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 Social Skills and Children with Attention-Deficit Hyperactivity Disorder (ADHD) -

Treatment Approaches

by Serana Chester and Ernest J. Bordini, Ph.D. *
2121 NW 40th Terrace Ste B, Gainesville FL 32605  352-336-2888
Presented 1/20/05 at the chapter meeting of the North Central Florida Chapter of Children and Adults with Attention-Deficit Hyperactivity Disorder

Social skill deficits are widely considered an important dimension of the multiple problems which face ADHD children.  This population commonly suffers behavior problems, which often involves conflict in the home and difficulties with peer relationships.  These deficits can contribute to social rejection and teasing by peers, impacting on subsequent social skill learning because of isolation and diminished self-esteem. 

Poor social skills in children diagnosed with ADHD and other frequently co-morbid disorders, such as Oppositional-Defiant Disorder and Conduct Disorder are likely to contribute to the negative outcome of some ADHD children in adolescence and adulthood.  This may include higher rates of substance abuse, academic failure, affective disruption and more frequent engagement in delinquent behaviors in some ADHD children (Greene, 1997).
Social skill difficulties in ADHD preschoolers has been demonstrated as early as four and five-years of age in terms of free-play and a reduced level of symbolic play (Gillis, Gigler, Pennington and Defries, 1991).  Deficits in early play and social skills may result in peer rejection.  Landau Milich and Diener (1998) suggested rejection and isolation further exacerbate social deficits throughout development because of the subsequent diminished opportunities to interact socially.  Gillis et. al., (1991), Campbell and Paulauskas (1979) found that social rejection impacts social adjustment by decreasing self-esteem. 
Studies demonstrate ADHD children tend to be rejected by peers and tend to engage in higher rates of disruptive and aggressive behaviors.  ADHD children commonly experience peer rejection since disruptive and aggressive behaviors are viewed by peers as aversive.   For example, in a study in which non-behavioral factors were taken into account, Erhardt and Hinshaw (1994) observed that ADHD boys were rejected within short periods of first time interactions with normal populations.  Aggressive and disruptive behaviors were equally predictive of increased negative nominations by peers.  Observational data confirmed ADHD subjects engaged in significantly higher rates of aggressive and disruptive behaviors than controls.  
Pelham and Milich (1984) described additional evidence suggesting impaired peer relationships in children with ADHD.  This included maternal, teacher and self-reports of disturbances in peer interactions.
Psycho-social and psycho-stimulant interventions are often used to address the interpersonal difficulties faced by ADHD sufferers.  Parent Training (PT) focuses on mitigating non-compliance, to reduce conflicts within the family, and theoretically impact positively on functioning in the social domain at school, since non-compliance has been connected to greater levels of peer rejection.  Social Skills Training (SST), when structured to provide training that is geared not only to reduce poor awareness of social skills, but also to impart methods of anger management and to encourage self-monitoring, may be instrumental in addressing poor psycho-social adjustment.  Medications are often prescribed to treat hyperactivity, impulsiveness, and distractibility in ADHD children.  These traits likely contribute to behavior that peers of ADHD children rate as aversive on socio-metric ratings as was demonstrated by Erhardt & Hinshaw, (1994).  
Psycho-stimulant therapy appears to be the most common treatment for children with ADHD (ADHD; Barkley, 1990).  Stimulant medication has demonstrated efficacy in reducing both verbal and physical aggression as well as non-compliance in ADHD populations (Hinshaw and Henker, 1989).  Stimulant medication treatment has also demonstrated increases in self-esteem (Frankel, Cantwell, Myatt & Feinberg, 1999).  However, research has indicated that medication management alone does not have significant impact on the quality or quantity of positive social behaviors (Hinshaw et al., 1989; Landau & Moore, 1991). ADHD children may receive increased benefit from behavioral interventions when taking medication (Hinshaw et al., 1989) as this may increase the frequency and effectiveness of social skills already present in the child’s knowledge base. 
The practice of combining psycho-social interventions and stimulant therapy is largely consistent with general recommendations of the necessity of multi-modal treatment for ADHD (Hinshaw, Henker & Whalen, 1989; Cousins & Weiss, 1993; Erk, 1997; Whalen & Henker, 1991; MTA Cooperative Group, 1999)
Parent Training (PT) and Social Skills Training (SST) are two methods of psycho-social intervention that have been studied in their application to ADHD symptoms and associated social deficits.  These therapies often lead to reductions in general familial levels of distress, and improvement in the child’s interpersonal relationships, both of which are often seen as problem areas in families with ADHD children (Cousins & Weiss, 1993).  A number of training systems have been developed for parents of children diagnosed with ADHD;  many employ similar principles of step-by-step training and practice in specific parenting skills in order to produce improvements in the child’s level of compliance with parental requests and family rules (Cousins & Weiss, 1993), although there may be differences in specific applications of skills.
Newby, Fisher and Roman (1991) reviewed outcome studies, including the Patterson PT program, the Barkley Program and the Forehand Program. The Patterson program (Forgatch, Bullock & Patterson, 2004), demonstrated the normalization of behavioral problems of 76% of families at post-treatment; 84% of those families remained at the normal level at one-year follow-up.  Barkley (1990) described a similar parent training program that includes general education about the nature of ADHD and behavior management, development of parental attention and communication skills with their child, detailed instructions on developing token systems and time-out procedures, and work with parents in developing their own problem-solving skills for future use.
Results of SST training have been mixed.  Multiple studies have shown that the social behavior of ADHD children may be altered; however, the permanence and stability of these changes has not always been demonstrated (DuPaul & Eckert, 1994; Cousins & Weiss, 1993; Landau & Moore, 1991; Pelham & Milich, 1984).  This has lead to the development of methods of SST training that attempt to take an environmentally broader approach to treatment.  Guevremont (in Barkley, 1990) advocates an approach involving 1) social skills and cognitive-behavioral training, 2) generalization programming, and 3) strategic peer involvement.  The general outline for this approach includes teaching children social entry and conversational skills, conflict resolution and problem solving skills, and anger control techniques.  Within-training generalization is encouraged through realism and self-monitoring of behavior and internal, physiological cues associated with emotional responses to external factors.  Environmental generalization is encouraged through the recruitment of parents and teachers in the use of contingency programs to influence behavior. 
A preliminary study conducted by one of the authors* previously presented to the North Central Florida Chapter of the Florida Psychological Association reviewed preliminary data from ADHD children involved in Parent Training and/or Social Skills Training Groups modeled on the Barkley programs.  The preliminary data suggested that outcomes were treatment modality specific.  Decreased oppositional and conduct problem ratings were associated with parent involvement in parent training for dealing with oppositional and defiant children, while parental ratings of child assertiveness, anxiety and shyness as well as child self ratings on skills and self esteem were associated with child participation in social skills training groups.
Thus, research tends to support a multidisciplinary and multimodal approach to the treatment of ADHD.  Treatment interventions may produces specific improvements on various dimensions of problems with Attention-deficit Hyperactivity Disorder may produce.  While most of the studies on stimulants has focused on cognitive task performance and school behaviors, therapies directed at managing disruptive behaviors or developing social skills that are important for establishment of self-esteem and adjustment are also often necessary.
*Ernest J. Bordini, Ph.D.
Executive Director
Clinical Psychology Associates of North Central Florida
2121 NW 40th Terr. Suite B
Gainesville, FL  32605
www.CPANCF.COM  352-336-2888

Greene, Ross W. Further Validation of Social Impairment as a Predictor of Substance Use Disorders: Findings from a Sample of Siblings of Boys with and without ADHD; Journal of Clinical Child Psychology, Vol. 28, 1999

Steven Landau; Richard Milich; Mary Beth Diener.  Peer Relations of Children with Attention-Deficit Hyperactivity Disorder. Reading & Writing Quarterly: Overcoming Learning Difficulties, 1521-0693, Volume 14, Issue 1, 1998, Pages 83 – 105

Campbell SB, Paulauskas S.  Peer relations in hyperactive children. Child Psychol Psychiatry. 1979 Jul; 20(3):233-46.

Erhardt, D., & Hinshaw, S. (1994). Initial sociometric impressions of attention-deficit hyperactivity disorder and comparison boys: Predictions from social behaviors and from nonbehavioral variables. Journal of Consulting and Clinical Psychology, 62, 833-842.

Pelham, W., & Milich, R. (1984). Peer relationships in children with hyperactivity/attention deficit disorder. Journal of Learning Disabilities, 17, 560-567. 

Barkley, R. A. (1990).  Attention Deficit Hyperactivitv Disorder: A handbook for diagnosis and treatment.  New York: Guilford Publications. Second edition revised and published in 1998.  Third edition revised and published in 2006.

Hinshaw SP, Henker B, Whalen CK, Erhardt D, Dunnington RE Jr.  Aggressive, prosocial, and nonsocial behavior in hyperactive boys: dose effects of methylphenidate in naturalistic settings. J Consult Clin Psychol. 1989 Oct; 57(5):636-43.

Landau, S., & Moore, L. A. (1991). Social skill deficits in children with attention-deficit hyperactivity disorder. School Psychology Review, 20, 235-251.

Frankel F; Cantwell DP; Myatt R; Feinberg DT  Do stimulants improve self-esteem in children with ADHD and peer problems?  J Child Adolesc Psychopharmacol 1999;9(3):185-94.

Cousins LS, Weiss G.  Parent training and social skills training for children with attention-deficit hyperactivity disorder: how can they be combined for greater effectiveness? Can J Psychiatry. 1993 Aug; 38(6):449-57.

Erk, R. R. (1997). Multidimensional Treatment of Attention Deficit Disorder: A Family Oriented Approach, Journal of Mental Health Counseling, 19, 3-22.

Whalen, C. K., & Henker, B. (1991). Therapies for hyperactive children: Comparisons, combinations, and compromises. Journal of Consulting and Clinical Psychology, 59, 126-137.

The MTA Cooperative Group. A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder.  Arch Gen Psychiatry. 1999; 56:1073-1086.

Newby, R. F., Fischer, M., and Roman, M. (1991). Parent training for families with children with Attention Deficit Hyperactivity Disorder (ADHD) children. School Psychology Review, 20, 252-265.

Forgatch, M. S., Bullock, B. M., & Patterson, G. R. (2004). From theory to practice: increasing effective parenting through role-play. The Oregon model of parent management training (PMTO). In H. Steiner (ed.), Handbook of Mental Health Interventions in Children and Adolescents: An Integrated Developmental Approach (pp. 782-814). San Francisco: Jossey-Bass.

DuPaul, George J.; Eckert, Tanya L. The Effects of Social Skills Curricula: Now You See Them, Now You Don't.  School Psychology Quarterly, v9 n2 p113-32 Sum 1994












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