Assessment of children's social functioning
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Social Functioning and Emotion Regulation in Children with Different Subtypes of ADHD
As you are probably aware, the current diagnostic criteria for ADHD identifies 3 distinct subtypes. Children with both inattentive and hyperactive/impulsive symptoms are diagnosed with ADHD, Combined Type. Those with predominantly inattentive symptoms but few hyperactive/ impulsive symptoms are diagnosed with ADHD, Predominantly Inattentive Type. When the opposite is true, the diagnosis would be ADHD, Predominantly Hyperactive/Impulsive Type. (Click here for a complete discussion of diagostic criteria.).
Since the criteria for these different subtypes were published in 1994, researchers have sought to identify meaningful differences between them in addition to differences in the primary ADHD symptoms that children with different subtypes of ADHD display. This is important not only to establish the validity of this subtyping scheme (after all, if children in the different groups do not differ on any important dimensions other than the symptoms used to define each subtype, the utility of such classification would certainly be questioned), but also to establish what may be the particular difficulties associated with the different subtypes to which treatment could be directed. In other words, by identifying meaningful differences in functioning between children with the inattentive, hyperactive/impulsive, and combined subtypes of ADHD, it might be possible to develop treatments that could be specifically tailored to these subtype specific problems.
An interesting study published in a recent issue of the Journal of Child Clinical Psychology is a good example of the work being done in this area (Maedgen, J.W. & Carlson, C.L. (2000). Social functioning and emotional regulation in the ADHD subtypes. Journal of Child Clinical Psychology, 29, 30-42.) In this study, the authors examined whether children diagnosed with different subtypes of ADHD might differ in the primary reason for social difficulties that they experienced.
For example, some children who have difficulty getting along with peers actually lack the knowledge of ways to get along better - i.e. they really don't know more appropriate ways of interacting. These children have what the authors refer to as social knowledge deficits. Other children with peer difficulties know what they should do, but have difficulty putting this knowledge into practice. For these children, social performance deficits is a more apt description of their difficulties. The authors hypothesized, based on some preliminary work in this area, that children with ADHD, Combined Type and children with ADHD, Predominantly Inattentive Type would have social performance deficits, but that only the latter would also show deficits in social knowledge. (Note: Children with the hyperactive/ impulsive subtype were not included because this is a very infrequently occurring subtype among school-age children, and is more typically found in preschoolers.)
In addition to examining children's social functioning, the authors were also interested in studying how emotion regulation skills might differ between the ADHD subtypes. Children with problems in emotion regulation tend to be overly intense in their displays of emotion and frequently overreact to emotionally provoking situations. In his recent theory of ADHD, Dr. Russ Barkley hypothesizes that deficits in emotional regulation represent one of four primary areas of impairment in children with the combined subtype of ADHD. Problems with emotion regulation can also contribute to difficulties in children's relations with peers. The authors predicted that children with the combined subtype of ADHD would display significantly greater difficulties in this area than inattentive ADHD children.
Participants in this study were 16 children diagnosed with ADHD, Combined Type, 14 children with ADHD, Inattentive Type, and 17 children without ADHD (i.e. control subjects). Most of the participants were being treated with medication at the time of the study. All children were between the ages of 8 and 11 and about 30% in each group were girls.
Assessment Of Children's Social Functioning
Children's social performance - i.e. how they actually behave in a variety of different situations - was assessed in several ways. First, each child's parent(s) and teacher completed a measure called the Children's Assertiveness Behavior Scale (CABS). This measure consists of 27 items that describe different social situations that are important and relevant for children in this age range. For each item, the parent and teacher were required to select from several options the way they believed the child would most likely respond in the sitatuation described. Either competent responses (i.e. assertive) or incompetent responses (i.e. passive or aggressive types of responses) could be selected.
For each child, separate passive, aggressive, and passive + aggressive scores were computed based on the number of times these options were chosen. These scores were computed separately for the parent and teacher ratings. Thus, each child's scores provide an index of how likely his or her parent(s) and teacher believe the child is likely to enact incompetent responses in social situations - passive or aggressive - as opposed to more competent - i.e. assertive - responses. Previous research has indicated that children's scores on the CAB provide valid estimates of their actual behavior with peers.
In addition to these data on children's social performance, parents and teachers were also asked to provide estimates of how well-liked the child was by his or her peers. These ratings were used to estimate the proportion of peers who were thought to dislike the child, like the child, or be more or less indifferent to the child (i.e. ignore him or her).
In addition to obtaining these data about social functioning from parents, children themselves were also asked to provide ratings of their social performance and social knowledge skills. This was obtained using the CABS measure described above. To assess each child's estimate of their social performance ability, they were asked to select the response they would be most likely to enact in each of the situations described. To assess social knowledge, they were asked to choose what was the best response to make, even though this might be different from what they felt they would do themselves. This enabled the researchers to examine whether children were able to recognize the most appropriate response in different situations (i.e. social knowledge) even if they reported that they would behave differently in that situation (i.e. social performance).
Assessment Of Emotion Regulation
Children's emotion regulation skills were assessed in a creative and clever way. Children were told that they would be receiving prizes for their help in the study, were shown 10 potential prizes to choose from, and asked to rank these prizes from least to most desired. The impression conveyed was that they would receive their highest rank prize. After completing the measures of social knowledge and social performance described above, they were presented instead with the lowest-ranked prize choice. This was done by a second examiner who presumably would not have been aware of the child's rankings.
Children's reactions to receiving their least-favorite prize were videotaped (children had been informed that they would be taped during the session), and these tapes were later reviewed so that each child's reaction to receiving the disappointing prize could be carefully observed. Judges who were blind to child's diagnosis (i.e. ADHD Combined, ADHD Inattentive, or control) rated each child for the intensity of the child's emotional display and the child's effectiveness at regulating his or her emotional display. Thus, this procedure enabled the authors to observe how strongly children reacted to a disappointment and how well they were able to manage/ regulate their negative emtions. (At the end of the study, of course, children were informed about the reasons for the procedure and presented with their highest ranked prize.)
Results
As is generally the case with an elaborate study such as this, there are more data presented in the results section than can be fully reviewed here. Below, however, are the findings from this study that seem most important.
Children With Adhd, Combined Type, Were Less Popular With Peers According To Parents And Teachers.
The results on the peer liking issue were consistent and straight forward. As a group, children with ADHD, Combined Type were regarded by parents and teachers as having great difficulty getting along with peers. In fact, they were not only perceived to be liked less by peers than children without ADHD, but were also seen as less liked than children with the inattentive subtype of ADHD. The inattentive ADHD children, in contrast, were not regarded as less well liked than control children by either parents or teachers.
Children With Both Types Of Adhd Had Social Performance Deficits According To Parents And Teachers, But The Nature Of These Deficits Was Very Different.
As discussed above, social performance was assessed in this study by having parents and teachers identify how they believed the child would respond to a variety of different social situations. Incompetent responses could take the form of either aggression or passivity.
As one might expect, children diagnosed with ADHD, Combined Type, were rated by parents and teachers as more likely than inattentive children or controls to enact aggressive responses. The magnitude of this difference was exceedingly large - about 3-4 times higher for these children than for other children. It must be noted that teacher ratings of aggressive behavior were this high even though most of these children were being treated with medication, and teachers had rarely observed them when not on meds.
For passive responses (i.e. just letting things go without taking appropriate steps to deal with the situation), the results were exactly the opposite. Here, both parents and teachers indicated that inattentive children were far more likely to respond in passive ways than children in the other 2 groups. The magnitude of these differences, although not quite as large as those noted above, were also substantial.
Children's Ratings Of Their Own Performance And Knowledge Skills Did Not Show Substantial Differences Between The Groups.
As discussed above, each child was asked how he or she would act in the identical situations rated by parents and teachers. They were also asked what the most appropriate response was - even thought this might be different from what they would actually do. The former was used to assess children's self- appraisal of their social performance and the latter assessed their knowledge of appropriate social behavior.
In contrast to the clear differences between the 3 groups of children described above, virtually no differences were found for children's own reports. In other words, even though parents and teachers reported that children with ADHD, Combined Type, were far more likely than others to enact aggressive responses, these children did not indicate that they would act aggressively. And, children with ADHD, Inattentive Type, did not indicate that they would be more likely than others to respond to these situations in a passive manner.
There was, however, one interesting difference in regards to children's social knowledge. Here, children with the inattentive type of ADHD were slightly less knowledgeable about the most socially appropriate ways to respond compared to control children. Children diagnosed with ADHD, Combined Type, however, did not show this same deficiency in their social knowledge.
Emotion Regulation
As discussed above, children's ability to regulate their emotions was evaluated by observing how they reacted when presented with their least favorite prize. Specifically, the researchers were interested in the intensity of the negative reaction they displayed and how well they were able to manage their disappointment.
Interesting differences on this task were found. Consistent with what had been predicted, children with ADHD, Combined Type, displayed significantly more negative behavior, this behavior was judged to be of greater intensity, and they were less able to effectively mask or regulate their disappointment. Thus, not only did they seem to become more upset than others, but they were also less willing/able to keep their negative emotions in check. In contrast, children with the inattentive type of ADHD did not differ in their emotion regulation skills as assessed by this task relative to the control children.
Summary And Implications
There are a number of interesting findings to emerge from this study. First, children with the combined subtype of ADHD are having significantly greater difficulty getting along with peers than inattentive children according to their parents and teachers. This is probably because these children are more likely to act aggressively towards peers, who naturally dislike being the victims of this aggression. These children are also apparently more prone to intense displays of negative emotion and have difficulty regulating their negative emotions compared to other children their age. Certainly, problems with emotion regulation could contribute to their being disliked by peers.
Given these findings, it is somewhat surprising that the children with ADHD, Combined Type, were not deficient in their social performance skills based on their own reports. Thus, relative to parents and teachers, these children tended to dramatically underestimate their proclivity to behave towards others in an aggressive manner.
Because actual observational studies have clearly demonstrated that children with ADHD, Combined Type, are indeed more prone to act aggressively, it seems likely that the parent and teacher ratings were more accurate than children's own ratings. One possible explanation for children's more positive ratings is that they were responding in ways to make themselves "look good" - that is, they were deliberately providing inaccurate assessments of their behavior. Alternatively, many of these children may be relatively oblivious about the ways that they typically behave. That is, they may be truly misinformed about how frequently they behave towards others in an aversive manner.
Regardless of which explanation is correct - and each may apply to different children - the absence of any social knowledge deficits suggests that these children do know how they should act even though they may often fail to do so. This is consistent with Barkley's suggestion that for many children with ADHD, the problem is getting them to do what they already know (i.e. a performance deficit) rather than making sure they know what to do (i.e. a knowledge deficit).
It also bears repeating that the peer difficulties teachers reported for children in the ADHD, Combined Type group was so pronounced even though teachers had typically not observed these children except when they were on medication. Clearly, this implies that medication was not being effective in managing important aspects of these children's difficulties. Whether this was because medication was not being administered in the most efficacious way, or whether these were children who clearly required additional interventions beyond medication is not clear. The important point, however, is that most of these children were having difficulties that were not being addressed adequately in the treatment they were receiving.
For the inattentive children, the social problems were less severe and were of a different sort. These children were seen as more passive by parents and teachers, and their social knowledge tended to be somewhat lower than that of children without ADHD. Surprisingly, however, they were not regarded by parents and teachers as being less well-liked by their peers.
This latter finding is somewhat inconsistent with what has been reported in previous studies and thus needs to be considered quite cautiously. One possible explanation is that because these children are highly passive rather than aggressive, the kinds of social difficulties they have with peers are of the type that adults are less aware of. If this were true, then these children's peers might report that they did not like them very much even though adults tend to be unaware of this fact.
It is also possible that for inattentive ADHD children, difficulties getting along with peers do not emerge until later in their development. Perhaps peers do not become as aware of these children's difficulties until older ages - after all, their problems are certainly less obvious than those of children with the combined subtype of ADHD - and it is only then that these children begin to have problems in their peer relationships. As the demands of peer relationships become more complex with advancing age, it is plausible to hypothesize that children with the inattentive subtype of ADHD would experience increasing difficulty. This would be an interesting developmental question to examine in subsequent research.
In regards to the immediate implications of these results, there are several things that come to mind. First, the results tentatively suggest that children with ADHD, Combined Type, and children with ADHD, Predominantly Inattentive Type, may benefit from different treatment approaches. Children with ADHD, Combined Type, are more likely to require interventions that address their difficulties with emotion regulation, as these difficulties may often contribute to their behaving aggressively. As evidenced by the results of this study, medication as typically prescribed is not likely to sufficiently address the social difficulties that these children have. Children with the inattentive type of ADHD, in contrast, may benefit more from an approach that encourages appropriately assertive behavior with peers as an antidote to their frequent passivity. This type of assistance can be provided to children in a well-designed social skills curriculum.
(Note: I'd like to suggest an excellent book that can be used by parents who are interested in trying to help their child with his or her peer relationships. It is called Socially ADDept - A Manual for Parents of Children with ADHD and/or Learning Disabilities and it is written by Dr. Janet Giler. I think you will find that this is really helpful in your efforts to assist your child in getting along better with peers. Professionals will find that this book can be quite helpful to them as well, especially in working with parents to help their child.)
The findings that children with ADHD Combined Type, were regarded as being relatively disliked by peers also underscores the need to pay attention to children's peer relationships. Often times, this is not an area that physicians will target in a child's treatment, being content instead to rely on medication alone to treat the primary ADHD symptoms. As seen in this study, however, these children continued to be regarded as unpopular even though most were receiving medication. This is really quite important because being disliked and rejected by peers can be a very difficult experience for children. In addition, other research has shown that as children who are disliked by their "mainstream" peers get older, they tend to hang around with more "devaint" and less socially competent kids because these are frequently the only peers who will accept them. This process of gravitating towards deviant peers, which becomes especially problematic as children move into middle school and beyond, can lead in many cases to the development of increasingly deviant and antisocial behavior.
This developmentat progression underscores the need for parents to take an active role in trying to help their child who may be struggling with peer relations. Perhaps the most direct way to help with this is to work hard to try and make sure that your child develops and maintains even a single good friendship. Having a friend - even if one is generally disliked by other children - has been shown to make an important difference in how children feel about themselves, and in helping them feel less lonely and more positive. Working with an experienced child mental health professional can also be important for developing a good approach to assisting your child in developing more positive peer relations.
It is important to emphasize, of course, that a particular child with ADHD may not necessarily fit the pattern of behavior suggested by group findings such as these. For example, these data suggest that most children with ADHD, Combined Type, know how to behave socially even though they often fail to act accordingly. Even so, however, a particular child may still have important social knowledge deficits that underlie his or her difficulties and addressing these deficits would be an important aspect of that child's treatment. This is why it is so important that treatment decisions about what is best for each child with ADHD be based on a thorough and individualized assessment of that child's strengths and weaknesses.
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.