Although it is well established that childhood ADHD and rejection by peer each predict a wide range of future adjustment problems, it is also apparent that some children with these risk factors fare quite well during adolescence. What helps some youth at risk for negative developmental outcomes make more satisfactory adjustments while many others do not? This is an extremely important question as understanding what protects some children with ADHD from developing significant emotional and behavioral problems during adolescence could perhaps help to prevent many more from experiencing these negative outcomes.
Identifying factors that protect some children with ADHD and/or peer rejection from experiencing negative outcomes during adolescence was the focus of a study published recently in the Journal of Abnormal Child Psychology [Mikami & Hinshaw (2006). Resilient adolescent adjustment among girls: Buffers of childhood peer rejection and attention-deficit/hyperactivity disorder, 34, 825-839]. The focus on examining protective factors in children with ADHD is a unique aspect of this study; what makes it more unique is that it examines development in a sample of girls with ADHD as well as the contribution that ADHD may make to the development of eating pathology.
Participants 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. (For a review of current ADHD diagnostic criteria go to www.helpforadd.com/criteria.htm For information about evaluation guidelines, go to www.helpforadd.com/evaluate.htm )
Fifty-three percent of girls 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 represented.
All girls - those with ADHD as well as the comparison girls - participated together in a 5-week summer enrichment day camp. 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. 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. (Note: Results pertaining to behavior ratings were published earlier in another study reviewed in Attention Research Update. You can find the review of this prior study at http://www.helpforadd.com/2002/october.htm
Baseline measures (described below) were collected on all girls during their participation in the summer program. Approximately 4.5 years later, participants and their families were invited to return for a follow-up assessment so that girls' current functioning could be assessed.
The primary focus of this study was to examine how adolescent adjustment among girls with ADHD is related to the combination of risk and protective factors that were present during childhood. The risk and protective factors that were assessed during the summer camp program are described below.
Peer rejection - Girls were asked to identify 3 girls in their group that they liked the most and 3 girls that they liked the least. These nominations were used to identify girls that were consistently disliked and rejected by their peers. As noted above, findings from a number of studies indicate that children who are rejected by peers are at increased risk for a range of negative outcomes during their development.
Externalizing behavior - Externalizing behavior refers to acting out behavior such as aggression, oppositionality, and delinquent acts. Externalizing behavior tends to be stable over time, and many children with high levels of externalizing behavior show this pattern across development and get into more serious trouble during adolescence. Measures of externalizing behavior at baseline were obtained by having each girl's parents and teachers complete standardized behavior rating scales. In addition, camp staff provided daily ratings of the externalizing behavior displayed by each girl.
Internalizing behavior - Internalizing behavior refers to feelings of anxiety, depression, and worry. Although internalizing behavior tends to be less stable than externalizing behavior, girls develop depression and other internalizing disorders in adolescence at higher rates than boys, and internalizing behavior during childhood may thus be an important risk factor for girls. Baseline measures of internalizing problems were derived from ratings provided by parents, teachers, camp staff, and girls themselves.
Academic Achievement - Poor academic achievement during childhood is also a risk factor for negative adolescent outcomes. To assess academic achievement, each girl was administered the math and reading portions of the Wechsler Individual Achievement Test, a well-normed and widely used test of academic achievement.
Protective factors are those that buffer a child against the development of negative outcomes, even when one or more risk factors are present. The factors hypothesized to serve this role for girls with ADHD that were investigated in this study are described below.
Self-perceived scholastic competence - This pertains to an individual's belief that she is capable of academic success and may be especially important for girls with ADHD because of the major academic difficulties that ADHD frequently contributes to. Girls who believe they can succeed academically, even if ADHD is contributing to academic struggles, are more likely to remain invested in school and continue to focus on achievement. The authors suggest that believing in one's ability to succeed academically will predict better more positive adolescent outcomes above and beyond the child's actual level of academic achievement. In other words, believing you will succeed will predict better outcomes irrespective of what the child's actual academic competence at the time happens to be.
This protective factor was measured using the scholastic competence scale from the Harter Self-Perception Profile for Children. This 6-item self-report measure described different children (e.g., "some kids feel that they are very good at their school work, but other kids worry about whether they can do the school work assigned to them") and asked the participant to indicate which description was most like herself. The different items assessed the degree to which children perceived themselves to be good at understanding class work, good at tests, and intelligent.
Popularity with adults - Longitudinal studies of at-risk youth have consistently found that positive relationships with a non-parental adult increases the likelihood of youth becoming competent adults. Because girls who are popular with adults would be more likely to develop positive relationships with them, the authors hypothesized that girls with ADHD who were better liked by camp staff would have more positive outcomes as adolescents. Popularity with adults was assessed by having camp staff identify the 3 campers they liked most and the 3 they liked least. Ratings were averaged across the different staff so that a composite popularity score could be computed for each child.
Goal-directed play - The authors hypothesized that constructive, goal-direct play when alone, as opposed to disorganized and purposeless solitary behavior, would also buffer girls with ADHD from negative adolescent outcomes. This was based on the belief that purposeful, goal-directed play may reduce a child's feelings of sadness and loneliness when isolated. Girls' tendency to engage in goal-directed play was assessed by having camp staff make repeated observations of girls' behavior during the camp session, and recording girls' activity during periods when they were by themselves.
Approximately 4.5 years after attending the summer camp program, all girls - those with and without ADHD - and their families were invited back so that girls' adjustment during adolescence could be evaluated. Externalizing and internalizing behavior was measured by parent and teacher rating scales as well as girls' own self-reports; academic achievement was measured by the same achievement test that had been administered previously. Girls also completed the Eating Disorders Inventory so that pathology related to eating behavior could be assessed and the Substance Abuse Questionnaire so that information related to this important adolescent outcome could be obtained.
Although the authors' primary interest was to examine whether self-perceived scholastic competence, popularity with adults, and goal-directed solitary play protected girls with ADHD from negative adolescent outcomes, they first examined how adolescent functioning in girls with and without ADHD compared.
Not surprisingly, compared to girls without ADHD, those with ADHD had significantly higher rates of internalizing and externalizing symptoms at follow-up. They also had lower levels of academic achievement, higher rates of substance use, and, interestingly, higher rates of eating pathology.
Peer rejection during childhood was also independently associated with all of
these negative outcomes except for substance use. Contrary to the authors'
predictions, the combination of childhood ADHD and peer rejection did not confer
additional risk above that associated with each risk factor independently.