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Abstract

Anxiety comorbidity is quite common in children with attention-deficit hyperactivity disorder (ADHD). What is known about the relationship between anxiety, attachment and emotion regulation in such children is still limited. We aimed to investigate the associations between attachment, emotion regulation and comorbid anxiety in children with ADHD. 100 children with ADHD and 100 children without any diagnosis aged 8–13 years were included. After the participants were clinically evaluated, Turgay ADHD Scale, Emotion Regulation Checklist, Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV) and Kerns’ Security Scale were completed. According to the RCADS-CV scores, ADHD/ANX(+), ADHD/ANX(−), and control groups were formed. The emotional lability/negativity levels were higher in the ADHD groups compared to the non-ADHD controls. Paternal and maternal attachment security levels were lower in the ADHD/ANX(+) group compared to the controls. The regression analysis indicated that higher hyperactivity/impulsivity symptom levels and lower maternal attachment quality were associated with higher anxiety in children with ADHD. These results suggest that focusing on attachment quality and emotion regulation problems may be significant in management of core symptoms and comorbid anxiety problems in children with ADHD.

Keywords

attention deficit hyperactivity disorder anxiety emotion regulation attachment

Introduction

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, and impairments in daily functioning refer to the difficulties experienced by the child and family in many areas, including social, academic, or occupational (Cortese et al., 2018). ADHD is defined as a self-regulation disorder since problems in self-regulation skills such as impulse control, calming, and focusing on a goal constitute the core symptoms of ADHD. In addition to the core symptoms, comorbidities appear to be associated in most cases, such as anxiety disorders with a prevalence of approximately 12% (Reale et al., 2017). Most externalizing disorders show an intertwined nature with internalizing disorders such as anxiety and depression (Isdahl-Troye et al., 2022). The presence of comorbid anxiety in ADHD affects overall global functioning negatively, causes higher placement rates into special classes, and is associated with increase in the need for mental health treatment (Hammerness et al., 2010).

Although comorbidities are common in ADHD and anxiety, the underlying mechanisms have not been clearly explained. Uncovering the nature of anxiety comorbidity in ADHD may help explain the etiology and underlying neurobiological basis of these disorders, leading to more effective treatment approaches (Koyuncu et al., 2022). Gair et al. showed that ADHD symptoms predict later anxiety symptoms, but anxiety symptoms do not predict later ADHD symptoms (Gair et al., 2021). ADHD symptoms may cause negative feedback from the environment causing peer rejection, which can increase anxiety (Bubier & Drabick, 2009). The neurobiological approach suggests that ADHD and anxiety disorders share common neurobiological dysfunction and genetic risk factors (D’Agati et al., 2019). Dopamine transporter availability in the striatum was documented to be lower than the control group in both ADHD and anxiety patients (Curatolo et al., 2009; Lee et al., 2015).

Attachment theory gains importance in understanding the etiology of ADHD. Children with problems in attachment may have difficulties in emotional and behavioral regulation, impulse control, self-calming, and maintaining social ties (Cavallina et al., 2015). The quality of the relationship between the infant and the caregiver forms the basis for development of secure attachment patterns in later life. Individuals with insecure attachment styles are more likely to exhibit risk-taking behaviors in adolescence and adulthood. Similar risky behaviors can also be seen in individuals with ADHD as a result of impulse control problems. Individuals with emotion regulation problems may have difficulty regulating their situation-specific negative emotions, which is also a common feature in ADHD. The links between insecure attachment, emotion regulation problems, and ADHD symptoms were reported (Asadi et al., 2021). In a recent study, attachment insecurity was found to be positively correlated with ADHD symptoms through problems of executive functioning and emotion regulation. It was reported that poor emotion regulation also contributed to increased anxiety at two-year follow-up in these patients (Frick et al., 2022).

In this study, we aimed to investigate the associations between attachment and anxiety in children with ADHD. We hypothesized that higher levels of externalization problems, attachment insecurity, and emotion regulation problems would be associated with higher rates of comorbid anxiety symptoms in children with ADHD. Our other hypothesis was that children with ADHD would have lower attachment quality and higher emotion regulation problems than their peers without ADHD.

Materials and method

Participants

The study was conducted with 8-13-year-old unmedicated children with a diagnosis of ADHD and volunteer controls matched by gender and age. While the ADHD group consisted of children who applied to the Child and Adolescent Psychiatry outpatient clinic, the control group consisted of children who applied to the Pediatrics outpatient clinic of our hospital in the years 2020-2021 mostly with flu-like symptoms. The exclusion criteria from the study were having a past or current diagnosis of autism spectrum disorder, psychotic illness, intellectual disability or specific learning disorder, having a neurological or genetic disease, a history of traumatic brain injury, a chronic and serious physical illness or vision and hearing problem. ADHD diagnoses were made by clinical interviews in compliance with the ADHD module of the Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime Version (K-SADS-PL) designed for DSM-5 criteria. 5 patients with comorbid dyslexia and 7 patients with chronic medical illnesses were excluded from the study. Control group consisted of 36 females and 64 males. ADHD group consisted of 24 females and 76 males. After the participants were clinically evaluated, Turgay ADHD Scale, Emotion Regulation Checklist, Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV) and Kerns’ Security Scale were completed by all participants. Then ADHD group was divided into two subgroups according to anxiety scores obtained from The Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV). Children with ADHD with a score below 65 on the RCADS-CV were grouped into the ADHD(+)/ANXIETY(−) subgroup, whereas children with ADHD with a score of 65 or more were grouped into the ADHD(+)/ANXIETY(+) subgroup. Statistical comparisons were conducted between the control group, the ADHD/ANX(−) subgroup, and the ADHD/ANX(+) subgroup. This study was approved by the ethics committee of the Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty (20/07/2020-92540). Verbal and written consents were obtained from the children and their parents for participation in the study.

Measures

Sociodemographic questionnaire included age, gender, family unity, family income, familial psychiatric history of the participants.

Schedule for affective disorders and schizophrenia for school age children present and lifetime version (K-SADS-PL)

This semi-structured interview method was developed by Endicott and Spitzer and reorganized by Kaufman et al. to adapt the diagnostic procedure to DSM-5 diagnoses (Kaufman et al., 2016). It is used by health care professionals to screen and diagnose present psychopathologies in children and adolescents aged between 6–18 years (Kaufman et al., 1997). Validity and reliability study of its Turkish version was conducted by Ünal et al. in 2019. The consistencies of the diagnoses were good giving a Kappa coefficient more than .60 (Unal et al., 2019).

Turgay DSM-IV based child and adolescent behavior disorders screening and rating scale

The Turgay DSM-IV-Based Child and Adolescent Behavior Disorders Screening and Rating Scale administered to the parents was used to measure the attention, hyperactivity, and impulsiveness of the participants. This scale was developed by Turgay (1995) with the aim of screening for disruptive behavior disorders based on DSM-IV diagnostic criteria. Its validity and reliability have been studied in Turkey (Ercan et al., 2001). The scale consists of three sections that evaluate attention deficit, hyperactivity/impulsivity, and comorbid features associated with ADHD using a three-point Likert scale (0 = rarely, 1 = sometimes, 2 = often, and 3 = very often). Higher scores indicate more severe psychopathology (Ercan et al., 2001).

The revised child anxiety and depression scale-child version (RCADS-CV)

The Revised Child Anxiety and Depression Scale-Child Version (RCADS-CV) was developed to screen for DSM-IV symptoms of anxiety disorders and depression in children and adolescents (Chorpita et al., 2000). It is a three-point Likert scale that consists of six subdivisions and forty-seven items assessing symptoms of generalized anxiety disorder, separation anxiety disorder, panic disorder, obsessive compulsive disorder, social phobia, and major depressive disorder. Validity and reliability study of the Turkish version of the scale was done in 2017 giving a Cronbach’s alpha coefficient value of .95 (Gormez et al., 2017). Scores of 65 and above indicate borderline clinical thresholds, while scores of 70 and above are considered as clinical thresholds (Chorpita et al., 2000).

Emotion regulation checklist

We used The Emotion Regulation Checklist (ERC) to evaluate emotion regulation in each group. ERC was developed by Shields & Cicchetti (1997). It measures the emotion regulation abilities of children in 6–13 age group. The scale consists of 24 items administered to the parents. Scale items are scored between ‘never (1)’ and ‘almost always (4)’ and evaluated as a four-point Likert scale. The scale has Emotional Lability/Negativity and Emotion Regulation subscales. Higher scores on Emotional Lability/Negativity subscale indicate a rise in emotion regulation problems. In contrast, higher scores on Emotion Regulation subscale indicates an increase in emotion regulation strength. Turkish validity and reliability study of the scale was done, and Cronbach’s alpha coefficient was found to be .84 (Kapçı et al., 2009).

Kerns’ security scale

Attachment aspects were studied using the Kerns’ Security Scale (KSS), a self-report instrument assessing the attachment security of the subjects. The scale, developed by Kerns et al (1996), consists of 15 items. It is used to evaluate attachment security in middle childhood and preadolescence. Turkish validity and reliability study of the scale was conducted by Sümer and Şendağ. The mother form of the scale assesses the attachment quality between the mother and the child whereas the father form assesses the attachment characteristics between the father and the child. The Cronbach’s alpha coefficient for the mother form of the scale was .84 and the Cronbach’s alpha coefficient for the father form was .88 (Sümer & Şendaǧ, 2009). Higher total scores correspond to a more secure attachment to the mother and the father.

Statistical analyses

Statistical analyses were performed using SPSS version 27.0 for Windows. Kolmogorov-Smirnov (K-S) test is used to determine if the data were normally distributed. Chi-square test was used for statistical comparison of categorical variables such as gender, family unity, income level and psychiatric history of the parents. Statistical comparison of numeric variables like age, Turgay ADHD, RCADS-CV and KSS scores between groups was done with Kruskal-Wallis test. The relationship between the Turgay ADHD, ERC and KSS scale and subscale scores of the participants with ADHD was evaluated with Pearson correlation analysis. The predictive effects of ADHD symptom severity, emotion regulation problem levels and maternal and paternal attachment levels on presence of accompanying anxiety in the ADHD group was evaluated by binary logistic regression analysis. Statistical significance was set at p < .05.

Results

The sample group consisted of 200 children in total. While 50% (n = 100) of them were children diagnosed with ADHD, the remaining 50% (n = 100) were controls without ADHD. There was no statistically significant difference between the distributions of the groups in terms of age, gender, and family unity (p > .05). The income level of the control group was significantly higher than the ADHD groups (p = .033). The first-degree familial psychiatric disease rates were found to be significantly higher in the ADHD groups (p = .025). Sociodemographic data of the groups are shown in Table 1.

Table 1.

Comparison of Sociodemographic Data Between the Groups.

		ADHD group		Control group	p
		ANX(−)	ANX(+)	N = 100
		N = 78	N = 22	N = 100
Age	Mean ± SD	10.8 ± 1.8	10.6 ± 1.6	10.7 ± 1.8	.050 K
Gender	Females (n,%)	19, %24	5, %22	35, %35	.231X²
Gender	Males (n,%)	59, %76	17, %78	65, %65	.231X²
Family unity	Married (n,%)	70, %89	21, %95	90, %90	.908X²
	Separated (n,%)	1, %1	0, %0	2, %2
	Divorced (n,%)	7, %10	1, %5	8, %8
Income level	Low (n,%)	8, %10	6, %27	10, %10	.033X²
	Middle (n,%)	55, %70	11, %50	56, %56
	Upper (n,%)	15, %20	5, %23	34, %34
Familial psychiatric illness	(−), (n,%)	67, %85	18, %81	96, %96	.025X²
Familial psychiatric illness	(+), (n,%)	11, %15	4, %19	4, %4	.025X²

K: Kruskal-Wallis (Mann-Whitney-U test)/X²: Chi square test, ANX (+): total T score of anxiety≥65 in RCADS-CV.

While Turgay total scores and subscale scores were significantly higher in the ADHD groups compared to the control group (p < .001), no significant difference was observed between the ADHD/ANX(+) and the ADHD/ANX(−) subgroups. The Emotional Lability/Negativity scores were found to be significantly higher in the ADHD groups than the control group (p < .001). The Emotional Lability/Negativity scores were also significantly higher in the ADHD/ANX(+) subgroup than the ADHD/ANX(−) subgroup (p = .035). The Emotion Regulation scores were significantly lower in the ADHD/ANX(+) subgroup than the ADHD/ANX(−) subgroup (p = .024). Kerns’ Security Scale’s Mother and Father scores of the ADHD/ANX(+) subgroup were statistically significantly lower than the control group (p = .007, p = .032 respectively). There was no statistically significant difference in Kerns scores among the other groups (Table 2).

Table 2.

The Scale Scores’ Comparison of the ADHD and the Control Groups.

		1-ADHD ANX(−)	2-ADHD ANX(+)	3-Control	p	p1,2	p1,3	p2,3
		N = 78	N = 22	N = 100	p	p1,2	p1,3	p2,3
Turgay ADHD scale
Attention deficit	Mean ± SD	14.0 ± 5.5	16.0 ± 5.5	4.0 ± 3.3	<.001^K	.493	<.001	<.001
Hyperactivity/Impulsivity	Mean ± SD	11.7 ± 6.4	15.0 s 6.1	3.6 ± 3.3	<.001^K	.248	<.001	<.001
ODD	Mean ± SD	8.4 ± 6.2	10.6 ± 5.7	3.7 ± 2.7	<.001^K	.185	<.001	<.001
Conduct disorder	Mean ± SD	2.0 ± 3.5	2.5 ± 3.5	.3 ± 0.8	<.001^K	.499	<.001	.001
Emotion regulation checklist
Emotional lability/Negativity	Mean ± SD	29.9 ± 7.1	33.4 ± 5.4	25.0 ± 3.9	<.001^K	.035	<.001	<.001
Emotion regulation	Mean ± SD	23.0 ± 4.0	20.5 ± 3.8	22.2 ± 4.1	.019^K	.024	.183	.420
Kerns' security scale
Kerns mother	Mean ± SD	46.4 ± 6.9	43.4 ± 7.3	48.9 ± 6.5	.003^K	.435	.061	.007
Kerns father	Mean ± SD	44.7 ± 8.7	41.7 ± 10.6	47.5 ± 7.5	.016^K	.722	.132	.032

K: Kruskal-Wallis test. ANX(+): total T score of anxiety≥65 in RCADS-CV. Values with p < .05 were considered significant and marked in bold.

The anxiety scores were positively correlated with the Attention Deficit (AD) (r = .263), Hyperactivity/Impulsivity (H/I) (r = .246) and the Oppositional Defiant Disorder (ODD) scores (r = .273) of the Turgay ADHD Scale. The anxiety scores were also positively correlated with the Emotional Lability/Negativity (r = .290) and negatively correlated with the Emotion Regulation scores (r = −.200) of the ERC. There were also negative correlations between the anxiety scores and Kerns Mother (r = −.204) and Father (r = −.240) scores. The results of the correlation analysis are presented in Table 3.

Table 3.

Results of the Correlation Analysis of the ADHD Group’s Scale Scores.

	Turgay AD	Turgay H/I	Turgay ODD	Turgay CD	Emotional lability/Negativity	Emotion regulation	Kerns mother	Kerns father
Anxiety score	.263**	.246*	.273**	.167	.290**	−.200*	−.204*	−.240*
Emotional lability/Negativity	.424**	.656**	.709**	.592**
Emotion regulation	−.184	−.233*	−.115	.058	−.271**
Kerns mother	−.160	.136	.049	.101	−.005	−.013
Kerns father	.014	.063	−.019	−.001	−.103	−.024	.601**

N = 100. Pearson correlation analysis.

AD: Attention-Deficit, H/I: Hyperactivity/Impulsivity, ODD: Oppositional Defiant Disorder, CD: Conduct Disorder, RCADS-CV: Revised Child Anxiety and Depression Scale-Child Version.

*p < .05 **p < .01.

Backward Stepwise (Likelihood Ratio) regression analysis was used to investigate the effects of Turgay Attention Deficit, Hyperactivity/Impulsivity, ODD, CD subscale and total scores, Emotional Lability/Negativity scores of the Emotion Regulation Checklist, Kerns Mother, Kerns Father scores and gender on anxiety levels of the children with ADHD. As shown in Table 4, results showed that Turgay Hyperactivity/Impulsivity scores (B = .092, p = .022) and Kerns Mother scores (B = −.070, p = .047) have significant effects on anxiety in final model.

Table 4.

Regression Analysis for the Prediction of Anxiety Levels in Children With ADHD.

		B	SE	Wald	df	p	OR	95% CI for OR
		B	SE	Wald	df	p	OR	Lower	Upper
Step 7	Turgay H/I	.092	.040	5.243	1	.022	1.097	1.013	1.187
	Kerns mother	−.070	.035	3.945	1	.047	.932	.869	.999
	Constant	.671	1.584	.179	1	.672	1.956

Backward Stepwise (Likelihood Ratio) regression analysis. Dependent Variable: Child Anxiety T scores ≥65.

OR: Odds Ratio, SE: Standard Error, CI: Confidence Interval, H/I: Hyperactivity/Impulsivity.

First model included Turgay Attention Deficit, Hyperactivity/Impulsivity, ODD, CD, and total scores, Emotional Lability/Negativity, Kerns Mother, Kerns Father scores and gender.

Discussion

In this study, the associations between attachment quality, emotion regulation skills and comorbid anxiety in children with ADHD were investigated. In accordance with the hypotheses, children with ADHD with and without comorbid anxiety were found to have more externalization problems and higher levels of emotional lability/negativity than typically developing children. Anxiety comorbid ADHD group had also higher emotional lability/negativity than the ADHD without anxiety group. Likewise, comorbid anxiety group had poorer emotion regulation abilities compared to the anxiety negative ADHD group. Secure attachment levels of the children with ADHD and comorbid anxiety were found to be lower than those of the control group. The regression analysis indicated that higher hyperactivity/impulsivity scores and poorer maternal attachment quality were associated with comorbid anxiety in children with ADHD.

Even though several studies show a link between the type of attachment and the presence of attentional difficulties and hyperactivity in children, the nature of this link remains unclear (Wylock et al., 2021). A review showed that there is a reciprocal relationship between ADHD and attachment problems, and when one occurs, the risk of developing the other increases (Storebø et al., 2016). Similarly, in a study examining the attachment characteristics of children with ADHD between the ages of 6 and 10, showed that ADHD symptoms were more severe in children with disorganized attachment than in those with secure attachment (Scholtens et al., 2014). It has been reported that attachment problems may influence self-development and interaction with other people negatively by affecting the internal working models (Zimmermann & Iwanski, 2019). In our study, we would expect insecure attachment levels to be higher in all of the children with ADHD than in non-ADHD controls. However, the results unexpectedly showed that insecure attachment levels were higher only in children with ADHD and comorbid anxiety but not in those without anxiety, when compared to non-ADHD controls. This finding suggests that poor attachment quality may be detected in children with ADHD, especially when comorbid anxiety problems are present. As the current study focused only on anxiety comorbidity in ADHD, further studies are needed for other comorbid conditions as depression.

When we investigated the effect of parental attachment on ADHD and anxiety association, results showed that insecure attachment to the mother is associated with comorbid anxiety problems in children with ADHD. This finding supports that maternal attachment problems may be linked to development of anxiety in children with ADHD. It can be assumed that an individual with ADHD who has emotion regulation problems due to insecure attachment patterns may have high levels of anxiety (Laible et al., 2000). Although the advantages of secure attachment to more than one attachment figure were stated in the literature, especially maternal attachment was found to be mainly effective on developing of attachment patterns of an individual (Bretherton, 1985). Duchesne et al. stated in their longitudinal studies that maternal attachment problems were associated with development of depressive symptoms during adolescence, while paternal attachment problems did not have a determining effect on that (Duchesne & Ratelle, 2014). They attributed this result to the fact that the mother was more active in emotional support within the family and that the adolescents' negative emotions were regulated more easily and effectively with interaction with the mother. Consistent with these data explaining the underlying factors that contribute to the development of depressive symptoms in teens, our study also showed that anxiety in children with ADHD is associated more with maternal than paternal attachment problems.

Attachment problems can influence emotion regulation (Brumariu, 2015). Emotion regulation problems were reported as 38% in a community sample (Althoff et al., 2006) and as 24%–50% in a clinical sample of children with ADHD (Shaw et al., 2014). Researchers report that children with ADHD show high negative emotionality and overly reactive positive emotionality (Martel & Nigg, 2006; Sanson & Prior, 1999; Steinberg & Drabick, 2015). Emotion regulation problems in children with ADHD can affect daily functioning due to high comorbidity (Steinberg & Drabick, 2015). Our results showed that the emotion regulation skills of children with ADHD were worse than those of control group and accompanying anxiety increased the level of emotional lability/negativity in these patients. In a study evaluating emotion regulation skills during a competitive task with peers, children with ADHD had more difficulty in hiding their emotions and calming themselves than children without ADHD (Walcott & Landau, 2004). Another recent study, comparing children with and without ADHD in terms of parasympathetic and sympathetic system functions, showed that childhood ADHD is associated with abnormalities in parasympathetic mechanisms responsible for emotion regulation (Musser & Nigg, 2019).

The current study suggests that hyperactivity/impulsivity symptoms are associated with anxiety problems in children with ADHD. This can be explained by the similarity of the symptoms of restlessness/nervousness seen in hyperactivity and impulsivity as well as in anxiety disorders (Jarrett & Ollendick, 2008). Another way of understanding the relationship between anxiety and ADHD could be through the excessive arousal model. According to this model, overstimulation in ADHD causes attention dysfunction, hyperactivity and impulsivity, leading to increased threat perception and development of anxiety (Schatz & Rostain, 2006). Since this is a cross-sectional study, data on casualty is limited. Therefore, further studies are needed in this area.

In children with ADHD, as the severity of symptoms and comorbidities increase, academic and social functioning becomes more impaired, and difficulties in these areas become more evident (DuPaul et al., 2016). In cases with comorbid anxiety, increase in symptom severity and additional problems may lead to worsening of functionality. Since studies up to date have focused mainly on bilateral relations between attachment, emotion regulation, ADHD and anxiety, our study may contribute to the literature in terms of examining these variables all together.

Conclusion and practical implications

As a result of our study, hyperactivity/impulsivity and poor attachment quality were associated with comorbid anxiety in children with ADHD. It was found that especially attachment to the mother was associated more with anxiety symptoms in ADHD than the attachment to the father.

In addition, while externalizing problems were found to be higher in children with ADHD regardless of comorbid anxiety, emotional lability/negativity levels were much higher in these patients if comorbid anxiety was present. Our study has important implications for exploring ADHD-anxiety comorbidity and its relations to attachment and emotion regulation. Considering this, preventive and target-specific interventions gain importance to help such children in clinical settings. Regulation of parental relationships and emotional problems along with appropriate treatment of hyperactivity/impulsivity in children with ADHD may help improve anxiety symptoms and functionality of these patients. Since it was a cross-sectional study, obtained information about causality between these clinical situations was limited. Limited sample size and the adequacy of measuring attachment patterns in school-age children by a questionnaire may also be considered as limitations. It should be kept in mind that challenges of parenting a child with ADHD may also have effects on parent-child attachment. Further studies are needed to thoroughly uncover the nature of ADHD, attachment and anxiety coexistence.

Footnotes

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.

Ethical statement

ORCID iD

Nihal Serdengeçti

Author biographies

Hazal Akman is a doctor of Child and Adolescent Psychiatry at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey. She graduated from Cerrahpaşa Medical Faculty in 2014. She became a child and adolescent psychiatrist in 2021.

Nihal Serdengeçti is a doctor of Child and Adolescent Psychiatry at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey. She graduated from Cerrahpaşa Medical Faculty in 2017. She became a child and adolescent psychiatrist in 2022.

Mesut Yavuz is an associate professor of Child and Adolescent Psychiatry at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey. He graduated from Cerrahpaşa Medical Faculty in 2005. He became a child and adolescent psychiatrist in 2012.

Muhammed Tayyib Kadak is an associate professor of Child and Adolescent Psychiatry at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey. He graduated from Marmara University Medical faculty in 2005 and became a child and adolescent psychiatrist in 2011.

Oya Ercan is a professor of Pediatrics Department at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey.

Burak Doğangün is a professor of Child and Adolescent Psychiatry at Istanbul University-Cerrahpaşa, Cerrahpaşa Medical Faculty, Turkey. He graduated from Cerrahpaşa Medical Faculty in 1999. He became a child and adolescent psychiatrist in 2004.

References

Althoff

R. R.

Copeland

W. E.

Stanger

Derks

E. M.

Todd

R. D.

Neuman

R. J.

van Beijsterveldt

T. C. E. M.

Boomsma

D. I.

Hudziak

J. J.

(2006). The latent class structure of ADHD is stable across informants. Twin Research and Human Genetics: The Official Journal of the International Society for Twin Studies, 9(4), 507–522. https://doi.org/10.1375/183242706778025008

Asadi

Shoham

Pollak

(2021). Intertwined associations among attachment styles, emotional dysregulation, and ADHD: Examining unique associations with general risk-taking behavior. Journal of Neural Transmission, 128(7), 957–968. https://doi.org/10.1007/s00702-021-02320-4

Bretherton

(1985). Attachment theory: Retrospect and prospect. In Attachment Theory: Retrospect and Prospect (Vol. 50, pp. 66-104). Monographs of the Society for Research in Child Development.

Brumariu

L. E.

(2015). Parent-child attachment and emotion regulation. New Directions for Child and Adolescent Development, 2015(148), 31–45. https://doi.org/10.1002/cad.20098

Bubier

J. L.

Drabick

D. A. G.

(2009). Co-occurring anxiety and disruptive behavior disorders: The roles of anxious symptoms, reactive aggression, and shared risk processes. Clinical Psychology Review, 29(7), 658–669. https://doi.org/10.1016/j.cpr.2009.08.005

Cavallina

Pazzagli

Ghiglieri

Mazzeschi

(2015). Attachment and parental reflective functioning features in ADHD: Enhancing the knowledge on parenting characteristics. Frontiers in Psychology, 6, 1313. https://doi.org/10.3389/fpsyg.2015.01313

Chorpita

B. F.

Yim

Moffitt

Umemoto

L. A.

Francis

S. E.

(2000b). Assessment of symptoms of DSM-IV anxiety and depression in children: A revised child anxiety and depression scale. Behaviour Research and Therapy, 38(8), 835–855. https://doi.org/10.1016/S0005-7967(99)00130-8

Cortese

Adamo

del Giovane

Mohr-Jensen

Hayes

A. J.

Carucci

Atkinson

L. Z.

Tessari

Banaschewski

Coghill

Hollis

Simonoff

Zuddas

Barbui

Purgato

Steinhausen

H.-C.

Shokraneh

Xia

Cipriani

(2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727–738. https://doi.org/10.1016/S2215-0366(18)30269-4

Curatolo

Paloscia

D’Agati

Moavero

Pasini

(2009). The neurobiology of attention deficit/hyperactivity disorder. European Journal of Paediatric Neurology: EJPN: official journal of the European Paediatric Neurology Society, 13(4), 299–304. https://doi.org/10.1016/j.ejpn.2008.06.003

10.

D’Agati

Curatolo

Mazzone

(2019). Comorbidity between ADHD and anxiety disorders across the lifespan. International Journal of Psychiatry in Clinical Practice, 23(4), 238–244. https://doi.org/10.1080/13651501.2019.1628277

11.

Duchesne

Ratelle

C. F.

(2014). Attachment security to mothers and fathers and the developmental trajectories of depressivesymptoms in adolescence: Which parent for which trajectory? Journal of Youth and Adolescence, 43(4), 641–654. https://doi.org/10.1007/s10964-013-0029-z

12.

DuPaul

G. J.

Morgan

P. L.

Farkas

Hillemeier

M. M.

Maczuga

(2016). Academic and social functioning associated with attention-deficit/hyperactivity disorder: Latent class analyses of trajectories from kindergarten to fifth grade. Journal of Abnormal Child Psychology, 44(7), 1425–1438. https://doi.org/10.1007/s10802-016-0126-z

13.

Ercan

Amado

Somer

Çıkoğlu

(2001). Dikkat eksikliği Hiperaktivite bozukluğu ve yıkıcı davranım bozuklukları için bir test bataryası geliştirme çabası. Turk J Child Adolesc Ment Health, 8(3), 132–144.

14.

Frick

M. A.

DarlingRasmussen

Brocki

K. C.

(2022). Can attachment predict core and comorbid symptoms of attention‐deficit/hyperactivity disorder beyond executive functions and emotion regulation? British Journal of Clinical Psychology, 61(1), 93–111. https://doi.org/10.1111/bjc.12317

15.

Gair

S. L.

Brown

H. R.

Kang

Grabell

A. S.

Harvey

E. A.

(2021). Early development of comorbidity between symptoms of ADHD and anxiety. Research on Child and Adolescent Psychopathology, 49(3), 311–323. https://doi.org/10.1007/s10802-020-00724-6

16.

Gormez

Kılınçaslan

Orengul

A. C.

Ebesutani

Kaya

Ceri

Nasıroglu

Filiz

Chorpita

(2017). Psychometric properties of the Turkish version of the revised child anxiety and depression scale – child version in a clinical sample. Psychiatry and Clinical Psychopharmacology, 27(1), 84–92. https://doi.org/10.1080/24750573.2017.1297494

17.

Hammerness

Geller

Petty

Lamb

Bristol

Biederman

(2010). Does ADHD moderate the manifestation of anxiety disorders in children? European Child & Adolescent Psychiatry, 19(2), 107–112. https://doi.org/10.1007/s00787-009-0041-8

18.

Isdahl-Troye

Villar

Domínguez-Álvarez

Romero

Deater-Deckard

(2022). The development of co-occurrent anxiety and externalizing problems from early childhood: aLatentTransition analysis approach. Research on Child and Adolescent Psychopathology, 50(4), 505–519. https://doi.org/10.1007/s10802-021-00865-2

19.

Jarrett

M. A.

Ollendick

T. H.

(2008). A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: Implications for future research and practice. Clinical Psychology Review, 28(7), 1266–1280. https://doi.org/10.1016/j.cpr.2008.05.004

20.

Kapçı

E. G.

Uslu

R. İ.

Akgün

Acer

(2009). İlköğretim çağı çocuklarında duygu ayarlama: Bir ölçek uyarlama çalışması Ve duygu ayarlamayla i̇lişkili etmenlerin belirlenmesi. Çocuk ve Gençlik Ruh Sağlığı Dergisi, 16(1), 13–20.

21.

Kaufman

Birhamer

Axelson

Brent

Perepletchikova

Ryan

(2016). K-Sads-Pl Dsm-5. 1–69.

22.

Kaufman

Birmaher

Brent

Rao

Flynn

Moreci

Williamson

Ryan

(1997). Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child & Adolescent Psychiatry, 36(7), 980–988. https://doi.org/10.1097/00004583-199707000-00021

23.

Kerns

K. A.

Klepac

Cole

(1996). Peer relationships and preadolescents’ perceptions of security in the child-mother relationship. Developmental Psychology, 32(3), 457–466. https://doi.org/10.1037/0012-1649.32.3.457

24.

Koyuncu

Ayan

Ince Guliyev

Erbilgin

Deveci

(2022). ADHD and anxiety disorder comorbidity in children and adults: Diagnostic and therapeutic challenges. Current Psychiatry Reports, 24(2), 129–140. https://doi.org/10.1007/s11920-022-01324-5

25.

Laible

D. J.

Carlo

Raffaelli

(2000). The differential relations of parent and peer attachment to adolescent adjustment. Journal of Youth and Adolescence, 29(1), 45–59. https://doi.org/10.1023/A:1005169004882

26.

Lee

L.-T.

Tsai

H. C.

Chi

M. H.

Chang

W. H.

Chen

K. C.

Lee

I. H.

Chen

P. S.

Yao

W. J.

Chiu

N. T.

Yang

Y. K.

(2015). Lower availability of striatal dopamine transporter in generalized anxiety disorder: A preliminary two-ligand SPECT study. International Clinical Psychopharmacology, 30(3), 175–178. https://doi.org/10.1097/YIC.0000000000000067

27.

Martel

M. M.

Nigg

J. T.

(2006). Child ADHD and personality/temperament traits of reactive and effortful control, resiliency, andemotionality. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 47(11), 1175–1183. https://doi.org/10.1111/j.1469-7610.2006.01629.x

28.

Musser

E. D.

Nigg

J. T.

(2019). Emotion dysregulation across emotion systems in attention deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 48(1), 153–165. https://doi.org/10.1080/15374416.2016.1270828

29.

Reale

Bartoli

Cartabia

Zanetti

Costantino

M. A.

Canevini

M. P.

Termine

Bonati

(2017). Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. European Child & Adolescent Psychiatry, 26(12), 1443–1457. https://doi.org/10.1007/s00787-017-1005-z

30.

Sanson

Prior

(1999). Temperament and behavioral precursors to oppositional defiant disorder and conduct disorder. In Handbook of disruptive behavior disorders (pp. 397–417). Springer US. https://doi.org/10.1007/978-1-4615-4881-2_18

31.

Scholtens

Rydell

A.-M.

Bohlin

Thorell

L. B.

(2014). ADHD symptoms and attachment representations: Considering the role of conduct problems, cognitive deficits and narrative responses in non-attachment-related story stems. Journal of Abnormal Child Psychology, 42(6), 1033–1042. https://doi.org/10.1007/s10802-014-9854-0

32.

Shaw

Stringaris

Nigg

Leibenluft

(2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966

33.

Shields

Cicchetti

(1997). Emotion regulation in school age children: The development of a new criterion Q-sort scale. Dev Psychol, 33, 906–916.

34.

Steinberg

E. A.

Drabick

D. A. G.

(2015). A Developmental psychopathology perspective on ADHD and comorbid conditions: The role of emotion regulation. Child Psychiatry and Human Development, 46(6), 951–966. https://doi.org/10.1007/s10578-015-0534-2

35.

Storebø

O. J.

Rasmussen

P. D.

Simonsen

(2016). Association between insecure attachment and ADHD: Environmental mediating factors. Journal of Attention Disorders, 20(2), 187–196. https://doi.org/10.1177/1087054713501079

36.

Sümer

Şendaǧ

M. A.

(2009). Orta çocukluk döneminde ebeveynlere baǧlanma, benlik algisi ve kaygi. Türk Psikoloji Dergisi, 24(63), 86–103.

37.

Turgay

(1995). Çocuk ve ergenlerde davranım bozuklukları için DSM-IV’e dayalı tarama ve değerlendirme ölçeği (Published Scale). ntegrative Therapy Institute.

38.

Unal

Oktem

Cetin Cuhadaroglu

Cengel Kultur

S. E.

Akdemir

FotoOzdemir

Cak

H. T.

Unal

Tiras

Aslan

Kalayci

B. M.

Sultan Dogan

Kutuk

Yanar

Karaokur

Karabucak

Karakok

Karaer

Artik

(2019). Reliability and validity of the schedule for affective disorders and schizophrenia for school-age children-present and lifetime version, DSM-5 November 2016-Turkish adaptation (K-SADS-PL-DSM-5-T). Turkish Journal of Psychiatry, 30(1), 42–50. https://doi.org/10.5080/u23408

39.

Walcott

C. M.

Landau

(2004). The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 33(4), 772–782. https://doi.org/10.1207/s15374424jccp3304_12

40.

Wylock

J.-F.

Borghini

Slama

Delvenne

(2021). Child attachment and ADHD: A systematic review. European Child & Adolescent Psychiatry, 32(1), 5–16. https://doi.org/10.1007/s00787-021-01773-y

41.

Zimmermann

Iwanski

(2019). Attachment disorder behavior in early and middle childhood: Associations with children’s self-concept and observed signs of negative internal working models. Attachment & Human Development, 21(2), 170–189. https://doi.org/10.1080/14616734.2018.1499212

Attachment and comorbid anxiety in ADHD

Abstract

Keywords

Introduction

Materials and method

Participants

Measures

Schedule for affective disorders and schizophrenia for school age children present and lifetime version (K-SADS-PL)

Turgay DSM-IV based child and adolescent behavior disorders screening and rating scale

The revised child anxiety and depression scale-child version (RCADS-CV)

Emotion regulation checklist

Kerns’ security scale

Statistical analyses

Results

Discussion

Conclusion and practical implications

Footnotes

Declaration of conflicting interests

Funding

Ethical statement

ORCID iD

Author biographies

References