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Children with Attention-Deficit/Hyperactivity Disorder: Peer Relationships and Peer-Oriented Interventions

By: Sylvie Mrug, Betsy Hosa, and Alyson C. Gerdes

Background studies

In addition to the primary symptoms of inattention, hyperactivity and impulsiveness, children with ADHD also experience secondary symptoms of conduct problems, academic underachievement and problems interacting with peers and adults (Hoza, Owens & Pelham, 1999). These poor outcomes are also found in children in the general school population who also have negative peer relationships. It seems that altering the peer relationships can affect outcome.

Three hypotheses

  1. There is a causal link between peer relationships and later problems.

    For example:

    1. Classmates pick on Jimmy.
    2. Jimmy gets frustrated and hits the boy next too him when the teacher isn’t looking.
    3. Jimmy is put in time out and he begins a cycle of getting into trouble following problems with classmates and peers.
    4. Jimmy then begins to fail assignments. Now as a peer rejected child he is more likely to experience more difficulties in later life.

    Increased risk for later problems

    • Delinquency
    • School Drop out
    • Academic Underachievement
    • Unemployment
  2. Problems with peers and poor adjustment are caused by another factor, such as an underlying behavioral deviance or lack of social skills.

    Underlying factors such as a social skills deficit or something like LD or ADHD could result in misperception of social interactions. This creates problems with peers and leads to poor adjustment. Jimmy misreads the cues and yells at another child or hits the child. The child did not reject Jimmy first but now he does not want to play with Jimmy and Jimmy really does not understand why the child will not play with him. This leads to other adjustment problems and can also cause later problems such as delinquency and high school drop out.

  3. There is a possible buffering role of positive peer relationships.

    Jimmy is doing well in school because he feels that other kids like him. He feels good about himself and thus achieves well in school and at home. Because he feels good about himself he is likely to reach his goals. Good peer relationships buffer other problems and Jimmy succeeds in school. Jimmy had some behavior problems but his friends like him so they “put up with these quirks.” Jimmy knows his friends like him and he tries not to upset them. His self-esteem is good so he is less likely to act out disruptively.

Peer relationships of ADHD children

Children with ADHD pay less attention to others verbally in games and other activities. They have similar rates of praise for other children. They differ from other children in the number of intense, unmodulated, often inappropriate behaviors, in social contexts. For example they are more likely to yell, run around and talk at inappropriate times. They also tend to want to dominate play, engage in off task behaviors and engage in more teasing and physical jostling of peers. This sets up a process of peer rejection. The inattentive behaviors of ADHD children seemed to be related to peer rejection independently of the aggressive, impulsive and hyperactive behaviors of ADHD children.

Treatments

Current treatments are based on behavioral interventions such as reward systems, medications, and combination of these two. Many ADHD children are on medication such as Ritalin and must also have their homework assignments sheets recorded each afternoon so that parents know work is complete. Parents reward good work. These treatments, however, do not really look at the role of peers.

Social skills interventions

Social skills intervention models are based on the concept of social skills deficit. This model suggests that a child's lack of social skills results in less peer interactions and thus lower social status. Social skills training programs have been found to be effective for helping children in general education programs learn how to interact more effectively with classmates.

Social skills training has been found to be less effective among children with ADHD. The authors suggest this is because the underlying premise of the training is different for ADHD children. The authors cite research indicating that social skills training with behavior management programs is effective for improving the behavior of ADHD children toward their peers.

A critical component of the response of the child with ADHD is their difficulty in modulating behavior and shifting behaviors with situation demands. They also have apparent social-cognitive deficits that limit their ability to encode and recall rules of social cues.

The authors suggest a technique called the Match Game. Both the adults and children with ADHD evaluate their behaviors using the same scale. The goal is that the rating should match. Thus, after the rating, the children and adults discuss their ratings and the reasons for the rating selected. Children are then rewarded for good behavior and for accuracy of ratings. Thus, even if a child behaved inappropriately, if the child with ADHD can correctly evaluate the level of severity of the behavior, he or she would also be rewarded. Such a game can teach children the needed self-monitoring and self-evaluating skills that can help build positive peer interactions. This model attempts to decrease the unwanted behaviors while at the same time reinforcing the positive.

Linking research to practice

  1. It is important to recognize the power of peers to influence positive outcomes.
  2. Knowing that peers are important, it is also important to let a child work with children whom s/he likes or with children by whom s/he thinks s/he is liked. Parents and teachers can create greater problems if children are forced to play with peers who reject them.
  3. Both parents and teachers can create a game like the Match Game. Using this technique helps a child learn self-modulation and fosters self-esteem by reinforcing positive behaviors.
  4. Knowing that peers are very important is critical. Understanding that children with ADHD may need social skills intervention training, reinforcement for good behaviors and often medication can help parents and teachers develop programs that can better alter behaviors.
  5. Activities in the community or after school activities such as sports, 4-H, band and other groups are important to building a sense of social skills and understanding.

New Directions for Child and Adolescent Development, Spring, 2001, pages 51-77