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.