Children with Attention Deficit Hyperactivity Disorder
Attention Deficit and Hyperactivity Disorder (ADHD) is characterized by inattentiveness, impulsivity, and excessive activity (DSM IV; American Psychiatric Association 1994), and has a prevalence rate of 3 percent to 5 percent (Pelham, Wheeler, and Chronis 1998). Children with ADHD also have a high risk of experiencing academic (Henker and Whalen 1989) and social problems in school (Landau and Milich 1988).
ADHD is one of the most prominent expressions used in schools to describe children who do not stay put," meaning that they have too much energy and excitement during class and recess time. Although these observations could be the results of teacher or staff misperceptions, they also may be symptoms of ADHD, childhood depression, or consequences of an unstructured environment. In most cases, behavior that differs from peers is a combination of the above factors.
However, sometimes we have to identify those with ADHD to serve them appropriately via proper individualized programs and possibly medicine. Longitudinal studies suggest that such children are likely to experience problems related to social functioning at an early age and throughout adolescence and into adulthood (Weiss and Hechtman 1986). These problems can be seen in various situations (e.g., home, school, community), across people (e.g., parents, siblings, teachers, peers) and activities (e.g., academic work, play, recreation) (Carey 1996).
For example, Fischer et al. (1993) studied the behavioral ratings of 108 children meeting research diagnostic criteria for hyperactivity, as well as a control sample of 61 children. They ranged in age of 4 to 12, and were followed over 8 years into adolescence and young adulthood. Those diagnosed as hyperactive remained more deviant in the ratings than the control children during follow-up observations. A decline in deviant behavior was observed for individual children, although the end results were still more deviant than those of the control children.
Hansen, Weiss, and Last's (1999) more recent longitudinal study produced some encouraging results. This study compared the psychosocial functioning in 18 young adult men who had been diagnosed with ADHD 10 years ago. Their average age at the time of follow-up was 21. The researchers matched their subjects with 18 male controls who had never had any kind of psychiatric illness.
Through the use of interviews to assess subjects' educational, occupational, residential and marital status, as well as use of mental health services and psychological status (experience of depression, anxiety, drugs and alcohol problems), they discovered that young adults with ADHD were significantly more likely than control subjects to be using mental health services, report psychological problems, and have fathered children. School dropout rates were higher for subjects with ADHD; however, they were likely to attain a graduate equivalency diploma. Men with ADHD had higher rates of trouble with the law; however, they did not differ significantly from controls in terms of current legal problems.
This study gives hope for the future of young adults with ADHD, as they appear to have overcome the various educational and legal difficulties experienced during high school. In the area of psychological functioning, results are consistent with the findings of other longitudinal studies. In general, though, the above studies indicate that we should expect the children with ADHD to continue to have problems in the social domain, since they remained at a disadvantaged state in psychological functioning and still rated behaviorally as being deviant after 8 and 10 years.
The longitudinal study of Cowen et al. (1973) demonstrates the link between early peer problems and later maladjustment. In this study, children were asked to nominate their peers according to both positive and negative qualifications. Negative nominations of third-grade class peers were found to be the best predictor of psychiatric problems when a follow-up was conducted when the children were 11 to 13 years old. This result indicates the seriousness and consistency of problems experienced in peer relationships as early as 9 years of age.
In addition, peer rejection has been found to correlate with premature dropping out of school, juvenile delinquency, job termination, poor military performance, police contact, and psychiatric hospitalization (Parker and Asher 1987).
However, the difference between correlation and causation needs to be considered when interpreting these studies. In their chapter of Assessment of Children's Social Status and Peer Relations (1990), Landau and Milich emphasize that linkages found between peer rejection and later difficulties are correlational, and not causal.
Generalization of social skills training programs
There are many social skills training programs designed to increase peer acceptance. Some of the most common are ACCEPTS (not an acronym), ACCESS (not an acronym), Skillstreaming, Think Aloud, ASSET (not an acronym), RECESS (Reprogramming Environmental Contingencies for Effective Social Skills), and PEERS (Procedures for Establishing Effective Peer Relationship Skills) (DuPaul and Eckert 1994). Although these programs are taught as solutions to peer relationship problems, teaching children in isolation and then expecting them to perform successfully in real life is usually not a successful strategy.
DuPaul and Eckert reviewed the literature and found a total of only seven studies that had used commercially available social skills training programs that considered generalizing skills to real-life situations. To assess the generalization over time, those seven studies did follow up assessments 1 to 3 months after treatment ended. The authors concluded this period too brief to be able to assert that intervention is generalized. They stress the effects of treatment being more prominent in those studies using multiple strategies to promote generalization. Among those strategies, teaching social skills within a real environment seemed to be the most fruitful one.
The generalization issues of social skills trainings also are discussed by Carey and Stoner (1994). They suggest considering a technology of applied behavioral analysis and application of strategies to ensure the maintenance of newly learned behaviors reinforced by natural contingencies In this context, applied behavioral analysis is defined as studying what happens in the environment before, during, and after the problematic behaviors' occurrence, and then rearranging the environmental factors to promote the desired behaviors and suppress the problematic behaviors.
Another similar discussion is found in Moore (1994). She argues that behaviors which are not functional for the child, will not generalize. The behavior's functionality is defined as how much the behaviors are linked to socially meaningful outcomes or elicit natural reinforcements from the environment. She further states that an increase in social interaction and eliminating negative behaviors do not ensure peer acceptance. Instead, documenting concomitant increases in positive, reinforcing, pro-social behaviors, which have been linked to peer acceptance, popularity, and friendship, was suggested. She also mentions the importance of designing interventions for particular children in particular settings, rather than using a one-size-fits-all program.
Most recently Sheridan, Hungelmann, and Maughan (1999) explained the contextualized framework for the purpose of linking assessment to intervention and generalization planning. They state that identifying target behaviors that are critical for a child to socialize successfully is poorly understood. In other words, behaviors that predict positive social status in immediate social context are unclear, although clinicians and researchers often assume that the skills being taught in structured settings are those that are relevant in places and at times that extend beyond training. However, little empirical research has been done on whether these skills are actually important for children's abilities to develop and maintain social relationships (Sheridan et al. 1999).
According to Sheridan et al., two methods can be used to select meaningful target skills. The first one is to normatively compare the target child with children considered socially adjusted. This involves listing the behaviors believed to increase peer acceptance and decrease rejection, and comparing the rating of each child in the peer group. This social comparison method allows researchers to determine whether the child's behavior following intervention is similar to the peers' behavior.
The second method is template matching, or identifying relevant and meaningful social behaviors based on input from significant others and peers by asking them to identify the most important behaviors for them in a particular social context. Sheridan et al. emphasize doing direct observations of socially desirable behaviors, recording the narrative descriptions, and then collecting them from the social recipients. Then the intervention would focus on decreasing the discrepancy between the template and the target child's behaviors, utilizing the qualities listed in the template as the intervention's objectives.
What are the social dynamics?
Hymel (1986) demonstrated that children interpret identical actions in different ways, depending on their liking of the actor. They tend to credit liked peers for positive behavior, and make excuses rather than blame them for negative behavior. Moreover, for children who are disliked, positive behavior is perceived as a result of unstable causes that are unlikely to recur. Children were found to be not so eager to change their perceptions of disliked peers or to expect more positive behaviors from them in the future when they notice behavioral improvements.
In 1949, 24 boys from similar backgrounds were brought to an isolated site to test two hypotheses:
1. When individuals having no established relationships are brought together to interact in group activities with common goals, they produce a group structure with hierarchical statuses and roles.
2. If those artificially formed groups are brought into a functional relationship under conditions of competition and group frustration, reciprocal hostile attitudes and actions will arise across groups.
The results obtained through direct observations of the children's behavior confirmed those two hypotheses. The study was replicated later with the addition of a new component. Superordinate goals that could be accomplished only by the cooperation of both groups were induced to reduce inter-group tension and integrate the two hostile groups. Sheriff and Harvey reduced the inter-group tension and formed a new group by integrating the two groups back together by creating a problem that would affect both of them negatively.
The above-mentioned empirical studies calls for a reconsideration of the issue, and possibly the addition of new conditions: Children with ADHD are likely to be rejected by their peers and therefore will drop out of school and will be in trouble with law, unless more effective programs specializing in manipulating social dynamics are developed, along with equipping children with ADHD with the necessary social behaviors by using direct instruction and guided practice.
- Achenbach, T. M. Manual for the Child Behavior Checklist and 1991 Profile. Burlington, VT: Univ. of Vermont: 1991.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.
- Bloom, M., J. Fischer, and J. G. Orme. Evaluating Practice: Guidelines for the Accountable Professional. Boston, MA: Allyn & Bacon, 1999
- Carey, S. P. and G. Stoner. Contextual Considerations in Social Skills Instruction. School Psychology Quarterly 9 (1994): 137-41.
- Carey, J. P. Training Parents To Arrange and Monitor Peer Social Activities for Children with Attention Deficit Hyperactivity Disorder. Ph.D. diss., Univ. of Oregon, 1996.
- Cowen, E. et al. Long-term Follow-up of Early Detected Vulnerable Children. Journal of Consulting and Clinical Psychology 41 (1973): 438-46.
- DuPaul, G. J. and T. L. Eckert. The Effects of Social Skills Curricula: Now You See Them, Now You Don't. School Psychology Quarterly 9 (1994): 113-32.
- Fischer, M. et al. The Stability of Dimensions of Behavior in ADHD and Normal Children over an
- 8-year Follow-up. Journal of Abnormal Child Psychology 21, no. 3 (1993): 315-37.
- Hansen, C., D. Weiss, and C. G. Last. ADHD Boys in Young Adulthood: Psychosocial Adjustment. Journal of American Academy of Child and Adolescent Psychiatry 38:2 (1999): 165-71.
- Henker, B. and C. K. Whalen. Hyperactivity and Attention Deficits. American Psychologist 44 (1989): 216-23.
- Hook, C. L. and G. J. DuPaul. Parent Tutoring for Students with Attention Deficit Hyperactivity Disorder: Effects on Reading Performance at Home and School. School Psychology Review 28, no. 1 (1999): 60-75.
- Hymel, S. Interpretations of Peer Behavior: Affective Bias in Childhood and Adolescents. Child Development 57 (1986): 431-45.
- Landau, S. and R. Milich. Social Communication Patterns of Attention-deficit Disordered Boys. Journal of Abnormal Child Psychology 16 (1988): 69-81.
- Assessment of Children's Social Status and Peer Relations. In Through the Eyes of the Child, edited by A. M. La Greca. Boston: Allyn and Bacon. 1990, 259-91.
- Moore, Lisa A. The Effects of Social Skills Curricula: Were They Apparent Initially? School Psychology Quarterly (1994): 9.
- Parker, J. G. and Asher, S. R. Peer Relations and Later Personal Development: Are Low Accepted Children At Risk? Psychological Bulletin 102 (1987): 357-89.
- Pelham, W. E. Jr., T. Wheeler, and A. Chronis. Empirically Supported Psychosocial Treatments for Attention Deficit Hyperactive Disorder. Journal of Clinical Child Psychology, 27, no. 2 (1998): 190-205.
- Sheridan, S. M., A. Hungelmann, and D. P. Maughan A Contextualized Framework for Social Skills Assessment, Intervention, and Generalization. School Psychology Review 28, no. 1 (1999): 84-103.
- Sheriff, Muzafer and O. J. Harvey. Intergroup Conflict and Cooperation: The Robbers Cave Experiment. Norman, OK: Institute of Group Relations, 1961.
- Weiss, G. and L. Hechtman. Hyperactive Children Grown Up. New York: Guilford Press: 1986.
- White, Karen J., K. Jones, and Michelle D. Sherman. Reputation Information and Teacher Feedback: Their Influences on Children's Perceptions of Behavior Problem Peers. Journal of Social & Clinical Psychology 17, no. 1 (1998): 11-37.