ADHD Symptoms in Middle Childhood: The Role of Child Attachment and Maternal Emotional Availability in an Inpatient Clinical Sample

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This study explores the role of child attachment and maternal emotional availability in relation to ADHD symptoms in an inpatient clinical sample, which is an interesting topic with both theoretical and practical consequences. There are several significant methodological inconsistencies that should be clarified, please refer to the observations below:

Lines 17, 21, 22- all abbreviations should be defined the first time they are used in the “Abstract” section;

Line 19- please avoid starting that sentence with “N=71”;

Lines 25-27- since this is a cross-sectional study with no control group, the conclusion is too ambitious and not fully supported by the study’s results, please consider reformulating it;

Line 117- consider erasing “N=”, just mentioning “71 mother-child dyads” is enough;

Lines 117-127- How were the variables related to mothers’ mental health controlled? EA may be influenced by a wide variety of mental and behavioral disorders. Also, there is no control group, this is a major limitation that should be mentioned in the dedicated paragraph. Were the children evaluated for ADHD by any psychiatrist prior to their inclusion in the study? Were these children on psychiatric medication, or were they included in a psychotherapy program? These are variables that may interfere with the assessed outcomes. Besides the criteria listed in lines 119-123, were there any other inclusion criteria for this study? What about exclusion criteria? It is not clear how the population was selected, i.e., were these dyads consecutively admitted, selected based on certain characteristics, etc.? Please clarify the sentence in lines 126-127 (“35%  were recoded by an independent trained rater”).

Line  129- “ASCT” is not defined;

Table 1—Who, when, and using what methods made the diagnoses of “emotional disorder,” ÄDHD,” “hyperkinetic conduct disorder,” “conduct disorder,” and “other”?  Also, what does “other” mean specifically since 32.4% of the subjects are in this group?

Line 205- “intattention” is a typo.

Comments on the Quality of English Language

Minor editing of the English language is needed.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Dear colleagues!

 

Thank you for the current research, the questions of which are related to childhood and the problems of assessing ADHD symptoms. Today, when some anti-scientific approaches are trying to destroy the important connection between child and mother, it is especially useful to conduct research on the emotional background, guided by the principles of evidence-based medicine.

 

The relevance of the study is beyond doubt.

In Materials and Methods, if appropriate, a formula for calculating sample size can be added

The bibliography cites sources that are 10 or more years old. If this is not fundamental research, then it is advisable to either replace or supplement with relevant

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

I would like to thank the authors for this work, which I think is really interesting.

I believe that work like this can also offer interesting insights in the clinical field in the knowledge and study of ADHD.

I only have a few minor considerations:

-In the abstract I would not use EA immediately but disambiguate it by clarifying its meaning.

-The tables I recommend justifying them in the left margin for better understanding

-Check the citations in the text that they are all in Vancouver style because some are in APA

-I think it is essential to supplement the conclusions and implications with clinical insights and protocol development to support this study.

I really appreciate this study, I think it should be replicated in other settings to compare the results.

Best regards

Author Response

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Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

Abstract

Acronyms must be written in full at least the first time.

 

Introduction

Specify whether the prevalence of ADHD is in the German, European, or international population.

Mention Nathan Fox's work on the prevalence of ADHD in children in orphanages.

 

Methods

The authors say that "Participants were included if the children had an IQ > 50". Were there children with diagnosed intellectual disabilities? Why did the authors decide to include them?

Who administers the EAS scale?

How was ADHD diagnosed?

Did they have no other diagnoses (i.e., explosive-intermittent or oppositional-defiant disorder)?

 

Discussion

The authors should further emphasize the limitation of the study, i.e. the cross-sectional design, highlighting studies that investigated the role of ADHD diagnosis in influencing maternal behavior. On the contrary, the comment on the association between ADHD and attachment seems exhaustive to me.

 

General comments

Check punctuation.

 

I think the work deserves to be published after some revisions by the authors.

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript significantly improved. Please refer to the following additional observations:

Line 20- consider removing ”N=”, because it is redundant, as you mentioned in the sentence „inpatient mother-child dyads”; therefore, „In a socio-pediatric clinic in Germany, 71 inpatient mother-child dyads” is enough;

Lines 75-76 – „the elevated ADHD symptoms...was...” is grammatically incorrect;

Line 265- the same observation for inserting „n=” in the middle of the sentence< please consider deleting it, and leave only „71 participant data”;

Lines 302-303- delete the F63 mentioned outside the brackets, it is redundant;

Lines 397-398- since the author mentioned is the same, the references may be compacted, i.e., „by Forslund et al. [69,70]”;

Line 431- decide if there must be a colon (in this case, no capital letter is needed afterward), or if (better) a full stop after „our sample”;  

Lines 487-490- consider inserting this information in the „Discussion” section (section 4.1), and only refer to it in the „Conclusions” section; it is not customary to insert new data, unapproached in the body test, in the „Conclusions” chapter.

Comments on the Quality of English Language

Minor editing of the English language may be needed to improve the flow of the sentences.

Author Response

Answer Letter round 2 to Reviewer 1

ejihpe-3014305

 

Dear Reviewer,

Thank you for your very attentive reading and your valuable feedback which has helped us to improve our manuscript. We have implemented your suggestions as follows (Note: Page and line details refer to the track changes version):

 

R1: Line 20- consider removing ”N=”, because it is redundant, as you mentioned in the sentence „inpatient mother-child dyads”; therefore, „In a socio-pediatric clinic in Germany, 71 inpatient mother-child dyads” is enough

RESPONSE: Thank you for this comment, we removed "N". (p.1, l.20)

 

R1: Lines 75-76 – „the elevated ADHD symptoms...was...” is grammatically incorrect

RESPONSE: Thank you for this annotation, we changed the sentence to “They found that the elevated ADHD symptoms in children from institutionalized care were mediated by poor child executive functions [26].“  (p.2, ll.68-70)

 

R1: Line 265- the same observation for inserting „n=” in the middle of the sentence< please consider deleting it, and leave only „71 participant data”

RESPONSE: Thank you for your comment, we removed "n". (p.5, l.209)

 

R1: Line 117- consider erasing “N=”, just mentioning “71 mother-child dyads” is enough

RESPONSE: Thank you for this note, we erased “N”. (p.3, l.139)

 

R1: Lines 302-303- delete the F63 mentioned outside the brackets, it is redundant

RESPONSE: Thank you for your very attentive reading - we removed “F63” outside the brackets. (p.6, l.227)

 

R1: Lines 397-398- since the author mentioned is the same, the references may be compacted, i.e., „by Forslund et al. [69,70]”

RESPONSE: Thank you for your suggestion, we compacted the reference to: "...were found by Forslund et al. [70,71]." (p.9, l.322)

 

R1: Line 431- decide if there must be a colon (in this case, no capital letter is needed afterward), or if (better) a full stop after „our sample”;

RESPONSE: Thank you for your comment, we changed the colon to a full stop: "Furthermore, a change of interaction quality due to hospitalization would give us an idea why the child attachment representation was not linked to maternal interaction quality in our sample." (p.9, l.345-347)

 

R1: Lines 487-490- consider inserting this information in the „Discussion” section (section 4.1), and only refer to it in the „Conclusions” section; it is not customary to insert new data, unapproached in the body test, in the „Conclusions” chapter.

RESPONSE: Thank you for your comment. As suggested, we have included this information earlier in the discussion: “The link between parent-child interaction quality and child ADHD is also addressed by psychotherapeutic interventions. For instance, Interaction Therapy, an intervention that aims to enhance parent-child relationships, has shown to be an effective treatment option for child ADHD by reducing child ADHD symptoms and improving parenting behaviors [60].” (p.8, ll.277-282) and removed the reference from the conclusions section: “The identification of factors associated with child ADHD are essential for prevention and intervention. Our results implicate that the role of the parent-child interaction quality should be considered in the treatment of ADHD. This may be achieved by parent education, aiming to improve the understanding of the disease as well as by specifically working on hostile interaction patterns in the intervention, e.g. in Parent-Child Interaction Therapy. Thus, the vicious circle of negative interactions could be broken at an early stage which might positively influence the course of ADHD.” (p.10/11, l.399-408)

 

R1: Minor editing of the English language may be needed to improve the flow of the sentences.

RESPONSE: We tried to improve the reading flow by shortening/dividing some sentences, e.g. “In a meta-analysis, Claussen et al. [10] derived from 16 studies that parental sensitivity/warmth was inversely correlated with child inattention and hyperactivity. Furthermore, they found that parental intrusiveness as well as harsh discipline were positively correlated to overall ADHD symptoms.” (p.2, ll.70-73), “From preschool to primary school age, a frequently used tool to assess child attachment representation are story stems procedures. In this task, children are told to complete stories which activate the attachment system.” (p.3, ll.92-95), “Most studies investigating the association between parent-child interaction quality and ADHD symptoms have not used multidimensional tools to assess the interaction quality. On the other hand, studies using the EA concept have only been investigated with regard to child externalizing problems more generally, but not specifically with regard to ADHD symptoms.” (p.3, ll. 112-116)

Reviewer 4 Report

Comments and Suggestions for Authors

The article can be published in its current version.

Author Response

Dear Reviewer,

Thank you for your positive feedback. We are pleased to hear that we have incorporated your suggestions appropriately. Thank you again for your time to review the manuscript.