Attachment Representations in Mothers and Their Children Diagnosed with ADHD: Distribution, Transmission and Impact on Treatment Outcome
Little is known about the distribution and intergenerational transmission of attachment representations in ADHD populations and further how attachment may influence the prognosis of ADHD. In this study we aimed to investigate attachment distribution, intergenerational transmission and the potential impact of maternal and child attachment representations on treatment response in a sample of children with ADHD.
Sixty mother-child dyads from families with offspring ADHD were recruited. Attachment representations were assessed with the Adult Attachment Interview (AAI) and the Child Attachment Interview (CAI). ADHD symptom severity was assessed at four time points with the ADHD-Rating Scale.
Of the children, only 15% and among the mothers, only 23% were securely attached. Contrary to predictions, the association between maternal and child attachment representations (Secure versus Insecure) did not reach statistical significance as we found overall concordance rate to be 63% (kappa = −0.05). Neither child nor maternal attachment significantly predicted treatment response.
In families with offspring ADHD, the prevalence of insecure attachment was remarkably high in the children as well as in the mothers. Intergenerational transmission of attachment was very low and in short-term follow up, attachment representations did not affect treatment outcome. Our findings support previous research in suggesting that the relationship between ADHD and Insecure attachment is complex. Nevertheless, the importance of considering attachment as a factor in the treatment, functional impairment and long term prognosis of children with ADHD remains.
P.D.R. designed and executed the study, assisted with the data analyses, and wrote the paper, Y.SG. collaborated in the writing and editing of the final manuscript. E.S. collaborated with the design and writing of the study, A.B.B. analyzed the data and wrote part of the results, N.B. and O.J.S. collaborated with the design and writing of the study.
This research was supported by a research grant from Produktion, Forskning og Innovation and Lægeforeningens Forskningsfond.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
The participants received written and oral information according to the Helsinki declaration before they gave their consent.
- Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: assessed in the strange situation and at home. Hillsdale: Erlbaum.Google Scholar
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Association.Google Scholar
- Barkley, R. A., & Robin, A. L. (1999). Defiant teens: A clinician’s manual for assessment and family intervention. New York: Guilford Publications.Google Scholar
- Birmaher, B., Ehmann, M., Axelson, D. A., Goldstein, B. I., Monk, K., Kalas, C., & Brent, D. A. (2009). Schedule for affective disorders and schizophrenia for school-age children (K-SADS-PL) for the assessment of preschool children—a preliminary psychometric study. Journal of Psychiatric Research, 43(7), 680–686. https://doi.org/10.1016/j.jpsychires.2008.10.003.Google Scholar
- Bowlby, J. (1958). The nature of the child’s tie to his mother. Journal of Psychoanalysis, 39, 350–373.Google Scholar
- Bowlby, J. (1960a). Grief and mourning in infancy and early childhood. Psychoanalytic Study of the Child, 15, 9–52.Google Scholar
- Bowlby, J. (1960b). Separation anxiety. Journal of Psychoanalysis, 41, 89–113.Google Scholar
- Bowlby, J. (1973). Attachment and loss. Anxiety and anger (vol. 2). London: Hogarth Press: Institute of Psycho-analysis.Google Scholar
- Bowlby, J. (1988). A secure base: clinical applications of attachment theory. London: Routledge.Google Scholar
- Cassidy, J. & Marvin, R. (1992). Attachment organization in preschool children: Procedures and coding manual. Unpublished Manuscript, University of Virginia.Google Scholar
- Crittenden, P. M. (1994). The preschool assessment of attachment. Coding manual. Miami: Family Relations Institute.Google Scholar
- Crittenden, P. M., & Kulbotton, G. R. (2007). Familial contributions to ADHD: An attachment perspective. Tidsskrift Norsk Psykologorening, 10, 1220–1229.Google Scholar
- Dalsgaard, S., Østergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. (2015). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. The Lancet, 385(9983), 2190–2196. https://doi.org/10.1016/S0140-6736(14)61684-6.Google Scholar
- Deault, L. C. (2010). A systematic review of parenting in relation to the development of comorbidities and functional impairments in children with attention-deficit/ hyperactivity disorder (ADHD). Child Psychiatry and Human Development, 41(2), 168–192. https://doi.org/10.1007/s10578-009-0159-4.Google Scholar
- Dozier, M., Chase Stovall, K., & Albus, K. E. (1999). Attachment and psychopathology in adulthood. In I. J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 497–519). New York: Guilford.Google Scholar
- DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD rating scale-IV. New York: Guilford.Google Scholar
- Egeland, B., & Farber, E. A. (1984). Infant-mother attachment: factors related to its development and changes over time. Child Development, 55(3), 753–771.Google Scholar
- George, C., Kaplan, N., & Main, M., et al. (1985). Attachment interview for adults. Berkeley: University of California. Unpublished Manuscript.Google Scholar
- Grice, H. (1989). Paul: Studies in the way of words. Cambridge: Harvard UP.Google Scholar
- Hechtman, L. (1996). Families of children with attention deficit hyperactivity disorder: a review. Canadian Journal of Psychiatry Revue, 41(6), 350–360.Google Scholar
- Johnston, C., Mash, E. J., Miller, N., & Ninowski, J. E. (2016). Parenting in adults with attention-deficit/hyperactivity disorder (ADHD). Clinical Psychology Review, 32(4), 215–228.Google Scholar
- Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., & Ryan, N. D. (1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7), 980–988. https://doi.org/10.1097/00004583-199707000-00021.Google Scholar
- Licata, M., Zietlow, A.-L., Träuble, B., Sodian, B., & Reck, C. (2016). Maternal emotional availability and its association with maternal psychopathology, attachment style insecurity and theory of mind. Psychopathology, 49(5), 334–340.Google Scholar
- Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age 6: predictable from infant attachment classifications and stable over a 1-month period. Developmental Psychology, 24(3), 415.Google Scholar
- Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective development in infancy (pp. 95–124). Westport: Ablex Publishing.Google Scholar
- Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 121–160). US: University of Chicago Press.Google Scholar
- Molina, B. S., Hinshaw, S. P., Swanson, J. M., Arnold, L. E., Vitiello, B., Jensen, P. S., & Houck, P. R. (2009). The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Acadamy of Child and Adolescent Psychiatry, 48(5), 484–500. https://doi.org/10.1097/CHI.0b013e31819c23d0.Google Scholar
- Oyen, A.-S., Landy, S., & Hilburn-Cobb, C. (2000). Maternal attachment and sensitivity in an at-risk sample. Attachment & Human Development, 2(2), 203–217.Google Scholar
- Polanczyk, G., Zeni, C., Genro, J. P., Guimarães, A. P., Roman, T., Hutz, M. H., & Rohde, La (2007). Association of the adrenergic alpha2A receptor gene with methylphenidate improvement of inattentive symptoms in children and adolescents with attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 64(2), 218–224. https://doi.org/10.1001/archpsyc.64.2.218.Google Scholar
- Roy, A., Hechtman, L., Arnold, L. E., Swanson, J. M., Molina, B. S. G., Sibley, M. H., & Stern, K. (2017). Childhood predictors of adult functional outcomes in the multimodal treatment study of attention-deficit/hyperactivity disorder (MTA). Journal of the American Academy of Child and Adolescent Psychiatry, 56(8), 687–695.e7. https://doi.org/10.1016/j.jaac.2017.05.020.Google Scholar
- Seay, B., Hansen, E., & Harlow, H. F. (1962). Mother-infant separation in monkeys. Journal of Child Psychology and Psychiatry, 3(3–4), 123–132. https://doi.org/10.1111/j.1469-7610.1962.tb02047.x.Google Scholar
- Sonugo-Barker, E. J. S., & Halperin, J. M. (2010). Developmental phenotypes and causal pathways in attention deficit/hyperactivity disorder: potential targets for early intervention? Journal of Child Psychology and Psychiatry, 51(4), 368–389.Google Scholar
- Skovgaard, A. M., Olsen, E. M., Houmann, T. B., Christiansen, E., Lichtenberg, A., & Jørgensen, T. (2007). [Markers of mental health problems based on public health nurses’ assessments of 0- to 1-year-old children: the Copenhagen County Child Cohort 2000]. Danish Medical Bulletin, 169(11), 1006–10.Google Scholar
- Spencer, T. J., Biederman, J., Wilens, T. E., & Faraone, S. V. (2002). Overview and neurobiology of attention-deficit/hyperactivity disorder. Journal of Clinical Psychiatry, 63(suppl. 12), 3–9.Google Scholar
- Sroufe, A. L. (2005). Attachment and development: a prospective, longitudinal study from birth to adulthood. Attachment and Human Development, 7(4), 349–367.Google Scholar
- Starck, M., Grünwald, J., & Schlarb, A. A. (2016). Occurrence of ADHD in parents of ADHD children in a clinical sample. Neuropsychiatric Disease and Treatment, 12, 581–588.Google Scholar
- Sundhedsstyrelsen. (2014). National klinisk retningslinje for udredning og behandling af ADHD hos børn og unge [National Clinical Guideline for investigation and treatmen of ADHD in children and adolescents]. https://sundhedsstyrelsen.dk/da/nyheder/2014/~/media/A7931B11333540A184C73465181E29CE.ashx.
- Swanson, J. M., Arnold, L. E., Molina, B. S. G., Sibley, M. H., Hechtman, L. T., Hinshaw, S. P., & Kraemer, H. C. (2017). Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: Symptom persistence, source discrepancy, and height suppression. Journal of Child Psychology and Psychiatry and Allied Disciplines, 58(6), 663–678. https://doi.org/10.1111/jcpp.12684.Google Scholar
- Szomlaiski, N., Dyrborg, J., Rasmussen, H., Schumann, T., Koch, S. V., & Bilenberg, N. (2009). Validity and clinical feasibility of the ADHD rating scale (ADHD-RS) a Danish Nationwide Multicenter Study. Acta Paediatrica, International Journal of Paediatrics, 98(2), 397–402. https://doi.org/10.1111/j.1651-2227.2008.01025.x.Google Scholar
- Target, M., Fonagy, P., Shmueli-Goetz, Y., Datta, A., & Schneider, T. (2007). The child attachment interview (CAI) protocol. Unpublished Manuscript, University College London.Google Scholar
- van IJzendoorn, M. H. (1992). Intergenerational transmission of parenting: a review of studies in no clinical populations. Developmental Review, 12, 76–99.Google Scholar
- van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (1996). Attachment representations in mothers, fathers, adolescents, and clinical groups: a meta-analytic search for normative data. Journal of Consulting and Clinical Psychology, 64(1), 8–21. https://doi.org/10.1037/0022-006X.64.1.8.Google Scholar
- van IJzendoorn, M. H., Feldbrugge, J., Derks, F. C. H., De Ruiter, C., Verhagen, M. F. M., Philipse, M. W. G., & Riksen-Walraven, J. M. A. (1997). Attachment representations of personality-disordered criminal offenders. American Journal of Orthopsychiatry, 67(3), 449.Google Scholar
- van IJzendoorn, M. H., Goldberg, S., Kroonenberg, P. M., & Frenkel, O. J. (1992). The relative effects of maternal and child problems on the quality of attachment: a meta‐analysis of attachment in clinical samples. Child Development, 63(4), 840–858. https://doi.org/10.1111/j.1467-8624.1992.tb01665.x.Google Scholar
- Waters, E., Vaughn, B. E., & Egeland, B. R. (1980). Individual differences in infant-mother attachment relationships at age one: antecedents in neonatal behavior in an urban, economically disadvantaged sample. Child Development, 51(1), 208–216.Google Scholar