ADHD Symptoms and Attachment Representations: Consideringthe Role of Conduct Problems, Cognitive Deficits and NarrativeResponses in Non-Attachment-Related Story Stems

Sara Scholtens & Ann-Margret Rydell & Gunilla Bohlin &

Lisa B. Thorell

# Springer Science+Business Media New York 2014

Abstract The overall aim of the present study was to inves-tigate ADHD symptoms in relation to attachment representa-tions. We used both attachment- and non-attachment-relatedstory stems, which allowed us to investigate whether problemswith narrative production can explain the relation betweenADHD symptoms and attachment representations. We alsoinvestigated the role of cognitive deficits and conduct prob-lems in these relations. The sample consisted of 89 children(27 % girls) between 6 and 10 years old, with an oversamplingof children with high levels of ADHD symptoms. ADHDsymptoms and conduct problems were rated by parents andteachers. Cognitive functioning was investigated using labo-ratory tests of inhibition, working memory and sustainedattention. Attachment representations were coded as secure,organized insecure and disorganized categories. Narrativeresponses to non-attachment-related story stems were codedfor incoherence and negative content. Results showed thatchildren in the disorganized attachment category had signifi-cantly higher levels of ADHD symptoms compared to those inthe secure category. Both ADHD symptoms and disorganizedattachment were related to incoherence and negative content.Attachment representations were not associated with ADHDsymptoms when controlling for negative content in responseto non-attachment-related story stems. These results suggestthat the associations between attachment security and ADHDare yet to be fully understood. Importantly, a propensity to

envisage negative events seems to characterize children withhigh levels of ADHD symptoms.

Keywords ADHD symptoms . Attachment representations .

Cognitive deficits .Narrative . Incoherence .Negative content

Attention Deficit/Hyperactivity Disorder (ADHD) is one ofthe most commonly diagnosed and widely studied psychiatricdisorders in children. Children with ADHD display activitylevels that are far in excess of their age group, and they havedifficulty sustaining attention and maintaining persistence totasks (American Psychiatric Association 2000). The clinicalfeatures of ADHD are increasingly being recognized asrepresenting the extreme end of normal traits, rather than adistinct category (e.g., Bauermeister et al. 2007; Kraemer et al.2004; Larsson et al. 2012; Sonuga-Barke et al. 2003). In otherwords, considering a wide range of ADHD symptoms is ofinterest when studying relations between ADHD and otheraspects of child functioning.

ADHD is recognized as having a multifactorial etiology. Inextant models of ADHD, behavioral disinhibition andworking-memory deficits have garnered particular attention,although it should also be recognized that not all children withADHD symptoms have cognitive deficits (Willcutt et al.2005). Alongside the cognitive-deficiency perspective, possi-ble etiological factors tied to the child’s family context havebeen found (e.g., Biederman et al. 2002; Counts et al. 2005).In this vein, an attachment perspective on the background ofADHD has been explored (e.g., Pinto et al. 2006). Accordingto attachment theory, an infant’s early experiences with care-givers establish the foundation for mental representations laterdeveloped in childhood. These internal working models reg-ulate the child’s understanding of interactions with others andhelp regulate behavior. When caregivers are sensitive andresponsive to the needs of the child, a secure attachment

Author Note This research was supported by a grant from The SwedishCouncil for Working Life and Social Research to Gunilla Bohlin

S. Scholtens :A.<M. Rydell :G. Bohlin (*)Department of Psychology, Uppsala University, Box 1225,75142 Uppsala, Swedene-mail: gunilla.bohlin@psyk.uu.se

L. B. ThorellKarolinska Institutet, Stockholm, Sweden

J Abnorm Child PsycholDOI 10.1007/s10802-014-9854-0

relationship is likely to develop. When caregivers are lesssensitive, an insecure attachment relationship is likely to de-velop. Insecure avoidant and insecure ambivalent attachmentare considered organized in the sense that the children havecoherent strategies to handle stress and anxiety, whereas dis-organized insecure attachment is identified by the lack of suchstrategies, presumably because parents are experienced asfrightening or frightened. Disorganized insecure attachmentis the subgroup of insecure attachment that has been shown tobe most strongly linked to psychopathology in previous re-search (Fearon et al. 2010; van Ijzendoorn et al. 1999).

Attachment and ADHD

In the limited literature on attachment and symptoms ofADHD, some support for a link between disorganized attach-ment and ADHD behaviors has been presented. The study byPinto et al. (2006) showed that disorganized attachment ininfancy was significantly associated with symptoms of inat-tention and hyperactivity at age seven, in a non-clinical sam-ple. In addition, Goldwyn et al. (2000) found that disorgani-zation was concurrently related to the attention problem sub-scale of the Child Behavior Checklist (CBCL, Achenbach andEdelbrock 1981) and not to aggression or rule-breaking be-haviors. In two studies, which also found an associationbetween disorganized attachment and symptoms of ADHD,the cognitive deficit perspective was simultaneously consid-ered in relation to ADHD. The first study by Thorell et al.(2012) found that disorganized attachment assessed at 8 ½years, using story stem methodology, was associated withsymptoms of ADHD 1 year later in a non-clinical sampleand this was independent of cognitive deficits and conductproblems. Second, the study by Bohlin et al. (2012), using thesame methodology, found that disorganized attachment at age5 was significantly predictive of ADHD symptoms at age 7,and that disorganized attachment co-varied to some extentwith inhibition and even more so with conduct problems.More studies examining the link between disorganizationand ADHD symptoms are clearly needed, especially studiestrying to further elucidate the complex relation by also includ-ing measures of cognitive performance.

As in the studies referred to above, attachment, whenstudied beyond infancy, is typically assessed by consideringthe child’s verbal responses to a story stem containing ascenario that involves parental figures—a scenario that ismeant to elicit their secure-base-seeking impulses (i.e., de-scribing circumstances of distress, threat, separation or re-union). The narrative the child produces in response to thestory is considered to reflect the child’s representation of theattachment relationship. As argued by, for example, Oppen-heim and Waters (1995), the task of assessing attachmentrepresentations using story-stem methodology is complex

because the attachment classification relies on both narrativeorganization and content.

Generally speaking, secure children describe positive in-teractions with supportive parental figures in a coherent way,whereas insecure children’s narratives may contain elementsof a story that do not connect well to each other, do not includecoherent reasons for emotional states, and/or the children maydistance themselves from the topic. Incoherent narratives andnarratives including scary events are seen as signs of thechild’s attachment system being flooded or blocked in situa-tions when it is activated (e.g., George and Solomon 2000).However, it is possible that the coherence and content aspectsof narrative responses reflect more general narrative produc-tion problems and not necessarily attachment representations.

Producing, or resolving, a story involves sorting out rele-vant information and proficiently linking together actions andgoals in an organized manner, which are skills that childrencould lack for reasons other than being insecurely attached.Thus, when studying attachment representations using story-stem methodology, it is important to take into considerationchildren’s responses to non-attachment-related story stems. Ifaspects of narrative organization and content are specific tosituations when the attachment system is activated (i.e., pri-marily in cases of separation from the attachment figure, infearful situations or when the child is physically injured), andnot present in responses made to more neutral stimuli, thiswould support the conclusion that “true” attachment represen-tations have been measured. To our knowledge, only oneprevious study has related attachment representations to con-current narrative responses to non-attachment-related stories.Using attachment representations coded according to the At-tachment Story Completion Task (ASCT; Bretherton et al.1990), Greenberg et al. (1997) found that, in their responsesto attachment stories, insecure children showed higher levelsof aggression and lower levels of engagement with the inter-viewer. No such difference was found in the responses to non-attachment-related stories. These results point to the ability ofattachment-related story stems to trigger a specific type ofresponse, although this issue is clearly in need of furtherexamination.

ADHD and Narrative Problems

The content and organization of children’s narratives havebeen linked to behavioral competencies and risks (for reviewsee, e.g., Emde et al. 2003; Holmberg et al. 2007).With regardto ADHD specifically, studies have found associations be-tween ADHD and difficulties with narrative production evenwhen the method used was not meant to trigger attachmentbehaviors. Children with ADHD have been found to produceless coherent narratives when asked to retell tales read to themor shown on television, compared to children without ADHD

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(Lorch et al. 2010; Tannock et al. 1993). These ADHD-relatedproblems with incoherence have been found even when thememory demands of the narrative production task were low(Renz et al. 2003). In addition, Flory et al. (2006) found thatcoherence difficulties among children with ADHD couldmainly be accounted for by problems with sustained attentionand not inhibition or planning/working memory.

Symptoms of inattention, or externalizing behavior prob-lems in general, have also been related to the inclusion ofnegative content in narratives. Although negative contentshould perhaps not be seen as problematic in itself, it has beenrelated to problem behaviors. For example, Warren et al.(1996) found positive correlations between negative themes(e.g., descriptions of anger, aggression, destruction and per-sonal injury) and externalizing behavior, and Zahn-Waxleret al. (1994) found that inattention, as assessed by the CBCLwas related to aggression in narratives. In addition, von Klitz-ing et al. (2000) found that a measure of negative content(including aggression, escalation of conflict and disorganizedresponses with a “negative tone”) was positively correlatedwith externalizing behavior both concurrently and longitudi-nally. The aforementioned studies investigating negative con-tent used broad measures of externalizing problems. HowADHD symptoms specifically are related to negative contentis not known. Previous studies have also, to a relatively largeextent, employed story stems developed to assess attachmentrepresentations, which means that it is unclear whether thedisposition to include negative content in narratives reflectsinsecure attachment or whether it is an outflow of the child’sexternalizing behaviors as such. In order to shed further lighton this issue, it is necessary to include both attachment-relatedand non-attachment-related story stems, as done in the presentstudy.

The Present Study

As described above, associations between ADHD symptomsand insecure attachment representations, primarily disorgani-zation, have been found using story-stem methodology. How-ever, the role of concurrent narrative problems has yet to beaddressed. In addition, the role of cognitive deficits and con-duct problems needs to be further elucidated. The overall aimof the present study was therefore to investigate ADHDsymptoms in relation to attachment representations, whileconsidering conduct problems, cognitive deficits and narrativeresponses to non-attachment-related story stems. By includingnarrative responses to non-attachment-related story stems, weinvestigated the extent to which associations between attach-ment representations and ADHD symptoms could be ex-plained by general narrative features associated with highlevels of ADHD symptoms. It was expected that ADHDsymptoms would be related to disorganized rather than to

secure or organized insecure attachment representations.Based on the idea of a true association between disorganizedattachment and ADHD symptoms (i.e., not an associationexplained by general narrative features of children with highlevels of ADHD symptoms), we expected that the associationbetween disorganized attachment and ADHD symptomswould hold when controlling for narrative responses to non-attachment-related story stems. Further, in line with previousfindings (Bohlin et al. 2012; Thorell et al. 2012) we expectedrelations between ADHD symptoms and disorganized attach-ment independent of cognitive deficits; for conduct problemsthe previous inconclusive results made us leave the issue ofindependent relation open. In sum, if the expected associa-tions were found to be independent of conduct problems,cognitive deficits and narrative responses to non-attachment-related story stems, we would take this as support for a truerelation between attachment representations and ADHDsymptoms.

Method

Participants

The sample consisted of 89 children between 6 and 10 yearsold (M=8.27, SD=0.96 years). To capture a wide range ofADHD symptoms, in line with our dimensional approach toADHD, we recruited 27 children expected to have high levelsof ADHD symptoms through an ADHD center (20 boys and 7girls). Sixty-two children, selected to correspond to the chil-dren from the ADHD center in age and gender, were recruitedfrom the community population via local schools (45 boys and17 girls). Letters were sent out to parents and they signed upfor participation. Three of the 30 children initially contactedthrough the ADHD center fell ill on the day of the testing andthey were excluded from the study. Sixty-two of the 65children, recruited through schools, fell within the age rangeof the study. There was no significant age difference betweenthose recruited through the ADHD centers and those recruitedthrough schools (p>0.05). ADHD symptom levels overlap-ped, that is, some of the children recruited through schools hadhigher levels than some of the children recruited through theADHD center.

None of the children recruited through schools were onADHD medication. Twenty-three of the 27 children recruitedthrough the ADHD center were normally on ADHD medica-tion; the parents of 16 of these children allowed them to be offmedication on the day of testing. For the sample as a whole,maternal education was high, as 55 % had a college or auniversity degree; 76 % of the children lived with both bio-logical parents, and about 20 % of the parents were immi-grants. There were no significant differences between thechildren recruited through the ADHD center and those

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recruited through schools in any of these background vari-ables (p>0.05).

Procedure

The study was approved by the local Ethics Committee (Dnr2010/334), and all parents provided informed written consentfor their child’s participation in the study. Research assistantscollected data on attachment representations and cognitivefunctioning during a visit to the child’s school, which lasted1–1½h. The child was first administered the cognitive perfor-mance tasks and a vocabulary task, and thereafter the story-stem task. Questionnaires were distributed to teachers at theschool visit, and the parents received their questionnairesthrough the mail. Non-responders received two reminders.Teachers received one movie ticket voucher for completingthe questionnaire, and the children received a toy worth ap-proximately 5 Euros for participating.

Measures

Parent and Teacher Ratings Teachers and parents ratedADHD symptoms and conduct problems. ADHD symptomswere measured using the ADHD Rating Scale IV, an 18-itemmeasure reflecting DSM-IV-criteria (American PsychiatricAssociation 1994). This scale is well validated and extensive-ly used within ADHD research (DuPaul et al. 1998). Nineitems measure inattention and nine items measurehyperactivity/impulsivity. The response format used rangedfrom 0 (never or rarely) to 3 (very often), α=0.97 for parentratings and α=0.94 for teacher ratings. Conduct problemswere rated using five items from the externalizing scale ofthe Children’s Behavior Questionnaire (CBQ; Rutter et al.1970). We used the following items: “Often disobedient”,“Often fights with other children”, “Angers easily”, “Hasstolen things/money”, “Sometimes lies”. The rating scaleranged from 1 (Does not apply) to 5 (Applies very well), α=0.76 for parent ratings and α=0.83 for teacher ratings. Threechildren were missing the parent report, and four childrenwere missing the teacher report. Parent and teacher ratingswere highly correlated, r=0.65, p<0.001 for ADHD symp-toms and r=0.59, p<0.001 for conduct problems, and themean of parent and teacher ratings was therefore used in thepresent study. The ADHD symptom and conduct problemscales had kurtosis values<1.10 and skewness values<1.35,indicating sufficiently normal distributions (Kline 1998).

Story-Stem Task A story-stem task was used to assess thechildren’s attachment representations and the narrative fea-tures of their story completion. The story stems were toldusing doll materials (e.g., doll family, doll house, furniture,toy car, toy schoolyard equipment, etc.). The administratorstarted by introducing the characters and the setting to be used

in the story stem and then proceeded by telling the child thescripted beginning of a story. The main character of each storystem was a child doll of the same sex as the participant. Thechildren were then asked to complete the story both verballyand by showing actions using the doll material, prompted tobegin by the administrator saying “So can you show me whathappened next? You finish the story!” The children werepresented with a total of six different story stems. Three ofthe story stems were attachment related and three were non-attachment-related (i.e., did not require the parent for comfortor protection). The story stemswere presented in a fixed order:the first one was non-attachment-related, the second, third andfourth were attachment-related, and the final two were non-attachment-related. The situation was videotaped and tran-scribed verbatim together with a description of how the dollmaterial was handled.

Attachment Representations To assess attachment representa-tions, we used three stories commonly used in several otherstory-stem methods (i.e., Bretherton and Oppenheim 2003;Goldwyn et al. 2000): Hurt Knee, Monster in the Bedroom,and Separation-Reunion. These three stories are thought togradually increase activation of the attachment system, begin-ning with the Hurt Knee and ending with Separation-Reunion.In the Hurt Knee the child is outside playing and hurts herself/himself while the mother doll is inside sitting in the livingroom. In Monster in the Bedroom, the child doll thinks thatthere is a monster in his/her room during the night and isfrightened, while the mother doll is sitting in the living room.In the Separation-Reunion story, the parent dolls leave thechild doll in the care of a grandmother doll for a week and thencome back.

Transcriptions of the completions of the attachment-relatedstory stems were classified according the Attachment DollPlay Classification System developed by George and Solo-mon (2000). Each story completion is scored as belonging toone of four attachment categories: secure, ambivalent,avoidant or disorganized. A secure classification is obtainedwhen the child describes an immediate and adequate responsefrom the parent in the form of a solution to the problem athand. A classification of ambivalent attachment is character-ized by cognitive disconnection, whereby the child acknowl-edges the attachment problem although he/she actively tries todirect attention away from the source of the distress andeffective ways of coping with it (e.g., the character is involvedin a busy activity not related to the attachment problem).Avoidant attachment is characterized by deactivation of theattachment system; this classification is given when the childconveys that there is no need for the parent to provide care andprotection (e.g., solving the problem without the help of theparent or denial of injury). These classifications are all con-sidered organized. A disorganized classification is obtainedwhen the stories are characterized by either, a) poor coherence,

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chaos, violence and scary events, without a solution to theattachment problem or b) mental blocking and freezing, a raretype of reaction, shown by complete refusal to tell a story,repeating comments like”I don’t know”, “Nothing happens”.As the stories are meant to gradually increase activation of theattachment system the Separation-Reunion story weighsheavily in the final classification; even if the other two storiesare scored as insecure, a Separation-Reunion story scored assecure will give a secure classification. Validity of the story-stem methodology has been demonstrated through associa-tions with Strange Situation security classifications, made at18 months, and through concurrent security assessments,made at age 3, of observed separations and reunions(Bretherton et al. 1990). Validation of the classification meth-od used in this study has been obtained by comparison withconcurrent reunion behavior after separation (Solomon et al.1995).

All attachment-related stories were coded independently bytwo coders, whom were blind to all other participant informa-tion (GB and LT). Agreement on classificationwas kappa 0.69for the three categories secure, insecure organized and inse-cure disorganized. Disagreements were discussed, and thefinal classifications of such cases were based on unanimousdecisions. This coding resulted in 58 children being classifiedas secure, 7 as ambivalent, 14 as avoidant and 10 as disorga-nized. For our purposes, the ambivalent and avoidant catego-ries, both considered to be insecure but organized, were col-lapsed into one “organized insecure” group.

Non-Attachment-Related Story Stems To assess whether chil-dren had narrative problems, the following non-attachment-related story stems were used: Lost Kitten, Broken Pitcher andLocked in the Classroom. These story stems were developedby our research group to mimic the attachment story stems incomplexity, but to provide a problem to be solved that did notinvolve the need for parental figures to give comfort or pro-tection. In Lost Kitten, the child doll is at home with his/hermother and a neighbor comes to the door with a lost kitten. InBroken Pitcher, the child doll and his/her same sex friend arehome alone playing in the living room in the friend’s houseand the friend accidentally knocks over and breaks a pitcher.In Locked in the Classroom, the child doll is in a classroom atschool with his/her classmates (six other child dolls, boys andgirls) and when the school bell rings for recess the teacher dollis unable to open the classroom door to let the children out toplay as she has lost the key.

The transcriptions of the non-attachment-related storieswere rated with regard to incoherence and negative contentby separate coders blind to all other participant scores. Themeasure of incoherence was based on the Narrative Coher-ence Scale used by Sher-Censor and Oppenheim (2004), used5 levels, and was reversed so that ascending numbers wouldreflect incoherence. Central to this scale are storyline shifts,

defined as abrupt and unexplained changes of events. Thedegree of incoherence was coded by one of the authors (SS)on a scale from 1 (a logical story completion with a series ofevents that are related to the theme of the story stem and thatdemonstrate an understanding of the problem given and asolution to the problem”, for example a story where the childtakes several steps to find the owner of the kitten, makes fliers,put them up in neighborhood, and then mentions that theowner is found or the kitten gets to stay with the child), to 5(the story completion shows no recognition of the problem,there are no suggestions for a solution and/or there are a largenumberof shifts in the storyline, for example a story where thedilemma with the lost kitten is not mentioned and child in thestory does a number of unrelated things without explanation).The mean of the ratings across the three non-attachmentstories was used (α=0.73). Inter-rater reliability wasestablished with a separate coder (AMR) on the narrativesfrom 26 children, r=0.88, p<0.001. Due to lost data, incoher-ence for the Lost Kitten story stem could not be coded for onechild.

The negative content measure was developed for the pres-ent study and took into consideration both the number andseverity of negative events. A negative event is defined as theoccurrence of something unpleasant, harmful or threatening(these events ranged from unpleasant such as verbal threats ofviolence to serious events such as figures in the story killingseveral others). Ratings were given on a scale of 1 none to 5several very unpleasant events, or one or more very seriousevents such as death. The mean of the rating across the threenon-attachment-related stories was used as the measure (α=0.64). All children gave responses that could be coded fornegative content. Negative content was rated by a researchassistant and inter-rater reliability for 26 children wasestablished with one of the authors (AMR), r=0.86, p<0.001.

WISC-IV Vocabulary Children’s vocabulary was assessedusing the vocabulary subtest fromWechsler Intelligence Scalefor Children—4th Ed (WISC-IV; Weschler 2003), whichmeasures the child’s word knowledge and verbal conceptformation. The vocabulary task consisted of a total of 29words of increasing difficulty and we used the raw scores,scored according to the WISC-IV handbook.

Opposite Pairs, Stroop Task Response inhibition was mea-sured with a Stroop-like task developed by Berlin and Bohlin(2002) that did not require reading skills. This task is derivedfrom the Day–Night Stroop task (Gerstadt et al. 1994), inwhich conflict is provided by asking the children to say theopposite of what is in the picture (i.e., to say “night” when thepicture “day” is shown on the screen). Four picture pairs wereused: day–night, up–down, big–small and boy–girl. The sumof the number of incorrect responses and response correctionswas used tomeasure disinhibition. Validity information for the

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opposite pairs task was given in Bohlin et al. (2012), wherethe task loaded together with other inhibition measures on asingle dimension using Factor Analysis.

The go/no-go Task A go/no-go task developed by Berlin andBohlin (2002), which was administered using the Psytoolssoftware (Delosis, London), was used to measure sustainedattention. The task consisted of a blue square, a blue triangle, ared square, and a red triangle, each object being presented oneat a time on a computer screen. During the first part of the task,the children were instructed to press a key (“go”) when afrequent stimulus (a blue figure) appeared on the screen, butto make no response (“no-go”) when an infrequent stimulus (ared figure) appeared. The same stimuli were used for thesecond part of the task, but the children were then instructedto press a key every time they saw a square, and to inhibit theirresponse every time they saw a triangle, irrespective of color.Altogether the task included 60 stimuli, with a duration of1,200 ms and an interstimulus interval of 1,000 ms. The “gorate” was 66 %. The total number of omission errors (notpressing the key when a “go” target was presented) and thestandard deviation of the reaction times (i.e., reaction timevariability) were standardized and averaged to form a measureof sustained attention, α=0.62. Three outliers (> 3 SD) inreaction time variability in the second part of the task wereidentified and rescored with the fourth highest value on thisvariable. High values denote poor sustained attention. Forinformation on reliability and validity of the go/no-go para-digm, we refer to Berwid et al. (2005).

Children’s Size-Ordering Task Averbal working-memory task,the Children’s Size-Ordering Task (McInerney et al. 2005),was used to measure working memory. In this task, commonnouns (e.g., cat, car, apple) are read aloud at a rate of one itemper second to the child, who is then asked to repeat them backto the administrator according to size, from smallest to largest.Two practice trials were administered first. The actual testbegan with two items per trial, and became progressivelymore difficult. All children were administered all trials, re-gardless of their performance. The total number of pairs ofitems ordered correctly across all trials was added together andthen reversed (i.e., a higher score indicated working memorydeficits). Validity information in terms of demonstrated corre-lations with other working memory measures was presentedby McInterney et al. (2005).

Statistical Analyses

Potential differences in maternal education, parental immi-grant status, living situation and gender were examined usingt-tests and χ2 analyses. Relations between continuous vari-ables were calculated using Pearson’s correlations. Potentialage differences between attachment categories were analyzed

with a univariate analysis of variance (ANOVA). To investi-gate how the attachment categories related to ADHD symp-toms as well as to other variables, we carried out a series ofANOVAs. In case of a significant ANOVA, the three attach-ment categories were compared using Bonferroni corrections.Finally, we tested whether the attachment categories had anindependent effect on ADHD symptoms by performing anal-yses of covariance (ANCOVAs) with relevant controls, that is,with variables related to ADHD symptoms and attachmentcategories, again using Bonferroni corrections.

Results

There was no significant difference between the attachmentcategories with regard to maternal education, parental immi-grant status or living situation (p>0.05).With regard to genderdifferences, the results showed that there was an associationwith attachment category, χ2=6.03, p=0.05; 83 % of the girlsand 59 % of the boys were categorized as secure, and all 10 ofthe children categorized as disorganized were boys. In addi-tion, boys were significantly more incoherent, t(87)=−3.79,p<0.001, and their narratives included more negative events,t(87)=−1.99, p=0.05. With regard to age, there was an agedifference for attachment category, F(2, 86)=3.02, p=0.05,with the children in the secure category being the oldest. Agewas positively related to vocabulary, r=0.39, p<0.001, andnegatively related to the cognitive measures and to narrativefeatures, r=−0.31 to −0.41, p<0.01. Based on these findings,gender and age were used as covariates in the remaininganalyses.

The correlations between all continuous variables are pre-sented in Table 1. As seen in the table, ADHD symptomswerepositively related to conduct problems, cognitive deficits andnarrative problems. Incoherence was positively related toworking-memory deficits and sustained attention problems.Negative content was positively related to conduct problemsand sustained attention problems. The two narrative measureswere moderately correlated with each other. Vocabulary wasnegatively related to cognitive deficits, but was not related tobehavioral problems or narrative features.

Attachment, ADHD Symptoms and Narrative Problems

Significant associations were found between attachment cate-gory and ADHD symptoms, incoherence, and negative con-tent (see Table 2). The Bonferroni corrected comparisonsbetween attachment categories revealed that, compared tothe children classified as secure, the children classified asinsecure disorganized received significantly higher ratings ofADHD symptoms, and their responses to non-attachment-related story stems were more incoherent and had more neg-ative content. In addition, children classified as insecure

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organized told stories with significantly higher levels of neg-ative content than did children classified as secure. The onlydifference between the two insecure categories was that chil-dren classified as disorganized had higher levels of negativecontent in their narratives than did children classified as orga-nized. There were no significant effects of attachment onconduct problems, vocabulary, disinhibition, sustained atten-tion or working memory deficits.

Controlling for Narrative Problems

As reported above, the results showed that narrative problemsin responses to non-attachment-related story-stems were relat-ed to attachment as well as to ADHD symptoms. TwoANCOVAs testing the association of attachment category(secure, organized insecure or disorganized) to ADHD symp-toms, were therefore performed; one with control for incoher-ence and one with control for negative content (as well as sexand age). The three attachment categories were againcontrasted using Bonferroni correction. The other potentialcontrol variables (i.e., conduct problems, vocabulary, disinhi-bition, sustained attention and working memory deficits) werenot included in these analyses as the three attachment

categories did not differ significantly with regard to thesevariables. The association between attachment and ADHDsymptoms remained significant with control for incoherence,F(2, 83)=3.80, p<0.05 (secure vs insecure organized ns,secure vs. insecure disorganized p<0.05, insecure organizedvs insecure disorganized, ns). However, when controlling fornegative content, the association between attachment andADHD symptoms was no longer significant, F(2, 83)=1.46,p>0.10.

Discussion

The overall aim of the present study was to contribute toextant knowledge on the association between ADHD symp-toms and attachment representations, studied through thecompletion of attachment-related story stems, by investigatingthe role of conduct problems, cognitive deficits and narrativefeatures found in responses to non-attachment-related stories.In line with previous research (Lorch et al. 2010; Renz et al.2003; Tannock et al. 1993), ADHD symptoms were positivelyrelated to incoherence in narratives, even with the more freeresponse format allowed by the story-stem method. We also

Table 1 Descriptive statistics and partial correlations between variables controlling for age and gender (N=89)

2. 3. 4. 5. 6. 7. 8. Min Max M SD

1. ADHD symptoms 0.74** −0.10 0.27* 0.25* 0.41*** 0.24* 0.37*** 0.03 2.47 0.82 0.65

2. Conduct problems −0.13 0.22* 0.32** 0.29** 0.20 0.26* 1.00 3.70 1.92 0.69

3.Vocabulary −0.27* −0.48*** −0.29* −0.17 −0.06 7.00 31.00 16.75 5.22

4. Disinhibition 0.20 0.42*** −0.01 0.06 0.00 15.00 4.09 3.27

5. WM deficits 0.42*** 0.26* 0.15 0.00 30.00 13.26 6.26

6. Sustained Attention Problems 0.25* 0.25* −0.83 2.57 0.00 0.68

7. Incoherence 0.40*** 1.00 4.67 3.00 0.81

8. Negative content 1.00 4.67 2.01 0.93

*p<05, ** p<0.01, ***p<0.001

Table 2 Results of ANCOVAs on ADHD symptoms, conduct problems, cognitive functioning and narrative features in relation to attachmentcategories, controlling for age and gender

Secure (1) Organized insecure (2) Disorganized (3)(n=58) (n=21) (n=10)Adj M (SE) Adj M (SE) Adj M (SE) F Bonferroni corrected comparisons

ADHD symptoms 0.67 (0.08) 0.98 (0.14) 1.38 (0.20) 5.90** 1 vs 2ns, 1 vs 3 **, 2 vs 3ns

Conduct problems 1.87 (0.09) 1.99 (0.16) 2.09 (0.23) 0.48

Vocabulary 16.31 (0.65) 17.71 (1.07) 17.32 (1.58) 0.66

Disinhibition 4.13 (0.42) 3.94 (0.69) 4.19 (1.02) 0.03

WM deficits 13.10 (0.79) 12.34 (1.30) 16.12 (1.92) 1.4

Sustained Attention problems −0.11 (0.09) 0.11 (0.14) 0.40 (0.21) 2.76

Incoherence 2.84 (0.09) 3.09 (0.14) 3.70 (21) 6.99** 1 vs 2ns, 1 vs 3 **,2 vs 3ns

Negative content 1.70 (0.10) 2.27 (0.16) 3.31 (0.24) 19.85** 1 vs 2 *, 1 vs 3 ***,2 vs 3 **

*p<05, ** p<0.01, ***p<0.001

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found a link between ADHD symptoms and negative contentin the narrative responses to non-attachment-related storystems. This is a new finding given that previous research hasused broad definitions of externalizing behavior rather thanADHD symptoms specifically (von Klitzing et al. 2000; War-ren et al. 1996; Zahn-Waxler et al. 1994). Here, it should bekept in mind that children’s narrative performance, measuredas incoherence or negative content, did not relate to theirlanguage ability as evaluated by theWISC-IV vocabulary test.

In line with our expectations, children classified as disor-ganized had higher levels of ADHD symptoms comparedwiththose classified as secure. This is in agreement with previousfindings (Bohlin et al. 2012; Thorell et al. 2012). In addition,our study was able to add new important information byshowing that this relation could not be accounted for by theoverlap between ADHD symptoms and either conduct prob-lems or cognitive deficits. As regards the role of cognitivedeficits in the associations between attachment and ADHDsymptoms, both of the studies addressing this issue (Bohlinet al. 2012; Thorell et al. 2012) found additive effects ofattachment disorganization and EF deficits. The present studystrengthens the conclusion that it is the ADHD symptomsthemselves, and not cognitive deficits associated with ADHD,that are related to disorganized attachment representations.However, it is not possible to draw conclusions about thedirection of effects based on our results. To further elucidatethese relations, there is a need for longitudinal studies withrepeated assessments of both ADHD symptoms and attach-ment representations, which also should include additionalvariables that could possibly explain this relation in moredetail.

One aspect of our results that may seem surprising is thefailure to show a relation between disorganized attachmentand conduct problems, as disorganized attachment has typi-cally been found to be associated with externalizing behaviorproblems (van Ijzendoorn et al. 1999; Fearon et al. 2010). Onthe other hand, Goldwyn and co-workers (2000), also usingstory-stem methodology, found that disorganization was notrelated to aggression or rule-breaking behaviors, which is alsoin line with the findings of Thorell et al. (2012). However,Bohlin et al. (2012) did show a significant longitudinal rela-tion between disorganized attachment and conduct problems.Whether a connection between disorganized attachment rep-resentations and conduct problems is found may depend onthe sample and the extent of comorbidity, and in a widerperspective, also on the method used for assessing attachmentquality. Further studies are needed to clarify this issue.

Do Children with High Levels of ADHD Symptoms“Appear” Disorganized?

Because the narrative problems shared associations withADHD and attachment disorganization, they could possibly

have accounted for the association between symptoms ofADHD and attachment disorganization. In line with our hy-pothesis, the results showed that the association remainedwhen controlling for incoherence in response to non-attachment related story stems. However, contrary to ourhypothesis, negative content did account for the association.This is in line with the idea that, when using the story-stemmethodology, children with high levels of ADHD symptomssimply appear disorganized because they generally producenegative narratives. There could be some feature of theADHD syndrome that predisposes children to imagine thatnegative events will occur in a variety of situations, irrespec-tive of the quality of their attachment relationship. One suchfeature could be co-occurring conduct problems, as broadexternalizing problems have been associated with negativecontent in narratives (Warren et al. 1996; von Klitzing et al.2000). As pointed out, however, links to conduct problemswere not supported by our data. It is possible that real-lifeencounters with various problematic social situations, whichare likely to be frequent among children with high levels ofADHD symptoms, generate associations to negative eventswhen these children imagine situations requiring someamount of social problem-solving (e.g., Crick and Dodge1994).

So, do our result that children with high levels of ADHDsymptoms could simply “appear” disorganized indicate thatinsecure attachment does not genuinely contribute to ADHDsymptoms? Not necessarily. The attachment story-stem meth-odology rests on the idea that attachment-related stories (i.e.,stories where the parent is present and the child experiencessome kind of vulnerability) activate the attachment system(Greenberg et al. 1997; Solomon and George 2008). However,little attention has been paid to whether insecure children arelikely to produce negative content in response to non-attachment-related story stems. One exception is the studyby Greenberg et al. (1997), which did include neutral (i.e.,non-attachment-related) stories, and found that onlyattachment-related story stems elicited different behaviorsand amounts of aggressive content in insecure and securechildren. Thus, they found support for the specificity ofattachment-relevant story stems in activating the attachmentsystem. The question is, however, whether the “neutral” storystems were relevant for comparison with the attachment-related stories, as there seemed to be no problem that neededto be addressed. Perhaps the non-attachment-related storieswere simply not very engaging. We tried to address thislimitation in our study by introducing story stems with aproblem to be solved. These stories might have spurred theproduction of elaborated narratives, demonstrating the highlevels of negative content in the non-attachment-relatedstories that distinguished both disorganized and organizedinsecure children from secure children. The production ofnegative content as a correlate of especially disorganized

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attachment is shown by the fact that children in this categorydiffered also from the organized insecure children. One way tounderstand these findings, would be to argue that the mentalrepresentations of children with insecure attachment, and spe-cially the disorganized ones, depict the self as generally beingat risk for adverse events with little hope of getting protectionand help. Such mental representations could lead to negativeand hostile imaginations even when parents are not present.However, more studies comparing responses to attachment-related and non-attachment-related stories are needed in orderto further address this issue. Finally, in order to validate thelinks that have been found between attachment and ADHDusing story-stemmethodology, studies are called for assessingattachment using other methods.

A central finding of the present study is that children’sdisposition to include negative content in response to non-attachment-related story stems is an important individual dif-ference characteristic of young children. Inclusion of negativecontent in non-attachment-related stories was related to con-duct problems as well as to ADHD symptoms, whereas dis-organized attachment was only associated with ADHD symp-toms. These results suggest that the disposition to imaginenegative content in response to neutral story stems has other,and perhaps more severe implications. The ease with whichdestructive and violent narrative motifs were triggered byrelatively innocuous story stems could indicate easily pro-voked aggressive and destructive behavior. There is a possibleconnection to the findings of Dunn and Hughes (2001), whoshowed that violent fantasy play was associated with antiso-cial behavior in four-year-olds. Further, in the present study,the category of negative content included a variety of specificevents, such as the appearance of scary ghosts, mean aliens,property being destroyed or people getting injured or killed.Negative content could reflect different mental sets such asanxiety and aggression, where anxiety would be connectedwith insecure attachment and aggressive events with conductproblems. It stands out as an interesting and important task totry to differentiate between different types of negative contentand clarify associates, both antecedent and concurrent, withthe tendency to include specific types of negative content innarratives.

Conclusions

As to the main issue of whether attachment insecurity isassociated with symptoms of ADHD, our results suggest thatfor attachment studied using story-stem methodology, thisquestion is open for further discussion. The insight into chil-dren’s minds provided by story-stem methodology paints adark picture of ADHD symptoms, linking them to an imagi-nation that is riddled with negative content. The whys andhows of the relation between narrative themes of aggression

and hostility and symptoms of ADHD need to be addressed,with a special focus on the fact that emotional factors seem toact independently of poor cognitive functioning in explainingADHD symptoms. A question of concern that arises is to whatextent this kind of imaginative world contributes to the poorschool adjustment and social outcomes related to ADHD.

An interesting and important aspect of the results of thethree studies that have looked at attachment and cognitivefunctions concomitantly (Bohlin et al. 2012; Thorell et al.2012, and the present study) is that children with high levelsof ADHD symptoms show cognitive deficits in addition tofulfilling the criteria for disorganized attachment, suggestingthat attachment disorganization and cognitive dysfunctioncould be independent and additive factors in the developmentof ADHD symptoms. However, in the present study, we haveproblematized the use of story-stem methodology in investi-gating ADHD and attachment. Our results indicate that thenarrative style of children with high levels of ADHD symp-toms could be an explanatory variable. Therefore, there is astrong call for further investigations into the specifics of therelations between attachment representations, ADHD and nar-rative production.

Conflict of Interest We have no interests to declare.

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