The Complex Issue of Attachment Disorders

Attachment may be defined as a composite of behaviors in an infant, toddler, or young child that is designed to achieve physical and emotional closeness to a mother or preferred caregiver when the child seeks comfort, support, nurturance, or protection.¹ Attachment experiences are vital for sound social and emotional development. Effects of secure attachment include trust, intimacy, affection, development of reciprocal relationships, positive self-esteem, future independence and autonomy, ability to manage impulses and emotions, and resilience in the face of adversity.²

Attachment disorders are the effects of significant disruptions in attachment, especially disturbed social relatedness, mostly because of abuse, neglect, or prolonged maltreatment during early development. Pathogenic care is the cause of the disorder.^3,4 The effects of disrupted attachment are the converse of a secure attachment.

Case Vignette

At 9 years of age, Jim was referred for a psychiatric evaluation by his psychotherapist of the last year and a half. Jim had lived with his adoptive parents for 5 years; before that he had been with those same parents in a foster placement for 2 years. He had been removed from his birth mother at 2 years of age because of pathogenic care.⁵

Jim's symptoms began before he was 2 years old and included acting out; he was easily agitated, disruptive, and intrusive. He was verbally and physically aggressive, exhibited temper outbursts and rage reactions, and was assaultive toward his peers and parents. His adoptive parents described him as having up-and-down cycles: when up, Jim was easy to please and wanted to please others; when down, he was disruptive and intrusive. Regardless of his cycles, he had consistent difficulty in falling asleep.

Jim's birth mother had a history of physical and sexual abuse. His birth father had an extensive juvenile criminal history and his familial history included substance abuse, sexual abuse, and domestic violence.

Jim had been treated for attention-deficit/hyperactivity disorder (ADHD) for 3 years with high doses of methylphenidate, with minimal benefit. During a mental status examination, Jim presented as a thin, fidgety, hyperactive boy who had trouble staying in his seat. He appeared immature, anxious, and had a difficult time expressing the reasons his parents had brought him for help. He was easily distracted and evidenced some mood lability and inappropriate affect. During the 2-hour evaluation his mood vacillated from anxious to agitated to giggly to irritated to dysphoric to calm. There was no evidence of delusions, hallucinations, or homicidal or suicidal ideation. He was oriented to person, place, time, and situation. His intelligence appeared to be within a low average range. His short- and long-term memory was intact. His judgment and insight were fair to poor.

Jim's history, symptoms, and mental status were indicative of mood disorder not otherwise specified: juvenile-onset bipolar disorder (BD), oppositional defiant disorder, and reactive attachment disorder.

A recommendation to discontinue the methylphenidate and to start a trial of lithium was accepted. At the 6-week follow-up visit, Jim was described as "a lot better, a completely different kid, calm, polite, settled at night, helpful and loving...considerate and sharing."

While behaviorally improved, Jim had intermittent difficulties with motivation, attention, and task completion. Several months later, a trial of bupropion augmentation was initiated, with resultant improvement in all symptoms.

At age 12 years his symptoms significantly deteriorated, with increasing opposition, temper outbursts, and rage reactions. Risperidone was added to the medication regimen, and on follow-up, Jim was described as "the best ever."

Jim has been well from age 13 to his current age of 20 years. He has had no temper outbursts or oppositional tendencies and is dealing with his issues in a verbally appropriate manner. Because of concerns about adverse effects, the lithium Jim was taking was replaced with lamotrigine and the risperidone with aripiprazole, each with positive effects.

This case vignette demonstrates how an accurate diagnosis of childhood BD can provide the information needed for effective medical treatment plans in children with disruptive behavioral disorders with histories of significant abuse, neglect, or maltreatment. These reconceptualizations of childhood BD affecting foster and adoptive children have resulted in a significant quality of life enhancement for the children, their families, and society.

Correct diagnosis as the key to treatment planning

Medications can promote or inhibit well-being, especially in children with disruptive behavioral disorders associated with early abuse or neglect who are presently in foster or adoptive care. Accurate diagnosis is essential. Pediatric BD and pervasive developmental disorders (autistic spectrum disorders) are underdiagnosed and misdiagnosed in this population. Diagnosis of these coexistent disorders takes both trauma and attachment theories into account. Table 1 provides a summary of suggested diagnostic guidelines.

Underdiagnosis of a mood or developmental disorder can lead to ineffective treatment; anxiety disorders, traumatic disorders, and psychological factors must also be taken into account. Based on my experience in treating more than 3000 children with attachment disorders, I believe that there has been an overidentification of ADHD in such children, which has led to the use of stimulant medications, often with poor, exacerbating results. A more accurate correlation of attachment disorders is with BD. With treatment for BD, these children show greater emotional accessibility, receptivity, and social reciprocity. They exhibit better emotional and behavioral self-control and improved mood and self-esteem, and act in more loving and lovable ways.

Personality characteristics of children with attachment issues are extensions of these issues. Young children with attachment issues are capable of manifesting a diversity of symptoms including mood lability, depression, anxiety, distractibility, and aggression as adaptive compensations to maltreatment circumstances. Treatment within a stable environment will result in an improvement in bonding and attachment. Without treatment, this disorder worsens over the years, and the patients is likely to develop antisocial character traits.

The trauma of maltreatment creates psychoneurophysiological effects. The effects of trauma create CNS hyperarousal, hypervigilance, cortisol elevation, and other effects. Children with attachment disorder are distractible and have poor cause-and-effect thinking. Their perceptions are self-centered primary processes resulting in reality distortions. They lack trust in themselves and do not feel their world is safe. They often feel powerless and helpless. Lacking trust, they present as superficially charming, insincere, and nonintimate. With pain avoidance as their primary motive, they may develop survival skills and become calculating and devious. Their self-esteem is low, and peer relationships are poor.

Prognosis is more favorable if the degree of maltreatment is not severe, the age of relinquishment young, the child has a sound temperament, and adequate treatment is received. If all of the above is true, but significant opposition and defiance with rage reactions persist, a mood or developmental disorder should be considered. Often medication cannot completely address these issues. On the other hand, medications may indirectly help by reducing arousal and enhancing receptiveness and responsiveness to caregivers. Medications are helpful for moderating arousal symptoms associated with oversensitivity, overreactivity, irritability, opposition and defiance, rage reactions, grandiosity, and dysphoria (what I believe to be the bipolar piece of the diagnostic puzzle).

Initial consultation with caregivers specifically regarding the child's needs for security, stability, clarity and unambiguity of expectations, nurturance, and encouragement helps foster and adoptive parents to be more effective. As the child matures, family therapy is often appropriate.

Attachment disorders have so many comorbidities that the presentation can be complex and confusing.⁶ Atypical antipsychotic medication and mood stabilizers (used off-label) appear to be the medical treatments of choice for children with attachment disorders and psychiatric comorbidities.

The use of off-label medications is commonplace, and a new community standard is being formed. (At the time of the writing of this article, risperidone was approved by the FDA for aggression within autistic spectrum disorders and for short-term treatment of manic or mixed episodes of bipolar I disorders in children and adolescents aged 10 to 17 years.) Several manufacturers of atypical antipsychotic medications are actively pursuing approval of pediatric indications. The FDA has approved some anticonvulsant medications that have potential mood stabilizing effects for use in children.

For a discussion of psychiatric diagnoses commonly seen in parents who have abused their children, see "Psychiatric Diagnoses of Abusive Parents."

Attachment disorders as adaptations

Adaptation, defined as a change within an organism to better equip it for survival in various environmental conditions, is the most common unifying characteristic of all living things and a key component of survival.⁷ Our highest instinct and priority is pain avoidance, and it is the most common instinct within an adaptational framework. If maltreated, how would an infant or toddler adapt?

If one considers adaptation from a trauma theory perspective, reactive attachment disorder is a posttraumatic stress disorder (PTSD) of infancy and toddlerhood. In trauma theory, persistent fear leads to hypervigilance, emotional and behavioral withdrawal, avoidance of stimuli, and behavioral overcompliance. Persistent fear also leads to increased arousal and heart rate, startle responses, and sleep disturbance. Defiance, opposition, and overt resistance occur only when experiencing actual terror.⁸

From an attachment theory perspective, the inability to securely bond leads to anxious, ambivalent, and avoidant attachments.⁹ The effects are anxiety and distrust of oneself and others. Children with these problems have depressed moods and feel helpless and hopeless; they adapt but feel unloved, worthless, rejected, and abandoned. They perceive the world as unsafe. Their anger is often self-directed. They are often regressed and fixated with motives of pain avoidance and self-protection.

Treatment planning

An effective medical treatment plan focusing on the disruptive behavioral disorder component-in many cases, BD-has a more favorable outcome than one in which a child is mistakenly treated for ADHD. Table 2 provides suggested treatment guidelines.

Pediatric BD is characterized by the presentation of significant mixed symptoms. The majority of the characteristics described earlier would be consistent with hypomanic or manic manifestations in children. However, dysphoria is also a prominent symptom of pediatric BD. A relatively small percentage of children with BD exhibit significant depressive symptoms; most, however, exhibit negativity, pessimism, and anhedonia. Misdiagnosing major depressive disorder or dysthymia and treating with antidepressants carries the risk of intensifying bipolar symptoms.

Conduct disorder, oppositional defiant disorder, and PTSD are also historically diagnosed in children with attachment disorders. It is important from both a diagnostic and treatment perspective to place the PTSD symptoms as secondary to the primary one of BD. Treatment providers who place PTSD as the primary diagnosis, thereby prescribing antidepressant medications, again run a significant risk of intensifying an underlying bipolar condition.

It is my experience that in some children with comorbid attachment disorder and BD, the actual abuse or neglect they experienced was relatively mild, even nonexistent-certainly not enough to promote severe brain maturational problems or explain the severity of their symptoms. Their birth parents' severe alcohol or substance abuse, and/or bizarre or antisocial behavior, was enough to warrant removal from the home. Some of the children had no direct or indirect trauma. Some have been very minor witnesses to violence rather than being actual victims of violence themselves.

We are still in a toddlerhood ourselves in understanding the enormous complexities inherent within these children. A theory of genetic vulnerability to mental illness is not in opposition to trauma theory, but expands on it and offers different and, at times, more valid explanations for these children's problems.⁵ One hopes that future studies will elucidate the multiple causes, including both the effects of trauma on an immature CNS and genetic vulnerability and predisposition to severe mental illness.

References:

1. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder of Infancy and Early Childhood. American Academy of Child and Adolescent Psychiatry; 2005. Available at: http://www.aacap.org/galleries/PracticeParameters/rad.pdf. Accessed August 8, 2007.
2. Bowlby J. Attachment and Loss, Volume I. New York: Basic Books; 1982.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:130.
4. Boris NW, Zeanah CH. Reactive attachment disorder. In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry. 8th ed. Philadelphia: Williams & Wilkins; 2005.
5. Alston JF. Correlation between childhood bipolar disorder and reactive attachment disorder, disinhibited type. In: Levy T, ed. Handbook of Attachment Interventions. San Diego, Calif: Academic Press; 2000:193.
6. Zilberstein K. Clarifying core characteristics of attachment disorders: a review of current research and theory. Am J Orthopsychiatry. 2006;76:55-64.
7. Darwin C. The Origin of Species. Rev ed. Hertfordshire, UK: Wordsworth Editions Ltd; 1998.
8. Perry BD, Pollard R, Blakely T, et al. Childhood trauma, the neurobiology of adaptation and "use-dependent" development of the brain: how "states" become "traits." Infant Mental Health J. 1995;16:271-291.
9. Ainsworth MDS, Blehar MS, Waters E, Wall S. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum; 1978.
10. Scheer M. Identification and reporting of child abuse and maltreatment: New York State Syllabus; 2001. Available at: http://socialwork.adelphi.edu/childabusemodule/coursematerial/03characteristics.php. Accessed August 24, 2007.
11. Alston JF. New findings in diagnosis: correlation between bipolar disorder and reactive attachment disorder. Attachments J. 1996:49-52.