ADHD and Attachment ADHD and Attachment Victoria Thompson Victoria Thompson

April 6April 6thth, 2009, 2009

Overview Overview

AttachmentAttachment

LiteratureLiterature

2 Empirical Studies2 Empirical Studies

Developmental ModelDevelopmental Model

Reactive Attachment DisorderReactive Attachment Disorder

AttachmentAttachment

Close emotional bond between two people Close emotional bond between two people that is enduring across space and timethat is enduring across space and time

Proximity-seeking behavior by a Proximity-seeking behavior by a dependent organism when he or she feels dependent organism when he or she feels discomfortdiscomfort

Internal Working ModelsInternal Working Models– Mental representations of the self, attachment Mental representations of the self, attachment

figures, and relationships in general.figures, and relationships in general.– Include expectations regarding behaviors and Include expectations regarding behaviors and

emotions emotions Source: Ladnier & Massanari, 2000Source: Ladnier & Massanari, 2000

Attachment Styles Attachment Styles SecureSecure– Caregiver as a secure baseCaregiver as a secure base

InsecureInsecure– 3 Types3 Types

AmbivalentAmbivalent– Child contacts caregiver for support while simultaneously rejecting her Child contacts caregiver for support while simultaneously rejecting her

attempts to soothe himattempts to soothe him

AvoidantAvoidant– Child rejects or avoids caregiverChild rejects or avoids caregiver

Disorganized/DisorientedDisorganized/Disoriented– Child lacks a consistent strategy for organizing his comfort seeking behaviorsChild lacks a consistent strategy for organizing his comfort seeking behaviors

Source: Ladnier & Massanari, 2000Source: Ladnier & Massanari, 2000

Converging Body of LiteratureConverging Body of LiteratureExecutive Functioning (EF)Executive Functioning (EF)– Early healthy attachment experiences necessary for Early healthy attachment experiences necessary for

the development of EFthe development of EF– Insecurely attached children show EF deficitsInsecurely attached children show EF deficits– Children with ADHD typically show EF deficitsChildren with ADHD typically show EF deficits

Hypothalamic-Pituitary-Adrenal (HPA) AxisHypothalamic-Pituitary-Adrenal (HPA) Axis– Insecure attachments associated with atypical Insecure attachments associated with atypical

reactivity of this system to stressorsreactivity of this system to stressors– Secure attachment associated with typical reactivitySecure attachment associated with typical reactivity– Some children with ADHD show atypical reactivitySome children with ADHD show atypical reactivity

Source: Crittendon & Kulbotten, 2007Source: Crittendon & Kulbotten, 2007

Literature cont.Literature cont.Orbitofrontal Cortex Orbitofrontal Cortex – Crucial to emotional regulation, decision-making and Crucial to emotional regulation, decision-making and

processing of rewardsprocessing of rewards– Anxious attachment inhibits development of the Anxious attachment inhibits development of the

orbitofrontal cortexorbitofrontal cortex– Anxious attachment may result in chronic Anxious attachment may result in chronic

Emotion labilityEmotion lability

ImpulsivityImpulsivity

Unpredictable and intense behaviorUnpredictable and intense behavior

– Orbitofrontal cortex has been found to be functionally Orbitofrontal cortex has been found to be functionally disturbed in people with ADHDdisturbed in people with ADHD

Source: Crittendon & Kulbotten, 2007Source: Crittendon & Kulbotten, 2007

Literature cont.Literature cont.Dopamine Receptor D4 (DRD4) Gene Dopamine Receptor D4 (DRD4) Gene – Link between infant attachment and DRD4 geneLink between infant attachment and DRD4 gene

– Same gene found to be linked to ADHDSame gene found to be linked to ADHD

– Disorganized attached children carry 7 repeat allele of the DRD4 Disorganized attached children carry 7 repeat allele of the DRD4 genegene

– Securely attached children do not carry this alleleSecurely attached children do not carry this allele

– Not carrying this allele may act as a resilience factor in the optimal Not carrying this allele may act as a resilience factor in the optimal development of attachmentdevelopment of attachment

– Children with ADHD who have 7 repeat allele tend to be more Children with ADHD who have 7 repeat allele tend to be more impulsive then children with ADHD who do not have this alleleimpulsive then children with ADHD who do not have this allele

– Early attachment might mediate or moderate the DRD4-related Early attachment might mediate or moderate the DRD4-related genetic risk for ADHDgenetic risk for ADHD

Source: Crittenden & Kulbotten, 2007Source: Crittenden & Kulbotten, 2007

Literature cont.Literature cont.Children that are insecurely attached and children with ADHD Children that are insecurely attached and children with ADHD show EF deficitsshow EF deficits

Insecure attachment and ADHD is associated with atypical Insecure attachment and ADHD is associated with atypical reactivity of the HPA axis to stressorsreactivity of the HPA axis to stressors

Children that have an anxious attachment style and children with Children that have an anxious attachment style and children with ADHD show abnormalities of the orbitofrontal cortexADHD show abnormalities of the orbitofrontal cortex

Both insecure attachment and ADHD have been linked to the Both insecure attachment and ADHD have been linked to the DRD4 geneDRD4 gene

These findings suggest a possible interaction between genetic These findings suggest a possible interaction between genetic vulnerability and early attachment experience, which is expressed vulnerability and early attachment experience, which is expressed in the form of symptoms that define ADHDin the form of symptoms that define ADHD

Source: Crittenden & Kulbotten, 2007Source: Crittenden & Kulbotten, 2007

Self-RegulationSelf-RegulationAttachment theory: the early parent-child Attachment theory: the early parent-child relationship serves as the foundation for the relationship serves as the foundation for the emergence of self-regulation skills emergence of self-regulation skills

Research has consistently shown that insecurely Research has consistently shown that insecurely attached children are more vulnerable to deficits attached children are more vulnerable to deficits in self-regulation then securely attached childrenin self-regulation then securely attached children

Insecure attachment is associated with deficits in Insecure attachment is associated with deficits in self-regulation, as is ADHDself-regulation, as is ADHD

Source: Clark, Ungerer, Chahoud, Johnson, & Stiefel, 2002Source: Clark, Ungerer, Chahoud, Johnson, & Stiefel, 2002

Social FunctioningSocial Functioning

Insecurely attached children have trouble Insecurely attached children have trouble developing and maintaining healthy developing and maintaining healthy relationshipsrelationships

Children with ADHD show difficulties in Children with ADHD show difficulties in social functioning as wellsocial functioning as well

Source: Clarke et al., 2002Source: Clarke et al., 2002

Secure Infant Attachment Secure Infant Attachment HistoriesHistories

Increased attention spanIncreased attention span

High levels of positive affectHigh levels of positive affect

High levels of persistence in problem-solving High levels of persistence in problem-solving situationssituations

FlexibilityFlexibility

Impulse controlImpulse control

Task orientationTask orientation

Delay of gratificationDelay of gratification

Children with ADHD experience difficulties in the Children with ADHD experience difficulties in the above areasabove areas

Source: Clarke et al., 2002Source: Clarke et al., 2002

Family Functioning Family Functioning

Insecure attachment relationships are associated Insecure attachment relationships are associated with parental involvement characterized by:with parental involvement characterized by:– Minimal involvementMinimal involvement– Negativity Negativity – Lack of responsivity to infant signalsLack of responsivity to infant signals– IntrusivenessIntrusiveness

In lab settings, mothers of children with ADHD In lab settings, mothers of children with ADHD show similar behavior show similar behavior (Danforth, Barkley, & Stokes, 1991 (Danforth, Barkley, & Stokes, 1991 for review). for review).

Source: Clarke et al., 2002Source: Clarke et al., 2002

Family Function cont.Family Function cont.Families of children with ADHD experience Families of children with ADHD experience difficulties in a number of areas that are difficulties in a number of areas that are considered risk factors for insecure considered risk factors for insecure attachment:attachment:– Poor psychological functioningPoor psychological functioning– Increased levels of depression and other Increased levels of depression and other

psychiatric diagnoses in parentspsychiatric diagnoses in parents– High rates of marital distress and separationHigh rates of marital distress and separation– Social isolationSocial isolation

Source: Clark et al., 2002Source: Clark et al., 2002

Early Parent-Child Relations Early Parent-Child Relations and ADHDand ADHD

Maternal intrusiveness assessed when infants Maternal intrusiveness assessed when infants were 6 months old more powerfully predicted were 6 months old more powerfully predicted distractibility in early childhood and distractibility in early childhood and hyperactivity in middle childhood, than did hyperactivity in middle childhood, than did biological or temperament factors biological or temperament factors (Carlson, (Carlson,

Jacobvitz, & Sroufe, 1995)Jacobvitz, & Sroufe, 1995)

Clinical case reviews suggest that children Clinical case reviews suggest that children with ADHD have early parent-child with ADHD have early parent-child relationships that are similar to those with relationships that are similar to those with insecure attachmentsinsecure attachments

Early Parent-Child Relations Early Parent-Child Relations and ADHD cont.and ADHD cont.

Haddad and Garralda (1992) described Haddad and Garralda (1992) described severely disrupted early attachment severely disrupted early attachment relationships in children presenting to clinics relationships in children presenting to clinics with ADHD, which were not accompanied by with ADHD, which were not accompanied by biological indicatorsbiological indicators

Stiefel (1997) linked the emergence of Stiefel (1997) linked the emergence of symptoms in a clinical cohort of ADHD to a symptoms in a clinical cohort of ADHD to a lack of sustained parental attention during lack of sustained parental attention during the first years of the child’s lifethe first years of the child’s life

Converging Body of LiteratureConverging Body of Literature

Suggests:Suggests:– Attachment not peripheral to an understanding of Attachment not peripheral to an understanding of

ADHDADHD– Appears to be an association between attachment Appears to be an association between attachment

and ADHDand ADHD– Attachment theory offers a new perspective on Attachment theory offers a new perspective on

ADHD, which might help us to better treat those ADHD, which might help us to better treat those with the disorderwith the disorder

Source: Clarke et al., 2002Source: Clarke et al., 2002

Clarke, Ungerer, Chahoud, Clarke, Ungerer, Chahoud, Johnson, & Stiefel, 2002Johnson, & Stiefel, 2002

ParticipantsParticipants– 19 boys, 5 – 10 yrs old with ADHD 19 boys, 5 – 10 yrs old with ADHD – 19 boys, 5 – 10 yrs old without ADHD19 boys, 5 – 10 yrs old without ADHD

Compared on 3 representational Compared on 3 representational measuresmeasures– 2 Internal Working Models2 Internal Working Models– 1 Self1 Self

Clarke et al., 2002Clarke et al., 2002Separation Anxiety TestSeparation Anxiety Test– Pictures of parent-child separation experiencesPictures of parent-child separation experiences– Questions about character’s feelings and actionsQuestions about character’s feelings and actions

How does the boy feel?How does the boy feel?

What is the boy going to do?What is the boy going to do?

How does it all end? How does it all end?

– ScoringScoringVulnerability and need in severe separationsVulnerability and need in severe separations

Self-confidence about handling mild separationsSelf-confidence about handling mild separations

Degree of avoidance in discussing the separationDegree of avoidance in discussing the separation

Containment of negative emotionsContainment of negative emotions

Child’s general emotional experience of the parent-child Child’s general emotional experience of the parent-child relationshiprelationship

Clarke et al., 2002Clarke et al., 2002Family DrawingsFamily Drawings– Draw a picture of family, identify all persons in the drawing and Draw a picture of family, identify all persons in the drawing and

state relationship to each personstate relationship to each person– Scored based on the presence or absence of 24 specific Scored based on the presence or absence of 24 specific

drawing signsdrawing signs– To assess the context and patterning of the drawing signs, 8 To assess the context and patterning of the drawing signs, 8

global rating scales were used:global rating scales were used:Family Pride/HappinessFamily Pride/Happiness

VulnerabilityVulnerability

Emotional Distance/IsolationEmotional Distance/Isolation

Tension/AngerTension/Anger

Role ReversalRole Reversal

Bizarreness/DissociationBizarreness/Dissociation

Global PathologyGlobal Pathology

Self-InterviewSelf-Interview

20 Questions assessing self-concept20 Questions assessing self-concept– Can you tell me something you like about Can you tell me something you like about

yourself?yourself?– Can you tell me 5 words that describe you?Can you tell me 5 words that describe you?

ScoringScoring– Richness of DescriptionsRichness of Descriptions– Openness/FlexibilityOpenness/Flexibility– CoherencyCoherency

ResultsResultsOverall, ADHD group obtained poorer Overall, ADHD group obtained poorer scores on all three measures, indicating scores on all three measures, indicating predominantly insecure attachmentspredominantly insecure attachments

Separation Anxiety TestSeparation Anxiety Test– Less likely to express an appropriate level of Less likely to express an appropriate level of

concern, fear, or feelings of sadness about concern, fear, or feelings of sadness about difficult separationsdifficult separations

– Expressed extreme feelings and behaviorsExpressed extreme feelings and behaviors– Less likely to express confidence and feelings Less likely to express confidence and feelings

of well being in the context of easier of well being in the context of easier separationsseparations

Results cont.Results cont.– Coping strategies involving retribution, hostility, Coping strategies involving retribution, hostility,

or hatredor hatred– Situations spiraled into disasters beyond their Situations spiraled into disasters beyond their

and others’ controland others’ control– Predominantly negative descriptions of the Predominantly negative descriptions of the

parent-child relationshipparent-child relationship

Family DrawingsFamily Drawings– Differed markedly from control groupDiffered markedly from control group– Suggested lower levels of family pride and Suggested lower levels of family pride and

higher levels of vulnerability, tension, anger, role higher levels of vulnerability, tension, anger, role reversal in the mother-child relationship, reversal in the mother-child relationship, bizarreness, dissociation, and overall pathology bizarreness, dissociation, and overall pathology

Results cont.Results cont.– Relationship anxiety tended to predominateRelationship anxiety tended to predominate– Themes of anger, confusion, and low self-Themes of anger, confusion, and low self-

esteemesteem– These themes were expressed in a variety of These themes were expressed in a variety of

ways:ways:

Distorted and/or frightening figuresDistorted and/or frightening figures

Unusual symbolsUnusual symbols

Little color or detailLittle color or detail

Overall reckless qualityOverall reckless quality

Results cont.Results cont.Self-InterviewSelf-Interview– In the ADHD group, their self-descriptions were In the ADHD group, their self-descriptions were

less richly developed and coherent relative to less richly developed and coherent relative to controls, conveying a less developed sense of controls, conveying a less developed sense of selfself

– Less open and flexible in their self-conceptLess open and flexible in their self-concept– Often presented a negative self-conceptOften presented a negative self-concept– Often appeared emotionally disconnectedOften appeared emotionally disconnected

Overall Overall Results suggest that the nature of attachment insecurity Results suggest that the nature of attachment insecurity in this ADHD group is one of heightened emotional in this ADHD group is one of heightened emotional expression characterized by strong, out of control affects expression characterized by strong, out of control affects

Didn’t display the open, flexible emotional expression Didn’t display the open, flexible emotional expression that is considered to reflect a secure internal working that is considered to reflect a secure internal working modelmodel

Responses suggest insecure attachment styleResponses suggest insecure attachment style

In this context, the impulsivity, negative attention-In this context, the impulsivity, negative attention-seeking, recklessness, hyperactivity, and frequent seeking, recklessness, hyperactivity, and frequent oppositionality seen in ADHD children can be viewed as oppositionality seen in ADHD children can be viewed as a strategy to gain attention from a less than optimally a strategy to gain attention from a less than optimally available caregiver available caregiver

DiscussionDiscussionFindings contrary to the results of Chahoud (2000), in Findings contrary to the results of Chahoud (2000), in which the same exact participants were used as in which the same exact participants were used as in Clarke et al. (2002)Clarke et al. (2002)

Chahoud rated segments of child-directed play, Chahoud rated segments of child-directed play, mother-directed play, a teaching task, and clean-up mother-directed play, a teaching task, and clean-up activity on variables such as gratification, activity on variables such as gratification, involvement, and sensitivityinvolvement, and sensitivity

Results showed no differences between the ADHD Results showed no differences between the ADHD group and controlsgroup and controls

16 of the 19 children in the ADHD group were being 16 of the 19 children in the ADHD group were being treated with stimulant medications and 15 had treated with stimulant medications and 15 had received some level of psychological interventionreceived some level of psychological intervention

DiscussionDiscussionClaim that the effects of these medical and Claim that the effects of these medical and behavioral interventions may have been to mask behavioral interventions may have been to mask underlying relational problems, at least in terms of underlying relational problems, at least in terms of their manifestation in a lab-based interactiontheir manifestation in a lab-based interaction

Traditional treatment approaches may temporarily Traditional treatment approaches may temporarily or even permanently improve the behavioral or even permanently improve the behavioral manifestations of ADHD, but they do not attempt to manifestations of ADHD, but they do not attempt to impact on the child’s internal working model or the impact on the child’s internal working model or the parents’ view of the childparents’ view of the child

So, parent-child relationship problems will still be So, parent-child relationship problems will still be evidentevident

DiscussionDiscussion

Discrepancy between their findings and those of of Discrepancy between their findings and those of of Chahoud (2000) challenge the claim that research Chahoud (2000) challenge the claim that research showing reversal of problematic parent-child showing reversal of problematic parent-child interactional patterns following treatment with interactional patterns following treatment with stimulant medications indicates that the difficult stimulant medications indicates that the difficult interactions seen in unmedicated kids are mainly interactions seen in unmedicated kids are mainly due to child factorsdue to child factors

Implications for TreatmentImplications for TreatmentIf we can identify secure and insecure children with If we can identify secure and insecure children with ADHD, we can tailor their treatment more to their ADHD, we can tailor their treatment more to their needsneeds– If there is a secure relationship, parent training may be If there is a secure relationship, parent training may be

appropriate, as parents may be able to focus on the appropriate, as parents may be able to focus on the current interaction and apply behavior management skills current interaction and apply behavior management skills objectively and consistentlyobjectively and consistently

– However, if the relationship is insecure, relationship However, if the relationship is insecure, relationship issues may need to be addressed first before parents can issues may need to be addressed first before parents can be expected to focus on applying behavior management be expected to focus on applying behavior management skills and making enduring changesskills and making enduring changes

LimitationsLimitationsADHD group all referrals ADHD group all referrals

No inclusion of non-ADHD psychiatric control No inclusion of non-ADHD psychiatric control group and/or a non-clinic sample with ADHDgroup and/or a non-clinic sample with ADHD

Small sample size prevented examination of the Small sample size prevented examination of the impact of comorbidity on attachment insecurity in impact of comorbidity on attachment insecurity in children with ADHD or a comparison of findings for children with ADHD or a comparison of findings for the different subtypesthe different subtypes

All boysAll boys

Inclusion of children of hospital employees in Inclusion of children of hospital employees in control groupcontrol group

Unanswered QuestionsUnanswered QuestionsNot clear whether quality of caregiving Not clear whether quality of caregiving contributes directly to the development of contributes directly to the development of ADHD-related problems or if the child’s ADHD-related problems or if the child’s behaviors lead to disturbances in interactions behaviors lead to disturbances in interactions

Role of child characteristics should not be Role of child characteristics should not be overlookedoverlooked

Likely a transactional model in which Likely a transactional model in which attachment processes are conceptualized as a attachment processes are conceptualized as a function of complex and ongoing interactions function of complex and ongoing interactions among parent, child, and among parent, child, and environmental/experiential factorsenvironmental/experiential factors

Unanswered Questions cont.Unanswered Questions cont.

Longitudinal research is needed to disentangle Longitudinal research is needed to disentangle the effects of these different factors on the the effects of these different factors on the development of attachment security and ADHDdevelopment of attachment security and ADHD

Provide info regarding risk and protective factors Provide info regarding risk and protective factors and suggest strategies for early interventions and suggest strategies for early interventions

Pinto, Turton, Hughes, White, & Pinto, Turton, Hughes, White, & Gillberg, 2006Gillberg, 2006

Is there an association between Is there an association between disorganized/disoriented attachment and disorganized/disoriented attachment and later ADHD?later ADHD?

ParticipantsParticipants– Cohort of 104 childrenCohort of 104 children

1 yrs old: Attachment style assessed by 1 yrs old: Attachment style assessed by using the Strange Situationusing the Strange Situation

6 – 8 yrs old: ADHD assessed6 – 8 yrs old: ADHD assessed

Pinto et al., 2006Pinto et al., 2006Assessment of ADHDAssessment of ADHD– ADHD Rating Scale-IVADHD Rating Scale-IV

Mothers and teachers independentlyMothers and teachers independently

– Observer-rated assessment of ADHD (developed Observer-rated assessment of ADHD (developed by Pinto et al.)by Pinto et al.)

30 min doll-play story completion task30 min doll-play story completion task

Child was required to listen to the story and Child was required to listen to the story and then complete a series of story stems then complete a series of story stems presented presented

Pinto et al., 2006Pinto et al., 2006

3 broad areas, each with different measures:3 broad areas, each with different measures:– Hyperactivity: fidgeting, getting up from chair and Hyperactivity: fidgeting, getting up from chair and

talkativenesstalkativeness

– Inattention: lack of persistent active listening, distractibility, Inattention: lack of persistent active listening, distractibility, and needing prompting to continue with the storyand needing prompting to continue with the story

– Impulsivity: child interrupting the assessor to take over the Impulsivity: child interrupting the assessor to take over the narrative before story stem completion and interrupting with narrative before story stem completion and interrupting with something unrelated before the question is finished something unrelated before the question is finished

Measures were rated on a 4-point Likert-type scale Measures were rated on a 4-point Likert-type scale (0=never, 1=occasionally, 2= some of the time, and (0=never, 1=occasionally, 2= some of the time, and 3=constantly)3=constantly)

Pinto et al., 2006Pinto et al., 2006– Put the mother-rated, teacher-rated, and observer-rated Put the mother-rated, teacher-rated, and observer-rated

assessments together to arrive at a categorical assessments together to arrive at a categorical diagnoses for ADHDdiagnoses for ADHD

– Probable case: child was given a score of 20 or more on Probable case: child was given a score of 20 or more on the parent-rated and teacher-rated assessment plus a the parent-rated and teacher-rated assessment plus a score of 2 or more for the observed ratingsscore of 2 or more for the observed ratings

– Possible case: the above criteria were not met but the Possible case: the above criteria were not met but the child was given a score of 18 or more on either the child was given a score of 18 or more on either the parent- or teacher-rated assessment and a score of 10 parent- or teacher-rated assessment and a score of 10 or more on the same scale rated by the other (parent or or more on the same scale rated by the other (parent or teacher), plus a score of 2 or more for the observed teacher), plus a score of 2 or more for the observed ratingrating

ResultsResults26% of infants were classified as 26% of infants were classified as disorganizeddisorganized

7.8% of children met ‘probable’ ADHD case7.8% of children met ‘probable’ ADHD case criteria criteria

10.7% of children met ‘possible’ ADHD case 10.7% of children met ‘possible’ ADHD case criteriacriteria

23.1% of mothers vs. 24.3% of teachers rated 23.1% of mothers vs. 24.3% of teachers rated the child above cut-off score of 20the child above cut-off score of 20

Mother and teacher-rated ADHD scores were Mother and teacher-rated ADHD scores were highly correlated highly correlated

Results cont.Results cont. No association between infant disorganized No association between infant disorganized

attachment and later childhood ADHD casenessattachment and later childhood ADHD caseness Rate of probable ADHD caseness in the children Rate of probable ADHD caseness in the children

was similar to that of the general population rate for was similar to that of the general population rate for ADHDADHD

Mean disorganized scores were 4.06 (SD=1.43) in Mean disorganized scores were 4.06 (SD=1.43) in the probable case group, 3.68 (SD=1.87) in the the probable case group, 3.68 (SD=1.87) in the possible case group, and 3.58 (SD. 1.72) in the possible case group, and 3.58 (SD. 1.72) in the noncase groupnoncase group

Significant correlation between disorganized scores Significant correlation between disorganized scores and teacher rated ADHD symptoms (more strongly and teacher rated ADHD symptoms (more strongly associated with inattention than hyperactivity)associated with inattention than hyperactivity)

DiscussionDiscussionWhat are the attributes of disorganized infants that What are the attributes of disorganized infants that

teachers (but not mothers) observe several years later teachers (but not mothers) observe several years later as ADHD symptoms?as ADHD symptoms?

Likely that both mothers and teachers would find Likely that both mothers and teachers would find hyperactivity hard to manage but that mothers may be hyperactivity hard to manage but that mothers may be less sensitive to inattention and perhaps are not less sensitive to inattention and perhaps are not troubled or become habituated to this aspect of ADHDtroubled or become habituated to this aspect of ADHD

Lent credence by the trend in their results for Lent credence by the trend in their results for disorganized attachment to be more strongly disorganized attachment to be more strongly associated with teacher-rated inattention than with associated with teacher-rated inattention than with hyperactivity hyperactivity

LimitationsLimitations

Small sample sizeSmall sample sizeHalf of the cohort had experienced a major Half of the cohort had experienced a major

trauma (stillbirth), whereas the other half had trauma (stillbirth), whereas the other half had notnot

In depth clinical psychiatric examination In depth clinical psychiatric examination specifically for ADHD and comorbid conditions specifically for ADHD and comorbid conditions was not includedwas not included

Therefore, the conclusions can only be tentativeTherefore, the conclusions can only be tentative

  

Clinical ImplicationsClinical Implications

Attachment issues should be addressed in Attachment issues should be addressed in children presenting with disruptive children presenting with disruptive behavior disorder, at least in those behavior disorder, at least in those presenting with symptoms of ADHD that presenting with symptoms of ADHD that do not amount to full-blown clinical ADHD do not amount to full-blown clinical ADHD casenesscaseness

Ladnier’s & Massanari’s (2000) Ladnier’s & Massanari’s (2000) ModelModel

Based on theory and clinical experienceBased on theory and clinical experienceNoticed that many of their ADHD patients shared Noticed that many of their ADHD patients shared

deficits in deficits in

– ability to regulate emotions and behavior ability to regulate emotions and behavior

– ability to form healthy relationships with othersability to form healthy relationships with othersConsistent with the classic symptoms of an Consistent with the classic symptoms of an

attachment-disordered childattachment-disordered child

Ladnier & Massanari, 2000 Ladnier & Massanari, 2000

Also noted that research has shown that a Also noted that research has shown that a failure to form a secure attachment early in failure to form a secure attachment early in life, can result in cognitive, emotional, and life, can result in cognitive, emotional, and behavioral changes behavioral changes

– HyperactivityHyperactivity

– ImpulsivityImpulsivity

– Impaired social functioningImpaired social functioning

Ladnier & Massanari, 2000Ladnier & Massanari, 2000

Sought to answer two questions: Sought to answer two questions: – 1. Is there a causal connection between 1. Is there a causal connection between

attachment failure and ADHD?attachment failure and ADHD?– 2. Would it be possible to create a 2. Would it be possible to create a

developmental model, based on attachment developmental model, based on attachment theory, that would provide a valid and credible theory, that would provide a valid and credible explanation for the origin of ADHD and explanation for the origin of ADHD and suggest a treatment plan that could offer a suggest a treatment plan that could offer a child more than temporary relief from child more than temporary relief from symptoms?symptoms?

Ladnier & Massanari, 2000 Ladnier & Massanari, 2000 Underlying belief that attachment trauma in early Underlying belief that attachment trauma in early

childhood results in developmental deficits which, in the childhood results in developmental deficits which, in the absence of remedial parenting, are likely to be manifested absence of remedial parenting, are likely to be manifested as the symptoms of ADHDas the symptoms of ADHD

The model can be most simply stated as the following:The model can be most simply stated as the following:– Bonding breaks —> Attachment deficits —> Symptoms Bonding breaks —> Attachment deficits —> Symptoms

of ADHDof ADHD Bonding break is an event or combination of events that Bonding break is an event or combination of events that

causes physiological trauma and developmental arrest causes physiological trauma and developmental arrest and interferes with a child’s opportunity to form a secure and interferes with a child’s opportunity to form a secure attachment with a caregiverattachment with a caregiver

Ladnier & Massanari, 2000Ladnier & Massanari, 2000Begins with 3 major assumptions: Begins with 3 major assumptions:

– 1. A child diagnosed with ADHD has 1. A child diagnosed with ADHD has experienced a bonding break(s) before the experienced a bonding break(s) before the age of 2age of 2

– 2. The bonding break(s) have interfered with 2. The bonding break(s) have interfered with the process of healthy attachment between the process of healthy attachment between child and caregiver and created child and caregiver and created developmental deficits in the childdevelopmental deficits in the child

– 3. The family system the child grew up in was 3. The family system the child grew up in was not healthy enough to overcome those deficitsnot healthy enough to overcome those deficits

Ladnier & Massanari, 2000Ladnier & Massanari, 2000Basic idea:Basic idea:

– The failure to attach to an adult caregiver as a The failure to attach to an adult caregiver as a result of a bonding break(s) results in psychological result of a bonding break(s) results in psychological and physiological traumaand physiological trauma

– This trauma interferes with an infant’s neurological This trauma interferes with an infant’s neurological and hormonal maturationand hormonal maturation

– This interference results in developmental delays This interference results in developmental delays (attachment deficits)(attachment deficits)

– These delays are reflected in emotional and These delays are reflected in emotional and behavioral problems that are manifested in the behavioral problems that are manifested in the symptoms of ADHDsymptoms of ADHD

Bonding BreaksBonding Breaks

4 Types: 4 Types: – Prenatal InfluencesPrenatal Influences– Inattentive CaregiversInattentive Caregivers– Situational TraumasSituational Traumas– Faulty Parenting Faulty Parenting

Most experience a combination of bonding Most experience a combination of bonding breaks, sequentially or simultaneouslybreaks, sequentially or simultaneously

Prenatal InfluencesPrenatal Influences In typical development, a healthy newborn arrives in In typical development, a healthy newborn arrives in

the world programmed to attach to a suitable caregiver the world programmed to attach to a suitable caregiver However, some newborns arrive in a state of distress However, some newborns arrive in a state of distress

and extreme hyperarousal. For example, premature and extreme hyperarousal. For example, premature babies; babies that were exposed prenatally to chronic babies; babies that were exposed prenatally to chronic and acute levels of stress hormones or chemical and acute levels of stress hormones or chemical compounds or toxinscompounds or toxins

These newborns are not programmed to seek out a These newborns are not programmed to seek out a caregiver because their state of emotional alarm caregiver because their state of emotional alarm prevents them from responding to attaching cues in prevents them from responding to attaching cues in their caregivertheir caregiver

Inattentive CaregiversInattentive Caregivers Occurs when a healthy infant is born to caregivers who fail Occurs when a healthy infant is born to caregivers who fail

to provide the minimum amount of warmth needed for to provide the minimum amount of warmth needed for attachment to occurattachment to occur

Do not provide behaviors such as eye contact, soothing Do not provide behaviors such as eye contact, soothing words and touch, breast-feeding, holding, rocking and words and touch, breast-feeding, holding, rocking and smilingsmiling

These behaviors are needed for attachment to occurThese behaviors are needed for attachment to occur Inattentive caregivers neglect their infants because they Inattentive caregivers neglect their infants because they

are self-centered and lack empathy for others or because are self-centered and lack empathy for others or because they lack sufficient info or motivation to provide the they lack sufficient info or motivation to provide the nurturance their infant needsnurturance their infant needs

Situational TraumasSituational Traumas

Includes a variety of conditions and events Includes a variety of conditions and events that occur outside the control of the that occur outside the control of the primary caregiver primary caregiver

For example, premature babies, For example, premature babies, separation for caregiver due to death, or separation for caregiver due to death, or illness on the part of the parent or childillness on the part of the parent or child

Faulty Parenting Faulty Parenting Prevalent in home situations where the child Prevalent in home situations where the child

experiences trauma that is very difficult, if not experiences trauma that is very difficult, if not impossible, for him or her to overcomeimpossible, for him or her to overcome

These situations are typically characterized by These situations are typically characterized by the following: the following: – 1. Absence of a healthy relationship between two 1. Absence of a healthy relationship between two

caring adultscaring adults– 2. A pattern of exposure to yelling, criticism, 2. A pattern of exposure to yelling, criticism,

sarcasm, and violencesarcasm, and violence– 3. Parenting that lacks respect, discipline, structure 3. Parenting that lacks respect, discipline, structure

and consistency and consistency

Attachment Deficits Attachment Deficits Bonding breaks result in attachment deficits:Bonding breaks result in attachment deficits:

characteristics that appear to be absent or characteristics that appear to be absent or underdeveloped in a child, as evidenced by emotions underdeveloped in a child, as evidenced by emotions and behaviors that are developmentally inappropriateand behaviors that are developmentally inappropriate

These deficits might correspond to specific These deficits might correspond to specific regions of neural circuitry in a child’s brain that regions of neural circuitry in a child’s brain that have not developed normally because of early have not developed normally because of early bonding breaks bonding breaks

Attachment Deficits are divided into two groups: Attachment Deficits are divided into two groups: – Deficits in Self RegulationDeficits in Self Regulation– Deficits in Relating SkillsDeficits in Relating Skills

Deficits in Self Regulation Deficits in Self Regulation

Impulse ControlImpulse ControlSelf-soothing Self-soothing InitiativeInitiativePerseverancePerseverancePatience Patience InhibitionInhibition

Deficits in Self-Relating SkillsDeficits in Self-Relating Skills

EmpathyEmpathyTrustTrustAffectionAffectionReciprocityReciprocityExpressionExpressionRespectRespect

Cycle of Conflict Between Cycle of Conflict Between Caregiver and ChildCaregiver and Child

Cycle perpetuates and worsens the symptoms of ADHD.Cycle perpetuates and worsens the symptoms of ADHD.– Child experiences strong negative emotion (anger, fear, Child experiences strong negative emotion (anger, fear,

sadness)sadness)

– Since the child lacks the capacity for self-soothing, Since the child lacks the capacity for self-soothing, impulse-control and expression, he or she attempts to impulse-control and expression, he or she attempts to connect with the parent through intrusive, demanding, connect with the parent through intrusive, demanding, attention-seeking behaviorsattention-seeking behaviors

– Parent begins to feel irritation and resentment and is Parent begins to feel irritation and resentment and is unable to express empathy, affection or respect for the unable to express empathy, affection or respect for the childchild

Cycle of Conflict Between Cycle of Conflict Between Caregiver and ChildCaregiver and Child

– Parent responds by criticizing, threatening or hitting Parent responds by criticizing, threatening or hitting childchild

– Child reacts by tuning the parent out and silently Child reacts by tuning the parent out and silently planning revenge or becomes defiant and coercive planning revenge or becomes defiant and coercive and raises the level of his acting-out behaviorsand raises the level of his acting-out behaviors

– Parent feels angry and scared and either gives up Parent feels angry and scared and either gives up and withdraws or raises the level of conflict in an and withdraws or raises the level of conflict in an effort to defeat the child. effort to defeat the child.

– Both child and parent are left frustrated and angry Both child and parent are left frustrated and angry and determined to get even by winning the next fightand determined to get even by winning the next fight

Treatment Treatment

Treatment of choice should be family therapyTreatment of choice should be family therapyChildren are not likely to make significant Children are not likely to make significant

changes in their thoughts and behaviors without changes in their thoughts and behaviors without simultaneous changes in their family systemssimultaneous changes in their family systems

Developed a model for family therapy based on Developed a model for family therapy based on corrective attachment theory, family systems corrective attachment theory, family systems theory, and cognitive and behavioral techniquestheory, and cognitive and behavioral techniques

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Parents ProblemsParents Problems– Medication-Seeking ParentMedication-Seeking Parent– Exhausted, Overwhelmed ParentExhausted, Overwhelmed Parent– Guilty ParentGuilty Parent

CotherapistsCotherapists– Collect biopsychosocial info about the parentsCollect biopsychosocial info about the parents– Child’s historyChild’s history– Outline basic goals and objectives of treatmentOutline basic goals and objectives of treatment– Listen to Parents’ Concerns Listen to Parents’ Concerns

Formulate a Detailed Formulate a Detailed Assessment of the Child’s Assessment of the Child’s

ProblemsProblems BehaviorBehavior Feeling Feeling ThinkingThinking

– A child who does not form a secure attachment A child who does not form a secure attachment with a primary caregiver does not think the with a primary caregiver does not think the same thoughts as a healthy childsame thoughts as a healthy child

– Distorted thoughts and delusional belief are a Distorted thoughts and delusional belief are a consequence of bonding breaks and consequence of bonding breaks and attachment deficitsattachment deficits

  

Formulate a Detailed Formulate a Detailed Assessment of the Child’s Assessment of the Child’s

ProblemsProblems

– For example, a child that doesn’t learn to trust For example, a child that doesn’t learn to trust will develop core beliefs such as: will develop core beliefs such as: Adults are unreliable, unresponsive and Adults are unreliable, unresponsive and

untrustworthyuntrustworthyBeing close to others is not pleasantBeing close to others is not pleasantI must control others in order to be safeI must control others in order to be safe

Formulate a Detailed Formulate a Detailed Assessment of the Child’s Assessment of the Child’s

ProblemsProblems– A child that doesn’t receive the modulating A child that doesn’t receive the modulating

responses he needs from a primary caregiver responses he needs from a primary caregiver fails to learn self-regulation and may hold fails to learn self-regulation and may hold beliefs such as:beliefs such as:I am not able to control myselfI am not able to control myselfWhen I want something, I should not have When I want something, I should not have

to wait forto wait for

Formulate a Detailed Formulate a Detailed Assessment of the Child’s Assessment of the Child’s

ProblemsProblems

– A child who lacks sufficient soothing A child who lacks sufficient soothing interaction with a caregiver does not learn interaction with a caregiver does not learn self-soothing and may be convinced that:self-soothing and may be convinced that:Feelings are dangerous and should be Feelings are dangerous and should be

avoidedavoidedThings that are not stimulating or Things that are not stimulating or

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– Eliminate hitting, yelling, criticism, and sarcasm Eliminate hitting, yelling, criticism, and sarcasm from family interactionsfrom family interactions

– Create empathy, affection and respectCreate empathy, affection and respect– CommunicationCommunication– Create consist rules, roles, and routinesCreate consist rules, roles, and routines– Establish limits and boundariesEstablish limits and boundaries– CooperationCooperation

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Teach specific ways to use physical contact Teach specific ways to use physical contact to promote affection and trust between child to promote affection and trust between child and caregiverand caregiver

Teach parent how to express empathy Teach parent how to express empathy towards childtowards child

Teach playful interactions between child and Teach playful interactions between child and caregivercaregiver

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Group Therapy Group Therapy EEG BiofeedbackEEG BiofeedbackArt and Play Therapy Art and Play Therapy Organized Sports Organized Sports MedicationMedication

–Last resortLast resort–Will only bring about temporary change, Will only bring about temporary change,

whereas other therapy, such as family therapy, whereas other therapy, such as family therapy, will bring about more permanent change.will bring about more permanent change.

Access Collateral Therapies to Access Collateral Therapies to Increase Self-Regulation and Increase Self-Regulation and

Relating Skills Relating Skills Medications cont.Medications cont.

– Medications that maintain a state of Medications that maintain a state of lethargy or euphoria can hinder other types lethargy or euphoria can hinder other types of therapyof therapy

– However, there are cases where they must However, there are cases where they must be usedbe used

– Medication can improve symptoms, but Medication can improve symptoms, but cannot help in the reparation of the cannot help in the reparation of the attachment deficits caused by bonding attachment deficits caused by bonding breaks between caregiver and child breaks between caregiver and child

Problems with ModelProblems with Model Based on strictly clinical populationBased on strictly clinical population No researchNo research Doesn’t explain people with ADHD who came from Doesn’t explain people with ADHD who came from

healthy functioning familieshealthy functioning families Doesn’t explain people who have experienced bonding Doesn’t explain people who have experienced bonding

breaks and come from unhealthy functioning families, breaks and come from unhealthy functioning families, but have not developed ADHDbut have not developed ADHD

Doesn’t explain why some people can take medication Doesn’t explain why some people can take medication only with no other form of intervention and lead healthy only with no other form of intervention and lead healthy and fulfilling livesand fulfilling lives

Applied to any group with psychological problems Applied to any group with psychological problems

Stiefel, 1997Stiefel, 1997Emphasizes the detrimental role of early stress on Emphasizes the detrimental role of early stress on

the attachment relationship and that this could the attachment relationship and that this could possibly lead to ADHDpossibly lead to ADHD

Points out that not every child who experiences Points out that not every child who experiences early stressors will develop ADHD early stressors will develop ADHD

Claims that it is sequential patterns of interactional Claims that it is sequential patterns of interactional stress between the parent and child that hinders stress between the parent and child that hinders attachment and possibly leads to ADHD, rather attachment and possibly leads to ADHD, rather then multiple one point in time stressors then multiple one point in time stressors

Stiefel, 1997 cont. Stiefel, 1997 cont. You can have multiple early life stressor, but if you have some You can have multiple early life stressor, but if you have some

intervening variable, such as psychosocial buffering and support, intervening variable, such as psychosocial buffering and support, this can alleviate the stress and allow a healthy attachment this can alleviate the stress and allow a healthy attachment relationship to develop and thus possible prevent the relationship to develop and thus possible prevent the development of ADHD development of ADHD

If there are no intervening variables, and the stress continues, If there are no intervening variables, and the stress continues, this is going to hinder the attachment relationship and possibly this is going to hinder the attachment relationship and possibly lead to ADHD lead to ADHD

Therefore, if we can identify families who experience high levels Therefore, if we can identify families who experience high levels of stress and then intervene, we can possible prevent ADHD from of stress and then intervene, we can possible prevent ADHD from developing in some childrendeveloping in some children

Reactive Attachment Disorder Reactive Attachment Disorder (RAD)(RAD)

Attachment disorder characterized by Attachment disorder characterized by disturbed and developmentally inappropriate disturbed and developmentally inappropriate social relatedness that begins before 5 years social relatedness that begins before 5 years of ageof age

Develops from a failure to form a healthy Develops from a failure to form a healthy attachment with a primary caregiver as a result attachment with a primary caregiver as a result of severe early experiences of pathological of severe early experiences of pathological care, such as extreme abuse and/or neglectcare, such as extreme abuse and/or neglect

It is uncommonIt is uncommonSource: American Psychiatric Association, 1994Source: American Psychiatric Association, 1994

Reactive Attachment Disorder cont. Reactive Attachment Disorder cont. Two types: Two types:

– Inhibited: Inhibited: Failure to initiate and respond to most social interactions in a Failure to initiate and respond to most social interactions in a

developmentally appropriate way, as manifest by excessively developmentally appropriate way, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory inhibited, hypervigilant, or highly ambivalent and contradictory responsesresponses

– Disinhibited: Disinhibited: Indiscriminate sociability with marked inability to exhibit Indiscriminate sociability with marked inability to exhibit

appropriate selective attachment (e.g., excessive familiarity with appropriate selective attachment (e.g., excessive familiarity with relative strangers or a lack of selectivity in choice of attachment relative strangers or a lack of selectivity in choice of attachment figures)figures)

Source: American Psychiatric Association, 1994Source: American Psychiatric Association, 1994

Reactive Attachment DisorderReactive Attachment Disorder

DSM-IV points out that the Disinhibited type must DSM-IV points out that the Disinhibited type must be distinguished from the impulsive or hyperactive be distinguished from the impulsive or hyperactive behavior seen in ADHDbehavior seen in ADHD

The disinhibited behavior in RAD is associated with The disinhibited behavior in RAD is associated with attempting to form a social attachment after a very attempting to form a social attachment after a very brief acquaintance brief acquaintance

RAD is typically comorbid with other disorders, RAD is typically comorbid with other disorders, such as ODD and ADHDsuch as ODD and ADHD

Source: American Psychiatric Association, 1994Source: American Psychiatric Association, 1994

Reactive Attachment DisorderReactive Attachment Disorder

RAD diagnostic study that also looked at RAD diagnostic study that also looked at comorbiditycomorbidity– Participants: 40 RAD children, 5 - 8 yrs oldParticipants: 40 RAD children, 5 - 8 yrs old– Assessed RAD symptoms with an18-itemAssessed RAD symptoms with an18-item– Assessed ADHD with ?Assessed ADHD with ?– ResultsResults

68% of the RAD cases met criteria for ADHD68% of the RAD cases met criteria for ADHDNo children met criteria for ADHD but not RADNo children met criteria for ADHD but not RAD

Source: Reactive Attachment Study, n.d.Source: Reactive Attachment Study, n.d.

Questions…Questions…