Attention-deficit/hyperactivity disorder and social dysfunctioning

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Abstract

Attention-deficit/hyperactivity disorder (ADHD) is associated with functional impairments in different areas of daily life. One such area is social functioning. The purpose of this paper is to critically review research on social dysfunctioning in children with ADHD. Children with ADHD often have conflicts with adults and peers, and suffer from unpopularity, rejection by peers, and a lack of friendships, in part as a consequence of their ADHD symptoms. Comorbid oppositional defiant or conduct disorder aggravates these impairments. In some cases the inadequate social behavior of children with ADHD may be phenomenologically and etiologically related to pervasive developmental disorders (PDD). However, the causes and consequences of PDD symptoms in ADHD are understudied. Also, the relative contributions of ADHD, on the one hand, and comorbid disorders, on the other, to the course of social impairments are unknown. Social dysfunctioning in children with ADHD appears to increase their risk of later psychopathology other than ADHD. Thus far effective treatment for social dysfunctioning is lacking. Future research should address the exact nature and long-term consequences of social dysfunctioning in children with ADHD, and focus on development of effective treatment strategies.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is characterized by inattention, impulsivity, and hyperactivity and has recently been estimated to affect 3.5% of school-aged children worldwide (Polanczyk, de Limas, Horta, Biederman, & Rohde, 2007), being one of the most common psychiatric disorders of youth (American Psychiatric Organisation [APA] 2000). Based on the pattern of symptoms present, the Diagnostic and Statistical Manual (DSM-IV; APA, 1994) distinguishes three subtypes, the inattentive, the hyperactive/impulsive, and the combined subtype. The latter is by far the most common. Although ADHD symptoms tend to decline with age, at least 50% of children with ADHD will still experience impairing symptoms in adulthood (Faraone, Biederman, & Mick, 2006); in other words, it is a chronic and sometimes life-long disorder.

ADHD is associated with impairments of functioning in cognitive, academic, familial, and eventually occupational domains of daily life (Barkley, 2003). Another important area that is impaired in ADHD is social functioning. This may become manifested as rejection by peers and conflicts with other children and adults. Social dysfunctioning may be of crucial importance for the prognosis of children with ADHD on both short and long-term (Greene et al., 1996, Greene et al., 1997). The behaviors that cause social impairments may in at least some children be a direct consequence of the defining symptoms of ADHD. Some of the criteria for ADHD in DSM-IV even refer directly to inadequate social behavior, such as “interrupting or intruding on others.” In general, the combination of hyperactivity, impulsivity, and inattention is likely to affect adequate fine-tuning of social behavior. Nevertheless, not all children with ADHD show inadequate social behavior. Furthermore, the DSM-IV ADHD-criteria are not sufficient to describe all inadequate social behaviors that can be observed in children with ADHD. Other important indicators of social impairment are oppositional behaviors and conduct problems as seen in oppositional defiant disorder (ODD) and conduct disorder (CD). This corresponds with the high rates of comorbid ODD and CD in children with ADHD. Estimates for the co-occurrence of either disorder range from 30 to 50% in both clinical and epidemiologic samples (Spencer, 2006).

It is an intriguing question why some children with ADHD, despite having difficulties in performing tasks at school, have a healthy social life, and why others appear to be unable to connect with peers and other people in a normal way. The latter group of children may have a diminished capacity for social reciprocity and difficulties in understanding social cues. These features appear similar to what constitutes the core of pervasive developmental disorders (PDD), in DSM-IV described under the heading of problems in social interaction.

This interesting link between PDD and ADHD is one of the topics we will elaborate on in this review. We will start, however, by describing the inadequate social behaviors that are commonly observed in children with ADHD. These behaviors show overlap with the characteristics of the other childhood disorders that primarily affect social functioning, i.e., ODD, CD, and PDD, thus leading to diagnostic difficulties that will be discussed in the second section. Next, we will report on findings that may support the idea that at least in some cases the inadequate social behaviors of children with ADHD may be phenomenologically and etiologically related to PDD. Also, the prognostic relevance of social dysfunctioning associated with ADHD will be described. Furthermore, currently used assessment methods and treatments for problematic social behavior will be summarized. Finally, we will provide suggestions for future research.

Publications reviewed here were found by internet-based literature searches in PubMed and EBSCOhost. In addition to this, we explored the literature references of relevant papers. Our searches were not limited to certain key-words, as the terminology used in the topics we reviewed varied widely between studies. When publications on a topic were scarce, older relevant publications were studied as well. Table 1 provides a summary of the key publications of this review.

Throughout this review, the term social dysfunctioning is used to refer to a broad range of social problems (that are not specific for ADHD), including problems in adequately tuning behavior to different social situations, difficulties in understanding social information, reduced contact and social interest, or a lack of meaningful relations.

Section snippets

How do children with ADHD behave socially?

In understanding the link between ADHD and social dysfunctioning, it is important to first understand how children with ADHD behave socially. Important studies on this subject are summarized in Table 1. In observational studies, children with ADHD appeared to be more socially intrusive (Frankel & Feinberg, 2002) and to initiate interaction with other children more frequently than control children (Buhrmester et al., 1992, Erhardt and Hinshaw, 1994, Grenell et al., 1987, Pelham and Bender, 1982,

Is social dysfunctioning Inherent to ADHD or a consequence of comorbidity?

The findings reviewed so far demonstrate that ADHD is associated with dysfunctional social behavior. A question that is more difficult to answer is whether or not social dysfunctioning is inherent to ADHD in itself and therefore might be uniformly present in children with ADHD, if in varying degrees of severity. Some of the behaviors that significantly contribute to the social dysfunctioning of children with ADHD are directly related to DSM-IV-TR criteria for ADHD. For instance, the intrusive

Overlap between ADHD and PDD

The inadequate social behaviors of many children with ADHD are characterized by an apparent lack of comprehension of the impact of their actions on others, and the presence of a limited repertoire of social responses. These features are similar to those that apply to the social behavior of children with PDD and suggest a certain degree of symptomatic overlap between ADHD and PDD. It is an interesting question whether the social problems in children with ADHD are not only similar in presentation

The prognostic relevance of social problems in children with ADHD

In the previous sections, we have described the nature of social problems in children with ADHD, and the role of comorbid ODD/CD and PDD. To get a sense of the relevance of these problems, we will next review what is currently known about the long-term consequences of social dysfunctioning in children with ADHD. Acquiring the ability to adequately interact with other people is a crucial aspect of a child's development. Children with ADHD have been found to demonstrate problems in social

Methods for assessing social behavior

As reviewed, the area of ADHD and social dysfunctioning is understudied, which may be due to a lack of reliable assessment methods. Although sociometric studies may be a good way to assess social impairment in children, these are impractical and time-consuming in large and clinical samples. Parent reports are now the most frequently used alternative. In the following, we will review currently used parent questionnaires for assessing social problems in children with ADHD.

Often, subscales derived

Concluding remarks and suggestions for future research

ADHD is a highly prevalent developmental disorder that in many children is associated with dysfunctional social behavior, thus affecting what may be the most important area of human functioning. The hyperactive behavior of children with ADHD, combined with the often aggressive nature of their interactions may lead to unpopularity and rejection by peers. Social problems may also be present in adolescents and adults who may or may not have outgrown a childhood diagnosis of ADHD. Available

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    Author note: The authors thank Professor Michael Gill for his contributions to this review.

    1

    Equally contributed to this study.

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