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Section 17
Social Skills Training for ADD Children

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Children with attention deficit hyperactivity disorder (ADHD) often have difficulties in the social domain. Bothersome, unpleasant, noncompliant, and socially inept are adjectives often used to depict these children, and parents and teachers frequently report interpersonal problems as one of the critical elements defining the disorder. These interpersonal problems tend to be enduring and repetitive and to intensify over time. There is some evidence that children with ADHD with interpersonal problems are at increased risk of developing substance abuse problems later in life. Even the effect of labeling a child as “ADHD” is thought to have a negative impact on peer attributions and behavior. Stimulated by the National Institutes of Health Consensus Conference on ADHD (National Institutes of Health, 2000), a great deal of research in ADHD has begun to focus on the differences between children with Inattentive subtype (ADHD–I) and children with the Combined subtype (ADHD–C). Children with ADHD–I, of which far less is known, are likely to be neglected by their peers and have skill knowledge deficits rather than performance difficulties. Conversely, children with ADHD–C are more likely to evoke peer rejection and have difficulties with skill performance rather than skill knowledge. Despite these noted differences, some research posits the two subtypes are comparable in terms of social functioning. Additional research is needed to help clarify the social profiles of these children. Barkley and colleagues concluded that children with ADHD–C are more deviant in peer relations. Barkley’s behavioral inhibition theory of ADHD suggests that emotional regulation difficulties in the ADHD–C subtype largely account for the peer difficulties experienced by these children. Other research has similarly found that children with ADHD–C have more difficulty in peer relations and are more likely to demonstrate aggression, a trait less prominent in the ADHD–I subtype. Based primarily on ADHD–C, several differing conceptualizations exist to help explain social dysfluency in ADHD (e.g. Saunders & Chambers). Summing up the previous models, Pfiffner, Calzada, and McBurnett concluded that problems in (a) affect regulation, (b) behavioral intensity control, (c) cognitive distortions, and (d) lack of social skills are common elements in all conceptualizations. Many different remediation strategies and interventions exist and focus on these core elements of social dysfunction, including social skill interventions. Social skills training (SST) approaches have been demonstrated to be effective for improving the social functioning of aggressive and antisocial children. Individual SST interventions and classroom-based models exist, yet most SSTs are group-based formats in which children can learn and practice appropriate interpersonal skills (Hinshaw, 1996). In addition to children’s groups, most programs also include concurrent parent sessions aimed at improving general parenting skills. Parent groups alone, however, have been successfully used to address children’s social skills.

Hypotheses
Based on a thorough review of the literature, we generated the following research hypotheses: 1. Children with ADHD who receive SST, compared with children with ADHD in the control group, were expected to improve on parent and child ratings of social behavior at the posttreatment and follow-up periods. Our hypothesized mechanism of change is behavioral (e.g., teaching social skills) rather than through improvements in the child’s cognitive control of behavior. 2. The diagnostically heterogeneous groups were hypothesized to improve on ratings of social behavior as compared to the groups comprised of diagnostically homogeneous children. 3. Finally, with regard to the individual children in the SST groups, children with ADHD–I, compared with children with ADHD–C, were expected to demonstrate greater improvements. Our hypothesis is based on the lower rates of oppositional defiant disorder (ODD), less emotional regulation difficulties seen in ADHD–I, as well as the primary knowledge, rather than performance, deficits seen in ADHD–I.

Treatment Curriculum
For the purpose of this study, SST was defined as treatment aimed at increasing positive prosocial behaviors exhibited by the children. Our curriculum was a slightly modified version of Milich and colleagues’ 10-week treatment program; we altered the curriculum to address the skills and deficits of children with ADHD within 8 weeks.

Treatment protocol. Children in the ten treatment groups received eight 90-min group sessions during consecutive weeks. To ensure consistency, all sessions were taught by the same two therapists, a male doctoral student in psychology and a female master’s student in social work. These two treatment providers received considerable training in the SST intervention, and intervention delivery was standardized across providers.  Multiple target social skills were modeled, role played, and coached to promote acquisition and generalization of skills. Six modules were covered during the 8-week class: (a) cooperation with peers—learning how to take other’s perspective and share; (b) problem solving—using a five-step procedure for identifying the problem and generating and implementing solutions; (c) recognizing and controlling anger—inhibiting verbal and nonverbal interactions in a response to provocation; (d) assertiveness—group entry techniques and using assertive communication with others; (e) conversations—giving and receiving compliments, how to give and receive appropriate complaints; and (f) accepting consequences—gracefully accepting a perceived negative circumstance as a choice for dealing with frustration. These modules targeted many of the social-interaction deficits that children with ADHD often exhibit with their peers (e.g., Hinshaw, 1996).

To maximize child attendance and involvement, the structure of each session was as follows: First, in all sessions after the initial group meeting, group leaders elicited a brief review of the child’s report of his or her use of the target social skill during the previous week. Second, leaders introduced the new skill to be learned (one per week) through didactic and modeling styles of presentation. A review of how, why, and when to employ the skill followed with extensive child participation and a group challenge game (e.g., if all children were able to correctly reproduce the skill(s) covered, all group members earned points) was introduced to reinforce participation and attention to task. Third, the therapists modeled the skill several times. Fourth, the children role-played skill use, using brief scripts of common problem situations with peers or siblings (e.g., entering a game, being teased), with parents (e.g., not getting to do a desired activity), and in the classroom (e.g., being distracted by classmates). Children evaluated each other’s performance (thumbs down or up) of the social skill immediately after each role play and were called on to give specific reasons for their ratings. Finally, the children participated in a 15-min free period in which they were prompted to use positive social skills with one another, and they received points for each correct use of a target skill. Children were given a homework assignment to practice the skill at home and at school and were held responsible for reporting on their homework at the next group meeting. To limit disruptive behavior as well as distractibility in the group, children earned points for attending, following group rules, participating, and completing homework. Points (individually earned) during each session were exchanged for child-selected games or activities during the last 15 min (free period). Brief redirections and time-outs were issued for destructive behavior. Three parent sessions, at Weeks 1, 4, and 8, were included. During the initial meeting, parents were informed of (a) the course of treatment, (b) the methods that would be employed during the children’s group, (c) a brief description of each skill module (e.g., cooperation) that would be covered, and (d) a discussion of how to properly assess and monitor homework completion. The parents were not informed, however, as to which treatment group (diagnostically homogeneous or diagnostically heterogeneous) their child was assigned. Failing to inform the parents of their child’s treatment group type was done to limit any potential effects on their ratings as a function of knowing their children’s treatment group type. The parent meeting at Week 4was utilized for assessing progress and discussing behavioral management techniques (e.g., time-out, response cost, token economy) and also permitted parents to exchange information among themselves. Our final parent meeting, held during Week 8,was utilized for data collection as well as a brief synopsis of the children’s group. In addition, this group meeting also provided parents opportunities to discuss (in the group setting) any changes, both positive and negative, observed in their child.

Discussion
Our results do not strongly support the efficacy of SST, especially for children with comorbid ODD. Despite this, an area of some promise is the improvement noted in assertion skills. Furthermore, the diagnostic heterogeneity of SST groups for children with ADHD appears to be a variable worthy of further investigation.Our preliminary results indicate that diagnostically heterogeneous groups produced greater improvements on parent report of their child’s cooperation and assertion abilities as well as children’s report of their own empathy skills. Diagnostically heterogeneous groups appear promising for children with ADHD–C, yet may be contraindicated for children with ADHD–I. Diagnostically homogeneous groups, on the other hand, generated greater decreases in externalizing behaviors at posttreatment yet not at follow-up. Finally, children with ADHD–I improved more in assertion skills, yet the two diagnostic entities did not differ in improvement levels across all other social skills. Our results are consistent with other research that has failed to demonstrate the efficacy of SST groups for children with ADHD. There are a variety of potential reasons for this lack of empirical validation, yet most authors have implicated the primacy of the ADHD symptoms as well as the impact of comorbidity. Our finding, in contrast to the MTA study (Conners et al., 2001), found that ODD may increase the social impairment in children with ADHD and suggests that comorbid ODDis an important treatment variable to consider. In addition to comorbid ODD, the success of our SST may have been limited by the predominance of the ADHD symptoms, particularly impulsivity. Impulsiveness has been defined as the primary problem in children with ADHD and has been suggested as being chiefly responsible for the negative functional outcomes in ADHD. Our SST did not specifically target impulsivity (or other ADHD symptoms), and it was not surprising to see no decreases in problematic behaviors. What is interesting, however, is that more positive, prosocial skills did not develop. This may be due to the overriding impact of poor impulse control (Barkley, 1997) as well as the concomitant learning disabilities often found in ADHD. Although not formally assessed or controlled for in our study, learning disabilities may have interfered with the children learning and implementing these social skills.

Assertion is the primary area of social functioning that did appear to be positively impacted. Our SST participants improved in assertion skills, yet, given Barkley’s behavioral inhibition theory of ADHD, it is unclear if improvements in assertion are a beneficial improvement for children with ADHD–C. Possibly for this reason, the overwhelming majority of parents of children with ADHD–C rated their child as unchanged by the SST, although none viewed their child as “worsened” after participation. Our SST led to improvements in parents’ view of their child’s cooperation abilities as well as children’s view of their own empathy skills. Diagnostically heterogeneous groups, although appearing to have drawbacks for children with ADHD–I, did lead to improvements in cooperation and empathy across both diagnostic groups. (Empathy improvements are particularly encouraging in light of the research indicating children with ADHD have difficulty with empathy development) Improvement in cooperation and empathy skills is consistent with other group psychotherapy research and suggests that group heterogeneity provides an important context for interpersonal interaction. Supporting this notion, Putallaz and Wasserman found that some children fail to pair the appropriate social skill with the social cues present. In this sense, familiar social cues may have substantial implications and SSTs should incorporate as many representative social cues as possible. If only a limited number of social cues are present in the group setting, the trained behaviors are likely to occur only in settings or situations in which the same or similar social cues are present. Therefore, the heterogeneity of the group could have assisted in increasing the number of social cues to which the group members were exposed, leading to the increases reported in cooperation skills. Evidence from SST with unpopular children suggests that heterogenenous peer involvement contributes significantly to improvements in peer interactions. Parents of children in the diagnostically homogeneous groups reported greater decreases in externalizing behaviors at posttreatment but not at follow-up. Our SST did not include a focus on decreasing externalization, although behavioral management techniques were outlined in the second parent meeting. It may be that, as a result of these three sessions, parents altered the manner in which they viewed their own child’s social skills. For instance, a parent of child with ADHD–C may view his or her child as more assertive after hearing of the behaviors of children with ADHD–I. Likewise, a parent of a child with ADHD–I may view his or her own child as more cooperative after hearing about children with ADHD–C. Generalizability and maintenance, although planned for in our SST design, were not sustained. Children with ADHD need specific prompts to highlight appropriate setting-specific behavior as well as reinforcement to support and strengthen their use of appropriate social skills. Both of these likely do not exist outside of the clinic setting, helping to explain our lack of generalizability and maintenance.

Another reason for the limited efficacy of our SST may have been the exclusive focus on the child with ADHD while neglecting the peer group. Reciprocal processes between unpopular children and their peers maintain peer difficulties. Multimodal interventions are a necessity in remedying social deficits in children with ADHD, and including the child’s natural peers may have improved our outcomes. Perhaps most striking, a small but palpable minority of parents of children with ADHD–I rated their child as socially worse after treatment completion. All of these parents had children in the diagnostically heterogeneous groups, possibly implicating social contagion effects, with fellow participants serving as a stimulus for imitation. Children with ADHD–I may have adopted some of the ADHD–C type behaviors and appeared worse to their parents. Alternatively, the acceptability of certain behaviors (e.g., hyperactivity) varies as a function of peer group norms, and diagnostically heterogeneous treatment groups may have had group norms that were more accepting of negative behaviors. Another salient finding from our study was the sizeable discrepancy between how the parents and children rated the child’s social skills. The children uniformly viewed their social skills as being more advanced than their parents did. This may be due to the external attributions and embellished self-assessments that have arisen adaptively in children with ADHD.

The lack of appreciable findings is likely not due to our choice of SST, which attempted to provide the children with social skills knowledge and then permitted ample opportunity to practice these skills in a therapeutic environment. Attention deficits of the children were taken into consideration in treatment planning, and we focused on skill acquisition and accurate application. Our SST program is consistent with Guevremont’s approach and focused on the most prominent social skill deficits for children with ADHD. Our SST also used nonaversive methods (e.g., coaching, modeling, and reinforcement), techniques preferred by parents and teachers. Although it is only conjecture, one possibility is that utilization of these methods may have enhanced treatment acceptability, contributing to our high attendance and retention rates. In addition, parental involvement, although not a primary component of our SST program, was maintained via three 90-min parent group sessions. Lack of parent involvement has been a criticism of other SST programs, and including parents isnot likely to have negatively affected our outcomes.
- Antshel, KM and R Remer; Social skills training in children with attention deficit hyperactivity disorder: a randomized-controlled clinical trial; Journal of Clinical Child and Adolescent Psychology; Mar 2003, Vol. 32 Issue 1, p 153

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Personal Reflection Exercise #3
The preceding section contained information about social skills training for children with ADD.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 17
According to the study conducted by Antshel, what area of social functioning is most positively impacted by social skills training? Record the letter of the correct answer the Answer Booklet.