Friendships and Social Networks of Adolescents With ADHD

May 25, 2018 | Research Updates

Here is a blog based on a poster presented by Barbara Wise, Ph.D. from Indiana Wesleyan University at the 2018 APSARD conference

Although much research has examined social difficulties of children and adolescents with ADHD (Barkley, 2014; Glass, Flory, & Hankin, 2012; Marton, Wiener, Rogers, & Moore, 2015; Normand et al., 2011; Rokeach & Wiener, 2017; Storebø et al., 2011), no sociometric or social network analysis has been located that examined the friendship networks of adolescents with ADHD. Peer problems in adolescents with ADHD have been linked to risker sexual behaviors and substance abuse (Barkley, 2014; Umberson, Crosnoe, & Reczek, 2010). Many other adolescent health behaviors have been linked to peer influence. For clinicians working with adolescents with ADHD, an understanding of their friendships and social networks will assist in understanding their types of social difficulties, providing accurate anticipatory guidance, and serve as a foundation for building effective interventions for youth with ADHD that are struggling socially.

In this study, I looked at two questions:

1. How do adolescents with ADHD compare with adolescents without ADHD on measures of perceived social acceptance, strength of ties, presence of one mutual same gender friend, social network measures, and extracurricular activity participation?
2. Are there differences in these measures among the ADHD subtypes of inattentive, hyperactive, and combined?

This was a descriptive study utilizing secondary analysis of school social network data from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative sample initially collected in 7th through 12th grades. Friendship nominations were collected in Wave I for all students in 122 schools; each student could nominate up to 5 male and 5 female friends. This allowed for whole network analysis of schools with >50% participation. Adolescents with ADHD symptoms in childhood were identified by retrospective self-report in wave III (N=703).
Table one gives the characteristics of the participants, comparing those who did and did not meet ADHD diagnostic criteria.

The findings are summarized below:

Perceived social acceptance. Youth with ADHD inattentive and impulsive self-reported significantly less social acceptance than those without ADHD.
Friendships. The presence of one mutual friend and time spent with friends increased with age among all participants, and this trajectory was not significantly different among those with ADHD symptoms. Multiple linear and logistic regressions demonstrated that those with ADHD were no more likely to be isolates or pendants (to have no or only one social tie) than others. Those with ADHD had similar strengths of ties with their friends as others, with those with hyperactive ADHD only reporting more time spent with friends than average.
Social network measures. There was no difference in popularity (in-degree) among those with ADHD than others, although those with inattentive ADHD reported fewer friends (out-degree) on average than others. Those with inattentive ADHD also had lower centrality and reach within their social networks.
Extracurricular involvement. Youth with ADHD had no significant difference in the total number of extracurricular activities with which they were involved than others, but were significantly less likely to be involved in an academically focused extracurricular activity.

Table 2: comparison of those meeting ADHD criteria with those not meeting, by subtype, for selected social network measures

ns=no significant differences

Conclusions
This study found fewer social deficits in adolescents than suggested in the literature, possibly because most studies of childhood social networks were carried out in clinical samples, where ADHD severity is likely higher. These findings may also reflect that no previous study examined whole social networks of high school students, so that analyses of adolescent social ties were based on self-report, teacher report and parent report. Discrepancies between teacher, parent, and adolescent reports were considered to indicate that the adolescent with ADHD had an inaccurate representation of their own popularity. However, when the student nominated by an adolescent with ADHD as a friend reciprocates that nomination, then this is the most accurate way to measure the existence of a social tie. Perceived lack of social acceptance was striking among ADHD subgroups. This may reflect that while those with ADHD had friends, those friends may not have been in prestigious cliques; social acceptance can mean prestige to an adolescent rather than number of people that name the youth as a friend (Borgatti, Everett, & Johnson, 2013). A more detailed analysis of who adolescents with ADHD are friends with, rather than simply that they have friends, would be valuable.
In clinical practice, the results of this study allow clinicians to offer reassurance to children and parents of children with ADHD that most of the participants who had significant childhood ADHD symptoms appeared to be functioning well socially in adolescence, despite most differences in their perception about their level of social acceptance. The lack of significant differences on most measures, including presence and strength of social ties suggests that there is room for a positive, strengths based approach to the social problems of adolescents with ADHD.
This study does not predict outcomes. Further research is needed to identify to what extent friendship networks and characteristics predict future health behaviors and academic and career success. Further research is needed to explore the effects of comorbidities such as depression and Oppositional Defiant Disorder on the social networks of those with ADHD, as well as specific environmental factors that might be associated with better social outcomes, such as the size of the school and participation in specific types of extracurricular activities. Lastly, there is a noticeable gap in research addressing effective interventions for helping the minority of adolescents with ADHD who have more significant social difficulties affecting their quality of life.
A major strength of this study is that it is the largest population based examination of the social position of adolescents with ADHD in school social networks to date, and the only one describing specific social network characteristics. Limitations of the study include the age of the data, the lack of longitudinal whole network data, and the self-reported nature of the ADHD symptoms.

References
Barkley, R. A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. (4rth ed.). New York: Guilford Press.
Glass, K., Flory, K., & Hankin, B. L. (2012). Symptoms of ADHD and close friendships in adolescence. Journal of Attention Disorders, 16(5), 406-417. doi:10.1177/1087054710390865
Marton, I., Wiener, J., Rogers, M., & Moore, C. (2015). Friendship characteristics of children with ADHD. Journal of Attention Disorders, 19(10), 872-881. doi:10.1177/1087054712458971
Normand, S., Schneider, B. H., Lee, M. D., Maisonneuve, M., Kuehn, S. M., & Robaey, P. (2011). How do children with ADHD (mis)manage their real-life dyadic friendships? A multi-method investigation. Journal of Abnormal Child Psychology, 39(2), 293-305. doi:10.1007/s10802-010-9450-x
Rokeach, A., & Wiener, J. (2017). Friendship quality in adolescents with ADHD. Journal of Attention Disorders, , 1087054717735380. doi:10.1177/1087054717735380
Storebø, O. J., Skoog, S., Damm, D., Thomsen, P. H., Simonsen, E., & Gluud, C. (2011). Social skills training for attention deficit hyperactivity
disorder (ADHD) in children aged 5 to 18 years . Cochrane Database of Systematic Reviews, 12(Art. No.: CD008223), 1-89. doi:DOI: 10.1002/14651858.CD008223.pub2.
Umberson, D., Crosnoe, R., & Reczek, C. (2010). Social relationships and health behaviors across the life course. Annual Review of Sociology, 36, 139-157. doi:10.1146/annurev-soc-070308-120011

Brain Stimulation and Impulsivity in Adult ADHD

May 21, 2018 | Research Updates

J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine

Impulsivity is one of the core symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). A recent study published online ahead of print in the journal Brain Stimulation reported on the results of a sham controlled study of the potential benefit of transcranial direct current stimulation (tDCS) for adults with ADHD. The stimulation targeted the dorsolateral prefrontal cortex to promote downstream effects on cognitive control circuits in this region in order to improve impulse control.
Thirty-seven adult participants with ADHD completed two periods of three sessions of either active tDCS or sham. Sessions occurred two weeks apart in a within-subject, double-blind, counterbalanced order. Outcome measures of impulsivity were Conners Continuous Performance Task (CPT) scores and stop signal task (SST) reaction times. Measures were obtained at baseline, at the end of treatment, and 3-day post-stimulation follow-up.
Results indicated a significant stimulation condition-by-session interaction for change in CPT false positives, driven primarily by a reduction of CPT false positives at the end of treatment; this effect did not persist at 3-day follow-up. There was no significant change in CPT false negative errors, hit response time, or SST reaction time. Nonetheless, these preliminary findings suggest a potential therapeutic benefit of tDCS targeting the DLPFC for reducing impulsivity symptoms.

Note: APSARD Board Members Anthony L. Rostain, M.D. and J. Russell Ramsay, Ph.D. are co-authors on this study.

Reference: Allenby C, Falcone M, Bernardo L, Wileyto P, Rostain A, Ramsay JR, Lerman C, Loughead J (2018). Transcranial direct current brain stimulation decreases impulsivity in ADHD, Brain Stimulation, online ahead of print. doi: 10.1016/j.brs.2018.04.016

Link to study: https://www.brainstimjrnl.com/article/S1935-861X(18)30138-4/fulltext

APSARD Blog: Sluggish Cognitive Tempo in Adult Outpatients Seeking an ADHD Evaluation

May 2, 2018 | Research Updates

Jessica Lunsford-Avery, Ph.D.

By Jessica R. Lunsford-Avery & John T. Mitchell

Sluggish Cognitive Tempo (SCT) is a set of symptoms including mental fogginess, slowed cognition and behavior, and daydreaming. Researchers are currently uncertain whether SCT is a transdiagnostic construct or a separate diagnosis, and if it is a separate diagnosis, there’s discussion about whether to call it SCT or something else, such as Concentration Deficit Disorder. Either way, this set of symptoms is distinct from ADHD and uniquely contributes to psychiatric and functional outcomes in children. Measures of SCT have also been found to be reliable and valid for use with both children and college students. However, no studies have examined the psychometric properties of a SCT measure among adult outpatients, which limits clinicians’ ability to use it with their patients. Our study sought to examine the reliability and validity of an SCT measure in an applied clinical setting using both self and other report (e.g., spouse or parent) as well as links between SCT and home, occupational, academic, social, and community functioning in an adult sample.

John T. Mitchell, Ph.D.

One-hundred twenty-four adults participated in our study. All participants presented to an outpatient psychiatry clinic for an evaluation for ADHD. Participants completed a thorough psychiatric evaluation. In addition, participants and a person who knows them well, such as a spouse or parent, completed measures of SCT (9-item Barkley Adult ADHD Rating Scale-IV SCT subscale; BAARS-IV) and ADHD symptom severity (Conners’ Adult ADHD Rating Scale; CAARS). Eighty participants met criteria for ADHD and 44 received other primary diagnoses, such as depression and anxiety disorders. Among individuals receiving an ADHD diagnosis, comorbid diagnoses were common, occurring in 53% of adults with ADHD.

Across raters, the SCT subscale demonstrated good internal consistency and yielded three factors: Slow/Daydreamy, Sleepy/Sluggish, and Low Initiation/Persistence. Total SCT score exhibited convergent validity with ADHD symptoms on the CAARS by both reporters. SCT factors were also associated with ADHD symptoms with the exception of the Sleepy/Sluggish factor, which was associated with increased inattention but not with hyperactivity. Adults with ADHD were rated more highly on the SCT measure than those with other psychiatric disorders by the other reporter but not by their own report. When comorbidity was considered, however, adults with ADHD rated themselves more highly on the SCT measure than those without ADHD, but only if comorbidity was present. Finally, greater SCT severity was associated with poorer functioning in home, social, and academic settings by other report, and with deficits in social and community functioning by self-report, after accounting for ADHD.

Our study highlights the potential of SCT measures to inform diagnostic presentation and treatment planning in clinical settings. Specifically, the BAARS-IV SCT subscale can be reliability and validly collected adult outpatient settings and provides important clinical information related to poor functioning over and above the assessment of ADHD. Further, we found that SCT symptoms cluster into three separate factors, as opposed to one factor. Finally, this study underscores the importance of collecting SCT information from someone who knows the patient well, such as a spouse or parent, as their report detected SCT symptoms contributing to functional impairment in additional areas not captured by self-report.

We appreciated the opportunity to present our work at the 2018 APSARD meeting and would like to thank our colleagues at the Duke ADHD Program – Drs. Scott Kollins, Naomi Davis, Julia Schechter, Maggie Sweitzer, Cara Lusby, and Jessica Sloan – as well as Kayla McCoy and Michelle Lepsch-Halligan for their contributions to this study.