friendsAttention Deficit Hyperactivity Disorder (ADHD) manifests with symptoms of inattentiveness, hyperactivity and impulsivity, in varying combinations, and affects around five percent of the school-going population. Due to the pervasive nature of these symptoms in childhood, the diagnosis cannot be made unless there is significant functional impairment associated with the symptoms. Academic underachievement is perhaps the most obvious area of impairment cited, but in many cases it is the domain of social functioning which causes the most distress to the child. This article will focus on the impact of ADHD on peer relationships.

Children with ADHD are often gregarious and may have little or no difficulty initiating friendships, but over time they often have difficulties maintaining these relationships. Excessive impulsivity causes children to lash out physically and blurt out verbally. This is especially true of children with the combined subtype of ADHD, more common in boys, who present with significant hyperactivity and impulsivity. The normal ‘filter’ which assists in restraining impulses is inadequately developed in these children. They battle to take turns in games and their over-exuberance and excitability result in excessively rough play and an inability to know ‘when to stop.’ Without necessarily intending to be malicious or hurtful, hyperactive children easily become labelled as bullies, by both peers and teachers. In the preschool years it is often this impulsive aggression which causes the most impairment and can jeopardise a child’s school placement. They thus often become ostracised, which further erodes self-esteem and a vicious cycle ensues with ever-increasing desperate attempts to win approval.

The inattentive subtype of ADHD tends to be commoner in girls. In this subtype the prevailing symptoms are those of inattentiveness, without excessive hyperactivity or impulsivity. These children tend to have fewer social problems, but as a group they are by no means unaffected in this area. They struggle to maintain concentration whilst listening to their peers and thus often miss out on aspects of conversations, for example when the rules of a game are explained. There is also a growing body of research revealing more subtle social skills deficits in ADHD, for example recognising facial expressions and tone of voice. Taken together, these deficits leave the child and her peers frustrated and also result in alienation from the group. In addition, academic underachievement itself can impact on a child’s social standing; if she is always the last one finished she is less likely to be chosen for group activities and again can be excluded as a result.

ADHD commonly co-exists with other conditions, which are often themselves associated with difficulties forming and maintaining friendships. Depression, anxiety disorders, Autistic Spectrum Disorder and Oppositional Defiant Disorder may all co-occur with ADHD may all be more socially impairing than ADHD itself.

The quality of peer relationships is thus of paramount importance in assessing a child for ADHD, but is also a very important target symptom in planning and monitoring treatment. After initiation of pharmacological and/or behavioural treatment, social functioning usually improves along with the core ADHD symptoms of inattentiveness, hyperactivity and impulsivity; if it doesn’t we must question the effectiveness of our treatment. In fact, certain children become excessively quiet and subdued on ADHD medications and may be socially worse off than before the treatment, even if their academic functioning has improved. It is thus very important to monitor for this side-effect and take appropriate action, which might entail changing the dosage or switching the medication.

There are some interesting findings on self-esteem in ADHD. There is evidence that self-esteem is inherently low in those with the condition, and not exclusively mediated by repeated negative feedback. This may at least partly explain the correlation between ADHD and depression. Nonetheless, a child’s self-concept is a very helpful barometer in assessing the effectiveness of treatment of this condition, and whilst improved academic functioning is certainly important, it is often the quality of relationships – positive feedback from those at home and at school – which play a more decisive role in a boosting a developing child’s self-confidence and self-esteem.


Dr Brendan Belsham is a child psychiatrist and author of What’s the fuss about ADHD?