A Cooperative Learning Classroom Intervention for Increasing Peer’s Acceptance of Children With ADHD

Abstract

Objective: The hypothesis behind this study was that trained teachers using cooperative learning procedures with children in their classroom (aged from 6 to 10 years) can influence the social skills of children with ADHD symptoms and their acceptance by their peers. Method: The study involved 30 children with ADHD symptoms attending 12 different classes, where cooperative learning was adopted in some, and standard practices in others. ADHD children’s symptoms, social skills, and cooperative behavior were assessed by means of a teacher’s questionnaire, and the social preferences of the children in their class were collected. Results: Changes emerged in teachers’ assessments of the children’s cooperative behavior in the experimental classes. Improvements in the sociometric status of children with ADHD symptoms were only seen in the cooperative learning classes. Conclusion: These results show the importance of well-structured intervention in classes that include children with ADHD symptoms. Implications of these findings for future intervention are discussed.

Keywords

ADHD cooperative learning peer acceptance social preferences

ADHD is a neurobiological developmental disorder characterized by a persistent inattention and/or hyperactivity-impulsivity that interfere with the normal psychological development of children and hinder their performance in common daily activities, making them unable to adjust their behavior to the expectations of outside word (Capodieci & Cornoldi, 2013). In particular, symptoms of ADHD tend, by their very nature, to prevent successful interaction with peers (Mrug, Hoza, Pelham, Gnagy, & Greiner, 2007). Specifically, children with such symptoms are often rejected because of their inclination to be domineering, tactless, unyielding, disturbing, touchy, careless, and heedless of the rules in organized games. The classroom behavior of children with ADHD that is associated with their rejection by their peers includes being off-task, troublesome, rude, and incapable of self-control (Rich, Loo, Yang, Dang, & Smalley, 2009). Little attention has been paid to the issue of how to contain this problem.

Reported prevalence rates of ADHD among schoolchildren of all ages in Europe and worldwide are typically high (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007; Wittchen et al., 2011), meaning that nearly every classroom may include a child with symptoms of ADHD. The classroom is a very important place for all children because it is where they learn how to relate to others, as well as gaining academic skills. Relationships in the classroom represent a primary setting in which children learn to cooperate, negotiate, solve conflicts—skills crucial to effective social functioning throughout life (Hoza, 2007). The troubled social relationships of children with ADHD are associated with numerous negative longitudinal outcomes, including serious conduct problems (Bagwell, Molina, Pelham, & Hoza, 2001). High negative sociometric nomination rates may anticipate subsequent psychopathology (Mikami et al., 2015). For example, boys with ADHD and difficult relationships with their peers in childhood are associated with more criminality, depression, and substance use in adolescence than boys with ADHD but no social problems with their peers (Greene, Biederman, Faraone, Sienna, & Garcia-Jetton, 1997). In a sample of girls with ADHD, rejection by peers in childhood significantly contributed to academic disappointment in adolescent, disruptive behavior, and internalizing symptoms (Mikami & Hinshaw, 2006).

Given their importance, social aspects and peer acceptance have been taken into account in intervention programs for ADHD. Stimulant medication and behavioral management can reduce the core symptoms of ADHD and may improve parents’ and teachers’ ratings of the affected children’s social skills (Swanson et al., 2001), but there is no evidence of any improvement in their sociometric status, that is, of their peers’ attitudes toward them (Mrug, Hoza, & Gerdes, 2001). Training for children with ADHD to improve their social skills has produced unclear results, when assessed with sociometric measures (Abikoff et al., 2004), prompting pessimistic conclusions on the feasibility of including peer problems in the treatment of this population (Hoza et al., 2005).

There is a potential weakness in the literature, however, concerning intervention on the social skills and peer relations of children with ADHD. The social aspects of children, including peer acceptance and rejection, have often been measured by means of class nominations, but social skills programs for children with ADHD have often considered these particular children from an individual point of view and outside the normal classroom setting. It is worth nothing that changes in the behavior of children with ADHD may not necessarily induce changes in the attitude to their behavior taken by their peers. It has been demonstrated, for instance, that the same behavior is interpreted differently depending on whether the child concerned has a high or low social preference rating (Peets, Hodges, & Salmivalli, 2008). Peers are willing to give the benefit of the doubt to children they already like, whereas a child they dislike behaving in the same way may be judged negatively. In other words, peers are unlikely to change their opinions of their classmates with ADHD even when the latter’s behavior improves (Mikami, Lerner, & Lun, 2010).

Although it is generally assumed that the classroom is one of the most important social settings for children with ADHD to develop and maintain positive social relationships with others, this important social environment has seldom been considered in investigations and interventions (Chang, 2004). Furthermore, not enough importance has been attributed to the role of teachers (Mikami, Griggs, Reuland, & Gregory, 2012) despite the fact that teacher’s behavior is known to influence children’s social preferences (Mikami et al., 2012). Teachers who personally like and accept children with behavioral problems have been shown to attenuate the typically strong correlation between such children’s behavior and their sociometric status. Likewise, the extent to which a teacher exhibits frustration with such children or criticizes their behavior mediates the association between these children’s behavior and their rejection by peers (McAuliffe, Hubbard, & Romano, 2009). This evidence goes to show that the classroom should be seen as the main setting for intervention on the social aspects of children with ADHD, as it is the primary environment for their social interactions. This is confirmed by the use commonly made of class nominations as the main measure of students’ peer relations in social behavior studies. The solidity of social preference is usually conceptualized as resulting from children’s steady behavior over time, and especially from consistency in the troublesome conduct of unpopular children. Strong social inclination may also be propagated by subjective predispositions held by the peer group, however, and appropriate educational strategies might be able to influence such predisposition.

Educational practices may have a key impact on such aspects of classroom life. To give an example, children who watched a video in which a teacher delivered experimentally manipulated feedback to a child with a negative reputation, altered their perception accordingly (White & Jones, 2000). As suggested by Mikami and colleagues (2013), training regular classroom teachers to make the peer group more inclusive may have a positive effect on the children with ADHD in these teachers’ classroom. A durable change in teacher’ practices may also prevent children with ADHD enrolling in their future classes from being rejected by their peers.

Cooperative Learning (CL) appears to be particularly relevant among the educational practices in the classroom that could have positive implications for the child with ADHD. CL involves students working in small, organized groups to reach shared objectives. It is broadly recognized as a teaching strategy that promotes learning and socialization among students of all ages and across various subject domains. It has been used successfully to promote academic achievement, upgrade students’ willingness to work cooperatively and productively with others who have different learning levels and needs, and improve intergroup relations with children from different backgrounds. It has been argued that CL experiences are crucial to avoiding and mitigating many of the social problems related to children, adolescents, and young adults (for a review, see Gillies, 2014).

CL has been widely accepted as a teaching strategy obtaining documented improvements in achievement, applications of knowledge, and motivation (across subject areas and grades) by comparison with traditional teaching methods (Emmer & Gerwels, 2002; Gillies, 2003). CL has a wide base of support among educators and researchers, who have documented increased motivation and academic gains in every academic subject area, grade level, and type of school, especially when it includes certain elements (e.g., individual accountability, positive interdependence, group rewards, structure; Antil, Jenkins, Wayne, & Vadasy, 1998; McMaster & Fuchs, 2002).

Positive effects of CL have been documented in whole-classroom observational research. For example, it generated fewer off-task verbalizations and more positive verbal interactions (in groups of typical eighth graders) at schools defined as being scarce and inexpert users of CL (Beyda, Zentall, & Ferko, 2002; Gillies, 2003). It has to be said that, because it is difficult to randomly assign conditions in naturalistic whole-classroom research, the effects obtained might be attributable to previous differences between teachers, classrooms, or schools (e.g., teachers choosing to adopt these practices may have other teacher variables that contribute to these gains). A completely random assignment to a CL condition would contrast with the ethical standards typically required for school-based studies in which participants are properly informed volunteers. Overall, the findings of research using different designs, types of participant, and definitions of CL suggest that the CL approach warrants more systematic study. A first step would probably involve establishing clear definitions and crucial variables (Kuester & Zentall, 2012).

There are some important elements to consider when organizing lessons to be conducted according to the CL method (as done in the present study) given their demonstrated importance (Johnson, Johnson, & Smith, 2007): (a) Positive interdependence: when people see that they can achieve their objectives if and only if the other individuals with whom they are cooperatively linked reach their goals too and therefore endorse each other’s efforts to achieve the result. (b) Individual accountability: This exists when the performance of each single child is monitored and the outcomes are offered back to the individual and the group. Each member is held responsible by the other member of the group contributing to the group’s success. (c) Enhanced interaction: To encourage each other’s success, group members help and support each other, exchange the necessary resources such as information and materials, offer each other feedback, challenge each other’s conclusions and reasoning, and act in trusting and responsible ways. (d) Use of social skills: Some skills like decision making, communication management, and conflict resolution have to be taught just as carefully as academic skills. (e) Group processing: Effective group work is influenced by whether or not groups periodically reflect on how well they are functioning and how they may improve their learning processes. Teachers need to give the class time for group processing and show students how to examine their processes efficiently.

Although CL has been widely and sometimes even too enthusiastically and generically accepted as a teaching strategy, educators’ perceptions of the difficulties involved in adopting this approach might clarify their inclination to exclude scholars with hyperactivity or inattention from group experiences. This would also help to explain why educators use cooperative practices less frequently than they think would be desirable (Lopata, Miller, & Miller, 2003), especially with children in Grades 3 to 8 (Race & Powell, 2000).

In addition, despite the potential importance of CL in the case of ADHD, only a few studies have analyzed the effects of CL on children with this disorder (Kuester & Zentall, 2012; Mikami et al., 2013; Zentall, Kuester, & Craig, 2011). They generally found that the social interactive rules that CL entails reduced the negative verbal and off-task behavior and improved the proportion of problems solved by all children but sociometric measures did not change significantly. This could be due partly to the different places being used to conduct the CL intervention and to record the sociometric measures and partially to the limited importance attributed to the teacher’s preparation and role in influencing social preferences of the children in their classrooms.

The aim of our research was to draw on the strengths of previous studies on CL, and to overcome their weaknesses, by proposing a CL intervention in normal classroom with well-trained teachers. CL sessions were organized in classes where children with ADHD-related problems interacted with typically developing children (TD) supervised by teachers specifically trained to teach children with symptoms of ADHD. Adequately trained teachers, reportedly consider CL an effective and useful strategy to use with students who have been diagnosed with (or have symptoms of) ADHD (Garcia, 2013).

The main purpose of the present study was to test the hypothesis that teaching through CL can help children with symptoms of ADHD to become better integrated in class and more appreciated by their peers, improving their social and collaborative skills as a result. These aspects were measured on the basis of both teachers’ ratings and children’s sociometric choices. Although the teachers’ ratings might be biased by the presence among the raters of the same teachers who conducted the classroom activities, such ratings were the only procedure practicable and permitted by schools participating in this study, thus replicating the methods adopted in previous research on similar issues (e.g., Kuester & Zentall, 2012).

Method

Participants

The study involved 30 children (aged between 6 and 9.8 years) attending 12 classes (Grades 1 to 5) that included one or more children with symptoms of ADHD, at nine different schools in northeastern Italy. All the teachers of the 12 classes were part of a group that had received information on ADHD and on the nature of the project, and they were being trained (on a voluntary basis) on how to teach children with ADHD. Six classes adopted the CL teaching method (number of students = 132, number of students with ADHD symptoms = 16) while the other six classes, with similar characteristics in terms of size, location, teachers’ age, and positive attitude toward CL (number of students = 121; number of students with ADHD symptoms = 14) taught the same content as the CL classes but using standard teaching methods. The inclusion of a class in the experimental (CL) group could not be completely randomized because it was also affected by the teachers’ and their school administrations’ willingness to fulfill all the requirements of the study. The two groups of children with ADHD were comparable in terms of age, gender, rated intellectual ability, socioeconomic level, presence of concurrent minor psychopathological problems, and educational level (investigated by a questionnaire; see Table 1). The different subtypes of ADHD were also similarly represented in the CL and in the control groups, with, respectively, six and six inattentive children, three and two hyperactive/impulsive, and seven and six with the combined subtype.

Table 1.

Characteristics (M and SD in parenthesis) of Children With Symptoms of ADHD in the CL Group and the Standard Learning (Control) Group.

	CL group (n = 16)	Control group (n = 14)	χ²	p
Male (%)	87.5	85.7	.54	.44
	M (SD)	M (SD)	Range^a	t(28)	p
Age (months)	97.94 (14.87)	98.14 (15.32)	72-118	0.04	.97
Disadvantaged family environment (COM)	1.00 (.89)	.71 (1.07)	0-3	−0.80	.43
Cognitive abilities (COM)	4.45 (2.66)	5.21 (3.40)	0-10	0.62	.54
Inattention (SDAI)	18.13 (5.01)	16.57 (5.27)	0-27	−0.83	.42
Hyperactivity (SDAI)	12.88 (8.37)	12.21 (5.89)	0-27	−0.25	.81
CD symptoms (COM)	1.88 (2.28)	2.43 (2.85)	0-12	0.59	.56
ODD symptoms (COM)	3.30 (3.51)	4.00 (4.26)	0-15	0.53	.60
Internalizing symptoms (COM)	3.19 (4.17)	3.07 (3.29)	0-15	−0.08	.93
Social skills (COM)	3.94 (2.70)	3.71 (3.32)	0-12	−0.20	.84
Cooperation (COM)	6.44 (2.61)	7.64 (3.75)	0-18	1.03	.31

Note. CL = cooperative learning; CD symptoms = minor symptoms of conduct disorder; ODD symptoms = minor symptoms of oppositional defiant disorder; Internalizing symptoms = presence of minor symptoms of anxiety or depression. COM = comorbidity; SDAI = Scala per i Disturbi di Attenzione/Iperattività per Insegnanti [ADHD scale for teachers].

Ranges for scores refer to the lowest and highest possible value considered by the measure.

As explicit diagnoses are infrequently made in Italy, the children with ADHD group were identified by the authors on the basis of a screening process that included interviews and a score of 14 or higher (the diagnostic cutoff given in the Manual) on one or both the subscales of the SDAI (Scala per i Disturbi di Attenzione/Iperattività per Insegnanti [ADHD scale for teachers]; Marzocchi & Cornoldi, 2000). This scale is widely used in Italy and has been validated for the Italian population, with high interjudge and test–retest reliabilities (r > .8 in both cases), discriminatory power, and concurrent validity obtained by correlating the scale with other scales (r > .95; Marzocchi, Re, & Cornoldi, 2010). The scale exactly reflects the 18 symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) for diagnosing ADHD and therefore includes two subscales, one for inattention (nine items) and one for hyperactivity/impulsivity (nine items). Teachers were asked to closely monitor a child’s behavior for about 2 weeks and report the frequency of the types of symptomatic behavior described in each item. Scores for the items of the SDAI scale range from 0 (problematic behavior never present) to 3 (very often present). Teachers were also asked to answer the COM (comorbidity) questionnaire to identify any minor symptoms of other psychological and psychopathological problems, and to collect relevant information on the children (Marzocchi et al., 2010). In both the CL group and the control group, the children with ADHD symptoms had an average cognitive level, no other serious psychological problems (oppositional behavior or internalizing problems), and none of them were socioeconomically disadvantaged (see Table 1). Teachers and parents were interviewed informally to collect further evidence of the children’s ADHD symptoms, not only at school but also in other settings to rule out children with other relevant difficulties. None of the children had a history of neurological or psychiatric problems. Written consent was obtained from children’s parents before they participated in the experiment. The teachers taking part in the research were all female, with a mean age of 42.3 years, and with a lengthy teaching experience.

Material and Procedure

Teachers’ ratings of children’s social skills and cooperative practices

To investigate the children’s social ability (four items) and cooperation (six items), we used the Social Questionnaire, a supplementary section of the COM scale (Rivetti & Capodieci, in press). The Social Questionnaire was completed by the group of teachers responsible for the class, including the teacher involved in the CL activities, among others. The social ability subscale identifies any social problems. On the basis of data collected from 907 primary school children, its mean score is 1.06 and Cronbach’s alpha is .75. The cooperation subscale describes a child’s cooperative skills, and the mean score and Cronbach’s alpha (obtained with the same sample of 907 children) are 12.56 and .87, respectively.

To analyze children’s social preferences (Elledge, Elledge, Newgent, & Cavell, 2016), we asked them to nominate three classmates with whom they most liked to play. As suggested by Asher and Dodge (1986), “liked-least” nominations were avoided. Instead, children rated how much they liked to play with each classmate on a 5-point scale, where 1 counted as liked-least nominations. Children were asked to write the names of their three favorite mates, and then to answer three questions for each classmate, on a scale from 1 = not at all to 5 = very much: “How much do you like to play with him/her?” “How much would you like him/her as a desk mate?” and “How much would you like him/her as a teammate?” As the number of classmates providing nominations varied between classrooms, scores were converted to z scores within each class—as is normal practice in sociometric research (e.g., Coie & Dodge, 1983)—to enable comparison between scores for students in class of different sizes.

Social preference scores were computed by subtracting “liked-least” ratings from “liked-most” nominations, then dividing this number by the number of student raters minus 1 (i.e., students could not rate or nominate themselves). Children were classified as “rejected” on the ground of the following three criteria (Coie, Dodge, & Coppotelli, 1982):

Standardized social preference scores < −1.0;

Standardized liked-least scores >0;

Standardized liked-most scores <0.

Social preference scores and rejected sociometric status were considered as separate indicators of children’s social risk and were used to analyze changes.

Teacher training and CL activities

All six teachers involved in implementing CL attended a course on teaching methods and educational psychology for pupils with ADHD. The teachers received specific instructions on the use of CL and the experimental sessions started after the teachers and children had completed the questionnaires. During the training, teachers implemented a specific CL activity in class. A clinic psychologist expert in this field monitored the activities and suggested any necessary changes. The six subsequent sessions were held once a week and lasted 2 hr.

For each activity, teachers had to provide (a) general information on the class (number of children, number of males and females, children with a particular diagnosis or special educational needs), (b) learning objectives, (c) relational/social objectives, (d) timetable, (e) type of activity, (f) tools and materials, and (g) a final discussion and summary. In the relational and social objectives section, teachers were asked to specify which aspects of CL they have touched (positive interdependence, individual accountability, promotive interaction, use of social skills, group processing) and how.

The six sessions followed the procedure described in the Manual for Personalized Cooperative Learning (Rivetti & Capodieci, in press) and were completed in the months of November and December 2015, during the normal class time. The activities were organized so that the first two sessions were devoted to creating the class’s climate and training the children’s social abilities. They included play situations to help the children get to know each other better, trust each other, and learn to accept others and be part of a group. The next two sessions involved simple cooperative activities with children in small groups undertaking simple tasks, such as finding support for an explanation or an idea previously proposed by a teacher. The final two sessions involved complex learning activities. Children in groups of three to five had to follow specific rules (see the appendix for an example of the activities involved). Meanwhile, children in the classes forming the control group spent the same amount of time on their usual activities devoted to improving their academic learning. Teachers were asked to use similar contents and offer similar opportunities for the children to interact with their classmates as in the CL classes, but to avoid CL activities. Treatment fidelity was controlled both by receiving information and offering feedback before each activity and by meeting teachers. In particular, teachers’ adherence to the program was tested by holding meetings with them during the formative lessons proposed, in the context of the master course every week. During these meetings, we also checked that the classes in the control group had not been involved in any CL activities. This careful monitoring ensured that there was no lack of adherence to the instructions. During the study period, the children with ADHD received no medical or psychological treatment. Approximately 1 week after the six sessions, the baseline study measures were collected again, that is, teachers completed the SDAI and the Social Questionnaire and the children reported their sociometric nominations.

The study was conducted in accordance with the ethical standards required by the Italian Scientific Community (Associazione Italiana di Psicologia, 2014) and had the approval of all the school authorities and parents involved.

Results

The children with symptoms of ADHD who attended the CL sessions were compared with the children with symptoms of ADHD attending normal classes, using a Group (CL vs. Control) × Time (pre- vs. post-CL) ANOVA for a mixed design.

Table 2 presents the mean scores and standard deviations for the teachers’ ratings and, in the last two columns of the table, the F values and the respective p values obtained for the main effect of time (indicating whether there were any general changes after 2 months of the study period), and the Pre–Post × Group interaction (which indicates whether one group changed to a different extent from the other).

Table 2.

Mean Scores (SD in Parenthesis), Main Effect Size, and Interactions for the Two Groups of Children With Symptoms of ADHD (CL Group vs. Control Group) on Teachers’ Ratings and Peers’ Class Nominations.

	CL group (n = 16)		Control group (n = 14)		Time effect		Time × Group
	Pre	Post	Pre	Post	F(1, 28)	p	F(1, 28)	p
Teachers’ ratings
SDAI inattention	18.13 (5.01)	15.88 (5.28)	16.57 (5.27)	15.27 (5.98)	12.45	.001	0.93	.34
SDAI hyperactivity	12.88 (8.37)	10.31 (7.78)	12.21 (5.89)	10.79 (6.10)	20.39	<.001	1.65	.21
COM sociality	3.94 (2.70)	3.06 (2.38)	3.71 (3.32)	3.07 (2.67)	11.21	.002	0.26	.61
COM cooperation	6.44 (2.61)	8.31 (2.85)	7.64 (3.75)	6.00 (3.74)	0.68	.80	15.68	<.001
Class nominations
As a preferred playmate, Q1	−.29 (.24)	−.17 (.25)	−.26 (.31)	−.28 (.32)	2.83	.10	4.72	.04
As a preferred desk mate, Q2	−.31 (.29)	−.22 (.25)	−.33 (.35)	−.36 (.35)	1.04	.32	3.57	.07
As a preferred teammate, Q3	−.35 (.31)	−.22 (.23)	−.31 (.33)	−.31 (.34)	4.30	.05	5.07	.03

Note. Question (Q) 1: “How much do you like to play with him/her?” Q2: “How much would you like him/her as a desk mate?” Q3: “How much would you like him/her as a teammate?” CL = cooperative learning; SDAI = Scala per i Disturbi di Attenzione/Iperattività per Insegnanti [ADHD scale for teachers]; COM = comorbidity.

Considering the teachers’ questionnaire (Table 2), we found a significant main effect of time (with a medium effect size; Sullivan & Feinn, 2012) on the dimensions of inattention, F(1, 28) = 12.45, p = .001, $η_{p}^{2}$ = .31; hyperactivity, F(1, 28) = 20.39, p < .001, $η_{p}^{2}$ = .42; and sociability, F(1, 28) = 11.21, p = .002, $η_{p}^{2}$ = .29, but no significant Time × Group interaction. Table 2 shows that both groups scored lower in the teachers’ perception of the children’s inattentive, hyperactive, or socially problematic behavior. Considering the area of cooperation of teachers’ questionnaire (where a higher average score means a higher level of cooperation), we found no significant main effect of Time (F < 1), but Time × Group interaction was significant, F(1, 28) = 15.68, p < .001, here again with a medium effect size, $η_{p}^{2}$ = .36 (Sullivan & Feinn, 2012). Only the CL group improved in the children’s level of cooperation, and this improvement was significant, Student’s t(15) = 3.70, p = .002

Concerning the results of peers’ sociometric nominations, we analyzed the three questions (“How much do you like to play with him/her?” “How much would you like him/her as a desk mate?” “How much would you like him/her as a teammate?”) separately. For the first question, we found no significant main effect of Time (F < 1), but the Time × Group interaction was significant, F(1, 28) = 4.72, p = .04, $η_{p}^{2}$ = .14. The interaction was due to the fact that only the children with ADHD symptoms in the CL group were judged more positive by their peers at the post-test, student’s t(15) = 2.77, p = .014. In the question about how much the children wanted his or her peer as a desk mate, there was no main effect of Time (F < 1), and the Time × Group interaction only approached significance, F(1, 28) = 3.57, p = .07, $η_{p}^{2}$ = .11. In the third question, we found the main effect of Time, F(1, 28) = 4.30, p = .05, $η_{p}^{2}$ = .13, and a significant Time × Group interaction, F(1, 28) = 5.07, p = .03, $η_{p}^{2}$ = .15. Here again, only the children with ADHD symptoms in the CL group were judged more positively by their peers, Student’s t(15) = 3.01, p = .009.

Then we analyzed whether the sociometric status of the children with symptoms of ADHD changed after the period of intervention in the three different areas (playmate, desk mate, and teammate) using the procedure described in the “Method” section (see also Coie et al., 1982), and we performed a chi-square test for dichotomous variables (rejected vs. accepted). Table 3 shows that there were no differences between the two groups before the intervention, whereas some differences were apparent afterwards. As regards playing together, we found a significant difference between the number of children with ADHD symptoms in the two groups who were rejected by their peers before and after the intervention χ²(1) = 4.69, p = .03. However, the difference only approached the significance for rejection as a desk mate and teammate, χ²(1) = 3.21, p = .07, but the data show that the switch from a rejected to an accepted status only occurred for the children attending CL lessons. These effects varied slightly by grade (and classes) involved in the CL project. For the first two questions, there was a change from pre-test to post-test among first graders from two rejected to one; in second grade, from three rejected to none; in third grade, from two rejected children to none; and in fourth grade from three rejected to two. For the third question, there was no change for one child in first grade, a change from two rejected children to none in second grade, from two rejected children to one in third grade, and from three rejected children to two in fourth grade. Should be noted, however, that one child in fifth grade changed status from accepted to rejected for the first two questions.

Table 3.

Changes From Rejected to Accepted Children in the Two Groups of Children With Symptoms of ADHD (CL Group vs. Control Group).

	CL group (n = 16)		Control group (n = 14)			p
	Pre	Post	Pre	Post	χ²(1)	p
Accepted as a playmate	6	12	6	5	0.09	.77
Rejected as a playmate	10	4	8	9	4.69	.03
Accepted as a desk mate	6	12	5	6	0.01	.91
Rejected as a desk mate	10	4	9	8	3.21	.07
Accepted as a teammate	8	12	6	6	0.15	.70
Rejected as a teammate	8	4	8	8	3.21	.07

Note. Peers were asked, “How much do you like to play with him/her?” “How much would you like him/her as a desk mate?” “How much would you like him/her as a teammate?” CL = cooperative learning.

Discussion

Poor social skills prevent children with symptoms of ADHD from interacting successfully with their peers (Mrug et al., 2007). These problems lead to their rejection by their peers and have negative longitudinal outcomes in adolescence: These individuals are more likely to suffer from psychological or conduct problems (Bagwell et al., 2001).

The main context in which children refine their social skills is the classroom, where peers and teachers tend to give children with symptoms of ADHD a more or less constantly negative feedback about their social problems and the difficulty to control their behaviors. Some studies have investigated how to improve social skills in children with ADHD, focusing mainly on their social acceptance by peers by measuring changes in their class nominations (Kuester & Zentall, 2012; Mikami et al., 2013). In the past, the sociometric status of children with ADHD has proved refractory to treatment, but studies have failed to thoroughly analyze the importance of involving regular classroom teachers and pupils, despite the suggestion that improving inclusiveness could lead to improvements and changes in social preferences (Mikami et al., 2013). In the present study, we examined the implications of taking action on standard classroom interactions by using CL procedures. CL has shown positive effects in whole-classroom observational research (Beyda et al., 2002; Gillies, 2003), but more systematically and controlled studies are needed, and the particular case of children with ADHD has never been considered. Teachers who have children with ADHD in their classes are often reluctant to use CL because, although they think it would be useful and they would like to use it more (Garcia, 2013; Lopata et al., 2003), they perceived CL as a difficult method and too demanding for children with behavioral problems. Training teachers on how to manage children with symptoms of ADHD, and providing them with a basis for putting the CL method into practice would thus be the first step toward the success of an intervention to help children with ADHD symptoms improve socially and be reconsidered by their peers, giving them a chance to be accepted.

The aim of the present study was to analyze how the practice of teaching according to the CL method (in the hands of experienced and knowledgeable teachers) can help children with symptoms of ADHD to fit in the rest of the class, be more appreciated by their peers, and improve their social and cooperative skills.

Our results show that, after 2 months, teachers generally noticed an improvement and a reduction of some symptoms of inattention and hyperactivity in the children with ADHD symptoms in the CL group and the control group (classrooms conducting standard lessons). The children’s scores relating to the presence of ADHD symptoms remained high, of course, but there was an important reduction with a good effect size. The improvement was general, however, and concerned both groups, so it may have been due not only to teachers’ increased attention to ADHD but also to measurement artifacts, and in particular to a regression to the mean. Teachers noted an improvement in all the children’s social abilities, but an improvement in the cooperation skills only in the children taking part in the CL activities (and there was even reportedly some deterioration in the other children’s cooperation).

Concerning peer preferences based on class nominations, we found a specific improvement for children with ADHD symptoms who took part in the CL sessions. In particular, there was an increase in the number of their classmates who would choose to play with children with symptoms of ADHD, in those who would like them as a teammate, and also a trend toward an increase in the number of their peers who would want a child with ADHD symptoms as a desk mate. We compared the changes in sociometric status (rejected vs. accepted) of the children with symptoms of ADHD between the two groups. An important change emerged for the playmate area, with the children in the CL group passing from a situation where six were accepted and 10 were rejected to a situation where 12 were accepted and only four were still rejected. Positive, but less evident changes were found for the desk mate and teammate areas too, where the number of accepted children being accepted increased only in the CL group and not at all for the control group.

To sum up, our study offers some new input on the importance of implementing CL in classrooms attended by children with symptoms of ADHD and TD. In our view, an important factor concerns the training and attitude of teachers, who needed to be sensitive and knowledgeable about ADHD and CL to be able to create an adequate setting (McAuliffe et al., 2009). It should be noted that the CL activities were proposed gradually in this study, enabling the children to learn some basic social abilities, practice communicating with others, and solving interpersonal problems, before working together toward academic goals (Johnson et al., 2007). The present study only involved six sessions (plus an initial practice session) and the effects of CL would probably be more substantial if a more prolonged CL educational program were implemented (and this could be done in a normal class).

A feature of the present project lay in that the students with symptoms of ADHD worked together with the other children in the classroom—unlike the case of other interventions to improve the social skills of children with ADHD (e.g., Abikoff et al., 2004; Mikami et al., 2013)—and this may have helped their peers to get to know them better and nurtured a mutual exchange of help and needs (Chew, Jensen, & Rosén, 2009). In fact, a study involving college students showed that more negative than positive adjectives were endorsed by college students in describing classmates with ADHD, but more frequent contact with individuals with ADHD was associated with more favorable ratings, suggesting the importance of facilitating peer normalization (Chew et al., 2009).

Despite the interest of the findings, the present study suffers from a number of limitations. In particular, our sample was relatively small and our results should be replicated with larger samples. Our study benefited from particular conditions that enabled us to involve expert teachers (who were also attending a course on the management of children with ADHD) and to give them training on the use of CL, but their timetable left us only 2 months for our classroom intervention and prevented any subsequent follow-up. Because the teachers were attending a course on ADHD and their selection for the study was not fully randomized, it is hard to say to what extent the improvements observed were due to the teachers being better prepared or more motivated rather than to the CL procedure. Another important limitation lies in that we were unable to collect organized information from parents (who were asked to complete a questionnaire, but only few did so). Another issue concerns the measures used in the study, which were based on teachers’ subjective ratings or on children’s feelings, with no observational measures or blind subjective ratings. Future research should include objective observations on the actual interactions between children with ADHD and their classmates, though it has to be said that the measures and method used in the present study are standard in this type of research because of the complexity of objective assessment. It was impossible for us to include a blind outside observer, but teachers made an effort to be as objective as possible, also basing their ratings on consultations with other members of teaching staff. The fact that their ratings were consistent in their differentiation between the areas offers some indication of their reliability. Concerning pupils’ responses, it may be that they were also influenced by the more positive atmosphere created in the classroom. This atmosphere is a crucial factor in changing social interactions. It is worth nothing, however, that the children’s class nominations differed for the three questions they were asked, indicating that they were not giving general responses, but were considering each question specifically.

To conclude, this study offers new important insight on the feasibility of developing situations for social interaction in a standard class for promoting the social skills and acceptance of children with ADHD. To the best of our knowledge, it is the first case study to report some positive changes being induced in the sociometric measures concerning children with ADHD. Given some skepticism in the literature on the effects of psychoeducational interventions on ADHD, and the scarcity of research on CL (partly due to the difficulty of conducting interventional research and controlling all the variables involved), the present study offers quite an optimistic view and should prompt further research and educational efforts in this area. It seems important for the future of children with symptoms of ADHD to prepare and train teachers to influence the social preferences of the children in their classes and to implement CL activities to help students to cooperate and appreciate one other.

Footnotes

Appendix

Example of a complex CL activity for second graders.

The activity was conducted briskly but was very productive. The children kept essentially to their assigned roles, the most problematic proving the voice controller because the children talked together while making their fish characters because they were not satisfied with each other’s work.

Acknowledgements

The authors are grateful to all the teachers who took part in this study and with their knowledge and expertise helped children to develop their skills.

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) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Agnese Capodieci is a PhD student in General Psychology at University of Padua. She has specialized in psychopathology of learning disabilities and behavior problems and is a member of the Italian Society for developmental disabilities (Associazione Italiana per la Ricerca e l’Intervento nella Psicopatologia dell’Apprendimento [AIRIPA]).

Thomas Rivetti is a Child and Adolescent Psychologist and Psychotherapist with expertise in human development and family dynamics as well as a member of the Italian Society for developmental disabilities (AIRIPA) and personal trainer for teachers, pedagogues, and psychologists. He organizes training sessions in schools giving his support to teachers in the educational process, helping them understand classroom dynamics and support to children in their school social life and individual development. He also works as therapist for families groups in their problematic relationship with their children and parenting issues.

Cesare Cornoldi is a full Professor of Psychology, Director of the service for school difficulties of University of Padova, and national president of the Italian Society for developmental disabilities (AIRIPA).

References

Abikoff

Hechtman

Klein

R. G.

Gallagher

Fleiss

Etcovitch

J. O. Y.

… Pollack

(2004). Social functioning in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 820-829.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Antil

L. R.

Jenkins

J. R.

Wayne

S. K.

Vadasy

P. F.

(1998). Cooperative learning: Prevalence, conceptualizations, and the relation between research and practice. American Educational Research Journal, 35, 419-454.

Asher

S. R.

Dodge

K. A.

(1986). Identifying children who are rejected by their peers. Developmental Psychology, 22, 444-449.

Associazione Italiana di Psicologia [Italian association of Psychology]. (2014). Codice etico per la ricerca in psicologia [Ethic code for research in psychology]. Retrieved from http://www.aipass.org/files/Codice_Etico_AIP.pdf

Bagwell

C. L.

Molina

B. S.

Pelham

W. E.

Hoza

(2001). Attention-deficit hyperactivity disorder and problems in peer relations: Predictions from childhood to adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1285-1292.

Beyda

S. D.

Zentall

S. S.

Ferko

D. J.

(2002). The relationship between teacher practices and the task-appropriate and social behavior of students with behavioral disorders. Behavioral Disorders, 27, 236-255.

Capodieci

Cornoldi

(2013). Bambini disattenti e iperattivi: Strategie di intervento a scuola [Inattentive and hyperactive children: Intervention strategies at school]. Giunti.

Chang

(2004). The role of classroom norms in contextualizing the relations of children’s social behaviors to peer acceptance. Developmental Psychology, 40, 691-702.

10.

Chew

B. L.

Jensen

S. A.

Rosén

L. A.

(2009). College students’ attitudes toward their ADHD peers. Journal of Attention Disorders, 13, 271-276.

11.

Coie

J. D.

Dodge

K. A.

(1983). Continuities and changes in children’s social status: A five-year longitudinal study. Merrill-Palmer Quarterly, 29, 261-282.

12.

Coie

J. D.

Dodge

K. A.

Coppotelli

(1982). Dimensions and types of social status: A cross-age perspective. Developmental Psychology, 18, 557-570.

13.

Elledge

L. C.

Elledge

A. R.

Newgent

R. A.

Cavell

T. A.

(2016). Social risk and peer victimization in elementary school children: The protective role of teacher-student relationships. Journal of Abnormal Child Psychology, 44, 691-703. doi:10.1007/s10802-015-0074-z

14.

Emmer

E. T.

Gerwels

M. C.

(2002). Cooperative learning in elementary classrooms: Teaching practices and lesson characteristics. The Elementary School Journal, 103, 77-91. doi:10.1086/499716

15.

Garcia

M. M.

(2013). Reaching all learners: A study of teacher’s perspectives about cooperative learning and students diagnosed with ADHD (Doctoral dissertation). Capella University, Minneapolis, MN.

16.

Gillies

R. M.

(2003). The behaviors, interactions, and perceptions of junior high school students during small-group learning. Journal of Educational Psychology, 95, 137-147. doi:10.1037/0022-0663.95.1.137

17.

Gillies

R. M.

(2014). Developments in cooperative learning: Review of research. Anales de Psicología / Annals of Psychology, 30, 792-801.

18.

Greene

R. W.

Biederman

Faraone

S. V.

Sienna

Garcia-Jetton

(1997). Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: Results from a 4-year longitudinal follow-up study. Journal of Consulting and Clinical Psychology, 65, 758-767.

19.

Hoza

(2007). Peer functioning in children with ADHD. Journal of Pediatric Psychology, 32, 655-663.

20.

Hoza

Mrug

Gerdes

A. C.

Hinshaw

S. P.

Bukowski

W. M.

Gold

J. A.

… Arnold

L. E.

(2005). What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology, 73, 411-423.

21.

Johnson

D. W.

Johnson

R. T.

Smith

(2007). The state of cooperative learning in postsecondary and professional settings. Educational Psychology Review, 19, 15-29.

22.

Kuester

D. A.

Zentall

S. S.

(2012). Social interaction rules in cooperative learning groups for students at risk for ADHD. The Journal of Experimental Education, 80, 69-95.

23.

Lopata

Miller

K. A.

Miller

R. H.

(2003). Survey of actual and preferred use of cooperative learning among exemplar teachers. The Journal of Educational Research, 96, 232-239.

24.

Marzocchi

G. M.

Cornoldi

(2000). Una scala di facile uso per la rilevazione dei comportamenti problematici dei bambini con Deficit di Attenzione e Iperattività [An easy scale for the identification of problematic behavior in children with ADHD]. Psicologia Clinica dello Sviluppo, 4, 43-63.

25.

Marzocchi

G. M.

A. M.

Cornoldi

(2010). BIA: Batteria Italiana per l’ADHD [Italian Battery for ADHD]. Trento, Italy: Centro Studi Erickson.

26.

McAuliffe

M. D.

Hubbard

J. A.

Romano

L. J.

(2009). The role of teacher cognition and behavior in children’s peer relations. Journal of Abnormal Child Psychology, 37, 665-677.

27.

McMaster

K. N.

Fuchs

(2002). Effects of cooperative learning on the academic achievement of students with learning disabilities: An update of Tateyama-Sniezek’s review. Learning Disabilities Research & Practice, 17, 107-117.

28.

Mikami

A. Y.

Griggs

M. S.

Lerner

M. D.

Emeh

C. C.

Reuland

M. M.

Jack

Anthony

M. R.

(2013). A randomized trial of a classroom intervention to increase peers’ social inclusion of children with attention-deficit/hyperactivity disorder. Journal of Consulting and Clinical Psychology, 81, 100-112.

29.

Mikami

A. Y.

Griggs

M. S.

Reuland

M. M.

Gregory

(2012). Teacher practices as predictors of children’s classroom social preference. Journal of School Psychology, 50, 95-111.

30.

Mikami

A. Y.

Hinshaw

S. P.

(2006). Resilient adolescent adjustment among girls: Buffers of childhood peer rejection and attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 34, 823-837.

31.

Mikami

A. Y.

Hoza

Hinshaw

S. P.

Arnold

L. E.

Hechtman

Pelham

W. E.

(2015). Cross-setting correspondence in sociometric nominations among children with attention-deficit/hyperactivity disorder. Journal of Emotional and Behavioral Disorders, 23, 52-64.

32.

Mikami

A. Y.

Lerner

M. D.

Lun

(2010). Social context influences on children’s rejection by their peers. Child Development Perspectives, 4, 123-130.

33.

Mrug

Hoza

Gerdes

A. C.

(2001). Children with attention-deficit/hyperactivity disorder: Peer relationships and peer-oriented interventions. New Directions for Child and Adolescent Development, 2001(91), 51-78.

34.

Mrug

Hoza

Pelham

W. E.

Gnagy

E. M.

Greiner

A. R.

(2007). Behavior and peer status in children with ADHD: Continuity and change. Journal of Attention Disorders, 10, 359-371.

35.

Peets

Hodges

E. V.

Salmivalli

(2008). Affect-congruent social-cognitive evaluations and behaviors. Child Development, 79, 170-185.

36.

Polanczyk

de Lima

M. S.

Horta

B. L.

Biederman

Rohde

L. A.

(2007). The worldwide prevalence of ADHD: A systematic review and metaregression analysis. American Journal of Psychiatry, 164, 942-948.

37.

Race

K. E.

Powell

K. R.

(2000). Assessing student perceptions of classroom methods and activities in the context of an outcomes-based evaluation. Evaluation Review, 24, 635-646.

38.

Rich

E. C.

Loo

S. K.

Yang

Dang

Smalley

S. L.

(2009). Social functioning difficulties in ADHD: Association with PDD risk. Clinical Child Psychology and Psychiatry, 14, 329-344.

39.

Rivetti

Capodieci

(in press). Apprendimento cooperativo personalizzato per bambini ADHD [Manual for Personalized Cooperative Learning for Children with ADHD]. Trento, Italy: Centro Studi Erickson.

40.

Sullivan

G. M.

Feinn

(2012). Using effect size-or why the P value is not enough. Journal of Graduate Medical Education, 4, 279-282.

41.

Swanson

J. M.

Kraemer

H. C.

Hinshaw

S. P.

Arnold

L. E.

Conners

C. K.

Abikoff

H. B.

… Hechtman

(2001). Clinical relevance of the primary findings of the MTA: Success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 168-179.

42.

White

K. J.

Jones

(2000). Effects of teacher feedback on the reputations and peer perceptions of children with behavior problems. Journal of Experimental Child Psychology, 76, 302-326.

43.

Wittchen

H. U.

Jacobi

Rehm

Gustavsson

Svensson

Jönsson

… Fratiglioni

(2011). The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology, 21, 655-679.

44.

Zentall

S. S.

Kuester

D. A.

Craig

B. A.

(2011). Social behavior in cooperative groups: Students at risk for ADHD and their peers. The Journal of Educational Research, 104, 28-41.