Identifying ADHD Symptoms Most Associated with Impairment in Early Childhood, Middle Childhood, and Adolescence Using Teacher Report

Social Functioning Outcomes of a High School-Based Treatment Program for Adolescents with ADHD

OBJECTIVE

We evaluated the extent to which receiving the multi-component treatment of the Challenging Horizons Program (CHP) would lead to significant improvements in social functioning, as well as in inattention, internalizing symptoms, parent stress, and emotion dysregulation for high-school-aged adolescents with attention-deficit hyperactivity disorder (ADHD).

METHOD

Participants were 186 high-school-aged adolescents (74% White) with a diagnosis of ADHD who were randomly assigned to either CHP (n = 92; 80% boys; M age = 15.0; SD = 0.8) or Community Care (CC; n = 94; 78% boys; M age = 15.1; SD = 0.9) within each of 12 participating schools. Parent and adolescent reports of social functioning were the primary outcome measures. Secondary outcomes included ratings of symptoms of ADHD and related disorders, parent stress, and emotion regulation.

RESULTS

Intent-to-treat analyses using hierarchical linear modeling revealed significant group-by-time interactions of medium magnitude (d range = .40 to .52) on parent-rated social skills. Significant group-by-time benefits were also identified for adolescent self-rated social skills as well as the secondary outcomes of parent-rated inattention symptoms, emotion regulation, and parenting stress.

DISCUSSION

CHP appears to benefit social skills along with related characteristics for adolescents with ADHD. Understanding these unique findings for this population informs additional research related to treatment mechanisms and effectiveness trials.

Cost-Effectiveness of a Training Intervention for Adolescents with ADHD

OBJECTIVE

The aim of this study was to examine the costs and cost-effectiveness of a school-based training intervention delivered at varying levels of intensity with adolescents with attention-deficit/hyperactivity disorder (ADHD). Costs were examined in relation to post-treatment and 6-month follow-up effects of the Challenging Horizons Program (CHP), a training intervention for adolescents with ADHD.

METHOD

A total of 326 middle-school students (71% male; 77% White) with ADHD were randomized to an after-school version of the CHP (CHP-AS), a less-intensive mentoring version (CHP-M), or routine community care. Detailed time logs were maintained throughout the study and were used to estimate costs associated with each condition. Student grade point average (GPA) and parent-rated ADHD symptoms and organization skills were collected at post-treatment and 6-month follow-up.

RESULTS

The cost analysis revealed that CHP-AS was more costly per student than CHP-M, both in terms of overall costs and direct expenses to the school. However, CHP-AS was less costly per hour of intervention provided to the youth than CHP-M. Incremental cost-effectiveness ratios revealed that CHP-M may be the more cost-effective option for post-treatment effects, yet CHP-AS may be the more cost-effective option in the long term for sustained gains in organization skills and GPA.

CONCLUSIONS

This study provides stakeholders important information to make decisions regarding allocation of finite monetary resources to meet their prioritized goals.

The association between different sources of distraction and symptoms of attention deficit hyperactivity disorder

Introduction

Adults with Attention-Deficit/Hyperactivity Disorder (ADHD) are generally distractible. Yet, the precise relationship between ADHD and distractibility remains under-specified in two respects. First, different sources of distraction, such as background noise or mind wandering, may not be equally associated with ADHD. Second, ADHD itself comprises a variety of symptoms that show considerable heterogeneity and it is unclear which ADHD symptoms are associated with which type of distraction.

Methods

The current study addresses these questions using one clinically evaluated sample (N = 69) and two large non-clinically evaluated samples (N = 569, N = 651). In all samples, participants completed questionnaires about their susceptibility to external distraction, unwanted intrusive thoughts, spontaneous mind-wandering and ADHD symptomatology.

Results

Traditional regression and novel network analyses revealed an overwhelming contribution of spontaneous mind-wandering in explaining ADHD symptoms, although external distraction and unwanted intrusive thoughts were also associated with a small number of ADHD symptoms.

Discussion

Findings support a growing body of literature linking spontaneous mind-wandering and ADHD, and they highlight the heterogeneity in the association between ADHD symptoms and different sources of distraction.

Understanding Factors that Moderate the Relationship Between Student ADHD Behaviors and Teacher Stress

Teaching is a stressful profession, and teacher stress has been shown to be associated with job dissatisfaction, attrition from the field, and negative outcomes for teachers and their students. A major contributor to teacher stress is disruptive student behavior. Given that students with or at-risk for attention-deficit/hyperactivity disorder (ADHD) demonstrate high rates of disruptive behaviors and are present in nearly every classroom, studying the connection between student ADHD symptoms and teacher stress may provide useful insights for better supporting teachers and their students. Aims of this study were to (1) assess the replicability of a previous finding that teachers rate their students with elevated ADHD symptoms to be more stressful to teach than students without these symptoms and (2) explore the extent to which key factors (i.e., overall work-related stress and student-teacher relationship quality) moderate the relationship between student ADHD symptoms and related teacher stress. Participants were 97 K-2nd grade teachers who completed an online survey about themselves and two male students in their classroom. Results showed that teachers report students with elevated levels of ADHD symptoms and impairment to be more stressful to work with than students who do not exhibit these symptoms (d = 1.52). Additionally, overall work-related stress and conflict in the student-teacher relationship exacerbated the relationship between student ADHD symptom severity and related teacher stress, whereas closeness in the student-teacher relationship mitigated this association. Implications of these findings and directions for future research are discussed.

Social difficulties in adolescent attention deficit hyperactivity disorder: Social motivation, social anxiety and symptom severity as contributing factors

BACKGROUND

Many interventions have been developed to address the social difficulties commonly experienced by adolescents with attention-deficit/hyperactivity disorder (ADHD), yet they are largely ineffective.

OBJECTIVE

This study examined social impairment among adolescents with and without ADHD, determining whether gender, social anxiety, age, and ADHD symptom type (inattention and hyperactivity/impulsivity) and severity are associated with social impairment.

METHOD

Parents and primary caregivers of adolescents (aged 13-17) with (n = 76) and without ADHD (n = 36) completed the Strengths and Weaknesses of ADHD and Normal Behavior, Social Responsiveness Scale 2nd Edition, and Spence Children's Anxiety Scale.

RESULTS

Adolescents with ADHD scored significantly higher than TD adolescents across social impairment domains. ADHD symptoms were associated with severity of impairment in all domains excluding Social Motivation. Hyperactivity/impulsivity and social anxiety predicted social impairment, whereas gender did not.

CONCLUSION

Adolescents with ADHD are more likely to experience social impairment than TD adolescents, and interventions targeting symptom reduction and social anxiety may improve these social impairments.

ADHD and Psychological Need Fulfillment in College Students

OBJECTIVE

Self-determination theory suggests that the satisfaction and frustration of basic psychological needs-autonomy, competence, relatedness-are uniquely associated with overall well-being. Undergraduates with attention-deficit/hyperactivity disorder (ADHD) experience more academic-related impairment and are less likely to graduate. Thus, well-being is important to understand and aim to improve in these students.

METHOD

Students at four universities (N = 2,197) completed a survey and reported previous diagnoses, ADHD symptoms, and psychological need satisfaction and frustration. Group differences were explored via t-tests; associations were explored via structural equation modeling.

RESULTS

The ADHD group reported lower satisfaction and higher frustration across all psychological needs. Inattention and hyperactivity/impulsivity were uniquely associated with aspects of need fulfillment beyond the impact of comorbid symptoms. Sex differences emerged such that women with ADHD had the lowest overall need satisfaction.

CONCLUSIONS

Addressing need fulfillment, both satisfaction and frustration, in interventions with undergraduates with clinical/subclinical levels of ADHD may optimize treatment effectiveness.

Identifying Symptoms of ADHD and Disruptive Behavior Disorders Most Strongly Associated with Functional Impairment in Children: A Symptom-Level Approach

To enhance the understanding of how symptoms of attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders such as oppositional defiant disorder (ODD), conduct disorder (CD), including callous-unemotional (CU) traits, differentially relate to functional impairment (FI). Participants were 474 German school-age children (age: M = 8.90, SD = 1.49, 81% male) registered for participation in the ESCAschool trial (ESCAschool: Evidence-based, Stepped Care of ADHD in school-aged children). Clinicians assessed the severity of individual symptoms and five FI domains specifically associated with ADHD symptoms or ODD/CD/CU symptoms using a semi-structured clinical interview. We conducted two multiple linear regression analyses, combined with relative importance analyses, to determine the impact of individual symptoms on global FI associated with ADHD and ODD/CD/CU symptoms. Next, we estimated two networks and identified the strongest associations of ADHD symptoms or ODD/CD/CU symptoms with the five FI domains. Symptoms varied substantially in their associations with global FI. The ADHD symptom Easily Distracted (15%) and ODD symptom Argues with Adults (10%) contributed most strongly to the total explained variance. FI related to academic performance, home life and family members, and psychological strain were most strongly associated with ADHD inattention symptoms, whereas FI related to relationships with adults and relationships with children and recreational activities were most strongly associated with hyperactivity-impulsivity symptoms. By comparison, the ODD/CD/CU symptoms most closely linked to FI domains originated from the ODD and CD dimensions. Our findings contribute to a growing body of literature on the importance of analyzing individual symptoms and highlight that symptom-based approaches can be clinically useful.

Data-Driven Methods for Predicting ADHD Diagnosis and Related Impairment: The Potential of a Machine Learning Approach

Current diagnostic criteria for ADHD include several symptoms that highly overlap in conceptual meaning and interpretation. Additionally, inadequate sensitivity and specificity of current screening tools have hampered clinicians' ability to identify those at risk for related outcomes. Using machine learning techniques, the current study aimed to propose a novel algorithm incorporating key ADHD symptoms to predict concurrent and future (i.e., five years later) ADHD diagnosis and related impairment levels. Participants were 399 children with and without ADHD; multiple informant measures of ADHD symptoms, global impairment, academic performance, and social skills were included as part of an accelerated longitudinal design. Results suggested eight symptoms as most important in predicting impairment outcomes five years later: (1) Has difficulty sustaining attention in tasks or play activities, (2) Does not follow through on instructions and fails to finish work, (3) Has difficulty organizing tasks and activities, (4) Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort, (5) Is often easily distracted, (6) Is often forgetful in daily activities, (7) Fidgets with hands or feet or squirms in seat, and (8) Interrupts/intrudes on others. The algorithm comprising this abbreviated list of symptoms performed just as well as or significantly better than one comprising all 18 symptoms in predicting future global impairment and academic performance, but not social skills. It also predicted concurrent and future ADHD diagnosis with 81-93% accuracy. Continued development of screening tools will be key to ensuring access to clinical services for youth at risk for ADHD.

Cerebral blood flow characteristics of drug-naïve attention-deficit/hyperactivity disorder with social impairment: Evidence for region-symptom specificity

Background

Social deficits are among the most important functional impairments in attention-deficit/hyperactivity disorder (ADHD). However, the relationship between social impairment and ADHD core symptoms as well as the underlying cerebral blood flow (CBF) characteristics remain unclear.

Methods

A total of 62 ADHD subjects with social deficits (ADHD + SD), 100 ADHD subjects without social deficits (ADHD-SD) and 81 age-matched typically developing controls (TDC) were enrolled. We first examined the correlation between the Social Responsiveness Scale (SRS-1) and ADHD core symptoms (inattention, hyperactivity, and impulsion) and then explored categorical and dimensional ADHD-related regional CBF by arterial spin labeling (ASL). For the categorical analysis, a voxel-based comparison of CBF maps between the ADHD + SD, ADHD-SD, and TDC groups was performed. For the dimensional analysis, the whole-brain voxel-wise correlation between CBF and ADHD symptoms (inattention, hyperactivity/impulsivity, and total scores) was evaluated in three groups. Finally, correlations between the SRS-1 and ADHD-related regional CBF were investigated. We applied Gaussian random field (GRF) for the correction of multiple comparisons in imaging results (voxel-level P < 0.01, and cluster-level P < 0.05).

Results

The clinical characteristics analysis showed that social deficits positively correlated with ADHD core symptoms, especially in social communication and autistic mannerisms domains. In the categorical analysis, we found that CBF in the left middle/inferior temporal gyrus in ADHD groups was higher than TDCs and was negatively correlated with the social motivation scores. Moreover, in dimensional analysis, we found that CBF in the left middle frontal gyrus was negatively correlated with the inattention scores, SRS total scores and autistic mannerisms scores in ADHD + SD subjects.

Conclusion

The present study shows that inattention, hyperactivity, and impulsivity may be responsible for the occurrence of social deficits in ADHD, with autistic traits being another significant contributing factor. Additionally, CBF in the left middle/inferior temporal gyrus and the left middle frontal gyrus might represent the corresponding physiological mechanisms underlying social deficits in ADHD.

Effect of short-term methylphenidate on social impairment in children with attention deficit/hyperactivity disorder: systematic review

Attention Deficit/Hyperactivity disorder (ADHD) is one of the most common disorders in school-age children. In addition to learning difficulties associated with the disorder's core symptoms of inattention and hyperactivity, children with ADHD display substantial social impairments. Methylphenidate (MPH) in formulations such as Ritalin or Concerta mitigates inattention and hyperactivity, but the effects of the therapy on social behavior in children with ADHD are not clear. This review aims to determine the effectiveness of short term (up to 6 months) MPH treatment on three domains of social skills in children aged 6-14 with ADHD: (i) Recognition of nonverbal emotional expressions, which are a marker of inherent (unlearned) social understanding, (ii) theory of mind (ToM) components that relate to learned cognition and social communication, and (iii) social competence in everyday environments. 15 relevant studies were identified based on inclusion/exclusion criteria. The results show mixed effects: the overall social performance as evaluated by parents, teachers or peers, and some components of ToM, were found to improve following a weeks-long course of MPH treatment. However, the effects of the medication are less clear when evaluating momentary/nonverbal social responses such as reactions to emotional facial expressions. While the findings of this review indicate that an MPH medication regime of order weeks to months could improve, to a degree, social impairment in children with ADHD, more studies are required to identify the medications' mechanism and confirm such a conclusion.

Paths to postsecondary education enrollment among adolescents with and without childhood attention-deficit/hyperactivity disorder (ADHD): A longitudinal analysis of symptom and academic trajectories

We examined developmental trajectories of attention-deficit/hyperactivity disorder (ADHD) symptoms, standardized achievement, and school performance for adolescents with and without ADHD who did and did not enroll in postsecondary education (PSE; N = 749; 79% boys; 63% White, 17% non-Hispanic Black, 10% Hispanic, and 10% other ethnicities). In a multisite study (recruitment based in New York, North Carolina, Pennsylvania, California, and Quebec), participants were originally enrolled between 1994 and 1998 at ages 7 to 9.9 and followed up through 2012 (M_age = 25 at final follow-up). Adolescents who eventually enrolled in PSE had less severe symptoms, but differences were modest and trajectories were similar over time. For all adolescents, standardized achievement trajectories declined up to two thirds of a standard deviation from ages 9 to 17. By the end of high school, the average GPA of adolescents with ADHD was three quarters of a point higher for those who eventually enrolled in PSE compared to those who did not. Overall, school performance mattered more than academic achievement for understanding eventual enrollment of adolescents with ADHD.

Exploring ADHD Symptoms and Associated Impairment across Development

OBJECTIVE

ADHD symptoms typically decline with age, but less is known about whether the presentation of specific ADHD symptoms differs across development. This study aimed to examine the frequency and associated impairment of specific ADHD symptoms in childhood, adolescence, and young adulthood.

METHOD

A prospective, longitudinal cohort, the Avon Longitudinal Study of Parents and Children, was utilized (N = 2,327). ADHD symptoms and impairment were assessed using the Development and Well Being Assessment at ages 7, 15, and 25.

RESULTS

Specific ADHD symptom frequencies and their associated impairment varied across development for the majority of symptoms, although easily distracted was one of the most commonly reported symptoms at each age, and difficulty sustaining attention was consistently associated with high levels of impairment.

CONCLUSION

These findings suggest differences in the presentations of ADHD symptoms across development: current understanding of how ADHD presents in childhood/adolescence may not be generalizable to young adulthood.

How much impairment is required for ADHD? No evidence of a discrete threshold

BACKGROUND

A diagnosis of attention-deficit/hyperactivity disorder (ADHD) requires the presence of impairment alongside symptoms above a specific frequency and severity threshold. However, the question of whether that symptom threshold represents anything more than an arbitrary cutoff on a continuum of impairment requires further empirical study. Therefore, we present the first study investigating if the relationship between ADHD symptom severity and functional impairment is nonlinear in a way that suggests a discrete, nonarbitrary symptom level threshold associated with a marked step increase in impairment.

METHODS

Parent reports on the ADHD-Rating Scale (ADHD-RS-IV), the Weiss Functional Impairment Rating Scale (WFIRS-P), and the Strengths and Difficulties Questionnaire were collected in a general population sample of 1st, 2nd, and 3rd graders (N = 1,914-2,044).

RESULTS

Piecewise linear regression analyses and nonlinear regression modeling both demonstrated that the relationship between symptom severity (ADHD-RS-IV total score) and impairment (WFIRS-P mean score) was characterized by a gradual linear increase in impairment with higher symptom severity and no apparent step increase or changing rate of increase in impairment at a certain high ADHD-RS-IV total score level. Controlling for socioeconomic status, sex, and co-occurring conduct and emotional symptoms did not alter these results, though comorbid symptoms had a significant effect on impairment.

CONCLUSIONS

There was no clear evidence for a discrete, nonarbitrary symptom severity threshold with regard to impairment. The results highlight the continued need to consider both symptoms and impairment in the diagnosis of ADHD.

Variation in latent social profiles of adolescent ADHD and related clinical features

Social impairment is a hallmark of Attention-deficit/hyperactivity disorder (ADHD), but the extent of variation in adolescent social strengths and weaknesses is unclear. We compared teacher-reported characteristics of social functioning in adolescents with a history of ADHD (N = 340), and without ADHD (N = 182) from the NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD (MTA) at 72-month follow-up (13 - 15.9 years-old). Latent profile analysis of teacher-reported cooperation, assertion and self-control on the Social Skills Rating System (SSRS), was used to identify "social profiles". Their associations with clinical features were explored. Significant differences in social functioning were identified between adolescents with a history of ADHD, and without ADHD (ES = 0.54 - 0.77). Four distinct social profiles were identified in adolescents with a history of ADHD: unskilled (N = 24, 7%), low average (N = 144, 42%), average (N = 141, 41%), and skilled (N = 31, 9%). Profiles with worse social functioning (low average, unskilled) displayed more symptoms of inattention, hyperactivity/impulsivity, oppositionality, depression, global impairment, and were less liked, more rejected and ignored by peers than average and skilled. Social profile membership was not associated with sex, anxiety symptoms, or remittance / persistence of ADHD. Social functioning in adolescents with a history of ADHD is variable, and associated with worse symptomology, global functioning, and peer relationships, irrespective of persistence or remittance of ADHD. Group level summaries of social difficulties in ADHD may be inadequate given nearly half of adolescents with a history of ADHD presented with average or skilled social profiles.

Organization interventions as a mediator of change in grades in the Challenging Horizons Program

This study evaluated whether an organization intervention was a mediator of change for grade point average (GPA) in a randomized clinical trial of a school-based treatment program for adolescents with attention deficit hyperactivity disorder (ADHD). A demographically diverse sample of 148 participants (105 males) with a diagnosis of ADHD were recruited from nine middle schools. Comprehensive diagnostic evaluations were completed and participants were randomized into one of three conditions (two active treatment conditions, one control condition) for a randomized clinical trial that lasted an entire school year. The results of the trial are reported elsewhere (Evans et al., 2016; Schultz et al., 2017); in this study we evaluated four of the criteria for determining mediation as reported by Kazdin (2007) to determine whether response to the organization intervention in this school-based treatment program mediated the relationship between dosage and GPA beyond previous GPA. The results provided evidence that response to the organization intervention mediated the relationship between intervention dosage and change in GPA.

Unique Associations Between Specific Attention-Deficit Hyperactivity Disorder Symptoms and Related Functional Impairments

OBJECTIVE

The purpose of this study was to explore the unique relationships between specific attention-deficit hyperactivity disorder (ADHD) symptoms and functional impairment in school-age children using parent and teacher ratings.

METHODS

Parents and teachers rated ADHD symptoms and comorbidities (internalizing and oppositional behaviors) as well as impairments (academic, relationship, and classroom behavior) for 8689 children using the Vanderbilt ADHD Diagnostic Rating Scales. Stepwise regression was used to determine which of the 18 ADHD symptom items were most associated with specific domains of impairment with relevant demographic and clinical characteristics used as covariates (e.g., sex, comorbidities, medication status, and age).

RESULTS

"Careless mistakes" and "avoids tasks" significantly predicted academic impairment across content areas and across parent- and teacher-rating models. ADHD symptoms accounted for limited variance in impairment in the family and peer relationship domains or in organized activities when oppositional symptoms were entered as a covariate. Regarding teacher-rated classroom behavior, the strongest predictor of impairment was "talks too much."

CONCLUSION

The findings indicate that the symptoms that were most predictive of impairment varied by domain of impairment.

Clarifying ADHD and Sluggish Cognitive Tempo Item Relations with Impairment: A Network Analysis

Despite the pervasive nature of various forms of impairment associated with attention-deficit/hyperactivity disorder (ADHD), the precise nature of their associations with ADHD and related sluggish cognitive tempo (SCT), particularly at the heterogeneous item level, remains ambiguous. Using innovative network analysis techniques, we sought to identify and examine the concurrent validity of ADHD and SCT bridge items (i.e., those demonstrating the most robust relations with various forms of impairment) with respect to Overall, Home-School, and Community-Leisure impairment domains. Parents of a nationally representative sample of 1742 children (50.17% male) aged 6-17 years completed rating scales of ADHD, SCT, and impairment. Assessment of Bridge Expected Influence suggested eight bridge items primarily from impulsive and Task Completion (i.e., overlapping SCT and inattentive) domains that demonstrated relations with impairment in school performance, completing chores at home, interacting with family members, following rules, and playing sports. Sum scores only including bridge items exhibited relations with Overall, Home-School, and Community-Leisure impairment domains comparable to that of sum scores including all items. Bridge impairment areas were generally consistent across "Childhood" (6-11 years) and "Adolescence" (12-17 years). Problems listening and slowness emerged as bridge items in Childhood, whereas difficulties following through on instructions, problems waiting one's turn, and social withdrawal emerged in Adolescence. Given the comparable validity of ADHD- and SCT-related bridge items versus all items, bridge items, together, may be the most efficient indicators of impairment. Further clarification is needed across development to inform personalized assessment and intervention protocols that account for item-level heterogeneity in ADHD, SCT, and impairment phenotypes.

Factors Associated with Healthy and Impaired Social Functioning in Young Adolescents with ADHD

There is variability in the extent to which adolescents with attention-deficit/hyperactivity disorder (ADHD) exhibit social impairment, as the same diagnosis does not necessarily entail impairment in the same area(s) of functioning. The current study entailed a cross-sectional examination of enhancers to healthy social functioning and risk factors to parent- and self-rated social impairment in 324 middle school youth (ages 10-14 years) with ADHD. A series of binary logistic regression analyses were conducted to evaluate a risk-resilience model for social functioning, including testing compensatory (i.e., main; buffering) and protective (i.e., interaction) effects of enhancers in the presence of identified risk factors. Youth conduct problems, youth depression, and negative parenting emerged as risk factors. Self-rated social acceptance, activity participation (breadth and intensity), and parent involvement were enhancers of healthy social functioning. Of these enhancers, activity participation (breadth and intensity) and parent involvement showed buffering effects against the negative impact of the risk factors on social functioning. None of the enhancers displayed protective effects. The findings of this study enhance our understanding of the social functioning of young adolescents with ADHD, who comprise an understudied population relative to younger children with similar problems.

Evaluating the Factor Validity of the Children's Organizational Skills Scale in Youth with ADHD

Children and adolescents with ADHD often have difficulties with organization, time management, and planning (OTMP) skills, and these skills are a common target of intervention. A limited array of tools for measuring these abilities in youth is available, and one of the most prominent measures is the Children's Organizational Skills Scale (COSS). Although the COSS fills an important need, a replication of the COSS factor structure outside of initial measure development has not been conducted in any population. Given that the COSS is frequently used in ADHD research, the current study evaluated the factor structure of the parent-rated COSS in a sample (N = 619) of adolescents with ADHD. Results indicated that the original factor structure could be replicated, although the use of item parcels appeared to affect model fit statistics. An alternative bi-factor model was also tested that did not require the use of parcels, with results suggesting similar model fit in comparison to the original factor structure. Exploratory validity tests indicated that the domain-general factor of the bi-factor model appears related to broad executive functioning abilities.

Social Functioning in Children With or At Risk for Attention Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Considerable work has demonstrated significant impairment in social functioning for children with attention deficit/hyperactivity disorder (ADHD). The social functioning profiles of children with ADHD are marked by impairments across diverse domains as they tend to experience greater rates of peer rejection, have lower levels of social skills, and have impaired social cognitions. The purpose of this study was to (a) quantitatively examine the association between ADHD and deficits across several domains of social functioning (peer functioning, social skills, social information processing), (b) examine differences in the magnitude of such associations, and (c) examine the effect of potential moderators. A meta-analysis of 109 studies (n = 104,813) revealed that children with ADHD have the most impairment within the peer functioning domain (weighted effect size [ES] r = .33) followed by significantly smaller effects within the social skills (weighted ES r = .27) and social information-processing domains (weighted ES r = .27). When examining potential moderators, results revealed that the association between ADHD and deficits within the social skills domain was weaker among studies that controlled for co-occurring conduct problems (CP). Studies that utilized sociometric and teacher reports of peer status reported the largest effects within the peer functioning domain. In addition, studies that utilized the "gold standard" approach to diagnosing ADHD documented the largest effects within both the social skills and peer functioning domains. Last, studies utilizing younger samples revealed the largest effects for deficits within the peer functioning domain. Theoretical and clinical implications are discussed.

Impaired Social Decision-Making Mediates the Association Between ADHD and Social Problems

Attention-deficit/hyperactivity disorder (ADHD) reliably predicts social dysfunction, ranging from poor social competence and elevated peer rejection to inadequate social skills. Yet, the factors mediating predictions of social problems from childhood ADHD are not well understood. In the present study, we investigated social functioning in 186 (69 % male) 6 to 10 year-old (M = 7.88, SD = 1.17) children with (n = 98) and without (n = 87) ADHD who were followed prospectively for two years. We implemented a well-validated measure of social problems as well as a novel social decision-making task assessing dynamic response to changing affective cues at the two-year follow-up. According to separate parent and teacher report, baseline ADHD symptoms positively predicted social problems at the two-year follow-up; individual differences on the social decision-making task mediated this association. This finding was replicated when ADHD dimensions (i.e., inattention and hyperactivity/impulsivity) were separately examined. These findings suggest that the deficient use of affective cues to effectively guide behavior may partially underlie poor social functioning among children with ADHD. If replicated, these preliminary findings suggest that social skills interventions that target interpretation of affective cues to aid in social decision-making behavior may improve social outcomes negatively affected by early ADHD symptoms.

Emotion perception in adult attention-deficit hyperactivity disorder

This study examined identification of emotional information in facial expression, prosody, and their combination in 23 adult patients with combined attention deficit-hyperactivity disorder (ADHD) versus 31 healthy controls (HC) matched for gender, age, and education. We employed a stimulus set which was carefully balanced for valence as well as recognizability of the expressed emotions as determined in an independent sample of HC to avoid potential biases due to different levels of task difficulty. ADHD patients were characterized by impaired recognition of all employed categories (neutral, happiness, eroticism, disgust, anger). Basic cognitive functions as assessed by neuropsychological testing, such as sustained attention, constancy of alertness, and verbal intelligence partially explained lower recognition rates. Removal of the correlated variance by means of regression analyses did not abolish lower performance in ADHD indicating deficits in social cognition independent of these neuropsychological factors (p < 0.05). Lower performance correlated with self-rated emotional intelligence (r = 0.38, p < 0.05) indicating that adults with ADHD are aware of their problems in emotion perception. ADHD patients could partly compensate their deficit in unimodal emotion perception by audiovisual integration as revealed by larger gains in emotion recognition accuracy during bimodal presentation (p < 0.05) as compared to HC. These behavioral results can serve as foundation for future neuroimaging studies and point rather towards sensory-specific regions than audiovisual integration areas in perception of emotional information in adult ADHD.