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Running head: SOCIAL FUNCTIONING IN CHILDREN
Social Functioning Impairment in Children with Attention-Deficit/Hyperactivity Disorder
Using Data from the 2002 National Health Interview Survey
Amy R. Jones
University of North Carolina at Charlotte
This study assessed social impairment in children with Attention-Deficit/ Hyperactivity Disorder (ADHD) by comparing social functioning in children with ADHD to children without ADHD diagnosis. Using the 2002 National Health Interview Survey (NHIS-02), which provides a wealth of knowledge pertaining to the mental and physical health of over 12,500 children, the impact of child characteristics on social functioning was examined. Scores on a scale of social functioning indicate that children with ADHD have greater social impairment than children without ADHD. Sex of the child also impacted social functioning, with boys scoring worse than girls on the measure. Race did not have a salient impact on social functioning scores. This study indicates that children with ADHD have overall worse social functioning than children without ADHD and that this could be due to a combination of demographic, diagnostic, and environmental factors.
Social Functioning Impairment in Children with Attention-Deficit/Hyperactivity Disorder
Using Data from the 2002 National Health Interview Survey
Children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) experience symptoms that can adversely impact every area of daily life. ADHD is the most common psychological disorder among children, impacting between 4 to 6 percent of school-aged children (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). According to Mrug et al, (2009), ADHD symptoms of inattention, impulsivity and hyperactivity are the core criteria for the diagnosis of ADHD. These symptoms greatly contribute to the impairment of social functioning in children with ADHD. Social dysfunction refers to a broad range of social problems including problems in changing behavior to fit social situations, difficulties in understanding social information, reduced social interest, and lack of meaningful relationships (Nijmeijer et. al. 2008). These social problems are evident when examining social functioning in children with ADHD and include internalizing and externalizing problems (Thorell & Rydell, 2008). Development of adequate social skills and positive peer relationships is an essential aspect of childhood that is hindered my ADHD symptoms and associated problems.
Influences on Social Functioning
Problem Characteristics and Behaviors. The social experience of children with ADHD is often hindered by aggressive and disruptive behavior that negatively impacts peer impressions and interactions (Rich et al., 2009). Nijmeijer et al. (2008) assessed social functioning in children with ADHD using parent judgments from the Child Behavior Checklist (CBCL) and Social Skills Rating Scale (SSRS). According to these results, there is a negative and aggressive nature in children with ADHD that is manifested through rule violations, the use of hostile and controlling behavior and the uses of physical and verbal aggression (Nijmeijer et al., 2008). This aggressive nature is paired with hyperactive and impulsive behavior, which includes restless and intrusive actions that are often inappropriate in a given context and resistant to correction (Nijmeijer et al., 2008). The aggressive tendencies and problematic behavior of children with ADHD are strong predictors of peer rejection and a lack of positive peer association in children with ADHD (Nijmeijer et al., 2008).
Demographic Factors. Social functioning is likely to be effected by a combination of the diagnosis of ADHD and other demographic factors. To measure age and gender differences in social functioning, Thorell and Rydell (2008) used parent ratings of associated behavioral problems, social competence, the negative impact of everyday life, and family burden. The results indicate that there are not significant differences in social competence and problem behaviors for specific age groups, but the social and behavioral impairment of older children does seem to have more of a negative impact on daily life and family functioning (Thorell & Rydell, 2008). Parent ratings also indicate that boys are more severely impacted by ADHD symptoms then girls, which contributes to greater social impairment among boys with ADHD at any childhood age (Thorell & Rydell, 2008). This could be partly due to girls with ADHD having higher risk for the emergence of internalizing symptoms such as depression and anxiety while boys are more prone to outward symptoms (Lee & Hinshaw, 2006). Additionally girls show higher rates of empathy and a greater ability to understand and integrate the perspectives of others, which contributes to better overall social functioning in girls with ADHD (Marton et al., 2008). Taking demographic factors into account when assessing social functioning in children with ADHD helps to gain a better understanding of how ADHD symptoms impact different children in different ways.
Subtypes of ADHD. Social skills, behavior, and association vary depending on which subtype of ADHD a child has. Children with the Combined (CB) ADHD subtype display behavior that suggests difficulties in inhibitory control and are typically described as intrusive, impatient, and hyperactive (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). In contrast, children with the Predominantly Inattentive (PI) subtype of ADHD experience more anxiety and depression and are characterized as drowsy, sluggish, and day dreamy (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). Solanto, Pope-Boyd, Tryon, and Atepak (2009) assessed differences in social functioning of children with the CB and PI subtypes of ADHD using the Conner’s Parent Rating Scale (CPRS), the Social Skills Rating Scale (SSRS) and a diagnostic interview. Results indicate that children with the CB subtype are impaired in self-control and cooperation and exhibit more behavioral problems and oppositionality than children with the PI subtype (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). Furthermore, children with the PI subtype show impaired assertiveness and higher ratings of anxiety (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). Even when taking subtype variations into account, both CB and PI children have substantially worse social skills than typical children (Solanto, Pope-Boyd, Tryon, & Atepak. 2009). With this social and behavioral variation it can be implied that the nature of social impairment is not universal for all children with ADHD.
Family Functioning. Examining family influence can demonstrate how environmental factors either negatively or positively impact social functioning in children with ADHD. Family loneliness, parental warmth, power assertive discipline, and the quality of parent-child attachment contribute to overall social functioning in children with ADHD (Hurt, Hoza, & Pelham 2007). Hurt, Hoza, and Pelham (2007) examined these factors through administration of the Parent-Child Relationship Questionnaire (PCRQ) and Network and Dyadic Loneliness Scale (NDLS) to over 100 families with ADHD children. Results indicated that lower levels of parental loneliness combined with higher levels of parental warmth are associated to greater peer acceptance, less peer rejection, and more appropriate social behavior (Hurt, Hoza, & Pelham 2007). Paternal power assertion involving modeling aggressive behaviors was associated to impaired social functioning and peer acceptance only when low levels of family loneliness was reported( Hurt, Hoza, & Pelham 2007). Additionally, higher levels of parental loneliness were related to negative peer associations and social behavior regardless of parental warmth or power assertion level (Hurt, Hoza, & Pelham 2007). Family functioning plays an important role in the promotion or prevention of social dysfunction in children with ADHD.
Co-morbidity of Other Disorders. The social impairment of children with ADHD is worsened with the presence of co-morbid psychiatric disorders (Rich et al., 2009). Rich et al (2009) reported that over two-thirds of individuals diagnosed with ADHD have a co-morbid psychiatric disorder, which could include mood disorders, anxiety, and depression. Commonly reported co-morbid disorders among children with ADHD include Operational Defiant Disorder (ODD), Conduct Disorder (CD), Pervasive Developmental Disorder (PDD), and depression. There are high co-morbidity rates for OCD (30-60%) and CD (20%) in children with ADHD, which is strongly associated with increased social impairment in these children (Nijmeijer et al., 2007) To examine social functioning and its association with PDD risk in children with ADHD, Rich et al. (2009) used reports of problem behavior in the Child Behavior Checklist (CBCL) and a PDD screening test. Results indicate that social immaturity and peer rejection are two factors that are strongly associated with both impaired social functioning in children with ADHD and PDD risk (Rich et al. 2009). This suggests that high PDD risk in children with ADHD is paired with high social deficits.
There are also high rates of co-occurring ADHD and depression, to the extent that the combination of ADHD and depressive disorder could represent a distinct ADHD subtype (Blackman, Ostrander, & Herman, 2005). Blackman, Ostrander, and Herman (2005) examined social functioning in children with ADHD and children with co-morbid ADHD and depression with use of parent ratings on measures of behavioral tendencies, social skills, anxiety, academic achievement, social competence, and self concept. This study indicates that children with co-morbid ADHD and depression have higher levels of depression and anxiety then children with just ADHD but do not have more extreme forms of ADHD and aggressive outward behaviors (Blackman, Ostrander, & Herman, 2005) Additionally, children with both ADHD and depression have greater social and academic impairment compared to ADHD controls (Blackman, Ostrander, & Herman, 2005). Social dysfunction of children could not only be an outcome of ADHD diagnosis, but also the presence of co-morbid psychiatric disorders in these children.
Cognitive Impairment. The cognitive function of children with ADHD can have a strong impact on every domains of life. Previous research has yielded an association between poor executive brain functioning and ADHD symptoms (Wahlsteft, Thorell, & Bohlin, 2008). Inhibitory control has been tied to the ADHD symptoms of hyperactivity, inattention, and late externalizing problems (Wahlsteft, Thorell, & Bohlin, 2008). In order to gain a better understanding of how cognitive impairments affect ADHD children, Wahlsteft, Thorell, and Bohlin (2008) assessed predictive associations of ADHD symptoms and executive function impairment in an array of domains. Results indicate that ADHD symptoms and executive function impairment serve as predictors of continual problems in domains such as inhibition, working memory, intelligence, and social competence (Wahlsteft, Thorell, & Bohlin, 2008). Cognitive impairment is another domain in which a combination with ADHD symptoms contributes to greater social dysfunction.
Impairment in social cognition has also been supported as a strong contributor to social dysfunction in children with ADHD (Marton et al., 2008). Children with ADHD have been assessed to have difficulty in applying cognitive abilities to interpret social cues and solve social problems which is in large part due to deficits in inhibitory control (Marton et al., 2008). To assess social cognition in children with ADHD, Marton et al. (2008), used parent and teacher ratings of empathy and social perspective taking. Results indicate that children with ADHD have lower levels of empathy and lack sufficient social perspective taking or the understanding of others’ social perspective (Matron et al., 2008). Social functioning deficits are largely a factor of the cognitive impairment associated with ADHD.
Adverse Outcomes Associated with Poor Social Functioning
In Childhood and Adolescence. Peer rejection and a lack of meaningful friends that accompanies social impairment in children with ADHD are strong predictors of future outcomes (Mrug et al 2007). According to Mrug at al. (2007), rejected adolescents are more likely to drop out of school, develop various externalizing problems. Lee and Hinshaw (2006) assessed adolescent outcomes in ADHD children with conduct problems. Results indicate that hyperactivity-impulsivity symptoms, noncompliance, and negative peer status predicted poor academic achievement, school suspensions and expulsions, substance abuse, and internalizing problems (Lee & Hinshaw, 2006).
In Adulthood. Social impairments can have a lasting impact and are tied to problems in multiple domains of later life. Rejection and a lack of quality friendships in childhood can contribute to poorer adjustment, difficulties in relationships, and more mental health concerns in early adulthood (Mrug et al. 2007). ADHD girls with social impairment experience more diverse outcomes than those of ADHD boys, including internalizing disorders, marital problems, and suicidality (Lee & Hinshaw 2006). Nijmeijer et al. (2008) found that the social impairments in ADHD children can lead to an array of problems in adulthood including substandard academic performance, trouble keeping jobs, financial management difficulties, and problems linked to sexuality. Research shows that social dysfunction in childhood paves the way for negative outcomes in adulthood.
Improving Social Functioning in Children with ADHD
With the difficult reality of the ADHD child’s social world, avenues for effective treatment of social dysfunction should be explored and promoted. Even though it has benefits pertaining to attention and disruption, medication has not been found to improve desired social behaviors or increase peer status (Nijmeijer et al. 2008). Social skills training is another method that has been met with little support and strength due to lack of generalization and long-term social effects (Nijmeijer et al. 2008). Even though both methods of promoting social functioning improvement are faulty, medication serves as a more effective avenue than social skills training and has been shown to lead to better social outcomes (Nijmeijer et al., 2008) Mrug et al. (2007) found even though social skills training is primarily ineffective, increasing helping behaviors and following activity rules are related to positive changes in peer status for children with ADHD. This indicates that training aims to improve social functioning would benefit by targeting these behaviors (Mrug et al., 2007). Further research is needed to develop effective treatment for the social impairments of children with ADHD, which should integrate an understanding of co-morbidity, ADHD subtype, and demographic factors of these children (Blackman, Ostrander, & Herman, 2005).
National Health Interview Survey
This study examined data from the 2002 National Health Interview Survey. The NHIS-02 is an extensive, nationally administered survey that has generated health information pertaining to over 40,000 families by means of personal interviews. The Centers for Disease Control and Prevention (2004) controls access to NHIS data and provides the survey information to the public as a CD-ROM program. The survey assesses information pertaining to social functioning of disabled individuals including mental health conditions, behavioral and emotional tendencies, cognitive function, and demographic factors. This data was used to compare social functioning of children with ADHD to children without ADHD. NHIS data provides access to a large sample of children with ADHD, which permits easy analysis of a variety of factors that relate to social functioning in these children.
The hypothesis in this study was that children with ADHD would fare worse across measures of social functioning than children without ADHD and that social functioning would also vary depending on sex and race.
Subjects were children under that age of 18 from the NHIS-02 who either had a diagnosis of ADHD or did not have an ADHD diagnosis. Children without ADHD were chosen as a comparison group in order to assess differences in social functioning of children with ADHD to the general child population. There was a sufficient sample of children with ADHD diagnosis in the NHIS-02 survey. There were 696 children in the ADHD diagnosis group, as well as 696 children in the non-ADHD group that were randomly selected from the remaining NHIS sample. The majority of children in the ADHD group were white males (n=514), but there was still an adequate sample of female (n=182) and black (n=121) children in the sample. Six questions from the NHIS-02 were representative of social functioning including if the child is often unhappy, has difficulties with emotions, frequently worries, is generally well behaved, gets along better with adults, and has a good attention span. A nineteen point social functioning scale was created by additively combining these variables, with lower scores indicating lower social functioning. A univariate analysis of variance was conducted to assess social functioning for the two participant samples and to assess if any main effects or interactions were present for ADHD diagnosis, sex, and race. Crosstabs analysis was also conducted to assess the frequency of occurrence of ADHD among sex and race variables.
The hypothesis that there would be significant differences in social functioning when comparing children diagnosed with ADHD to children without an ADHD diagnosis was tested by comparing scores on a scale for social functioning derived from questions in the NHIS-02 database. An ANOVA [F (1, 1238) =643.47, p<.001)] found that children with ADHD had significantly worse social functioning scores then children without ADHD. Sex of the child also significantly impacted social functioning [F (1, 1238) =8.73, p<.01)] with boys scoring worse than girls on the measure. Figure 1 illustrates the mean scores of male and female children in both conditions. There was not a significant main effect for race indicating that blacks did not score significantly lower on social functioning then did whites. Additionally, there were not significant interactions between sex and diagnosis of DHD and between race and diagnosis. Figure 2 shows the percentage of males and females in the sample and Figure 3 illustrates the percentage of white and black racial groups in the sample. Along with support for sex differences in social functioning, many more males have ADHD than females, Chi-square (1, N=696) = 158.37, p<.001. A crosstabs chi-square analysis indicated that there are not significant differences in social functioning for black and white racial groups.
This study aimed to examine the social impairment that is characteristic of children with ADHD and assess what factors contribute and are hindered by this social dysfunction. The findings of this study are aligned with the wealth of ADHD research that supports the notion that children with ADHD experience greater social impairment than children without ADHD diagnosis. The findings also indicate that there are significant differences in the social behavior of boys and girls with ADHD, which implies a variation of social outcomes depending on gender. Future research would benefit from further examining the nature of social impairment in boys and girls with ADHD, as well as general differences. ADHD differences based on race were not significant in this study, indicating that some demographic factors are more predictive of impaired social functioning than others. With the highest prevalence of ADHD among white boys, most research has had a substantially larger sample of white boy participants than girls and blacks. Having a larger and more representative sample of both girls and black children with ADHD could allow for a better understanding of how ADHD impacts children differently in relation to race and sex. Assessing other demographic factors such as age, family size, family income, and parental marital status would also be beneficial to future research.
Assessment of the presence of social differences in ADHD children is a relatively simple task, but uncovering the domains in which these differences lie requires more in depth inquiry. Previous research has indicated many influences on social functioning of ADHD children including family functioning, co-morbidity, ADHD subtypes, and demographics. This suggests that social functioning should be examined not solely in relation to ADHD symptoms, but also in association with other factors that have a profound impact on daily life. An important implication for clinical practice and treatment would be to assess the presence and nature of these factors in children with ADHD in order to effectively promote the improvement of social functioning and effective treatment. Furthermore, theories of social functioning in children would benefit by assessing the degree of impact that these factors have on different domains of a child’s life. A broader focus when examining the social nature of children with ADHD could ensure a better understanding of ADHD symptoms and associated outcomes, which could in turn promote effective treatment of social impairment in children with ADHD.
Blackman, G., Ostrander, R., & Herman, K. (2005). Children with ADHD and depression: A multisource, multimethod assessment of clinical, social, and academic functioning. Journal of Attention Disorders, 8(4), 195-207.
Centers for Disease Control and Prevention. (2004). 2002 National Health Interview Survey, CD-ROM Series 10, no. 17A. Hyattsville, MD: Nation Center for Health Statistics.
Hurt, E., Hoza, B., & Pelham, W. (2007). Parenting, family loneliness, and peer functioning in boys with attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology: An official publication of the International Society for Research in Child and Adolescent Psychopathology, 35(4), 543-555.
Lee, S., & Hinshaw, S. (2006). Predictors of Adolescent Functioning in Girls With Attention Deficit Hyperactivity Disorder (ADHD): The Role of Childhood ADHD, Conduct Problems, and Peer Status. Journal of Clinical Child and Adolescent Psychology, 35(3), 356-368.
Marton, I., Wiener, J., Rogers, M., Moore, C., & Tannock, R. (2009). Empathy and social perspective taking in children with attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology: An official publication of the International Society for Research in Child and Adolescent Psychopathology, 37(1), 107-118.
Mrug, S., Hoza, B., Gerdes, A., Hinshaw, S., Arnold, L., Hechtman, L., et al. (2009). Discriminating between children with ADHD and classmates using peer variables. Journal of Attention Disorders, 12(4), 372-380.
Mrug, S., Hoza, B., Pelham, W., Gnagy, E., & Greiner, A. (2007). Behavior and peer status in children with ADHD: Continuity and change. Journal of Attention Disorders, 10(4), 359-371.
Nijmeijer, J., Minderaa, R., Buitelaar, J., Mulligan, A., Hartman, C., & Hoekstra, P. (2008). Attention-deficit/hyperactivity disorder and social dysfunctioning. Clinical Psychology Review, 28(4), 692-708.
Rich, E., Loo, S., Yang, M., Dang, J., & Smalley, S. (2009). Social functioning difficulties in ADHD: Association with PDD risk. Clinical Child Psychology and Psychiatry, 14(3), 329-344.
Solanto, M., Pope-Boyd, S., Tryon, W., & Stepak, B. (2009). Social functioning in predominantly inattentive and combined subtypes of children with ADHD. Journal of Attention Disorders, 13(1), 27-35.
Thorell, L., & Rydell, A. (2008). Behaviour problems and social competence deficits associated with symptoms of attention-deficit/hyperactivity disorder: Effects of age and gender. Child: Care, Health and Development, 34(5), 584-595.
Wĺhlstedt, C., Thorell, L., & Bohlin, G. (2008). ADHD symptoms and executive function impairment: Early predictors of later behavioral problems. Developmental Neuropsychology, 33(2), 160-178.
Figure 1. Social Functioning Means Across ADHD Diagnosis and Sex. Low scores indicate poor social functioning.
Figure 2. Percentage of Male and Female Children With and Without ADHD
Figure 3. Percentage of White and Black Children With and Without ADHD
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