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Helping Children with ADHD Develop Friendships
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 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/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.
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. In fact, prior research has shown that many children with ADHD begin to be rejected by unfamiliar children after only a single day of contact. And, once a negative reputation with peers has been established, it can be difficult to change even if a child's social behavior improves.
Because developing positive peer relations can be so difficult for children with ADHD, there have been several studies in which efforts to peer relations in children with ADHD have been examined. Although standard ADHD treatments (i.e. psychostimulant medication and behavioral therapy) can be somewhat helpful, these interventions do not generally normalize the social standing for children with ADHD. In addition, efforts to directly teach social skills to children with ADHD have so far yielded results that are less positive than one would hope.
One limitation of research on improving peer relationships for children with ADHD is that researchers have typically focused on improving children's overall standing in the peer group, rather than trying to help them develop a single close friendship. Although the former is certainly important, the presence vs. absence of even a single close friendship is important as well.
Whether or not a child has a close friendship can be relatively independent of the child's social standing within the wider peer group, and may be just as important for both current and future adjustment. For example, research has shown that 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, it appears that having a close friend can help compensate for the negative effects of being rejected by the larger peer group.
Some ADHD researchers have suggested that social interventions for children with ADHD should include efforts to help them develop and maintain a close friendship rather than focusing exclusively on improving their overall level of peer acceptance. These researchers have argued that helping a child establish a good friendship should be easier than trying to overcome a child's negative reputation in the larger peer group. And, the known benefits of having a close friend suggest that this could improve the social outcomes for children with ADHD. Of course, not all children with ADHD are disliked by peers or lack friends, but for those who do, helping them make and keep a friend could be very important.
Although this is a compelling and logical idea, there has not been prior research on this topic. A study published in the April 2003 issue of the Journal of Attention Disorders, however, provides an interesting preliminary examination of efforts to help children with ADHD develop friendships (Hoza, B. et al., A friendship intervention for children with AD/HD: Preliminary findings. Journal of Attention Disorders, 6, 87-97).
Participants were 209 5-12 year old children (188 boys and 21 girls) with ADHD who participated in an intensive summer treatment program (STP). The STP is an intensive 8-week behavioral treatment program that children attend all day, 5 days/week.
A variety of child-focused interventions are implemented during the program including a behavioral point system, social skills training, social problem solving training, and sports skills training. Children also spend part of each day in a structured classroom environment where regular academic lessons are taught. All interventions are embedded in a summer day camp context that includes ample time for recreational activities. Children attending the STP typically do not know each other before the program begins.
In addition to the interventions mentioned above, a program called "the buddy system" was implemented to promote the development of dyadic friendship skills. This involved pairing each child with an age and gender matched "buddy". Whenever possible, children were paired according to friendship preferences they expressed 2 weeks into the program. Buddies were also paired based on similarities in behavioral, athletic, and academic competencies and on whether children lived close enough together that play dates could occur outside of camp.
Parents were encouraged to talk with the parents of their child's buddy's t arrange play dates outside of the STP. Children and their buddies were also given special privileges within the STP in order to optimize the chance for children to get to know one another and form a friendship. In addition, a camp counselor served as a friendship coach for each buddy pair. Each morning, the coach checked in with members of the pair to learn how the child and his/her buddy were getting along, and to suggest ways to handle any problems that were reported. At the end of each week, the coach met with both children together to help them work out any difficulties in their friendship that emerged during the week. Through these efforts, it was hoped that each child would have the experience of developing and maintaining a good friendship during the STP.
As part of the STP, extensive information was collected on all children. This included behavior ratings by counselors, teachers, and parents, and teacher ratings of academic performance during classroom activities. Ratings were obtained at the beginning and end of the program so that change could be evaluated on a variety of different dimensions.
Counselors, teachers, and children also rated the quality of each child's relationship with his or her buddy. This allowed the researchers to evaluate factors that influenced the quality of children's buddy relationship, as well as factors the predicted improvement in behavioral and academic functioning during the STP.
Results
The authors first examined factors that predicted the quality of children's relationship with their buddy. Children who engaged in more antisocial behavior during the program were seen by their teachers as achieving a relationship of lower quality with their buddy. Children whose parents were more supportive of the buddy intervention - i.e. those who parents arranged frequent meetings outside of the STP - tended to show better relationship quality according to counselors. And, when parents supported the buddy program, children tended to be seen as more positive and adaptive by counselors at the end of the program.
Importantly, parents' support of the buddy program also predicted children's perception of the quality of their buddy relationship: when parents were more supportive children were more satisfied with the friendship they developed.
A final noteworthy finding concerns the impact of the buddy's antisocial behavior on children's outcomes in the program. The more antisocial behavior a child's buddy displayed, the less likely teachers were to see academic or behavioral improvement in the child. Conversely, when a child's buddy was less antisocial, children were more likely to be regarded by teachers as making academic and behavioral gains.
Summary And Implications
This study represents an initial effort to evaluate an intervention designed to help children with ADHD establish and maintain a friendship. The results of this preliminary work are both instructive and encouraging, and have potentially important implications for helping children with ADHD.
First, it is noteworthy that the antisocial behavior of a child's buddy influenced how teachers perceived the child. Specifically, when a child's buddy was highly antisocial, teachers rated the child as less successful both academically and behaviorally.
Although teachers' may have rated children with an antisocial buddy in a more negative manner than was truly warranted, children with an antisocial buddy may also have been negatively influenced by their buddy's behavior. It is well established that children who associate with disruptive and antisocial peers tend to become more antisocial themselves, and the finding in this study is consistent with this. This highlights how important it is for parents to monitor who their child is spending time with, and to work hard to keep their child from associating with antisocial peers. This can be critically important in preventing a child from traveling down an antisocial path him or herself.
Second, it was encouraging to learn that when parents worked hard to support the buddy program by arranging play dates for their child and his/her buddy, child developed higher quality friendships. Furthermore, there was some indication that parent support of the buddy program was associated with more positive behavior in their child by the end of the STP.
These findings highlight the important role parents can play in helping children with ADHD develop a close peer relationship. Because many children with ADHD struggle to make and keep friends, and having a close friend can compensate for the negative effects of being rejected by the larger peer group, parents who help their child develop a good friendship are providing an enormous benefit for their child.
Although research to guide parents' efforts to assist their child develop a friendship is needed, it appears that this is an area where parents can make an important difference in their child's life. Teachers and professionals can help support parents' efforts in this regard, perhaps by acting as a "buddy coach" as counselors did in this study.
Helping children with ADHD build close peer relationships is an important goal to focus on, and is one that may often be overlooked when concerns about behavior and academic performance are prominent. Results from this study indicate that parents have an important role to play in achieving helping their child accomplish this important social goal, and one hope that additional research in this area with be forthcoming.
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.