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Attention-Deficit/Hyperactivity Disorder and the Challenges of Social Exclusion

Abstract and Keywords

Attention-Deficit/Hyperactivity Disorder (ADHD) is a prevalent diagnosis among school-age children and symptoms frequently persist into adolescence and adulthood. This chapter describes the high levels of social exclusion faced by individuals with ADHD. Distinctions are made between children and adults with this disorder, as well as between males and females, when possible. In addition, ways in which ADHD subtype and comorbidity impact social relationships are also considered. Reasons why individuals with ADHD tend to be excluded by their peers, and the effectiveness of existing interventions for social problems in ADHD, are next summarized. The chapter concludes with suggestions for future research directions, including speculation regarding ways to improve the treatment of social exclusion.

Keywords: ADHD, behavior problems, disorders, intervention, psychopathology, treatment


Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent disorders, beginning in childhood but often continuing to impair functioning across the life span. It has been well-established that youth with ADHD are at high risk for maladjustment in multiple areas including delinquency and conduct problems; school failure; substance abuse; depression and anxiety; and poor interpersonal relationships with family, teachers, and peers (Barkley, 2002; Mannuzza & Klein, 2000). Although each domain of impairment merits attention, this chapter focuses primarily on the social exclusion from peers faced by individuals with ADHD.

It is estimated that ADHD affects 3% to 7% of elementary school-aged children in the United States (American Psychiatric Association, 2000; Jensen et al., 1995). To receive a diagnosis of ADHD, individuals must display developmentally inappropriate, clinically significant symptoms of (a) inattention, and/or (b) hyperactivity/impulsivity. Symptoms must have been present prior to age 7 and are required to cause impairment. Furthermore, symptoms must show themselves in more than one setting (e.g., both home and school).

The current chapter begins by summarizing the magnitude of social exclusion that individuals with ADHD experience, with consideration of individuals’ age, gender, and ADHD subtype. Next, reasons for this social exclusion are discussed. Third, interventions for individuals with ADHD that target social exclusion from peers are reviewed. The chapter concludes with recommendations for future research and suggestions for improving the effectiveness of interventions for social exclusion in ADHD.

Magnitude of Social Exclusion in ADHD

It is difficult to overstate the level of social exclusion from peers that individuals with ADHD typically face. In fact, social exclusion is so extreme in magnitude that, although interpersonal difficulties are not currently part of the diagnostic criteria (p. 229) for ADHD, some have argued that they should be included (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997; Whalen & Henker, 1985; Wheeler & Carlson, 1994).

Among elementary school-aged children, the age group in which ADHD is typically diagnosed and most commonly studied, it is estimated that over 50% of children with ADHD are peer-rejected, relative to peer rejection base rates of 10% to 15% in typical classrooms (Hoza, Mrug et al., 2005). The definition of being peer- rejected is that the majority of peers name this child, during confidential sociometric interviews, as being someone whom they dislike, whereas few peers name the child as being someone whom they like (Coie, Dodge, & Coppotelli, 1982). Although children with ADHD are also rated by parents and teachers as being peer-rejected (Solanto, Pope-Boyd, Tyron, & Stepak, 2009), having peers directly report on their liking and disliking preferences to assess rejection is considered the gold standard in defining peer rejection.

Another study using peer sociometric measures found that 82% of a sample of 49 children with ADHD scored one standard deviation above their classroom average of being disliked by peers (Pelham & Bender, 1982). Fully 60% of children with ADHD scored two standard deviations above the average of being disliked, that is, in the top 2.5% of their class (Pelham & Bender, 1982). Some research suggests that children with ADHD are more actively disliked (e.g., nominated by peers as someone they do not want to be around) than are children with Conduct Disorder or depressive disorders, but not ADHD (Asarnow, 1988).

Social rejection of children with ADHD happens extremely quickly—occurring within less than one day (Erhardt & Hinshaw, 1994) or even within one hour of meeting unfamiliar peers (Hodgens, Cole, & Boldizar, 2000; Mikami, Jack, Emeh, & Stephens, 2010). Further, once established, the rejection of children with ADHD tends to be highly stable. Correlations between nominations of being disliked by peers are as high as r =.7–.8 over six weeks among an ADHD sample (Blachman & Hinshaw, 2002).

Yet, it is relatively unknown the extent to which peers’ affective disliking of children with ADHD manifests itself in behavioral forms of social exclusion, such as observable ostracism or victimization. Although it has been established that peer rejection typically increases the likelihood of subsequent victimization more than vice versa (Schwartz, McFayden-Ketchum, Dodge, Pettit, & Bates, 1999), these studies have not been specific to ADHD populations. Despite the peer rejection of children with ADHD being well documented, the literature on behavioral ostracism or victimization among ADHD youth is not as advanced, particularly when multimeasure assessment procedures are involved. Nonetheless, there are suggestions that children with ADHD are more likely to be victimized, based on self-report, teacher report, and parent report, relative to comparison youth (Shea & Wiener, 2003; Wiener & Mak, 2009). However, children with ADHD may also have elevated rates of being bullies and bully-victims, as well as victims (Wiener & Mak, 2009). It is unknown whether the predictors of victimization are similar for children with ADHD relative to comparison children. To summarize, the rejection of children with ADHD has been extremely well established, but an area for future research is the ways in which this affective dislike may be behaviorally displayed in bullying and ostracism.

ADHD Subtype and Comorbidity

Children with ADHD are not a homogenous group, and their social behaviors and type of social exclusion faced may differ depending on ADHD subtype and patterns of comorbidity with other disorders. The DSM-IV-TR criteria specify that individuals with ADHD can be classified into three subtypes (American Psychiatric Association, 2000). The Combined Type (ADHD-C) is designated for individuals with both inattention and also hyperactivity/impulsivity. The Predominantly Inattentive Type (ADHD-I) is appropriate for the presence of inattention without hyperactivity/impulsivity, and the Predominantly Hyperactive/Impulsive Type (ADHD-HI) for hyperactivity/impulsivity without inattention. The majority of the research to date has involved participants with ADHD-C. The most common subtype in epidemiological studies is ADHD-I, but children with this subtype are underdiagnosed and underreferred for treatment (Robison, Sclar, Skaer, & Galin, 2004), and ADHD-HI is most salient for children younger than school-age (Lahey et al., 1998).

Evidence suggests that elementary school-age children with ADHD-C tend to have an intrusive, aggressive interpersonal style that may lead to them being rejected by peers, that is, actively disliked. By contrast, children with ADHD-I may behave passively or seem apathetic during peer interactions, which contributes to them being more (p. 230) neglected and ignored by their peers as opposed to actively rejected (Hodgens et al., 2000; Mikami, Huang-Pollock, Pfiffner, McBurnett, & Hangai, 2007; Milich, Balentine, & Lynam, 2001). This suggests that the nature of social exclusion may be different for the two subtypes; it may be purposeful for youth with ADHD-C but accidental for youth with ADHD-I.

To date, the different types of social exclusion experienced by youth with ADHD-C versus ADHD-I have been conceptualized to result from pre-existing differences in interpersonal behaviors between the two subtypes. Unstudied is whether the impact of active exclusion (rejection) versus passive exclusion (neglect) may also contribute to subsequent differential functioning among youth with ADHD-C versus ADHD-I. Recent work, using a college undergraduate sample, suggests that active exclusion experiences lead to participants reporting increased agitation, thoughts about actions one should not have taken, and withdrawal from contact; by contrast, passive exclusion experiences may evoke dejection, thoughts about actions one should have taken, and increased engagement in social contact (Molden, Lucas, Gardner, Dean, & Knowles, 2009). Whether these processes would apply to children with ADHD and their naturalistic exclusion experiences, and potentially exacerbate behavioral differences between the two subtypes, remains unknown.

Confounded with subtype is comorbidity. Half of children with ADHD have comorbid disruptive behavior problems (e.g., Oppositional Defiant Disorder, Conduct Disorder), and about 25% to 33% are estimated to have comorbid internalizing disorders such as anxiety or depression (Jensen, Martin, & Cantwell, 1997). Children with ADHD-C are more likely to have comorbid disruptive behavior disorders than are children with ADHD-I, and the presence of comorbid aggression exacerbates peer rejection (Milich et al., 2001; Pfiffner, Calzada, & McBurnett, 2000). Less studied are internalizing comorbidities with ADHD, but these are suggested to be equal among ADHD subtypes (Power, Costigan, Eiraldi, & Leff, 2004), and to be associated with peer neglect (Karustis, Power, Rescorla, Eiraldi, & Gallagher, 2000). However, some children with ADHD have both disruptive and internalizing comorbidities (Jensen et al., 1997), and little is known about the compounding effect of both types of comorbidities on peer relationships.

To summarize, the social relationships of children with ADHD appear to differ based on subtype and comorbidity, suggesting the importance of considering these factors when depicting interpersonal functioning. Collectively, evidence suggests that children who have ADHD-C and disruptive comorbidities are most at risk for being actively rejected. By contrast, children who have ADHD-I and internalizing comorbidities may be more neglected by peers.

Adolescents and Young Adults

The current ADHD literature has an under-representation of participants past elementary school age. Nonetheless, all available evidence suggests that adolescents and adults with ADHD remain impaired socially with peers (Bagwell, Molina, Pelham, & Hoza, 2001) and in their romantic relationships (Canu & Carlson, 2003). Notably missing from this work, however, is research that links behavioral forms of exclusion with these relationship difficulties among adolescents and adults with ADHD. In adult peer groups, social exclusion may take more subtle forms (e.g., coworkers don’t invite a colleague to lunch; college classmates are hesitant to work with the student) that are more difficult to measure. However, these forms of ostracism may be relevant for adults with ADHD. In conclusion, extremely little is known about how adults with ADHD may experience social exclusion. However, because work suggests continuing interpersonal impairment among adults with this disorder, the social exclusion of adults with ADHD may represent a valuable topic for future study.

Gender Differences

The existing ADHD literature also has an under-representation of girls with the disorder relative to boys. Males outnumber females 3:1 in community samples, and up to 9:1 in clinical samples (Lahey et al., 1994). However, the research that does exist suggests that girls with ADHD face at least the same level of social exclusion from peers as do boys, if not more (Blachman & Hinshaw, 2002; Gaub & Carlson, 1997). For instance, rates of peer rejection among girls with ADHD far exceed those found for girls without ADHD (Hoza, Mrug et al., 2005). Similar to boys who have this disorder, the rejection of girls with ADHD is established very quickly in previously unfamiliar groups of peers (Blachman & Hinshaw, 2002).

Interestingly, it is possible that girls with ADHD may have additional trouble socially, relative to their male counterparts, because ADHD symptoms and conduct problems commonly associated (p. 231) with ADHD are more norm violating among girls (Mikami & Lorenzi, 2011). Further, inattentive and hyperactive/impulsive behaviors may interfere with the greater verbal give-and-take that characterizes female peer groups (Keenan & Shaw, 1997). Thus, although little research has been conducted among girls with ADHD, social exclusion is likely quite salient for females with this disorder.

Reasons for Social Difficulties in ADHD

Deficits among Individuals with ADHD

To date, the vast majority of the research on reasons for social exclusion has focused on problem behaviors enacted by youth with ADHD that are off-putting to peers. One of the main findings is that the core symptoms of ADHD interfere with appropriate social behavior. Among children, inattention not only affects schoolwork, but it also may compromise ability to read social cues, to attend to the rules of a game, and to follow fast-paced conversations with peers. Hyperactivity and impulsivity may interfere with the ability to wait one’s turn in line or in a game, to listen to peers’ concerns patiently, and to be a good sport by restraining impulses to be upset when losing (Landau, Milich, & Diener, 1998).

In addition, children with ADHD have deficient social-cognitive skills, which may also contribute to their peer problems. During peer interactions, children with ADHD have social goals of “winning”; by contrast, comparison youth are more likely to have the goal of “having fun and making a new friend” (Melnick & Hinshaw, 1996). Children with ADHD may struggle with taking the perspective of a peer, as is reflected in their difficulty giving directions to a peer who is prevented from seeing the same information as the child with ADHD (Whalen & Henker, 1992; Whalen, Henker, Collins, McAuliffe, & Vaux, 1979). Finally, children with ADHD may be more likely than comparison youth to interpret ambiguous peer provocations as hostile in intent, and less likely to propose adaptive strategies to solve hypothetical social conflicts (Matthys, Cuperus, & van England, 1999; Mikami, Lee, Hinshaw, & Mullin, 2008). Collectively, these behaviors on the part of children with ADHD are thought to cause their social exclusion from peers. In fact, children with ADHD have been called “negative social catalysts” (Whalen & Henker, 1985, 1992), reflecting the perspective that they possess characteristics that they bring to every interpersonal situation, which cause their relationship problems.

Biases of the Peer Group

Although children with ADHD do have behavior problems that contribute to their ostracism by peers, peer rejection does not occur in a vacuum in which only the behaviors of the child with ADHD are important. Rather, social exclusion is a mutual, reciprocal process that also involves the behaviors and values of the larger peer group that excludes the child with ADHD (Mikami, Lerner, & Lun, 2010).

One factor that may influence peer relationships above and beyond deficits within the child with ADHD is the extent to which the peer group views a child with ADHD as deviant and not like themselves. Research in developmental and social psychology, not specific to ADHD, supports this hypothesis. Even after accounting for a rejected child’s behaviors, the magnitude that a child is disliked increases if his/her behavior is more deviant from whatever the norm is in that particular peer group (Boivin, Dodge, & Coie, 1995; Stormshak et al., 1999; Wright, Giammarino, & Parad, 1986). Thus, aggressive children are more rejected in peer groups in which aggressive behavior is unusual than those in which others also behave aggressively; similarly, withdrawn children are more rejected in peer groups in which withdrawal is unusual than those in which withdrawal is common. As an example of the robustness of this relationship, in one study of 4,650 children, the peer group norm of aggression accounted for 19% of the between-group variation in the association between peer rejection and aggressive behavior (Chang, 2004). These findings demonstrate that there is no set path between any particular behavior and rejection, and that rejection depends on the interpretations and values of the larger peer group.

Children may also be marginalized by peers if they are atypical demographically, not just behaviorally, demonstrating the strength of children’s tendencies to reject individuals who violate group norms in a variety of ways (including harmless ways). Children who are a racial minority in their classroom are more likely to be disliked than are children in the majority (Jackson, Barth, Powell, & Lochman, 2006). Specifically, African-American children are more peer-rejected in predominantly white relative to predominantly black classrooms, but white children are more likely to be rejected in predominantly black relative to predominately white classrooms (Kistner, Metzler, Gatlin, & Risi, 1993). In sum, a body of literature suggests that simply being different from the group norm may encourage rejection from that peer group. (p. 232)

The peer group may also have cognitive biases against disliked children that perpetuate these children’s rejected status (Hymel, Wagner, & Butler, 1990). Peers interpret the ambiguous behaviors of children whom they dislike as hostile in intent while interpreting the ambiguous behaviors of children whom they like as benign (Peets, Hodges, Kikas, & Salmivalli, 2007; Peets, Hodges, & Salmivalli, 2008). Peers selectively remember disliked children’s negative behavior while forgetting their positive behaviors (Flannagan & Bradley, 1999), and attribute the negative behavior of a disliked child to internal, stable traits, while attributing positive behavior to situational causes; these attributions are reversed to favor popular children (Guerin, 1999; Hymel, 1986). Even children as young as preschool to first grade have been found to possess these cognitive biases (Denham & Holt, 1993; Mrug & Hoza, 2007). Collectively these findings suggest that peers are disposed to give the benefit of the doubt to their friends, whereas the identical actions by a disliked child are interpreted in such a way as to maintain that child’s negative reputation and peer-rejected status.

Although the aforementioned research has not specifically focused on youth with ADHD, there is reason to believe that factors in the peer group affect the social status of children with this disorder. Children with ADHD engage in behaviors that may tax the patience of even the most inclusive peer group. However, behavior change among youth with ADHD is a necessary but probably not sufficient condition for improvements in social exclusion to occur. There are two reasons for this. First, even if child-focused treatment succeeds in reducing the most noxious disruptive and aggressive behaviors common among children with ADHD, clinicians often comment that many treated children remain awkward, odd, prone to daydreaming, or persist in engaging in socially off-time behaviors (Landau et al., 1998). Peer groups that are tolerant of harmless, but still deviant, behaviors such as these may be more likely to accept a child with ADHD, or the magnitude of the social rejection faced by a child with ADHD may be less extreme among such peers than it would be in a less tolerant peer group. Recent work has suggested that the correlation between ADHD symptoms and sociometrically-assessed peer rejection varies across classrooms, and may be attenuated when teachers personally like children with ADHD (McAuliffe, Hubbard, & Romano, 2009; Mikami, Griggs, Reuland, & Gregory, 2012).

Second, the tenacity of the negative reputations of children with ADHD is also likely to be just as strong, if not stronger, than for typically developing children. Therefore, even when a child with ADHD displays more positive behaviors, the peer group may be resistant to altering their impressions about that child. This may occur because peers’ awareness that a child has the disorder of ADHD evokes rejection in and of itself. Merely labeling a target as “ADHD” (even if s/he does not in fact have ADHD) has been shown to create a stereotype such that unfamiliar peers make negative judgments about the target that extend beyond the information provided (Whalen, Henker, Dotemoto, & Hinshaw, 1983), and report lowered desire to be friends with the target (Canu, Newman, Morrow, & Pope, 2008). In another study, peers were told that certain children with whom they were about to interact had ADHD. In reality, the label of ADHD was falsely applied to randomly selected children who were unaware that their peers had been given this information. During the interaction afterwards, peers were more likely to reject children whom they thought had ADHD, and children labeled as ADHD were judged by observers to have poorer social skills than were children not labeled as ADHD (Harris, Milich, Corbitt, Hoover, & Brady, 1992).

Interventions for Social Exclusion in ADHD

To date, existing interventions for peer problems largely attempt to remediate deficits within the child with ADHD, but they have made only circumscribed progress towards improving peer relationships (Landau et al., 1998; Mrug, Hoza, & Gerdes, 2001). The first-line treatments for ADHD, stimulant medication and behavior management, are well validated for ameliorating the core symptoms of the disorder (MTA Cooperative Group, 1999), yet their usefulness for peer problems is modest. These treatments do reduce children’s intrusive and disruptive behaviors (Chronis, Jones, & Raggi, 2006; Hinshaw, Henker, Whalen, Erhardt, & Dunnington, 1989; Murphy, Pelham, & Lang, 1992), and may result in improved social skills as rated by adults (Klein & Abikoff, 1997). Unfortunately, a corresponding reduction in peer exclusion (as assessed on sociometric measures wherein peers name their liking, disliking and friendship preferences) often does not follow (Hoza, 2007; Hoza, Gerdes et al., 2005). Because peer reports have greater validity in predicting subsequent adjustment than do adult informant ratings of social skills (p. 233) (Parker & Asher, 1987) gains on peer-reported acceptance and friendship are the desirable standard.

Some exceptions exist whereby, in small samples, children receiving stimulant medication (Whalen et al., 1989) and behavioral management (Pelham & Bender, 1982) may improve in peer-reported acceptance after treatment. Nonetheless, in both these studies, peer relationships were far from normalized. These positive outcomes must also be considered in light of a larger collection of null effects on peer-reported measures (Hoza, Gerdes et al., 2005; Landau et al., 1998; Landau & Moore, 1991; Mrug et al., 2001). For example, in the Multimodal Treatment Study of Children with ADHD (MTA Cooperative Group, 1999), both intensive medication and behavioral management failed to increase peer reports of acceptance or friendship at the immediate conclusion of the 14-month active treatment period (though treatments produced gains in adult informant-reported social skills). Relative to a matched sample of comparison youth, children with ADHD remained profoundly socially impaired, no matter which treatment they had received (Hoza, Gerdes et al., 2005). As discussed by the authors, it is notable that even the state-of-the-art treatments, delivered under ideal circumstances, did not improve peer relationships significantly.

Although social skills training is a widely used treatment for children with ADHD (Mrug et al., 2001; Nixon, 2001; Stormont, 2001), its efficacy for improving peer-assessed acceptance has received inconsistent empirical support (Gresham, Cook, Crews, & Kern, 2004; Mikami & Pfiffner, 2006; Pfiffner et al., 2000). In a study of 103 children with ADHD, Abikoff et al. (2004) found no added benefit of receiving social skills training plus stimulant medication over medication alone on adult-informant ratings or observations of social skills, either at the end of a 1-year intensive treatment period or a 2-year follow-up wherein treatment was provided less frequently. Although this study lacks a comparison condition of unmedicated children, other investigations have compared short-term, less intensive social skills training to no treatment and failed to find improvement in peer relationships, particularly when peer reports of liking are used to assess effectiveness (Abikoff et al., 2004; Antshel & Remer, 2003; Kolko, Loar, & Sturnick, 1990). Although some social skills training programs appear promising, especially when parents are involved to encourage generalization (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007), multiple investigators have concluded that social skills training is not as useful for children with ADHD as originally hoped (Abikoff, 1985; Barkley, 2004; de Boo & Prins, 2007; Guevremont & Dumas, 1994; Mrug et al., 2001; Pelham, Wheeler, & Chronis, 1998).

One reason why medication, behavioral management, and social skills training interventions may have circumscribed effectiveness on peer relationships is because none of these interventions consider factors in the peer group that contribute to social status. To the extent that these treatments reduce disruptive behaviors among youth with ADHD (MTA Cooperative Group, 1999), this may explain findings that adult informants report improvements in children’s social skills. However, improvements in sociometrically-assessed peer exclusion may not always follow from such interventions (Hoza, Gerdes et al., 2005; Mikami & Pfiffner, 2006) because these treatments do nothing to encourage the peer group to be more tolerant of a child with ADHD who remains socially awkward after treatment in harmless ways, to eliminate the stigma associated with this diagnosis, or to make the peer group notice positive behavior changes resulting from treatment that would alter their impressions. In support of this hypothesis, Mikami et al. (in press) found that children with ADHD who received an intervention that supplemented behavioral management with procedures to increase the inclusiveness of the peer group displayed better peer sociometric acceptance relative to those children who receive behavioral management alone.

In sum, more research is needed to improve the efficacy of interventions for social exclusion among ADHD populations. Including novel targets of intervention, such as addressing the biases among the peer group that rejects the child with ADHD, is a potentially worthwhile direction.


The social exclusion from peers that children with ADHD face is pronounced, and may persist into adolescence and adulthood. Peer rejection occurs for both boys and girls with ADHD, which may be exacerbated if other comorbid disorders are present. Research has traditionally focused on deficits within youth with ADHD that are off-putting to peers and contribute to their ostracism. However, factors in the peer group may also be relevant in determining the extent to which children with ADHD are socially excluded. Interventions most commonly attempt to remediate deficits within children with ADHD, but peer rejection is often resistant to (p. 234) treatment. It is possible that, in addition to focusing on behavior change in the child with ADHD, other interventions may be needed to encourage the peer group to be more inclusive and accepting.

Future Directions

Overall, the social exclusion of individuals with ADHD is profound and does not fully remediate in response to existing treatments. Future studies would benefit from incorporation of understudied populations, in particular, adolescents and adults with ADHD. All available evidence suggests that individuals this age with ADHD continue to struggle with social relationships, but the nature of social exclusion may change and be more difficult to measure in adulthood relative to in childhood. This may be because of the fact that adults’ social networks are not confined to a single classroom. The field is in need of studies with sensitive, developmentally appropriate measures of social exclusion in ADHD populations past childhood. In addition, girls with ADHD, the Inattentive Type of ADHD, and youth with ADHD and internalizing comorbidities, are all understudied groups in the existing research. Incorporation of these populations would lead to a more complete understanding of how social exclusion operates for individuals with ADHD.

Because peer relationship problems may exacerbate maladjustment in ADHD populations (Mikami & Hinshaw, 2006), treatments for social exclusion have high public health significance. Yet the limited effectiveness of existing interventions suggests that the field is in need of alternative ways to facilitate peer relationships among youth with ADHD. Although speculative, interventions that also target the peer group to be more accepting of youth with ADHD, and to notice positive behavior changes among youth with ADHD, may be a promising direction.


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