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Improving Social Adjustment in Children With Attention-Deficit/Hyperactivity Disorder
Louis H. McCormick, MD
Arch Fam Med. 2000;9:191-194.
ABSTRACT
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Objective To determine if sending motivational letters would improve peer relations in children with social maladjustment and attention-deficit/hyperactivity disorder (ADHD).
Design From a consecutive sample, a case series was followed up for 2 years.
Setting Primary care, private physician, office-based practice.
Patients Ninety-five children diagnosed as having ADHD by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria made up the consecutive sample. Twenty-one children qualified with a comorbid social maladjustment disorder with baseline t scores of 1.5 SDs or greater above the mean on the asocial domain of the Conners' Teacher Rating Scale. Seventeen children completed the study. There were no significant differences between these patients and those who did not complete the study (P = .55 for baseline score differences and P = .85 for age).
Interventions In addition to conventional therapy for ADHD when children achieved a goal, such as an improved report card or better conduct, a personal letter about their success was mailed to them. Letters averaged 5 per student per year.
Main Outcome Measures The asocial domain of the Conners' Teacher Rating Scale was repeated during the next 2 school years for comparison. Statistical analysis was by a repeated-measures analysis of variance and Helmert contrasts.
Results Of 17 students who completed the study, 16 improved on the Conners' Teacher Rating Scale asocial domain, and the results were statistically significant (P<.001).
Conclusions Difficulties with peer relations are commonly seen in children with ADHD. Sending motivational letters correlated with improved social adjustment in these children. The data suggest that busy practitioners might consider incorporating this successful, and time-efficient, intervention into their ADHD treatment regimens.
INTRODUCTION
ATTENTION-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral syndrome that is frequently diagnosed and managed by primary care physicians.1-2 The estimated prevalence of ADHD is 3% to 5% of school-aged children.3 In 1995, more than 1 million students were treated for ADHD with stimulant medication.4 Attention-deficit/hyperactivity disorder does coexist with other disorders, and social impairments are commonly seen.5-7 These difficulties with socialization, which can complicate ADHD, are important variables in the long-term prognosis of affected individuals.8 A 4-year longitudinal study9 showed that children with ADHD and social deficits were at increased risk for poor outcomes.
The present study was initiated to further explore the occurrence of social problems concurrent with ADHD and to evaluate a treatment protocol. Research was designed to determine if sending motivational letters would improve peer relations in children with social maladjustment and ADHD.
PATIENTS AND METHODS
The participants came from a consecutive sample of 95 children who were diagnosed as having ADHD by using information obtained from parents and teachers and applying Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.10(pp78-85) All patients were from a rural, office-based practice (L.H.M.). From this consecutive sample, 21 children qualified with a comorbid social maladjustment disorder with baseline t scores of 1.5 SDs or greater above the mean on the asocial domain of the Conners' Teacher Rating Scale.11 The asocial domain was repeated each school year for the following 2 years for comparison.
There were 13 boys and 8 girls who ranged in age from 79 to 136 months (mean ± SD age, 102.62 ± 15.38 months). Eighteen were white, and 3 were African American. Nineteen were diagnosed as having ADHD, combined type, and 2 were diagnosed as having ADHD, inattention only. Nine lived with both biological parents, 7 resided with a parent and a stepparent, and 5 were from single-parent homes.
Two children in the study had social difficulties as the only comorbidity with ADHD. Two participants had an additional comorbidity, and 13 had multiple comorbidities. These included dysgraphia (n = 10), oppositional defiant disorder (n = 10), psychosomatic complaints (n = 4), enuresis (n = 4), learning disabilities (n = 3), anxiety (n = 3), communication disorder (n = 2), and gross motor incoordination (n = 1).
Oppositional defiant disorder and enuresis were diagnosed by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.10(pp93,94,109,110) Learning disabilities and communication disorders were diagnosed by school psychologists and speech language pathologists, respectively. Anxiety symptoms, psychosomatic complaints, gross motor incoordination, and fine motor dyspraxia were descriptive problems and not considered disorders using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria.10(pp54,55,113,393,394,449-452)
In the families, 4 mothers had a history of major depression (3 married and 1 single), 1 single mother and 1 married father had a history of substance abuse, and 1 single mother had a history of schizophrenia. In the latter household, the maternal grandmother was the major caregiver.
All report cards were sent to the medical office (L.H.M.). When students achieved a goal such as an improved grade, better conduct, or showing extra effort, a personal letter about their success was mailed to them. Letters averaged 5 per student per year. No one received less than 4 letters per year (Figure 1).
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Examples of motivational letters mailed from the medical office (L.H.M.) to students in recognition of their achievements.
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In addition, all participants received conventional therapy for ADHD, including education about the disorder, a pharmacological intervention, and delineation and treatment of any existing comorbidities.
Statistical analysis was performed by a repeated-measures analysis of variance with 3 levels (baseline and 1- and 2-year follow-up results). Helmert contrasts were used as a comparison method that tested the 1- and 2-year follow-up results vs baseline results and then the differences between the follow-up scores.
RESULTS
Seventeen students completed the study. There were no significant differences between these patients and those who did not complete the study (P = .55 for baseline score differences and P = .85 for age).
There were 11 boys and 6 girls (mean ± SD age, 102.29 ± 15.89 months). Fifteen were white, and 2 were African American. Thirteen resided with married parents, and 4 resided in single-parent homes. In addition, these participants had 30 comorbid conditions. Three of the 4 mothers with a history of major depressive disorder, the 2 parents with a history of substance abuse, and the household with the grandmother as the guardian because of maternal schizophrenia were in the participating group.
Two male and 2 female subjects only completed the baseline phase of the study. They were similar in demographic characteristics and baseline ratings compared with the participants. Three were white, and 1 was African American. Three resided with married parents, and 1 lived with a single parent. These patients had 7 comorbid conditions. The mean ± SD age of the nonparticipants (104.00 ± 15.03 months) was compared with that of the participants who completed the study using an independent sample t test. The difference was not significant (P = .85). Moreover, no significant (P = .55) differences using a 1-way analysis of variance were found on the asocial domain between those who completed the study (n = 17) and those who did not (n = 4) (mean ± SD score, 75.94 ± 10.87 vs 79.75 ± 13.86).
Using an analysis of variance with the data from the 17 participants, a significant effect across time was found, indicating a difference among the 3 means. Using Helmert contrasts, the means from the 2 follow-up ratings were significantly less than the means from the baseline ratings. No difference was found between the 1- and 2-year follow-up ratings. Sixteen of the 17 participants who completed the study improved on the asocial domain of the Conners' Teacher Rating Scale (Table 1).
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Scores on the Asocial Domain of Conners' Teacher Rating Scale at Baseline and at Each Year of the Study*
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COMMENT
Roizen and colleagues12 suggest that research on adaptive dysfunction and ADHD in a non–referral-based population is needed. The present study, from a private physician, office-based practice, showed that sending motivational letters correlated with improved social adjustment in children with peer relation difficulties and ADHD. These positive findings remained stable during 2 additional school years.
A comprehensive approach to the diagnosis and management of ADHD is essential.13 Other variables that may have influenced the social outcomes seen in the present study merit discussion.
All children in the study received stimulant medication, and the ADHD behavior improved in 13 students. Psychostimulants are indicated when social impairment and ADHD coexist.14 However, not all social problems are responsive to medication, and there are limitations when using stimulants for treatment of interpersonal difficulties and ADHD.15-17
Oppositional defiant disorder was treated by instructing parents and teachers on the use of behavior modification techniques and contingency management. Four participants improved, while 5 either remained the same or had increased oppositional behavior.
At the inception of the study, 2 students were attending resource classes with an educational diagnosis of learning disabled. During the study, 2 pupils became eligible for resources under the "other health impaired" classification. The remainder of the cohort qualified for accommodations and modifications in mainstream classrooms under section 504 of the Rehabilitation Act of 1973 guidelines.
In the children with enuresis, 1 child's condition resolved during the study. Three patients remained symptomatic and were treated pharmacologically.
None of the participants with psychosomatic complaints or anxiety symptoms progressed to a diagnosed disorder. During the study, 1 additional child developed anxiety symptoms.
Two mothers with major depression continued to be treated for their condition during the study. The other mothers with a history of previous major depression and the parents with a history of substance abuse remained in remission. None of the single parents married during the study, but 3 couples experienced marital difficulties that required counseling.
The number of comorbidities occurring with ADHD in the children and the frequency of the psychiatric disorders in their families are consistent with other reports.18-21 It is important to identify and treat any impairments that coexist with ADHD.22-23 In the present study, multiple interventions that addressed individual needs were used. In a reciprocal way, successful treatment in 1 area of dysfunction positively influenced therapeutic goals with other impairments.
None of the students participated in a social skills training program. These 8- to 12-week sessions24-25 may not be feasible in a private practice setting. In addition, only limited success has been reported for social skills training sessions that treat social deficits and ADHD.26
Limitations to the present study include the small sample size and the lack of a control group. However, the robust findings obtained from a community-based practice with children and families in their natural environment support the success of the study's intervention.
Children and adolescents enjoy receiving mail. Personal letters written and addressed by their physician are powerful builders, reinforcers, and enhancers of self-esteem. Students with disabling conditions other than ADHD and even pupils without a disability benefit from receiving these motivational letters.
Many primary care physicians cite time constraints as a limiting factor in the treatment of ADHD.27-28 The present study showed that, as a part of a multimodal treatment protocol, sending motivational letters correlated with improved social adjustment in children with peer relation difficulties and ADHD. The data suggest that busy practitioners might consider incorporating this successful, and time-efficient, intervention into their ADHD treatment regimens.
AUTHOR INFORMATION
Accepted for publication May 4, 1999.
Presented at the 91st Assembly of the Southern Medical Association Pediatrics and Adolescent Medicine Section, Charlotte, NC, November 1997.
Reprints: Louis H. McCormick, MD, Family Care Center, PO Box 1186, 606 Haifleigh St, Franklin, LA 70538 (e-mail: buckylou2{at}aol.com).
From the Family Care Center, Franklin, La.
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