Problems with Danforth's Early Diagnosis and Observational Bias in Behavior Management

ABSTRACT

Many children diagnosed with Attention-Deficit/Hyper-activity Disorder (ADHD) experience difficulties in social relations. While psychosocial approaches based on a combination of skills training and contingency management approaches do appear to improve social behavior, evidence that these benefits generalize and persist following training has been limited. We describe a social skills training program designed to help parents promote the display of appropriate social behavior and better athletic performance in sports settings. The program consists of standard psychological assessment, behavioral parent training, functional assessment, parent-mediated social and sports skills coaching, and generalization and maintenance programming. The goals of this intervention are to promote retention of the child in team sports and facilitate friendship acquisition. Training parents to coach their children effectively in sports-related social skills may prove useful in promoting the maintenance and generalization of skills as well as preventing some of the negative effects of social isolation that frequently accompany an ADHD diagnosis.     

A psychometric evaluation of the social skills rating system in children with attention deficit hyperactivity disorder

The social skills rating system (SSRS) was developed to assess social skills of children, as observed by multiple raters (teacher, parent, child). Studies of the SSRS have been conducted with handicapped, mentally retarded and learning disabled children. No studies have reported the psychometric properties of the SSRS in a clinical ADHD sample. This is important, because deficient social functioning is associated with ADHD. The present study assesses the psychometric properties of the teacher, parent and child versions of the SSRS in children with ADHD (n = 123), and normal controls (n = 239). Also, the social skills of children with ADHD, as rated on the SSRS were examined. Results support the factor structure and internal consistency of the original SSRS-teacher version. Moreover, support was found for 3 out of 4 scales of the SSRS-parent version. The factor structure of the SSRS-child version could not be replicated. An explanatory factor analysis on the SSRS-child version yielded two factors. Evidence was found for discriminative ability of the SSRS between normal controls and children with ADHD. Finally, informant agreement between raters was found to be poor.     

Social Problems in ADHD: Is it a Skills Acquisition or Performance Problem?

Recent models suggest that social skills training’s inefficacy for children with ADHD may be due to target misspecification, such that their social problems reflect inconsistent performance rather than knowledge/skill gaps. No study to date, however, has disentangled social skills acquisition from performance deficits in children with ADHD. Children ages 8–12 with ADHD (n?=?47) and without ADHD (n?=?23) were assessed using the well-validated social behavioral analysis framework to quantify cross-informant social skills acquisition deficits, performance deficits, and strengths. Results provided support for the construct and predictive validities of this Social Skills Improvement System (SSIS) alternate scoring method, including expected magnitude and valence relations with BASC-2 social skills and ADHD symptoms based on both parent and teacher report. Acquisition deficits were relatively rare and idiosyncratic for both the ADHD and Non-ADHD groups, whereas children with ADHD demonstrated cross-informant social performance deficits (d?= 0.82–0.99) on several specific behaviors involving attention to peer directives, emotion regulation, and social reciprocity. Relative to themselves, children with ADHD were perceived by parents and teachers as exhibiting more social strengths than social acquisition deficits; however, they demonstrated significantly fewer social strengths than the Non-ADHD group (d?=??0.71 to ?0.89). These findings are consistent with recent conceptualizations suggesting that social problems in ADHD primarily reflect inconsistent performance rather than a lack of social knowledge/skills. Implications for refining social skills interventions for ADHD are discussed.     

Friendship Intimacy Exchange Buffers the Relation between ADHD Symptoms and Later Social Problems among Children Attending an After-School Care Program

The friendships of children displaying symptoms of attention-deficit/hyperactivity disorder (ADHD) have been understudied, particularly in comparison to the domain of peer rejection. This study tested whether friendship intimacy exchange buffers the prospective relation between ADHD symptoms and social problems 1 year later in a sample of children attending a community-based after-school program. Children (N?=?131; 53 % boys; 66 % African American) ranging from 5 to 13 years of age participated in this study. At baseline, children reported on friendship intimacy exchange with their identified best friend, and program staff rated children on ADHD symptoms and social problems. Staff ratings of children’s social problems were collected again 1 year later. Multiple regression analyses indicated that, after controlling for demographic variables and baseline social problems, friendship intimacy exchange significantly moderated the association between ADHD symptoms and social problems at the one-year follow-up. Specifically, the relation between ADHD and social problems was no longer significant for children reporting high levels of friendship intimacy exchange. This moderation was not further qualified by either child age or sex, although boys were more likely than girls to report low rates of friendship intimacy exchange. These findings indicate the importance of friendship intimacy for children displaying ADHD symptoms, who often experience significant peer problems. Friendship quality may be a promising target for prevention and intervention efforts in mitigating some of the long-term social problems associated with ADHD symptomatology, and future research is needed to extend these findings to other domains of friendship quality and clinical samples of children with ADHD.     

Effects of a Summer Treatment Program on Functional Sports Outcomes in Young Children with ADHD

Participation in youth sports can be very beneficial, but children with Attention Deficit Hyperactivity Disorder (ADHD) may participate less often and less successfully. The current study evaluated functional sports outcomes for children with ADHD who attended an intensive behavioral treatment program that included a sports training component, and it compared outcomes to children with ADHD who did not attend the program. Results suggest that treatment resulted in significant improvements in many aspects of children’s sports functioning, including knowledge of game rules, in vivo game performance, and fundamental skill tasks (motor proficiency, ability to trap a soccer ball appropriately, reduced handball penalties in soccer, and improved ability to catch a baseball). Parents also reported improved sports skills and good sportsmanship in the treatment group. No differences between groups were evident on additional skill tasks evaluating accurately kicking a soccer ball, throwing a baseball, or hitting a baseball off a tee. These results suggest intensive behavioral intervention that includes sports training can significantly improve functional sports outcomes for young children with ADHD.     

The Role of Maternal and Child ADHD Symptoms in Shaping Interpersonal Relationships

The current study investigated the influence of maternal ADHD symptoms on: (a) mothers’ own social functioning; (b) their child’s social functioning; and (c) parent–child interactions following a lab-based playgroup involving children and their peers. Participants were 103 biological mothers of children ages 6–10. Approximately half of the children had ADHD, and the remainder were comparison youth. After statistical control of children’s ADHD diagnostic status and mothers’ educational attainment, mothers’ own inattentive ADHD symptoms predicted poorer self-reported social skills. Children with ADHD were reported to have more social problems by parents and teachers, as well as received fewer positive sociometric nominations from playgroup peers relative to children without ADHD. After control of child ADHD status, higher maternal inattention and hyperactivity/impulsivity each predicted children having more parent-reported social problems; maternal inattention predicted children receiving more negative sociometric nominations from playgroup peers. There were interactions between maternal ADHD symptoms and children’s ADHD diagnostic status in predicting some child behaviors and parent–child relationship measures. Specifically, maternal inattention was associated with decreased prosocial behavior for children without ADHD, but did not influence the prosocial behavior of children with ADHD. Maternal inattention was associated with mothers’ decreased corrective feedback and, at a trend level, decreased irritability toward their children with ADHD, but there was no relationship between maternal inattention and maternal behaviors for children without ADHD. A similar pattern was observed for maternal hyperactivity/impulsivity and mothers’ observed irritability towards their children. Treatment implications of findings are discussed.     

A Review of: “Bear,G. G. (2010). School Discipline and Self-Discipline: A Practical Guide to Promoting Prosocial Student Behavior.”

Previous research demonstrates that children with attention-deficit/hyperactivity disorder (ADHD) can experience social difficulties. Therefore, the current study examined the effects of cross-age peer coaching on social behaviors of first graders with significant symptoms of ADHD using a multiple baseline design. Four students who met criteria for ADHD participated, along with four third- or fourth-grade coaches without ADHD. Coaching pairs met each morning to establish a goal for the younger child to meet during free time. Although results were variable, findings suggested that the cross-age coaching program led to decreases in negative social behavior, and was highly acceptable to participants.     

Treatment Response in CP/ADHD Children with Callous/Unemotional Traits

The current study examines the role of callous/unemotional (CU) traits in response to treatment among children with conduct problems (CP) and attention-deficit/hyperactivity disorder (ADHD). Fifty-four children with CP/ADHD and 16 controls (age = 9.48, SD = 1.58) took part in a summer treatment and research program. Simple correlations showed that CU and CP were associated with a number of treatment outcome measures. When examined together in regression analyses, CU and CP were uniquely associated with three treatment outcomes each (CU—improvement in social skills and problem solving, negative behaviors in time-out; CP—time-outs per day, peer ratings, peer dislike). The implications for these findings with regard to treatment response in children with CP/ADHD with and without CU traits are explored.     

Parental Influence on Children with Attention-Deficit/Hyperactivity Disorder: II. Results of a Pilot Intervention Training Parents as Friendship Coaches for Children

We report findings from a pilot intervention that trained parents to be “friendship coaches” for their children with Attention-Deficit/Hyperactivity Disorder (ADHD). Parents of 62 children with ADHD (ages 6–10; 68% male) were randomly assigned to receive the parental friendship coaching (PFC) intervention, or to be in a no-treatment control group. Families of 62 children without ADHD were included as normative comparisons. PFC was administered in eight, 90-minute sessions to parents; there was no child treatment component. Parents were taught to arrange a social context in which their children were optimally likely to develop good peer relationships. Receipt of PFC predicted improvements in children’s social skills and friendship quality on playdates as reported by parents, and peer acceptance and rejection as reported by teachers unaware of treatment status. PFC also predicted increases in observed parental facilitation and corrective feedback, and reductions in criticism during the child’s peer interaction, which mediated the improvements in children’s peer relationships. However, no effects for PFC were found on the number of playdates hosted or on teacher report of child social skills. Findings lend initial support to a treatment model that targets parental behaviors to address children’s peer problems.     

An Evaluation of a Summer Treatment Program for Adolescents With ADHD

Although adolescents with attention-deficit/hyperactivity disorder (ADHD) experience serious life impairment (Molina et al., 2009; Wolraich et al., 2005), very few effective psychosocial interventions exist to treat this population (Pelham & Fabiano, 2008; Smith, Waschbusch, Willoughby, & Evans, 2000). Intensive child-directed interventions are an important component in the treatment of childhood ADHD (Pelham et al., 2005), yet no study exists that fully evaluates an intensive adolescent-directed intervention. The current investigation is a pilot study of 19 adolescents with ADHD (age range: 11-16) who participated in an 8-week intensive Summer Treatment Program–Adolescent (STP-A) during the summer of 2009. The program was developed to address specific difficulties associated with ADHD in adolescence. As such, the program was designed to be ecologically valid, age appropriate, and parent-involved. Results suggest that almost all adolescents who attended the STP-A benefitted from the program according to parent, self, and staff ratings and objective measures. These ratings also indicated that participants showed moderate improvement in each of the 6 domains targeted by treatment (i.e., conduct problems, adult-directed defiance, social functioning, inattention/disorganization, mood/well-being, and academic skills). All parents indicated that both they and their children benefitted from the program and all but 1 parent indicated that the STP-A was more effective than the treatments they had utilized in the past. A case example is presented to illustrate typical improvement patterns during the STP-A. Discussion addresses the role of the STP-A in the treatment of ADHD in adolescence.     

Diagnosis and Treatment of Adults With Attention Deficit Hyperactivity Disorder

It is estimated that between 30% and 50% of children diagnosed with attention deficit hyperactivity disorder (ADHD) will continue to exhibit symptomatology that is disruptive throughout their adult lives. Identification and diagnosis of adult ADHD, as well as primary and secondary characteristics and comorbid disorders, are discussed in this article. Counseling strategies are suggested to help clinicians treat adults with ADHD, such as educating the client about the disorder and providing training in attention management techniques, self-management skills, interpersonal and social skills, stress and time management, anger management, and problem-solving skills. Clinicians are encouraged to prepare themselves for understanding, identifying, diagnosing, and treating the adult population with ADHD.     

A Teacher-Consultation Approach to Social Skills Training for Pre-Kindergarten Children: Treatment Model and Short-Term Outcome Effects

This study evaluated the post-treatment outcome effects of a classroom-based social skills program for pre-kindergarten children, using a teacher-consultation model. The pre-K RECAP (Reaching Educators, Children, and Parents) program is a semi-structured, cognitive-behavioral skills training program that provides teachers with in-classroom consultation on program implementation and classroom-wide behavior management. Data on children's social skills and behavior problems were collected from parents and teachers at pre- and post-treatment, for 149 children aged 4–5 years (of whom 56% were girls). Significant treatment effects were found for teacher but not parent reports, with treatment group children improving significantly more than comparison group children in their teacher-rated social skills and internalizing and externalizing problems. These results provide some preliminary support for the efficacy of the program on children's social skills and behavior problems, and for a teacher-consultation model for training teachers to implement school-based mental health programs.     

School-Based Intervention for Social Skills in Children from Divorced Families

Divorce is an increasingly prevalent occurrence in society that has the potential to result in many adverse short- and long-term consequences for children and their parents. Social skills, such as those with peers, are one of the problems that may emerge for children of divorce. Despite this growing problem, there is a paucity of research available to effectively address the social skills needed to build and maintain positive peer interactions and subsequent relationships in students whose parents are no longer married. It was hypothesized that a social skills training program would be effective in remediating social skill deficits related to building relationships with peers in students from divorced families. The purpose of this study was to employ COPE, a school-based social skills program, to examine the effect on social skills in elementary students whose parents are divorced. Results of the social skills intervention indicated that the treatment was effective for most participants, but generalization of the COPE program had mixed results.     

The Role of Simple Emotion Recognition Skills among School Aged Boys at Risk of ADHD

Poor social skills and behavioral problems are a major component of ADHD. The different explanations offered so far, such as cognitive deficits and deficient self regulation, have not been able fully to account for the various aspects of the social dysfunction, suggesting that other mechanisms might underlay this impairment. Our study sought to assess the emotion recognition of Israeli boys at risk of ADHD, and to evaluate its associations with their social skills. A group of 111 boys (grades 4 and 5) were assigned to an At-risk (n=50) and a control (n=61) group based on their scores in an ADHD symptoms questionnaire. The two groups were matched on age, socio-economic status and class and school environment. Group comparisons revealed that compared to their non-At-risk counterparts, At-risk boys have impaired emotion recognition. Finally, multiple groups Structural Equation Modeling analyses (SEM) demonstrated that emotion misrecognition plays a significant role in the At-risk children's social functioning and behavioral problems compared to its role in the social competence and behavioral problems among the comparison group. Implications for the understanding and treatment of social skills problems among children at risk of ADHD are proposed.     

Measuring Parental Treatment Adherence in a Multimodal Treatment Program for Children with ADHD: A Preliminary Investigation

This study evaluated the clinical significance of measuring between session parental adherence on child and parent outcomes for 51 children (age 4 to 8.5 years) with attention deficit/hyperactivity disorder (ADHD) in a multimodal group training program. Three group treatment conditions: (a) child-only treatment (C1), (c) child and parent training (C2), and (c) C2 + Parent Adherence Measure [PAM (C3)] were compared to assess the clinical significance of measuring parental adherence on child behavioral problems, socialization skills, and parental efficacy. Parents administered the PAM (C3) displayed, in general, better outcomes on child and parent measures than the other two conditions. Results suggest that a multimodal group training program for young children with ADHD is favorable to child group training only. This study offers preliminary support for the clinical utility of measuring parental adherence in a child ADHD multimodal group training program.     

When Adolescents Experience Co-Occurring Social Anxiety and ADHD Symptoms: Links With Social Skills When Interacting With Unfamiliar Peer Confederates

Adolescents with elevated social anxiety commonly experience peer-related impairments – particularly with same-age, unfamiliar peers – stemming from their avoidant behaviors. Yet, peer-related impairments are not unique to social anxiety. For example, adolescents who experience social anxiety may also experience symptoms of attention deficit/hyperactivity disorder (ADHD), which also increase risk for peer-related impairments. Relative to social anxiety, peer-related impairments linked to ADHD symptoms more likely stem from hyperactivity (i.e., approach behaviors). These distinct pathways point to adolescents with elevated social anxiety and ADHD symptoms (i.e., social anxiety + ADHD) experiencing particularly high peer-related impairments, which commonly manifest as behavioral displays of low social skills when interacting with unfamiliar peers. We tested this notion in a mixed-clinical/community sample of 134 14- to 15-year-old adolescents and their parents. Adolescents participated in a series of social interaction tasks designed to simulate how adolescents interact with same-age, unfamiliar peers. Trained observers independently rated adolescents on observed social skills within these interactions. Both parents and adolescents completed parallel surveys of social anxiety and ADHD symptoms, which we used to identify social anxiety + ADHD adolescents as well as other combinations of social anxiety and ADHD symptoms (i.e., neither, elevated on one but not the other). Adolescents with social anxiety + ADHD displayed significantly lower social skills, relative to all other groups. Among adolescents, social anxiety + ADHD may have a compounding effect on social skills. As such, therapists working with social anxiety + ADHD adolescents should probe for peer-related impairments and factors implicated in the development and maintenance of these impairments.     

Social Skills Mediate the Association of ADHD and Depression in Preadolescents

Childhood attention-deficit/hyperactivity disorder (ADHD) is a replicated risk factor for depression, but the explanatory factors underlying this association have not been reliably identified. Given that social skills (i.e., cooperation, assertion, responsibility, self-control) are sensitive to early ADHD and predict later depression, we tested whether individual differences in social skills individually and collectively mediated predictions of depressive symptoms from early ADHD symptoms. In an ethnically diverse (50 % non-Caucasian) sample of 232 children with (n = 124) and without ADHD (n = 108) followed prospectively for two years (aged 5–10 at Wave 1; 7–12 at Wave 2), we gathered multi-informant (i.e., parent, teacher) and multi-method (e.g., rating scale, structured interview) assessment of key constructs. Using a multiple mediation framework with bootstrapping and statistical control of sex, Wave 1 depression, Wave 1 oppositional defiant disorder (ODD), Wave 1 anxiety, and Wave 2 ADHD symptoms, an independent mediation effect emerged for parent-rated self-control in the prediction of Wave 2 depression (parent-rated) from Wave 1 ADHD symptoms (combined parent and teacher ratings). Teacher-rated social skills at Wave 1 also collectively mediated this association, with teacher-rated assertion emerging as a unique mediator. We discuss the role of social skills in emergent depression among youth with ADHD and consider implications for prevention and intervention.     

Clinical and functional correlates of processing speed in pediatric Attention-Deficit/Hyperactivity Disorder: a systematic review and meta-analysis

It is well established that processing speed is negatively impacted in children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). Unfortunately, exactly how processing speed vulnerabilities manifest in daily functioning has not been well established. To support clinical care of youth with ADHD, it is important to better understand the functional consequences and relevant outcomes associated with processing speed deficits. This systematic review and meta-analysis sought to identify the association between processing speed and clinical or functional correlates among children or adolescents diagnosed with ADHD. A total of 409 abstracts were screened, of which, 60 full-text articles were identified as potentially relevant, and 8 of these studies met inclusion criteria. Domains evaluated across these studies included reading skills, mathematics skills, written expression, anxiety, self-appraisals of competence, and adaptive functioning. Six studies reported an association between processing speed and reading skills, allowing for meta-analysis. Processing speed difficulties among youth with ADHD appear strongly associated with several clinical and functional correlates including weaker academic skills, poorer adaptive skills, increased self-reported anxiety, and overestimates of social competence. Meta-analytic results for studies reporting the association between processing speed and reading skills indicate a medium overall weighted mean effect size (r = 0.33, 95% CI = 0.28 –0.39) with minimal heterogeneity (I² = 0.17). Clinical implications of these findings, limitations in the current knowledge base, and suggestions for future research are discussed.     

Longitudinal Associations of Parental Emotion Socialization and Children’s Emotion Regulation: The Moderating Role of ADHD Symptomatology

Theory and research suggest that parents’ reactions to children’s emotions play a critical role in teaching children effective emotion regulation (ER) skills, but no studies have directly examined the role that parent emotion socialization plays in the development of ER in children with ADHD. Gaining insight into the causes of impaired ER, particularly in youth with ADHD who are known to have poor ER, has important theoretical and translational significance. The present study is the first to longitudinally examine whether emotion socialization predicts later physiological and adult-reported measures of ER in children with and without ADHD. It also sought to determine if these relations are moderated by ADHD symptoms. Participants were 61 children (31 girls, 30 boys; M = 10.67 years, SD = 1.28) with and without clinically significant ADHD symptoms. At Time 1, parent reports of emotion socialization and parent- and teacher-report of child ADHD symptoms were collected. At Time 2, child ER measures were collected based on parent- and teacher-report and physiological reactivity during an impossible puzzle and a social rejection task. Physiological measures included respiratory sinus arrhythmia and skin conductance level (SCL). Supportive parenting practices were associated with better parent-rated emotion regulation skills for all children and greater SCL reactivity for children with high ADHD symptoms. Non-supportive parenting reactions were associated with greater adult-rated emotional lability for children with high ADHD symptoms. Results highlight the importance of considering multiple aspects of ER, including physiological manifestations. Findings suggest that parents’ use of adaptive emotion socialization practices may serve as a protective factor for children’s ER development and may be particularly critical for youth with ADHD. Our findings support the use of interventions addressing parent emotion socialization to help foster better ER in children.