Symptoms of ADHD and Close Friendships in Adolescence

Abstract

Objective: This study examined the relationship of ADHD symptoms to different aspects of close friendship quality as rated by both adolescents (target adolescent and a close friend) within a friendship dyad. Method: Participants were 41 same-sex friendship dyads who completed questionnaires about their friendship. Separate symptom dimensions of ADHD (inattention and hyperactivity-impulsivity) were examined. Teacher and parent ratings of social functioning were also used. Results: Symptoms of inattention, hyperactivity-impulsivity, and overall ADHD were positively related to target-reported friendship quality, and symptoms of inattention and total ADHD were positively associated with friend-reported friendship quality. Potential explanations for these surprising findings were explored. Conclusion: Results suggest that the close friendships of adolescents with symptoms of ADHD may be distinct from the peer rejection commonly faced by this population and that adolescents with symptoms of ADHD may have at least one close, positive friendship. Treatment implications and future research directions are discussed.

Keywords

ADHD close friendships relationship quality adolescence

ADHD is a widely studied childhood behavioral disorder that often persists into adolescence and adulthood (Barkley, 2006). Peer relationships are particularly impaired among children and adolescents with symptoms of ADHD. Research has documented the general problems that youth with ADHD have with peers, including peer rejection and social skills deficits, but fewer researchers have focused on the close friendships of youth with the disorder (Hoza, 2007; Mrug, Hoza, & Gerdes, 2001). Furthermore, most research on peer relationships and ADHD have focused on children rather than adolescents, despite the importance of close friendships during adolescence and the persistence of social problems for many adolescents with ADHD (e.g., Helsen, Vollebergh, & Meeus, 2000; Stormont, 2001). Although some research has examined close friendships among adolescents with symptoms of ADHD, these studies have relied on one adolescent’s report of the friendship rather than the perspectives of both adolescents (Hoza, 2007; Mrug et al., 2001). The current study examined the relationship between symptoms of ADHD and different aspects of close friendship quality reported by both adolescents within the friendship.

The Importance of Close Friendships in Adolescence

Peer interactions become increasingly critical during adolescence; therefore, studying close friendships is important in understanding adolescent social development (Mrug et al., 2001; Normand, Schneider, & Robaey, 2007). High-quality close friendships characterized by mutual liking, intimacy, and companionship have been shown to predict better adjustment (e.g., greater school involvement and higher self-esteem; Berndt, 2002). In contrast, negative relationships (e.g., high in conflict) are associated with deleterious outcomes, including deviant peer associations and substance use (Mrug et al., 2001). However, understanding how friendships affect developmental outcomes is complex, as some research has found that high-quality friendships can also lead to negative outcomes, such as deviancy, corumination, and increased internalizing symptoms (Hartup, 2005; Rose, 2002). The impact of friendship quality on adolescent outcomes may depend on other characteristics of the friendship and the adolescents themselves, such as whether the adolescent displays deviant behaviors or symptoms of ADHD (Hartup, 2005).

The Friendships of Adolescents With ADHD

Research suggests that youth with symptoms of ADHD have significant peer problems (Hoza, 2007; Mrug et al., 2001; Normand et al., 2007); these peer problems have been linked to many detrimental outcomes (Hoza, 2007; Mrug et al., 2001), including higher school dropout rates, delinquency, and substance abuse (Lee & Hinshaw, 2004). Although many broad peer factors have been examined (e.g., deviant peer associations [Hoza, 2007], social skill deficits [Nixon, 2001], and having fewer friends [Mrug et al., 2001]), the most widely documented of these factors is peer rejection. Youth with ADHD experience greater peer rejection than their classmates without ADHD, and this rejection occurs early in peer interactions (Hoza, 2007; Landau, Milich, & Diener, 1998). However, research on peer rejection often uses classroom-level peer evaluations and does not assess specific friendship quality. Thus, it is important to examine how symptoms of ADHD are related to adolescent close friendships. It is also important to assess close friendship quality as perceived by both adolescents within a relationship to prevent bias. Examining the nature of these social relationships is important for understanding the complex social functioning among youth with ADHD, and understanding these complexities could help to inform interventions that target social problems.

The few studies that have examined close friendships among youth with ADHD suggest that these individuals have fewer close friendships, exhibit more socially aversive behaviors, and view close friendships differently than their peers with few symptoms of ADHD (e.g., Bagwell, Molina, Pelham, & Hoza, 2001; Heiman, 2005; Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003; Nijmeijer et al., 2008). Heiman (2005) found that children with ADHD defined close friends as fun companions, whereas those without ADHD defined close friends as emotionally supportive partners to share thoughts with. Other researchers (e.g., Nijmeijer et al., 2008) have noted the socially aversive behaviors (e.g., interrupting conversations) that these youth exhibit may affect their ability to establish and maintain close friendships, but none of these studies explicitly examined close friendship quality. Some studies (e.g., Heiman, 2005; Nijmeijer et al., 2008) found that individuals with ADHD have fewer close friendships as reported by parents and teachers; however, the youth themselves do not always report having fewer friends. Thus, relatively little is known about the close friendships among adolescents with symptoms of ADHD.

Factors Related to Understanding the Friendships of Adolescents With ADHD

Given the limited research on close friendships among adolescents with symptoms of ADHD, questions remain about the nature of these friendships. Understanding how adolescents with high levels of ADHD symptomatology view their close friendships, as well as how these friends view the adolescents, will help to inform the literature on social functioning and ADHD. Previous research has hypothesized about the nature of these dyadic relationships, suggesting that adolescents with high levels of ADHD may hold positively biased views of their own social functioning (the positive illusory bias [PIB]; Hoza, Pelham, Milich, Pillow, & McBride, 1993) or that adolescents with high levels of ADHD may have at least one mutual friendship that serves their social needs (Hoza et al., 2003), but very little empirical work has actually examined these theories. Furthermore, research on the close friendships of adolescents in general has highlighted important developmental differences (e.g., age) and gender differences related to aspects of adolescent friendships (Johnson, 2004; Phillipsen, 1999). Although these factors have also not been empirically examined related to friendships among adolescents with ADHD, there are important gender and developmental differences related to ADHD in general, and so exploring age and gender with respect to friendships is an important extension of the literature.

PIB

The PIB (Hoza et al., 1993) purports that adolescents with ADHD overestimate their social competence and the quality of their close friendships, as they tend to hold overly positive, inaccurate views of their social functioning compared to how others (e.g., teachers, parents, and classmates) view them (Hoza, Pelham, Dobbs, Owens, & Pillow, 2002; Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007). Although this theory has been consistently supported in previous research, most studies have examined the discrepancy between the adolescent’s report of their social functioning and an adult rater’s report of the individuals’ social skills, failing to consider how the individual’s friends or peers view their relationships. Thus, to expand this literature and to better understand how symptoms of ADHD affect adolescent social relationships, we used multiple informants of the adolescent’s social network (e.g., self, friend, teacher, and parent).

One close friendship and ADHD

Examining the specific friendships of adolescents with ADHD is important for understanding the broader social functioning of this group. For instance, although it is well documented that youth with ADHD are widely rejected by peers, some of these adolescents may have a positive friendship with at least one close friend who may buffer against the negative effects of rejection, assist with social adjustment, and meet their social needs (Hoza et al., 2003). However, because research on the dyadic friendships of adolescents with ADHD is scant, the current literature on social functioning of youth with ADHD has not addressed this question. There may be a subgroup of youth with ADHD who have at least one positive friendship that could potentially have a positive effect on their overall social adjustment. Addressing this research question could have important implications for treatment and intervention, as interventions might focus on enhancing the positive aspects of existing friendships.

Gender, age, and adolescent friendships

For youth with ADHD, like those without the disorder, gender and stage of development (age) may play an important role in friendships. Although no studies have directly examined the influence of age or gender on the friendships of adolescents with ADHD, there are significant gender differences in the prevalence of ADHD, as more males than females demonstrate symptoms of ADHD throughout childhood and adolescence (Barkley, 2006). Research also suggests that the manifestation and presentation of ADHD symptoms may change from childhood to adolescence, as many adolescents experience fewer hyperactive-impulsive symptoms but a similar number or increase in inattentive symptoms compared to younger children with ADHD (Barkley, 2006). Thus, examining whether the relationship between symptoms of ADHD and friendship quality differs for males and females or is related to age is important for understanding these adolescent close friendships.

There is substantial research on gender- and age-related differences in adolescent friendships in general. Regarding gender, males and females view adolescent friendships differently (Buhrmester & Furman, 1987; Johnson, 2004; Rose & Rudolph, 2006). Female adolescents develop more intimate friendships than males, and females focus on friendships characterized by loyalty, intimacy, and commitment (Clark & Ayers, 1992; Johnson, 2004). Male adolescents, however, focus on achievement, status, and dominance in friendships (Clark & Ayers, 1992; Phillipsen, 1999). Although males and females may approach close friendships differently and may develop intimate friendships in different ways, research suggests that the development of supportive, intimate friendships is important for adolescents of both genders (Phillipsen, 1999).

There are also important differences in how adolescents of different ages view and approach friendships, and the progression of friendships from early to late adolescence has been a focus of much research in developmental psychology (Buhrmester, 1990; McNelles & Connolly, 1999; Phillipsen, 1999). For instance, during middle childhood (ages 8-12), social interactions are focused on understanding peer group norms and being included in same-gendered peer groups (and avoiding peer rejection; Parker & Gottman, 1989; Phillipsen, 1999). During early adolescence, however, adolescent social goals shift to reflect more self-exploration, intimacy, and self-disclosure in close friendships (Buhrmester, 1990; Phillipsen, 1999). These developmental changes in social functioning and goals may correspond to the increasing desire for autonomy and identity that most adolescents face. Furthermore, it may be especially important for adolescents to maintain more supportive, intimate friendships than overall peer acceptance as they face more specific stressors related to adolescence (Buhrmester, 1990). Thus, adolescents with symptoms of ADHD, particularly more inattentive-related symptoms that are common in adolescence, may have more difficulties maintaining supportive, intimate friendships as they get older. Exploring whether the relationship between ADHD symptoms and friendship quality differ as a function of age is another important aspect of peer functioning for the current study.

The Current Study

The current study is one of the first to include adolescent close friend dyads and to use multi-informant data to explore different aspects of close friendships among adolescents with symptoms of ADHD. Specifically, we examined whether the target adolescent’s symptoms of ADHD were related to close friendship quality (positive and negative) as reported by both adolescents. We also examined whether symptoms of ADHD moderated the relationship between target and friend-reported friendship quality, as this may further elucidate the nature of the relationship. Furthermore, we explored whether the target adolescent’s perceptions of their friendships were consistent with adult ratings (e.g., parent and teacher) of social functioning, as large discrepancies might suggest a PIB, and we examined whether youth with symptoms of ADHD had at least one positive friendship. Finally, we examined whether gender or age moderated the relationship between symptoms of ADHD and friendship quality. As there is very little research on specific dyadic close friendships among adolescents with ADHD, our study represents an important step in moving the field forward. As a result, our analyses are largely exploratory, and we did not make specific hypotheses about the expected directions of our results.

Because this was a pilot study using a small community sample, we examined continuous symptoms of ADHD rather than clinical diagnoses. Clinical samples can be limiting as they often overrepresent severe cases of ADHD and individuals with comorbid disorders, and underrepresent females with ADHD (Carlson & Mann, 2000). Furthermore, some researchers have suggested that ADHD may be better conceptualized in adolescence using continuous symptoms rather than discrete diagnoses (Levy, Hay, McStephen, Wood, & Waldman, 1997). We also explored separate dimensions of ADHD (i.e., inattention and hyperactivity-impulsivity) to identify the effects of each core deficit as well as the overall effect of symptoms of ADHD on close friendship quality.

Method

Participants

Participants were 41 adolescents and their friends. “Target adolescent” refers to the adolescents of primary interest, whereas “friend” refers to the same-sex close friend that they brought to the study. The adolescents ranged in age from 11 to 17 (M_target = 13.83, SD = 1.72; M_friend = 13.90, SD = 1.90). A total of 58% of the dyads were female (n = 24). Roughly, 71% of the target adolescents and 75% of the friends identified as White, 27% of the targets and 22% of the friends identified as African American, and 2% each of targets and friends identified as Other racial ethnicities. The mean household income of the target adolescents was US$41,000 to US$60,000. A summary of the demographic information, as well as means for many of the measures described in the following sections, is included in Table 1.

Table 1.

Demographic Information and Summary of Descriptive Means

	Target				Friend
Variable	M	SD	%	n	M	SD	%	n
Demographics
Age	13.83	1.72	—	—	13.90	1.99	—	—
Female gender	—	—	58.5	24	—	—	58.5	24
Household income <US$40,000 per year	—	—	37.5	15	—	—	NA	NA
Household income US$40,000-US$80,000 per year	—	—	22.5	9	—	—	NA	NA
Household income >US$80,000 per year	—	—	40	16	—	—	NA	NA
Race
White	—	—	70.7	29	—	—	75.6	31
African American	—	—	26.8	11	—	—	22	9
Native American	—	—	0	0	—	—	2.4	1
Asian/Pacific Islander	—	—	0	0	—	—	2.4	1
Other	—	—	2.4	1	—	—	2.4	1
ADHD Rating Scale
Hyperactivity-impulsivity	4.90	5.15	—	—	NA	NA	—	—
Inattention	8.10	7.21	—	—	NA	NA	—	—
Total ADHD	13.00	11.61	—	—	NA	NA	—	—
Network of Relationships Inventory
Companionship	3.56	0.68	—	—	3.74	0.72	—	—
Instrumental aid	2.89	1.14	—	—	3.03	0.90	—	—
Support	2.89	1.18	—	—	3.10	1.29	—	—
Intimacy	3.24	1.17	—	—	3.35	1.16	—	—
Nurturance	3.44	0.97	—	—	3.47	1.01	—	—
Affection	3.56	0.96	—	—	3.80	0.80	—	—
Reliable alliance	3.78	1.00	—	—	4.04	0.85	—	—
Admiration	3.74	0.86	—	—	3.85	0.76	—	—
Positive friendship composite	3.39	0.80	—	—	3.55	0.78	—	—
Conflict	1.47	0.48	—	—	1.47	0.51	—	—
Antagonism	1.58	0.72	—	—	1.63	0.64	—	—
Negative friendship composite	1.52	0.54	—	—	1.55	0.54	—	—
Impairment Rating Scale–Parent Report
Parent-rated social problems with peers	0.98	1.37	—	—	NA	NA	—	—
Teacher-rated social functioning
Teacher-rated peer accepted	4.58	0.83	—	—	NA	NA	—	—
Teacher-rated peer rejected	1.17	0.48	—	—	NA	NA	—	—
Teacher-rated peer ignored	1.38	0.65	—	—	NA	NA	—	—

Note: NA indicates data for that variable was not collected for the participant.

Procedure

Target adolescents and their parents were recruited in two ways for the current study. One method involved recruiting families from a previous study that was completed the year before the current study examining family, cognitive, and emotional factors related to cigarette smoking among adolescents with ADHD and/or depression and a control group (total N = 67). Families were recruited for this earlier study using flyers and advertisements in various community locations to target adolescents with and without ADHD (department stores, public libraries, as well as local schools specializing in teaching children with ADHD and doctor’s offices). Families were contacted about the current study, and 25 target adolescents were recruited from the previous study this way. Of the families from the earlier study who refused to participate in the current study, approximately 7 (10%) declined participation because their child did not have a same-sex close friend to participate in the study with. Chi-square analyses revealed no significant differences in sex, race, or socioeconomic status between participants from the original study who completed the current peer study and those who did not. A one-way ANOVA similarly found no differences in age for participants who completed the current study versus those who did not.

The second recruitment method involved recruiting participants directly into the current study by posting and handing out flyers throughout the community and to the school specializing in teaching children with ADHD, similar to the methods employed in recruitment for the previous study. An additional 16 participants were recruited in this way, and chi-square analyses revealed no significant differences in sex, race, or socioeconomic status for participants who were recruited from the original study versus those who were recruited later for the current study. A one-way ANOVA also found no differences in age for participants who were recruited from the original study versus those who were recruited later.

Interested parents called the laboratory and were given information about the study, at which time they decided whether to participate. The target adolescents identified a same-sex close friend (“someone you know well, spend time with, and talk with about things that happen in your life”) to participate with them in the study, and the friend’s parents were contacted and told about the study to obtain consent and coordinate scheduling. Both adolescents rated how “good” of friends they considered one another on a 5-point scale (1 = not at all friends, 5 = best friends). The target and friend ratings were strongly correlated (r = .51, p < .001), and the mean of these ratings (M_target = 4.51, SD = 0.68; M_friend = 4.68, SD = 0.57) suggested that the friendships were generally mutually agreed on. Adolescents were excluded from participation if they had ever been diagnosed with severe learning, emotional, or behavioral problems (e.g., pediatric bipolar disorder, severe learning disability, psychosis, and developmental disability). Only one interested adolescent was excluded for these reasons. Written consent and assent were obtained from the parents of both adolescents and the adolescents themselves, respectively. Participants were paid for their involvement, and all procedures were approved by the university’s Institutional Review Board.

The target adolescent, his or her parent, and the friend completed the study together in a research lab accompanied by undergraduate and graduate research assistants. The target parent completed written questionnaires assessing aspects of their child’s emotions, behaviors, and peer relationships, whereas both adolescents filled out measures asking about aspects of their emotions, behaviors, and their friendship with one another. The adolescents completed their questionnaires in separate rooms accompanied by research assistants. The target adolescent also provided the name of a current teacher to complete classroom behavior rating measures. Questionnaires were mailed to teachers with postage paid return envelopes, and teachers were compensated if they completed the questionnaire.

Measures

Symptoms of ADHD

Symptoms of ADHD were assessed using parent and teacher forms of the ADHD Rating Scale–IV (ARS-IV; DuPaul, Power, Anastopoulos, & Reid, 1998). The ARS-IV is an 18-item scale with items derived from Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; DSM-IV-TR; American Psychiatric Association, 2000) criteria for ADHD. Items are measured on a 4-point scale (0 = not at all/rarely to 3 = very often), with higher scores indicating greater symptom endorsement. For the current study, the highest score between raters was taken for each item. Scores were summed for each factor, yielding separate scores for inattention and hyperactivity-impulsivity, along with a total score (M_inattention = 8.10, SD = 7.21; M_{hyperactivity-impulsivity} = 4.90, SD = 5.15; M_totalADHD = 13.00, SD = 11.61). See Table 1 for descriptive information for the sample regarding this and other measures for the current study.

The parent and teacher forms for the ARS-IV demonstrate adequate psychometric properties (DuPaul, Power, McGoey, Ikeda, & Anastopoulos, 1998), including good internal consistency (teacher form: α_total = .97, α_inattention = .97, α_{hyperactivity-impulsivity} = .93, this sample; parent form: α_total = .94, α_inattention = .94, α_{hyperactivity-impulsivity} =.87, this sample) and stability over a 4-week period (teacher form: r_total = .90, r_inattention = .89, r_{hyperactivity-impulsivity} = .88; parent form: r_total = .85, r_inattention = .78, r_{hyperactivity-impulsivity} = .86). They are also significantly correlated with parent, teacher, and direct observations of behavior. Although we used a continuous measure of ADHD symptoms, our sample included participants with a wide range of ADHD symptoms. For example, based on scores from the ARS-IV, 41% of our participants (n = 17) met the clinical threshold for ADHD based on parent or teacher ratings exceeding the 85th percentile (see DuPaul, Power, Anastopoulos, et al., 1998). Because the ARS-IV is a symptom checklist and not a strict diagnostic tool, we also note that approximately 22% of our sample met diagnostic criteria for ADHD based on clinical structured interviews with parents and adolescents (Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Aged Children [K-SADS]; Kaufman et al., 1997). This discrepancy suggests that, although we recruited a community sample of adolescents, clinically significant ADHD symptomatology is well represented within the sample.

Friendship quality

The Network of Relationships Inventory (NRI; Furman, 1998) assessed friendship quality. Both adolescents completed the 39-item measure answered on a 5-point scale (1 = little or none to 5 = the most) about different aspects of their friendship with each other. Overall scores of positive and negative friendship quality were computed using the method outlined by Furman (1998). For positive friendship quality, scores for 8 of the subscales (7 score scales of companionship, instrumental aid, intimacy, nurturance, affection, admiration, reliable alliance, and an optional scale of support) were averaged (M_target = 3.55, SD = 0.78; M_friend = 3.39, SD = 0.80). Computing negative friendship quality involves averaging two scales (conflict and antagonism) with the option to include criticism and dominance. Each subscale consisted of three items. Because, internal consistency was inadequate (α < .50) for these two optional negative friendship subscales, this composite was derived using only the conflict and antagonism subscales (M_target = 1.52, SD = 0.54; M_friend = 1.55, SD = 0.54). Internal consistency for the other subscales was good, with α levels greater than .80 for all subscales except the companionship (α_target = .61, α_friend = .63) and conflict (α_target = .68, α_friend = .66) subscales. The NRI friendship quality composites also demonstrated good internal consistency (α_{target posfriendship quality} = .96, α_{peer posfriendship quality} = .96, α_{target negfriendship quality} = .84, α_{peer negfriendship quality} = .86, this sample). The NRI has demonstrated adequate psychometric properties, including satisfactory test–retest reliability over a 1-month period, with rs between .66 and .70 (Furman, 1998). The mean levels of friendship quality in the current study were similar to levels of friendship quality found in other community-recruited adolescent samples (e.g., LaGreca & Mackey, 2007).

Social impairment

The Impairment Rating Scale (IRS; Fabiano et al., 2006) assessed social impairment. The IRS is a brief parent-report instrument assessing commonly impaired domains in individuals with ADHD, including social impairment. For our analyses, one item assessed whether the child’s problems affected their peer relationships. Parents responded on a 7-point Likert-type scale (0 = no problem to 6 = extreme problem), and higher scores reflected more significant peer relationship problems (M = .98, SD = 1.37). Compared with the sample used by Fabiano and colleagues (2006), this mean rating is somewhat lower than the mean for children with ADHD (M = 2.69) but somewhat higher than the mean for comparison children (M = .23). A second dichotomous item asked whether the child had a “best” friend. Approximately 93% of parents (n = 39) in the current study reported that their child had a best friend. This statistic was not reported in the Fabiano et al. (2006) normative data. The IRS has demonstrated adequate psychometric properties, including temporal stability and predictive validity (see Fabiano et al., 2006, for more psychometric information).

Social acceptance

Social acceptance was assessed using the teacher peer social skills measure (TPRSK; Dishion & Kavanagh, 2003). This three-item teacher-report measured how accepted, rejected, or ignored the target adolescent was within his or her classroom. Items were phrased as “What proportion of the child’s peers (male and female) like and accept him/her?” Teachers responded on a 5-point scale (1 = very few [less than 25%], 2 = some [around 25%], 3 = about half [50%], 4 = most [around 75%], and 5 = almost all [more than 75%]; M_accepted = 4.58, SD = 0.83; M_rejected = 1.17, SD = 0.48; M_ignored = 1.38, SD = 0.65). These mean levels suggest that our sample was generally accepted by their peers, according to teacher report. This measure has adequate psychometric properties, including good internal consistency (α = .80) among adolescent samples (Dishion & Kavanagh, 2003; Stormshak, Comeau, & Shepard, 2004).

Results

Preliminary Analyses

Correlations among ADHD symptoms (hyperactivity-impulsivity, inattention, and total ADHD), positive and negative friendship quality (target- and friend-report), and covariates (sex, age, and race) were calculated, and results are displayed in Table 2. Symptoms of inattention, hyperactivity-impulsivity, and total ADHD symptoms were significantly positively correlated with target-reported positive friendship quality. Symptoms of hyperactivity-impulsivity and total ADHD were marginally positively correlated with friend-reported positive friendship quality. Symptoms of ADHD were not significantly correlated with negative friendship quality (either reporter). Several covariates were significantly correlated with the variables of interest and were included in any analyses that involved those variables. For instance, gender was significantly positively associated with target- and friend-reported positive friendship quality, suggesting that females were more likely to provide higher ratings of positive friendship quality. Furthermore, age (target and friend) was significantly negatively associated with friend-reported negative friendship quality suggesting that older adolescents had lower ratings of friend-reported negative friendship quality. Finally, target-reported race was significantly negatively associated with friend-reported positive friendship quality, suggesting that White target adolescents were more likely to have lower friend-reported positive friendship quality ratings.

Table 2.

Bivariate Correlations

Variable	Inattention	H/I	ADHD	TPFQ	FPFQ	TNFQ	FNFQ	G	TA	FA	TR	FR
Inattention symptoms	—	.76***	.96***	.35**	.25	.13	.03	−.19	−.06	.04	−.20	.00
H/I symptoms		—	.91***	.42***	.27*	.03	.21	.01	−.36**	−.28	−.15	.16
Total ADHD symptoms			—	.41***	.28*	.10	.11	−.11	−.20	−.10	−.19	.07
TPFQ				—	.51***	−.37**	.01	.38**	−.13	−.04	−.23	−.13
FPFQ					—	−.34**	−.01	.50***	−.09	−.04	−.33**	−.19
TNFQ						—	.18	−.15	.05	−.002	−.004	−.03
FNFQ							—	.25	−.41***	−.37**	.06	−.10
G								—	−.09	−.12	−.11	−.13
TA									—	.94***	.13	−.09
FA										—	.11	−.06
TR											—	.63***
FR												—

Note: H/I = hyperactivity-impulsivity; TPFQ = target positive friendship quality; FPFQ = friend positive friendship quality; TNFQ = target negative friendship quality; FNFQ = friend negative friendship quality; G = gender; TA = target age; FA = friend age; TR = target race; FR = friend race.

p < .10. **p < .05. ***p < .01.

Relationship Between ADHD Symptomology and Close Friendship Quality

Separate linear regression models examined total ADHD symptomology, hyperactivity-impulsivity, and inattention as well as target- and friend-reported positive and negative friendship quality separately. Thus, there were 12 models. Results of these models are found in Table 3 and indicate that symptoms of inattention, hyperactivity-impulsivity, and total ADHD were significantly positively related to target-reported positive friendship quality, whereas symptoms of inattention and total ADHD were significantly positively associated with friend-reported positive friendship quality. Furthermore, there was a trend toward a positive relation of hyperactivity-impulsivity symptoms predicting friend-reported positive friendship quality. None of the models predicting negative friendship quality (either reporter) resulted in significant findings.

Table 3.

Regression Parameters for Symptoms of ADHD Predicting Friendship Quality

Parameter	B	SE	β	F	R ²
Model 1: Inattention predicting TPFQ				9.47***	.33
Inattention	.05***	.02	.44***
Gender	.75***	.22	.47***
Model 2: Hyperactivity-impulsivity predicting TPFQ				5.90***	.32
Hyperactivity-impulsivity	.07***	.02	.44***
Target age	.03	.07	.05
Gender	.61***	.22	.38***
Model 3: Total ADHD predicting TPFQ				10.25***	.35
Total ADHD	.03***	.01	.45***
Gender	.70***	.21	.43***
Model 4: Inattention predicting FPFQ				8.72***	.41
Inattention	.03**	.01	.31**
Gender	.84***	.20	.54***
Target race	−.36	.22	−.21
Model 5: Hyperactivity-impulsivity predicting FPFQ				5.60***	.38
Hyperactivity-impulsivity	.04*	.02	.25*
Target age	.03	.06	.07
Gender	.74***	.21	.48***
Target race	−.43*	.23	−.25*
Model 6: Total ADHD predicting FPFQ				8.47***	.41
Total ADHD symptoms	.02**	.01	.29**
Gender	.80***	.20	.51***
Target race	−.38*	.22	−.22*
Model 7: Inattention predicting TNFQ				.69	.02
Inattention	.01	.01	.13
Model 8: Hyperactivity-impulsivity predicting TNFQ				.11	.01
Hyperactivity-impulsivity	.01	.02	.06
Target age	.02	.06	.08
Model 9: Total ADHD predicting TNFQ				.37	.01
Total ADHD symptoms	.01	.01	.10
Model 10: Inattention predicting FNFQ				2.51*	.17
Inattention	.00	.01	−.01
Target age	−.17	.15	−.55
Friend age	.04	.13	.15
Model 11: Hyperactivity-impulsivity predicting FNFQ				2.58*	.17
Hyperactivity-impulsivity	.01	.02	.07
Target age	−.15	.15	−.49
Friend age	.03	.12	.11
Model 12: Total ADHD predicting FNFQ				2.52*	.17
Total ADHD symptoms	.001	.01	.02
Target age	−.16	.15	−.52
Friend age	.03	.13	.13

Note: TPFQ = target positive friendship quality; FPFQ = friend positive friendship quality; TNFQ = target negative friendship quality; FNFQ = friend negative friendship quality.

p < .10. **p < .05. ***p < .01.

We also examined whether ADHD moderated the relationship between target-reported friendship quality and friend-reported friendship quality (positive and negative) using hierarchical linear regression. For the model including positive friendship quality, there was a main effect of target-reported positive friendship quality (B_posfriend = .47, p < .01) but no main effect of ADHD and no significant interaction predicting friend-reported positive friendship quality. Regarding negative friendship quality, there were no significant main effects (B_negfriend = .16, p = .36; B_ADHD = .01, p = .53) and no significant interaction (B = .004, p = .78), suggesting that ADHD did not moderate the relationship between target- and friend-reported friendship quality.

PIB

To address whether symptoms of ADHD in target adolescents were associated with a positively biased self-report of their social relationships, we examined correlations between symptoms of ADHD and teacher-reported social acceptance and parent-reported social impairment. Symptoms of ADHD were significantly positively correlated with parent-rated peer relationship impairment (r = .78, p < .01) and teacher-rated being ignored by peers (r = .45, p < .05); marginally positively correlated with teacher-rated peer rejection (r = .40, p = .06); and marginally negatively correlated with teacher-rated peer acceptance (r = −.37, p = .07). These results suggest that parents and teachers report that adolescents with greater symptoms of ADHD have impairments in their peer relationships and are ignored or rejected by many of their peers, and the PIB may be operating among our sample for both adolescents. However, it is also possible that the close friendships of adolescents with high levels of ADHD symptoms are different from their broader peer relationships, as suggested earlier, or that the parents and teachers are not good reporters of close friendship quality. For instance, target-reported positive friendship quality was significantly positively correlated with teacher-rated being ignored by peers (r = .57, p < .01) and parent-rated social impairment (r = .38, p < .05), suggesting that self-reported close friendship quality may be distinct from teacher- or parent-rated broad social functioning.

Do Adolescents With Symptoms of ADHD Have At Least One Close Friendship?

To determine whether adolescents with symptoms of ADHD have at least one positive close friendship, we examined the total number of friends of the target adolescent based on reports of the target adolescent and their parent. The number of self-reported friends ranged from 4 to 100 (M = 18.72, SD = 24.96). Symptoms of ADHD were positively correlated with number of self-reported friends (r = .51, p < .01). The number of friends reported by the parent ranged from 3 to 50 (M = 11.19, SD = 8.78) and was not significantly correlated with symptoms of ADHD (r = −.15, p = .39). Furthermore, parent and self-report on the target adolescent’s number of friends were not significantly correlated (r = −.194, p = .26). So, although results from the number of self-reported friends suggest that greater symptoms of ADHD are related to more friends, this is not supported by parent report. In fact, there were negative (although not significant) correlations between symptoms of ADHD and parent-reported number of friends as well as between target and parent reports of number of friends. Our results suggest that the target adolescent and their parent may view the friendship networks differently. Furthermore, our findings do not provide conclusive evidence that the adolescents in our study with many symptoms of ADHD had only one close friend with whom to participate in our study.

Gender and Age as Moderators

We used hierarchical linear regression to examine whether gender or age moderated the relationship between symptoms of ADHD and friendship quality. For the models examining gender as a moderator, the main effects of ADHD symptoms and gender were significant predictors of positive friendship quality (predicting target positive friendship quality: B_ADHD = .03, B_gender = .68, both p < .01; predicting friend positive friendship quality: B_ADHD = .02, p < .05 B_gender = .81, p < .01), but the interaction terms were not significant (target report: B_ADHD × _Gender = .02, p = .32; friend report: B_ADHD × _Gender = −.02, p = .36). For the models predicting negative friendship quality, there were no significant main effects or interaction terms (target negative friendship quality: B_ADHD = .01, p = .43, B_gender = −.13, p = .45, and B_ADHD × _Gender = −.02, p = .24; friend negative friendship quality: B_ADHD = .01, p = .36, B_gender = .30, p = .09, and B_ADHD × _Gender = −.004, p = .81). Therefore, although these analyses also suggested that females rated the friendships more positively, gender did not moderate the relationship between symptoms of ADHD and positive or negative friendship quality. This suggests that our findings of positive associations between symptoms of ADHD and positive friendship quality did not differ for males or females.

Results regarding age as a moderator of the relationship between symptoms of ADHD and friendship quality were also nonsignificant. For the models predicting positive friendship quality, there were main effects of ADHD (target-report: B_ADHD = .02, p < .05, B_age = −.01, p = .86; friend-report: B_ADHD = .02, p < .05, B_age = −.04, p = .60) but no significant interactions (target-report: B_ADHD × _Age = −.01, p = .35; friend report: B_ADHD × _Age = .01, p = .13). For the model predicting target-reported negative friendship quality, there were no significant main effects or interaction (B_ADHD = .01, p = .37; B_age = .01, p = .79; B_ADHD × _Age = .004, p = .37), and for the model predicting friend-reported negative friendship quality, there was a main effect of age (B_age= −.13, p < .05; B_ADHD = .001, p = .85) but not a significant interaction (B_ADHD × _Age = .000, p = .94). Thus, although older adolescents rated the relationship as less negative, age and gender did not moderate the relationship between ADHD symptoms and friendship quality.

Discussion

Although the current results are somewhat surprising given the extensive research documenting the social problems affecting youth with ADHD, it should be noted that this previous work focused on broad peer groups rather than close friendships and on children with ADHD rather than adolescents (Nixon, 2001; Normand et al., 2007; Stormont, 2001). Our sample was one of the first to include adolescent close friend dyads and to use multi-informant data.

Results of this study suggest that adolescents with greater symptoms of ADHD viewed their close friendships more positively than adolescents with fewer symptoms. Adolescents with higher inattentive and total ADHD symptoms also had friends who rated their friendships more positively than adolescents with lower ratings of these symptoms. Symptoms of ADHD were not significantly associated with negative friendship quality as reported by either adolescent. Symptoms of ADHD also did not moderate the relationship between target- and friend-reported friendship quality, as the relationship between target- and friend-reported friendship quality did not differ for individuals with different levels of ADHD. Furthermore, despite substantial literature on the influence of gender and age on adolescent friendships, we found no evidence for either of these demographic variables as moderators of the relationship between ADHD symptoms and friendship quality.

As our findings were surprising, we examined a few different possible explanations for these results, including the PIB and whether youth with symptoms of ADHD have at least one close friendship. Our findings examining the PIB suggest that although adolescents with high levels of ADHD rated their friendships more positively, parents and teachers reported that adolescents with greater symptoms of ADHD have impairments in their peer relationships and are ignored or rejected by many of their peers. Finally, results suggest that symptoms of ADHD were associated with self-reported greater number of friends, although this was not supported by the parent’s report of the number of friends the adolescent had. Thus, according to self-report, it appears that adolescents with high levels of ADHD symptoms do have at least one close friend, which is consistent with our findings related to positive friendship quality. Taken together, however, these results suggest that the target adolescents and their parent or teacher may view the friendship network and social functioning differently.

Although many of our findings suggest that adolescents with symptoms of ADHD have positive friendships, our findings that included parent or teacher ratings of adolescent social functioning suggest that youth with symptoms of ADHD do have some social impairments, including more social problems and peer rejection than youth with few or no ADHD symptoms. One explanation for these findings is that target adolescents with high levels of ADHD symptoms exhibited a PIB regarding their friendship quality. However, adolescents with higher ratings of inattention and overall ADHD symptoms also had more positive friendship quality as rated by their friend, suggesting that these ratings may not have been overestimated. Because adolescents tend to be friends with individuals who are similar to themselves (Prinstein & Dodge, 2008), it is possible that both adolescents had similarly high levels of ADHD and that both adolescents overestimated the positive qualities of the friendship due to these high levels of ADHD. However, we were unable to assess this in the current study because we did not have ratings of the friend’s level of ADHD symptoms. Another explanation for these findings is that the close friendships of adolescents with high levels of ADHD may be distinct from the broader peer deficits that these individuals often experience and that adolescents with symptoms of ADHD may have one mutually agreed-on close friendship to help meet their social needs. Our findings provide some preliminary support for this idea, and continued work examining the dyadic friendships of adolescents with symptoms of ADHD will help to clarify these explanations by using large, representative samples and assessing various aspects of close relationship quality as well as broad peer status and social skills.

Although we did not find that age or gender significantly moderated the relationship between ADHD and friendship quality, there were several interesting findings regarding the relationship of demographic variables to our variables of interest. For instance, there were significant negative correlations between the target adolescent’s age and friend-reported negative friendship quality, suggesting that older adolescents may be less likely to rate the friendship negatively. However, there were no significant correlations between age- and target-reported negative friendship quality or any ratings of positive friendship quality, suggesting that age did not affect positive ratings of friendship quality. There were also no main effects for most of the analyses examining age as a moderator of the relationship between ADHD symptoms and friendship quality, except for the model predicting friend-reported negative friendship quality in which there was a significant inverse main effect of target age on negative friendship quality. These main effects similarly indicate that older adolescents had lower ratings of negative friendship quality (e.g., less negative).

Furthermore, there were significant negative correlations between target-reported negative friendship quality and both ratings of positive friendship quality; however, the correlations between positive friendship quality and friend-reported negative friendship quality were nonsignificant, which was unexpected. It is noteworthy that these findings both involved the friend-reported negative friendship quality scale. These unexpected findings could be merely spurious or related to low power, but they might also reflect difficulties in measuring negative friendship qualities given the confines of the current research paradigm or the limits of the measure of negative friendship quality (which only included two subscales assessing conflict and antagonism—a total of 6 items). Also, negative relationships often involve more than just conflict and antagonism, and more sensitive measures may provide more information about negative relationships in future studies. These findings could also be due to difficulties assessing negative relationship quality due to the design of our study. That is, the peer who was invited to participate in the study may have been hesitant to describe negative aspects of his or her relationship with the friend who invited them to participate in the study, particularly since the study was about friendships. Future studies should use multiple methods (e.g., observations and experimentally manipulated tasks) to assess friendship quality, particularly negative aspects of the relationship.

Summary, Strengths, and Limitations

Overall, our results provide some support for Hoza’s assertion (2007) that the close friendships of individuals with ADHD are distinct from their standing in the peer group as accepted, rejected, or ignored. Adolescents with ADHD, despite having general social problems, may be able to maintain a mutually agreed on, positive close friendship, and this may be a viable way for these adolescents to meet their social needs. Positive friendships may protect against the negative outcomes associated with peer rejection commonly found among this population, though this was not a focus of the current study.

Methodological strengths of this study include the following: the examination of specific dyadic friendships rather than classroom dynamics or unacquainted children (Nixon, 2001; Stormont, 2001), the exploration of multiple explanations for our results to extend our understanding of close friendships of adolescents with ADHD, and the inclusion of multiple informants to get a less-biased view of adolescent peer relationships and symptoms of ADHD. Finally, we extended work on friendships and symptoms of ADHD to adolescence, a developmental period where social relationships take on greater importance and which has received little empirical attention for those with ADHD (Bagwell et al., 2001; Harpin, 2007).

Despite these methodological strengths, our study may have been limited by our small sample size and limited power to find effects. Other studies on adolescent dyadic friendships have more than 100 dyads (e.g., Allen, Porter, & McFarland, 2006); however, these samples are often recruited from schools and do not target clinical populations such as adolescents with symptoms of ADHD. Our study therefore provides some initial results in a sample that targeted a more clinical population. We also examined continuous symptoms of ADHD rather than clinical diagnoses, limiting our ability to generalize results to adolescents with a clinical diagnosis of ADHD. However, a significant number of our participants (41%) met the clinical threshold for ADHD based on the normative data for the rating scale used, suggesting that participants in our sample had a range of clinically relevant symptoms of ADHD. Furthermore, there may have been some measurement problems with our assessment of friendship quality, particularly negative friendship quality, which limited our findings. We chose not to include two optional subscales in the negative friendship quality composite due to low internal validity. Thus, our measure of negative friendship quality included only two subscales (compared to eight subscales measuring positive friendship quality). This may have limited the conceptualization of negative friendship quality and contributed to some of the null or confusing results. Finally, as previously mentioned, we did not include measures of the friend’s ADHD symptoms, so we could not examine how the friend’s level of ADHD symptoms might have affected our results.

Clinical Implications

Our results have important clinical implications for addressing social deficits of adolescents with ADHD. If some adolescents with ADHD have reciprocated positive close friendships, then accentuating these relationships may be an effective way to intervene socially with this population. Exploring social skills treatments that focus on specific friendships—for example, emphasizing positive friendships and working to generalize positive friendship qualities to other areas of social functioning—may be more effective for this population than some previously used group treatments that have focused on general social skills training and generally demonstrate little evidence of efficacy (Antshel & Barkley, 2008).

In conclusion, the current study suggests that adolescents with greater symptoms of ADHD have positive close friendships as rated by both themselves and their close friend and that the close friendships of adolescents with high levels of ADHD may be distinct from the broader peer relationships problems among these adolescents. Further understanding the close friendships of adolescents with symptoms of ADHD may help to inform interventions targeting the social problems of these adolescents. Future studies should use larger samples, examine externalizing behaviors of both adolescents, and consider using diagnostic and continuous measures of ADHD.

Footnotes

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

The authors received financial support from the University of South Carolina Research Consortium for Children and Families for the research in this article.

Bios

Kerrie Glass, MA, is currently enrolled in the doctoral program in Clinical-Community Psychology at the University of South Carolina and is preparing to go on internship. Her research interests include substance use and social outcomes among adolescents and young adults with ADHD.

Kate Flory, PhD, is an assistant professor in the Department of Psychology at the University of South Carolina. Her research focuses on the adolescent and young adult negative outcomes experienced by children with ADHD, including substance use, risky sexual behavior, and social difficulties.

Benjamin L. Hankin, PhD, is an associate professor in the Department of Psychology at the University of Denver. His research interests include the development of depression among children, adolescents, and adults as well as vulnerability-stress models of psychopathology.

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