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ADHD and Attachment
Victoria Thompson
April 6th, 2009
Overview
Attachment
Literature
2 Empirical Studies
Developmental Model
Reactive Attachment Disorder
Attachment
Close emotional bond between two people
that is enduring across space and time
Proximity-seeking behavior by a
dependent organism when he or she feels
discomfort
Internal Working Models
– Mental representations of the self, attachment
figures, and relationships in general.
– Include expectations regarding behaviors and
emotions
Source: Ladnier & Massanari, 2000
Secure
Attachment Styles
– Caregiver as a secure base
Insecure
– 3 Types
Ambivalent
– Child contacts caregiver for support while
simultaneously rejecting her attempts to soothe him
Avoidant
– Child rejects or avoids caregiver
Disorganized/Disoriented
– Child lacks a consistent strategy for organizing his
comfort seeking behaviors
Source: Ladnier & Massanari, 2000
Converging Body of Literature
Executive Functioning (EF)
– Early healthy attachment experiences necessary for
the development of EF
– Insecurely attached children show EF deficits
– Children with ADHD typically show EF deficits
Hypothalamic-Pituitary-Adrenal (HPA) Axis
– Insecure attachments associated with atypical
reactivity of this system to stressors
– Secure attachment associated with typical reactivity
– Some children with ADHD show atypical reactivity
Source: Crittendon & Kulbotten, 2007
Literature cont.
Orbitofrontal Cortex
– Crucial to emotional regulation, decisionmaking and processing of rewards
– Anxious attachment inhibits development of the
orbitofrontal cortex
– Anxious attachment may result in chronic
Emotion lability
Impulsivity
Unpredictable and intense behavior
– Orbitofrontal cortex has been found to be
functionally disturbed in people with ADHD
Source: Crittendon & Kulbotten, 2007
Literature cont.
Dopamine Receptor D4 (DRD4) Gene
– Link between infant attachment and DRD4 gene
– Same gene found to be linked to ADHD
– Disorganized attached children carry 7 repeat allele of
the DRD4 gene
– Securely attached children do not carry this allele
– Not carrying this allele may act as a resilience factor in
the optimal development of attachment
– Children with ADHD who have 7 repeat allele tend to be
more impulsive then children with ADHD who do not
have this allele
– Early attachment might mediate or moderate the DRD4related genetic risk for ADHD
Source: Crittenden & Kulbotten, 2007
Literature cont.
Children that are insecurely attached and children with
ADHD show EF deficits
Insecure attachment and ADHD is associated with atypical
reactivity of the HPA axis to stressors
Children that have an anxious attachment style and
children with ADHD show abnormalities of the orbitofrontal
cortex
Both insecure attachment and ADHD have been linked to
the DRD4 gene
These findings suggest a possible interaction between
genetic vulnerability and early attachment experience,
which is expressed in the form of symptoms that define
ADHD
Source: Crittenden & Kulbotten, 2007
Self-Regulation
Attachment theory: the early parent-child
relationship serves as the foundation for
the emergence of self-regulation skills
Research has consistently shown that
insecurely attached children are more
vulnerable to deficits in self-regulation then
securely attached children
Insecure attachment is associated with
deficits in self-regulation, as is ADHD
Source: Clark, Ungerer, Chahoud, Johnson, & Stiefel, 2002
Social Functioning
Insecurely attached children have trouble
developing and maintaining healthy
relationships
Children with ADHD show difficulties in
social functioning as well
Source: Clarke et al., 2002
Secure Infant Attachment
Histories
Increased attention span
High levels of positive affect
High levels of persistence in problem-solving
situations
Flexibility
Impulse control
Task orientation
Delay of gratification
Children with ADHD experience difficulties in
the above areas
Source: Clarke et al., 2002
Family Functioning
Insecure attachment relationships are
associated with parental involvement
characterized by:
– Minimal involvement
– Negativity
– Lack of responsivity to infant signals
– Intrusiveness
In lab settings, mothers of children with
ADHD show similar behavior (Danforth, Barkley, &
Stokes, 1991 for review).
Source: Clarke et al., 2002
Family Function cont.
Families of children with ADHD experience
difficulties in a number of areas that are
considered risk factors for insecure
attachment:
– Poor psychological functioning
– Increased levels of depression and other
psychiatric diagnoses in parents
– High rates of marital distress and separation
– Social isolation
Source: Clark et al., 2002
Early Parent-Child Relations
and ADHD
Maternal intrusiveness assessed when
infants were 6 months old more powerfully
predicted distractibility in early childhood
and hyperactivity in middle childhood, than
did biological or temperament factors
(Carlson, Jacobvitz, & Sroufe, 1995)
Clinical case reviews suggest that children
with ADHD have early parent-child
relationships that are similar to those with
insecure attachments
Early Parent-Child Relations
and ADHD cont.
Haddad and Garralda (1992) described
severely disrupted early attachment
relationships in children presenting to clinics
with ADHD, which were not accompanied by
biological indicators
Stiefel (1997) linked the emergence of
symptoms in a clinical cohort of ADHD to a
lack of sustained parental attention during
the first years of the child’s life
Converging Body of Literature
Suggests:
– Attachment not peripheral to an
understanding of ADHD
– Appears to be an association between
attachment and ADHD
– Attachment theory offers a new perspective
on ADHD, which might help us to better treat
those with the disorder
Source: Clarke et al., 2002
Clarke, Ungerer, Chahoud,
Johnson, & Stiefel, 2002
Participants
– 19 boys, 5 – 10 yrs old with ADHD
– 19 boys, 5 – 10 yrs old without ADHD
Compared on 3 representational
measures
– 2 Internal Working Models
– 1 Self
Clarke et al., 2002
Separation Anxiety Test
– Pictures of parent-child separation experiences
– Questions about character’s feelings and actions
How does the boy feel?
What is the boy going to do?
How does it all end?
– Scoring
Vulnerability and need in severe separations
Self-confidence about handling mild separations
Degree of avoidance in discussing the separation
Containment of negative emotions
Child’s general emotional experience of the parent-child
relationship
Clarke et al., 2002
Family Drawings
– Draw a picture of family, identify all persons in the
drawing and state relationship to each person
– Scored based on the presence or absence of 24
specific drawing signs
– To assess the context and patterning of the drawing
signs, 8 global rating scales were used:
Family Pride/Happiness
Vulnerability
Emotional Distance/Isolation
Tension/Anger
Role Reversal
Bizarreness/Dissociation
Global Pathology
Self-Interview
20 Questions assessing self-concept
– Can you tell me something you like about
yourself?
– Can you tell me 5 words that describe you?
Scoring
– Richness of Descriptions
– Openness/Flexibility
– Coherency
Results
Overall, ADHD group obtained poorer
scores on all three measures, indicating
predominantly insecure attachments
Separation Anxiety Test
– Less likely to express an appropriate level of
concern, fear, or feelings of sadness about
difficult separations
– Expressed extreme feelings and behaviors
– Less likely to express confidence and feelings
of well being in the context of easier
separations
Results cont.
– Coping strategies involving retribution, hostility,
or hatred
– Situations spiraled into disasters beyond their
and others’ control
– Predominantly negative descriptions of the
parent-child relationship
Family Drawings
– Differed markedly from control group
– Suggested lower levels of family pride and
higher levels of vulnerability, tension, anger, role
reversal in the mother-child relationship,
bizarreness, dissociation, and overall pathology
Results cont.
– Relationship anxiety tended to predominate
– Themes of anger, confusion, and low selfesteem
– These themes were expressed in a variety of
ways:
Distorted and/or frightening figures
Unusual symbols
Little color or detail
Overall reckless quality
Results cont.
Self-Interview
– In the ADHD group, their self-descriptions were
less richly developed and coherent relative to
controls, conveying a less developed sense of
self
– Less open and flexible in their self-concept
– Often presented a negative self-concept
– Often appeared emotionally disconnected
Overall
Results suggest that the nature of attachment
insecurity in this ADHD group is one of heightened
emotional expression characterized by strong, out
of control affects
Didn’t display the open, flexible emotional
expression that is considered to reflect a secure
internal working model
Responses suggest insecure attachment style
In this context, the impulsivity, negative attentionseeking, recklessness, hyperactivity, and frequent
oppositionality seen in ADHD children can be
viewed as a strategy to gain attention from a less
than optimally available caregiver
Discussion
Findings contrary to the results of Chahoud (2000),
in which the same exact participants were used as
in Clarke et al. (2002)
Chahoud rated segments of child-directed play,
mother-directed play, a teaching task, and clean-up
activity on variables such as gratification,
involvement, and sensitivity
Results showed no differences between the ADHD
group and controls
16 of the 19 children in the ADHD group were being
treated with stimulant medications and 15 had
received some level of psychological intervention
Discussion
Claim that the effects of these medical and
behavioral interventions may have been to mask
underlying relational problems, at least in terms of
their manifestation in a lab-based interaction
Traditional treatment approaches may temporarily
or even permanently improve the behavioral
manifestations of ADHD, but they do not attempt to
impact on the child’s internal working model or the
parents’ view of the child
So, parent-child relationship problems will still be
evident
Discussion
Discrepancy between their findings and those of of
Chahoud (2000) challenge the claim that research
showing reversal of problematic parent-child
interactional patterns following treatment with
stimulant medications indicates that the difficult
interactions seen in unmedicated kids are mainly
due to child factors
Implications for Treatment
If we can identify secure and insecure children
with ADHD, we can tailor their treatment more
to their needs
– If there is a secure relationship, parent training may
be appropriate, as parents may be able to focus on
the current interaction and apply behavior
management skills objectively and consistently
– However, if the relationship is insecure, relationship
issues may need to be addressed first before
parents can be expected to focus on applying
behavior management skills and making enduring
changes
Limitations
ADHD group all referrals
No inclusion of non-ADHD psychiatric control
group and/or a non-clinic sample with ADHD
Small sample size prevented examination of
the impact of comorbidity on attachment
insecurity in children with ADHD or a
comparison of findings for the different
subtypes
All boys
Inclusion of children of hospital employees in
control group
Unanswered Questions
Not clear whether quality of caregiving
contributes directly to the development of
ADHD-related problems or if the child’s
behaviors lead to disturbances in interactions
Role of child characteristics should not be
overlooked
Likely a transactional model in which
attachment processes are conceptualized as a
function of complex and ongoing interactions
among parent, child, and
environmental/experiential factors
Unanswered Questions cont.
Longitudinal research is needed to disentangle
the effects of these different factors on the
development of attachment security and ADHD
Provide info regarding risk and protective factors
and suggest strategies for early interventions
Pinto, Turton, Hughes, White, &
Gillberg, 2006
Is there an association between
disorganized/disoriented attachment and
later ADHD?
Participants
– Cohort of 104 children
1 yrs old: Attachment style assessed by
using the Strange Situation
6 – 8 yrs old: ADHD assessed
Pinto et al., 2006
Assessment of ADHD
– ADHD Rating Scale-IV
Mothers and teachers independently
– Observer-rated assessment of ADHD
(developed by Pinto et al.)
30 min doll-play story completion task
Child was required to listen to the story and
then complete a series of story stems
presented
Pinto et al., 2006
3 broad areas, each with different measures:
– Hyperactivity: fidgeting, getting up from chair and
talkativeness
– Inattention: lack of persistent active listening,
distractibility, and needing prompting to continue with
the story
– Impulsivity: child interrupting the assessor to take over
the narrative before story stem completion and
interrupting with something unrelated before the
question is finished
Measures were rated on a 4-point Likert-type
scale (0=never, 1=occasionally, 2= some of the
time, and 3=constantly)
Pinto et al., 2006
– Put the mother-rated, teacher-rated, and observerrated assessments together to arrive at a
categorical diagnoses for ADHD
– Probable case: child was given a score of 20 or
more on the parent-rated and teacher-rated
assessment plus a score of 2 or more for the
observed ratings
– Possible case: the above criteria were not met but
the child was given a score of 18 or more on either
the parent- or teacher-rated assessment and a
score of 10 or more on the same scale rated by
the other (parent or teacher), plus a score of 2 or
more for the observed rating
Results
26% of infants were classified as
disorganized
7.8% of children met ‘probable’ ADHD
case criteria
10.7% of children met ‘possible’ ADHD
case criteria
23.1% of mothers vs. 24.3% of teachers
rated the child above cut-off score of 20
Mother and teacher-rated ADHD scores
were highly correlated
Results cont.
No association between infant disorganized
attachment and later childhood ADHD caseness
Rate of probable ADHD caseness in the children
was similar to that of the general population rate
for ADHD
Mean disorganized scores were 4.06 (SD=1.43)
in the probable case group, 3.68 (SD=1.87) in
the possible case group, and 3.58 (SD. 1.72) in
the noncase group
Significant correlation between disorganized
scores and teacher rated ADHD symptoms
(more strongly associated with inattention than
hyperactivity)
Discussion
What are the attributes of disorganized infants
that teachers (but not mothers) observe several
years later as ADHD symptoms?
Likely that both mothers and teachers would find
hyperactivity hard to manage but that mothers
may be less sensitive to inattention and perhaps
are not troubled or become habituated to this
aspect of ADHD
Lent credence by the trend in their results for
disorganized attachment to be more strongly
associated with teacher-rated inattention than
with hyperactivity
Limitations
Small sample size
Half of the cohort had experienced a major
trauma (stillbirth), whereas the other half
had not
In depth clinical psychiatric examination
specifically for ADHD and comorbid
conditions was not included
Therefore, the conclusions can only be
tentative
Clinical Implications
Attachment issues should be addressed in
children presenting with disruptive
behavior disorder, at least in those
presenting with symptoms of ADHD that
do not amount to full-blown clinical ADHD
caseness
Ladnier’s & Massanari’s (2000)
Model
Based on theory and clinical experience
Noticed that many of their ADHD patients shared
deficits in
– ability to regulate emotions and behavior
– ability to form healthy relationships with others
Consistent with the classic symptoms of an
attachment-disordered child
Ladnier & Massanari, 2000
Also noted that research has shown that a
failure to form a secure attachment early in
life, can result in cognitive, emotional, and
behavioral changes
– Hyperactivity
– Impulsivity
– Impaired social functioning
Ladnier & Massanari, 2000
Sought to answer two questions:
– 1. Is there a causal connection between
attachment failure and ADHD?
– 2. Would it be possible to create a
developmental model, based on attachment
theory, that would provide a valid and credible
explanation for the origin of ADHD and
suggest a treatment plan that could offer a
child more than temporary relief from
symptoms?
Ladnier & Massanari, 2000
Underlying belief that attachment trauma in early
childhood results in developmental deficits which, in
the absence of remedial parenting, are likely to be
manifested as the symptoms of ADHD
The model can be most simply stated as the
following:
– Bonding breaks —> Attachment deficits —>
Symptoms of ADHD
Bonding break is an event or combination of events
that causes physiological trauma and developmental
arrest and interferes with a child’s opportunity to
form a secure attachment with a caregiver
Ladnier & Massanari, 2000
Begins with 3 major assumptions:
– 1. A child diagnosed with ADHD has
experienced a bonding break(s) before the
age of 2
– 2. The bonding break(s) have interfered with
the process of healthy attachment between
child and caregiver and created
developmental deficits in the child
– 3. The family system the child grew up in was
not healthy enough to overcome those deficits
Ladnier & Massanari, 2000
Basic idea:
– The failure to attach to an adult caregiver as a
result of a bonding break(s) results in
psychological and physiological trauma
– This trauma interferes with an infant’s
neurological and hormonal maturation
– This interference results in developmental
delays (attachment deficits)
– These delays are reflected in emotional and
behavioral problems that are manifested in
the symptoms of ADHD
Bonding Breaks
4 Types:
– Prenatal Influences
– Inattentive Caregivers
– Situational Traumas
– Faulty Parenting
Most experience a combination of bonding
breaks, sequentially or simultaneously
Prenatal Influences
In typical development, a healthy newborn arrives
in the world programmed to attach to a suitable
caregiver
However, some newborns arrive in a state of
distress and extreme hyperarousal. For example,
premature babies; babies that were exposed
prenatally to chronic and acute levels of stress
hormones or chemical compounds or toxins
These newborns are not programmed to seek out a
caregiver because their state of emotional alarm
prevents them from responding to attaching cues in
their caregiver
Inattentive Caregivers
Occurs when a healthy infant is born to caregivers
who fail to provide the minimum amount of warmth
needed for attachment to occur
Do not provide behaviors such as eye contact,
soothing words and touch, breast-feeding, holding,
rocking and smiling
These behaviors are needed for attachment to occur
Inattentive caregivers neglect their infants because
they are self-centered and lack empathy for others or
because they lack sufficient info or motivation to
provide the nurturance their infant needs
Situational Traumas
Includes a variety of conditions and events
that occur outside the control of the
primary caregiver
For example, premature babies,
separation for caregiver due to death, or
illness on the part of the parent or child
Faulty Parenting
Prevalent in home situations where the child
experiences trauma that is very difficult, if not
impossible, for him or her to overcome
These situations are typically characterized
by the following:
– 1. Absence of a healthy relationship between two
caring adults
– 2. A pattern of exposure to yelling, criticism,
sarcasm, and violence
– 3. Parenting that lacks respect, discipline,
structure and consistency
Attachment Deficits
Bonding breaks result in attachment deficits:
characteristics that appear to be absent or
underdeveloped in a child, as evidenced by emotions
and behaviors that are developmentally inappropriate
These deficits might correspond to specific
regions of neural circuitry in a child’s brain that
have not developed normally because of early
bonding breaks
Attachment Deficits are divided into two groups:
– Deficits in Self Regulation
– Deficits in Relating Skills
Deficits in Self Regulation
Impulse Control
Self-soothing
Initiative
Perseverance
Patience
Inhibition
Deficits in Self-Relating Skills
Empathy
Trust
Affection
Reciprocity
Expression
Respect
Cycle of Conflict Between
Caregiver and Child
Cycle perpetuates and worsens the symptoms of
ADHD.
– Child experiences strong negative emotion (anger,
fear, sadness)
– Since the child lacks the capacity for self-soothing,
impulse-control and expression, he or she attempts to
connect with the parent through intrusive, demanding,
attention-seeking behaviors
– Parent begins to feel irritation and resentment and is
unable to express empathy, affection or respect for
the child
Cycle of Conflict Between
Caregiver and Child
– Parent responds by criticizing, threatening or
hitting child
– Child reacts by tuning the parent out and silently
planning revenge or becomes defiant and
coercive and raises the level of his acting-out
behaviors
– Parent feels angry and scared and either gives
up and withdraws or raises the level of conflict in
an effort to defeat the child.
– Both child and parent are left frustrated and
angry and determined to get even by winning the
next fight
Treatment
Treatment of choice should be family therapy
Children are not likely to make significant
changes in their thoughts and behaviors without
simultaneous changes in their family systems
Developed a model for family therapy based on
corrective attachment theory, family systems
theory, and cognitive and behavioral techniques
Parents Problems
– Medication-Seeking Parent
– Exhausted, Overwhelmed Parent
– Guilty Parent
Cotherapists
– Collect biopsychosocial info about the parents
– Child’s history
– Outline basic goals and objectives of
treatment
– Listen to Parents’ Concerns
Formulate a Detailed
Assessment of the Child’s
Problems
Behavior
Feeling
Thinking
– A child who does not form a secure
attachment with a primary caregiver does not
think the same thoughts as a healthy child
– Distorted thoughts and delusional belief are a
consequence of bonding breaks and
attachment deficits
Formulate a Detailed
Assessment of the Child’s
Problems
– For example, a child that doesn’t learn to trust
will develop core beliefs such as:
Adults are unreliable, unresponsive and
untrustworthy
Being close to others is not pleasant
I must control others in order to be safe
Formulate a Detailed
Assessment of the Child’s
Problems
– A child that doesn’t receive the modulating
responses he needs from a primary caregiver
fails to learn self-regulation and may hold
beliefs such as:
I am not able to control myself
When I want something, I should not have
to wait for
Formulate a Detailed
Assessment of the Child’s
Problems
– A child who lacks sufficient soothing
interaction with a caregiver does not learn
self-soothing and may be convinced that:
Feelings are dangerous and should be
avoided
Things that are not stimulating or
pleasurable are a waste of time
Eliminate hitting, yelling, criticism, and sarcasm
from family interactions
Create empathy, affection and respect
Communication
Create consist rules, roles, and routines
Establish limits and boundaries
Cooperation
Teach specific ways to use physical contact
to promote affection and trust between child
and caregiver
Teach parent how to express empathy
towards child
Teach playful interactions between child and
caregiver
Group Therapy
EEG Biofeedback
Art and Play Therapy
Organized Sports
Medication
–Last resort
–Will only bring about temporary change,
whereas other therapy, such as family
therapy, will bring about more permanent
change.
Access Collateral Therapies to
Increase Self-Regulation and
Relating Skills
Medications cont.
–Medications that maintain a state of
lethargy or euphoria can hinder other
types of therapy
–However, there are cases where they
must be used
–Medication can improve symptoms, but
cannot help in the reparation of the
attachment deficits caused by bonding
breaks between caregiver and child
Problems with Model
Based on strictly clinical population
No research
Doesn’t explain people with ADHD who came from
healthy functioning families
Doesn’t explain people who have experienced
bonding breaks and come from unhealthy
functioning families, but have not developed ADHD
Doesn’t explain why some people can take
medication only with no other form of intervention
and lead healthy and fulfilling lives
Applied to any group with psychological problems
Stiefel, 1997
Emphasizes the detrimental role of early stress on
the attachment relationship and that this could
possibly lead to ADHD
Points out that not every child who experiences
early stressors will develop ADHD
Claims that it is sequential patterns of interactional
stress between the parent and child that hinders
attachment and possibly leads to ADHD, rather
then multiple one point in time stressors
Stiefel, 1997 cont.
You can have multiple early life stressor, but if you
have some intervening variable, such as psychosocial
buffering and support, this can alleviate the stress and
allow a healthy attachment relationship to develop and
thus possible prevent the development of ADHD
If there are no intervening variables, and the stress
continues, this is going to hinder the attachment
relationship and possibly lead to ADHD
Therefore, if we can identify families who experience
high levels of stress and then intervene, we can
possible prevent ADHD from developing in some
children
Reactive Attachment Disorder
(RAD)
Attachment disorder characterized by
disturbed and developmentally
inappropriate social relatedness that
begins before 5 years of age
Develops from a failure to form a healthy
attachment with a primary caregiver as a
result of severe early experiences of
pathological care, such as extreme abuse
and/or neglect
It is uncommon
Source: American Psychiatric Association, 1994
Reactive Attachment Disorder cont.
Two types:
– Inhibited:
Failure to initiate and respond to most social
interactions in a developmentally appropriate way,
as manifest by excessively inhibited, hypervigilant,
or highly ambivalent and contradictory responses
– Disinhibited:
Indiscriminate sociability with marked inability to
exhibit appropriate selective attachment (e.g.,
excessive familiarity with relative strangers or a
lack of selectivity in choice of attachment figures)
Source: American Psychiatric Association, 1994
Reactive Attachment Disorder
DSM-IV points out that the Disinhibited type
must be distinguished from the impulsive or
hyperactive behavior seen in ADHD
The disinhibited behavior in RAD is
associated with attempting to form a social
attachment after a very brief acquaintance
RAD is typically comorbid with other
disorders, such as ODD and ADHD
Source: American Psychiatric Association, 1994
Reactive Attachment Disorder
RAD diagnostic study that also looked at
comorbidity
– Participants: 40 RAD children, 5 - 8 yrs old
– Assessed RAD symptoms with an18-item
– Assessed ADHD with ?
– Results
68% of the RAD cases met criteria for ADHD
No children met criteria for ADHD but not RAD
Source: Reactive Attachment Study, n.d.
Questions…