Although it is well established that childhood ADHD and
rejection by peer each predict a wide range of future adjustment
problems, it is also apparent that some children with these risk
factors fare quite well during adolescence. What helps some youth
at risk for negative developmental outcomes make more
satisfactory adjustments while many others do not? This is an
extremely important question as understanding what protects some
children with ADHD from developing significant emotional and behavioral
problems during adolescence could perhaps help to prevent many more
from experiencing these negative outcomes.
Identifying factors that protect some children with ADHD and/or peer
rejection from experiencing negative outcomes during adolescence was
the focus of a study published recently in the Journal of Abnormal
Child Psychology [Mikami & Hinshaw (2006). Resilient adolescent
adjustment among girls: Buffers of childhood peer rejection and
attention-deficit/hyperactivity disorder, 34, 825-839]. The focus
on examining protective factors in children with ADHD is a unique
aspect of this study; what makes it more unique is that it examines
development in a sample of girls with ADHD as well as the
contribution that ADHD may make to the development of eating
pathology.
-
Participants
-
Participants were 228 6-12 year old girls with ADHD from the San
Francisco Bay Area, and 88 comparison girls without ADHD
recruited from the same communities. Girls with ADHD were recruited
from medical settings (e.g. pediatric practices, HMOs), mental
health settings, school districts, ADHD parent groups, and
newspaper advertisements. Comparison girls were recruited from
similar school districts, newspaper ads, and medical settings. All
girls in the ADHD group received a rigorous diagnostic evaluation
- regardless of whether they had been previously been diagnosed - to
insure that all met DSM-IV diagnostic criteria. (For a review of
current ADHD diagnostic criteria go to
www.helpforadd.com/criteria-for-add/
For information about
evaluation guidelines, go to
www.helpforadd.com/evaluation-guidelines/
)
Fifty-three percent of girls were Caucasian, 27% were African American,
11% were Latina, and 9% were Asian. Girls from families across
the entire socioeconomic spectrum - from families on public
assistance to upper income families - were represented.
All girls - those with ADHD as well as the comparison girls -
participated together in a 5-week summer enrichment day camp. Parents
of girls who were already taking medication were asked to have their
daughters participate in the camp while unmedicated, and the majority
complied with this request. Daily activities included classroom, art,
drama, and outdoor activities that allowed for ample social
interaction and extensive observation of girls' behavior. Classes
of 25-26 girls (60% with ADHD and 40% comparison) participated together
for each day's events. Activities were supervised by a head teacher and
4-6 counselors who were unaware of which girls had been diagnosed with
ADHD and which had not. These staff provided daily ratings of the
girls' behavior. (Note: Results pertaining to behavior ratings were
published earlier in another study reviewed in Attention Research
Update. You can find the review of this prior study at
http://www.helpforadd.com/2002/october.htm
Baseline measures (described below) were collected on all girls during
their participation in the summer program. Approximately 4.5
years later, participants and their families were invited to
return for a follow-up assessment so that girls' current functioning
could be assessed.
-
Baseline
Measures -
The primary focus of this study was to examine how adolescent
adjustment among girls with ADHD is related to the combination of risk
and protective factors that were present during childhood. The
risk and protective factors that were assessed during the summer camp
program are described below.
-
Risk
Factors -
Peer rejection - Girls were
asked to identify 3 girls in their group that they liked the most and 3
girls that they liked the least. These nominations were used to
identify girls that were consistently disliked and rejected by their
peers. As noted above, findings from a number of studies indicate that
children who are rejected by peers are at increased risk for a range of
negative outcomes during their development.
Externalizing behavior -
Externalizing behavior refers to acting out behavior such as
aggression, oppositionality, and delinquent acts. Externalizing
behavior tends to be stable over time, and many children with high
levels of externalizing behavior show this pattern across development
and get into more serious trouble during adolescence. Measures of
externalizing behavior at baseline were obtained by having each girl's
parents and teachers complete standardized behavior rating scales. In
addition, camp staff provided daily ratings of the externalizing
behavior displayed by each girl.
Internalizing behavior - Internalizing behavior
refers to feelings of anxiety, depression, and worry. Although
internalizing behavior tends to be less stable than externalizing
behavior, girls develop depression and other internalizing disorders in
adolescence at higher rates than boys, and internalizing behavior
during childhood may thus be an important risk factor for girls.
Baseline measures of internalizing problems were derived from ratings
provided by parents, teachers, camp staff, and girls themselves.
Academic Achievement - Poor
academic achievement during childhood is also a risk factor for
negative adolescent outcomes. To assess academic achievement,
each girl was administered the math and reading portions of the
Wechsler Individual Achievement Test, a well-normed and widely used
test of academic achievement.
-
Protective
Factors -
Protective factors are those that buffer a child against the
development of negative outcomes, even when one or more risk factors
are present. The factors hypothesized to serve this role for
girls with ADHD that were investigated in this study are described
below.
Self-perceived scholastic competence
- This pertains to an individual's belief that she is capable of
academic success and may be especially important for girls with ADHD
because of the major academic difficulties that ADHD frequently
contributes to. Girls who believe they can succeed academically,
even if ADHD is contributing to academic struggles, are more likely to
remain invested in school and continue to focus on achievement. The
authors suggest that believing in one's ability to succeed academically
will predict better more positive adolescent outcomes above and beyond
the child's actual level of academic achievement. In other words,
believing you will succeed will predict better outcomes irrespective of
what the child's actual academic competence at the time happens to be.
This protective factor was measured using the scholastic competence
scale from the Harter Self-Perception Profile for Children. This
6-item self-report measure described different children (e.g., "some
kids feel that they are very good at their school work, but other kids
worry about whether they can do the school work assigned to them") and
asked the participant to indicate which description was most like
herself. The different items assessed the degree to which
children perceived themselves to be good at understanding class work,
good at tests, and intelligent.
Popularity with adults -
Longitudinal studies of at-risk youth have
consistently found that positive relationships with a non-parental
adult increases the likelihood of youth becoming competent
adults. Because girls who are popular with adults would be more
likely to develop positive relationships with them, the authors
hypothesized that girls with ADHD who were better liked by camp staff
would have more positive outcomes as adolescents. Popularity with
adults was assessed by having camp staff identify the 3 campers they
liked most and the 3 they liked least. Ratings were averaged
across the different staff so that a composite popularity score could
be computed for each child.
Goal-directed play - The
authors hypothesized that constructive,
goal-direct play when alone, as opposed to disorganized and purposeless
solitary behavior, would also buffer girls with ADHD from negative
adolescent outcomes. This was based on the belief that
purposeful, goal-directed play may reduce a child's feelings of sadness
and loneliness when isolated. Girls' tendency to engage in
goal-directed play was assessed by having camp staff make repeated
observations of girls' behavior during the camp session, and recording
girls' activity during periods when they were by themselves.
-
Adolescent
Outcomes -
Approximately 4.5 years after attending the summer camp program, all
girls - those with and without ADHD - and their families were invited
back so that girls' adjustment during adolescence could be
evaluated. Externalizing and internalizing behavior was measured
by parent and teacher rating scales as well as girls' own self-reports;
academic achievement was measured by the same achievement test that had
been administered previously. Girls also completed the Eating
Disorders Inventory so that pathology related to eating behavior could
be assessed and the Substance Abuse Questionnaire so that information
related to this important adolescent outcome could be obtained.
-
Results -
Although the authors' primary interest was to examine whether
self-perceived scholastic competence, popularity with adults, and
goal-directed solitary play protected girls with ADHD from negative
adolescent outcomes, they first examined how adolescent functioning in
girls with and without ADHD compared.
Not surprisingly, compared to girls without ADHD, those with ADHD had
significantly higher rates of internalizing and externalizing symptoms
at follow-up. They also had lower levels of academic achievement,
higher rates of substance use, and, interestingly, higher rates of
eating pathology.
Peer rejection during childhood was also independently associated with
all of these negative outcomes except for substance use. Contrary
to the authors' predictions, the combination of childhood ADHD and peer
rejection did not confer additional risk above that associated with
each risk factor independently.
-
Does
Childhood ADHD Predict Increases in Behavior and Academic
Achievement Problems? -
The authors make the important point that just because girls with ADHD
showed higher rates of behavior problems and lower levels of academic
achievement during adolescence does not necessarily mean that their
ADHD symptoms contributed to increases in these difficulties over
time. After all, at the baseline assessment, girls with ADHD were
already showing more internalizing and externalizing behaviors than
comparison girls, as well as lower levels of academic
achievement. Thus, it is important to test whether ADHD directly
contributed to negative change in problem behaviors.
To examine this, the authors reran their analyses predicting adolescent
outcomes of interest with the baseline scores for these outcomes
included. The question addressed by these analyses is whether ADHD or
peer rejection in childhood predicts changes over time in internalizing
symptoms, externalizing symptoms, and academic achievement. In
other words, if a girl is already showing high rates of
emotional/behavioral/academic problems during childhood, does having
ADHD or being rejected by peers contribute to these difficulties
increasing over time?
Results indicated that this was not the case for either externalizing
or internalizing behavior, i.e., after controlling for baseline scores
on these variables, childhood ADHD and peer rejection did not predict
increases in these problems over time. For academic achievement,
however, childhood ADHD and peer rejection both predicted significant
declines in achievement over time. Because baseline measures of eating
pathology and substance use were not collected, they could not examine
whether ADHD or peer rejection predicted changes in these variables
over time.
-
The Role of
Protective Factors -
As noted above, the authors' primary interest was whether any of
their hypothesized protective factors - self-perceived
scholastic competence, popularity with adults, or engagement in goal
directed play - would predict better adolescent adjustment in girls
with ADHD. The results obtained were quite interesting.
Contrary to the authors' predictions, neither popularity with adults
nor high levels of goal directed play predicted more positive
adolescent outcomes for girls with ADHD. Self-perceived academic
competence, in contrast, was associated with more positive outcomes in
every area. Specifically, even after controlling for actual academic
achievement at baseline, girls who were more confident about their
ability to succeed academically showed:
- reductions in internalizing symptoms over time;
- reductions in externalizing symptoms over time;
- actual gains in academic achievement;
- lower levels of adolescent substance use;
Interestingly, girls' actual level of academic achievement at baseline
did not emerge as a significant predictor of change in externalizing or
internalizing problems, nor did it predict girls' substance use.
Not surprisingly, however, it was a strong predictor of academic
achievement in adolescence.
-
Summary
and Implications -
Both peer rejection and ADHD in childhood predicted a wide range of
negative adolescent outcomes including externalizing behavior,
internalizing behavior, poor academic achievement, and eating
pathology. In addition, ADHD - but not peer rejection - predicted
higher levels of adolescent substance use. The finding that AHD
in girls predicted greater eating pathology is an important one, and
suggests that "...girls with ADHD may be at particular risk for eating
pathology because of the impulsivity that is central to both ADHD and
bulimia/binge eating disorders."
In examining change in problem behavior from childhood to adolescence,
peer rejection and ADHD did not predict increases in externalizing and
internalizing problems from childhood to adolescence. Instead,
the only significant predictor of these problems during adolescence was
how much difficulty girls were displaying in these areas 4.5 years
earlier. Thus, while ADHD may have contributed to the development of
these difficulties in childhood, once they have emerged, it does not
appear that ADHD contributes to their escalating over time.
This was not the case, however, for academic achievement. In this
important domain, both ADHD and peer rejection predicted significant
declines in achievement over time, even after controlling for academic
achievement in childhood. This finding points to the enduring
negative impact of ADHD on girls' academic success. It also
highlights the importance of carefully monitoring academic performance
over time and working to provide whatever academic supports may be
required by the child.
Of particular interest was that girls with greater confidence in their
ability to succeed academically, regardless of their actual level of
academic achievement, had better outcomes in all areas. Thus,
perceived scholastic competence protected girls against increases in
internalizing behavior, externalizing behavior, and substance
use. It also predicted actual gains in academic achievement.
While the reasons for this important protective effect cannot be
determined from this study alone, it is possible that girls who believe
they can succeed academically remain more invested in school and
achievement. As a result, they may do better in school over time
and be less inclined to become involved in activities that could
undermine their success.
As exciting as this finding is, it would be important for it to be
replicated in another study. Also, it is not possible to know whether
the protective effects conferred by girls' feelings of competence would
be specific to the academic domain, as was assessed here, or whether
perceiving oneself as competent in other areas, e.g., social, athletic,
etc., would provide the same buffering effects. Because this
study was limited to girls - a rarity in the ADHD literature, it also
cannot be assumed that a protective effect of self-perceived scholastic
competence would be found for boys.
In summary, this interesting study sheds new light on the development
of girls with ADHD. Important new findings are that ADHD may
predispose girls to the development of eating pathology and that
self-perceived scholastic competence may help protect girls with ADHD
from negative developmental outcomes. The study highlights the
value of longitudinal research and will hopefully inspire other
researchers to examine factors that promote resilience in children with
ADHD and to understand the mechanisms by which these
resiliency-promoting factors operate.
Thanks
again to Cogmed and
Shire US, Inc.
for supporting Attention Research Update
(c) 2007 David Rabiner, Ph.D.
Information presented in Attention Research Update is for
informational purposes only, and is not a substitute for professional
medical advice. Although newsletter sponsors offer products and
services
that I believe will be of interest to subscribers, sponsorship of
Attention Research Update does not constitute a specific endorsement or
guarantee of any company's product or services.