A consistent finding 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 with more harmonious peer relations.  This may occur because rejected children often gravitate towards one another during adolescence, and reinforce/escalate each other's antisocial behavior.  Rejection by peers can also have a negative affect on children's self-esteem and contribute to the development of loneliness and depression.

Unfortunately, many children with ADHD struggle in their relations with peers, and may begin to be rejected after only a single day of contact. Although this is concerning, a child's overall standing in his or her peer group can be relatively independent of whether the child has a close friend and what the quality of that friendship is like.  And, having a good quality friendship may be just as important as overall peer acceptance to children's current and future adjustment.  For example, even if a child is disliked by many peers, having a close friend is associated with less loneliness, more positive family relationships, and higher feelings of general self-worth.  Thus, having a close friend can help compensate for the negative effects of being rejected by the larger peer group.

Because many children with ADHD can be unpopular in their peer group, learning about the quality of their friendships established is an interesting and important topic to pursue.  This was the focus of a study recently published online in the Journal of Abnormal Child Psychology [Normand, et.al. (2010). How do children with ADHD (mis)manage their real-life dyadic friendships? A multi-method investigation. Journal of Abnormal Child Psychology.] 

Participants were 87 children with ADHD (76% boys; ages 7-13) and 46 comparison children without ADHD.  Eighty-two percent of the children with ADHD were being treated with medication.  Each child was asked to invite his/her best friend to the lab where they engaged in a number of different activities to enable the researchers to learn about the quality of their friendship. (Parental permission to participate was obtained from both the participants as well their friends.)  The tasks children completed were as follows:


Friendship Quality Measure - This is a 43-item measure that children use to rate the quality of their relationship with their best friend. The items inquire about both positive and negative aspects of the friendship including providing support, companionship, confiding in one another, degree of conflict, demands for exclusivity, and aggression.  An overall score for positive and negative friendship features is calculated based on the child's responses.

Car-Race Task - This task was designed to stimulate interaction between friends in a fast-paced and engrossing game.  The goal of the game is to win a race that involves transporting a number of wooden blocks from one end of a 'race track' to another using a toy truck.  The track cannot accommodate two trucks side by side and the rules prohibit players from lifting their truck from the track or deliberately blocking the other truck.  Players can thus compete energetically without breaking the rules, can compete in ways that violate the rules, or can choose to avoid conflict with their opponent even if it reduces their chances of winning.

This task was designed to observe difference in how children with and without ADHD behaved towards their friends during a competitive task.

Card sharing and Game-choice tasks - In the card sharing task, children were presented with 15 appealing trading cards and asked to select 5 cards that they both liked the most.  Then, they were instructed to decide together how to share the 5 cards.  They could share them any way they liked, as long as they both agreed.  This task allowed the researchers to observe how children with and without ADHD negotiated with their best friend.

For the game-choice task, participants were presented with a number of appealing games and asked to choose together which games they would play at the end of the session.  This task provided another opportunity to observe how children were able to negotiate and resolve potential disagreements.

In addition to these activities, the researchers obtained behavioral ratings from parents and teachers of all children, including the best friends.  This enabled them to see whether the friends of children with and without ADHD differed on a variety of behavioral dimensions according to parents and teachers.


- Results -

Behavioral and Social Characteristics of the Invited Friends - Friends of children with ADHD were rated as displaying more ADHD symptoms than friends of comparison children by both parents and teachers.  Of the friends with symptom ratings in the clinically elevated range (n=22), all were friends of children with ADHD. They were also rated as being more oppositional. 

Friendship Quality - Children with ADHD rated their best friendships as higher on negative qualities and lower on positive qualities than the comparison children.  In addition, the friends of children with ADHD rated their friendships less positively than did the friends of comparison children.  Furthermore, both children with ADHD and their invited friends were significantly less satisfied overall with their friendship than were comparison children and their friends.

Car-race task - Children with ADHD displayed both more legal and illegal maneuvers during the game with their friend.  On average, they engaged in twice as many illegal maneuvers as comparison children.

Card sharing task  - Children with ADHD made more insensitive and self-centered proposals for sharing the cards with their friend than comparison children made with their friend.  They also asked their friends for their sharing preferences less frequently and the exchange was more likely to be characterized as displaying a power differential between the friends.  Of the 7 dyads that never agreed on how to divide the cards, all of these involved a child with ADHD.

Game-choice task - Children with ADHD made more proposals that were rated as insensitive and also refused their friend's proposal more often.

In addition to the primary analyses summarized above, the researchers conducted supplementary analyses to test whether the main results were modified by children's gender, age, and medication status.  Results of these analyses indicated that the effects described above did not vary according to the age or gender of the children, and also did not depend on whether children with ADHD were receiving medication treatment.


- Summary and Implications -

This ambitious study provided detailed information on the quality of friendships in children with ADHD from multiple perspectives.  Overall, the best friends of ADHD had more ADHD symptoms and oppositional behavior than the best friends of comparison children.  Children with ADHD and their best friends reported enjoying their friendship less than other children and children with ADHD were generally less sensitive to their friends needs/wishes during the social interaction tasks.  Overall, it appears that the friendships of children with ADHD were of lower quality.  Of course, it is important to remember that this overall average difference does not apply to all children with ADHD, many of whom are involved in high quality, positive friendships.

Results from this study highlight the potential value of coaching children with ADHD in friendship skills in an effort to improve the quality of their friendships.  Medication by itself did not appear to diminish the difference in friendship quality of children with and without ADHD highlighting the importance of interventions that target children's friendships directly.  Such efforts need to focus on increasing the positive attributes of their friendships and increasing their awareness of - and responsiveness to - their friend's wishes and desires. 

Results of other recently conducted research indicate that parents can play an important role in these efforts; in subsequent issues of Attention Research Update I will include summaries of this research.