Attachment and Autonomy Problems in Adults With ADHD

Abstract

Objective: Attachment security and autonomy were examined in adults with ADHD. Insecure attachment and autonomy problems were expected to be negatively associated with general psychological functioning. Method: Questionnaires were administered (Relationship Questionnaire, Autonomy-Connectedness Scale, Brief Symptom Inventory) in 84 late-diagnosed adults with ADHD. Results: Only 18% of participants were securely attached, as opposed to 59% in the normal population. Concerning autonomy, participants scored below average on self-awareness, above average on sensitivity to others, and average on capacity to manage new situations compared with the normal population. The preoccupiedly attached group reported more problems in psychological functioning than the secure and dismissive group. Sensitivity to others and capacity to manage new situations were associated with psychological functioning; self-awareness was not. Attachment security and autonomy contributed to general psychological functioning. Conclusion: Attachment and autonomy problems do exist in adults with ADHD and contribute negatively to their psychological functioning.

Keywords

ADHD interpersonal relations family relations personal autonomy adult psychological adaptation

ADHD is still a very much underdiagnosed condition in adults (Filipe, 2009; Simon, Czobor, Bálint, Mészáros, & Bitter, 2009). One of the reasons why diagnosing ADHD is difficult is insensitivity of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria to the development of the disorder across the life span. In recent years, various researchers (Faraone, Biederman, & Mick, 2006; Miller, Nigg, & Faraone, 2007) try to improve these criteria for adults. Another reason for underdiagnosis of ADHD is the fact that comorbidity is the rule, rather than the exception (Kooij, Aeckerlin, & Buitelaar, 2001; Spencer, Biederman, & Mick, 2007). About 80% of patients with ADHD have one or more additional disorders, such as mood and anxiety disorders, personality disorders, and substance use/dependence disorders (Fischer et al., 2007; McGough et al., 2005). The majority of cases of adult ADHD remain untreated although many individuals receive treatment for another disorder (Kessler et al., 2006). ADHD is thus often hidden underneath these comorbid disorders.

According to Karam et al. (2009), patients with late-onset ADHD show less severity of ADHD symptoms and lower frequency of externalizing symptoms but increased comorbidity with general anxiety disorder than patients with early-onset ADHD. They concluded that symptoms of late-onset ADHD are milder, but still dysfunctional. Faraone, Kunwar, Adamson, and Biederman (2009) found similar personality profiles in adults with late-onset as compared with adults with early-onset ADHD, and in a neuropsychological study, Faraone et al. (2006) found similar patterns of neuropsychological dysfunction in the two groups.

The estimated prevalence of adult ADHD in the United States is between 4% and 5% (Kessler et al., 2006; Wilens et al., 2009), in Belgium 4% (De Ridder, Bruffearts, Danckaerts, Bonnewyn, & Demyttenaere, 2008), and a careful estimation for the Netherlands is 2% (Tuithof, Ten Have, Dorsselaer, & De Graaf, 2010). Between 62% (Wilens et al., 2009) and 82% (Kooij et al., 2001) of adults with ADHD meet the requirements for the combined subtype (ADHD-C): They report symptoms of inattention and hyperactivity-impulsivity. There is strong evidence that ADHD is a neurobiological disorder, shaped by biological and environmental risk factors (Mash & Wolfe, 2010). Percentages of ADHD variance accounted for by genetic factors vary between 60% and 80% (Kooij, 2002), about 76% (Franke, Neale, & Faraone, 2009) and 64% (Edel, Juckel, & Brüne, 2010).

Many studies predict negative interactions between parental ADHD symptoms and the child’s ADHD symptoms (“similarity misfit hypothesis”), which may result in impaired rearing resources and dysfunctional parenting (Arnold, O’Leary, & Edwards, 1997; Edel et al., 2010; Harvey, Danforth, McKee, Ulaszek, & Friedman, 2003; Theule, Wiener, Rogers, & Marton, 2011). One recent study, however, suggests that when both child and parent have ADHD, parenting improves (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008). Other studies suggest that, in general, parents of children with ADHD have more psychiatric problems, such as depression and anxiety disorders, conduct and antisocial disorder, learning disorders, substance use disorders; more marital and family functioning problems; and a more negative parenting style than parents of children without ADHD (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Barkley, Murphy, & Fisher, 2008; Modesto-Lowe, Danforth, & Brooks, 2010). Many of these studies mention the stress of raising a child with ADHD as an important contribution to these problems.

Combining all the above, it can be concluded that parenting style and the parent–child relationship with ADHD children can be disturbed for many reasons. Less is known about the bonding capacity of adults with ADHD. Therefore, aim of the present study is to measure ADHD adults’ attachment style and autonomy and the relationship with their psychological functioning. First, we will shortly discuss psychological functioning. Then we will elaborate on the concepts of attachment and autonomy in relation to ADHD that will lead us to the research questions.

Psychological Functioning

According to Mikulincer and Shaver (2007), it is reasonable to believe that insecure attachment predisposes people to psychological disorders. In addition, Bekker and Belt (2006), for example, found low autonomy to be a risk factor for depression and anxiety. To be able to assess these effects, in this study, the concept of psychological functioning was used as a general measure for psychological distress on one or more primary symptom dimensions, such as signs and symptoms of depression and anxiety, the experience of unwanted thoughts and actions, distress resulting from perception of bodily dysfunction (somatization), and feelings of personal inadequacy. When high enough, psychological distress in any or more of these areas can lead to various psychological problems, psychopathology, and the need for therapeutic interventions (Derogatis & Melisaratos, 1983).

Attachment and ADHD

Bowlby (1973) defined attachment as a type of affectional bond of a child with a specific person, who is approached in times of distress. He considered the attachment relationship as a secure base that enables the individual to engage in exploration and develop and gain independence (Ainsworth, Blehar, Waters, & Wall, 1978; Berry, Barrowclough, & Wearden, 2007; Bowlby, 1988). As a result of the interaction between child and caregivers during infancy and childhood, young people develop mental representations of the self in relation to significant others and expectations about how others behave in social relationships. These working models would guide attention, interpretation, memory, and predictions about future interpersonal interactions (Bowlby, 1973; Cassidy, 1999; Pietromonaco & Barrett, 1997), and are similar to the construct of schema described within other theoretical perspectives (Feeney, Cassidy, & Ramos-Marcuse, 2008).

Adults would hold working models that may be based, in part, on those developed earlier in life. However, they also incorporate experiences in later significant relationships (Carnelly, Pietromonaco, & Jaffe, 1994; Hazan & Shaver, 1987; Pietromonaco & Barrett, 1997). Hazan and Shaver (1987) were the first to develop an adult attachment model, consisting of three attachment styles: secure, anxious, and avoidant. Bartholomew and Horowitz (1991) expanded on this model and developed a four-category attachment model, based on two dimensions: the person’s abstract image of self, which can be positive or negative, and the person’s abstract image of the other, which can be positive or negative as well. According to this model, securely attached people have a positive image of themselves and of others. They see themselves as being lovable and expect others to be generally accepting and responsive. Therefore, they feel comfortable with intimacy and autonomy. Persons who have a sense of unworthiness (negative self-image) and a positive evaluation of others are described as preoccupiedly attached. These people strive for self-acceptance by trying to gain the acceptance of valued others and are preoccupied with relationships. The third attachment style is the fearful style, characterized by a sense of unworthiness and unlovability about oneself with the expectation that others will be untrustworthy and rejecting, leading to avoidance of close involvement with others. Finally, the dismissive style is represented by people who find themselves lovable and worthy but have a negative attitude toward others. They protect themselves against disappointment by avoiding close relationships with others and maintaining a sense of independence and invulnerability.

If the parent–child relationship is disturbed, unsafe attachment of the child to one or both of their caretakers may be the result. This can affect the person into adulthood: When an event is perceived as threatening, the attachment system, thus one’s working models and action tendencies, is activated (Mikulincer & Shaver, 2007). For the United States, Mickelson, Kessler, and Shaver (1997) found 59% of adults to be securely attached. Van IJzendoorn and Bakermans-Kranenburg (1996) found the same percentage for the Netherlands; however, in a clinical sample, they found only 13% to be securely attached. Although these findings were based on the original model of three categories by Hazan and Shaver (1987), the same percentages for the main categories secure and insecure attachment are assumed to apply to the four-category model (Bartholomew & Horowitz, 1991; Shaver & Fraley, 2010).

Although some studies found that attachment style can change over a rather short period (Baldwin & Fehr, 1995; Pielage, Barelds, & Gerlsma, 2006), in general, attachment style is assumed to be relatively stable over time (Bowlby, 1988). Several studies found ADHD in children to be associated with insecurity of attachment (e.g., Clarke, Ungerer, Chahoud, Johnson, & Stiefel, 2002; Erdman, 1998; Franc, Maury, & Purper-Ouakil, 2009; Niederhofer, 2009). Some of these studies even suggest that attachment difficulties play a role in the development of (some cases of) ADHD. Because of the relative stability of attachment style over time, one might expect that an insecure attachment style will also be present in adulthood. However, attachment styles in adults with ADHD have not been studied directly yet.

Autonomy and ADHD

Secure attachment sets the stage for a healthy development of the individual, resulting in autonomous adults. Insecure attachment, however, generates autonomy problems (Bowlby, 1969). Bekker and van Assen (2006) broadened the concept of autonomy into “autonomy-connectedness,” reflecting that autonomy not only reflects independence but also incorporates the ability to initiate and maintain meaningful relationships with others. In this study, the shorter term autonomy will be used, but the underlying definition will be theirs. The concept has three components: self-awareness, sensitivity to others, and capacity for managing new situations. Self-awareness is the capacity to be aware of one’s own opinions, wishes, and needs, and the capacity to express these in social situations. Sensitivity to others is defined as sensitivity to the opinions, wishes, and needs of other people; empathy; and capacity and need for intimacy and separation. Capacity for managing new situations reflects (un)easy feelings in new situations, flexibility, an inclination to exploration, and dependence on familiar structures. A person with poor autonomy will have little self-awareness and capacity for managing new situations, and a relatively high or low sensitivity to others. An autonomous person will be self-aware, capable of managing new situations, and optimally sensitive to others.

No studies have been found that specifically describe self-awareness and sensitivity to others in adults with ADHD; several studies examine slightly different concepts. From a neurobiological point of view, Beitman and Nair (2005) found that people who suffer from psychiatric disorders such as schizophrenia, autism, or ADHD have a self-awareness deficit. Rucklidge, Brown, Crawford, and Kaplan (2007) reported that adults with ADHD, compared with controls, have a more external locus of control. Extrapolating from these studies, we expected self-awareness in people with ADHD to be below average compared with normals.

Concerning sensitivity to others, Friedman et al. (2003) stated that adults with ADHD view themselves as less socially competent but more sensitive toward violations of social norms than controls. Kohls, Herpertz-Dahlman, and Konrad (2009) found that children and adolescents with ADHD are hyperresponsive to social rewards, which is accompanied by limited self-awareness. Barkley et al. (2008) mentioned several studies that found adults with ADHD to score higher on the subscale interpersonal sensitivity of the Symptoms Checklist-90 than a clinical or normal control sample. Rapport, Friedman, Tzelepis, and van Voorhis (2002), however, found that adults with ADHD experience their own emotions with greater intensity than adults without the disorder and concluded that this disrupts their ability to be sensitivity to the emotions of others. Nonetheless, in this study, we expected adults with ADHD to score above average on sensitive to others compared with the normal population.

Concerning the capacity to manage new situations, several studies (as mentioned earlier) indicated that children with ADHD are less securely attached than children without ADHD, suggesting they would feel less confident in exploring the world around them and thus have more problems managing new situations. Supportive to this view is the fact that, in general, adults with ADHD tend to have a low sense of self-efficacy (e.g., Bramham et al., 2009). In addition, although ADHD symptoms such as impulsivity and hyperactivity might initially lower the threshold to engage in new situations, they might eventually hamper their capacity to manage them successfully.

Attachment, Autonomy, and ADHD

One study found a strong relation between attachment and autonomy but found the two concepts not to be confounded (Bekker & Croon, 2010). This would mean that, in addition to attachment, autonomy develops from other factors as well. For example, biological factors and gender role socialization might play a role (Bekker & van Assen, 2008). This led us to the question how much attachment and autonomy contribute to a person’s psychological well-being.

The Present Study

The first research question was as follows:

Research Question 1: Are adults with ADHD more insecurely attached than the normal population?

As the literature suggested a complex, mostly negative, interaction between parents and children in ADHD families, we hypothesized that adults with ADHD would be more often insecurely attached than the normal population.

Our second research question was as follows:

Research Question 2: What is the relationship between attachment and general psychological functioning of adults with ADHD?

We hypothesized that adults with ADHD who are insecurely attached would report more problems in psychological functioning than adults with ADHD who are more securely attached.

Concerning autonomy, the third research question was raised:

Research Question 3: Do adults with ADHD have more autonomy problems than the normal population?

We expected that adults with ADHD would score below average on self-awareness, above average on sensitivity to others, and below average on capacity to manage new situations compared with people without ADHD.

The fourth research question followed logically:

Research Question 4: What is the relationship between autonomy and general psychological functioning in adults with ADHD?

Bekker and Belt (2006) and Bekker and Croon (2010) found a negative relationship between autonomy and depression and anxiety. This supports the hypothesis of a positive relationship between autonomy and psychological functioning.

Finally, the fifth and last research question was as follows:

Research Question 5: To what extent can attachment and autonomy explain reported general symptoms in adults with ADHD?

We hypothesized that attachment as well as autonomy contributes to general psychological functioning in adults with ADHD.

Method

Participants and Procedure

Adults were selected who recently received a diagnosis for ADHD. To rule out subtype differences, a further selection was made by selecting people of the combined subtype. To minimize influences caused by treatment, participants were selected who did not start treatment yet or who were in the beginning phase of treatment at the participating institution. Furthermore, participants were excluded in case of a comorbid disorder in the autistic spectrum because attachment and autonomy might be influenced by this disorder.

Patients were recruited from a large mental health institution in the city of Eindhoven and from outpatient clinics in Tilburg, The Hague, and Roermond, all in the Netherlands. In addition, two general hospitals, in Hengelo and Geldrop, participated. Diagnoses were made by authorized professionals according to the protocol of the institution. Participants were asked to fill out three questionnaires and provide some demographic information as well. The questionnaires were collected at the institution, or participants were provided with a stamped and addressed return envelope to return the information. All information remained anonymous and the “Ethical Principles for Medical Research Involving Human Subjects” of the World Medical Association Declaration of Helsinki were followed (World Medical Association, 2008). Demographic information can be found in Table 1.

Table 1.

Demographic Information.

Demographic variables	Male n (%)	Female n (%)
Sex	46 (54.8)	38 (45.2)
Education^a
Low	8 (17.8)	16 (42.1)
Average	27 (60.0)	15 (39.5)
High	10 (22.2)	7 (18.4)
Marital status
Single	16 (34.8)	14 (36.8)
Relationship, not living together	7 (15.2)	2 (5.3)
Living together	8 (17.4)	5 (13.2)
Married	15 (32.6)	17 (44.7)
Age^b
20-30	17 (40.5)	15 (42.9)
31-40	18 (42.9)	11 (31.4)
41-50	7 (16.7)	7 (20.0)
51-60		2 (5.7)

Low = elementary education, lower secondary education; average = average secondary education, average tertiary education; high = higher secondary education, higher tertiary education.

Seven missing values.

Measures

By means of a short questionnaire, respondents provided demographic information: sex, age, marital status, and level of education. To measure attachment style, the Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991) was used, a self-report questionnaire that is partly forced-choice. All four attachment styles (secure, preoccupied, fearful, and dismissive) were shortly described, and participants had to choose the style that fits them best. Although the RQ is a very short questionnaire, its reliability and validity are good (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010).

The Autonomy-Connectedness Scale (ACS-30), developed by Bekker and van Assen (2006; adapted from Bekker, 1993), was used to measure the three components of autonomy: self-awareness, sensitivity to others, and capacity to manage new situations. This self-report questionnaire consists of 30 questions to be rated on a 5-point Likert-type scale from does not fit me at all to fits me completely. Bekker and van Assen (2006) reported good validity and found Cronbach’s alphas to vary between .81 and .86.

The Brief Symptom Inventory (BSI; Derogatis, 1975; Derogatis & Melsaratos, 1983), used to measure psychological functioning, is a self-report questionnaire that consists of 55 items that have to be rated on a 5-point Likert-type scale from not at all to extremely. The BSI has nine subscales and a total score, the global severity index. According to de Beurs and Zitman (2006), all subscales have good reliability (Cronbach’s alphas between .71 and .87), and the reliability of the total scale is .96. Reliability results of this study can be found in Table 3.

Statistical Analyses

The statistical analyses were performed in SPSS 16.0. Prior to the analyses, all assumptions were checked. A chi-square test comparing the percentages of occurrence of the various attachment styles in our sample with those reported in the literature regarding a normal sample was used to examine the first research question, whether adults with ADHD are more insecurely attached than the normal population. An analysis of variance was performed to investigate our second research question concerning the relationship between attachment style and general psychological functioning. We compared the average scores of participants with the norm data for the autonomy questionnaire (ACS-30) to examine the third research question, whether adults with ADHD have more autonomy problems than the normal population. By calculating correlations, we tested the relationship between autonomy and general psychological functioning, our fourth question. Finally, a hierarchical regression analysis was used to investigate the fifth question, concerning the predictive value of attachment security and autonomy for general psychological functioning, after controlling for the contribution of age, sex, education, and marital status. The demographic variables were entered as independent variables at Step 1, attachment security was entered at Step 2, and the three autonomy scales were entered at Step 3.

Results

Preliminary Analyses

Most scales were normally distributed or could be transformed (square root) to be normally distributed (see Table 3). The transformed scores were used in all analyses where a normal distribution of scores was assumed. Chi-square tests for independence between the descriptive variables revealed a statistically significant association between gender and level of education with men reporting a higher level of education than women, χ²(2, n = 84) = 6.28, p = .04, φ = .27.

Attachment Style and ADHD

In our sample, 82% were found to be insecurely attached (see Table 2), a percentage twice as high as reported regarding the normal population. When this latter percentage was applied to our sample, the difference was statistically significant, χ²(1, n = 83) = 57.59, p < .001). A chi-square test for independence showed no association between attachment style and gender, χ²(3, n = 81) = 5.58, p = .13, φ = .26.

Table 2.

Attachment Styles and Mean Scores on General Psychological Functioning (BSI Total), Mean Scores on Autonomy Scales for Norm and Sample Group.

	Male	Female		BSI total
Attachment style	n (%)	n (%)	Total (%)	M	SD	F(3, 77)	Post hoc
Secure	9 (20.5)	6 (16.2)	15 (18.5)	51.07	34.31	4.55, p = .005	Preoccupied > secure, dismissing
Fearful	15 (34.1)	21 (56.8)	36 (44.4)	76.72	35.34
Preoccupied	16 (36.4)	6 (16.2)	22 (27.2)	84.95	32.87
Dismissive	4 (9.1)	4 (10.8)	8 (9.9)	47.25	31.76
Total	44 (54.3)	37 (54.7)	81^a	71.30	36.38
	Norm group			Sample group			Score^b
Autonomy scales	Male M (SD)	Female M (SD)	Total M (SD)	Male M (SD)	Female M (SD)	Total M (SD)
Self-awareness			26.61 (4.71)			22.98 (6.40)	Below average
Sensitivity to others^c	52.35 (8.54)	60.05 (8.60)	56.04 (9.39)	61.52 (9.87)	69.50 (7.29)	65.13 (9.61)	Above average
Capacity to manage new situations			18.27 (4.93)			16.56 (5.70)	Average

Three missing values.

Score of sample group compared with norm group.

This autonomy scale has separate norm groups for males and females.

Attachment Style and General Psychological Functioning

An analysis of variance, examining the relationship between attachment style and general psychological functioning, showed a statistically significant difference at the p < .05 level in BSI scores for attachment style, F(3, 77) = 4.55, p = .005. The effect size, calculated using eta squared, was .15 indicating a large effect (Pallant, 2007). Post hoc comparisons using the Tukey’s Honestly Significant Difference test indicated that the mean scores for the secure and dismissive group differed significantly at the p < .05 level from the preoccupied group. These two groups reported fewer problems in general psychological functioning than the preoccupied group (see Table 2).

Autonomy and ADHD

Comparing the average scores of participants with the norm data for the autonomy questionnaire (ACS-30), we concluded that adults with ADHD scored below average on self-awareness and above average on sensitivity to others compared with the normal population (Table 2). The capacity to manage new situations in this group was average compared with normals. An additional one-way between-groups multivariate analysis of variance revealed a marginally significant difference in autonomy for attachment style (Wilks’s Lambda = .81, p = .061).

Autonomy and General Psychological Functioning

Correlations between autonomy and general psychological functioning are presented in Table 3. In general, medium to large negative correlations were found between capacity to manage new situations and all BSI scales. Furthermore, small to medium positive correlations were found between sensitivity to others, total BSI score, and six out of nine BSI subscales. Self-awareness only correlated negatively with the obsessive compulsive subscale.

Table 3.

Pearson Correlations and Reliability Measures for Autonomy Scales, BSI-Scales, Demographic Variables, and Attachment Security.

	α^a	1	2	3	4	5	6	7	8	9	10	11	12	13
1 Self -awareness	.81	—
2 Sensitivity to others	.80	−.26*	—
3 Capacity to manage new situations^b	.80	.28**	n.s.	—
4 BSI total score	.96	n.s.	.31**	−.51**	—
5 Somatization^b	.84	n.s.	n.s.	−.31**	.77**	—
6 Obsessive compulsive	.86	−.29**	.27*	−.45**	.74**	.52**	—
7 Interpersonal sensitivity^c	.80	n.s.	.46**	−.56**	.80**	.49**	.54**	—
8 Depression^b	.87	n.s.	.24*	−.39*	.83**	.58**	.53**	.67**	—
9 Anxiety^c	.83	n.s.	n.s.	−.39*	.86**	.70**	.61**	.56**	.62**	—
10 Hostility^b	.79	n.s.	n.s.	−.40**	.69**	.37**	.52**	.60**	.57**	.58**	—
11 Phobic anxiety^c	.78	n.s.	.26*	−.55**	.78**	.58**	.49**	.68**	.60**	.66**	.35**	—
12 Paranoid ideation^c	.70	n.s.	.31**	−.29**	.77**	.57**	.47**	.61**	.55**	.66**	.56**	.50**	—
13 Psychoticism^c	.58	n.s.	.27*	−.39**	.81**	.54**	.54**	.67**	.76**	.64**	.46**	.64**	.61**	—
14 Sex^d		n.s.	.42**	n.s.	n.s.
15 Age^d		n.s.	n.s.	.22*	n.s.
16 Education^d		n.s.	n.s.	n.s.	−.24*
17 Marital status^d		n.s.	n.s.	n.s.	n.s.
18 Secure attachment yes/no^d		n.s.	n.s.	n.s.	−.26**

Note: n.s. = not statistically significant (p > .05).

Calculated on raw scores.

Square root transformed variable.

Not normally distributed.

No correlation analysis performed with BSI subscales.

p < .05 (two-tailed). **p < .01 (two-tailed).

Attachment, Autonomy, and General Psychological Functioning

Results of the hierarchical regression analysis, predicting general psychological functioning from attachment security and autonomy, after controlling for age, sex, education, and marital status, are shown in Table 4. At the p < .10 level, the demographic variables together explained 11% of the variance in general psychological functioning with education being the largest contributor. After controlling for the demographic variables, attachment security did explain an additional 6% of the variance (p = .036). In the final model, autonomy explained an additional 22% of the variance in general psychological functioning. Sensitivity to others and capacity to manage new situations were significant predictors.

Table 4.

Summary of Hierarchical Regression Analysis for Variables Predicting General Psychological Functioning.

	Model 1			Model 2			Model 3
Variable	B	SE B	β	B	SE B	β	B	SE B	β
Education	−14.47	6.01	−.28**	−12.81	5.92	−.25**	−7.97	5.36	−.16
Age	−0.93	0.51	−.23*	−0.97	0.50	−.25*	−0.36	.46	−.09
Sex	0.01	8.39	.00	0.18	8.19	.00	−8.42	7.85	−.12
Marital status	0.33	3.53	.03	0.9	3.42	.03	−1.61	3.05	−.06
Securely attached yes/no^a				−21.85	10.45	−.24**	−16.98	9.32	−.18*
Self-awareness							0.29	0.60	.05
Sensitivity to others							1.01	0.42	.27**
Capacity to manage new situations							−21.28	5.6	−.41***
R ²		0.11			0.16			0.38
F for change in R²		2.08*			4.55**			8.01***

Secure = yes; fearful, preoccupied, or dismissive = no.

p ≤ .10. **p ≤ .05. ***p ≤ .01.

Discussion

The present study examined attachment and autonomy for late-diagnosed adults with ADHD. The percentage of securely attached adults with ADHD in this study is 18%, more than 3 times lower than in the normal population (59%). This percentage comes close to the percentage of 13 that is found by Van IJzendoorn and Bakermans-Kranenburg (1996) for a clinical sample of psychiatric patients. Most frequently, adults with ADHD reported the fearful attachment style (44%), followed by the preoccupied style (27%). These two styles are characterized by a negative image of self. Many studies demonstrate adults with ADHD to suffer from low self-esteem (e.g., Kooij et al., 2010; Ramsay & Rostain, 2005). The first hypothesis, adults with ADHD reporting more insecure attachment styles than the normal population, was confirmed.

Furthermore, we hypothesized that adults with ADHD with an insecure attachment style would report more psychological problems than those with a secure attachment style. This hypothesis was only confirmed partly: Adults with ADHD who have a preoccupied attachment style reported significantly more psychological problems than the secure and the dismissive group. For the fearful group, no significant differences were found with any of the other styles, both secure and insecure. These results indicated two interesting findings. First of all, the dismissive attachment style, which is an insecure style, could be seen as “equal” to the secure attachment style when general psychological functioning is considered. Wearden, Lamberton, Crook, and Walsh (2005) found similar results in their study of a normal population. Second, the preoccupied attachment style seemed to be associated with most psychological problems.

Analyzing the original model of attachment by Bartholomew and Horowitz (1991), the common factor between the secure and dismissive attachment style is a positive self-image. Applying this to the first finding, a positive image of self seems to have a larger impact on general psychological functioning than a positive image of others. Wearden et al. (2005) found dismissing individuals to be prone to the social desirability bias, suggesting they might have negative symptoms and feelings without reporting them. Murphy and Bates (1997), however, found dismissively attached individuals to be less critical of themselves and thus less vulnerable to depression, and reporting fewer symptoms. Another explanation might be related to the construct of psychological functioning itself that can be expected to be influenced more by someone’s self-image than by someone’s image of others.

Trying to explain the second result that the preoccupied attachment style seems to generate most psychological problems, led us to the original model as well. Supposedly, people with ADHD who have a negative image of themselves and a positive image of others (preoccupied) have even more problems in psychological functioning than people who have a negative image of themselves and a negative image of others (fearful). Many studies found fearful attachment to generate more psychological problems than preoccupied attachment (Murphy & Bates, 1997; Pielage, Gerlsma, & Schaap, 2000; Wearden et al., 2005). However, other studies found the preoccupied style to have the highest association with various psychological problems (Bogaerts & Daalder, 2011; Sumer, 2001; Verdecias, Girardin, Zizi, Casimir, & Browne, 2009). Verdecias et al.(2009), for example, stressed the rumination habits of preoccupiedly attached individuals. The original model of Bartholomew and Horowitz (1991) offers another possible explanation for the difference between the preoccupied and fearful style. By avoiding close involvement with others, persons with a fearful style protect themselves against anticipated rejection. Preoccupied individuals, however, need acceptance from others to increase their self-esteem and are therefore more at risk for experiencing rejection. As adults with ADHD often suffer from a chronic sense of failure already (Ramsay & Rostain, 2005), these additional failure experiences might damage their self-esteem even more, thus causing them to report more psychological problems.

In addition to attachment style, autonomy was studied in adults with ADHD. The first two hypotheses concerning autonomy were confirmed: Adults with ADHD scored below average on self-awareness and above average on sensitivity to others compared with the normal population. This agrees with the possible explanations mentioned before; in addition, still unknown factors might play a role as well. The findings of Rapport et al. (2002) that adults with ADHD would be less sensitive to others were contradicted by the results of this study.

Although we expected that adults with ADHD would be less capable of managing new situations, they were found to score average compared with the normal population. Several explanatory factors may have a neutralizing effect on each other, resulting in an average score on ccapacity for managing new situations for the whole group. The same principle may apply to subgroups within the sample, for example related to attachment style. More research is needed to further investigate this subject.

Concerning the relationship between the three autonomy components and psychological functioning, capacity to manage new situations correlated most strongly with all BSI scales, followed by sensitivity to others. The hypothesis concerning self-awareness was rejected. Interestingly enough, capacity to manage new situations was the only component of autonomy on which adults with ADHD did not deviate from the normal population.

Our hypothesis that attachment and autonomy would predict general psychological functioning was confirmed, except for self-awareness. Unexpectedly, educational level was found to have an impact on general psychological functioning as well. Many studies reported adults with ADHD to have a lower education than the normal population (e.g., Barkley et al., 2008; Kooij, 2007) and found them to be at risk for underachievement (Young, 2000). In addition, Kooij (2007) stated that having a higher education and a higher intelligence might compensate for severity of ADHD symptoms. However, in different populations similar results were found (Bekker & Belt, 2006; Ford, 2012; Smith & Baltes, 1997). Possibly, the relationship found is not exclusive for the ADHD group but is also valid for other populations.

This study has several limitations. First of all, self-report questionnaires were used as opposed to other, possibly not only more objective but also more time-consuming, ways of measurement. In addition, the RQ was a very short questionnaire while longer, slightly more reliable scales are also available. Moreover, attachment style was used as a categorical instead of continuous variable, which made statistical analyses easier but denied its dimensional characteristics. Finally, many relationships between variables were explored which, in combination with a relatively small sample size and limited amount of other studies in this area, has led to results and hypothetical explanations that above all stress the need for further research. It is clear that the results of this study should be viewed with care.

Implications for Clinical Practice

Despite its limitations, this study could have some implications for clinical practice already. First of all, without doubt, most adults with ADHD have an insecure attachment style. Therefore, it might be wise to have a new look at present treatment plans that often emphasize medication, psychoeducation, and coaching. Making more room for attachment-related issues, such as interpersonal functioning, could be beneficial. Another implication might be prevention: Children with ADHD can be assumed to be at risk to develop an insecure attachment style, and parents and professional could work together to prevent this. Possibly, a relationship also exists between insecure attachment and the high comorbidity rate in adults with ADHD. In addition, adults with ADHD reported several autonomy problems that contributed more strongly to their present psychological functioning than attachment style. Therefore, working on autonomy-related issues such as their sensitivity to others and capacity to manage new situations could positively add to treatment as well.

At last, helping ADHD adults to live up to their educational potential might be a more powerful means to improve their psychological well-being than we had foreseen.

Footnotes

Acknowledgements

Thanks are due to all participating patients and to J. R. M. van Erven and E. C. M. van Amstel from GGZ Eindhoven; P. de Niet from PsyQ Tilburg; T. I. Bron and J. J. S. Kooij from PsyQ Haaglanden, The Hague; M. Heijmans and F. Houkes from PsyQ Roermond; J. S. Thé from Ziekenhuisgroep Twente in Hengelo; and St. Anna Ziekenhuis in Geldrop for their efforts in collecting the data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Rosalien G. Koemans received her MSc in clinical psychology from Tilburg University in Tilburg, the Netherlands. Prior to that, she received her MA in counseling from Midwestern State University in Wichita Falls, Texas. She is currently employed at Psychology Practice Oog in Eindhoven, the Netherlands. She has personal and professional experience with adults with ADHD and is interested in increasing knowledge about this group to improve treatment.

Susanne van Vroenhoven received her MSc in clinical psychology from Tilburg University in Tilburg. She is currently employed as a psychologist at HSK Group in the Netherlands.

Annemiek Karreman works as an assistant professor at the Department of Developmental and Clinical Psychology at Tilburg University in Tilburg, the Netherlands. Her research focuses mainly on personality, self-regulation, emotions, and psychopathology in children and adults.

Marrie H. J. Bekker, PhD, holds the chair of clinical psychology at Tilburg University in Tilburg, the Netherlands. Her main research area concerns autonomy and attachment in relation to various types of mental disorders, such as anxiety, mood, eating, and personality disorders.

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