Friendship Difficulties Among Children and Adolescents with ADHD: Why They Occur and How Parents and Teachers Can Address Them

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1 Friendship Difficulties Among Children and Adolescents with ADHD: Why They Occur and How Parents and Teachers Can Address Them Amori Yee Mikami, PhD University of British Columbia WESTERN PSYCHIATRIC INSTITUTE 7 th Annual Conference on ADHD and Executive Function September 14, 2018

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3 ADHD and peer problems

4 Peer rejection Disliked by peer group Occurs within 1 hour of meeting unfamiliar peers Friendship problems Few friends Less closeness, positivity in friendships More conflict, negativity in friendships Instability of friendships What about for Inattentive kids? (Hoza et al., 2006) (Normand et al. 2011; 2013)

5 Peer rejection matters Peer problems persist across lifespan Children with ADHD have higher risk for: delinquency, depression, school failure, drug abuse, anxiety, eating disorders If peer rejected, the risk increases Why? (Marshal, Molina, & Pelham, 2003; Greene, Biederman, et al., 1997; Mikami & Hinshaw, 2006; Mikami et al., 2008)

6 But friendships also matter If a child has good friends, it might protect against adjustment problems even if the child remains disliked overall Friendship may be a good treatment target (Bagwell et al., 1998; Mikami, 2010)

7 Interventions for ADHD Multimodal Treatment of ADHD Study Medication Behavioral management/social skills training Medication + behavioral/social skills training Community care (control) (MTA Cooperative Group, 1999; Hoza et al, 2006)

8 Barrier #1 Why is it so hard to change peer problems in ADHD? Knowing what to do Doing what you know

9 Why is it so hard to change peer problems in ADHD? Negative reputations with peers Barrier #2 Stigma about ADHD

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11 So how can we address these barriers? Parental Friendship Coaching (PFC) Making Socially Accepting Inclusive Classrooms (MOSAIC)

12 Parental Friendship Coaching 10 group sessions, 90 minutes each Parents of kids with ADHD and peer problems No child treatment component

13 Training parents to: Helps kids do what they know instruct their child in social skills (and reinforce them) PLUS provide social opportunities where peers are likely to have fun with children with ADHD Helps change peers impressions

14 Helps kids do what they know Parents. How to listen so kids will talk and talk so kids will listen Guidance about friendship behaviors Practicing friendship behaviors at home Setting expectations for good friendship behaviors In the moment reminders Catching the child being good

15 Parents. Network and befriend other parents Arrange opportunities to socialize with peers Keep playdates fun Monitor and intervene (without looking like it) Overcome parental shyness, stigma Mikami, Jack, Emeh, & Stephens, 2010; Mikami, Chong, Saporito & Na (2015); Frankel et al. (1997; 2011)

16 Example Sarah, age 9, gets very upset when she is losing at games. She then tries to change the rules so she will win.

17 Example Her parents stopped playdates because nobody will come over, and Sarah shows poor sportsmanship. Her parents stopped family game night because Sarah throws tantrums and it is stressful for the whole family.

18 What to do Restart family game night Talk to Sarah first about being a good sport What does your face look like What does your body look like What can you say to yourself? What can you say to the other person?

19 What to do Before the game, remind Sarah of what being a good sport looks like During the game, praise Sarah when she is showing good sport behavior If Sarah starts to have trouble, repeat what behavior you want to see Consider giving a reward if Sarah shows good sport behavior Stay calm and positive

20 What to do Identify a peer who might get along with Sarah This peer should be positively inclined toward Sarah or at least not dislike her Talk to the teacher about who would be good Volunteer at school or other extracurricular activity and check out other kids Chat up other parents at parent events

21 What to do Meet the parent of this peer Invite the peer for a playdate Prepare Sarah regarding good sport behaviors Could do a role play Consider providing a reward for doing well During the playdate, sneaky monitor for poor sport behaviors and intervene if needed Talk to Sarah after the playdate (praise)

22 Friendship first Peer acceptance may follow

23 Pilot study 62 children with ADHD (ages 6-10, 67% male) Random assignment to PFC or no intervention Mikami, Jack, Emeh, & Stephens (2010); Mikami, Lerner, Griggs et al. (2010)

24 Results Parents reported more social skills fewer negative behaviors on playdates Teachers reported classmates accepted and liked the child more No measures of friendship quality

25 Changes in parental behavior Receipt of treatment (randomly assigned) Formerly significant; now B=.02; p>.10 Improved parent and teacher ratings of child peer relations B=.14; p=.03 Changes in observed parental coaching B=.15; p=.02

26 Next step for PFC

27 Initial lessons learned 172 children with ADHD and peer problems Families randomized to PFC versus psychoeducation/support 163 completed intervention 161 have post-test data 154 have follow-up data Caveat: extremely preliminary data!

28 Demographics Ages 6-11 (mean age = 8.5) 70% male 69% ADHD combined, 26% inattentive, 5% hyperactive/impulsive 32% comorbid ODD/CD 27% comorbid depression/anxiety 59% medicated (stable dose) 67% white, 16% mixed, 6% asian

29 10, 90-minute group sessions Follows manualized PFC curriculum Skills teaching with focus on boosting children s friendships Therapist-driven content, therapist teaching parents

30 Coping with ADHD through Relationships and Education 10, 90-minute group sessions Psychoeducation about ADHD and friendship problems Advocacy and support, networking Parent-directed content, parents teaching parents

31 Primary outcome: Friendship quality Questionnaires reported by child, parent, friend, and friend s parent Observations of child and friend interactions on two lab-based tasks

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33 Positive friendship quality: Questionnaires PFC CARE baseline post-test follow-up

34 0.75 Negative friendship quality: Questionnaires PFC CARE baseline post-test follow-up

35 0.48 Positive friendship quality: Observations PFC CARE baseline post-test follow-up

36 Negative friendship quality: Observations PFC CARE baseline post-test follow-up

37 However Compared families with previous psychosocial treatment for ADHD (61%) to families for whom this was their first treatment (39%) Confusion Relief Guilt Questions

38 Positive friendship quality: Questionnaires PFC previous tx CARE previous tx baseline post-test follow-up

39 Positive friendship quality: Questionnaires PFC first tx CARE first tx baseline post-test follow-up

40 0.75 Negative friendship quality: Questionnaires PFC previous tx CARE previous tx baseline post-test follow-up

41 0.75 Negative friendship quality: Questionnaires PFC first tx CARE first tx baseline post-test follow-up

42 Positive friendship quality: 0.48 Observations PFC previous tx CARE previous tx baseline post-test follow-up

43 Positive friendship quality: Observations PFC first tx CARE first tx baseline post-test follow-up

44 Negative friendship quality: Observations PFC previous tx CARE previous tx baseline post-test follow-up

45 Negative friendship quality: Observations PFC first tx CARE first tx baseline post-test follow-up

46 Early reflections Children are improving somewhat in friendship quality No differences in PFC versus CARE on average However, it may depend on whether this is the family s first treatment or not

47 Early reflections

48 Secondary outcome: Friendship behavior Friendship behaviors Friendship quality

49 0.48 Positive friendship behavior: Observations PFC CARE baseline post-test follow-up

50 0.24 Negative friendship behavior: Observations PFC CARE baseline post-test follow-up

51 6 Parent report negative friendship behavior PFC CARE baseline post-test follow-up

52 Parent report positive social skills 84 PFC CARE baseline post-test follow-up

53 Teacher report positive social skills 89 PFC CARE baseline post-test follow-up

54 To be continued Parent behaviors Child adjustment Child peer acceptance

55 Early reflections Children may be improving more on friendship behaviors than friendship quality Parents think PFC is better for this

56 MOSAIC Mikami, Griggs, Lerner et al. (2013); Mikami, Reuland, Griggs, & Jia (2013)

57 MOSAIC Behavior management and social skills teaching of children with ADHD Helping peers to be more welcoming to children with ADHD + Helps change peers impressions Mikami, Griggs, Lerner et al. (2013); Mikami, Reuland, Griggs, & Jia (2013)

58 MOSAIC teachers. Show peers they like students with ADHD (despite behavior problems) Find commonalities between children with ADHD and peers Point out genuine positive qualities in children with ADHD in front of peers

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60 Special thanks to My wonderful lab and students Participating families and teachers Funding from Institute of Education Sciences (Goal 2, ) Canadian Institutes of Health Research (Operating Grant ) Michael Smith Foundation for Health Research (Scholar Award ) NIMH (R21 and R03 mechanisms ) Amori Yee Mikami