In this issue...

Does ADHD in Childhood Predict Peer Problems in Addolescence?

Which Intervention for ADHD are most Acceptable to Teachers?

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One of the most robust findings in studies designed to identify children at risk for negative developmental outcomes is that peer relationship difficulties predict a number of subsequent problems.  Rejected children (particularly those who act aggressively towards peers) fare significantly worse in adolescence and adulthood than children who can establish harmonious peer relations.  One reason this may occur is that rejected children often gravitate towards one another during adolescence, then reinforce and escalate each other's antisocial behavior.

An unfortunate aspect of ADHD for many children is difficulty with peer relations.  Because of their impulsive behavior and difficulties reading social cues that may result from attention deficits, many children with ADHD have problems getting along with peers.  Although this is well documented, there have been few studies in which ADHD children have been followed into adolescence so that the impact of ADHD on adolescent peer relations could be examined.  Because peer relations are so important to healthy development, this is a significant gap in the existing literature.

A recent study published in the Journal of the American Academy of Child and Adolescent Psychiatry  (JAACAP) provides an interesting examination of this issue (Bagwell, C.L., et al., (2001). ADHD and Problems in Peer Relations: Predictions from Childhood to Adolescence. JAACAP, 40, 1285-1292.)  Participants included 111 13 to 18-year-old adolescents with a childhood history of ADHD who had previously participated in an intensive summer treatment program during childhood.  96% of these participants were males and almost 90% were white.  In addition, 100 control participants (without ADHD) were recruited from the same schools the ADHD adolescents attended.

To establish participants' current diagnostic status, each adolescent and his/her parent(s) were administered a structured psychiatric interview. Additionally, information on the adolescents' behavior and peer relations at school was obtained from teachers.  Parents were also asked about their adolescent's peer relations and whether they believed their child's friends were a bad influence on him/her.  Adolescents were then asked whether they felt accepted by their peers, how many close friends they have and what those close friendships were like, how involved their friends are in conventional activities, and how many of their friends used illicit substances.

Results

A number of interesting and important results are reported in this study.  These results are summarized below.

How often did ADHD persist from childhood into adolescence?

Approximately 75% of adolescents diagnosed with ADHD in childhood continued to qualify for the diagnosis at follow up.  This was true despite the treatment many were receiving and underscores the chronic course of this condition for many individuals.

How did adolescents with ADHD in childhood perceive their peer relationships?

Adolescents diagnosed with ADHD in childhood did not perceive their peer relations any differently than control participants.  They did not report feeling less accepted by peers, said they had a similar number of close friends, and were not more likely to report that their friends were using illicit substances.  Compared to control participants, however, they did report that their friends were involved in significantly fewer conventional activities.

How did parents and teachers perceive the peer relations of adolescents who had been diagnosed with ADHD during childhood?

In contrast to the self-reports of adolescents, parents and teachers indicated that ADHD adolescents were significantly less liked by peers than the control participants.  Parents of ADHD adolescents also reported that their child had fewer close friends than did parents of control participants and were more likely to feel that their child's friends were a bad influence.

Did the peer relations of adolescents diagnosed with ADHD in childhood differ depending on whether their ADHD persisted into adolescence?

As noted above, about 75% of the adolescents diagnosed with ADHD in childhood continued to meet diagnostic criteria.  Therefore, it is important to determine whether peer relations in adolescence were related to whether or not a child's ADHD had persisted.

The results of analysis on this issue were mixed.  As before, adolescents' reports of their acceptance by peers and how many close friends they had did not differ between the groups.  Only adolescents with persistent ADHD, however, reported that their friends were involved in fewer conventional activities.

Compared to parents of control participants, parents of adolescents diagnosed with ADHD in childhood reported that their adolescent was less accepted by peers, regardless of whether the ADHD had persisted.  However, for those with persistent ADHD, parent ratings of rejection by peers were the highest.  In addition, only parents of adolescents with persistent ADHD reported that their child had fewer close friends.

How does the presence of Conduct Disorder (CD) influence the peer relations of adolescents with ADHD?

Conduct Disorder is a behavior disorder involving serious violations of rules and the rights of others. Many children with ADHD develop CD and for those who do, long-term outcomes tend to be much worse.  In this sample, 31 of the adolescents diagnosed with ADHD in childhood had developed CD while 80 had not.

The peer relations for these groups differed in several critical ways.  First, those with CD reported having friends who were involved in fewer conventional activities.  Second, they had friends who were more likely to be involved in substance use.  Thus, adolescents with ADHD and CD were involved with a more deviant group, and are likely to be at greater risk for serious antisocial behavior because of this.

Did medication treatment have any affect on adolescents' peer relations?

At the time of follow up, 48% of the adolescents with childhood ADHD were being treated with medication -- predominantly stimulants -- while 52% were not.  Medication status was not related to parent ratings of their adolescent's peer relations, nor was it related to adolescents' self-reports of their friendships.  Compared to control participants, however, non-medicated adolescents reported that their friends were involved in fewer conventional activities and were more likely to be involved in substance use.

Summary and Implications

The central findings of this study were that ADHD during childhood predicts later impairment in several aspects of adolescents' peer relations, including parents' reports of their adolescent's close friendships and acceptance by peers, as well as adolescents' reports of their friends "conventionality".   Thus, the study provides evidence that peer relationship difficulties associated with ADHD during childhood persist into adolescence for many individuals.   In addition, this can occur even for adolescents who no longer meet full diagnostic criteria for ADHD.

There are several qualifications to these primary findings that are important to note.  First, even though parents and teachers reported that adolescents in the ADHD group had greater difficulty getting along with peers, the adolescents themselves did not report this.  The reason for this discrepancy is not clear, but the authors suggest this results from a tendency among children with ADHD to overestimate their social competence.  In other words, children with ADHD may frequently be less aware than others of their actual status in the peer group.  Parents and clinicians thus need to be careful about relying solely on what a child/teenager with ADHD says about his/her peer relationships when deciding whether assistance is needed in this area, because a child's report may be inaccurate.

Second, it is probably the presence of comorbid Conduct Disorder, as opposed to ADHD by itself, which places adolescents with ADHD at risk for associating with more deviant peers.  Recall that it was only adolescents with ADHD and CD who reported their friends were involved in fewer conventional activities and more likely to use illicit substances.  Because associating with deviant peers during adolescence is an enormously important risk factor in the development or escalation of serious antisocial behavior, this finding underscores the importance of comorbid behavior problems in the negative long-term outcomes for children with ADHD.  When such problems are prevented with effective treatment, the prognosis for individuals with ADHD is significantly better, even if their ADHD symptoms persist.

Finally, although medication may be quite helpful in treating the core symptoms of ADHD, such treatment is not necessarily associated with significant improvements in all aspects of adolescents' peer relations.  Thus, there was no evidence that adolescents with ADHD who received medication were better liked by peers according to parents and teachers than those who did not.  On the other hand, ADHD adolescents receiving medication had friends who were more likely to be involved in conventional activities and less likely to use illicit substances.  These findings suggest that medication may improve some of the self-control vulnerabilities that lead to rule-breaking behavior and associations with deviant peers.  They also parallel prior research suggesting that medication treatment is associated with lower rates of illicit substance use among individuals with ADHD.

Overall, the results of this study extend current understanding of the longer-term associations between ADHD and social functioning with peers.  Because healthy peer relations are clearly linked to more positive long-term outcomes in many important domains, this is an area of functioning in children with ADHD to which parents and clinicians should carefully attend, in addition to monitoring how their child is doing academically and behaviorally.

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As almost any parent of a child with ADHD can tell you, teachers play a critical role in determining their child's success at school.  One important reason for this is that teachers are responsible for implementing the classroom accommodations and behavioral interventions that have been recommended to help a child succeed.  Teachers also play an important role in the development of these strategies.  Without a teacher's consistent cooperation and support for such plans, there is little chance that even the best-developed strategies will succeed.

For these reasons, it is important to learn more about how teachers regard different interventions for ADHD children.  This was the focus of an interesting study published recently in the Journal of Clinical Child Psychology (Pisecco, S. et al., (2001). The Effect of Child Characteristics on Teachers' Acceptability of Classroom-based Behavioral Strategies and Medication for the Treatment of ADHD. 30, 413-421.)

Participants were 159 experienced elementary school teachers from urban and suburban school districts in a large southwestern city.  Each teacher was given a short vignette describing the classroom behavior and academic performance of a "typical" child with ADHD.  For half the teachers, the child described was a boy and for the other half, the child described was a girl.  After reading the vignette, the teachers were given a brief description of four different interventions that could be used with the child.  These interventions were as follows:

Daily Report Card  (DRC): The DRC is an intervention that requires parents and teachers to identify 3-5 problem behaviors to work on.   These behaviors are translated into daily goals for the child.  For example, the daily goals for a child with ADHD might be: 1) Follow class rules, 2) Complete assigned work, and 3) Get along well with peers.  At the end of each day, the teacher gives the child a grade to indicate how well each goal was met and the child takes the report card home and either earns or loses privileges depending on the grades received for that day.  This intervention thus provides parents with a daily report of how their child is doing in key academic and behavioral areas and enables parents to provide their child with appropriate consequences.

Response Cost Technique (RCT): In this the child earns points in the classroom for exhibiting specific positive behaviors (e.g. completing tasks) and loses points for exhibiting negative behaviors (e.g. blurting out answers).  The teacher keeps a running tally of the child's point total and at predetermined times during the day, the child is allowed to redeem points for a list of pre-determined rewards (e.g. access to the class computer).  The different reward options are worked out in advance and each reward costs a specified number of points.

Classroom Lottery (CL): This is an intervention in which all children in the classroom earn points based on their behavior.  The teacher establishes a brief list of class rules and posts them.  Students are told they will earn class jobs (e.g. line monitor, office messenger) according to how well they follow the rules.  At unannounced times during the day, the teacher checks to see who is following the rules and the names of these children are written down.  At the end of the day, the names of children who were following the rules at a predetermined level (e.g. 4 out of 5 times checked) are written down and placed in a "hat".  The teacher then draws names from the hat to match the number of class jobs available and each child selects a job when their name is drawn.  A nice feature of this system is that it is used to manage an entire classroom and does not require special treatment for students with ADHD.

Stimulant Medication: Because medication is the most frequently used treatment for ADHD, it was also included as one of the possible interventions.  The specific medication described was Ritalin, because it is the one with which teachers are likely to be most familiar.

After reading the intervention descriptions, teachers rated each one on 3 different dimensions: 1) how acceptable it was to them, 2) how effective they believed it would be, and 3) how quickly they believed it would have an effect.  These ratings thus provided researchers with information on how teachers felt about 3 types of behavioral interventions as well as medication.
 

Results

Which interventions were most acceptable to teachers?

Overall, teachers rated the Daily Report Card intervention most acceptable.  This was strongly preferred to the other behavioral interventions for boys and girls while the Classroom Lottery intervention received the lowest acceptability ratings from teachers.

Interestingly, the DRC received significantly higher acceptability ratings than medication, and this was true for boys and girls.   In addition, for girls, the Response Cost Intervention received significantly higher acceptability ratings than medication.  Overall, teachers rated medication as a less acceptable treatment option for girls with ADHD than for boys with ADHD.

What expectations of effectiveness and timeliness do teachers have for different interventions?

Overall, teachers believed the Daily Report Card intervention would be as effective and as quick to produce change as medication.  They also indicated that the DRC intervention would be more effective for girls than for boys, and that medication would yield more rapid improvement in boys than in girls.  The Response Cost Intervention was rated to be as effective and timely as medication treatment for girls, but this was not true for boys.

Summary and Implications

Results from this study indicate that teachers do not necessarily favor the use of medication treatment for all students with ADHD.  The Daily Report Card was more acceptable to teachers than medication treatment for boys and girls with ADHD, and teachers believed this intervention would be as effective as medication.  For girls, a second behavioral technique -- the Response Cost Procedure -- was also more acceptable than medication treatment.  Overall, teachers regarded medication treatment as a less acceptable option for girls than for boys.

The interpretation of these results is not clear-cut.  On one hand, the finding that teachers regard medication as less acceptable than certain behavioral approaches and that they have positive expectations for behavioral interventions like the DRC can be seen as encouraging.  On the other hand, data from the MTA study suggest that teachers' belief that behavioral interventions will be as helpful and as quick to produce change as well-conducted medication treatment is unlikely to be correct.  One wonders, therefore, why medication treatment should be a less acceptable option to teachers than interventions that are not likely to be as helpful.  Perhaps it is more common for teachers to have a bias against medication than is generally believed.

The finding that teachers regard medication as less acceptable for girls than for boys is intriguing.  Existing data indicate that medication treatment has comparable effects for boys and girls. Therefore, it is not clear why teachers feel medication is more acceptable for boys.  Disruptive behavior problems are more likely to be evident in boys with ADHD than in girls with ADHD, and perhaps teachers are less inclined to believe that medication is as necessary for the former because ADHD girls are typically less disruptive in the classroom.

Regardless of the reason for this finding -- and this would be interesting to explore in subsequent research -- the authors suggest that teachers' belief that medication is more acceptable and works more quickly for boys than girls may possibly influence the likelihood of boys and girls receiving medication.  This is because a teacher who believes medication is less acceptable than other strategies may advocate interventions other than medication.  Unfortunately, it is possible that this could have the effect of depriving a child of a treatment that would provide important benefits. These findings suggest this would be more likely to occur for girls than for boys.

There are several limitations in this study that should be recognized.  First, the sample of teachers was from a relatively narrow geographic region, and one cannot assume that similar results would be found in other communities.  Ideally, this study should be extended to include a nationally representative sample of teachers.  It would also be important to gather teachers' ratings of combined treatments, in addition to their ratings of medication and behavioral interventions in isolation.  This is because results from the MTA study indicate that the combination of medication and behavioral intervention is likely to be more effective than either approach alone.

How teachers feel about "multi-modal" treatment, and what their expectations are for the success of such treatment, would thus be important to investigate.  Finally, it would be very helpful to learn why teachers find some treatments more acceptable than others, and, in particular, why they regard medication treatment more favorably for boys than for girls.  Learning more about the reasons for teachers' ratings would be especially important for developing more effective collaborative relationships between teachers, parents, and health-care providers.

Despite these limitations, the results of this study are both interesting and provocative.  One hopes that it will lead to additional work in this important area.