical research from the University of Pittsburgh after graduating from Kenyon College with a bachelor’s degree with high honors in neuroscience and psychology. Dr. Cox also maintains memberships in the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Academy of Psychiatry, and the Law.
So the two of them have shared these primary interests in terms of clinical care, advocacy, research including the nexus of trauma-related symptoms and disruptive behaviors, trauma-informed juvenile justice reform, and anti-racism in education and practice. Their vision for the future is to create a safe space for, and with youth in the community dedicated to meeting their [00:05:00] needs. So kids who too often must fend for themselves always have a place to go and caring people who will be there for them. They presented together many times and will continue to do so in promoting their recent book.
As you can tell, these folks have done so much and continue to put so much energy into this area and into these kids. And I’m excited to share that expertise with you.
So without further ado, Dr. Akeem Marsh and Dr. Lara Cox: Going beyond ODD and Conduct Disorder.
Hey Dr. Marsh, Dr. Cox, welcome [00:06:00] to The Testing Psychologist.
Dr. Lara: Thanks so much. It’s a pleasure to be here.
Dr. Akeem: Thank you for having us. We’re excited.
Dr. Sharp: Oh, good. Well, I am too. Like I said before we started to record, this is the best job in the world. I get to call up folks who know a lot about stuff that I’m really interested in and just ask a ton of questions and do tons of learning. I’m honored to have you all here.
I’m really thrilled to be able to talk about a topic that I have discussed with colleagues, supervises, and many folks over the years, this whole idea of diagnoses, behavioral disorders, and how disruptive behavior disorders are not maybe the best way to conceptualize a lot of the kids that we work with.
So I want to ask, as I always do to start off, what [00:07:00] led you to dedicate so much of your lives to writing a book on this topic? And whoever would like to go first.
Dr. Akeem: I want to say the kids themselves, kick it off to Lara, and then come back.
Dr. Sharp: Great.
Dr. Lara: I would agree with that. I think that is pretty much the answer. The kids that I have been lucky enough to get to work with are pretty phenomenal. And a lot of them have not gotten the kind of care or the kind of attention that they need. And I think sometimes our diagnoses have a lot to do with that. And so we wanted to really bring attention to a lot of the things that are going on in our kids’ lives, and that have shaped the behaviors that we end up seeing.
Dr. Akeem: And we started off our professional careers working in a juvenile detention setting. So as I came [00:08:00] into it, I’m sitting there thinking like, hmm, what’s really going on here. There has to be more to the story. Something happened in it that we’re not quite getting. And that was the seed that was planted that eventually led to this book.
Dr. Sharp: Sure. I like that, that process. I think a lot of us probably have that experience where it’s like, there’s something missing here but I just so admire authors, y’all like to actually take that feeling and do something about it. It is pretty impressive. And y’all really put together, I think a really nice book that covers a lot of ground and it gives a lot of good information around this whole paradigm of disruptive behavior disorders and trauma and attachment and everything [00:09:00] that goes into that. And so I’m excited to dig in.
I wonder if we might just start at the beginning and have you all talk a little bit about the basics around like trauma, how it affects attachment, how it affects our brain or our kids’ brains. Maybe we could start there.
Dr. Lara: I think one thing that I’ve learned, particularly working in detention, but with some of the youth that I got to work with even before that is just the extent of the trauma and the adversity that a lot of the kids that we see in those settings, in particular, are facing.
I’ve seen kids who have a trauma history that’s full-page, single-spaced bullet-pointed. And I know, I don’t know anywhere near all of it. And we’re [00:10:00] talking trauma in their homes, in their families of origin, sometimes trauma in placements outside their homes. We’re talking about trauma in the community. There’s one we often talk about the zip code that’s like right around the juvenile detention facility in Brooklyn, and there were between 10 and 12 shootings a month there for the last two years in one zip code. That’s not the thing that we often think about but even if a kid doesn’t see someone directly get shot that affects them.
Dr. Sharp: Of course.
Dr. Lara: So there is much more going on than a lot of us who have professional training and careers and that kind of income really appreciate.
Dr. Akeem: Yeah. And it’s like there are so many layers to it as well. A lot of the things that we put together in the book are things [00:11:00] that we may have learned about but we learned about it as distinct entities. And we’re just like, wait for a second, all of these things are connected. So we started to really view our patients and the kids that we worked with in those contexts. For example, like you mentioned, early childhood trauma and attachment, it kind of starts off there. And every little thing causes changes, some sort of may be epigenetic changes, things like that.
And if it was just one thing okay, maybe it would cause some mild disruption in the life, maybe not, but then you have one thing after another layered in different ways. And it just gives you [00:12:00] this presentation that you see. A lot of people don’t really nuance, don’t really appreciate all of that. So we really felt it important to add that perspective.
Dr. Lara: Like, if you think about how does living in a super violent community affect a kid, and then how does that affect a kid who at home, maybe their parent is working three jobs and they don’t have the time to be there to make sure that the kids are at home doing their homework but they also don’t have the time to be there helping the kid process everything that they’re experiencing when they go walk to school every day or in the halls at school, or when they’re out with their friends hanging out in the park. The kid never really gets the chance to learn how to cope with that in a way that is going to be called [00:13:00] well-regulated and able to stay sitting in class.
Dr. Sharp: Right. I mean, when we think of the primary attachment figure or figures as that safe space, ideally, to help co-regulate with our kids. And that’s a huge missing piece if that person is not available for whatever reason.
In the course of putting all this material together, do you get a sense of what drives what with these kiddos? Like, is it disrupted attachment that is driving the experience of trauma or vice versa? Or is there any way to even pull determiner a driver?
Dr. Lara: I think it’s all the things. Non of it really stops, right? If [00:14:00] your attachment is super disrupted from the time you were a very little kid, it often doesn’t stabilize as you get older. If you’re experiencing trauma all the time, that often continues, especially if you’re from a family that has experienced a lot of trauma in the past, and you have these epigenetic changes and vulnerabilities, right? All of that is constantly looping together and feeding into your reactions to other things which then can make you even more vulnerable to more trauma and more disruptive relationships.
Dr. Akeem: Yes. And then you end up in settings that further traumatize them and it ends up being a vicious cycle all around.
Dr. Sharp: Yes. Now, this might be one of those super naive, non-intuitive questions but I ask these sometimes on the podcast. Do we know, is there research to say that environments with, let’s say, higher [00:15:00] levels of trauma for lack of a more descriptive term, is that going to relate to attachment between kids and parents? Do we know that? Is there research out there to support that or is it just kind of intuitive?
Dr. Lara: That’s a really good question. I don’t know that there’s a ton of research specifically on that correlation but think about it logically, poverty and community violence are super linked. Poverty and child abuse are super linked to each other. So, what we call risk factors are all pretty correlated with each other. Ad whether or not there’s research that has been done on that to look at the connection to attachment, I’m not sure.
[00:16:00] Dr. Akeem: I wish I could recall a specific article but as you were talking, it just makes me think of certain circumstances, for example, natural disasters, or famines or war where the people who are experiencing that are basically in survival mode. They’re just trying to do their best to get through one day to the next and while that’s happening, as a parent, you’re not going to be able to meet the needs of your child like the emotional needs. You may be able to meet their basic physical but you’re certainly not going to be able to meet their emotional needs.And the children themselves being in that environment as well will also be in survival mode. So, that’s going to have a significant impact on the attachment system between them. And then the end result is going to be, [00:17:00] here we are having conflicted relationships on going.
Dr. Sharp: Of course. Yeah. It just makes a lot of sense. I wonder, before we go any further, if we could just do a little bit of basic education around trauma, disrupted attachment, and the brain. What are these things doing to kids’ brains in terms of emotional regulation, self-regulation relationships, any of those factors? What’s happening when kids go through these experiences?
Dr. Lara: Well, like we said, a lot of times kids who are living in environments where there’s a lot of trauma and disrupted attachment, their families are also living in those environments. And so their parents have gone through a lot as well. And so it starts off even before the kid is born with epigenetic changes in the ways that their systems respond to [00:18:00] stress.
So, a kid whose parents have experienced a lot of stress and trauma, their nervous system is basically pre-wired to react more strongly. That reaction lasts longer. It takes longer to calm down to a stressful situation which makes a baby more adaptable and more able to cope with that stressful environment, but it also makes them more fussy “difficult babies”, right? The ones that are difficult for their parents to manage, which can affect the attachment relationship that forms.
We learn to regulate ourselves both cognitively and behaviorally, but also physiologically from the people around us. So our nervous systems, our sympathetic nervous systems, and our cortisol which is the longer-term response to stress, so if sympathetic nervous system responds immediately in the moment, like within less than a minute, your [00:19:00] system is on go mode. And then your cortisol system takes minutes to an hour to ramp up and a little bit longer to calm down.
Your sympathetic nervous system is the basic fight or flight mode stuff, and then your cortisol system helps you respond to fight a little bit longer or run a little bit farther. So both of those things are more reactive in a kid whose parents were exposed to a lot of stress and their systems don’t co-regulate as well. So they don’t sync up with their parents’ systems. And that’s how most of us learned to regulate our emotions and our behavior on our nervous systems. So, you’re pre-wired to be more reactive and your system settles down a little bit less easily in response to other people’s [00:20:00] responses.
Over time, that sympathetic nervous system response stays super reactive. Often the cortisol system becomes less reactive to the kinds of stress we can study in a lab because those stressors that we can study in a lab, obviously ethically, they can’t be all that dangerous. But what we see then is this flattening and people often think of that in relationship to psychopathy but it actually, if you experienced a ton of chronic trauma is also what we see as well.
Then there are a lot of changes that happen to the brain. So those are the most basic parts of the brain, the things that even rats or mice or animals have as well. And then the more higher-order cognitive parts of our brain change as well, both in terms of emotion regulation, in terms of learning and memory- where we focus our attention becomes [00:21:00] narrowed and focused on in the moment more emotionally relevant information. We also have less cognitive regulation because our brains are so focused on that fight or flight, that need to protect yourself in the moment response that cognitive regulation gets pushed offline a little bit.
So the more distressed a kid is in, or the more trauma reminders they’re exposed to, the harder time they’re going to have regulating themselves because their system is just in this automatic survival mode, protect yourself. Like we’ll tell kids, use your words, right? A kid who’s been through a lot of trauma may literally not be able to use their words to express what’s going on with them in that moment because their system is just like, you need to survive right now. And they can’t even access that.
Dr. Sharp: Yeah. I appreciate you laying that out. And you’re kind of walking into [00:22:00] my next question which is, if it’s not completely clear, then just let us know the connection then between trauma, poor attachment, and what we call disruptive behavior, or problem behavior?
Dr. Lara: So there’s the internal self-regulation physiologic regulation piece. There’s also survival coping, right? So there’s how is your nervous system, your brain, your body reacting? And that is more reactive. You have much more trouble regulating. You have much more trouble using those skills that you might need to stay calm, to avoid getting into a fight, et cetera. And you’re more likely to overreact and defend yourself when you don’t need to.
But then also, you’re [00:23:00] living in this environment where your basic needs may not be getting met, and you have to figure out how to get them met, where you might be in literal physical danger on a pretty regular basis and have to protect yourself. And so, you learn these patterns as well in order to survive and get through, right? So there’s automatic physiologic stuff that you don’t necessarily have a ton of conscious control over but then there’s also the conscious strategies you’ve learned to deal with this environment that you’re in.
Dr. Sharp: Yes. I like how you separate those two layers. It is very, for lack of a better word, practical that you may have to get in fights and so forth to protect yourself but there’s this underlying emotional layer too, that just makes kids less able to regulate and more hypervigilant, and so forth.
Dr. Lara: And that’s tough too because that’s huge, right? If you [00:24:00] are ready to go and somebody bumps into you, then you’re going to interpret that in a much more threatening way than you might if you are walking down the street, somebody bumps into us.
Dr. Sharp: Of course.
Dr. Akeem: Yeah. Absolutely.
Dr. Sharp: So, I think this leads nicely into the diagnostic part of this. So in the DSM, we have a whole section on disruptive behavior disorders, and impulse control disorders, and so forth. Some of those are separate, but I’m thinking about the ODD or oppositional defiant disorder and conduct disorder. This is a very open-ended question, but I trust that it’ll go somewhere between the two of you. I would love to hear just how y’all think of these diagnoses in terms of their utility and accuracy and [00:25:00] how helpful they might be or not?
Dr. Akeem: Well, it’s like a lot of times the diagnoses just list certain types of behaviors which puts us at a point where you can’t make those diagnoses just based off of feedback without even speaking to the child directly. And the other side of it is like, the context is not there. It doesn’t say much or anything at all about the internal states of the child. So it’s like we have these things here that we’re putting labels on and what is the real reason for it? Like, what is the actual purpose of that? What’s the utility?
Dr. Lara: And I think [00:26:00] the issue there is that you are actually discouraged in the DSM in some places from looking at the context of those behaviors, like the diagnostic long text for ODD says, basically in certain contexts where these behaviors are in response to the environment, maybe put some more clinical attention on the environment but it doesn’t really say that’s a normal response in this environment.
And so it continues to pathologize it. And the problem is that because there’s no explanation for those behaviors, the diagnoses become this label of bad kid and they have these long-term ramifications that encourage people to ask even less, to consider what’s going on internally with the kid or in the kid’s life, even less because [00:27:00] here we know why they’re behaving this way. They’re behaving like that because they’ve got ODD. They’re behaving like that because they’ve got conduct disorder. There’s something wrong with the kid. And then they’re more likely to get punished than to get treatment.
If you look at the effect of a conduct disorder diagnosis in the court system, for example, a young kid who has a conduct disorder diagnosis, juries are, I think nine times more likely to find them guilty than a kid who doesn’t have that diagnosis even with all the other factors being the same. We’ve done some studies.
Dr. Sharp: Right. I think we’re on the same page here. I was talking to Dr. Marsh before we started a record that I just have a hard time finding the value in these diagnoses. And I’m always looking behind the scenes as to what might be driving these behaviors either cognitively or… [crosstalk] What’s that?
Dr. Lara: There’s always a reason. We behave in [00:28:00] ways for reasons. All of us do. We are adapted. We’ve got to look at those reasons if we want to help them change.
Dr. Sharp: Yeah. It begs the question just on the flip side, do you ever see scenarios where it is actually helpful to make these disruptive behavior diagnoses? Like are there times when that is the right path?
Dr. Lara: If you want to get a kid MST and there’s no other way to do it.
Dr. Sharp: Okay. And for anybody who doesn’t know, what does it mean, MST?
Dr. Lara: Multisystemic Therapy is one of the most intensive forms of therapy for a kid with disruptive behaviors. And the thing about it is that it intervenes in every single one of the systems the kids in and their whole family, with their school, if they’re on a sports team with the sports teams, like everywhere the kid’s life touches. So it’s basically treating this context that we’re talking about as much as the kid themselves. [00:29:00] And some places you need to have a conduct disorder diagnosis in order to get into MST. And that would be the reason that I would give that diagnosis and pretty much the only one.
Dr. Sharp: Yeah. I appreciate you clarifying that. I’m always thinking, and I, supervise a fair number of interns or postdocs and whatnot. And we have these conversations often because it’s easy to default to an ODD diagnosis just based on the behaviors, right? It’s always this question of like, where’s this coming from and what’s this going to help? Or how’s this going to support the kid or the parents for that matter? Does that actually do us any good? I think we’re all on the same page, but I was curious. Are there any times when it might actually be helpful? It seems pretty circumscribed.
So then we can talk about… I mean, y’all have done so much work with these kiddos. In my [00:30:00] experience, Kids in this world or with some of these characteristics can be really hard to connect with for one reason or another. Has that been y’all’s experience as well? You’re smiling. What’s going through your minds?
Dr. Akeem: I’m just flashing back to the very beginning when I first started with the, I guess you could say traditional mentality, like, Hey, which is like an authoritarian. Yeah, that’s the right word. It was like, “Hey, I’m the doctor, you’re the patient. You listen to me. I’m here for you. Look at me.” And it’s like, “No.” I’m very quickly realizing that’s just not the way. And then also on the [00:31:00] back of my mind are things like, there something going on with this person but I don’t know exactly what it is and I feel like they could use some assistance, some benefit, but how do I get myself to the point where I could be that person.
And then the other part of all of that is also like, Hey, I have strong feelings about everyone deserving of some quality mental health services, mental health care. So I also want to be that person as well. So then from there, I started just being curious trying to learn more about their experience, what’s going on with them [00:32:00] using whatever I could to try to make a connection. A lot of them were from the same areas that I had known or grown up around.
Although interestingly enough, thinking for myself that that was enough, it’s not really because, even though it was the same, it could have been the same area we could have even been living there at the same time but it’s not going to be the same experience because there’s a generational thing like I’m much older than them. And also, their individual worlds are different. Their family makeup is different. The way school is now is different. The music that people listen to is different.
So it was that bit of a learning curve. And then now, I would say [00:33:00] is at the point where I’m so much better at making a connection and maybe not initially, but at least initially starting the process for making a connection. And it just comes with what we call, be a person. Let me kick it off to Lara, get it, get it, get it.
Dr. Sharp: How do we be a person?
Dr. Lara: That is, I think one of the biggest pieces of it. Like Akeem said, when you walk in with this mentality that a lot of us learn in training and in school where you’re automatically assuming that people ought to trust you because you’re the clinician, you’re the doctor, and of course, they should trust you. You have good intentions. That’s why you’re there in the first place, that automatically has the opposite effect for a lot of our kids because that’s not the experience they had with people in [00:34:00] systems, right?
The people in systems who are supposed to help them don’t. And so if you walk back then, okay, you’re probably not going to trust me and that’s okay. And I expect that, and I don’t take that personally. It becomes somehow much easier to connect. The number of times I’ve looked at a kid and been like, of course, you don’t trust me. I’m some random white lady you met in jail. Why would you trust me? And they start to laugh. And then all of a sudden and[…] is very remarkable.
And being a person, not being as formal or as rigid about what you will and won’t say about yourself or about other things, I think makes a huge difference. So being a person, being curious, and not walking in just expecting that people ought to trust you. Those are all huge. And if you can do those things, then you connect much more easily. If you [00:35:00] don’t assume that the connection has to be there off the jump, it’s much easier to actually make it. You have to put the effort to build it.
Dr. Sharp: Yeah. You said something when we were talking before the podcast a few weeks ago that I wrote down, someone, I forget which of you said it, but you said there was no such thing as neutral in these interactions. Can you elaborate on that a little bit? I found that fascinating.
Dr. Lara: We learned, like that’s sort of like fright and neutrality, right? You’re not supposed to show your reaction to things you’re not supposed to have too much of an opinion about stuff, and you’re not supposed to share about yourself. And if you do those things, then the kid has nothing to form a connection with, right? You’re giving them a blank wall. Why would you connect to a blank wall? I wouldn’t want to connect with a blank wall and I [00:36:00] really don’t trust anyone at all. Why on earth would I trust a blank wall?
And there’s a way to not have a reaction to a lot of the things that our kids tell us. You can’t not react. Right? Sit there, try to pretend that you’re not having a reaction to a kid telling you about all of these horrible things that they’ve experienced. You lose your own humanity doing that because we can’t shut off our reactions like that. So there’s no way to be neutral and it’s not helpful to even try.
Dr. Sharp: Right. So the question that comes up for me sometimes when you say we can’t hold back our reactions, I wonder if, I know I’ve gotten caught up in this and maybe some others too, not wanting to react so strongly that it amplifies [00:37:00] the kids’ experience or it makes them think, oh my gosh, this really is crazy. What’s wrong with it? Or something along those lines. I’m curious, and I know this is hard to articulate what’s happening in the room, but I’m curious if you think through that and how you might balance some of that, being authentic but not sensational maybe it’s the word?
Dr. Lara: I think that’s how to put it. You react and stay well regulated. And one of the whole process, I think of healing is that you’re having these authentic reactions and reacting in a regulated way that maybe the kid hasn’t had a lot of in their life because they haven’t had that stable attachment. So maybe the people that they’ve been around haven’t had the opportunity themselves to learn to be well-regulated or have [00:38:00] so much stress going on that they can’t regulate as well.
And so if you have an authentic reaction, so the kid knows you really truly do care but you do so in a way that stays regulated and doesn’t freak out, then the kid learns that that’s possible and has an example of how to do that themselves.
Dr. Sharp: Right. I like them. So the risk of trying to define an organic process may be too much. I wonder if y’all do have other strategies of sorts or ways to be more authentic? That’s a funny thing to ask for.
Dr. Akeem: Oh yeah. No, that’s a great way to put it.
Dr. Sharp: Strategies that you bring into the room with these kiddos to help build that trust.
Dr. Akeem: Definitely. A lot of times actually it starts with [00:39:00] really basic things. And that would basically, be demonstrated interest, showing up for them. Like, in this setting we were working in, we would sometimes just sit with them. If we had time and it’s not like a session, we would come to the hall that they were on and do other things like play cards, or even just hang out and let them know I’m around. I’m interested.
When we would actually come to our own sessions, we would do things like maybe play some music and then the music that they were interested in which could then turn into conversations about, do you feel like whatever this person’s [00:40:00] talking about relates to you, or what is it about this person that appeals to you? Why do you like this person? And then things can go from there. We’ve also done things like taking advantage of using the internet specifically, Google maps, which has this feature called street view, where you can literally take a walk down the street.
And we found things like that really helpful because they could take us on a virtual tour of the neighborhood. And in doing that, that often triggers a lot of memories like, oh, this happened over there, or this is a school I had issues at, and all things. And that we’ve learned things about them that otherwise may not have come up or had come up in conversations. You got some thoughts, Lara?
[00:41:00] Dr. Lara: Yeah. I’m remembering a particular kid walked me down his street and it was, oh yeah, here’s the best place to get breakfast. There’s where my friend got shot. Here’s the best pizza in the whole city. There’s where my other friend got shot. Oh, here’s where I play basketball. Did I tell you I got shot in that park?Dr. Sharp: Oh, Jeez.
Dr. Lara: Yeah. And that kid really didn’t talk a lot about his experience. So it was a really powerful way to learn about what his day-to-day life was because this was literally walking down two blocks of the street in his neighborhood with that. I think being curious and being willing to make fun of yourself does go a long way.
Dr. Akeem: Absolutely.
Dr. Sharp: That does go a long way. Kids seem to love that universally when adults make fun of themselves.
[00:42:00] Dr. Lara: And surprising them. Being willing to acknowledge when you’ve said something dumb or ask the wrong question. Apologizing if you feel like you’ve done something wrong because that’s not something that our kids get a lot of, even if it’s like, oh, I asked that question in a way that you reacted to, and it seems like that upset you somehow, right? If you acknowledge that, that can actually work. I think also knowing when to press and not to press, being like, okay, you don’t have to talk about that if you don’t want to talk about that. And letting the kids know that they can set a limit is helpful. And like you said, reacting but not reacting too much.I think [00:43:00] sometimes, assuming that there’s a reason and assuming that they’re coming from a context that’s difficult also helps a lot. If you assume, okay, you’ve probably experienced all. Like the kids in detention have almost all of them experienced quite a bit of violence. And so, if you assume that coming in and talk about that as if it’s normal but not normal if that makes sense.
Dr. Sharp: Can you say more about that? When you say normal, but not normal, what does that look like in terms of how you talk with them about it?
Let’s take a quick break to hear from our featured partner.
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The FACT Teacher Form solicits the teacher’s perspective on the performance and behavior of children ages 4-18 years. It takes just 15 seconds to administer. And the available e-manual gives you detailed administration and scoring instructions. You can learn more or purchase the FACT Teacher Form by visiting parinc.com\fact_teacher.
All right, let’s get back to the podcast.
Dr. Lara: Well, so a lot of our kids will talk about having this laundry list of tremendously violent or difficult experiences and use the phrase regular shit. Pardon my language.
Dr. Sharp: You’re all good
Dr. Lara: And that a lot of times I think people assume just means the kid doesn’t care, but it means that this stuff happens so regularly that they [00:45:00] have to act like it’s regular. Or it’s overwhelming. So if you acknowledge yes, this stuff really does happen all the time. It’s true that happens in your life that you’re going through all of this stuff on a daily basis and point out that’s not normal, and, of course, that affects you. That’s what I mean by that normal, but not normal.
Unfortunately, it happens so often in your life and the lives of the people around you, that that’s “normal” for your experience, and it’s not totally normal as in it affects you and it affects your reactions. And that helps kids make sense of things for themselves because a lot of times kids are like, I must be crazy. There’s something wrong with me. Why did I do this? And they may not connect to all of that because it’s so “normal” [00:46:00] that they think it’s not supposed to affect them, or they’ve learned that it’s not supposed to affect them because boys don’t cry, for example.
Dr. Sharp: Right. Yeah, they don’t see their peers reacting in any kind.
Dr. Lara: Yeah, even though internally they’re all reacting.
Dr. Sharp: Right. I think that gets at something that we talked about before recording, and this idea that you can’t necessarily ask about traumatic experiences in a really straightforward way. We can’t really go down the DSM symptom list and just read them off and have the kids be like, yes, I am hypervigilant. And I thought that was cool the way that y’all conceptualize that. I wonder if we could talk more about ways to get at some of these experiences or [00:47:00] symptoms, I suppose, without directly asking. Can you all speak to that at all?
Dr. Akeem: Yes, absolutely. It just made me think of the rating scale questionnaire that’s often used that often says like, oh, tell me about your traumas, but then tell me which one was the worst. And like 10-15 things were the worse. So how do I decide? So instead of trying to sort that out, which you can, I’m going to just say nothing’s affected me and just keep it moving and that’s what the kids do, but, oh, sorry.
Dr. Lara: These rating scales use words like bad and scary, often. Our kids aren’t going to tell you something was scary.
Dr. Akeem: Not at all.
Dr. Lara: Then you’ve ruled bad [00:48:00] out just by the way that you’re asking about it. So I think you can ask about the things directly, but you have to ask about something that affected you, right? If you say something intense that you went through that affected you, that’s very different than saying something scary that bothered you. And you’re going to get a very different reaction from a kid. And using the words, abuse, for example, kids may react to it because they know you’re going to have to report that. But if you say some adult that was supposed to be taken care of you hit you, that’s a different reaction that you’re going to get.
Dr. Akeem: Yeah, a lot of times they’ll frame something like that too, is like tough love or tough parenting. And they won’t tell you that but in like, well, how did they show it? And then when the detail comes out and you’re like, they crossed the line there. Or what else, like in other situations you’re not going to say, oh, tell me about the [00:49:00] community violence? It will like, I feel like you’ve seen a lot of things. I get that feeling and at some point, things will start to trickle out where you get at some of those things. Sometimes it’ll come out in different contexts.
This brings me back to music. Some of the songs they’re listening to, I feel like often is a way to help process it. Or even sometimes the kids themselves will be writing song lyrics, and then you see things in there and you ask them about it and you’re like, okay, well that happened and that happened. And then that’s like trauma check, check, check.
And then, as far as the symptoms go is like, well, what do you do about it? These are ways in which this has affected you. They’re not always making that [00:50:00] connection but we can tell like, okay, if I’ve been shot at, I’m not going to go on this certain block or if they got assaulted on the subway or something, I don’t take the subway anymore. I just take a car service.
Dr. Lara: Or kids will be hyper-vigilant to take the train. So that’s why we see a lot and that’s actually one of the ways that I ask about hyper-vigilance. So, I’ll ask kids, do you take the train? If you take the train, where do you sit? And a lot of our kids will not even sit down on the train because it’s a closed environment, they can’t control it. And if they’re sitting down somebody could come at them. So kids will literally only stand on the side of the car that the door doesn’t open at the next stop. And that’s the only time they’ll sit. And if the car is too crowded, they’ll get off. They will walk wherever they have to go or they’ll take a cub instead.
[00:51:00] But if you ask, like, are you always on point, are you always monitoring your environment, they’re going to say, yeah, but of course, I am. And of course, they are because people are trying to get them. So that is an appropriate and normal reaction but it could affect their life in some way. Like they can’t take the train or they can’t sit in class or they can’t stand in a line in detention because they can’t have anybody behind them. Then you start getting at, okay, maybe this is affecting you in a way that’s causing you problems.Dr. Akeem: And the other thing that I have to chime in to on that note is that this document that Dr. Cox came up with which paraphrases reframes the language of post-traumatic stress disorder into an easily digestible format. So sometimes we will actually take that and show it to kids when we know like, [00:52:00] oh, we just have like a strong feeling that there’s a lot of trauma/trauma-related symptoms going on.
We’ll share it and then say, take a look at this. They’ll look at it, process it a little bit, give them some time and then we’ll circle back and be like, “Hey, so what do you think, some of the things in there apply to you or how does this relate to you?” And then there’s another way, lo and behold ding ding ding.
Dr. Lara: Yeah. So I went through and reworded the criteria in the language that our kids use. And I think that was the other thing that I was going to get at here. You have to ask about these symptoms in the context of the kid’s own life, not necessarily in the context that it’s described in the DSM, which I think often assumes that people’s lives are fairly safe and stable and they’ve had this single point trauma [00:53:00] that’s affecting them, but also then in the language the kids use themselves, right?
So if you ask a kid about nightmares, for example, some of the kids will say, oh, I dream about stuff that’s happened. But if you ask them, if they have nightmares, they’ll say no, because nightmares are things that never happened. It’s not real. So, if you ask about some of the stuff you’ve been through, they’ll say, yeah. And you’ll get this whole story of how they wake up every other hour with their heart racing, a nightmare.
Dr. Akeem: The other thing too is nightmares imply scary. So it’s like, “No, I don’t have nightmares” Okay, well what do you dream about? Somebody shooting at me. This thing blowing up. This thing burning but that’s not a nightmare. Oh, okay. And then the other side of that coin is, in order for me to actually get myself to sleep, I have to [00:54:00] take a lot of either marijuana or alcohol or the opioid drink called lean. I have to take something external to force myself to knock out because otherwise, I don’t get any sleep.
Dr. Sharp: Yeah.
Dr. Lara: Right. And I think that we also don’t think about substance use and avoidance. And so that’s another thing is that a lot of times kids are staying high all the time so they don’t feel what they’re feeling or they don’t have any thoughts and memories and all of those things flooding into their head constantly, or they don’t react super strong and get into fights every 10 seconds.
And so, they may not be experiencing those things but it’s only because they’re high. And so if you ask them, all right, what if you’re sober? What happens if you don’t smoke for two days? Then all of a sudden you’ve got all of the symptoms, but most of the time when they’re in the community, they may be [00:55:00] using enough that they’re not necessarily experiencing them. They’re not going to report them but that’s why they started using so much in the first place.
And so, if you think about that as a form of avoidance, then you start understanding what’s going on with them a lot more. Whereas if you don’t think about it, then you miss the whole trauma-related experience that’s happening before they started using in the first place.
Dr. Sharp: Right. Well, and that’s just another example of a descriptive diagnosis that doesn’t necessarily help us a whole lot. It’s like you could say, oh, that kid’s smoking weed 4 times a day, every day could be a substance use disorder or maybe it’s an avoidance tactic.
Yeah. I just want to highlight that. I’ve never really thought of it that way, though it does make sense, but to think of it, [00:56:00] it’s not just like avoiding that certain block or that part of the playground or whatever it might be. Substance use totally takes you out of the feeling. And that makes a lot of sense. I appreciate that perspective.
Dr. Lara: And the way that kids don’t necessarily tell you that that’s why. So one thing that I’ll ask sometimes, it’s like, what do you like about how you feel when you’re high? And then they’ll tell you that pretty readily. And so then you can either be like, okay, so how do you feel when you’re sober or say, oh, so is that the only time you feel that way and get at that negative difficult emotional experience that’s happening when they’re not using which they wouldn’t have told you spontaneously.
Dr. Sharp: Yeah. As we’re talking, it’s one of those moments where, again, it seems obvious but just the willingness to go beyond [00:57:00] the surface, and go beyond maybe what we were taught in grad school, that rote interviewing method. Just let the walls down a little bit and really get in there with kids.
Dr. Lara: Yeah. If you assume that there is more going on than you see or that you’re going to hear at first, that’s the key. There’s something going on. There’s a reason that you’re seeing what you’re seeing. And that’s the fundamental assumption I think is that it makes sense. Like whatever you’re seeing makes sense in the context of the kids’ internal experience or of their life. And so, to help figure out how it makes sense:
A) You understand what’s going on with them.
B) You can help them understand what’s going on with them which in and of itself is super helpful.
The number of times I’ve handed a kid these rewritten diagnostic criteria, and they’re like, [00:58:00] oh, that’s why I’m doing that.
Dr. Sharp: It can be validating.
Dr. Lara: It’s hugely validating. And if it makes sense to them, if they’re like, oh, that’s why I’m doing that. I’m not crazy. I’m not bad. It makes sense, in the context of my experience, then you have a way to help them have some hope and help them see that it’s possible to do something different.
Dr. Sharp: Well, I think that’s an awesome segue to treatment and intervention that actually work or maybe work. Before I totally transition though, I know people are screaming out there. They’re like, where is this document? So just to be clear, can people find that translation document that you keep talking about putting the PTSD criteria into more of that.
Dr. Lara: It’s something that I put together in a word doc. I’m happy to [00:59:00] email it to you and let you share it with people.
Dr. Sharp: Okay. So it’s not a book?
Dr. Lara: No.
Dr. Sharp: It’s separate. Okay.
Dr. Akeem: I feel like it should be, but we had to take the space that we needed for things, so.
Dr. Sharp: sure. Okay. Can we talk about intervention and what y’all have found? I know we have like our evidence-based practices and then there’s other stuff. I’m curious. What are y’all’s thoughts on what actually works with these kids?
Dr. Akeem: Awesome. So I think at the core, it goes back to everyone meeting a person at least one stable person in their life to help reestablish the sense of safety and security in themselves, but also in humanity. And [01:00:00] then the individual person has to regain a sense of control over their whole body because with the trauma and disrupted attachments and everything, it’s like people really lose a sense of themselves. So, the core is really recovery. Other than that, everything we see, if it’s is the evidence-based practice or “non-traditional”, those are all different types of pathways to get to that point.
Then to build on that is like, there are things happening in their lives, right? So we’re talking about youth. They’re all part of some sort of family unit. So as [01:01:00] long as the family is not too toxic or too… Well, you know what, let me backtrack a little bit. They have their biological families but then they also sometimes will have an adoptive family. Between the two of them, hopefully, one of those is actually really supportive, loving, nurturing. And if that’s the case, work towards building that up.
And then a lot of times with the overall presentation, with the kids, we’ll see other issues that are going on like calling back to our conversation before we started the podcast with kids having some apparent education needs that may not be met. So, we’ll see, okay, they [01:02:00] need more comprehensive testing to identify those needs and then address those needs with appropriate services, speech therapy, occupational therapy. The other things that could be used would be things like, I guess some of the evidence-based treatments would be like parent management training. That’s like working with the parents. If they’re younger to try to really get them essentially approved the relationships. That’s what it comes down to, to be honest.
Dr. Lara: Yeah. I think that idea of having a person is one of the core pieces of it. And trying to be a genuinely caring, authentic human being in this kid’s life is one of the most [01:03:00] important things and all the rest of it is like tools in your tool belt. So some kids are going to need medications. Some kids are going to need specific trauma-focused therapies. Some kids are going to need something else and it all stems from that relationship. And if you don’t have that, then all of those tools are useless.
I think also thinking about the kid’s context is super important because if you’re only treating kids, so you’re treating the kid, great. You’re intervening and the kids still can’t walk out their front door to go to school because they’re going to get shot if they walk down the block, that’s useless. If they still got to rob because their mom can’t pay rent and so they’re going to get evicted and they’re trying to contribute, then your trying to get them to change that behavior isn’t very helpful because those needs still need to get met somehow.
So [01:04:00] you have to look at all of those contextual factors as well as the kids themselves in order to try to intervene. And I think Dr. Marsh’s point in speaking to the whole audience of the podcast about assessment and testing, a lot of the times kids may have an undiagnosed learning disability, or they may be really bright but they got into trouble so much when they were little. Starting from the time they were little, they missed a ton of the information that they would have needed to be at the same pace as their classmates.
And so then they get tracked into a special ED class because they can’t academically perform in a way that’s consistent with their intellectual capability, but they’re beyond bored because they’re super bright. They just don’t know the stuff that they would’ve needed to know. And so then checked out of school because they thought they couldn’t do it even though they’re incredibly intelligent.
And so understanding the kids’ needs and capabilities in terms of the [01:05:00] educational setting is huge and finding ways to actually meet those and maximize those capabilities. Because a lot of times, I’ve seen so many kids who are incredibly smart and incredibly capable, but they think like, oh, I can’t do school. Or they even think like, “I’m dumb,” but that’s not true. The opportunity wasn’t there or their needs weren’t recognized. And so, they didn’t get what they needed to perform at their capabilities or to get super engaged.
Dr. Sharp: Right. I love that you’re speaking my language now, the testing and assessment component. I think one of the best parts of the job is being able to dig in and find kids’ strengths and communicate that to them, especially in those cases where they don’t have that opinion of themselves.
[01:06:00] Dr. Lara: Which is almost always all of our kids.Dr. Sharp: Right.
Dr. Akeem: Absolutely.
Dr. Lara: The other thing about these diagnoses and about the way that we talk about is that I’m a bad kid gets so internalized.
Dr. Akeem: It’s not just the people around them. It’s also like messages that you get from society. It’s just constantly reinforced.
Dr. Lara: Like the media.
Dr. Sharp: Yes.
Dr. Lara: Unfortunately, there’s been a lot of gun violence in the city lately, and sometimes a kid will get shot and the article will be about their rap sheet.
Dr. Sharp: Right. What’s going on here?
Dr. Lara: And so then, why would a kid think that anybody cares? My friend just got shot and they’re talking about his criminal record. They’re not talking about his child or his relationship [01:07:00] or how well he was actually doing right now. It’s all the things that he did in the past. That gets so internalized and makes kids think, why would I care? Why would I try to change?
Dr. Sharp: Right. Yeah, that whole idea, I mean, we didn’t talk much about the idea of stereotype threat or self-fulfilling prophecy idea, that’s huge and this whole discussion, right? Is that these kids:
1)We have pretty good evidence, right? Kids of color are more frequently diagnosed with behavior disorders than white kids. And then you throw in this whole stereotype threat piece and like, what am I supposed to be? What do other people think of me? And it is so heavy.
Dr. Akeem: And the kids are very [01:08:00] sensitive to that, sensitive and reactive to it.
Dr. Sharp: Well, of course. Getting back to that component, is there a way to build or identify strengths, change that narrative a little bit?
Dr. Lara: And I think that’s one of the things in being a person is looking for those things that a kid is good at and mentioning them all the time.
Dr. Sharp: Right.
Dr. Lara: Not in a way that feels forced or fake, but that is like, wow, that was really funny. Or I noticed how you looked out for me. Somebody slammed the door open and you were looking to make sure that I was good. All those kinds of things in the moment are super helpful because [01:09:00] they don’t get noticed for that stuff. The stuff with a problem gets picked up but where they’re really kind of sweet or going out of their way for a friend, don’t get noticed.
Dr. Sharp: Right. We talk about this so much and it seems so obvious, but I think we have a hard time with this. It’s like getting into a different mindset and reframing behaviors and characteristics to be more positive and adaptive. It’s so easy to get lazy and not do that.
Dr. Lara: For example, there was a kid I knew who stayed away from the place that he was supposed to be overnight. He stayed with his friends and I think they stayed in the [01:10:00] project stairwell. But the reason that he did that was that his friend was super wasted and he didn’t want his friend doing that by himself and his friend didn’t have a place to go. So instead of going back to the place where he had, where he could’ve stayed overnight and then in a fairly safe place, he’s stayed with his friend in the project stairwell because he wanted to make sure his friend was okay. But most people just would really notice that he didn’t go where he was supposed to be that night and not figure out why. And the fact that that was actually a really kind and loyal thing to do.
Dr. Sharp: Right. And if you’re not thinking about that, it’s like full circle now, here we are at that criterion for conduct disorder, runs away from home, like, oh, it’s that.
Dr. Lara: Yeah.
Dr. Sharp: I just want to hammer that home so clearly that there are different ways to interpret behaviors. And I think it’s our job as clinicians to do the work, to get behind and find some of [01:11:00] the motivation for these behaviors. I know I’m preaching to the choir here and we’re all on the same page, but it’s important. We can’t take things at surface value.
Dr. Akeem: No.
Dr. Sharp: Oh my gosh. So let me see. We’ve talked about a lot of different things. I know y’all go into so much depth in your book on these topics and many others. Is there anything else that you feel like we have not touched on that you definitely want to mention or help folks understand before we wrap up today?
Dr. Lara: Our kids are pretty amazing and it is a privilege to get to discover the ways that that’s true. If that’s how you approach it, then you have an advantage in being able to intervene helpfully in a way that [01:12:00] a lot of the time our field doesn’t have.
Dr. Akeem: Yes, absolutely. I echo that sentiment. If you’re willing to go there, there’s a lot that potentially could be gained from the experience and it really has the power to transform lives, have an impact. I would say our lives have been transformed more than theirs, but some of them may tell you otherwise.
Dr. Sharp: Well, it’s clear that this work has had an incredible impact on y’all and that comes through pretty clearly. That’s pretty amazing.
Dr. Lara: I was going to, I think the word that we haven’t used yet, and it’s not one that we often use professionally is love, but that’s the key.
Dr. Sharp: Sure. [01:13:00] I can get on board with that. I can.
Akeem: Love, love, love.
Dr. Sharp: And I just want to say, I’ve been thinking throughout our interview, y’all work with kids that are in pretty, I would say, risky, dangerous situations right? That’s been y’all’s work. And people out there might be saying, oh, I’m not working in the city. This is not super relevant but I think the themes though, you can easily downward extend to less “risky situations”. It’s just like the idea that kids are doing the best they can, and it’s our job as clinicians to get in there, speak their language, be human, and look through these different lenses when we think about their behaviors.
Dr. Lara: What they’re doing makes sense in their context. And if we think about [01:14:00] what would we have done in that circumstance, kids are really, like you said, trying to do the best that they can in the situations that they’re in with the resources and the options and the knowledge and the backup and the skills that they have available. And being able to identify that and then help meet the needs so that they can do something different, I think you can extend that to pretty much any situation.
Dr. Akeem: Yes. And as you were talking just now made me think of something that comes up, what happens a lot in our society where folks often compare themselves to others, and then you have the kids that we work with comparing themselves to other people who are maybe successful in different ways and wondering why did I turn out this way and they turned out that way? And then I’m just like, well, in life, we’re all given a [01:15:00] deck of cards and it’s like, you just got a really bad hand in some ways compared to these other people. There are a lot more different types of hurdles you would have had to overcome compared to them. So it’s not even a realistic expectation for you to meet the same perceived success that the other person has.
Dr. Lara: And if we help change the cards you got in your deck, then maybe you will be able to.
Dr. Akeem: Yes.
Dr. Sharp: Right. Well said. Y’all, I’ve greatly enjoyed this. I’m just thankful that you were able to give me a little bit of your time. I know it’s close to the holidays and you’re busy folks, but this has been a lot of fun and super informative. So just one more time. Thanks again for being on the show.
Dr. Akeem: Oh, thank you so much for having us.
[01:16:00] Dr. Lara: Agreed.Dr. Sharp: All right. Y’all thank you for tuning in as always. I hope you found that helpful, informative, and even a bit entertaining. I loved talking with them. They clearly know their stuff, and gosh, I’ve just been doing the work for so many years. It was awesome to share space with them.
If you are a group practice owner or any practice owner, my goodness, if you’re any kind of practice owner beginner, intermediate, advanced, and you’d like some group coaching and support, check out The Testing Psychologist Mastermind Groups. I am enrolling for new cohorts, I think for, let’s see beginner practice and intermediate practice. I think our advanced cohort for January is full. I would love to talk with you. You can get more information at thetestingpsychologist.com/consulting and set up a pre-group call to see if it would be a good fit.
Okay, [01:17:00] y’all. I hope the holiday season continues to be a good one for you. I’ll catch you next time.
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