[Bipolar disorders and multiple etiologies : a link with attachment disorders ?] / Troubles bipolaires et étiologies multiples : un lien avec les troubles de l'attachement ?

Bipolar disorders (BD) bring together different forms of mood disorders, characterized by the occurrence of depressive, manic, hypomanic and/or mixed episodes. They are recognized as the seventh cause of disability per year of life among 15 to 44 year old people by the World Health Organization (WHO). It is therefore a frequently encountered pathology. On the etiological level, the avenues currently accepted concerning BD are multiple, yet they still remain at the hypothesis stage. Each of these avenues therefore has therapeutic potential. It therefore seems interesting to address the different major hypotheses existing to date on the etiological level. We will first describe BD from historical, nosological and epidemiological points of view. We will then develop the genetic etiological aspects and the neural aspects through brain imaging research. Finally, we will propose a reflection on the specific relational etiology and the avenues of research that result from it.

Les troubles bipolaires (TB) regroupent différentes formes de troubles de l'humeur, caractérisés par la survenue d'épisodes dépressifs, maniaques, hypomanes et/ou mixtes. Ils sont reconnus comme la septième cause de handicap par année de vie parmi les personnes âgées de 15 à 44 ans par l'Organisation Mondiale de la Santé (OMS). Il s'agit donc d'une pathologie fréquemment rencontrée. Sur le plan étiologique, les pistes actuellement retenues concernant les TB sont multiples et restent encore au stade d'hypothèses. Chacune de ces pistes contribue à élargir le champ des ressources thérapeutiques possibles. Il nous semble, dès lors, intéressant d'aborder e les différentes hypothèses majeures existant à ce jour sur le plan étiologique. Nous resituerons préalablement les TB sur les plans historiques, nosologiques puis épidémiologiques. Nous développerons ensuite les aspects étiologiques génétiques et les aspects neurobiologiques à travers les recherches en imagerie cérébrale. Enfin, nous proposerons une réflexion sur l'étiologie spécifiquement relationnelle et les pistes de recherche qui en découlent.

Recent contributions for understanding Inhibited Reactive Attachment Disorder.

This special issue brings together studies representing the current state of the art research on inhibited reactive attachment disorder (RAD) from developmental psychology and developmental attachment research. This editorial introduces and discusses conceptual topics of the development and  the assessment of inhibited RAD. Next, five empirical studies of this special issue cover timely topics from developmental trajectories and longitudinal stability of RAD to associations with caregiving experiences in institutions, IQ, and psychopathology, moreover aspects of internal working models of children with inhibited RAD are examined. The commentary meta-analytically integrates the empirical evidence of all five studies and offers theoretically derived suggestions for further research. In this editorial, we discuss unsettled issues and future directions for attachment oriented research in this field.

Attachment Disorder behavior in early and middle childhood: associations with children's self-concept and observed signs of negative internal working models.

Most research on attachment in childhood is based on observation. In contrast, research on reactive attachment disorder (RAD) is mainly based on caregiver reports. Moreover, little is known about self-concept or internal working models (IWMs) of self and others in children with RAD. The present study examined whether caregiver reports and the frequency of observed signs of RAD reveal differences between children at risk for developing RAD symptoms and healthy controls in middle childhood. In addition, children's self-concept, observable signs of negative IWMs, and mental health were assessed. Results revealed that the RAD risk group showed increased reported and observed signs of RAD, a more negative self-concept, and more signs of negative IWMs compared to healthy controls. Signs of RAD in middle childhood were expressed trans-relational to both caregivers and strangers. Moreover, RAD symptoms were associated with negative self-concept, observed signs of negative IWMs, and poor mental health.

Interventions for children with reactive attachment disorder.

Characterized by aggressive or violent behaviors, reactive attachment disorder (RAD) affects children who have been repeatedly exposed to traumatic experiences. This article discusses the underlying causes of RAD and provides insight on therapies and interventions.

Recognition of attachment difficulties and developmental trauma is the responsibility of all paediatricians.

This article provides an overview of attachment theory, developmental trauma and trauma-informed care for paediatricians. The impact of difficult or impoverished parent-child relationships on brain development and long-term health is now well known. Recent neuroscience research reveals the adverse neurological impacts of developmental trauma and supports the biological basis of attachment theory. There is also an increasing body of evidence that childhood adversity is common and impacts physical and mental health throughout the life-span. Comprehensive paediatric assessment should include an understanding of attachment difficulties and developmental trauma. Viewing children and their families through a 'trauma-informed lens' can provide critical insights into their clinical presentation and care needs. All paediatricians should be providing and practicing trauma-informed care.

Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care.

Two disorders of attachment have been consistently identified in some young children following severe deprivation in early life: reactive attachment disorder and disinhibited social engagement disorder. However, less is known about whether signs of these disorders persist into adolescence. We examined signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years in 111 children who were abandoned at or shortly after birth and subsequently randomized to care as usual or to high-quality foster care, as well as in 50 comparison children who were never institutionalized. Consistent with expectations, those who experienced institutional care in early life had more signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years than children never institutionalized. In addition, using a conservative intent-to-treat approach, those children randomized to foster care had significantly fewer signs of reactive attachment disorder and disinhibited social engagement disorder than those randomized to care as usual. Analyses within the ever institutionalized group revealed no effects of the age of placement into foster care, but number of caregiving disruptions experienced and the percentage of the child's life spent in institutional care were significant predictors of signs of attachment disorders assessed in early adolescence. These findings indicate that adverse caregiving environments in early life have enduring effects on signs of attachment disorders, and provide further evidence that high-quality caregiving interventions are associated with reductions in both reactive attachment disorder and disinhibited social engagement disorder.

Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment.

BACKGROUND: Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions. METHODS: We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms 'reactive attachment disorder,' 'attachment disorder,' 'indiscriminate behavior,' 'indiscriminate friendliness,' 'indiscriminate socially disinhibited reactive attachment disorder,' 'disinhibited social engagement disorder,' and 'disinhibited social behavior.' We also contacted investigators who have published on these topics. FINDINGS: A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries. CONCLUSIONS: Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.

Tourette syndrome is associated with insecure attachment and higher aggression.

This study explored the degree to which adult patients with Tourette syndrome (TS) exhibit particular attachment styles and the possible association between the underlying attachment dimensions and forms of aggression. Fifty-three TS patients (ages 17-72 years) and 54 matched healthy controls completed the Experiences in Close Relationships-Revised Scale (ECR-R) and the Aggression Questionnaire (AQ). The data were analysed with ANOVA F-tests, t-tests, and Pearson's correlation coefficient. TS patients showed significantly higher scores in relationship anxiety ( p < 0.001) and relationship avoidance ( p = 0.001) in the ECR-R and significantly higher aggression scores in the AQ ( p < 0.001). The total AQ score correlated significantly with the ECR-R dimension anxiety ( p < 0.001). These are the first findings on TS patients' attachment styles and anger symptoms. It remains unclear whether attachment anxiety and avoidance are risk factors for TS or whether the disorder itself induces attachment disorders. Prospective studies with detailed attachment interviews would help to explore this issue.

[Adverse Sensory Input of Childhood Maltreatment Modified by Early Experience Ascertaining the Neural Basis of Neurodevelopmental and Attachment Disorders].

Childhood maltreatment, which markedly increases the risk of psychopathology such as depression, PTSD, and reduced cognitive abilities, is associated with structural and functional brain differences. Our earlier studies elucidated potential discernible effects on the brain morphology of childhood maltreatment on the gray matter volume or cortical thickness. Further, our preliminary studies revealed a significantly reduced gray matter volume (GMV) in the left primary visual cortex (Brodmann area 17) in the reactive attachment disorder (RAD) group compared to the typically developed group. These visual cortex GMV abnormalities may also be associated with such visual stimulus-induced emotion regulation impairments of RAD, leading to an increase in the risk of future psychopathology. Brain regions that process and convey the adverse sensory input of the abuse might be modified specifically by such experiences, particularly in subjects exposed to a single type of maltreatment. Thus, exposure to multiple types of maltreatment is more commonly associated with morphological alterations in corticolimbic regions.

The significance of attachment security for children's social competence with peers: a meta-analytic study.

This meta-analytic review examines the association between attachment during the early life course and social competence with peers during childhood, and compares the strength of this association with those for externalizing and internalizing symptomatology. Based on 80 independent samples (N = 4441), the association between security and peer competence was significant (d = 0.39, CI 0.32; 0.47) and not moderated by the age at which peer competence was assessed. Avoidance (d = 0.17, CI 0.05; 0.30), resistance (d = 0.29, CI 0.09; 0.48), and disorganization (d = 0.25, CI 0.10; 0.40) were significantly associated with lower peer competence. Attachment security was significantly more strongly associated with peer competence than internalizing (but not externalizing) symptomatology. Discussion focuses on the significance of early attachment for the development of peer competence versus externalizing and internalizing psychopathology.

Psychometric properties of the mother and father compulsive caregiving scales: a brief measure of current young adult caregiving behaviors toward parents.

This study assessed the psychometric properties of the Mother and Father Compulsive Caregiving Scales (MFCC). Exploratory (N = 1283, 71.5% Caucasian) and confirmatory (N = 2203, 76.6% Caucasian) factor analyses revealed two-factor structures for each parent: burden and autonomy. Correlational analyses with retrospective self-reports of parent-child relationship quality, family risk indicators, and psychological symptoms demonstrated similar convergent validity for both mother and father burden factors while, interestingly, the findings for mother and father autonomous factors showed different patterns. Results support that the MFCC is a short and convenient measure that would be clinically useful for the assessment of controlling/caregiving behaviors in young adulthood.

The experience-dependent maturation of prefronto-limbic circuits and the origin of developmental psychopathology: implications for the pathogenesis and therapy of behavioural disorders.

The maturation of prefronto-limbic neuronal pathways that mediate essential affective and social regulatory functions is experience dependent. Immediately after birth the infant's affective experiences, especially those embedded in the relationship with the primary caregiver, trigger the reorganization and adaptive fine-tuning of synaptic circuits. Research in humans and in animal models supports the hypothesis that socio-emotional deprivation and emotional trauma during early childhood may leave 'scars' in prefronto-limbic function, brain regions that are essential for emotional behaviour, learning, and memory. The focus of this review is to point out that mechanisms involved in structuring and optimizing neural circuits during brain development might also be used in moulding personality and behaviour during psychotherapy in the adult brain.

Interaction of recalled parental ADHD symptoms and rearing behavior with current attachment and emotional dysfunction in adult offspring with ADHD.

Research into attachment and emotion regulation has shown that children with ADHD are at risk of developing attachment disorders and emotion regulation disturbances, which in part may be due to the rearing style of their parents. No such data exists for adults with persistent ADHD. We hypothesized that current attachment style and emotion processing of adult patients with ADHD may be influenced by the presence of parental ADHD symptoms when the now adult patients were children, assuming that ADHD symptoms of parents have an impact on their parenting style. We examined recalled parental ADHD symptoms and rearing style as well as current attachment and emotion regulation abilities in a sample of 73 adults with ADHD using several self-rating instruments. Recalled prevalence of ADHD symptoms in the mother, and less so in the father, of adult patients with ADHD was significantly associated with partly adverse parental rearing styles, current attachment problems in romantic partnerships and emotion regulation disturbances compared with adult ADHD patients without possibly affected parent. ADHD symptoms in parents of children with ADHD may present a risk factor for attachment problems and poor emotion regulation when ADHD children are grown.

Reactive attachment disorder as an evolutionary adaptation.

This paper suggests that the behaviours associated with the formal diagnosis of the "disinhibited" form of reactive attachment disorder (RAD) might be seen as a functional adaptation rather than a mental health problem, a facultative response enhancing the probability of survival that is triggered by certain conditions. Although disinhibited RAD is most commonly observed in institutionalised children, similar behaviours may also be a part of the emotional difficulties displayed by some fostered and adopted children (the latter includes those once institutionalised), and these may demonstrate not so much a discrete attachment disorder as either the need to fend for oneself following loss of dedicated caregiving or a lack of opportunity to build specific intimate relationships with dedicated caregivers. In many cases this may be inextricably mixed with the neurobiological and psychological seqelae of maltreatment. Indiscriminate attachment behaviour, from this proposed evolutionary perspective, is less a syndrome of mental ill-health than an astute survival manoeuvre following being orphaned, abandoned or fecklessly reared. Such a response, allied to the innate facility to access caregiving from different adults, could be expected to be initiated by specific events as are the other attachment configurations. Classing disinhibited RAD as an adaptation has implications for helping children brought up under extreme duress when their caregiving environment has changed for the better.

Links Between Reactive Attachment Disorder, Caregiving and Temperament: A Differential Susceptibility Perspective.

The links between Reactive Attachment Disorder (RAD) and temperament received relatively little research attention, in spite of their clinical and social relevance. Children with RAD sustain disproportionate burdens of early adversity related to their caregiving environment. However, there seem to be important individual differences in susceptibility to adversity, since only a small number of children show signs of RAD. Based on the work of Zeanah and Fox, this review aims to bring new insights to this relevant clinical issue in light of recent research. A differential susceptibility hypothesis will be considered as a promising and innovative approach toward a further understanding of the links between temperament and RAD.

A Systematic Review of Reviews of the Outcome of Severe Neglect in Underresourced Childcare Institutions.

The aim of the systematic review described in this article was to determine the outcomes for individuals exposed to severe neglect in congregate care institutions such as orphanages. In this context, severe neglect refers to failure to meet children's basic physical, developmental, and emotional needs due to inadequate resources. In this systematic review of previous systematic reviews and meta-analyses, searches of 10 databases were conducted, 18 papers that met inclusion and exclusion criteria were selected for review, their quality was assessed, and data were extracted and synthesized. The 550 primary studies included in the 18 systematic reviews and meta-analyses were relatively well designed, allowing confidence to be placed in their results. Severe neglect was associated with a wide range of problems in the domains of physical development, cognitive development, attachment, and mental health. The severity of adverse outcomes was partly influenced by the duration and severity of deprivation and a constellation of risk and protective factors. Prevention policies should aim to eliminate large underresourced congregate care institutions for infants. In taking steps toward this, policies should aim to adequately resource congregate care institutions to meet children's developmental needs for nutrition, stimulation, and attachment to a stable primary caregiver with adequate parenting skills and training. Early placement in adoptive or foster families, with access to routine physical and mental health-care service available in developed countries, is the most viable effective intervention for child survivors of severe neglect.

Obscure Dichotomy of Early Childhood Trauma in PTSD Versus Attachment Disorders.

There are two competing schools of thoughts involving children who have experienced early childhood trauma. One posture's nosology focuses on the post-traumatic stress responses; the other focuses on the deviant behaviors that ensue from pathogenic care in early childhood. This author sought to review the literature from a holistic perspective, embracing both diagnostic positions. Seventy-three articles addressing childhood trauma and the ensuing emotional or behavioral disturbances were evaluated, mostly empirical-including 16 that specified posttraumatic stress disorder (PTSD), 21 that specified attachment disorders, and 37 that included potential overlaps between both trauma derivatives. An additional 138 studies were reviewed but not included herein because those focused on broader issues. Statistical data, financial and emotional impacts, and the effects of disrupted attachments were addressed-including both children with secure attachments and those with compromised attachments. The critical effect of both positive and negative parental responses was evaluated, as well as correlations or overlaps in the diagnostic criteria and symptom manifestations of the children and any apparent gaps in the current research. The literature details that the prognosis and course of treatment vary significantly between the two etiologies-apparently at least in part due to possible clinician bias in conceptualizations of the two populations. There are clear overlaps in the diagnostic criteria that strongly suggest comorbidity between the disorders, however, which is especially critical to analyze in the future, since there are solid, empirical, evidence-based treatment protocols for PTSD, but not for attachment disorders resulting from pathogenic caregiver maltreatment.

Differences in attachment dimensions and reflective functioning between traumatized juvenile offenders and maltreated non-delinquent adolescents from care services.

BACKGROUND: Adverse childhood experiences, especially maltreatment, are regarded as significant risk factors for the development of antisocial behavior in adolescence. However, possible correlates are still to be investigated after considering the history of criminal records and the experience of institutionalization. OBJECTIVE: In this study, differences in attachment anxiety and avoidance, and reflective functioning (RF) between traumatized incarcerated juvenile offenders and non-delinquent adolescents institutionalized in child services because of domestic violence were examined. PARTICIPANTS, SETTING AND METHOD: Forty-two juvenile offenders (Nfemale = 19) and 43 inmates of institutions for adolescents without parental care (Nfemale = 20) with the history of trauma filled in the childhood trauma and attachment dimensions questionnaires, and were scored on the Reflective Functioning Scale. Groups were matched on age and education. RESULTS: Results indicate that both groups reported equally high levels of attachment anxiety and avoidance. Male juvenile offenders had lower scores on reflective functioning than both female convicted minors (B = 1.06; Odds Ratio = 2.88; Nagelkerkes R2 = 45) and non-delinquent adolescents of both genders (B = -.65; Odds Ratio = .52; Nagelkerkes R2 = 42). In comparison to non-convicted males, male offenders also had higher scores on the control scale of idealization (B = .35; Odds Ratio = 1.42; Nagelkerkes R2 = 42). No differences between females with and without a history of crimes were found. CONCLUSIONS: Results indicate a need for building RF in both traumatized samples, especially in male delinquents, and encourage further research in females.

Disinhibited social behavior among internationally adopted children.

Postinstitutionalized children frequently demonstrate persistent socioemotional difficulties. For example, some postinstitutionalized children display an unusual lack of social reserve with unfamiliar adults. This behavior, which has been referred to as indiscriminate friendliness, disinhibited attachment behavior, and disinhibited social behavior, was examined by comparing children internationally adopted from institutional care to children internationally adopted from foster care and children raised by their biological families. Etiological factors and behavioral correlates were also investigated. Both groups of adopted children displayed more disinhibited social behavior than the nonadopted children. Of the etiological factors examined, only the length of time in institutional care was related to disinhibited social behavior. Disinhibited social behavior was not significantly correlated with general cognitive ability, attachment-related behaviors, or basic emotion abilities. However, this behavior was negatively associated with inhibitory control abilities even after controlling for the length of time in institutional care. These results suggest that disinhibited social behavior might reflect underlying deficits in inhibitory control.

Understanding and promoting attachment.

Interest in early relationships has led to increased use of terms such as attachment disorder, attachment problems, and attachment therapy when describing behavioral/emotional regulation in young children. Unfortunately, such terms are vague and lead to clinical confusion and diagnostic inaccuracies. This article will introduce attachment theory, with a discussion of reactive attachment disorder and implications for treatment of children who have problems with social-emotional development.