Attention, Concentration, ADHD, and Insecure Attachment

Think you have attention-deficit/hyperactivity disorder (ADHD)? Not so fast. New research and theory by Cavicchioli, Stefanazzi, Tobia, and Ogliari (2023) makes a strong case that you may have a problem with your attachment system.

The attachment system is, at its core, an emotion regulation system that controls your attention, arousal, and related behaviors.

Many adults seek evaluations for ADHD because of memory problems and difficulties with attention, concentration, and emotional control. Whether they meet the criteria for a psychological diagnosis might be a moot point. Emotion dysregulation is a core feature of ADHD (Bunford, Evans, & Wyms, 2015).

Most psychological diagnoses say nothing about causes or what led a person to their present state of functioning. For the most part, Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses are symptom menus. If you meet a certain number of specified symptoms, you qualify for the diagnosis. But the cause still matters.

Do you want to treat the symptoms or the cause?

If the cause is strictly biological, then treatment would likely include medication along with psychotherapy or coaching to teach compensatory strategies. If, however, the cause involved childhood chaotic environments, trauma, or other attachment disruption, then treatment should include a trauma-focused or attachment-based intervention. If you treat the surface symptoms without addressing the cause, you may get some relief, but you are not actually fixing the problem.

Wylock and colleagues (2021) summarized research showing a significant positive relationship between insecure attachment and symptoms of ADHD. In their review of the research from 1971 to 2021, Cavicchioli et al. (2023) proposed that insecure attachment is a risk factor for the onset of ADHD in childhood and its later maintenance into adolescence and adulthood. This is because insecure attachment plays a primary role in the development of self-regulatory systems. For example, people with preoccupied and fearful attachment may struggle with hyperactivation of their attention and emotional systems combined with difficulty controlling approach/avoidance behaviors.

There is always a two-way interplay between the developing person and their social environment. Through a process known as “reciprocal determinism,” children, because of the temperament they are born with, might elicit different types of behavior from their parents. For example, it is very easy to be consistent, warm, available, and responsive to an easygoing and calm baby. A colicky or neuroatypical baby who is difficult to soothe and comfort, in contrast, might evoke more harsh and inconsistent parenting. The inconsistent parenting, sometimes warm but also agitated, angry, punitive, and loud is an indicator of the parents’ difficulty reading or responding to the child. This type of parenting is likely to then dysregulate the child’s attention, emotion, and behavioral systems further. Over time, this pattern might become chronic. When the child goes to school and gets similar responses from teachers and peers, the effect is likely to carry forward to cause and sustain a long-term ADHD presentation. This explains why across 26 studies reviewed, Cavicchioli et al. (2022) found a moderate (r = .27) correlation between ADHD and the severity of insecure attachment. Breaking down the findings revealed that dismissing and fearful attachment (both avoidant styles) were related to more inattentive ADHD symptoms, and preoccupied attachment was more related to hyperactivity ADHD symptoms.

You can look at some of the attention and anxiety issues as a form of avoidance. Scattering attention and focusing on problems takes the focus off of deeper and more aversive feelings of sadness. Sad and depressed emotions cannot be tolerated and in childhood were rejected by parents of dismissing/avoidant individuals. So, they cannot tolerate these emotions in themselves as adults. By extension, they do not attend to (but rather dissociate from) thoughts and people/situations that might evoke these feelings. People with preoccupied styles are overfocused (hypervigilant) on both their own psychological pain and the behavior of their relationship partners. So, they try to avoid the internal feelings of sadness and loss by being hyperactively focused on fixing the problem and relationship peers and partners.

Following the attachment-based theory of emotion dysregulation, treatment should not just involve medication and teaching compensation and coping strategies. Treatment should target the attention and emotion regulation systems directly using a trauma-informed and attachment-based approach. One treatment option that would make sense is exposure. This means exposing people to difficult emotions (sadness, depression, loss) and preventing them from running away. Gradually this forces people to stay with and regulate the distressing emotions directly. Avoidant people might run by pulling attention away from what upsets them. A skilled therapist can work with avoidant people by teaching emotion-regulation strategies and then exposing them to what upsets them while staying in a regulated state.

In the opposite direction, people with anxious/preoccupied attachment styles might run from their pain by frenetically trying to fix other people or situations. They are, in effect, trading sadness and grief for anxiety and ADHD symptoms (which are still uncomfortable but more tolerable). Sometimes getting all busy in your brain through ruminating and “fixing” is a type of avoidance of the more intolerable emotions.

Here are some strategies to learn emotion regulation, tolerance, and acceptance:

1. Get rid of the “sad is bad” rule. It is not weak or shameful to feel sad and vulnerable. Rather, it is weak to have to run and hide from it. So be brave and stand your ground and feel it.
2. Keep the focus on the target (person or situation). Don’t get rid of people or situations just because they make you uncomfortable (unless you are unsafe or abused). Stay with the situation, try to see the nuance in it, and stay away from black-and-white thinking.
3. No tuning out or fixing. Don’t try to distract yourself with work or other activities… and don’t try to fix other people or convince them to behave in a way that will take your pain away.
4. Learn to control your body. Breathe. Hold still. Let the emotions settle and realize that you can tolerate the feeling without your brain spinning.
5. Practice acceptance (of emotions) and keeping your thoughts and emotions separate. Practicing inner child work is one way to teach your cortex (conscious brain) to gently talk to and coach your emotional system (inner child).