Social Support in Children With ADHD: An Exploration of Resilience

Abstract

Objective: This study investigated the role of perceived social support in promoting emotional well-being among children with ADHD. Specifically, it examined how children with ADHD perceive support from key individuals in their lives and the relationships between this support and aspects of emotional well-being. Main versus buffering models of social support in the context of social preference status were also explored. Method: Participants were 55 school-age children with ADHD–combined or hyperactive/impulsive (ADHD-C/HI). Parent and child ratings evaluated source-specific social support, social status, and aspects of self-concept, anxiety, and depression. Results: Children with ADHD reported lower social support than normative samples. Social support had moderate positive associations with self-concept, with source-specific differences, but was not associated with internalizing symptoms. Regression models with social preference status supported a main effect model of perceived social support. Conclusion: Social support may provide a target for resilience-based interventions among children with ADHD in promoting their self-concept and well-being.

Keywords

ADHD children resilience social support

ADHD is a neurodevelopmental disorder with a relatively high prevalence and substantial impacts on those affected (Barkley, 2014). Although behavior-based in its core presentation and diagnostic criteria (see Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5; American Psychiatric Association (APA), 2013]), ADHD has a neurocognitive basis with deficits in executive function, and impacts functioning across academic, social, emotional, and occupational domains (Barkley, 2014). ADHD is typically diagnosed in childhood but has become increasingly recognized as having lifelong impact (Kessler et al., 2006), and thus is most aptly considered a chronic condition across the life span. This recognition highlights the need to better understand the factors and processes that in turn can help those with ADHD to achieve success and personal well-being (Climie & Mastoras, 2015).

Although our understanding of ADHD to date has been predominantly deficit focused, the applicability of resilience and strengths-based perspectives to children with ADHD is an emerging area of interest in recent literature (e.g., Climie, Mastoras, McCrimmon, & Schwean, 2013; Deault, 2010; Modesto-Lowe, Yelunina, & Hanjan, 2011). These perspectives draw greater attention to the roles of risk and protective factors in contributing to trajectories of the disorder, emphasizing outcomes of competence, adjustment, and well-being rather than simply core symptom reduction (Climie et al., 2013; Masten, 2001; Rutter, 1985). This approach therefore creates new avenues for understanding the heterogeneity in trajectories of the disorder and identifying novel and complementary interventions that support well-being and limit the overall impact of the disorder, which is particularly important given the recognized chronicity of ADHD (Climie & Mastoras, 2015). Ultimately, a resilience perspective has the potential to provide more positive messaging and a more balanced approach to understanding and working with these children.

Social Support as a Protective Factor

Social support is one of the most frequently cited protective factors within the resilience field (e.g., Masten, 2001; Rutter, 1985). Converging and compelling evidence has emerged for its role in promoting well-being among adults (Cohen & Wills, 1985) and, more recently, among children and adolescents (Chu, Saucier, & Hafner, 2010; Demaray & Malecki, 2002). Studies of children have demonstrated modest but significant associations between perceived social support and a range of positive outcome indicators, with the largest and most consistent effects on self-concept and psychological functioning (Chu et al., 2010). Most typically conceptualized as the perceived availability of support within one’s social network (Malecki, Demaray, & Elliott, 2000), social support is a subjective construct that reflects one aspect of the content or quality of social relationships (House, Umberson, & Landis, 1988). Importantly, perceptions of support have been found to be more predictive of outcomes than are more objective measures of support (Chu et al., 2010; Wethington & Kessler, 1986).

Supportive behaviors can come in varying forms, including emotional support (e.g., caring, acceptance), providing information or advice, providing feedback, and providing needed resources (e.g., time, money; Malecki et al., 2000; Shumaker & Brownell, 1984). Sources of support for children include parents, teachers, close friends, and the peer group, each having somewhat different functions and influencing distinct outcomes. Perceived parental support appears to be most predictive of a broad range of adjustment outcomes in children, with peer support also often impacting emotional well-being outcomes (Demaray, Malecki, Davidson, Hodgson, & Rebus, 2005; Rueger, Malecki, & Demaray, 2010). Perceived support from teachers may be more specifically related to school functioning outcomes (Rosenfeld, Richman, & Bowen, 2000). Support from other competent and caring adults has also received research attention, and may be influential particularly for children with less support from parents or peers (e.g., Harter, 1999; Werner & Johnson, 2004).

A vital issue from a resilience perspective involves understanding the mechanisms underlying the effects of social support; that is, how, when, and for whom it is beneficial. One main effect theory asserts that social support fulfills a basic psychological need for belongingness, attachment, and companionship that is necessary for achieving well-being, regardless of stress level (Cohen & Wills, 1985). A second main effect model, arising from social constructionist perspectives, suggests that supportive relationships contribute to the development, maintenance, and validation of self-identify and self-esteem (i.e., the “looking-glass self”; Harter, 1999; Lakey & Cohen, 2000; Shumaker & Brownell, 1984). Alternatively, the stress-buffering model (House et al., 1988; Lakey & Cohen, 2000; Shumaker & Brownell, 1984) suggests that the primary function of social support is to help individuals more effectively cope with stressors (e.g., by influencing their appraisal of stressors and their use of coping strategies), and thus, will more significantly benefit those in higher stress situations (House et al., 1988). Whereas research on adults most supports the stress-buffering model (Cohen & Wills, 1985), studies of children have been mixed in supporting main versus stress-buffering models depending on the particular stressor, outcome variables, and/or sources of support examined (e.g., Davidson & Demaray, 2007; Rigby, 2000; Tanigawa, Furlong, Felix, & Sharkey, 2011).

ADHD and the Relevance of Social Support

Given the broad-ranging benefits of perceived social support among at-risk children, there is reason to believe that it may be an influential factor in predicting resilient trajectories among children with ADHD. In addition to the behavioral challenges faced by these children, there are also increased rates of poor emotional outcomes, an area where social support has been found to be particularly beneficial. For instance, rates of comorbidity of approximately 25% to 30% have been reported for both anxiety disorders and depression (Barkley, 2014), and even subthreshold internalizing symptoms have been linked to poorer outcomes among these children (Carlson & Meyer, 2009). Research on self-esteem in ADHD is mixed due to findings of the positive illusory bias (PIB), in which these children have been found to over-report their competence in academic and social domains relative to both objective measures and reports from others (see Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007, for a review). Although the impact of these biased perceptions on functioning and outcomes remains unclear, there is some evidence that low self-esteem, or an absence of such biased ratings, may in turn predict subsequent increases in depression and/or internalizing problems (McQuade, Hoza, Waschbusch, Murray-Close, & Owens, 2011). In particular, “complex ADHD” models suggest that in some cases comorbid internalizing disorders may arise “as a result of the persistent demoralization from the problems associated with ADHD” (Tannock, 2009, p. 131).

Children with ADHD are also exposed to numerous stressors and frustration in their peer and adult relationships as a result of the deficits and disruptions caused by their symptoms (Barkley, 2014). In particular, up to 50% to 70% of these children are rejected by their peers, with a similar number having no reciprocated friendship (Hoza et al., 2005). Peer rejection has been identified as a significant risk factor for poor adjustment in both typical and ADHD populations (Burt, Obradović, Long, & Masten, 2008; Mrug et al., 2012). Moreover, the social difficulties faced by children with ADHD have proven particularly challenging to remediate (Pelham & Fabiano, 2008). Among other populations, social support has been found to play a protective role in buffering the effects of peer victimization on internalizing symptoms (e.g., Davidson & Demaray, 2007; Tanigawa et al., 2011), and thus, may have particular relevance for this subgroup of children with ADHD. However, children with ADHD may be at risk of experiencing lower levels of social support given the challenging relationships that have been reported with peers, parents, and teachers (Deault, 2010; Kos, Richdale, & Hay, 2006).

Research exploring the profile or role of perceived social support among children with ADHD has been limited, with only one study directly examining this issue. In this study, Demaray and Elliott (2001) found that boys (Grades 3-6) with ADHD characteristics were found to perceive lower overall social support than those without such behaviors, with more extreme ADHD behaviors associated with lower support ratings especially for classmates and friends. Correlations of social support with self-concept were surprisingly low among both the ADHD and comparison groups in this study. Significant associations between perceived close friend support and self-concept were found for both groups, whereas perceived teacher support and self-concept were associated only for the non-ADHD group. The relationship between social support and internalizing problems, however, was not explored.

Objectives of the Current Study

The current study examined the relationships between perceived social support and emotional well-being outcomes among 8- to 11-year-old children with ADHD–combined or hyperactive/impulsive type (ADHD-C/HI). First, this study aimed to better understand how children with ADHD perceive support from key sources in their lives, with a prediction that these children would report lower levels of support than have been found among typical populations. Second, the associations of social support with both positive (i.e., self-concept, self-worth, self-efficacy) and negative (i.e., anxiety, depression) indices of emotional well-being were examined. As found in other populations, it was predicted that higher levels of social support would be related to higher self-concept outcomes and lower internalizing symptoms. Finally, the potential protective effects of social support in the context of peer rejection were explored. Given the inconsistency in findings of main versus buffering effects of social support in other populations of children, no specific a priori predictions were made.

Method

Participants

Fifty-five 8- to 11-year-old children (M = 9.99 years, SD = 1.16) with ADHD-C/HI participated in this study (46 boys, 9 girls). All children were required to (a) reside with their parents or current guardians for at least the past 5 years; (b) attend school full-time within a local school district; (c) have no previous diagnosis or identification of autism spectrum disorders, psychosis, epilepsy, or gross neurological, sensory, or motor impairments; and (d) have received a previous diagnosis of ADHD from a psychologist or physician. Testing during the first research session was then used to confirm at least average intelligence and presence of ADHD symptomology, using criteria intended to ensure diagnostic rigor of this clinical group while allowing for variability in current symptoms resulting from medication or other interventions. Only participants who met these criteria during initial screening and testing were included in the final sample. Excluded from the sample were children meeting symptom thresholds for ADHD–inattentive type only, given the considerable distinctions in presentation and associated risks. Of the 59 participants who met the inclusion criteria, 1 refused to continue participation and an additional 3 were excluded for presenting significant validity concerns on the core social support measure necessary for all analyses of this study.

Based on the subtyping approach described further below, 49 children were identified as ADHD-C and 6 as ADHD-HI. The sample was comprised of 82% Caucasian participants, with the rest identifying as Asian, African American, Aboriginal, East Indian, or Hispanic. Participants were socioeconomically advantaged relative to the general population, with 46% of participants indicating family incomes of CAD$100,000 or greater and only 4% indicating incomes below CAD$25,000, as well as 76% of participants living in a two-parent home. Most participants were taking medications for ADHD symptoms, with 51% consistently taking medications, and another 29% taking medication at least on weekdays during the school year. Data regarding other treatment modalities could not be adequately represented given the wide range, informality, and inconsistency in implementation of such psychosocial interventions in community settings. Finally, 51% of children were reported by parents to have one or more comorbid disorders, including 15 participants with a learning or language disability, 5 with an anxiety disorder, 6 with oppositional defiant disorder, and 2 with developmental coordination disorder.

Measures

Measures to assess eligibility criteria

The Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) was used to evaluate cognitive ability, with participants required to obtain a Full Scale Intelligence Quotient (FSIQ) of at least 85 for inclusion in this study. The Conners-3 parent form (Conners, 2008) rating scale was used to confirm ADHD symptomology based on either a T-score ≥ 70 on one or both of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA, 2000)–based ADHD symptom scales (inattentive or hyperactive/impulsive) or a T-score ≥ 65 with at least five symptoms identified. Where parent ratings indicated subthreshold severity (e.g., potentially due to medication and/or intervention efforts), parents were asked to complete an additional Conners-3 form to retrospectively evaluate symptoms prior to treatment initiation. Subtype was then established based upon which scales surpassed these criteria.

Primary measures

Parents completed a background questionnaire of demographic information as well as medication status. In addition, the following measures were used to evaluate the primary variables of interest for this study.

Dishion Social Acceptance Scale (Dishion, 1990)

This three-item scale evaluates the peer rejection/acceptance status of children. Parents estimated the proportion of the child’s peers who like/accept, dislike/reject, and ignore him or her based on a 5-point Likert-type scale ranging from 1 (very few/less than 25%) to 5 (almost all/more than 75%). The dislike/reject raw score was then subtracted from the like/accept raw score to create a social preference score, a measure of social status found to be more reliable and stable than scores of peer rejection or acceptance alone (Jiang & Cillessen, 2005). Translated scores thus ranged from 4 to −4, with higher scores indicating greater social preference. This scale has been used in numerous studies including several of children with ADHD (e.g., Lee, Lahey, Owens, & Hinshaw, 2008) and has moderately strong correlations with sociometric peer ratings (Dishion, 1990).

Child and Adolescent Social Support Scale (CASSS; Malecki et al.,2000)

The CASSS measures the perceived social support of children and adolescents in Grades 3 to 12 and has been used in a number of studies evaluating social support in children and youth. Five 12-item subscales (Parent, Teacher, Classmate, Close Friend, and School) each contain items tapping four types of support (emotional, informational, appraisal, and instrumental). Participants were read each statement and asked to rate how often they perceive that form of support on a 6-point scale ranging from 1 (never) to 6 (always). For the current study, the parent, teacher, classmate, and close friend scales of the CASSS were used. The School scale was omitted and replaced with an “Other Adult” scale, intended to capture social support perceived from a non-parent or non-teacher adult in the child’s life. It was created by adapting relevant items from the Parent and Teacher scales, with items selected to match the general format of three items for each of four types of support. For the Other Adult scale, children were asked to identify another adult with whom they felt close and complete ratings based on this individual. Raw scores for each scale were calculated by averaging responses for each item. A total social support score was then calculated by averaging the means of the five subscales. In cases where the child was unable to identify a person of reference for whom to complete one of the scales, responses were coded as “1/never” for each item resulting in the minimum score of 1 for that scale, as endorsed by the scale authors (M. Demaray, personal communication, June 21, 2012). This occurred for one participant on the Close Friend scale and for three participants on the Other Adult scale.

The CASSS has strong internal consistency, test–retest reliability, and convergent validity, and factor analysis supports its source-specific framework (Malecki et al., 2000). For this sample, the CASSS had high reliabilities for the five subscales ranging from .91 to .97, and intercorrelations between subscales (sources of support) ranging from .36 to .72. The Other Adult scale had the weakest correlations with other subscales (.36-.47).

Behaviour Assessment System for Children–2nd edition (BASC-2; Reynolds & Kamphaus, 2004)

The BASC-2 is a broad-band, norm-referenced rating scale frequently used to evaluate the behavioral, social, and emotional functioning of children 4 to 18 years of age. This scale was completed both by parents (most often mothers) and children themselves. For the current study, only the depression and anxiety scales on the parent form were used to assess internalizing symptoms/emotional maladjustment. On the child form, the depression and anxiety scales, as well as the self-reliance scale were used, with the latter specifically evaluating self-efficacy or “confidence in one’s ability to solve problems; a belief in one’s personal dependability and decisiveness” (Reynolds & Kamphaus, 2004, p. 74).

Self-Perception Profile for Children (SPPC; Harter, 1985)

The SPPC is a 36-item self-report rating scale that evaluates global self-worth and six domain-specific self-perceptions of children in Grades 3 to 6. Each item is presented in a “structured alternative format” (Harter, 1985, p. 7), wherein the child is presented with two opposing perceptions (e.g., some kids often forget what they learn . . . but . . . other kids can remember things easily). Ratings are made in a two-step process; the child first chooses which child is more like him or her and then chooses whether this is “sort of true for me” or “really true for me.” Only three of the subscales were included for analysis: Global Self-Worth (“the extent to which the child likes oneself as a person, is happy the way one is leading one’s life, and is generally happy with the way one is”), Scholastic Competence (“the child’s perceptions of his/her competence or ability within the realm of scholastic performance”), and Social Acceptance (“the degree to which the child is accepted by peers or feels popular”; Harter, 1985, p. 6). Internal consistencies as reported in the manual range from .75 to .85 for the selected scales. The SPPC has been used frequently with children with ADHD (e.g., Hoza et al., 2004).

Procedure

Participants were recruited by information distributed through ADHD agencies, school boards, community newsletters, and local psychological clinics in a large Western Canadian city. Interested participants meeting initial eligibility criteria through a brief phone-based screening interview attended two 2-hr visits at the university research laboratory to allow for data collection required for a number of studies. Visits were typically 1 to 2 weeks apart and no more than 1 month apart. During visits, parents completed a number of questionnaires in a separate room while graduate student researchers administered child-focused measures. Assessment measures were administered in a pseudo-random order, with the WASI and Conners-3 always completed in the first visit to ensure eligibility.

Results

Research Question 1: Social Support Profile Among Children With ADHD

Table 1 presents CASSS means and standard deviations for the sample and comparisons with normative data (Malecki et al., 2000). Results were partially consistent with predictions, with the ADHD sample reporting lower support from parents, close friends, and teachers, but no differences in classmate support as compared with normative participants. Although no significant correlations were found between overall or source-specific support and either IQ or ADHD symptom severity, significant negative correlations were found between age and total social support (r = −.30, p = .03), and between age and both parent support (r = −.28, p = .04) and classmate support (r = −.33, p = .01). Inspection of descriptive data calculated by age suggested that this correlation was driven primarily by higher support reported by 8-year-olds, whereas declining scores were not observed across the remaining age-groups. Other adult support was further explored by categorizing the person identified into three groups: grandparents (n = 21, M = 5.17, SD = 0.82), other extended family (e.g., aunts, uncles, adult cousins; n = 13, M = 5.03, SD = 1.13), and community members (e.g., coach, family friend, friend’s parent; n = 13, M = 4.90, SD = 1.16). A one-way ANOVA comparing support means between these groups was not statistically significant, F(2, 44) = 0.301, p = .74. Five additional participants did not indicate the specific adult they were considering (M = 4.45, SD = 1.01).

Table 1.

Perceived Social Support in ADHD and Normative Samples.

Social Support Scale	ADHD-C/HI sample (N = 55)		CASSS manual norm scores^a			t-test results
Social Support Scale	M	SD	n	M	SD	t(54)	p	Cohen’sd
Parent	4.54	0.95	596	4.86	0.87	−2.50	.02	0.35
Teacher	4.54	0.98	692	5.05	0.89	−3.87	<.001	0.54
Classmate	4.05	1.05	675	4.16	1.18	−0.75	.46	0.10
Friend	4.49	1.17	697	4.85	1.12	−2.24	.03	0.31
Other Adult	4.76	1.33
Total	4.48	0.86

Note. ADHD-C/HI = ADHD–combined or hyperactive/impulsive; CASSS = Child and Adolescent Social Support Scale.

Significant t-tests presented in bold

Combined gender sample of 3^rd to 5^th grade children.

Research Question 2: Relationships of Social Support and Emotional Well-Being

Table 2 presents descriptive data for emotional well-being outcomes from the BASC-2 and SPPC. Correlations between social support and emotional well-being outcomes are presented in Table 3. Contrary to predictions, no significant relationships were found between social support and internalizing outcomes (depression, anxiety) as rated by children or their parents. However, total support showed moderate positive correlations with all indicators of self-concept (r = .34-.42). Furthermore, results highlighted differences in the relationships between specific sources of support and particular facets of self-concept. Global self-worth had moderate correlations with parent, classmate, and close friend support (r = .36-.53). However, self-reliance had significant and moderate correlations only with support from parents (r = .40) and other adults (r = .29). Scholastic competence was only related to parent and classmate support and did not show the expected relationships with teacher support. Social acceptance showed the strongest relationship with classmate support (r = .51) but more modest correlations with parent and teacher support.

Table 2.

Descriptive Statistics for Outcome Variables.

	n	M	SD
Depression Self-Report^a (median reported)	51	44.00	8.06
Depression Parent Report^a	52	56.48	13.01
Anxiety Self-Report^a	51	49.20	9.70
Anxiety Parent Report^a	52	52.90	11.54
Self-Reliance^b	51	49.88	9.80
Scholastic Competence^b	40	2.77	0.79
Social Acceptance^c	40	2.87	0.85
Global Self-Worth^c	40	3.33	0.56

Note. BASC-2 = Behaviour Assessment System for Children–2nd edition; SPPC = Self-Perception Profile for Children.

Based on T-scores from the BASC-2, M = 50, SD = 10, higher scores indicate a more negative outcome.

Based on T-scores from the BASC-2, M = 50, SD = 10, higher scores indicate a more positive outcome.

Based on raw scores from the SPPC self-report, scale range 1-4.

Table 3.

Correlations Between Social Support and Emotional Well-Being Outcomes.

Outcome scale	Parent SS	Teacher SS	Classmate SS	Friend SS	Other Adult SS	Overall SS
Depression Self-Report (Spearman’s rho)	−.09	−.01	−.02	−.04	−.01	−.05
Depression Parent Report	−.11	−.22	−.19	−.18	.06	−.15
Anxiety Self-Report	.02	−.04	.07	.07	.02	.04
Anxiety Parent Report	.08	−.10	.02	−.03	−.06	−.03
Self-Reliance	.40**	.25	.26	.25	.29*	.36**
Scholastic Competence	.40*	.29	.34*	.31	.08	.34*
Social Acceptance	.44**	.40*	.51**	.25	.01	.38*
Global Self-Worth	.36*	.22	.53**	.46**	.14	.42**

Note. All correlations represent Pearson’s product-moment except the correlations of self-reported depression with other outcomes, which are reported as Spearman’s rho due to the non-normal distribution. SS = social support.

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

To further evaluate the overall and relative contributions of support sources in predicting outcomes, standard linear regression analyses were conducted for those variables significantly correlated with social support. In each case, all sources of support that were found to correlate significantly with the outcome were entered together into the regression. For instance, for global self-worth, parent, classmate, and friend support were added as predictors. Results are presented in Table 4. In each case, the models were statistically significant but explained only a small amount of the variance in outcomes, ranging from 12% to 24%. Individual predictors did not consistently reach significance and held relatively small regression weights. Significant individual predictors included parent support in predicting self-reliance and classmate support in predicting global self-worth. Classmate support also approached significance as a predictor of social acceptance (p = .08). Thus, predictions were partially supported, in that social support was related to self-concept indicators but not indicators of emotional distress. Results further support the notion that different sources of support may have somewhat different functions, with parent and classmate support the most consistently influential.

Table 4.

Regression Analyses of Social Support Sources in Predicting Emotional Well-Being.

Outcome	n	Independent variables	β	R ²
Self-Reliance	51	Parent support*	.338	.134*
		Other adult support	.122
Scholastic Competence	40	Parent support	.336	.120*
		Classmate support	.089
Social Acceptance	40	Parent support	.059	.220**
		Teacher support	.146
		Classmate support	.383
Global Self-Worth	40	Parent support	−.103	.24**
		Classmate support*	.466
		Friend support	.200

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

Research Question 3: Social Support in the Context of Peer Rejection

The third research question evaluated the function of social support in the context of peer rejection, or more specifically, lower social preference. Only those participants with complete data for all variables of interest were included, resulting in a subsample of 38 ADHD-C/HI participants. Several preliminary analyses were required in preparation for the main analyses.

Emotional adjustment composite outcome

A composite approach was used to represent emotional well-being as the outcome of interest, as it allows for a broader and more clinically meaningful construct that reflects both the presence of positive well-being and the absence of negative symptoms. It also reduces the number of analyses (compared with conducting separate analyses for each individual outcome) and the impact of single rater bias. A composite was derived by combining global self-worth (SPPC) with the absence of depressive symptoms (BASC-2), following Harter’s (1999) work in modeling the relationships between social support, self-evaluations, and well-being. Parent-rated depression (reverse-scored) was selected due to the non-normal distribution of self-rated depression. T-score composites were created by standardizing each score for the subsample of 38 participants. The final emotional adjustment composite scale was normally distributed with a mean of 100 and a standard deviation of 16.55, with higher scores reflecting more positive well-being.

Social preference

As the majority of participants were rated as having relatively high social preference on the Dishion Social Acceptance Scale (M = 2.00, SD = 1.83 on scale of −4 to +4), it was dichotomized using a median split approach into high (score of 3 or 4, n = 19) and low (score of 2 or less, n = 19) and then dummy coded for use in regression analyses (0 = lower social preference, 1 = higher social preference). This approach allowed for a more meaningful comparison between those who are generally well-liked and rarely rejected versus those who are liked by less of their peers and/or more frequently rejected. Age was evenly distributed across lower (M = 10.20, SD = 1.19) and higher (M = 10.50, SD = 1.03) social preference groups. No significant differences were detected in the total social support score between lower and higher social preference groups, t(36)= −0.31, p = .76, d = 0.10, or in a MANOVA comparing specific sources of social support, F(5, 32) = 1.50, p = .22. However, an independent samples t test found that those with lower social preference scored significantly lower on the emotional adjustment composite score than those with higher social preference, t(36) = −3.86, p = .001, d = 1.25.

Regression analyses

Six simultaneous multiple regression analyses were conducted to examine the roles of each source of support with social preference in predicting emotional well-being. Following Wu and Zumbo (2008), social support scores were mean-centered before creating the interaction term. Each regression involved entering the dummy-coded social preference and one source of support at Step 1 and the interaction term at Step 2. As shown in Table 5, all regressions were significant at both steps. The regression incorporating total support was the strongest, accounting for 38% of the variance in emotional well-being. Regarding source-specific support, main effects for each independent predictor were found in the models including parent, classmate, and friend support whereas teacher and other adult support did not reach significance as individual predictors after accounting for social preference status. None of the interaction effects were significant for social preference with total or any source of support.

Table 5.

Regression Analyses of Social Preference and Social Support in Predicting Emotional Adjustment.

Step	Independent variables	B	R ²	ΔR²
1***	Social preference**	.501	.336	.001
	Parent support*	.284
2**	Social preference**	.500	.317
	Parent support	.264
	Social Preference × Parent Support	.032
1***	Social preference**	.497	.329	.000
	Teacher support	.272
2**	Social preference**	.496	.309
	Teacher support	.260
	Social Preference × Teacher Support	.020
1***	Social preference**	.485	.377	.003
	Classmate support*	.348
2***	Social preference**	.486	.362
	Classmate support*	.391
	Social Preference × Classmate Support	−.066
1***	Social preference**	.509	.340	.015
	Friend support*	.290
2**	Social preference**	.508	.337
	Friend support	.180
	Social Preference × Friend Support	.165
1**	Social preference***	.604	.308	.001
	Other adult support	.237
2**	Social preference***	.597	.288
	Other adult support	.172
	Social Preference × Other Adult Support	.070
1***	Social preference***	.523	.381	.001
	Total support*	.348
2***	Social preference***	.523	.363
	Total support	.320
	Social Preference × Total Support	.040

p < .05. **p < .01. ***p < .001.

Discussion

To better understand, predict, and positively influence the heterogeneous trajectories of children with ADHD, researchers and practitioners must consider the strengths and resources of this population, as well as the risks and challenges that they may face. This study explored the role of one potential protective factor, perceived social support, in relation to the emotional well-being of children with ADHD-C/HI. Findings regarding levels of social support among ADHD participants were only partially consistent with those of the one previous study that has explored this issue (Demaray & Elliott, 2001). Specifically, although both studies found lower total support among ADHD participants, current findings were more pervasive in documenting lower perceptions of support across most sources (with the exception of classmate support), and levels of support were in this case unrelated to symptom severity. Findings of equivalent classmate support diverged from the findings of Demaray and Elliott (2001) and the high rates of peer rejection typically reported in this population (Hoza et al., 2005), and may reflect a more well-functioning sample and a relatively young age group who have not yet experienced the full range of peer challenges. Nonetheless, classmate support remained a significant predictor of outcome variables, and thus remains an important variable for consideration.

As predicted, significant positive associations were found between total social support and all measures of self-concept, including global self-worth, self-reliance, and specific perceptions of scholastic competence and social acceptance. Consistent with findings from other populations (Chu et al., 2010; Rueger et al., 2010), parent and classmate support were most broadly and strongly associated with these outcomes. Regression analyses further demonstrated that social support was able to account for 12% to 24% of the variability in these self-concept outcomes. Thus, results demonstrate a moderate and significant relationship between how children with ADHD perceive themselves and how they perceive support from those around them. Although directionality cannot be determined here, when taken within the context of previous studies demonstrating an influence of perceived social support on emotional well-being over time (e.g., Demaray et al., 2005; Rueger et al., 2010), these findings suggest that perceived social support may play a similar role for children with ADHD.

Although it was expected that support from other adults would have weaker associations with outcomes relative to more prominent sources, an overall lack of such relationships aside from a modest correlation with self-reliance was instead observed. One contributing factor may have been the question presentation (i.e., children were asked to identify an adult to whom they felt close), which may have biased responses in favor of uniformly higher ratings. It is also possible that the greater variability in roles, closeness, and support functions captured by this scale (e.g., grandparents, coaches, family friends) masked possible associations of such support with specific outcomes, as the wide range of individuals fitting this category resulted in a less unified scale. The nature of other adult supportive relationships may also be somewhat distinct from other sources and may vary based on the needs of the particular child. For instance, Beam, Chen, and Greenberger (2002) have suggested that relationships with such adults are unique in simultaneously taking on aspects of peer and parent relationships. Relatedly, a possible compensatory role of other adult support primarily for those with low support from other sources (Harter, 1999) would also have masked overall results on this scale. Although sample sizes were too small in this case to effectively evaluate these various possibilities, further exploration of a potential role for other supportive adults would be valuable given the frequently cited relationship difficulties between many children with ADHD and their parents, teachers, and peers (Deault, 2010; Hoza et al., 2005; Kos et al., 2006) as well as findings on the importance of other adults in many at-risk youth populations (Masten, Best, & Garmezy, 1990).

Contrary to predictions, no associations were found between perceived social support and internalizing symptoms. Although such relationships have frequently been found in other samples, most of these studies have evaluated somewhat older children, and relationships when found have typically been smaller with these outcomes than with measures of self-concept (Chu et al., 2010; Demaray & Malecki, 2002). It may be that at this young age, there is relatively less clinically significant depression or anxiety, and thus the relationships between protective factors and such outcomes are not yet established. In particular, mean ratings on these scales fell close to the normative means, suggesting that the elevated rates of anxious/depressed symptoms reported among ADHD populations were not yet present to a significant degree at this age.

Results also highlight the importance of differentiating between facets of self-concept and between sources of support in understanding their associations. As a prominent example, whereas global self-worth was predicted primarily by classmate support (with associations also with parent and close friend support), self-reliance was associated only with parent and other adult support. This finding suggests a distinction between notions of “I like myself” versus “I believe in myself,” and in particular a distinction in the factors related to these facets of self-concept. As might be expected, liking and valuing oneself were related to feeling supported by the most prominent sources in one’s life, which for children are typically their parents and peers. However, the type of support provided by adults may have a unique relationship with one’s sense of self-mastery or self-efficacy, with adults providing more feedback on a child’s responsibility, independence, perseverance, and skill development. This further suggests that replacing one weak source of support with support from a distinct source (e.g., compensating for low parent support by building friend support) may not necessarily impact the same outcomes.

A note at this point is warranted on the possibility of a PIB that may have impacted self-report ratings. Although not explicitly measured, biased ratings, particularly in self-concept outcomes, would not be unexpected given that this is where they have been most consistently documented (Hoza et al., 2004; Owens et al., 2007). However, given the lack of consensus to date on whether the PIB should be considered protective or detrimental, its influence on interpretation is difficult to establish at this stage. With regard to social support ratings, a PIB effect appears less likely given that (a) ratings were reflecting other rather than self-behavior, where children with ADHD tend to be more accurate (Evangelista, Owens, Golden, & Pelham, 2008), and (b) results are consistent with expectations in documenting lower levels of support from this group. Moreover, as it is the perceptions of support that matter more than objectively measurable behaviors (Wethington & Kessler, 1986), whether a PIB is present may not significantly change the influence or implications of support ratings.

Finally, this study explored the role of perceived social support within the context of lower or higher social preference. It is notable that many of the children in this sample were rated by their parents as showing relatively high social preference with little to no peer rejection. These findings are not consistent with the extent of peer rejection typically documented among children with ADHD, and may reflect a relatively better functioning subset of the ADHD population and/or a more limited awareness of social status by parents versus teachers. That said, even without considerable rejection there remained significant differences across well-being outcomes between those with higher and lower social preference, supporting the notion that even relatively lower social preference served as a risk factor within this sample.

Results of the regression analyses demonstrated main effects for both social preference status and total social support, together predicting 38% of the variance in emotional adjustment. Source-specific regressions further demonstrated similar findings when specifically evaluating parent, classmate, and close friend support, whereas teacher and other adult support were not significant individual predictors. The non-significance of specific interaction effects and the lack of change in predictive value at this step of the models indicate that a buffering effect was not detected within this study. Thus, social support was not more important in predicting emotional adjustment for those of lower social preference, but rather appeared to have a similar role for all children in the sample. The present results as a whole seem to be most in line with the social constructionist main effect model of social support (Harter, 1999; Lakey & Cohen, 2000; Shumaker & Brownell, 1984), wherein one’s perceptions of support from valued others are proposed to contribute particularly to the establishment and maintenance of self-esteem and self-identity. In fact, this function of social support may be especially relevant for children, as the perceived views of others inform their developing self-image, which over time becomes internalized into a more stable and self-sustained self-concept in adulthood (Harter, 1999). This could have important ramifications for children with ADHD with regard to the feedback and messages they internalize, which may in turn impact their long-term self-concept and well-being.

Notably, given the smaller sample size and limited power, these results do not preclude a potential buffering effect that might be detected with a larger and more diverse sample of ADHD children. It is also possible that a stress-buffering role of social support might be more likely in the context of more overt and predominant peer rejection. Nonetheless, the lack of buffering effect found within this study does not negate the potential relevance of perceived social support in a resilience model of ADHD. Indeed, Masten (2001) has argued that protective factors with main effects (i.e., beneficial for all individuals regardless of risk) can be valuable contributors to resilience models, in that they can combine in an additive manner to help compensate for stressors that may threaten the outcome of interest. This perspective implies that it is through the accumulation of such protective factors (and the reduction of risks where possible) that children become more resilient in the face of stressors. This may be particularly relevant to children with ADHD, who do not consistently face one specific stressor but may face a range of challenges over time and across broad domains of functioning.

Limitations

Several limitations with regard to the characteristics and representativeness of the sample are notable that should be considered when interpreting and generalizing results. First, as a diagnostic assessment was outside the scope of this study, diagnoses of ADHD and comorbidities (by a qualified professional) were established based on parent report. However, well-established screening questionnaires were used to confirm a sufficiently high level and range of ADHD symptomology. As well, this sample appears to have been more advantaged than the general population of ADHD children given the relatively high income levels, two-parent families, and the predominance of Caucasian participants, as well as the relatively restricted range of reported social preference status within the sample. Although findings regarding the levels of support and their associations with outcomes may have varied with a more balanced and representative sample, the presence of significant associations even within this more advantaged and homogeneous sample does point toward the value of social support for children with ADHD.

The modest sample size (N = 55) of this study restricted the complexity and statistical power of analyses that could be conducted. In particular, the uneven numbers within subgroups of the sample (e.g., gender, medication status, comorbidities) limited the capacity to conduct in-depth within-group comparisons and subgroup analyses based on child characteristics, which might have elucidated factors that can influence perceptions of support and/or their associations with outcomes. For instance, the influence of medication or other treatment modalities on social support and related well-being outcomes would be a valuable area for further study. As well, although the gender ratio within the sample was consistent with reported rates of ADHD within the population (APA, 2000), findings of gender differences in other populations with regard to social support and its influence on particular outcomes (e.g., Rueger et al., 2010) point to a need to further explore possible gender differences among those with ADHD.

This study also relied heavily on the use of rating scales, which provide an efficient means to obtain information regarding perceptions and feelings that cannot be easily accessed through other methods. Nonetheless, rating scales can also be affected by personal characteristics of the rater, and the use of multiple ratings by the same individual can lead to over-inflation of associations due to shared variance in ratings. Such risks were mitigated to some degree by incorporating both parent and child report, adding richness and multiple perspectives to the data. As well, social preference ratings were provided by parents rather than teachers who may have had a more accurate picture of the children’s social status at school.

Finally, the novel approach to the measurement of other adult support may have impacted findings for this source. In previous work, its measurement has typically focused more on the presence rather than the specific supportive quality of such relationships, whereas within the current study, perceived support from other adults was measured by adapting relevant items from other subscales of the CASSS. Several conceptual confounds may also have impacted this scale, as discussed above. Ultimately, further consideration of how to best measure and quantify perceived support from other adults may improve the quality and utility of this information.

Future Directions

Results of the current study demonstrate clear associations between the perceptions of social support held by children with ADHD-C/HI and their valuations of self-esteem, including specific evaluations of their scholastic and social competence, their capacity to solve problems, and their overall sense of value and worth. Further research incorporating a matched non-ADHD comparison group would be useful in evaluating potential differences in the associations between social support and outcomes across ADHD status, and particularly to explore whether perceived social support might act as a buffer against the overall risks of ADHD in promoting resilience. Longitudinal research that follows children into adolescence and adulthood would also be informative both in identifying developmental changes in the associations of social support with outcomes and in examining the role of social support in predicting long-term well-being trajectories, particularly during a developmental period wherein internalizing problems may become more prominent. Exploring the role of social support for children with ADHD in relation to other outcomes of risk for this population (e.g., academic) would also be of value.

Although causality of current findings cannot be established, the main effects of these findings combined with previous research on social support suggest a benefit of enhancing the supportive qualities of parent, classmate, and close friend relationships for all children with ADHD. Further applied research would help to clarify the most influential features and approaches of such interventions, as well as potential indirect avenues for strengthening perceived social support. For instance, documented associations between social skills and social support among both ADHD and typical populations (Demaray & Elliott, 2001; Demaray & Malecki, 2002) suggest that social skill interventions might indirectly increase perceptions of support through their benefits on peer and adult relationships. Similarly, investigating whether commonly used parent-focused ADHD programs (e.g., behavioral management training or parent support groups) can improve children’s perceptions of parent support would prove valuable. Although much work remains to fully elucidate how to best promote this potential protective factor, regularly evaluating and nurturing positive and supportive interactions of children with ADHD with their families and peers would certainly be a positive place to begin.

Footnotes

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors had a grant from Alberta Centre for Child, Family, & Community Research (ACCFCR), and received funding from Social Sciences and Humanities Research Council (SSHRC, award # 767-2010-2727).

Author Biographies

Sarah M. Mastoras obtained her PhD in school and applied child psychology from the University of Calgary in 2013. She works as a psychologist for the Ottawa-Carleton District School Board, where she is leading initiatives to increase staff capacity in supporting children with ADHD. Her research interests are focused on resilience and strengths-based approaches to understanding and working with children with ADHD.

Donald H. Saklofske, PhD, is professor of psychology at the University of Western Ontario. His research is focused on intelligence, personality, individual differences, and psychological assessment.

Vicki L. Schwean, PhD, is dean, Faculty of Education, at the University of Western Ontario. Her research focuses on children’s mental health and well-being.

Emma A. Climie, PhD, RPsych, is an assistant professor in the school and applied child psychology program in the Werklund School of Education at the University of Calgary. She is also the lead researcher—Carlson Family Research Award in ADHD. Her research focuses on understanding children with ADHD from a strengths-based perspective, integrating primary research and school-based intervention in the areas of resilience, stigma and mental health, and physical activity.

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