The Complex Issue of Attachment Disorders

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."

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.

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.