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Attachment Anxiety Moderates the Association Between ADHD and Psychological Distress

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Abstract

This study aims at examining the possible moderating role of attachment style in the association between ADHD and psychological distress, namely, anxiety and depression symptoms. Study included ninty nine participants: Sixty adults with ADHD diagnosis and thirty nine adults without ADHD or other neurological and/or psychiatric disorders. All participants completed the Patient Health Questionnaire (PHQ-9), State-Trait Anxiety (STAI) questionnaires, Emotion in Close Relationships (ECR-R) questionnaire and Adult ADHD Self-Report Scale–Version 1.1 (ASRS-v1.1). Adults with ADHD had greater symptoms of depression (p < .001) and anxiety (p < .001) than adults without ADHD. Process analysis yielded that attachment anxiety moderated the association between ADHD, anxiety and depression, therefore only adults with ADHD that had moderate to high attachment anxiety exhibited higher levels of depression (p < .01) and anxiety (p < .001). No moderating effect was observed for attachment avoidance. Moreover, we did not find correlations between ADHD, anxiety and depression when secure attachment was the moderator; indicating that secure attachment could serve as a “protective factor” against psychological distress among ADHD individuals. Among anxiously attached adults, ADHD was associated with higher levels psychological distress. These findings highlight the important role of attachment style in mental health of adults with ADHD.

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Data Availability

The data that support the findings of this study are available from the corresponding author, [O.E], upon reasonable request.

References

  1. Al-Yagon M. Perceived close relationships with parents, teachers, and peers: Predictors of social, emotional, and behavioral features in adolescents with LD or comorbid LD and ADHD. J Learn Disabil. 2016;49(6):597–615. https://doi.org/10.1177/0022219415620569.

    Article  PubMed  Google Scholar 

  2. American Psychiatric Association. (2000). Diagnostic criteria from DSM-iV-tr. American Psychiatric Publishing ‏2019 Jul; 49(7):2733–2746. https://doi.org/10.1007/s10803-016-2936-9.

  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author; 2013. https://doi.org/10.1176/appi.books.9780890423349.

  4. Armsden GC, McCauley E, Greenberg MT, Burke PM, Mitchell JR. Parent and peer attachment in early adolescent depression. J Abnorm Child Psychol. 1990;18(6):683–97.

    Article  CAS  PubMed  Google Scholar 

  5. Austin DW, Jamieson RS, Richards JC, & Winkelman J. The relationship between attachment style, anxiety sensitivity and interpretive bias among adolescent nonclinical panickers. Behav Change. 2006;23(1), 31–41. https://doi.org/10.1375/bech.23.1.31

  6. Bar-Haim Y, Dan O, Eshel Y, Sagi-Schwartz A. Predicting children’s anxiety from early attachment relationships. J Anxiety Disord. 2007;21:1061–8. https://doi.org/10.1016/j.janxdis.2006.10.013.

    Article  PubMed  Google Scholar 

  7. Barkley RA. Differential diagnosis of adults with ADHD: The role of executive function and self-regulation. J Clin Psychiatry. 2010;71(7):1–17. https://doi.org/10.4088/JCP.9066tx1c.

    Article  Google Scholar 

  8. Belsky J. Interactional and contextual determinants of attachment security. In: Cassidy J, Shaver PR, editors. Handbook of Attachment: Theory, Research, and Clinical Applications. New York, NY: Guilford Press; 1999. p. 249–64.

    Google Scholar 

  9. Ben-Naim S, Hirschberger G, Ein-Dor T, Mikulincer M. An experimental study of emotion regulation during relationship conflict interactions: The moderating role of attachment orientations. Emotion. 2013;13(3):506. https://doi.org/10.1037/a0031473.

    Article  PubMed  Google Scholar 

  10. Ben-Naim S, Marom I, Krashin M, Gifter B, Arad K. Life With a Partner with ADHD: The Moderating Role of Intimacy. J Child Fam Stud. 2017;26(5):1365–73.

    Article  Google Scholar 

  11. Biederman J, Faraone SV. Attention-deficit hyperactivity disorder. Lancet. 2005;366(9481):237–48. https://doi.org/10.1016/j.biopsych.2005.02.006.

    Article  PubMed  Google Scholar 

  12. Biederman J, Faraone SV, Keenan K, Tsuang MT. Evidence of familial association between attention deficit disorder and major affective disorders. Arch Gen Psychiatry. 1991;48(7):633–42. https://doi.org/10.1001/archpsyc.1991.01810310051009.

    Article  CAS  PubMed  Google Scholar 

  13. Biederman, Faraone, VJ, Spencer, TJ, Wilens T, Norman D, Lapey K, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with Attention Deficit Hyperactivity Disorder Weiss. 1993;1792–1798. https://doi.org/10.1176/ajp.150.12.1792.

  14. Bowlby J. Attachment and loss: Separation, anxiety and anger. New York: Basic Books; 1973.

    Google Scholar 

  15. Bowlby J. Attachment and loss: Attachment. New York: Basic Books; 1982. https://doi.org/10.1111/j.1939-0025.1982.tb01456.x.

    Book  Google Scholar 

  16. Brennan KA, Clark CL, Shaver PR. Serf-report measurement of adult attachment: An integrative overview. In: Simpson JA, Rholes WS, editors. Attachment Theory and Close Relationships. New York, NY: Guilford Press; 1998. p. 46–76.

    Google Scholar 

  17. Burt SA. Are there shared environmental influences on attention-deficit/hyperactivity disorder? Reply to Wood, Buitelaar, Rijsdijk, Asherson, and Kunsti (2010). Psychol Bull. 2010;136(3):341–3. https://doi.org/10.1037/a0019116.

    Article  PubMed  Google Scholar 

  18. Canu WH, Carlson CL. Rejection sensitivity and social outcomes of young men with ADHD. J Atten Disord. 2007;10:261–75. https://doi.org/10.1177/1087054706288106.

    Article  PubMed  Google Scholar 

  19. Collins NL, Ford MB, Guichard AC, & Feeney BC. Responding to need in intimate relarionships: Normative processes and individual differences. In M. Mikulincer & G. Goodman (Eds.), The dynamics of love: Attachment, caregiving, and sex. New York: Guilford Press; 2006.

  20. Collins NL, Ford MB, Guichard AC, Kane HS, & Feeney BC. Responding to the need in intimate relationships: Social support and caregiving processes in couples. In M. Mikulincer, & P. R. Shaver (Eds.), Prosocial motives, emotions, and behavior. Washington, DC; American Psychological Association; 2010. p. 367–389.

  21. Colonnesi C, Draijer EM, Stams JJM, G., Van der Bruggen, C. O., Bögels, S. M., & Noom, M. J. . The relation between insecure attachment and child anxiety: A meta-analytic review. J Clin Child Adolesc Psychol. 2011;40(4):630–45. https://doi.org/10.1080/15374416.2011.581623.

    Article  PubMed  Google Scholar 

  22. Costa PT, McCrae RR. Neo PI-R professional manual. Odessa, FL: Psychological assessment; 1992. https://doi.org/10.4135/9781849200479.n9.

    Book  Google Scholar 

  23. Crittenden PM, Kulbotton GR. Familial contributions to ADHD: An attachment perspective. Tidsskrift for Norsk Psykologorening. 2007;10:1220–9.

    Google Scholar 

  24. Daviss WB. A review of co-morbid depression in pediatric ADHD: Etiologies, phenomenology, and treatment. J Child Adolesc Psychopharmacol. 2008;18(6):565–71. https://doi.org/10.1089/cap.2008.032.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Diamond LM. Contributions of psychophysiology to research on adult attachment: Review and recommendations. Pers Soc Psychol Rev. 2001;5:276–95.

    Article  Google Scholar 

  26. Diamond LM, Hicks AM. Attachment style, current relationship security, and negative emotions: The mediating role of physiological regulation. J Soc Pers Relat. 2005;22:499–518.

    Article  Google Scholar 

  27. Edelstein RS, Gillath O. Avoiding interference: Adult attachment and emotional processing biases. Pers Soc Psychol Bull. 2008;34:171–81. https://doi.org/10.1177/0146167207310024.

    Article  PubMed  Google Scholar 

  28. Fraley RC, Waller NG, Brennan KA. An item-response theory analysis of self-report measures of adult attachment. J Pers Soc Psychol. 2000;78:350–65. https://doi.org/10.1037//0022-3514.78.2.350.

    Article  CAS  PubMed  Google Scholar 

  29. Glasser S, Jacobson DM, Levitan G, Ponizovsky AM. Validation of the Hebrew and Arabic versions of the Outcome Questionnaire (OQ-45). Isr J Psychiatry Relat Sci. 2015;52(1):33.

    PubMed  Google Scholar 

  30. Goldberg S, Muir R, & Kerr J. (Eds.). Attachment theory: Social, developmental, and clinical perspectives. Routledge; 2013.

  31. Hazan C, Shaver PR. Romantic love conceptualized as an attachment process. J Pers Soc Psychol. 1987;52:511–24.

    Article  CAS  PubMed  Google Scholar 

  32. Humphreys KL, Katz SJ, Lee SS, Hammen C, Brennan PA, Najman JM. The association of ADHD and depression: Mediation by peer problems and parent–child difficulties in two complementary samples. J Abnorm Psychol. 2013;122(3):854.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi EVA, Ustun TB. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005;35(02):245–56. https://doi.org/10.1017/S0033291704002892.

    Article  PubMed  Google Scholar 

  34. Kissgen R, Franke S. An attachment research perspective on ADHD. Neuropsychiatrie. 2016;30(2):63–8. https://doi.org/10.1007/s40211-016-0182-1.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kobak RR, Sceery A. Attachment in late adolescence: Working models, affect regulation, and representations of self and others. Child Dev. 1988;59:135–46. https://doi.org/10.2307/1130395.

    Article  CAS  PubMed  Google Scholar 

  36. Kobak RR, Sudler N, Gamble W. Attachment and depressive symptoms during adolescence: A developmental pathways analysis. Dev Psychopathol. 1991;3(4):461–74. https://doi.org/10.1017/S095457940000763X.

    Article  Google Scholar 

  37. Koemans RG, van Vroenhoven S, Karreman A, Bekker MH. Attachment and autonomy problems in adults with ADHD. J Atten Disord. 2015;19(5):435–46. https://doi.org/10.1177/1087054712453170.

    Article  PubMed  Google Scholar 

  38. Konfortes H. Diagnosing ADHD in Israeli adults: The psychometric properties of the adult ADHD Self Report Scale (ASRS) in Hebrew. Isr J Psychiatry Relat Sci. 2010;47(4):308.

    PubMed  Google Scholar 

  39. Kroenke K, Spitzer RL, Williams JB. The phq-9. J Gen Intern Med. 2001;16(9):606–13. https://doi.org/10.1046/j.15251497.2001.016009606.x.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Levy KN, Johnson BN, Clouthier TL, Scala J, Temes CM. An attachment theoretical framework for personality disorders. Can Psychol. 2015;56(2):197. https://doi.org/10.1037/cap0000025.

    Article  Google Scholar 

  41. Lopez FG, Mauricio AM, Gormley B, Simko T, Berger E. Adult attachment orientations and college student distress: The mediating role of problem coping styles. J Couns Dev. 2001;79:459–64. https://doi.org/10.1002/j.1556-6676.2001.tb01993.x.

    Article  Google Scholar 

  42. Mikulincer M, Shaver PR. The attachment behavioral system in adulthood: Activation, psychodynamics, and interpersonal processes. Adv Exp Soc Psychol. 2003;35:53–152.

    Article  Google Scholar 

  43. Mikulincer M, Shaver PR. Attachment in adulthood: Structure, dynamics, and change. New York, NY: Guilford Press; 2006. p. 160–3.

    Google Scholar 

  44. Mikulincer M, Shaver PR. An attachment perspective on bereavement. Handbook of bereavement research and practice: Advances in theory and intervention; 2008. p. 87–112.

    Google Scholar 

  45. Nigg JT, Nikolas M, Burt SA. Measured gene-by-environment interaction in relation to Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. 2010;49:863–73. https://doi.org/10.1016/j.jaac.2010.01.025.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Overbey GA, Snell WE, Callis KE. Subclinical ADHD, stress, and coping in romantic relationships of university students. J Atten Disord. 2011;15(1):67–78. https://doi.org/10.1177/1087054709347257.

    Article  PubMed  Google Scholar 

  47. Panevska LS, Zafirova-Ivanovska B, Vasilevska K, Isjanovska R, Kadri H. Relationship between ADHD and depression among university students in Macedonia. Materia socio-medica. 2015;27(1):18. https://doi.org/10.5455/msm.2014.27.18-21.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Prevatt F, Dehili V, Taylor N, Marshall D. Anxiety in college students with ADHD: relationship to cognitive functioning. J Atten Disord. 2015;19(3):222–30. https://doi.org/10.1177/1087054712457037.

    Article  PubMed  Google Scholar 

  49. Scharf M, Oshri A, Eshkol V, Pilowsky T. Adolescents’ ADHD symptoms and adjustment: The role of attachment and rejection sensitivity. Am J Orthopsychiatry. 2014;84(2):209.

    Article  PubMed  Google Scholar 

  50. Simpson JA, Rholes WS, Phillips D. Conflict in close relationships: An attachment perspective. J Pers Soc Psychol. 1996;71:899–914.

    Article  CAS  PubMed  Google Scholar 

  51. Spielberger CD, Gorsuch RL, Luschene RE, Vagg PR, & Jacobs GA. Manual for the State-Trait Anxiety Inventory (Form Y). Menlo Park. CA: Mind Garden; 1983. http://hdl.handle.net/10477/1873

  52. Spitzer RL, Kroenke K, Williams JB, & Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282(18):1737–44. https://doi.org/10.1001/jama.282.18.1737.

    Article  Google Scholar 

  53. Stams GJJM, Juffer F, Van IJzendoorn, M. H. . Maternal sensitivity, infant attachment, and temperament in early childhood predict adjustment in middle childhood: The case of adopted children and their biologically unrelated parents. Development Psychology. 2002;38:806–21.

    Article  Google Scholar 

  54. Storebø OJ, Rasmussen PD, Simonsen E. Association between insecure attachment and ADHD: Environmental mediating factors. J Atten Disord. 2016;20(2):187–96.

  55. Sørensen L, Plessen KJ, Nicholas J, Lundervold AJ. Is behavioral regulation in children with ADHD aggravated by comorbid anxiety disorder? J Atten Disord. 2011;15(1):56–66. https://doi.org/10.1177/1087054709356931.

    Article  PubMed  Google Scholar 

  56. Thapar A, van den Bree M, Fowler T, Langley K, Whittinger N. Predictors of antisocial behavior in children with attention deficit hyperactivity disorder. Eur Child Adolesc Psychiatry. 2006;15(2):118–25. https://doi.org/10.1007/s00787-006-0511-1.

    Article  PubMed  Google Scholar 

  57. Thapar A, Cooper M, Eyre O, Langley K. What have we learnt about the causes of ADHD? J Child Psychol Psychiatry. 2013;54(1):3–16. https://doi.org/10.1111/j.1469-7610.2012.02611.x.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Torrente F, López P, Alvarez Prado D, Kichic R, Cetkovich-Bakmas M, Lischinsky A, & Manes F. Dysfunctional Cognitions and their Emotional, Behavioral, and Functional Correlates in Adults with Attention Deficit Hyperactivity Disorder (ADHD). Is the Cognitive-Behavioral Model Valid? J Attent Disord. 2014;18(5), 412–424. https://doi.org/10.1177/1087054712443153

  59. Van de Glind G, van den Brink W, Koeter MW, Carpentier PJ, van Emmerik-van Oortmerssen K, Kaye S, Moggi F. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug Alcohol Depend. 2013;132(3):587–96. https://doi.org/10.1016/j.drugalcdep.2013.04.010.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Verschueren K, Marcoen A, Schoefs V. The internal working model of the self, attachment, and competence in five-year olds. Child Dev. 1996;67:2493–511. https://doi.org/10.1111/j.1467-8624.1996.tb01870.x.

    Article  CAS  PubMed  Google Scholar 

  61. Waters E, Cummings EM. A secure base from which to explore close relationships. Child Dev. 2003;71:164–72. https://doi.org/10.1111/1467-8624.00130.

    Article  Google Scholar 

  62. Weems CF, Berman SL, Silverman WK, Rodriguez ET. The relation between anxiety sensitivity and attachment style in adolescence and early adulthood. J Psychopathol Behav Assess. 2002;24(3):159–68.

    Article  Google Scholar 

  63. Wei M, Heppner PP, Mallinckrodt B. Perceived coping as a mediator between attachment and psychological distress: A structural equation modeling approach. J Couns Psychol. 2003;50:438–47.

    Article  Google Scholar 

  64. Wei M, Mallinckrodt B, Russell DW, Abraham WT. Perfectionism as a mediator and moderator between adult attachment and psychological distress. J Couns Psychol. 2004;51:201–12.

    Article  Google Scholar 

  65. Wei M, Shaffer PA, Young SK, Zakalik RA. Adult attachment, shame, depression, and loneliness: The mediation role of basic psychological needs satisfaction. J Couns Psychol. 2005;52(4):591.

    Article  Google Scholar 

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Kordahji, H., Ben-David, S. & Elkana, O. Attachment Anxiety Moderates the Association Between ADHD and Psychological Distress. Psychiatr Q 92, 1711–1724 (2021). https://doi.org/10.1007/s11126-021-09919-6

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