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Does ADHD in Childhood Predict Peer Problems in Adolescence?
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.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.