J Abnorm Child Psychol
DOI 10.1007/s10802-014-9854-0
ADHD Symptoms and Attachment Representations: Considering
the Role of Conduct Problems, Cognitive Deficits and Narrative
Responses 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-related
story stems, which allowed us to investigate whether problems
with narrative production can explain the relation between
ADHD symptoms and attachment representations. We also
investigated 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 oversampling
of children with high levels of ADHD symptoms. ADHD
symptoms and conduct problems were rated by parents and
teachers. Cognitive functioning was investigated using labo-
ratory tests of inhibition, working memory and sustained
attention. Attachment representations were coded as secure,
organized insecure and disorganized categories. Narrative
responses to non-attachment-related story stems were coded
for incoherence and negative content. Results showed that
children in the disorganized attachment category had signifi-
cantly higher levels of ADHD symptoms compared to those in
the secure category. Both ADHD symptoms and disorganized
attachment were related to incoherence and negative content.
Attachment representations were not associated with ADHD
symptoms when controlling for negative content in response
to non-attachment-related story stems. These results suggest
that the associations between attachment security and ADHD
are yet to be fully understood. Importantly, a propensity to
Author Note This research was supported by a grant from The Swedish
Council 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, Sweden
e-mail: gunilla.bohlin@psyk.uu.se
L. B. Thorell
Karolinska Institutet, Stockholm, Sweden
envisage negative events seems to characterize children with
high levels of ADHD symptoms.
Keywords ADHD symptoms . Attachment representations .
Cognitive deficits . Narrative . Incoherence . Negative content
Attention Deficit/Hyperactivity Disorder (ADHD) is one of
the most commonly diagnosed and widely studied psychiatric
disorders in children. Children with ADHD display activity
levels that are far in excess of their age group, and they have
difficulty sustaining attention and maintaining persistence to
tasks (American Psychiatric Association 2000). The clinical
features of ADHD are increasingly being recognized as
representing the extreme end of normal traits, rather than a
distinct category (e.g., Bauermeister et al. 2007; Kraemer et al.
2004; Larsson et al. 2012; Sonuga-Barke et al. 2003). In other
words, considering a wide range of ADHD symptoms is of
interest when studying relations between ADHD and other
aspects of child functioning.
ADHD is recognized as having a multifactorial etiology. In
extant models of ADHD, behavioral disinhibition and
working-memory deficits have garnered particular attention,
although it should also be recognized that not all children with
ADHD symptoms have cognitive deficits (Willcutt et al.
2005). Alongside the cognitive-deficiency perspective, possi-
ble etiological factors tied to the child’s family context have
been found (e.g., Biederman et al. 2002; Counts et al. 2005).
In this vein, an attachment perspective on the background of
ADHD has been explored (e.g., Pinto et al. 2006). According
to attachment theory, an infant’s early experiences with care-
givers establish the foundation for mental representations later
developed in childhood. These internal working models reg-
ulate the child’s understanding of interactions with others and
help regulate behavior. When caregivers are sensitive and
responsive to the needs of the child, a secure attachment

relationship is likely to develop. When caregivers are less
sensitive, an insecure attachment relationship is likely to de-
velop. Insecure avoidant and insecure ambivalent attachment
are considered organized in the sense that the children have
coherent strategies to handle stress and anxiety, whereas dis-
organized insecure attachment is identified by the lack of such
strategies, presumably because parents are experienced as
frightening or frightened. Disorganized insecure attachment
is the subgroup of insecure attachment that has been shown to
be 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 of
ADHD, some support for a link between disorganized attach-
ment and ADHD behaviors has been presented. The study by
Pinto et al. (2006) showed that disorganized attachment in
infancy 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 and
Edelbrock 1981) and not to aggression or rule-breaking be-
haviors. In two studies, which also found an association
between 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 ½
years, using story stem methodology, was associated with
symptoms of ADHD 1 year later in a non-clinical sample
and this was independent of cognitive deficits and conduct
problems. Second, the study by Bohlin et al. (2012), using the
same methodology, found that disorganized attachment at age
5 was significantly predictive of ADHD symptoms at age 7,
and that disorganized attachment co-varied to some extent
with inhibition and even more so with conduct problems.
More studies examining the link between disorganization
and ADHD symptoms are clearly needed, especially studies
trying to further elucidate the complex relation by also includ-
ing measures of cognitive performance.
As in the studies referred to above, attachment, when
studied beyond infancy, is typically assessed by considering
the child’s verbal responses to a story stem containing a
scenario that involves parental figures—a scenario that is
meant 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 the
story is considered to reflect the child’s representation of the
attachment relationship. As argued by, for example, Oppen-
heim and Waters (1995), the task of assessing attachment
representations using story-stem methodology is complex
J Abnorm Child Psychol
because the attachment classification relies on both narrative
organization 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 elements
of a story that do not connect well to each other, do not include
coherent reasons for emotional states, and/or the children may
distance themselves from the topic. Incoherent narratives and
narratives including scary events are seen as signs of the
child’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 aspects
of 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 and
goals in an organized manner, which are skills that children
could lack for reasons other than being insecurely attached.
Thus, when studying attachment representations using story-
stem methodology, it is important to take into consideration
children’s responses to non-attachment-related story stems. If
aspects of narrative organization and content are specific to
situations when the attachment system is activated (i.e., pri-
marily in cases of separation from the attachment figure, in
fearful situations or when the child is physically injured), and
not present in responses made to more neutral stimuli, this
would support the conclusion that “true” attachment represen-
tations have been measured. To our knowledge, only one
previous 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 responses
to attachment stories, insecure children showed higher levels
of 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 of
attachment-related story stems to trigger a specific type of
response, although this issue is clearly in need of further
examination.
ADHD and Narrative Problems
The content and organization of children’s narratives have
been linked to behavioral competencies and risks (for review
see, e.g., Emde et al. 2003; Holmberg et al. 2007). With regard
to ADHD specifically, studies have found associations be-
tween ADHD and difficulties with narrative production even
when the method used was not meant to trigger attachment
behaviors. Children with ADHD have been found to produce
less coherent narratives when asked to retell tales read to them
or shown on television, compared to children without ADHD
J Abnorm Child Psychol
(Lorch et al. 2010; Tannock et al. 1993). These ADHD-related
problems with incoherence have been found even when the
memory demands of the narrative production task were low
(Renz et al. 2003). In addition, Flory et al. (2006) found that
coherence difficulties among children with ADHD could
mainly be accounted for by problems with sustained attention
and not inhibition or planning/working memory.
Symptoms of inattention, or externalizing behavior prob-
lems in general, have also been related to the inclusion of
negative content in narratives. Although negative content
should perhaps not be seen as problematic in itself, it has been
related 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-Waxler
et al. (1994) found that inattention, as assessed by the CBCL
was 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 disorganized
responses with a “negative tone”) was positively correlated
with externalizing behavior both concurrently and longitudi-
nally. The aforementioned studies investigating negative con-
tent used broad measures of externalizing problems. How
ADHD symptoms specifically are related to negative content
is not known. Previous studies have also, to a relatively large
extent, employed story stems developed to assess attachment
representations, which means that it is unclear whether the
disposition to include negative content in narratives reflects
insecure attachment or whether it is an outflow of the child’s
externalizing behaviors as such. In order to shed further light
on this issue, it is necessary to include both attachment-related
and non-attachment-related story stems, as done in the present
study.
The Present Study
As described above, associations between ADHD symptoms
and insecure attachment representations, primarily disorgani-
zation, have been found using story-stem methodology. How-
ever, the role of concurrent narrative problems has yet to be
addressed. In addition, the role of cognitive deficits and con-
duct problems needs to be further elucidated. The overall aim
of the present study was therefore to investigate ADHD
symptoms in relation to attachment representations, while
considering conduct problems, cognitive deficits and narrative
responses to non-attachment-related story stems. By including
narrative responses to non-attachment-related story stems, we
investigated the extent to which associations between attach-
ment representations and ADHD symptoms could be ex-
plained by general narrative features associated with high
levels of ADHD symptoms. It was expected that ADHD
symptoms would be related to disorganized rather than to
secure or organized insecure attachment representations.
Based on the idea of a true association between disorganized
attachment and ADHD symptoms (i.e., not an association
explained by general narrative features of children with high
levels of ADHD symptoms), we expected that the association
between disorganized attachment and ADHD symptoms
would hold when controlling for narrative responses to non-
attachment-related story stems. Further, in line with previous
findings (Bohlin et al. 2012; Thorell et al. 2012) we expected
relations between ADHD symptoms and disorganized attach-
ment independent of cognitive deficits; for conduct problems
the previous inconclusive results made us leave the issue of
independent 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 true
relation between attachment representations and ADHD
symptoms.
Method
Participants
The sample consisted of 89 children between 6 and 10 years
old (M=8.27, SD=0.96 years). To capture a wide range of
ADHD symptoms, in line with our dimensional approach to
ADHD, we recruited 27 children expected to have high levels
of ADHD symptoms through an ADHD center (20 boys and 7
girls). Sixty-two children, selected to correspond to the chil-
dren from the ADHD center in age and gender, were recruited
from the community population via local schools (45 boys and
17 girls). Letters were sent out to parents and they signed up
for participation. Three of the 30 children initially contacted
through the ADHD center fell ill on the day of the testing and
they were excluded from the study. Sixty-two of the 65
children, recruited through schools, fell within the age range
of the study. There was no significant age difference between
those recruited through the ADHD centers and those recruited
through schools (p>0.05). ADHD symptom levels overlap-
ped, that is, some of the children recruited through schools had
higher levels than some of the children recruited through the
ADHD center.
None of the children recruited through schools were on
ADHD medication. Twenty-three of the 27 children recruited
through the ADHD center were normally on ADHD medica-
tion; the parents of 16 of these children allowed them to be off
medication on the day of testing. For the sample as a whole,
maternal education was high, as 55 % had a college or a
university 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 the
children recruited through the ADHD center and those

recruited through schools in any of these background vari-
ables (p>0.05).
Procedure
The study was approved by the local Ethics Committee (Dnr
2010/334), and all parents provided informed written consent
for their child’s participation in the study. Research assistants
collected data on attachment representations and cognitive
functioning during a visit to the child’s school, which lasted
1–1½h. 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 the
school visit, and the parents received their questionnaires
through the mail. Non-responders received two reminders.
Teachers received one movie ticket voucher for completing
the questionnaire, and the children received a toy worth ap-
proximately 5 Euros for participating.
Measures
Parent and Teacher Ratings Teachers and parents rated
ADHD symptoms and conduct problems. ADHD symptoms
were measured using the ADHD Rating Scale IV, an 18-item
measure reflecting DSM-IV-criteria (American Psychiatric
Association 1994). This scale is well validated and extensive-
ly used within ADHD research (DuPaul et al. 1998). Nine
items measure inattention and nine items measure
hyperactivity/impulsivity. The response format used ranged
from 0 (never or rarely) to 3 (very often), α=0.97 for parent
ratings and α=0.94 for teacher ratings. Conduct problems
were rated using five items from the externalizing scale of
the Children’s Behavior Questionnaire (CBQ; Rutter et al.
1970). We used the following items: “Often disobedient”,
“Often fights with other children”, “Angers easily”, “Has
stolen things/money”, “Sometimes lies”. The rating scale
ranged from 1 (Does not apply) to 5 (Applies very well), α=
0.76 for parent ratings and α=0.83 for teacher ratings. Three
children were missing the parent report, and four children
were missing the teacher report. Parent and teacher ratings
were highly correlated, r=0.65, p<0.001 for ADHD symp-
toms and r=0.59, p<0.001 for conduct problems, and the
mean of parent and teacher ratings was therefore used in the
present study. The ADHD symptom and conduct problem
scales 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 the
children’s attachment representations and the narrative fea-
tures of their story completion. The story stems were told
using doll materials (e.g., doll family, doll house, furniture,
toy car, toy schoolyard equipment, etc.). The administrator
started by introducing the characters and the setting to be used
J Abnorm Child Psychol
in the story stem and then proceeded by telling the child the
scripted beginning of a story. The main character of each story
stem was a child doll of the same sex as the participant. The
children were then asked to complete the story both verbally
and by showing actions using the doll material, prompted to
begin by the administrator saying “So can you show me what
happened next? You finish the story!” The children were
presented with a total of six different story stems. Three of
the story stems were attachment related and three were non-
attachment-related (i.e., did not require the parent for comfort
or protection). The story stems were presented in a fixed order:
the first one was non-attachment-related, the second, third and
fourth 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 doll
material was handled.
Attachment Representations To assess attachment representa-
tions, we used three stories commonly used in several other
story-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 to
gradually 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 living
room. In Monster in the Bedroom, the child doll thinks that
there is a monster in his/her room during the night and is
frightened, while the mother doll is sitting in the living room.
In the Separation-Reunion story, the parent dolls leave the
child doll in the care of a grandmother doll for a week and then
come back.
Transcriptions of the completions of the attachment-related
story stems were classified according the Attachment Doll
Play Classification System developed by George and Solo-
mon (2000). Each story completion is scored as belonging to
one of four attachment categories: secure, ambivalent,
avoidant or disorganized. A secure classification is obtained
when the child describes an immediate and adequate response
from the parent in the form of a solution to the problem at
hand. A classification of ambivalent attachment is character-
ized by cognitive disconnection, whereby the child acknowl-
edges the attachment problem although he/she actively tries to
direct attention away from the source of the distress and
effective ways of coping with it (e.g., the character is involved
in a busy activity not related to the attachment problem).
Avoidant attachment is characterized by deactivation of the
attachment system; this classification is given when the child
conveys that there is no need for the parent to provide care and
protection (e.g., solving the problem without the help of the
parent or denial of injury). These classifications are all con-
sidered organized. A disorganized classification is obtained
when the stories are characterized by either, a) poor coherence,
J Abnorm Child Psychol
chaos, violence and scary events, without a solution to the
attachment problem or b) mental blocking and freezing, a rare
type 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 the
attachment system the Separation-Reunion story weighs
heavily in the final classification; even if the other two stories
are scored as insecure, a Separation-Reunion story scored as
secure will give a secure classification. Validity of the story-
stem methodology has been demonstrated through associa-
tions with Strange Situation security classifications, made at
18 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 with
concurrent reunion behavior after separation (Solomon et al.
1995).
All attachment-related stories were coded independently by
two coders, whom were blind to all other participant informa-
tion (GB and LT). Agreement on classification was kappa 0.69
for the three categories secure, insecure organized and inse-
cure disorganized. Disagreements were discussed, and the
final classifications of such cases were based on unanimous
decisions. This coding resulted in 58 children being classified
as 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 and
Locked in the Classroom. These story stems were developed
by our research group to mimic the attachment story stems in
complexity, but to provide a problem to be solved that did not
involve the need for parental figures to give comfort or pro-
tection. In Lost Kitten, the child doll is at home with his/her
mother and a neighbor comes to the door with a lost kitten. In
Broken Pitcher, the child doll and his/her same sex friend are
home alone playing in the living room in the friend’s house
and the friend accidentally knocks over and breaks a pitcher.
In Locked in the Classroom, the child doll is in a classroom at
school with his/her classmates (six other child dolls, boys and
girls) and when the school bell rings for recess the teacher doll
is unable to open the classroom door to let the children out to
play as she has lost the key.
The transcriptions of the non-attachment-related stories
were rated with regard to incoherence and negative content
by separate coders blind to all other participant scores. The
measure of incoherence was based on the Narrative Coher-
ence Scale used by Sher-Censor and Oppenheim (2004), used
5 levels, and was reversed so that ascending numbers would
reflect incoherence. Central to this scale are storyline shifts,
defined as abrupt and unexplained changes of events. The
degree of incoherence was coded by one of the authors (SS)
on a scale from 1 (a logical story completion with a series of
events that are related to the theme of the story stem and that
demonstrate an understanding of the problem given and a
solution to the problem”, for example a story where the child
takes several steps to find the owner of the kitten, makes fliers,
put them up in neighborhood, and then mentions that the
owner 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 large
number of shifts in the storyline, for example a story where the
dilemma with the lost kitten is not mentioned and child in the
story does a number of unrelated things without explanation).
The mean of the ratings across the three non-attachment
stories was used (α = 0.73). Inter-rater reliability was
established with a separate coder (AMR) on the narratives
from 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 one
child.
The negative content measure was developed for the pres-
ent study and took into consideration both the number and
severity of negative events. A negative event is defined as the
occurrence of something unpleasant, harmful or threatening
(these events ranged from unpleasant such as verbal threats of
violence to serious events such as figures in the story killing
several others). Ratings were given on a scale of 1 none to 5
several very unpleasant events, or one or more very serious
events such as death. The mean of the rating across the three
non-attachment-related stories was used as the measure (α=
0.64). All children gave responses that could be coded for
negative content. Negative content was rated by a research
assistant and inter-rater reliability for 26 children was
established with one of the authors (AMR), r=0.86, p<0.001.
WISC-IV Vocabulary Children’s vocabulary was assessed
using the vocabulary subtest from Wechsler Intelligence Scale
for Children—4th Ed (WISC-IV; Weschler 2003), which
measures the child’s word knowledge and verbal concept
formation. The vocabulary task consisted of a total of 29
words 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 derived
from the Day–Night Stroop task (Gerstadt et al. 1994), in
which conflict is provided by asking the children to say the
opposite of what is in the picture (i.e., to say “night” when the
picture “day” is shown on the screen). Four picture pairs were
used: day–night, up–down, big–small and boy–girl. The sum
of the number of incorrect responses and response corrections
was used to measure disinhibition. Validity information for the

opposite pairs task was given in Bohlin et al. (2012), where
the task loaded together with other inhibition measures on a
single dimension using Factor Analysis.
The go/no-go Task A go/no-go task developed by Berlin and
Bohlin (2002), which was administered using the Psytools
software (Delosis, London), was used to measure sustained
attention. The task consisted of a blue square, a blue triangle, a
red square, and a red triangle, each object being presented one
at a time on a computer screen. During the first part of the task,
the children were instructed to press a key (“go”) when a
frequent stimulus (a blue figure) appeared on the screen, but
to make no response (“no-go”) when an infrequent stimulus (a
red figure) appeared. The same stimuli were used for the
second part of the task, but the children were then instructed
to press a key every time they saw a square, and to inhibit their
response every time they saw a triangle, irrespective of color.
Altogether the task included 60 stimuli, with a duration of
1,200 ms and an interstimulus interval of 1,000 ms. The “go
rate” was 66 %. The total number of omission errors (not
pressing the key when a “go” target was presented) and the
standard deviation of the reaction times (i.e., reaction time
variability) were standardized and averaged to form a measure
of sustained attention, α=0.62. Three outliers (> 3 SD) in
reaction time variability in the second part of the task were
identified and rescored with the fourth highest value on this
variable. High values denote poor sustained attention. For
information on reliability and validity of the go/no-go para-
digm, we refer to Berwid et al. (2005).
Children’s Size-Ordering Task A verbal working-memory task,
the Children’s Size-Ordering Task (McInerney et al. 2005),
was used to measure working memory. In this task, common
nouns (e.g., cat, car, apple) are read aloud at a rate of one item
per second to the child, who is then asked to repeat them back
to the administrator according to size, from smallest to largest.
Two practice trials were administered first. The actual test
began with two items per trial, and became progressively
more difficult. All children were administered all trials, re-
gardless of their performance. The total number of pairs of
items ordered correctly across all trials was added together and
then reversed (i.e., a higher score indicated working memory
deficits). Validity information in terms of demonstrated corre-
lations with other working memory measures was presented
by McInterney et al. (2005).
Statistical Analyses
Potential differences in maternal education, parental immi-
grant status, living situation and gender were examined using
t-tests and χ2 analyses. Relations between continuous vari-
ables were calculated using Pearson’s correlations. Potential
age differences between attachment categories were analyzed
J Abnorm Child Psychol
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 of
ANOVAs. In case of a significant ANOVA, the three attach-
ment categories were compared using Bonferroni corrections.
Finally, we tested whether the attachment categories had an
independent effect on ADHD symptoms by performing anal-
yses of covariance (ANCOVAs) with relevant controls, that is,
with variables related to ADHD symptoms and attachment
categories, again using Bonferroni corrections.
Results
There was no significant difference between the attachment
categories with regard to maternal education, parental immi-
grant status or living situation (p>0.05). With regard to gender
differences, the results showed that there was an association
with attachment category, χ2=6.03, p=0.05; 83 % of the girls
and 59 % of the boys were categorized as secure, and all 10 of
the 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 age
difference for attachment category, F(2, 86)=3.02, p=0.05,
with the children in the secure category being the oldest. Age
was positively related to vocabulary, r=0.39, p<0.001, and
negatively related to the cognitive measures and to narrative
features, r=−0.31 to −0.41, p<0.01. Based on these findings,
gender and age were used as covariates in the remaining
analyses.
The correlations between all continuous variables are pre-
sented in Table 1. As seen in the table, ADHD symptoms were
positively related to conduct problems, cognitive deficits and
narrative problems. Incoherence was positively related to
working-memory deficits and sustained attention problems.
Negative content was positively related to conduct problems
and sustained attention problems. The two narrative measures
were moderately correlated with each other. Vocabulary was
negatively related to cognitive deficits, but was not related to
behavioral 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 comparisons
between attachment categories revealed that, compared to
the children classified as secure, the children classified as
insecure disorganized received significantly higher ratings of
ADHD 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
J Abnorm Child Psychol

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

organized told stories with significantly higher levels of neg-
ative content than did children classified as secure. The only
difference between the two insecure categories was that chil-
dren classified as disorganized had higher levels of negative
content in their narratives than did children classified as orga-
nized. There were no significant effects of attachment on
conduct problems, vocabulary, disinhibition, sustained atten-
tion or working memory deficits.
Controlling for Narrative Problems
categories did not differ significantly with regard to these
variables. The association between attachment and ADHD
symptoms 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 organized
vs insecure disorganized, ns). However, when controlling for
negative content, the association between attachment and
ADHD symptoms was no longer significant, F(2, 83)=1.46,
p>0.10.

As reported above, the results showed that narrative problems Discussion

in responses to non-attachment-related story-stems were relat-
ed to attachment as well as to ADHD symptoms. Two
ANCOVAs 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 sex
and age). The three attachment categories were again
contrasted using Bonferroni correction. The other potential
control variables (i.e., conduct problems, vocabulary, disinhi-
bition, sustained attention and working memory deficits) were
not included in these analyses as the three attachment
The overall aim of the present study was to contribute to
extant knowledge on the association between ADHD symp-
toms and attachment representations, studied through the
completion of attachment-related story stems, by investigating
the role of conduct problems, cognitive deficits and narrative
features 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 positively
related to incoherence in narratives, even with the more free
response format allowed by the story-stem method. We also

Table 2 Results of ANCOVAs on ADHD symptoms, conduct problems, cognitive functioning and narrative features in relation to attachment
categories, 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


found a link between ADHD symptoms and negative content
in the narrative responses to non-attachment-related story
stems. This is a new finding given that previous research has
used broad definitions of externalizing behavior rather than
ADHD symptoms specifically (von Klitzing et al. 2000; War-
ren et al. 1996; Zahn-Waxler et al. 1994). Here, it should be
kept in mind that children’s narrative performance, measured
as incoherence or negative content, did not relate to their
language ability as evaluated by the WISC-IV vocabulary test.
In line with our expectations, children classified as disor-
ganized had higher levels of ADHD symptoms compared with
those classified as secure. This is in agreement with previous
findings (Bohlin et al. 2012; Thorell et al. 2012). In addition,
our study was able to add new important information by
showing that this relation could not be accounted for by the
overlap between ADHD symptoms and either conduct prob-
lems or cognitive deficits. As regards the role of cognitive
deficits in the associations between attachment and ADHD
symptoms, both of the studies addressing this issue (Bohlin
et al. 2012; Thorell et al. 2012) found additive effects of
attachment disorganization and EF deficits. The present study
strengthens the conclusion that it is the ADHD symptoms
themselves, and not cognitive deficits associated with ADHD,
that are related to disorganized attachment representations.
However, it is not possible to draw conclusions about the
direction of effects based on our results. To further elucidate
these relations, there is a need for longitudinal studies with
repeated assessments of both ADHD symptoms and attach-
ment representations, which also should include additional
variables that could possibly explain this relation in more
detail.
One aspect of our results that may seem surprising is the
failure to show a relation between disorganized attachment
and conduct problems, as disorganized attachment has typi-
cally been found to be associated with externalizing behavior
problems (van Ijzendoorn et al. 1999; Fearon et al. 2010). On
the other hand, Goldwyn and co-workers (2000), also using
story-stem methodology, found that disorganization was not
related to aggression or rule-breaking behaviors, which is also
in 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 on
the sample and the extent of comorbidity, and in a wider
perspective, also on the method used for assessing attachment
quality. Further studies are needed to clarify this issue.
Do Children with High Levels of ADHD Symptoms
“Appear” Disorganized?
Because the narrative problems shared associations with
ADHD and attachment disorganization, they could possibly
J Abnorm Child Psychol
have accounted for the association between symptoms of
ADHD and attachment disorganization. In line with our hy-
pothesis, the results showed that the association remained
when controlling for incoherence in response to non-
attachment related story stems. However, contrary to our
hypothesis, negative content did account for the association.
This is in line with the idea that, when using the story-stem
methodology, children with high levels of ADHD symptoms
simply appear disorganized because they generally produce
negative narratives. There could be some feature of the
ADHD syndrome that predisposes children to imagine that
negative events will occur in a variety of situations, irrespec-
tive of the quality of their attachment relationship. One such
feature could be co-occurring conduct problems, as broad
externalizing problems have been associated with negative
content in narratives (Warren et al. 1996; von Klitzing et al.
2000). As pointed out, however, links to conduct problems
were not supported by our data. It is possible that real-life
encounters with various problematic social situations, which
are likely to be frequent among children with high levels of
ADHD symptoms, generate associations to negative events
when these children imagine situations requiring some
amount of social problem-solving (e.g., Crick and Dodge
1994).
So, do our result that children with high levels of ADHD
symptoms could simply “appear” disorganized indicate that
insecure attachment does not genuinely contribute to ADHD
symptoms? 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 experiences
some 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 are
likely to produce negative content in response to non-
attachment-related story stems. One exception is the study
by Greenberg et al. (1997), which did include neutral (i.e.,
non-attachment-related) stories, and found that only
attachment-related story stems elicited different behaviors
and amounts of aggressive content in insecure and secure
children. Thus, they found support for the specificity of
attachment-relevant story stems in activating the attachment
system. The question is, however, whether the “neutral” story
stems were relevant for comparison with the attachment-
related stories, as there seemed to be no problem that needed
to be addressed. Perhaps the non-attachment-related stories
were simply not very engaging. We tried to address this
limitation in our study by introducing story stems with a
problem to be solved. These stories might have spurred the
production of elaborated narratives, demonstrating the high
levels of negative content in the non-attachment-related
stories that distinguished both disorganized and organized
insecure children from secure children. The production of
negative content as a correlate of especially disorganized
J Abnorm Child Psychol
attachment is shown by the fact that children in this category
differed also from the organized insecure children. One way to
understand these findings, would be to argue that the mental
representations of children with insecure attachment, and spe-
cially the disorganized ones, depict the self as generally being
at risk for adverse events with little hope of getting protection
and help. Such mental representations could lead to negative
and hostile imaginations even when parents are not present.
However, more studies comparing responses to attachment-
related and non-attachment-related stories are needed in order
to further address this issue. Finally, in order to validate the
links that have been found between attachment and ADHD
using story-stem methodology, studies are called for assessing
attachment using other methods.
A central finding of the present study is that children’s
disposition to include negative content in response to non-
attachment-related story stems is an important individual dif-
ference characteristic of young children. Inclusion of negative
content 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 imagine
negative content in response to neutral story stems has other,
and perhaps more severe implications. The ease with which
destructive and violent narrative motifs were triggered by
relatively innocuous story stems could indicate easily pro-
voked aggressive and destructive behavior. There is a possible
connection to the findings of Dunn and Hughes (2001), who
showed 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 specific
events, 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 as
anxiety and aggression, where anxiety would be connected
with insecure attachment and aggressive events with conduct
problems. It stands out as an interesting and important task to
try to differentiate between different types of negative content
and clarify associates, both antecedent and concurrent, with
the tendency to include specific types of negative content in
narratives.
Conclusions
As to the main issue of whether attachment insecurity is
associated with symptoms of ADHD, our results suggest that
for attachment studied using story-stem methodology, this
question is open for further discussion. The insight into chil-
dren’s minds provided by story-stem methodology paints a
dark picture of ADHD symptoms, linking them to an imagi-
nation that is riddled with negative content. The whys and
hows 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 to
act independently of poor cognitive functioning in explaining
ADHD symptoms. A question of concern that arises is to what
extent this kind of imaginative world contributes to the poor
school adjustment and social outcomes related to ADHD.
An interesting and important aspect of the results of the
three studies that have looked at attachment and cognitive
functions concomitantly (Bohlin et al. 2012; Thorell et al.
2012, and the present study) is that children with high levels
of ADHD symptoms show cognitive deficits in addition to
fulfilling the criteria for disorganized attachment, suggesting
that attachment disorganization and cognitive dysfunction
could be independent and additive factors in the development
of ADHD symptoms. However, in the present study, we have
problematized the use of story-stem methodology in investi-
gating ADHD and attachment. Our results indicate that the
narrative style of children with high levels of ADHD symp-
toms could be an explanatory variable. Therefore, there is a
strong call for further investigations into the specifics of the
relations between attachment representations, ADHD and nar-
rative production.
Conflict of Interest We have no interests to declare.
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