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Attention Deficit Hyperactivity Disorder is Associated with Attachment Insecurity LEANNE CLARKE, JUDY UNGERER, & KATRINA CHAHOUD Macquarie University, Sydney, Australia

SUSAN JOHNSON & INGEBORG STIEFEL The Children’s Hospital at Westmead, Sydney, Australia

A B S T R AC T The literature on attention deficit hyperactivity disorder (ADHD) and attachment is reviewed, and we describe an investigation of the relationship between attachment insecurity and ADHD. Nineteen boys, aged 5–10 years with DSM-IV diagnoses of ADHD were compared with 19 control children on three representational measures assessing internal working models of attachment and the self: the Separation Anxiety Test, the Self Interview, and a Family Drawing rated with an attachment-based scoring system. Consistent support was found for the hypothesis that ADHD is associated with insecurity of attachment, with the ADHD group obtaining poorer scores on all three measures. The nature of attachment insecurity in the ADHD group was one of heightened emotional expression characterized by strong, out of control affects, and was consistent with an anxious-ambivalent or disorganized attachment style. We argue that quality of attachment with primary caregivers should be assessed when children present with symptoms of ADHD, and that where insecure attachment relationships are found, treatment must incorporate relationship-building components. K E Y WO R D S attachment, attention deficit hyperactivity disorder, internal working models

T H E R E C E N T I N C R E A S E in diagnoses of attention deficit hyperactivity disorder (ADHD), a syndrome characterized by developmentally inappropriate degrees of inattention, impulsivity and hyperactivity, has been viewed with concern by many professionals (e.g. Armstrong, 1995; Breggin & Breggin, 1994; Newman, 1996; Oberklaid & Jarman, 1996; Smelter, Rasch, Fleming, Nazos, & Baranowski, 1996). Children diagnosed with ADHD account for approximately half of the referrals to child psychology and psychiatry clinics (Frick & Lahey, 1991). However, an agreed upon etiology for the disorder is lacking, so there is limited direction for the development of effective therapies (Mellor, Storer, & Brown, 1996). The treatment focus has been narrow, with

Clinical Child Psychology and Psychiatry 1359–1045 (200204)7:2 Copyright © 2002 SAGE Publications (London, Thousand Oaks and New Delhi) Vol. 7(2): 179–198; 021918 179

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stimulant medication very often the treatment of first choice (Australian Psychological Society, 1997). There is considerable controversy over this form of medical intervention and concern over the recent escalation in its use (e.g. Breggin & Breggin, 1994; Oberklaid & Jarman, 1996; Valentine, Zubrick, & Sly, 1996; Vimpani, 1997). Research on ADHD has traditionally focused on identifying an underlying organic or neurological dysfunction that could account for the disorder, with psychosocial factors typically viewed as peripheral (Barkley, 1990; Cantwell, 1996; Frick & Lahey, 1991). However, no definitive biological cause has been established, and in recent years the professional literature has been criticized for its failure to address adequately the role of quality of parenting and other psychosocial issues in the etiology of ADHD (Jureidini, 1996). Increasingly, professionals are arguing for a shift in focus away from the isolated overt behaviors of the child, to consider these behaviors within the context of family dynamics and interactions. It has been proposed that attachment theory, which provides a basis for understanding socio-emotional dysfunction within this broader context, may offer an important perspective on the development of ADHD (Erdman, 1998; Newman,

A C K N O W L E D G E M E N T S : We gratefuly acknowledge the support of Dr Kenneth Nunn and our colleagues from the Department of Psychological Medicine, The Children’s Hospital at Westmead. We also acknowledge the support of the Department of Psychology, Macquarie University, which provided funds to assist with interview transcription. Thank you to the participating families and schools for their time and commitment. L E A N N E C L A R K E is a Clinical Psychologist and completed this research in partial fulfilment of the requirements of the Master of Clinical Psychology degree at Macquarie University. She works at Karitane, a service providing parentcraft and psychological support for families with children aged 0–5 years, and in private practice. She has a particular interest in the application of attachment theory to understanding and treating childhood emotional and behavioral problems. J U DY U N G E R E R is an Associate Professor in the Department of Psychology, Macquarie University, where she teaches life-span development and clinical child psychology. Her research has focused on identifying factors influencing the development of parent–child relationships in normal and clinical groups, particularly during the infancy and preschool years. C O N TA C T :

Department of Psychology, Macquarie University, Sydney, NSW 2109, Australia.

K AT R I N A C H A H O U D is a Clinical Psychologist and conducted a separate but related research project with the sample described in this article, in partial fulfilment of the requirements of the Master of Clinical Psychology degree at Macquarie University. She has a particular interest in family therapy, including working with children with developmental disabilities.

is a Clinical Psychologist now at the Department of Child and Adolescent Mental Health, Prince of Wales Hospital. She has considerable clinical experience working with children and adolescents in residential, hospital inpatient and outpatient services. Her special interests are in the areas of cognitive and family therapy.

SUSAN JOHNSON

I N G E B O R G S T I E F E L is a Senior Clinical Psychologist and Head of the Psychology Department at The Children’s Hospital, Westmead. She has extensive clinical experience in the field of child and family psychology. She has a special interest in systems and psychodynamic theory, particularly the interface between psychosocial and biological processes in child development.

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1996; Olson, 1996; Sandberg & Garralda, 1996; Stiefel, 1997). Specifically, it has been suggested that the symptoms of ADHD may develop in the context of an insecure attachment relationship. This research examines the proposition that ADHD is associated with attachment insecurity, through a controlled study of the quality of attachment representations in a group of 5–10-year-old boys with ADHD.

Attachment and ADHD While no empirical research has specifically investigated the association between attachment insecurity and ADHD, a significant body of literature converges in support of the existence of such an association.

Comparison of deficits associated with ADHD and insecure attachment Attachment theory proposes that the early parent–child relationship serves as the foundation for the emergence of self-regulation skills. Infants are initially dependent on the caregiver’s ability to provide containment and regulation of their psychophysiological states, with the development of self-regulatory capacities viewed as contingent on the sensitive responsiveness of the caregiver to infant signals (Cassidy, 1994; Field, 1994). Research indicates that insecurely attached individuals are indeed more vulnerable to problems with affective and behavioral regulation (see Cassidy, 1994 for a review). Deficits in self-regulation, which include problems with impulse control, self-soothing, initiative, perseverance, patience, and inhibition, feature prominently in the syndrome of ADHD. Indeed, ADHD may be best conceptualized as a disorder of self-regulation, involving a generalized difficulty in integrating cognitive, affective, and motor functions in response to varying situational demands (Barkley, 1997; Olson, 1996; Teeter, 1998). It has been suggested that the impairment in self-regulation seen in children with ADHD may have its roots in strained early caregiver–child interactions and disrupted primary attachments (Olson, 1996; Sandberg, 1996; Stiefel, 1997). Importantly, research indicates that attachment security has a positive effect on the development of specific areas of competence in which children with ADHD experience difficulties. Secure infant attachment histories are associated with: increased attention span (Maslin-Cole & Spieker, 1990) and higher levels of enthusiasm, positive affect, and persistence in problem-solving situations in toddlers (Matas, Arend, & Sroufe, 1978); increased ability to respond flexibly, persistently, and resourcefully in preschoolers (Arend, Gove, & Sroufe, 1979); and cognitive control over impulses, task orientation, and delay of gratification in 6-year-olds (Jacobsen, Huss, Fendrich, Kruesi, & Ziegenhain, 1997; Olson, Bates, & Bayles, 1990). Attachment theory further proposes that the child’s internal working model of attachment, derived from the child’s experience of care with the primary attachment figure, provides a model for the child’s later relationships with other adults and peers (Easterbrooks & Goldberg, 1990; Sroufe & Fleeson, 1986). Research supports this proposition, with insecurely attached individuals experiencing more problems in interpersonal relationships (e.g. Erickson, Sroufe, & Egeland, 1985; Jacobson & Wille, 1986; Lyons-Ruth, Alpern, & Repacholi, 1993). It is now well established that children with ADHD are at substantial risk for experiencing difficulties in social functioning (e.g. Carlson, Lahey, Frame, Walker, & Hynd, 1987; Greene et al., 1996; Whalen & Henker, 1985). Indeed, Whalen and Henker (1998, p. 185) state that ‘interpersonal difficulties are a hallmark of the disorder and are often the “last straw” that leads to clinic referral.’ This prominence of social deficits in ADHD provides further evidence of striking similarities between the developmental outcomes of insecure attachments and the difficulties seen in children with ADHD. 181

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Parenting and family functioning of children with ADHD Although no research has used early measures of attachment to predict the onset of ADHD symptoms, Carlson, Jacobvitz, and Sroufe’s (1995) longitudinal study provides important evidence for the role of early parent–child relations in the development of hyperactivity. In that study, 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. In addition, clinical case reviews suggest that children with ADHD have early relationship histories that are similar to those of children with insecure attachments. For example, Haddad and Garralda (1992) described severely disrupted early attachment experiences in children presenting to child psychiatry clinics with ADHD symptoms which were not accompanied by biological indicators. Similarly, Stiefel (1997) has linked the emergence of symptoms in a clinical cohort of children with ADHD to a lack of sustained parental attention during the child’s first year of life. Stiefel argued that prolonged and uninterrupted parent–child relationship stress led to escalating negative parent–child interactions and a disturbance in the attachment relationship, in turn impairing the development of selfregulatory capacities in these children. Research on concurrent parent–child interactions in children with ADHD also reveals deficits similar to those seen in the context of insecure attachment relationships. Specifically, insecure attachment relationships are associated with parental behavior characterized by minimal involvement, negativity, lack of responsivity to infant signals, or intrusiveness (Ainsworth, Blehar, Waters, & Wall, 1978; Isabella & Belsky, 1991). In laboratory settings, mothers of hyperactive children initiate fewer interactions with their children, are less responsive to positive or neutral child-initiated interactions, and use more negative-reactive, commanding and controlling responses and fewer positive parenting strategies than comparison mothers (see Danforth, Barkley, & Stokes, 1991 for a review). Furthermore, the families of children with ADHD experience difficulties in a number of areas that represent risk factors for insecure attachment, because of their potential negative impact on parent–child relationships (Belsky & Isabella, 1988; Cummings & Cicchetti, 1990; Cummings & Davies, 1994). These include poorer psychological functioning, increased levels of depression and other psychiatric diagnoses in parents (Cunningham, Benness, & Siegel, 1988; Johnston, 1996; Nigg & Hinshaw, 1998), higher rates of marital distress and separation (Brown & Pacini, 1989; Johnston, 1996), and social isolation (Cunningham et al., 1988; Mash & Johnston, 1983). While quality of parenting is critical to the attachment process, child characteristics also place stress on the family system. Mothers of hyperactive children frequently report that, during infancy, these children were highly active, hyperirritable, unsoothable, and resistant to changes in feeding routines (Campbell, Szumowski, Ewing, Gluck, & Breaux, 1982). These infants are difficult to care for, and their behaviors can interfere with parent–child attachment (Campbell, 1990). In summary, a significant body of literature challenges the notion that parent–child relations and family functioning are peripheral to an understanding of ADHD, and suggests that attachment theory may offer a new perspective on this disorder.

The current study This study compares the quality of attachment representations in 5–10-year-old boys with a diagnosis of ADHD to a group of same-age normal controls. This requires accurate operationalization of the concept of internal working models. In infant and preschool age groups, attachment is typically assessed using the well-validated Strange 182

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Situation procedure, which involves behavioral observations of children’s responses to separations and reunions with their caregiver (Ainsworth et al., 1978). Children’s behavior, particularly on reunion, is thought to reflect their internal working model of the attachment relationship. In school-age children, internal working models have been assessed more directly with representational measures. We have used a broad-based attachment assessment appropriate to this age group, incorporating three measures of representational models of attachment and the self: (i) the Separation Anxiety Test (Hansburg, 1972), which assesses children’s verbal responses to hypothetical separations; (ii) the Self Interview (Cassidy, 1988), which assesses children’s verbal descriptions of themselves in relation to significant others; and (iii) attachment-based ratings of Family Drawings (Fury, Carlson, & Sroufe, 1997), which provide non-verbal assessment of attachment relationships. Although the database supporting these measures is not large, validity data exist for all three measures (e.g. Cassidy, 1988; Fury et al., 1997; Main, Kaplan, & Cassidy, 1985). We predicted that the attachment and self-representations of children diagnosed with ADHD would be characterized by greater insecurity than those of control children.

Method Participants The ADHD group comprised 19 boys (mean age = 8.6 years, SD = 1.5) diagnosed with ADHD by a clinical psychologist or consultant psychiatrist at the Children’s Hospital, Westmead, following referral for clinical assessment and treatment. Diagnoses were made in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Only boys were included because ADHD is more common in boys and may have different underpinnings for girls (Hepinstall & Taylor, 1996; A. James & Taylor, 1990). Additional inclusion criteria were: (i) T-score above 65 on the ADHD DSM-IV Total subscale of the Revised Conners’ Parent Rating Scale (Conners, Sitarenios, Parker, & Epstein, 1998); (ii) index child aged between 5 and 10 years; (iii) index child living with biological mother, to ensure comparable exposure to the maternal primary caregiver; and (iv) mother and child speak English in the home. Exclusion criteria were the presence in the child of: (i) a serious medical problem; (ii) a history of psychosis; (iii) pervasive developmental disorder; (iv) estimated IQ below 80; or (v) evidence of overt neurological disorder or brain injury. In the ADHD group, seven boys met DSM-IV criteria for the inattentive subtype, three for the hyperactive subtype, and nine for the combined type. Seventeen boys had one or more co-morbid DSM-IV diagnosis: oppositional defiant disorder (n = 11), learning disorder (n = 9), separation anxiety disorder (n = 4), adjustment disorder with depressed mood (n = 2), adjustment disorder with disturbance of emotions and conduct (n = 1), disruptive behavior disorder not otherwise specified (n = 1), developmental coordination disorder (n = 1), enuresis (n = 1), and expressive language disorder (n = 1). In addition to receiving a diagnosis of ADHD as part of procedures for study entry, all boys had received the diagnosis of ADHD from at least one professional in the past. The duration of ADHD symptoms was 3 years or more for the majority of children (n = 16), with the age of onset of clinical symptoms ranging from 1 to 6 years (M = 3.4 years). At the time of the study, 16 boys were being treated with stimulant medication (eight with methylphenidate, eight with dextroamphetamine), eight with clonidine, and one with antidepressants. Only two were not taking any psychotropic medication. The families of nine boys had received behavioral intervention in the past, whereas six had received more intensive psychological intervention. 183

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The control group comprised 11 children recruited from two local infants and primary schools, and 8 children of hospital staff or their associates (mean age = 8.2 years, SD = 1.4). Controls were required to meet inclusion criteria (ii–iv) and all exclusion criteria, and to have a T-score of 55 or below on the ADHD DSM-IV Total subscale of the Revised Conners’ Parent Rating Scale.

Procedure Approval for study procedures was obtained from the relevant ethics committees prior to the study’s commencement. For clinical subjects, eligibility for study participation based on inclusion and exclusion criteria was established by clinical interview with the family, review of hospital records, and completion of the Revised Conners’ Parent Rating Scale. For controls, eligibility was established by telephone interview and confirmed through completion of the Conners’ Scale. The attachment assessments were conducted in one session lasting approximately 1.5 hours, with the child given breaks where necessary. After a brief introduction, mother and child were taken to the research room and provided with an overview of the planned assessments, in language understandable by the child. The researcher then left the room while the mother and child completed a series of play interaction tasks, the data for which are reported elsewhere (Chahoud, 2000). On completion of these tasks, the mother left the room and the researcher returned. Assessment of the child began with a few minutes of rapport building, such as discussion of interests (e.g. favorite television shows, pets). The child then completed the Family Drawing, followed by the Separation Anxiety Test and the Self Interview. All assessments were audiotaped or videotaped through a oneway mirror for later transcription and scoring.

Measures Demographic interview Details were obtained from the mother regarding family composition, the child’s country of birth, and the parent’s age, education, ethnicity, and country of birth.

The Revised Conners’ Parent Rating Scale (Conners et al., 1998) This scale provides comprehensive coverage of DSM-IV symptoms of ADHD and related disorders and yields standard scores based on a large normative sample. It has good internal reliability, high test–retest reliability, and is effective in discriminating children with ADHD from normal children (Conners et al., 1998).

The Separation Anxiety Test This is a semi-projective test developed to assess the attachment representations of children based on their responses to pictures of parent–child separation experiences. Supporting the validity of the Separation Anxiety Test (SAT), moderately high correlations have been found between responses to the SAT and attachment classifications made in the Strange Situation at age 12 months, as well as concurrent measures of attachment based on reunion behavior (Main et al., 1985; Shouldice & Stevenson-Hinde, 1992). The Klagsbrun and Bowlby (1976) adaptation for 4–7-year-olds of the original SAT (Hansburg, 1972) was used for children aged 7 and below, with photographs by Greenberg (1985). For children aged 8 and above, a modified version of the SAT for 8–12-year-olds was used (Wright & Binney, 1998). For children aged 5–7, the following scenes were presented, one at a time: (1) parents going out for the evening, leaving child home; (2) child’s first day at school, at point of separation from mother; (3) parents going away for the weekend, leaving child with aunt and uncle; (4) child at park with parents and told to 184

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play by himself; (5) parents going away for 2 weeks, leaving child at home, giving child a present; and (6) mother putting child to bed, about to go out the door. For children aged 8–10, the following scenes were presented: (1) child going away for 2 weeks on a school trip, saying goodbye to parents; (2) mother going shopping, with child staying home alone; (3) mother going to hospital, with child saying goodbye; (4) parents going out for the evening, leaving child home; (5) father leaving home after an argument with mother; (6) child in town with father and told to go off and spend pocket money; (7) parents going away for a few days, leaving child with uncle; and (8) child’s first day at a new school, point of separation from mother. After each picture was described, the child was asked the following questions: (1) How does the boy feel? (2) Why does the boy feel (e.g. sad, happy)? (3) What’s the boy going to do? (4) And then what happens? (5) How does it all end? The first three questions are used as part of the standard administration of the SAT, whereas the last two questions were suggested by Wright and Binney (1998) as a means of obtaining more detailed responses. If the child was reluctant to answer, the researcher encouraged the child with probes such as: ‘How do you think the child might feel?’ or ‘Go ahead and just guess.’ Further prompts were given if necessary, for clarification purposes. The even-numbered separation pictures were considered to be mild and easily handled by children in that age group, while the odd-numbered separation pictures were considered to be severe and more difficult for children to handle (Shouldice & Stevenson-Hinde, 1992; Slough & Greenberg, 1990; Wright & Binney, 1998). The scoring indices for the Seattle Version of the Separation Anxiety Test (Slough, Goyette, & Greenberg, 1988) were used, with responses allocated to one of 21 categories that are assigned weighted scores and combined to yield three factors: (i) Attachment: the child’s ability to express vulnerability or need about severe separations, computed on a 1–4 scale; (ii) Self-Reliant: the child’s ability to express self-confidence about handling the mild separations, computed on a 1–4 scale; (iii) Avoidant: the child’s degree of avoidance in discussing the separations, computed on a 1–3 scale. In addition to the standard SAT factor scores, two other variables were developed to assess specific areas where children with ADHD may be expected to experience difficulties: (i) the child’s containment of negative emotions (Containment: number of responses involving retribution, hostility, or hatred); and (ii) the child’s general emotional experience of the parent–child relationship (Global Relationship Index: overall pattern of positive versus negative emotional responses to the separations and reunions rated on a 1–5 scale, ranging from 1 = extremely positive to 5 = extremely negative, with half-point scores used). All deidentified verbatim transcripts were scored by the principal investigator. The first 16 transcripts (eight clinical, eight control) were scored independently by another experienced rater to establish inter-rater reliability. All transcripts were rated blind to any additional information about the child. Inter-rater reliability was calculated based on the initial category rating for each picture. The level of inter-rater agreement was high, with perfect agreement found for 81% of Attachment factor items, 87% of SelfReliant factor items, and 84% of Avoidant factor items. For the additional variables, perfect agreement was found for 94% of Containment scores, and agreement within 0.5 points was found for 100% of Global Relationship Index scores. Discrepancies between raters were resolved through conferencing. Rating decisions made during conferencing were used to inform rules for rating subsequent transcripts. Internal consistency analyses for the three SAT factors yielded Cronbach’s alphas of .50 for Attachment, .71 for Self-Reliant, and .60 for Avoidant for the 5–7-year-old sample (n = 11), and .68 for Attachment, .42 for Self-Reliant, and –.32 for Avoidant for the 8–10year-old sample (n = 27). The Attachment and Self-Reliant scales were significantly 185

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correlated for both ADHD and control groups, r(17) = .79, p < .001 and r(17) = .49, p < .05, respectively. Review of Avoidant scores for the 8–10-year-olds revealed that 93% of responses received a score of 1, indicating that the scale did not discriminate between different response styles. As this factor was non-discriminating in the older group and the number of subjects in the younger group was small, this scale was not used in subsequent analyses.

The Self Interview (Cassidy, 1988) This interview consists of 20 questions assessing selfconcept, such as: (1) Can you tell me something you like about yourself? (3) What do you think is not so good about you? (7) Is there any way that you could be a better kid? (8) What do you think your mum likes about you? (19) Can you tell me five words about you? Self Interview responses have been found to relate in predictable ways to attachment classification based on reunion behavior (Cassidy, 1988). In the present study, three scales adapted from the Working Model of the Child Interview (Zeanah & Benoit, 1995) were used to rate interview transcripts. The first scale, Richness of Descriptions, rates the extent to which the child describes the self in detail as an individual. Low scores are assigned where poverty of detail is striking throughout the interview and there is a pervasive sense that the child does not know himself in a differentiated way; high scores are assigned where details add fullness to the general sense of who the child is and the child describes self-perceived psychological attributes. The second scale, Openness/Flexibility, rates the extent to which the child presents a positive yet flexible presentation of the self. Low scores are given where rigidity in descriptions of the self is striking throughout the interview, with the child either describing the self as entirely perfect or only making negative statements about the self; high scores are given where the child describes the self in a positive way but is able to recognize and admit less than perfect aspects of the self, and to provide ideas on how things could be improved. The Coherence scale assesses overall coherency of self-concept and the organization and flow of ideas and feelings about the self. Low scores are assigned where self-descriptions are vague, confused, contradictory, or bizarre, and cannot be understood without effort; high scores are given where virtually all statements are direct and straightforward and the flow of ideas is clear and logical. Scores for all scales had a potential range of 0–4, and half-point scores were used, e.g. 2.5. All deidentified verbatim transcripts were scored by the principal investigator. The first 14 transcripts (six clinical, eight control) were scored independently by a second experienced rater. All transcripts were rated blind to any additional information about the child. The level of inter-rater agreement was high, with agreement within .5 points on 93% of transcripts for the Richness scale, 93% of transcripts for the Openness/Flexibility scale, and 86% of transcripts for the Coherence scale. Discrepancies were resolved through conferencing. Inter-scale correlations on the Self Interview ranged from r(15) = .45 to .80 for ADHD subjects, and r(17) = .60 to .66 for controls, with only the correlation between Openness/Flexibility and Coherence for the ADHD group failing to reach significance, r(15) = .45, p = .07.

Family Drawing (Fury et al., 1997) Following Fury et al. (1997), prior to beginning the family drawing, the child was asked to draw a person using a pencil and standard-sized sheet of paper. This task was designed to put the child at ease and reassure him that the drawing task was not a test of ability. Each child was then asked to draw a picture of his family on a 12  18 inch sheet of paper using 12 colored felt-tip pens placed on the table in a fixed order. No further direction was given in order to make the task as openended as possible. The upper time limit allowed for the task was 20 minutes. Upon 186

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completion, the child was asked to identify all persons included in the drawing and to state how they were related to the child. Ratings were made of the presence or absence of 24 specific drawing signs that have been found by Kaplan and Main (1985) to be associated with different infant attachment histories in their research with 5–7-year-old children (e.g. figures not grounded, incomplete figures, lack of individuation). The signs were scored according to the system refined by Fury and colleagues (1997) in their research with children aged 8–9 years. Theoretically derived global rating scales developed by Fury and colleagues (1997) to assess the context and patterning of individual drawing signs were then completed. These global ratings have been found to be associated in predictable ways with early attachment history (Fury et al., 1997). The eight global rating scales are defined as follows: (i) Vitality/Creativity: emotional investment in drawing seen in embellishment, details, and creativity; (ii) Family Pride/Happiness: child’s sense of belonging to and happiness in the family; (iii) Vulnerability: expressed in size distortions, placement of figures on the page, and exaggeration of body parts; (iv) Emotional Distance/Isolation: reflected in disguised expressions of anger, neutral or negative affect, or distance between mother and child; (v) Tension/Anger: inferred from figures that appear constricted, closed, lacking in color or detail, or careless in appearance; (vi) Role Reversal: inferred from relative sizes or roles of figures; (vii) Bizarreness/Dissociation: underlying disorganization reflected in unusual signs, symbols, or fantasy themes; (viii) Global Pathology: overall degree of negativity reflected in organization, completeness of figures, use of color, detail, affect, and background scenes. Ratings ranged from 1 (extremely low) to 7 (extremely high). All deidentified drawings were scored by the principal investigator, with two clinical psychologists each rating 19 different drawings blind to any additional information about the child. Inter-rater reliability analyses for individual drawing signs yielded Cohen’s kappa statistics ranging from .37 for exaggeration of facial features to 1.00 for signs including exaggeration of heads, disguised family members, etc. (M = .81). The level of inter-rater agreement on the global ratings was high, with agreement within 1 scale point ranging from 89% for Vulnerability to 100% for Role Reversal (M = 95%). All discrepancies on individual drawing sign items were resolved by conferencing. Scoring discrepancies of 1 point on the global ratings were resolved by averaging scores for the two raters; differences of more than 1 point were conferenced. The global ratings were significantly intercorrelated in the predicted direction for ADHD and control subjects, with the exception of Vitality–Creativity which was not correlated with any other scale for either group, and Role Reversal which was not correlated with any other scale for the control subjects. Although Emotional Distance/Isolation was not significantly correlated with Bizarreness/Dissociation for the ADHD group, or with Tension/Anger for the controls, the correlations were still of reasonable magnitude and approached statistical significance, r(16) = .45, p = .06 and r(17) = .41, p = .08, respectively.

Results Sample demographics Table 1 presents demographic characteristics for the ADHD and control groups. There were no significant differences between the groups in terms of age of the index child, age of the mother or father, number of children living in the household, birth order of the index child, the number of children and mothers born overseas, mother’s or father’s ethnicity, or father’s education. However, control children were somewhat more likely to live with both biological parents, their fathers were more likely to have been born overseas, and their mothers were more likely to have technical or university qualifications. 187

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Table 1. Group comparisons on demographic characteristics ADHD (n = 19) M Age (years) Child Mother Father Number of children in household

First born child Child lives with both biological parents Australian-born Child Mother Father Caucasian ethnicitya Mother Father Technical/university education Mother Father

8.6 38.1 39.6 2.3

(SD) (1.5) (5.4) (6.8) (1.0)

Controls (n = 19)

Test statistic

M

(SD)

t

(1.4) (4.5) (5.2) (1.0)

0.83 –0.20 –0.38 –0.33

8.2 38.4 40.4 2.4 %

(n)

p-Value

.415 .846 .703 .741

2

%

(n)

47 63

(9) (12)

37 89

(7) (17)

0.43 3.64

.511 .056

89 84 89

(17) (16) (17)

89 74 58

(17) (14) (11)

0.00 0.63 4.89

1.000 .426 .027

95 95

(18) (18)

84 84

(16) (16)

1.12 1.12

.290 .290

74 58

(14) (11)

100 79

(19) (15)

5.76 1.95

.016 .163

a

Other ethnicities were Aboriginal Australian (one ADHD mother and father) and Asian (three control mothers and three control fathers).

Between group comparisons on attachment measures Separate multivariate analyses of variance comparing the ADHD and control groups on each of the attachment measures (SAT, Self Interview, and Family Drawing global ratings) revealed significant between group differences, with the ADHD group obtaining poorer scores than controls on all three sets of measures (Table 2). Follow-up analyses showed that the ADHD group obtained significantly lower scores on the two SAT scales and the three Self Interview scales. For the Family Drawing global ratings, the ADHD group obtained significantly lower scores than controls on the Family Pride/Happiness scale, and significantly higher scores on the Vulnerability, Tension/Anger, Role Reversal, Bizarreness/Dissociation, and Global Pathology scales. No between group differences were found for the Vitality/Creativity or Emotional Distance/Isolation scales. Chi-squared analyses revealed no differences between groups in the number of children showing individual drawing signs (ps > .05). These findings are unlikely to be artifacts of any differences in developmental level between the two groups as, in general, scores on the three measures did not vary with the child’s age. The only scale significantly correlated with age was the Bizarreness/Dissociation scale of the Family Drawing global ratings for the ADHD group, r(16) = –.50, p < .05, whereas the correlation between age and the Emotional Distance/Isolation scale approached significance for the control group, r(17) = .46, p = .051. Given the high rates of co-morbidity in this sample, the multivariate analyses were repeated, with children with ADHD with and without co-morbid oppositional defiant disorder (ODD) and children with ADHD with and without a learning disorder (LD) compared separately with controls, holding age constant statistically (see annotation in 188

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Table 2. Between group comparisons on the Separation Anxiety Test, Self Interview, and Family Drawing global ratings ADHD M (SD)

Controls M (SD)

d.f.

4.04 7.37 5.87

.02614 .01014 .0214 .0412 .0441 .021134 .006234

p-Value c

F

Separation Anxiety Test (n = 38) Attachment Self-Reliant

2.9 (1.0) 2.0 (0.5)

3.5 (0.6) 2.5 (0.7)

3,34 1,36 1,36

Self Interview (n = 36) a Richness of Descriptions Openness/Flexibility Coherence

2.3 (0.9) 2.6 (0.7) 2.7 (0.5)

2.9 (0.7) 3.2 (0.6) 3.1 (0.4)

3,32 1,34 1,34 1,34

3.08 4.37 5.87 8.55

Family Drawing global ratings (n = 35) b Vitality-Creativity Family Pride/Happiness Vulnerability Emotional Distance/Isolation Tension/Anger Role Reversal Bizarreness/Dissociation Global Pathology

3.7 2.9 5.5 4.8 4.8 4.1 4.9 5.9

4.4 4.2 4.5 4.3 3.7 3.1 3.4 4.3

8,26 1,35 1,35 1,35 1,35 1,35 1,33 1,35 1,35

3.48 2.02 9.84 9.78 2.26 17.39 6.95 22.05 21.46

(1.6) (1.3) (1.0) (1.0) (1.0) (1.3) (1.1) (1.0)

(1.1) (1.1) (0.9) (1.0) (1.0) (1.0) (0.9) (1.0)

.007234 .1654 .0031234 .0041234 .142 .0001234 .01313 .0001234 .0001234

a Two

children in the ADHD group refused to complete testing. child in the ADHD group refused to draw his family. One ADHD child omitted his parents from the drawing and one control child omitted himself, so that a Role Reversal score could not be assigned for these drawings. Therefore, for the overall analysis and the Role Reversal analysis n = 35, whereas for all other Family Drawing global rating scales n = 37. c Significant differences between subgroups of ADHD children versus controls at p < .05: 1ODD (n = 9–11) vs. controls; 2 non-ODD (n = 8) vs. controls; 3 LD (n = 8–9) vs. controls; 4 non-LD (n = 9–10) vs. controls. b One

Table 2). Looking across all scale comparisons, differences between each clinical subgroup and the control group were found on at least some measures, with the Self Interview and Family Drawing global ratings being the most differentiating. Given the small sample sizes, it is not surprising that not all comparisons were significant, and results need to be interpreted with caution. For the SAT, only the ODD and non-LD groups differed significantly from controls, although the difference for the non-ODD group on the Self-Reliant scale showed a trend towards significance at p < .10. On the Self Interview scales, all ADHD subgroups showed some differences to controls. For the Family Drawing global ratings, each ADHD subgroup differed significantly from controls on the six scales where differences had been found between controls and the ADHD group as a whole, except that only trends towards significance (p < .10) were found for the ODD group on the Global Pathology scale and for the non-ODD and non-LD groups on the Role Reversal scale. Overall, the subgroup analyses indicated that the findings for the ADHD group as a whole applied equally to children with and without co-morbid diagnoses.

Between group comparisons on Containment and Global Relationship Index Scales The children with ADHD provided significantly more coping strategies involving retribution, hostility, or hatred, F(1,36) = 4.62, p < .05. A total of 19 such responses was 189

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provided by 10 (53%) children with ADHD compared with six such responses by five (26%) controls. In fact, two children with ADHD refused to complete the interview, with their responses and behavior becoming increasingly bizarre and hostile. The children with ADHD also obtained significantly lower scores on the Global Relationship Index, F(1,36) = 14.91, p < .001. Twelve (63%) control children provided entirely positive descriptions of the parent–child relationship, compared with only two (11%) children with ADHD. Nine (47%) children with ADHD described predominantly negative parent–child relationships, compared with three (16%) control children.

Discussion The findings of this study are consistent in their support of the hypothesis that ADHD is associated with insecure internal working models of attachment and the self. Importantly, the findings do not appear to be purely an artifact of developmental differences or of the high rates of co-morbid oppositional defiant disorder and learning disorder in the ADHD group. The specific findings for each attachment measure are discussed first, followed by a broader discussion of the implications of the overall results.

Attachment measures Separation Anxiety Test As predicted, children with ADHD obtained poorer scores on the SAT. Specifically, they were less likely to express an appropriate level of concern, fear, or feelings of sadness about more difficult separations (attachment), tending to express extreme feelings and behaviors. In addition, they were less likely to express confidence and feelings of well-being in the context of easier separations (self-reliance). Such findings are thought to reflect an attachment history in which caregivers have been less than optimally accessible and responsive to a child’s attachment needs and less competent in providing the support and structure necessary to help the child develop his own self-regulation skills (Slough et al., 1988). Clear differences were found between the ADHD and control children in containment of emotions, behavior, and predicted consequences. Specifically, the children with ADHD tended to provide more coping strategies involving retribution, hostility, or hatred, with situations spiraling into disasters beyond their and others’ control. For example, in response to the picture showing the boy going away for 2 weeks on a school trip, a child with ADHD described escalating hostility, explaining that the boy would feel ‘Angry. Because he has to leave his parents and he won’t be able to see them. He is going to be angry at everyone. Like whenever you get angry at one thing, you get angry at everybody. He might get off and maybe hurt other people.’ In response to the picture showing the mother going to hospital, another child with ADHD described a scenario that rapidly escalated into disaster, explaining that the boy would feel ‘Sad. Because his mother is going away and it could be for one week. If no one is looking after him and he had to make his own dinner he will probably light the house on fire. The house goes on fire and then probably he will start crying because he hasn’t got any more things because the house is on fire. The mother will probably be so angry.’ Even more marked differences were found in descriptions of the parent–child relationship. The majority of control children provided entirely positive descriptions of the parent–child relationship, describing feelings of happiness on reunion, with parents portrayed as empathic and responsive to the child’s emotional needs. In contrast, around half of the children with ADHD provided predominantly negative descriptions of the parent–child relationship. In some cases, parents were portrayed as unresponsive or 190

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unreliable. For example, in response to the picture showing the father telling the boy ‘Go and spend your pocket money. I’ll wait here,’ a child with ADHD replied that the boy would feel ‘Sad. Cause he might think that his Dad might leave him . . . And he comes back and his Dad’s not there.’ In other instances, parent and child were portrayed as entrenched in a negative cycle in which child misbehavior in response to separations elicits angry parental responses. For example, in response to a picture showing the mother going shopping and the boy staying home alone, a child with ADHD explained that the boy would feel ‘Angry. Because he doesn’t want his Mum to leave. He might play up, he might go and eat all the food that his Mum won’t let him eat while she’s gone. And he gets in trouble when she comes back.’

Self Interview The self-descriptions of children with ADHD were less richly developed and coherent relative to controls, conveying a less developed sense of who these children are as individuals, with frequent ‘don’t know’ and ‘no’ and brief or insubstantial responses. For example, a control child asked to provide five words about himself stated that he was ‘adventurous, humorous, shy, athletic,’ whereas a same-age child with ADHD stated ‘I like catching things [long pause], I don’t like school’ and was unable to generate any further self-descriptors despite prompting. According to attachment theory, the capacity to communicate and understand the feelings, desires, and attitudes of the self develops in the context of sensitive and responsive caregiving (Bowlby, 1969/1982). The ADHD group appeared to fall behind the controls in their development of this capacity. The responses of the children with ADHD also suggested less openness and flexibility in self-concept, with these children tending to present a negative selfconcept or appearing emotionally disconnected, and unable to generate possibilities for change. For example, in response to the question ‘Is there any way you could be a better kid?’, a control child who presented a positive self-concept was still able to identify possibilities for change, stating ‘By helping other people more with things, like mum and dad, like putting out the rubbish and doing what they tell me to.’ In contrast, a same-age child with ADHD who stated throughout the interview that he liked nothing about himself and that he was simply ‘bad’ answered ‘No . . . No way at all’ to that same question. Greenberg and Speltz (1988), in their discussion of children with externalizing behavior disorders, describe the development of a maladaptive pattern in which the parent indicates to the child that his negative or conflicting affects are intolerable or ‘bad’, but does not assist the child in developing internalized control or more mature forms of emotional expression. This scenario could be expected to produce the types of self-descriptions seen here in these children with ADHD.

Family drawing The family drawings of the children with ADHD differed markedly from the control group, suggesting lower levels of family pride and higher levels of vulnerability, tension and anger, role reversal in the mother–child relationship, bizarreness and dissociation, and overall pathology. Indeed, two-thirds of the children with ADHD and only two controls produced drawings that were classified as ‘disturbing’ and that, according to Fury et al.’s (1997) rating system, were considered to reflect a high degree of family disharmony, with themes of anger, confusion, low self-esteem and relationship anxiety predominating. These themes were expressed in a variety of different ways – some of these drawings contained distorted and/or frightening figures and/or unusual symbols, whereas others were impoverished, containing little color or detail, and some had an overall reckless quality. The lack of difference in vitality and creativity reflected the fact that, whereas one-third of the children with ADHD provided bland, bare-bones portrayals of their families and obtained low scores on this scale, a 191

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further 28% of the children with ADHD provided drawings that were very engaging to look at because of their unusual and at times frightening qualities and obtained high scores on this scale. Therefore, the mean score on this scale was not informative in the present context. The fact that expression of emotional distance was comparable between the groups suggests that avoidance may not be a discriminating feature of the attachment profile of children with ADHD. The lack of discriminating power of the individual drawing signs is perhaps not surprising. It has been argued elsewhere that individual rating signs have relatively poor predictive power, whereas the aggregation of signs through the use of rating scales is more powerful (Di Leo, 1983; Fury et al., 1997). The results of the current study lend further support to this position.

Overall summary of attachment findings The overall pattern of results suggests that the nature of attachment insecurity in these children with ADHD is one of heightened emotional expression characterized by strong, out of control affects. In general, these children do not display the open, flexible emotional expression thought to reflect a secure internal working model that develops in the context of experiences with a caregiver who sensitively responds to a range of infant affective signals (see Cassidy, 1994). Rather, their responses suggest an anxious-ambivalent or disorganized attachment style, as has been predicted by clinicians proposing an association between ADHD and attachment insecurity (e.g. Stiefel, 1997). In this context, the impulsivity, recklessness, negative attention-seeking, hyperactivity, and frequent oppositionality seen in these children can be viewed as a strategy to gain the attention of a less than optimally available caregiver.

Implications for understanding and intervening in parent–child relationships in ADHD The findings reported here are particularly interesting when considered alongside the results of research on mother–child interactions conducted with these same children (see Chahoud, 2000). In that research, segments of child-directed play, mother-directed play, a teaching task, and clean-up activity were rated on variables such as gratification, involvement, and sensitivity, with no differences found between ADHD and control groups on these variables. Previous research showing reversal of problematic parent–child interactional patterns following treatment with stimulant medication (e.g. Barkley, 1989) has been taken to support the position that the difficult interactions seen in unmedicated children with ADHD are primarily due to child factors (see Woodhead, 1995). The discrepancy between our findings of consistent differences between children with ADHD and controls on representational measures of attachment and an absence of differences in the actual mother–child interaction represents a significant challenge to this interpretation. In our sample, 16 of the 19 children with ADHD were being treated with stimulant medication at the time of the study and 15 had received some level of psychological intervention, typically in the form of parent training in behavior management techniques. The effect of these medical and behavioral interventions may have been to mask underlying relational problems, at least in terms of their manifestation in a structured laboratory-based interaction. This is consistent with Erdman’s (1998) suggestion that such treatments may have a ‘Band-Aid effect’ on the parent–child relationship, and points to serious limitations in traditional treatment approaches. The American Academy of Child and Adolescent Psychiatry (AACAP Work Group on Quality Issues, 1997, p. 91), in its formulation of practice parameters for the treatment of ADHD, has observed that ‘the most troubling difficulty with both psychosocial [typically behavioral] and pharmacological treatments of ADHD is the lack of 192

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maintenance of effects once treatment has been discontinued and the failure of generalization to settings in which treatment has not been active.’ The results of the present study provide a possible explanation for the limitations of current treatments. Specifically, although traditional treatment approaches may temporarily, or even permanently, improve the behavioral manifestations of ADHD, they do not attempt to impact on the child’s internal working model or the parents’ view of the child. In fact, such approaches may further reinforce the child’s working model of others as unresponsive to his needs (see Greenberg & Speltz, 1988). As Erdman (1998, p. 182) argues, ‘Children who are frustrated and anxious over the lack of a parental bond will feel more victimized if they are focused on as the problem.’ It is important to qualify this position by acknowledging that, although children with ADHD tended to obtain poorer scores on the attachment measures, some obtained scores suggestive of a more secure internal working model. So, although the symptoms presented by these boys were very similar, attachment assessments revealed differences that may have crucial implications for treatment. As DeKlyen (1996) has observed, where the attachment relationship is secure, parent training may be appropriate, as parents may be able to focus on the current interaction and apply behavior management skills objectively and consistently. In contrast, if the quality of the relationship is problematic, relationships issues may need to be addressed directly before families can be expected to make enduring changes. By adding relationship-building components, the generalization of treatment effects may be enhanced (for examples of such approaches, see Greenberg & Speltz, 1988; B. James, 1994). This approach would appear particularly critical given that the quality of the parent–child relationship appears to impact on the development of secondary conduct-related disorders in children with ADHD in adolescence (Weiss & Hechtman, 1993).

Limitations and directions for future research Interpretation of results must be tempered by consideration of the study’s limitations. First, the children in the ADHD group may not have been representative of children with ADHD generally, but are likely to reflect those who are referred to a tertiary-level teaching hospital, often because first-line treatments have not been effective. Attachment problems may be a motivation for such referrals. However, the design of this study does not allow variables associated with help-seeking to be distinguished from variables associated with the disorder itself and, as such, the data are exploratory rather than conclusive. Inclusion of a non-ADHD psychiatric control group and/or a non-clinic sample of children with ADHD would assist in disentangling these associations. The small sample size prevented a thorough examination of the impact of co-morbidity on attachment insecurity in children with ADHD or a comparison of findings for the different ADHD subtypes. Also, this sample included boys only. Given the likelihood of child gender effects on parenting and some reports of sex differences in the relationship between attachment and adjustment in childhood (Lewis, Feiring, McGuffog, & Jaskir, 1984; Olson et al., 1990), replication with a sample of girls with ADHD is required. The inclusion of children of hospital employees in the control group may have reduced the baseline comparability of the clinical and control groups. Although the clinical and control groups were comparable on most sociodemographic variables assessed, differences between the groups in maternal education and presence of both biological parents in the home may have impacted on the study’s findings. This study leaves unanswered many questions concerning the mechanisms that may relate attachment insecurity to ADHD. It is not clear whether quality of caregiving contributes directly to the development of ADHD-related problems or if the child’s 193

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challenging behaviors lead to disturbance in interactions. Although previous research suggests that the temperament or innate biological characteristics of the child are unable to independently predict distractibility and hyperactivity in early childhood (e.g. Carlson et al., 1995; Olson et al., 1990), the role of child characteristics should not be overlooked. It is likely that a transactional model is appropriate here, in which attachment processes are conceptualized as a function of complex and ongoing interactions among parent, child, and environmental/experiential forces (e.g. Belsky, 1984). Stiefel (1997), for example, described the development of a ‘demand–dissatisfaction cycle’ in the early histories of children with ADHD, characterized by difficulty between infant and caregiver in establishing a routine of management. This cycle is thought to develop as a result of an interaction between parental vulnerabilities (e.g. perinatal mood disorders, negative mental representations of the self/baby, unresolved losses), child vulnerabilities (e.g. perinatal medical stressors, genetics, gender, temperament), and psychosocial stressors (e.g. marital tension, lack of psychosocial support) (Stiefel, 1997). Prospective, longitudinal research is required to disentangle the effects of these different factors on the development of attachment security and ADHD. Such research would provide much needed information regarding risk and protective factors and suggest strategies for early intervention.

Conclusions Despite these limitations, our findings demonstrate the value of attachment theory and methodology for understanding children diagnosed with ADHD. As DeKlyen (1996) has argued, clinicians must reconsider the practice of distinguishing subgroups of children on the basis of presenting symptoms alone. A broader approach to clinical assessment is required that considers the child’s behaviors in the context of quality of attachment relationships and other psychosocial factors. This approach will facilitate the implementation of more comprehensive and, it is hoped, effective treatment for these children and their families.

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