FRIENDSHIP PATTERNS IN GIRLS WITH AND WITHOUT ADHD

One of the most consistent 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, and then reinforce and escalate each other’s antisocial behavior.  In addition, being rejected and not having a close friend is associated with feelings of loneliness and isolation, which, in turn, may increase the risk for becoming depressed.

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 for boys with ADHD, there has been virtually no published research on peer relations and friendship patterns among girls with ADHD.  It is thus quite encouraging that an excellent and long overdue study of this important area has recently been published (Blachman, D.R., & Hinshaw, S., (2002). Patterns of friendship among girls with and without Attention Deficit/Hyperactivity Disorder, Journal of Abnormal Child Psychology, 30, 625-640).

PARTICIPANTS

Participants in this study 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/ )

Among the participants, 53% 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 also represented.  Ninety-three of the girls with ADHD were diagnosed with the combined subtype (i.e. they showed both inattentive and hyperactive-impulsive symptoms), and 48 were diagnosed with the inattentive subtype (i.e. they showed predominantly inattentive symptoms and few if any hyperactive-impulsive symptoms).  Thus, this sample of girls with ADHD was more diverse than the samples that had previously been studied, and it is especially important that girls with the inattentive subtype of ADHD were included.  Relatively few girls meeting criteria for the hyperactive-impulsive subtype were found (this is the least frequently diagnosed ADHD subtype among school-age children), so these girls were not included in the analyses.

All girls - those with ADHD as well as the comparison girls - participated together in a 5-week summer enrichment day camp.  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 www.helpforadd.com/2002/october.htm  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.

QUESTIONS OF INTEREST

The researchers were interested in examining how several aspects of peer relations compared for girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD. These aspects of girls' peer relations included the following:

PEER REGARD - What was the general level acceptance by peers that characterized girls in the different groups.  Were girls with either or both subtypes of ADHD less well accepted overall than girls without ADHD?

This aspect of peer relations was measured by having each girl identify three girls in their camp class that they liked most and three girls they liked least.  These nominations were made at the beginning, middle, and end of camp (i.e. at the end of weeks 1, 3, and 5).  Each girl received a score for positive peer regard and negative peer regard by dividing the number of nominations of each type that she received by the total number of classmates providing nominations.

FRIENDSHIP PARTICIPATION - Was there a difference in the extent to which girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive type of ADHD developed mutual friendships?

To assess this aspect of girls' peer relations, each girl was asked to name up to three girls she considered to be her best friends at camp.  If a girl's nomination was reciprocated (e.g. if the girl child A nominated also nominated child A as one of her three best camp friends) the girl was considered to have a mutual friend.  These friendship nominations were obtained after weeks 1, 3, and 5 and each girl could have from 0 to 3 mutual friends at each time.

FRIENDSHIP STABILITY - Was there a difference in the extent to which girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD maintained stable friendships over the 5-week camp?

The authors examined the stability of girls' friendships between weeks 1 and 3, between weeks 3 and 5, and between weeks 1 and 5. To do this, they began with girls who had at least one mutual friendship at week 1 (as discussed below, not all girls did), and examined whether girls involved in a mutual friendship after week 1 continued to identify one another as best friends after week 3.

For example, if two girls nominated each other as one of their three best friends after weeks 1 and 3, this friendship was considered stable.  If either or both girls no longer nominated the other after week 3, however, the friendship was considered unstable.

This process was repeated for mutual friendships between week 3 and week 5, and between week 1 and 5. Thus, for each of the three time periods, girls received a score of 0 to 3 depending on the number of mutual friendships that persisted across the period.

FRIENDSHIP QUALITY - Was there a difference in the quality of mutual best friendships between girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD?

To examine this issue, researchers had girls complete a 43-item scale designed to measure the quality of children's best friendships. The broad friendship qualities assessed on this scale included positive friendship features and negative friendship features.

Postive friendship features include such attributes as: validation/caring, companionship/recreation, providing help/guidance, successful conflict resolution, and intimate exchange.

Negative features of friendships that are inquired about include conflict, exclusivity, overt aggression, and relational aggression (i.e. relational aggression is defined as such actions as threatening to end the friendship if one's friend does not do as one wishes).

Friendship quality interviews were conducted with each girl 4 weeks into the camp.  Becuase girls could have up to 3 mutual friends, they completed the questionnaire on their most stable mutual friend or the mutual friend that they identified as their highest ranked friend.

RESULTS

PEER REGARD - At the end of weeks 1, 3, and 5, girls with ADHD received fewer liked most nominations and more liked least nominations than comparison girls.  Thus, in regards to their general level of acceptance by peers, girls with ADHD were having a more difficult time than comparison girls.  Differences between girls with each ADHD subtype were not reported.

FRIENDSHIP PARTICIPATION - As noted above, girls were deemed to have a mutual best friend if one of the three class mates they nominated as a best friend also identified them.

Girls with ADHD were more likely than comparison girls to have no mutual best friends at the end of camp (i.e. 32% of girls with ADHD vs. only 17% of comparison girls).  In addition, girls with ADHD were less likely than other girls to have multiple friends at the end of camp (i.e. 29% vs. 52%).  Girls with the combined and inattentive subtypes of ADHD were essentially identical.

These results suggest that girls with ADHD had more trouble making any friends at all, and even when they were able to make one friend, they were less able to develop and retain multiple friendships.

FRIENDSHIP STABILITY - Differences between girls with and without ADHD were also found for friendship stability, and results revealed a somewhat different pattern for girls with the inattentive and combined subtypes.

Girls with the combined subtype of ADHD showed more instability in their friendships than comparison girls between weeks 1 and 3.  Fifty-one perceont of these girls had no stable friendships during this period while this was true for only 24% of comparison girls.

Girls with the inattentive subtype of ADHD had fewer stable friendships than comparison girls between weeks 3 and 5.  In addition, none of these girls were able to maintain multiple stable friendships over this period.

Collectively, these results suggest that girls with Combined-type ADHD had greater initial difficulty maintaining any stable friendships, while girls with Inattentive-type ADHD had more difficulty keeping more than one consistent friend during the second half of the camp.

FRIENDSHIP QUALITY - Because girls' ratings of positive and negative friendship features were not highly correlated, these two dimensions of friendship were analyzed separately.

In regards to positive friendship features, no differences were found between how girls with ADHD and comparison girls described their relationship with their best camp friend.

Girls with ADHD, in contrast, reported that more negative features characterized their best friendship. Follow-up analyses of specific items comprising the negative dimension friendship scale indicated that girls with ADHD described their best friendships as containing greater conflict, and more relational aggression.  Higher levels of these negative features were more characteristic of girls with Combined-type ADHD than of girls with Inattentive-type ADHD.

SUMMARY AND IMPLICATIONS

In this examination of friendship participation, stability, and quality that occurred in a naturalistic camp setting, girls with ADHD clearly had more difficulty than other girls.  During the 5-week program, they tended to be less well liked by peers in general, were more likely to have no friends and less likely to have multiple friends, and their friendships tended to be less stable and include more negative features.  Thus, not only are girls with ADHD more likely than others to experience low levels acceptance within the wider peer group, they are also more likely to have difficulty with dyadic friendship relations as well.  This is true for girls with both the inattentive and combined subtypes of ADHD, although there may be some differences between these groups as discussed above.

Results of a similar nature have previously been reported for boys with ADHD and the current study extends current knowledge by documenting that girls with ADHD are likely have similar patterns of social difficulty.  Given evidence that children without friends experience more concurrent and future adjustment difficulties, these findings suggest that social difficulties may play an important role in negative developmental outcomes for many girls with ADHD.

These are important and interesting finding, but it is helpful to consider them in light of several considerations.  First, it is important to keep in mind that not all girls with ADHD in this study experienced the pattern of friendship problems described above, and some were apparently doing fine socially.  Thus, although girls with ADHD are more likely to have for such problems than other girls, these difficulties are not inevitable.

Second, although the camp program provided a naturalistic setting to study friendship processes in girls with ADHD, results obtained here are not necessarily representative of what occurs in typical peer groups.  For example, as the authors of this study note, what occurred during the 5-week summer program does not necessarily translate into processes that develop over longer periods of times in regular classrooms.  Also, the context in which friendships were examined included a much higher concentration of girls with ADHD (i.e. they were in the majority) than is founde in naturally occurring peer groups.  How this may have affected the results is uncertain, although the authors suggest that the negative peer regard experienced by girls with ADHD in naturally occurring peer groups is likely to be greater than what was documented here.  This may be the case because their behavior would be more atypical in peer contexts where ADHD is much less common.

Finally, the authors note that they did not consider the potential impact of severity of ADHD symptoms or the presence of co-occurring conditions on girls' friendships.  Because many of the girls diagnosed with ADHD had other diagnoses as well (e.g. oppositional defiant disorder), it is possible that these other conditions contributed significantly to the friendship difficultes that were found.

Results from this study highlight the need to pay special attention to peer relations in girls with ADHD.  The same, of course, is true for boys.  Because behavioral and academic problems can often be so prominent in children with ADHD, however, difficulties they may be having in their social functioning are often overlooked.  As noted above, however, being disliked by their peers and unable to make and retain friends seems to be a unique risk factor for a variety of negative outcomes, and this issue thus requires careful attention in its own right.

What can be done for children with ADHD who are struggling socially?  One option is social skills training in which children are taught specific skills to assist them in developing better peer relations.  Unfortunately, such programs can be difficult to locate in most communities, although an increasing number of schools seem to be providing some type of social skills training.  It should also be noted that the evidence supporting the benefits of skills training for improving children's general level of acceptance by the wider peer regard has been inconsistent.

The authors of this study suggest that specific interventions focusing directly on friendship skills that are geared towards helping a child with ADHD develop and retain even a single close friendship may be a more realistic option than trying to enhance popularity with the larger peer group.  They rightfully point out that studies designed to teach friendship skills to children with ADHD, and to help them develop and retain close friends, has not been conducted.  Clearly, this is an area where important work needs to be done.

In the meantime, helping children develop a close friendship is an area where parents can often play a helpful role.  Research has shown that parents who take an active role in arranging play dates for their child and who "supervise" children's time with a friend to help make sure it goes well, tend to have children who are more socially competent.  This becomes harder to do as children get older, but parents can still work to remain involved in their child's social life, providing support when their child is having difficulty and trying to help their child think about ways to handle conflicts that may emerge with a friend that will not be damaging to the friendship. An excellent book that can be helpful in this task is "Good Friends are Hard to Find - Help your Child Find, Make, and Keep Friends" by Dr. Fred Frankel.  The program described in this book is based on a social skills training curriculum developed and tested at UCLA.

In some instances, however, children will continue to have a very difficult time socially despite parents' best efforts to provide help and support.  As noted above, sustained and serious difficulty getting along with peers can be detrimental to a child's development in important ways.  Thus, when such problems are persistent, arranging professional help for a child can be another very important step to take.