One of the most consistent findings in studies designed to identify children at risk for negative developmental outcomes is that peer relationship difficulties predict a number of subsequent problems. Rejected children (particularly those who act aggressively towards peers) fare significantly worse in adolescence and adulthood than children who can establish harmonious peer relations.

One reason this may occur is that rejected children often gravitate towards one another during adolescence, and then reinforce and escalate each other’s antisocial behavior. In addition, being rejected and not having a close friend is associated with feelings of loneliness and isolation, which, in turn, may increase the risk for becoming depressed.

An unfortunate aspect of ADHD for many children is difficulty with peer relations. Because of their impulsive behavior and difficulties reading social cues that may result from attention deficits, many children with ADHD have problems getting along with peers. Although this is well documented for boys with ADHD, there has been virtually no published research on peer relations and friendship patterns among girls with ADHD. It is thus quite encouraging that an excellent and long overdue study of this important area has recently been published (Blachman, D.R., & Hinshaw, S., (2002). Patterns of friendship among girls with and without Attention Deficit/Hyperactivity Disorder, Journal of Abnormal Child Psychology, 30, 625-640).

PARTICIPANTS

Participants in this study were 228 6-12 year old girls with ADHD from the San Francisco Bay Area, and 88 comparison girls without ADHD recruited from the same communities. Girls with ADHD were recruited from medical settings (e.g. pediatric practices, HMOs), mental health settings, school districts, ADHD parent groups, and newspaper advertisements. Comparison girls were recruited from similar school districts, newspaper ads, and medical settings. All girls in the ADHD group received a rigorous diagnostic evaluation - regardless of whether they had been previously been diagnosed - to insure that all met DSM-IV diagnostic criteria.

Among the participants, 53% were Caucasian, 27% were African American, 11% were Latina%, and 9% were Asian. Girls from families across the entire socioeconomic spectrum - from families on public assistance to upper income families - were also represented. Ninety-three of the girls with ADHD were diagnosed with the combined subtype (i.e. they showed both inattentive and hyperactive-impulsive symptoms), and 48 were diagnosed with the inattentive subtype (i.e. they showed predominantly inattentive symptoms and few if any hyperactive-impulsive symptoms). Thus, this sample of girls with ADHD was more diverse than the samples that had previously been studied, and it is especially important that girls with the inattentive subtype of ADHD were included. Relatively few girls meeting criteria for the hyperactive-impulsive subtype were found (this is the least frequently diagnosed ADHD subtype among school-age children), so these girls were not included in the analyses.

All girls - those with ADHD as well as the comparison girls - participated together in a 5-week summer enrichment day camp. Daily activities included classroom, art, drama, and outdoor activities that allowed for ample social interaction and extensive observation of girls' behavior. Classes of 25-26 girls (60% with ADHD and 40% comparison) participated together for each day's events. Activities were supervised by a head teacher and 4-6 counselors who were unaware of which girls had been diagnosed with ADHD and which had not. These staff provided daily ratings of the girls' behavior. Parents of girls who were already taking medication were asked to have their daughters participate in the camp while unmedicated, and the majority complied with this request.

QUESTIONS OF INTEREST

The researchers were interested in examining how several aspects of peer relations compared for girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD. These aspects of girls' peer relations included the following:

PEER REGARD

What was the general level acceptance by peers that characterized girls in the different groups. Were girls with either or both subtypes of ADHD less well accepted overall than girls without ADHD?

This aspect of peer relations was measured by having each girl identify three girls in their camp class that they liked most and three girls they liked least. These nominations were made at the beginning, middle, and end of camp (i.e. at the end of weeks 1, 3, and 5). Each girl received a score for positive peer regard and negative peer regard by dividing the number of nominations of each type that she received by the total number of classmates providing nominations.

FRIENDSHIP PARTICIPATION

Was there a difference in the extent to which girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive type of ADHD developed mutual friendships?

To assess this aspect of girls' peer relations, each girl was asked to name up to three girls she considered to be her best friends at camp. If a girl's nomination was reciprocated (e.g. if the girl child A nominated also nominated child A as one of her three best camp friends) the girl was considered to have a mutual friend. These friendship nominations were obtained after weeks 1, 3, and 5 and each girl could have from 0 to 3 mutual friends at each time.

FRIENDSHIP STABILITY

Was there a difference in the extent to which girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD maintained stable friendships over the 5-week camp?

The authors examined the stability of girls' friendships between weeks 1 and 3, between weeks 3 and 5, and between weeks 1 and 5. To do this, they began with girls who had at least one mutual friendship at week 1 (as discussed below, not all girls did), and examined whether girls involved in a mutual friendship after week 1 continued to identify one another as best friends after week 3.

For example, if two girls nominated each other as one of their three best friends after weeks 1 and 3, this friendship was considered stable. If either or both girls no longer nominated the other after week 3, however, the friendship was considered unstable.

This process was repeated for mutual friendships between week 3 and week 5, and between week 1 and 5. Thus, for each of the three time periods, girls received a score of 0 to 3 depending on the number of mutual friendships that persisted across the period.

FRIENDSHIP QUALITY

Was there a difference in the quality of mutual best friendships between girls without ADHD, girls with the combined type of ADHD, and girls with the inattentive subtype of ADHD?

To examine this issue, researchers had girls complete a 43-item scale designed to measure the quality of children's best friendships. The broad friendship qualities assessed on this scale included positive friendship features and negative friendship features.

Postive friendship features include such attributes as: validation/caring, companionship/recreation, providing help/guidance, successful conflict resolution, and intimate exchange.

Negative features of friendships that are inquired about include conflict, exclusivity, overt aggression, and relational aggression (i.e. relational aggression is defined as such actions as threatening to end the friendship if one's friend does not do as one wishes).

Friendship quality interviews were conducted with each girl 4 weeks into the camp. Because girls could have up to 3 mutual friends, they completed the questionnaire on their most stable mutual friend or the mutual friend that they identified as their highest ranked friend.