Attention Research Update

June 2007

"Helping parents, professionals and educators stay informed about new research on ADHD"

David Rabiner, Ph.D.  Senior Research Scientist, Duke University


      
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                              The Social Impact of Girls with ADHD


The social difficulties of boys with ADHD have been well-documented and initial research on girls with ADHD point towards similar social problems (for a review of one such study go to www.helpforadd.com/2003/march.htm. Research on the social interactions of girls with ADHD remains limited, however, and has primarily relied on parent and teacher reports of girls' social behavior while direct observations of girls' behavior have been rare.  This is an important limitation because parents and teachers are not necessarily privy to subtle aspects of social interaction that may play a significant role in the success - or lack thereof - that a girl experiences with her peers.

A study published in a recent issue of the Journal of Abnormal Child Psychology [Ohan & Johnston (2007). What is the social impact of ADHD in girls? A multi-method assessment. JACP, 35, 239-250] begins to address this limitation by examining girls' social interactions with observational methods in addition to incorporating reports from parents and teachers.

Participants were 40 9- to 12- year old girls diagnosed with ADHD and 40 comparison girls without ADHD.  Among the girls with ADHD, 22 met criteria for the combined type of ADHD (i.e., they had high rates of both inattentive and hyperactive-impulsive symptoms) while the remained were diagnosed with the inattentive type of ADHD (i.e., high rates of inattentive symptoms only).  Twenty-two of the girls with ADHD also met criteria for a diagnosis of Oppositional Defiant Disorder (ODD; for a description of ODD symptoms, go to www.helpforadd.com/oddcd.htm.  Almost all of these girls were from the ADHD Combined type group; the vast majority of girls with ADHD only were of the inattentive type.

The researchers were interested in comparing the levels of prosocial and aggressive behavior of girls with and without ADHD and they used a variety of measures to do this.  Before summarizing these measures, it is important to note that they chose to examine 2 types of aggression: overt aggression and relational aggression.

Overt aggression is the type of aggression that tends to be common among boys and involves physically aggressive behavior, intimidation, and threats.  This is the type of aggression that boys employ to bully others and establish themselves in the dominance hierarchy.  Although parents and teachers are not privy to all such aggressive acts, it is the type of aggressive behavior that is easy to observe.

Relational aggression, in contrast, refers to behaviors that are intended to harm or disrupt the victims' relationships with peers and is evident in gossiping or social exclusion.  A child is engaging in relational aggression when she/he spreads rumors about a peer to damage that peer's social reputation, attempts to turn others against a peer, or deliberately excludes a child from social activities.  Although the evidence remains somewhat equivocal, there are indications that relational aggression is more common among school age girls than boys, perhaps because girls tend to place greater value on intimacy and group belongingness.  In contrast to overt aggression, relational aggression is more subtle and difficult to observe, and is therefore less accessible to parents and teachers.


- Measures -

Below is a brief description of the measures that were collected on participants.

Child Behavior Checklist (CBCL) - The CBCL is a widely used measure of child behavior problems containing 114 items that parents rate from "never true" to "often or always true".  Items are grouped into a number of problem behavior scales that reflect internalizing difficulties (e.g., worries, sadness, anxiety), externalizing problems (e.g., disruptive behavior, oppositional behavior, aggression), and adaptive skills.  This form was completed by children's mothers.  For girls with ADHD who were being treated with medication, mothers were asked to report on their child's behavior when not on medication.

Children's Social Behavior Scale - This scale was completed by mothers and teachers to assess each girl's level of overt aggression, relational aggression, and prosocial behavior. 

Observational Measure - The unique aspect of this study was the use of an clever paradigm to collect observational data on girls' aggressive and prosocial behavior.  Girls were brought into the lab and given the choice to play a computer game called the "Girls Club!". Each girl was told that the game was developed for girls their age to play with each other and that she would be playing on-line with 2 other girls who were in other rooms and who she would meet at the end of the game.  In reality, however, no other girls would be playing; instead, the moves and comments (see below) of the "other" players were simulated and pre-programmed to be the same for every participant.

Each game began with girls in the "clubhouse".  The game involved rolling computerized dice to move around the board with the winner being the first girl back to the clubhouse.  Along the path, were 5 "chat centers" where girls could send messages to the "other girls", either to both at the same time or to one girl or the other. In reality, of course, there were no other girls receiving the messages.

As noted above, all moves and dice rolls were predetermined by the computer.    The participant always "won the game" and was appointed "Girl's Club President".  This gave her the right to make decisions about her "co-players" that each girl was told would be provided to future presidents to aid in their selection of who to play with.  Thus, each girl could indicate who to include or exclude in future games and could provide information about what the other girls were like and how good a friend they would be.  This provided an opportunity to assess overtly aggressive and relationally aggressive comments.  Girls were led to believe that the ratings of their peers collected after the game would not be shared with the other players.

Messages that girls sent at the Chat Centers, as well as the comments about other girls that were collected after the game, were coded into the following categories:

Overt Aggression - harmful/destructive messages that threatened, bossed or taunted; e.g., "shut up", "Ha, Ha, look like you lost!"

Relational Aggression - harmful/destructive messages that manipulated the victim's relationship with another player; e.g., "Don't tell her but I don't like her very much, do you?"

Prosocial - skilled and friendly messages; e.g., good game to everyone," "I really like playing with you guys.

Awkward - comments that were out of synch with social expectations; e.g., out-of-the-blue comments that did not fit into the flow of normal social exchange such as "I like fish," "Volleyball is a fun sport".


All messages were coded into 1 of these 4 mutually exclusive categories and the number of messages in each category was tallied to create a score in that category for each participant.  In addition to this coding, the intensity of each message was rated on a 1 to 5 scale.  For example, in the overt aggression category, the message "I'm going to win!" would receive a score of 1 while the message "I'm going to spit on you!" would receive a score of 5.  Intensity scores were averaged within each category. 

The scores resulting from this coding procedure provide an observational measure of the girls' overt and relationally aggressive behavior, as well as their tendency towards prosocial and socially awkward exchanges.  They are thus a nice complement to the parent and teacher ratings that were collected.

Some readers may be concerned by the deceptive nature of this study as girls were led to believe they were interacting with peers when this was not the case.  It should be noted that in this study, as in all studies conducted with human subjects, the procedures were reviewed and approved by a committee at the researchers' university whose job it is to safeguard the rights of participants in research studies. 


In addition, the girls' mothers were aware of the deception involved and provided consent for their child to participate.  Finally, at the end of each girl's participation, the researchers provided each girl with a complete explanation of what had occurred, and an explanation for why the deception was necessary.  The authors noted that none of the girls appeared to be upset by the experience.


- Results

Overt Aggression - Comparisons between girls with ADHD+ODD, ADHD only, and control girls for overt aggression were made for parent and teacher ratings as well as for the messages sent in the computer game.  On all 4 measures, girls with ADHD+ODD were more aggressive than girls with ADHD alone who, in turn, were more aggressive than girls in the control group.

Relational Aggression - According to mothers' reports, girls with ADHD+ODD displayed higher rates of relational aggression than girls with ADHD alone, and girls with ADHD alone were seen as more relationally aggressive than girls in the control group.  For teacher ratings, girls with ADHD+ODD were more aggressive than girls in both other groups who did not differ significantly from each other.

On the lab task, girls in the control group sent fewer relationally aggressive messages than both groups of girls with ADHD.  However, the intensity of the relationally aggressive messages was actually higher for girls in the control group than for girls with ADHD alone.  After being appointed "president" girls with ADHD+ODD were more prone to suggest excluding peers from future games than girls in the other groups. For rumor spreading, girls with ADHD only spread significantly fewer rumors than girls in the control group.

Prosocial Behavior - According to mothers' reports, girls with ADHD+ODD were less prosocial than girls with ADHD alone, who, in turn, were seen as less prosocial than girls in the comparison group.  Teachers reported that girls with ADHD+ODD were less prosocial than girls in both other groups, who did not differ significantly from each other.

On the simulated computer game, both groups of girls with ADHD sent fewer prosocial message than girls in the control group.

Awkward Behavior - Interestingly, girls with ADHD alone were judged to send more socially awkward messages than girls in the other two groups.  The intensity of their "awkwardness" was also judged to be higher.


** The Contribution of ODD symptoms, hyperactive-impulsive symptoms, and inattentive symptoms to girls' social behavior **

As a supplementary analysis, the authors examined the relative contribution of 3 types of symptoms - oppositional behavior, hyperactivity, and inattention - to the different types of social behavior rated in the study.

Girls' level of overt aggression was related to their ODD symptoms and hyperactive-impulsive symptoms, but not to their level of inattentive symptoms. Findings for girls' relational aggression were more mixed, with ODD, hyperactive, and inattentive symptoms all predicting relational aggression according to at least one source (i.e., parents, teachers, or lab observations). 

Girls who were higher in ODD symptoms were seen as less prosocial by mothers, teachers, and in the lab task.  Hyperactivity was related too less prosocial behavior only during the lab task, and inattention was not related to prosocial behavior on any of the measures.

Finally, for awkward behavior in the lab task, only inattentive symptoms emerged as a significant predictor.


* Relationship between lab task measures with mothers' reports of psychopathology for girls with ADHD *


To examine the validity of the lab task measures, the authors also calculated the association between these measures and mothers' reports of their child internalizing and externalizing problems from the Child Behavior Checklist.  Results indicated that higher rates of externalizing behavior problems were positively associated with the frequency and intensity of overtly aggressive messages, of exclusionary and rumor spreading messages, and with socially awkward messages.  Externalizing problems were also negatively associated with prosocial message frequency and intensity.

Internalizing (e.g., worries, sadness, anxiety) were strongly linked with the frequency and intensity of socially awkward messages, but not to overtly aggressive or relationally aggressive messages.

Finally, girls rated higher by mothers on adaptive skills sent fewer overtly and relationally aggressive messages that were also judged to be less intense. 

Overall, therefore, clear and meaningful relationships were found between mothers' ratings of their child's difficulties and children's behavior during the lab task used to assess their social behavior.


- Summary and Implications -

Results from this study indicate that girls with ADHD+ODD were more overtly and relationally aggressive and less prosocial than girls without either disorder, with girls having ADHD only falling in between these girls and girls without ADHD. 

It was especially noteworthy that compared to girls in the control group, girls with ADHD only showed less frequent prosocial behavior, more overt aggression, more frequent relationally aggressive messages, and more awkward social interactions.  Thus, even when not accompanied by significant oppositional behavior, ADHD was significantly associated with lower levels of social competence in girls.  Because girls were not taking medication at the time of the lab assessment, the degree to which these differences might be alleviated by medication treatment is not clear. 

One apparently paradoxical finding was that girls with ADHD only showed more frequent relationally aggressive messages than girls in the control group, but these messages were rated as being less intense.  They also engaged in less rumor spreading than girls in the control group. To explain these apparently contradictory results, the authors suggest that relational aggression that involves planning and organizational skills (e.g., gossiping and spreading rumors to damage another child's reputation) may be less common in girls with ADHD because they lack the planning and executive functioning skills that this behavior requires.  Thus, they may have been less able to generate the kinds of rumors about peers that were judged to be of an intense nature.

If, however, relational aggression takes the form of a rash and angry response to a conflict, girls with ADHD may engage in more of it than other girls because of their greater tendency to act impulsively. Future research should thus look more closely at the type of relational aggression that girls with ADHD tend to display.

The authors also call attention to the findings pertaining to socially awkward behavior, something that has not been examined in prior research.  They suggest that the inattentive nature of ADHD can make it difficult for children to accurately track ongoing conversational exchance, and may explain why girls with ADHD sent more tangential and awkwardly appearing messages.

In summary, results from this interesting study add to current knowledge of the social difficulties of girls with ADHD by highlightng a pattern of social behavior that includes higher rates of relational aggression, reduced prosocial behavior, and higher rates of socially awkward behavior.  When accompanined by ODD, increase in overt aggression are also prominent. As with all studies in which children with ADHD are compared to other children, it is important to recognize that not all children in the ADHD group displayed the behavioral deficits and excesses that were found to characterize the group as a whole.

Subsequent research should build on these findings through incorporating observational methods such as those incorporated hear and focus on the development of effective methods for addressing the pattern of social difficulties that was found.



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Information presented in Attention Research Update is for informational purposes only, and is not a substitute for professional medical advice.