Peer Functioning in Children with AD/HD and New Directions in the Application of Interventions Peer Functioning 1 Peer Functioning in Children with AD/HD: A Review of Current Understanding and Intervention Options Selda Ozdemir, PhD Gazi University, Turkey Address: Gazi University, Gazi Education Faculty Special Education Department Teknikokullar 06500 Ankara Turkey Email seldaozdemir@gazi.edu.tr Peer Functioning 2 Abstract This review critically evaluates the existing research literature on the peer relationship problems of children with attention deficit/hyperactivity disorder. Empirical evidence suggests that children with the disorder are severely impaired in the social area and strongly rejected by peers. The purposes of this article are to provide a review of key contributing factors to the peer relationship problems of children with AD/HD and to outline intervention options that have been supported as beneficial for children with the disorder. Finally, the article provides a framework to understand and address the complex social problems of children with the AD/HD. Key words: Attention Deficit Hyperactivity Disorder; Peer relationship problems; Peer rejection; Social skills; Emotion regulation; Interventions. Peer Functioning 3 Peer Functioning in Children with AD/HD: A Review of Current Understanding and Intervention Options Attention Deficit/Hyperactivity Disorder is the most commonly diagnosed childhood disorder characterized by symptoms of inattention, hyperactivity, and/or impulsivity (DSM-IV; American Psychiatric Association, 2000; Blachman & Hinshaw, 2002). International epidemiological studies using standardized diagnostic criteria suggest that 3 % to 7 % of the school-aged population is affected by the disorder (Barkley, 2006; Peterson, Pine-Cohen, & Brook, 2001). This prevalence estimate means that almost 1 in every 20 children, or at least 1 child per general education classroom, is likely to be identified as having AD/HD (Barkley, 2001; Barkley, 2006; McGoey, Eckert, & DuPaul, 2002; Peterson, et al., 2001). In addition to the primary symptoms of the disorder, increased rates of comorbid psychiatric conditions including oppositional defiant disorder (ODD) and conduct disorder (CD) (Barkley, 2006) and secondary impairments such as academic underachievement and learning problems are commonly reported in AD/HD (DuPaul, 2007; Farone et al., 1993). Social deficits in peer relations including social skills and social performance deficits (Maedgen & Carlson, 2000; Wheeler & Carlson, 1994) have been widely noted, as have difficulties in aggression (Hodgens, Cole, & Boldizar, 2000) and emotion regulation (Southam-Gerow & Kendall, 20002). Empirical evidence suggest that long term effects for some children with AD\HD include attending fewer years of school, achieving lower overall occupational status such as being ranked significantly lower than control groups (Mannuzza, Gittelman-Klein, Bessler, Malloy, & LaPadula, 1993; Weiss & Hechtman, 1993) and displaying worse job performance (Weiss & Hechtman, 1993), and experiencing greater range of social maladjustment and personality problems such as lower self-esteem depressive symptoms, antisocial and criminal status (Barkley, 2006; Treuting & Peer Functioning 4 Hinshaw, 2001; Young, 2002). Even those children with AD/HD who are monitored into adolescence and found to be free of psychiatric disorders appear to have some social problems, such as significantly less community and school activity involvement (Mannuzza, Klein, Bonagura, Konig, & Shenker, 1988). Although earlier research has focused primarily on the attentional, academic/learning, and behavioral problems associated with this disorder (DuPaul, 2007; Farone et al., 1993; Treuting & Hinshaw, 2001), the social domain is being increasingly accepted as one of critical importance for these youngsters (Blachman & Hinshaw, 2002; Hinshaw, & Melnick, 1995; Mikami & Hinshaw, 2003; Stroes, Alberts, & Van der Meere, 2003). The difficulties in the social domain are so common that some investigators have claimed that the phenomenon of disturbed social relations itself should serve as a classifying characteristic of the disorder (Landau & Moore, 1991; Whalen & Henker, 1991). Indeed, Erhardt and Hinshaw (1994) argued that social problems of children with AD/HD might be central to an understanding of the psychopathology of these children. The interpersonal behaviors of children with AD/HD are often described as more impulsive, intrusive, excessive, disorganized, engaging, aggressive, intense, and emotional (Bagwell, Molina, Pelham, & Hoza 2001; Mikami & Hinshaw, 2003; Stroes, Alberts, & Van der Meere, 2003). Thus, they are disruptive to the smoothness of the ongoing stream of social interactions, reciprocity, and cooperation, which is an increasingly essential part of the children’s social lives with others (Barkley, 2006). Problems caused by inattention and impulse control effect negatively the social performance of children with this disorder in a number of areas. First, they may enter ongoing peer activities in a sudden, disruptive manner. Second, their communication style often differs than their typically developing counterparts. Children with Peer Functioning 5 AD/HD have difficulty in following the implicit rules of good conversation (Stroes, et al., 2003). They are likely to interrupt others, talk more during spontaneous conversation, pay minimal attention to what others are saying, and respond in an irrelevant fashion to the queries or statements of peers (Landau & Milich, 1988; Stroes, et al., 2003; Zentall, 1988). Further, studies of language fluency and discourse organization indicate that children with AD/HD are likely talk less and be more dysfluent in response to confrontational questioning (Tannock & Schachar, 1996).Third, these children frequently approach interpersonal problems in an aggressive manner, lose their temper, and become angry quite easily (Blachman & Hinshaw, 2002; Hinshaw, & Melnick, 1995; Mikami & Hinshaw, 2003). Thus, arguments and fights with peers are very common among children with the disorder (DuPaul & Stoner, 2003). Being inflexible if another child appeals, having a need to take control of play situations, becoming intimidating, and being stubborn about having things occur the way they want them to happen are other common observable behaviors of children with AD/HD (Barkley, 2006). It is not surprising then, that children with AD/HD are rejected at higher rates than are their non-AD/HD peers (Blachman & Hinshaw, 2002; Guevromont & Dumas, 1994; Johnston, Pelham, & Murphy, 1985; Mikami & Hinshaw, 2003). Although peer rejection does not, in itself, indicates an externalizing behavior disorder, it is well known that low social status with peers significantly predicts a host of negative outcomes in later life (Parker & Asher, 1987) and covaries positively with disruptive and particularly aggressive behavior. It is essential to note that, when tracking children diagnosed with AD/HD into adolescence and adulthood, those who ultimately experience the most serious clinical problems (e.g., substance abuse, criminal arrests and incarceration, psychiatric hospitalization) were previously identified as having difficulties with aggression or social relations (Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1998; Parker & Asher, 1987; Peer Functioning 6 Young, 2002). Researchers have shown that from 45% to 84% of children and adolescents with AD/HD meet full diagnostic criteria for ODD alone or with CD (Barkley& Biederman, 1997; Pfiffner et al., 1999; Willens et al., 2002). Thus, most of these risks seem to be increased further by the coexistence of hostile, conduct disordered behavior patterns, or oppositional defiant disorder (ODD), with early onset hyperactive-impulsive behavior (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Barkley, 2006; Barkley, Fischer, Smallish, & Fletcher, 2004; Stormont-Spurgin & Zentall, 1995). To make the case worse, researchers have found that children with high ratings in kindergarten on hyperactivity and aggression were more likely than those initially rated average or low on hyperactivity and aggression to have third and fourth grade outcomes of peer rated aggression and self-reported delinquency (Vitaro, Tremblay, Gagnon, & Pelletier, 1994). Studies reveal that the early onset and persistence of CD symptoms such as lying, stealing, truancy and physical aggression are the hallmark of the later AD/HD+ODD/CD (Barkley, 2006). Overall, evidence suggest that impaired peer relationships is already set into motion by the early years of elementary school and is evident across various measures of peer functioning (Hoza et al., 2005). Further, impairment in peer relations has been found to persist into adolescence (Bagwell, Molina, Pelham, & Hoza, 2001) and young adulthood (Murphy, Barkley, & Bush, 2002). In general, extant data suggest that social problems of children with AD\HD are pervasive and put these children at heightened risk for future social maladjustment (Barkley, 2006; Landau, Milich, & Diener, 1998; Young, 2002). Such children are more likely to develop conduct disorder, to participate in more delinquent or illegal acts as adolescents, and to engage in greater substance experimentation and eventual dependence and abuse than are purely hyperactive or impulsive children (Barkley, Fischer, Edelbrock, & Smallish, 1990; Biederman et Peer Functioning 7 al., 1996). Indeed, follow-up studies suggest that early peer problems not only indicate concurrent difficulties for the child, but also represent a significant "at risk" marker for later emotional and behavioral disturbance (Landau & Milich, 1990; MacDougal, Hymel, Vaillancourt, & Mercer, 2001). Even if the long-term outcome measures did not reveal subsequent adjustment problems, one is left to wonder if children with AD/HD experience the same quality of life as other children (Landau & Moore, 1991). Given protracted nature of the disorder and the attendant long-term risks for a large percentage of children with AD/HD, there is an emerging consensus that peer relationship problems of children with AD\HD should be a crucial target for interventions. This article review the research relevant to the peer relationship problems of children with AD\HD including, emotion regulation deficits, social performance and social knowledge deficits, and aggression. Following section provides an overview of the various interventions that have been supported as beneficial for children with the disorder. Finally, this paper proposes a system perspective as a framework to understand and address the complex social problems of children with the disorder. Emotion Regulation Deficits Cole, Michel, and Teti (1994) define emotion regulation as processes or strategies used so that successful interpersonal functioning is possible. The construct of social competence is inexorably tied to emotion regulation (Saarni, 1999) and emotion regulation skills are essential to healthy social adaptation (Eisenberg, 2001; Gross & Munoz, 1995). Eisenberg (2001) argues that more important than having the cognitive ability to understand others’ expression of emotion, social competence involves the ability to adequately manage one’s own experience of emotion while interpreting signals from another. Accordingly, children who regulate emotion constructively are rated by their teachers as socially competent and by their peers as attractive Peer Functioning 8 playmates (Eisenberg, Fabes, Bernzweig, Karbon, Poulin, & Hanish, 1993). The social behaviors of children with AD/HD are suggestive of underlying difficulties with emotion regulation (Maedgen & Carlson, 2000; Melnick & Hinshaw, 2000; Southam- Gerow & Kendall, 2002). Children with AD/HD frequently exhibit increased emotionality, displaying greater degrees of explosive, unpredictable, and oppositional behavior (DuPaul, McGoey, Eckert, & Van Brakle 2001; Hinshaw & Melnick, 1995). Over reactions to minor inconveniences are common, and such children may seem overly aroused when in stimulating situations (Guevremont & Dumas, 1994; Waschbusch, Pelham, Jennings, Greiner, Tarter, & Moss, 2002). Cole, Zahn-Waxler, and Smith (1994) found that levels of negative affect were significantly correlated with symptoms of AD/HD. Likewise, peers tend to view these children as more aggressive, inflexible, intrusive, disruptive and annoying (Taylor, 1994). In an experimental design, Maedgen and Carlson (2000) examined emotion regulation problems of children with AD/HD along with their social skills problems. The researchers used an emotion control task that assesses children’s expressive responses to receiving a disappointing prize. Findings from the study indicated that children with AD/HD were more intense in their emotional displays (positive and negative) and displayed more positive behavior than children in the other two groups displayed during both a nondisappointing and disappointing period. Interestingly, Melnick and Hinshaw (2000) found that impairment in emotion regulation in children with AD/HD was related to comorbid aggression rather than simply AD/HD symptomatology alone. The researchers reported that children with AD/HD in the high- aggressive groups used a less constructive pattern of emotional coping, including overresponsive emotionality and diminished problem solving, than AD/HD children in the low-aggressive groups or non-AD/HD diagnosed children. While more research is needed, the apparent Peer Functioning 9 differences in emotion regulations skills between aggressive and non-aggressive children with AD\HD has led to the hypothesis that there may be an important distinction in underlying emotion regulation deficits (Sandstrom & Cramer, 2003). Specifically, children characterized by aggression display a distinct profile of social information processes (Sandstrom & Cramer, 2003). Studies have consistently found support for deviant social information encoding, response generation, response selection, and enactment in children with aggressive behavior (Dodge & Feldman, 1990; Dodge & Pettit, 2003; Sandstrom & Cramer, 2003). These distinct social information processes appear to be linked in transactional fashion with problems with emotion recognition, emotion regulation, and aggressive behavior. In a comprehensive review of both biological and psychological factors contributing to aggressive behavior, Dodge and Pettit (2003) noted that deficient social information processing (SIP) likely develops from a series of additive life events that gradually shape a child’s mental representation of the world. Early harsh and negative interactions with parents and peers might result in the amplification of social cognitive difficulties. Consistent negative interactions with parents and peers, coupled with the gradual alteration of the child’s environment lead to a self-fulfilling prophecy whereby emotional disturbances and aggressive behavior result from biased social cognitive processes and biased environmental factors (Dodge & Tomlin, 1987). Overall, deficits in emotion regulation signify one of the primary areas of impairment in AD/HD which eventually result in various problems in peer relationships (Barkley, 1997; Hinshaw & Melnick, 1995). Even though a link has been demonstrated between deficits in emotional competence and the presence of social problems in general (Eisenberg, et al., 2001; Lemery, Essex, & Smider, 2002), less work has been done addressing the emotional functioning of children with specific types of psychopathological difficulties (Southam-Gerow & Kendall, Peer Functioning 10 2002). According to Barkley (2006), most children with AD/HD have a disinhibitory deficit, which causes secondary impairments in domains of self-regulation such as emotion. Barkley (2006) emphasized that children with the disorder display greater prepotent emotional reactivity to “charged” events and less capacity to regulate emotion/arousal states in the service of goal- directed behavior. Certainly, there is a great need to move forward in our understanding of how emotion regulation develops in normative populations and how this process may become atypical in children with AD\HD (Southam-Gerow & Kendall, 2002). Information generated by research on children’s emotion regulation strategies eventually may yield reformulated interventions for children with the disorder. Such interventions could foster children’s abilities to reinterpret situations cognitively, build awareness of their acts on the negative or uncontrollable aspects of situations, and teach helpful ways of signaling distress (Melnick & Hinshaw, 1999). Social Knowledge Deficit versus Social Performance Deficit Social relationship problems of children with AD\HD can results from two types of deficits: social knowledge and social performance deficits, either of which may be accompanied by inferring problem behaviors such as anxiety and aggression. Social knowledge deficit refers to whether an individual knows the appropriate behavior that is called for in a given social situation (Landau, Milich, & Diener, 1998). In contrast, social performance deficit represents the presence of the social skills in a behavioral repertoire but failure to perform these skills at acceptable levels (Landau, Milich, & Diener, 1998; Maedgen & Carlson, 2000). Social performance deficit in children with AD/HD-Combined subtype is based on research findings showing that children with AD/HD interact with other people as much as their peers (Wheeler & Carlson, 1994). Because children with AD\HD frequently interact with peers, they arguably have similar opportunities to learn appropriate social behaviors (Whalen & Henker, 1985; Wheeler & Peer Functioning 11 Carlson, 1994). Evidence also suggests that children with AD\HD are able to initiate appropriate prosocial behavior. Further, according to DuPaul and Stoner (2003) children with AD/HD-C are able to state the rules for appropriate social behavior as well as their typically developing peers. However, what makes them have problems in social situations is that they often do not act in accord with these rules. This performance deficit is consistent with the hypotheses that children with AD/HD-C are impaired in delaying responses to the environment (Barkley, 2006). In his theory, Barkley (2006) proposes that children with AD/HD act before they have a chance to think. In fact, studies have found that children with AD/HD-C engage in higher rates of unmodulated behaviors that are often inappropriate in the given context and insensitive to social expectations (e.g.,yelling, running around, or talking at inappropriate times) both as verbal (teasing, commanding) and physical (hitting) (Barkley, 2006). Evidence suggests that impulsivity and hyperactivity can be the reasons that obstruct a child with AD/HD-C from displaying social knowledge properly (Maedgen & Carlson, 2000). Specifically, impulsivity may effect the social interactions of children with AD/HD negatively by causing them to act without thinking and to have a difficult time waiting their turn in games. Consequently, this behavioral style is expected to meet with dislike and subsequent peer rejection (Wheeler & Carlson, 1994). Although it appears that children with AD\HD-I have less severe social problems than children with AD\HD-C, they do present difficulties in social relationships (Bachman & Hinshaw, 2002; Faraone, Biederman, Weber, & Russell, 1998; Maedgen & Carlson, 2000). Rather than being rejected by peers for disruptive or aggressive behaviors, children with AD\HD-I are more likely to be socially isololated, neglected, ignored, and teased by peers (Hinshaw, 2002; Hodgens et al., 2000: McBurnett et al., 1999). According to Wheeler and Carlson (1994), children with AD/HD-I may have deficits in both social performance and Peer Functioning 12 knowledge, whereas children with AD/HD-C type have performance deficits. The researchers further argued that these deficiencies might be differentially mediated by the symptoms typically co-occurring with each subtype. Impulsivity and hyperactivity may prevent a child with AD/HD- C from using social knowledge appropriately, whereas the anxiety and disorganization that characterize children with AD/HD-I may limit social interactions and thereby restrict acquisition of adequate social knowledge (Maedgen & Carlson, 2000). If such a pattern is the nature of children with AD/HD-I, they may be too fearful to experience social interactions and therefore have fewer opportunities to learn appropriate social behaviors than children with AD/HD-C (Landau, Milich & Diener, 1998). Overall, the distinction is important because it suggests that different interventions may be necessary, depending on whether a child presents with knowledge or performance deficits. If a child lacks competency in the basic skills necessary for social interactions, remediation approaches will focus on skill acquisition. On the contrary, if one finds that child knows, but is unable to judge when to or what specific skills to apply, interventions will emphasize performance. In general, direct instruction, modeling, coaching, and behavioral rehearsal frequently are used to remediate social skills deficits whereas contingent reinforcement, token economies that manipulate antecedents and consequences are beneficial for children with social performance deficits (Landau, Milich, & Diener, 1998). Interventions targeting social performance deficits are designed to increase the frequency with which children display the appropriate social behaviors typically by manipulating antecedents and consequences. Providing immediate feedback to children with social performance deficits is an especially important part of intervention design. To sum, the distinction between children with AD\HD’s social knowledge and social performance deficits can directly address the risk factors of social failure and rejection Peer Functioning 13 by peers before children become attached to deviant peer groups that promote antisocial personality disorders (Landau, et al., 1998; Ozdemir, 2009). Aggression Aggression has been a popular focus of research for developmental psychology and special education (Melnick & Hinshaw, 1996). Researchers have shown that children with AD/HD display social behavior that is described as disruptive, controlling, trouble-making, and frequently aggressive (Melnick & Hinshaw, 1996; Reid, 1993). The primary features of AD/HD combined with aggression often interfere negatively with a child’s ability to interact effectively with peers, family members, and others (Bagwell, Molina, Pelham, & Hoza 2001; DuPaul, McGoey, Eckert, & Van Brakle, 2001). Temperamental and behavioral deficits observed in young children with AD/HD interfere with typical social interactions. They demand a great deal of attention from others, with their behaviors often being more intense or forceful than the situation requires (Sheridan, 1998). Researchers have found that at least one-half of all children with AD/HD are known to have comorbid problems with aggressive conduct (Hinshaw, 1987; Hodgens et al., 2000; Maedgen & Carlson, 2000). These children are more likely to propose aggressive solutions to a problem situation and are less able to anticipate negative consequences when compared to non-AD/HD peers (Matthys, Cuperus, & Van Engeland, 1999; Waschbusch et al. 2002). They frequently misinterpret neutral behaviors as hostile and confrontational, which may prompt an aggressive response (Hinshaw, 1987). Similar self-distortions were also found in aggressive rejected children (Dodge & Pettit, 2003). Sandstrom and Cramer (2003) proposed that aggressive rejected children are particularly prone to engage in biased encoding processes that “protect” them from negative peer feedback. Moreover, research has described that children with aggressive behavior not only misinterpret intent but also the degree of aggressive behavior in a Peer Functioning 14 social situation (Dodge & Feldman, 1990; Hubbard et al., 2001). For example, when involved in an aggressive interaction, children with aggressive tendencies are more likely to underestimate their own level of aggression than are other children. These results suggest that aggressive children misjudge their level of aggression possibly because they over-attribute hostile intention to their peers’ actions thereby justifying aggressive behavior. To make the case worse, aggression is one of the most pervasive social problems for children with the disorder (Landau, et al., 1998). Researchers showed that 67% of preschoolers at risk for AD/HD with aggression at age 3 continued to have behavior problems when they reached 9 years old (Campbell & Ewing, 1990). It is also important to note that in various studies, children with AD/HD were rated by their peers as starting fights and arguments more than non-AD/HD children (Hodgens, et al., 2000; Maedgen & Carlson, 2000). In fact, research documented that children with AD/HD tend to be aggressive without an obvious aim except to inflict harm on a peer and are also more likely to be aggressive to obtain something valuable for them, such as to come first in a game (Atkins & Stoff, 1993). The overlap of AD\HD with Oppositional Defiant Disorder (ODD) and Conduct Disorders (CD) has probably received the most attention of all in the literature on comorbidity in AD\HD (Barkley & Biederman, 1997; Pfiffner et al., 1999; Wilens et al., 2002). The comorbidity of ODD\CD with AD\HD is often associated with a poorer outcome than either disorder alone. This comorbidity is also a marker for increased levels of symptomatology within each of the disorders making up the comorbid group, and with increased levels of impairment in functioning. For example, individuals with both AD/HD and ODD or CD have higher levels of CD/ODD symptoms than children with pure CD (Hinshaw, Lahey, & Hart 1993; Maughan, Rowe, Messer, Goodman, & Meltzer, 2004), greater levels of parental psychopathology, conflictual interactions Peer Functioning 15 with parents, peer rejection, school problems, and psychosocial adversity (Fletcher, Fisher, Barkley, & Smallish, 1996). Overall, research suggests that the majority of children with AD/HD experience either social incompetence or aggression, or a combination of both problems (Barkley, 2006). It is important to note that the more a child exhibits aggressive behavior or related comorbid disorders, the more challenging the treatment will be (Barkley, 2006). Although medications may decrease aggressive behavior, children with AD\HD need interventions that promote social competence because medication does not “normalize” the behaviors that lead peer rejection (Landau & Moore, 1991). Hence, practitioners need to understand these comorbid conditions to plan and implement effective interventions. Interventions Improving behavior in children with AD\HD depends on addressing a range of inter- related issues at the family level, in the classroom and in relation to individual children. In general, most current evidence based treatments for AD\HD include: behavior modification procedures, stimulant medication, the combination of behavior modification and stimulant medication (American Academy of Pediatrics, 2001), parent training, and social skills training (Stormont, 2001). Various intervention programs exist but all strive to promote more positive, compliant, and generally prosocial behavior while decreasing negative, defiant, and disruptive behavior in children (Shelton et al., 2000). These programs typically include antecedent modifications, skill development, and consequent strategies and focus on peer and family relations, classroom conduct, and school achievement (Arnold et al., 1997; Bierman, Miller, & Stabb, 1987; DuPaul & Weyandtb, 2006). In general, evidence suggests that most of these approaches appear to be acutely effective interventions for children with AD\HD in reducing the Peer Functioning 16 symptoms of the disorder (DuPaul & Eckert, 1997; Pelham & Fabiano, 2007; Pelham, Wheeler, & Chronis, 1998). However, for the majority of children, a long-term intervention that requires the support and commitment of all people who have a close relationship with the children is crucial (DuPaul & Weyandtb, 2006). Despite the increased understanding and awareness about the nature of the disorder, many professionals face the challenges of designing programs that can be easily integrated into children’ life and are practical in use. There remains, therefore, a pressing need to further develop long-term multimodal interventions that are intended to address the complex problems exhibited by this population. Behavior Modification Interventions Behavior modification interventions is probably one of the most commonly used interventions in AD\HD (DuPaul & Eckert, 1997; DuPaul & Weyandtb, 2006; Pelham, Wheeler, & Chronis, 1998). These interventions focus on manipulating the environment to decrease inappropriate behavior and increase appropriate replacement behaviors (Reid & Maag, 1998). Behavior modification interventions typically involve a functional behavior assessment to determine the target behaviors, training parents and\or teachers in behavior management techniques, reinforcement contracts for home and school, and daily reinforcements and consequences. Token reinforcement and response cost procedures are the most universally employed set of classroom management techniques in reducing disruptive, off task behavior and enhancing work productivity (Fiore, Becker, & Nero, 1993). Token reinforcement involves awarding or removing tokens or points to children contingent upon specified desirable behaviors. These tokens or points are collected and exchanged later for activities, objects, or privileges (Carbone, 2001). A token economy may or may not include a response cost procedure (Barkley, 2006), which involves the loss of privileges, tokens or points contingent upon inappropriate Peer Functioning 17 behavior. It is widely accepted that behavior modification interventions can be of great value for children with AD\HD because children with the disorder need more structure, more frequent and powerful reinforces to act appropriately, more consistent and immediate negative consequences to avoid a fine, and accommodations of school work to address slow work style (DuPaul & Eckert, 1997; DuPaul & Stoner, 2003; Maag, 1999; Pelham, et al., 1998). Pertinent to this point, existing empirical support for token programs and the practical use of these programs with a wide range of problem behaviors have led to their widespread use in school settings (Rowland, Umbach, Stallone, Naftel, Bohlig, & Sandier 2002; McGoey & DuPaul, 2000; DuPaul & Eckert, 1997). According to Barkley (2006), behavioral interventions can be effective in managing the AD\HD symptoms, because the severity of the symptoms and that of comorbid conditions are very sensitive to environmental variables. Medications In addition to behavior modification interventions, pharmacological interventions with stimulant medication are also widely used to treat AD\HD. It is estimated that over 1.5 million school age children in the U.S. annually may be using stimulants for behavior management (Zito et al., 2003). Interestingly, research suggests that adolescents and adults meeting criteria for AD\HD are being increasingly prescribed for stimulants due to the persistence of the symptoms across multiple domains of life into adolescence and adulthood (Conner & Steingard, 2004). Not surprisingly, the use of medication in children with AD\HD has been the subject of some controversy and increased public concern. Despite remarkable popularity of pharmacological treatment of the disorder, not all children benefit from medication, and even those who do still do not “normalize” in their social relationships (Barkley, 2006). In fact, many professionals are hesitant to medicate young children and often remind that the use of psychostimulant drugs for Peer Functioning 18 the treatment of AD\HD symptoms in young children necessitates serious consideration of risks relative to potential positive effects (Kern et al., 2007). Supportive of this view, some data suggest that the nature and severity of side effects may vary and be more intensive in young children (KoUins & Greenhill, 2006; Wigal et al., 2006). A related concern is that little can be said about the effects of medications on the developing brain as well as long-term side effects (Rappley, 2006). Although, serious concerns raised by many practitioners and parents remain to be addressed about medicating children with AD\HD, it is particularly challenging to design interventions that will effectively control the symptoms and treat the disorder without using stimulant medications. Some practitioners wisely discuss that behavioral interventions, structured preschool experience (KoUins & Greenhill, 2006; Rappley, 2002) social skills training, and parent education are attractive alternatives to medication (Dawson, 2007). Clearly, this is an area that requires considerable attention and further research. Social Skills Training One of the most widely used psychosocial interventions that directly targets peer relationships is social skills training (SST). Social skills training was originally developed for the purpose of enhancing the peer relationships of rejected and neglected children. It is based on the social skills deficit model, which posits that a child’s lack of social skills results in less positive peer interactions and lower social status (Bierman & Greenberg, 1996; Durlak, 1997; Grossman et al., 1997; Kavale, Mathur, Forness, Rutherford, Quinn, 1997; Mrug, Hoza, & Gerdes, 2001; Pfiffner, Calzada, & McBurnett, 2000). Although short-term effects of SST are positive, long- term outcomes reveal discouraging results on social, vocational, and academic measures when it is applied to children with AD\HD (Carlson & Bunner, 1993; Kavale et al., 1997; Pfiffner et al., 2000). Apparently, the nature of the disorder requires certain changes in both the content and the Peer Functioning 19 form of the interventions (Mrug, et al., 2001). In particular, evidence exists that children with AD/HD-C display performance deficit rather than a skill deficit. In other words, children with AD/HD-C are able to express the socially appropriate rules and behaviors, but they often do not act accord with these rules (DuPaul & Stoner, 2003). It is important to note that social performance deficits are more complicated to ameliorate than social skills deficits. First, existing SST’s focus on deficits in skills rather than deficits in performance. Second, because social performance problems exist across settings, interventions addressing performance problems must be carried out by different individuals in a child’s natural environments (DuPaul & Stoner, 2003). The other main problem is that most SST programs are designed for children who are apparently rejected without considering the unique topography of each child's performance in the social domain. As Hinshaw (1992) noted, social skills problems of children with AD/HD are quite heterogeneous and are not likely to respond to one-size fits all approach. For example, social needs of children with AD/HD-I who are withdrawn and isolated are different than children with AD/HD-C who display hyperactive and impulsive symptoms (Wheeler & Carlson, 1994). Thus, a social skills deficit approach may be applied to the children with AD/HD-I whereas both skills and performance deficit approach may work with children with AD/HD-C when conducting any SST programs. Another important area to review is related to the structure of social skills interventions. Social knowledge and the acquisition of prosocial behaviors are thought and practiced generally in group therapy formats. However, research indicates that traditional group therapy format do not lead to stable changes in social relationships of children with AD/HD in “real-world” environments (DuPaul & Eckert, 1994; Gresham, 2003). The lack of maintenance and generalization of social skills training become a major problem because of the fact that Peer Functioning 20 appropriate social behaviors are not essentially prompted by adults and peers on a consistent basis (DuPaul & Weyandt, 2006; Gresham, 2003). Indeed, the generalization of the newly acquired skills to other contexts requires their reinforcement across different settings in the child’s natural environment for an enough period of time (Mrug, Hoza, & Gerdes, 2001). Essential components of environmental programming may involve teaching parents and teachers to reinforce children to perform the behaviors trained in the social skills sessions and developing contingency management programs at home and at school to prompt trained skills (DuPaul & Eckert, 1994). Therefore, it is critical to accomplish the inclusion of parents, teachers, and peers as crucial members of the “social skills treatment team” for generalization. However, individuals within the child's natural environment such as parents typically have not been involved in intervention programs. Providing parents with necessary knowledge and training not only increases the continuity of the program but also, the intensity. Indeed, parents are generally with their children more than are teachers; this puts parents in the top position to create difficult behavior environments, or, more constructively, to provide long-term interventions. Overall, research supports that parents who are educated in the description, causes, prognosis, and treatment of AD/HD are better able to facilitate behavioral change in their children (DuPaul, Guevremont, & Barkley, 1991). Likewise, interventions can be more effective especially with respect to generalization of improved behavior across settings, when parental involvement is combined with social skills training programs. In addition, inclusion of parents in the SST program establishes consistency between the school and home environments (DuPaul & Stoner, 2003). Discussing behavioral strategies, rewards, and limits with parents to ensure continuity of approach to dealing with challenging behaviors between home and school is crucial. In that way, parents can encourage the same skills Peer Functioning 21 and performance at home and in different peer groups. Indeed many children with AD/HD appear to need very strong and intense levels of reinforcement to produce appropriate behavior in certain settings (Barkley, 1997; Landau & Moore, 1991). Parents must learn to identify the specific behaviors they want to substitute and then by giving rewards for the new more appropriate behavior, teach the child how to control his actions and reactions (Barkley, 2006). This is particularly important for children who have difficulty with anger management. An anger management program focused on adaptive ways of managing anger in children with AD/HD and a behavioral skills training program focused on both social skills and motivation can be used to help children with AD/HD experience more positive social outcomes (Stormont, 2001). The other considerable problem is that once a child is rejected, peers cognitive processing of the child behavior becomes biased. In other words, the peers may develop a negative stereotypical perspective of the child, and as a result of their view, the peers may selectively perceive and respond to the stereotype-consistent behaviors (Mrug, et al., 2001). Thus, social skills interventions not only should work on changing the negative social behaviors of children with AD/HD, but also the interventions should attempt to increase peers awareness of positive changes in a child’s behaviors (Mrug, et al., 2001). In order to do that, peers should be allowed to play active roles in every phases of social skills intervention (Ang & Hughes, 2002). Specifically peers can participate in the social skills training sessions as role models and encourage the enactment of positive social behaviors of children with AD/HD (DuPaul & Stoner, 2003). Indeed, research supports that including diverse peer group rather than using only children with disturbed behaviors increases the success of social skills training (Ang & Hughes, 2002). Parent Training Peer Functioning 22 Another most widely used form of psychosocial interventions for young children is parent management training (Barkley, 2006). Studies have shown that parent management training alters parental disciplinary practices, including reducing the frequency of coercive exchanges between parents and children, reduces parenting stress, enhances parental confidence, and improves family relationships (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Bor, Sanders, & Markie-Dadds, 2002; Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). In addition, parents are encouraged to consistently monitor their children to prevent antisocial behavior (e.g., physical aggression) and to prevent accidental injuries associated with impulsive behavior (DuPaul & Stoner, 2003). Positive future outcomes for all children has been associated with stable family environments, consistent discipline, positive parental expectations for their future, positive parents-child relationships, perceptions of competence perceived by parents, and low rates of parental criticism. Research indicates that behavioral treatment that teaches parents to modify their reactions to the child’s primary symptoms, should directly alter parental negative responses, and also train parents to increase their positive responses to children (Barkley, 2006; Wells et al., 2000). However, it is also important to recognize that the use of family relationship as a positive corrective experience in changing the relationship patterns of the child requires insight and support over time (DuPaul et al., 2001; Podolski & Nigg, 2001). Family members should learn necessary skills to apply behavioral interventions in a supportive environment and gain knowledge to identify indicators of emerging negative manifestations that will need assessment and intervention modifications (Barkley, 2006). Observing the child/parent interaction and then coaching parents in providing corrective behavioral interventions can be used via home visits while utilizing an empathic approach to the child and parents. Even though extensive research documenting the importance of positive parenting practices in remediating Peer Functioning 23 children with AD\HD’s social relationship problems (Barkley, 2006; DuPaul et al., 2001; Podolski & Nigg, 2001), there is undoubtedly more to the etiological chain. In fact, research has shown that despite the success of training programs for parents of children with AD/HD, improvements in child behavior within the family do not significantly transfer to school or to other environments (Anastapoluos, Barkley, & Shelton, 1996). Anastopoulos and colleagues (1996) posit such programs work because they lower parental stress by teaching them to regard disruptive behaviors as less severe than previously thought. For example, the teaching of skills to ignore minor missteps is a common element in parental training programs (Barkley, 1997). Furthermore, parent training only treats one of the many environments of which a child is a part. Research suggests that the key to change is connecting conduct at home with conduct at school while creating a system of communication between the two (Goldstein & Goldstein, 1998). Discussion From an ecological perspective, behavior inextricably interviewed in the complex network of persons and environment (Cook & Plas, 1984). Interventions are most effective when key players from each ecology of the child’s world are involved in the treatment team. According to Noam & Hermann (2002), an important dynamic in selecting an intervention for at risk young children is that we specifically need programs placed directly in the natural ecology and developmental context where children grow up and that bridge the different worlds that children inhabit. Therefore, a key to developing effective interventions for children with AD\HD may be to adopt an ecological perspective, collectively addressing all of the factors that impact a child’s life. Within this perspective, it is viewed that three major dimensions of a child’s life may likely to determine the degree of AD\HD symptoms. These dimensions include family, school, and child related characteristics and risk factors. Indeed, many researchers strongly argue that the Peer Functioning 24 use of multiple treatment modalities in AD\HD produces therapeutic benefit greater than the sum of each modality’s contribution (Barkley, 2006, Stormont, 2001). For example, Ozdemir (2006) have examined the effectiveness of the First Step to Success Program on decreasing social emotional and academic problems of Turkish children with AD\HD. Her findings are particularly important for the current paper because of the focus on implementing a multi-component early intervention program with children with AD\HD. Study results revealed that all participant children displayed increased levels of academic engagement behavior and decreased levels of social emotional problems with the introduction of the program and at three months and two years follow-ups. The results of this study indicate compelling evidence that implementing a multi-component early intervention program can yield important benefits for children with AD/HD. In general, research supports that some current treatment approaches, if rigidly applied, could dramatically decrease certain symptoms of AD\HD in short term (Barkley, 2006). A multi- component approach, however, would result in an overall remission of the AD\HD symptoms which could serve as the basis of positive social emotional development (Ozdemir, 2006). Such an approach would remind us that risk factors to peer relationship problems of children with AD\HD are by no means simple or linear. Bowen’s concept of triangles (Bowen, 1978) can be used to articulate the dynamic shifts of alliance and discordance that occur among persons and systems. The systems theory implies that all the interior angles of the triangle will influence and be affected by transactional relationships within the triangle. Specifically, peer relationship problems of children with AD\HD appear to be in part mediated by family relational variables, school variables, and child related variables and the dynamic relationships between these elements. Thus, interventions that link different variables in the family-school-child triangle will Peer Functioning 25 benefit from a focus on the interactive nature of child problems. Conclusion Various intervention approaches to AD\HD are reviewed in this study. Even though these treatment approaches are all evidence based treatment approaches for treating AD\HD in different settings such as classroom and home, the research findings establishing these interventions generally contrast one of the treatment against a control group, rather than comparisons of their combination. Thus, critical questions remain to be answered regarding how different treatment approaches might be best combined into a more meaningful package. Furthermore, there is a compelling argument in favor of an increased emphasis on primary prevention efforts because of the heavy burden of suffering of AD/HD and the short-term effectiveness of the interventions (Kern et al., 2007; McGoey et al., 2002). Unfortunately, until recently, minimal research has been conducted to help practitioners in identifying and supporting young children at risk for this disorder. It is essential to note that these two critical research gaps emphasize the importance of continuing program of research to develop interventions that better meet the needs of children with AD\HD. Further advances in helping children with the disorder in having relationships that are more satisfying with peers depend upon the continued research efforts to address these critical research questions. Finally, consideration of a systems perspective may lead to refinement of current intervention models. Narrow conceptual models miss the complex nature of the disorder. In contrast, the systems perspective emphasizes that the systems interface and what happens in one system is likely to affect the child’s behavior in the other From such a perspective, interventions would be implemented most effectively with reference to a wider family, school, and child framework. Without intervention, children with AD/HD will likely remain frustrated, angry, Peer Functioning 26 stressed, unmotivated, and unsuccessful in school and they will carry these problems to their future. Thus, interventions need to offer an ecological and certainly longer-term enterprise to have long-term impact on children with AD\HD’s peer relationship problems and overall quality of life. Peer Functioning 27 References American Academy of Pediatrics. (2001). Clinical practice guideline: Treatment of the school aged child with attention-deficit\hyperactivity disorder. Pediatrics, 108, 1033-1044. American Psychiatric Association, (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Anastopoulos, A. D., Barkley, R. A., & Shelton, T. L. (1996). Family-based treatment: Psychosocial intervention for children and adolescents with AD/HD. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 267-284). Washington. D.C. American Psychological Association. Anastopoulos, A. D., Guevremont, D. C., Shelton, T. L., & DuPaul, G. J. (1992). Parenting stress among families of children with attention deficit hyperactivity disorder. Journal of Abnormal Child Psychology, 20(5), 503-520. Anatopoulos, A. D., Shelton, T. L., & DuPaul, G. J., & Guevremont, D. C. (1993). PT for attention deficit hyperactivity disorder: Its impact on child and parent functioning. Journal of Abnormal Child Psychology, 21, 581-596. Ang, R. P., & Hughes, J. N. (2002). Differential benefits of skills training with antisocial youth based on group composition: A meta-analytic investigation. The School Psychology Review, 31(2), 164- 185. Arnold, L. E., Abikoff, H. B., Cantwell, D. P., Connors, C. K., Elliott, G., Greenhill, L. L., et al. (1997). National Institute of Mental Health collaborative multimodal treatment study of children with ADHD (the MTA). Archives of General Psychiatry, 54, 865–870. Atkins, M. S., & Stoff, D. M. (1993). Instrumental and hostile aggression in childhood disruptive behavior disorders. Journal of Abnormal Child Psychology, 21, 165-178. Bagwell, C. L., Molina, B., Pelham, W. E., & Hoza, B. (2001). Attention-deficit hyperactivity disorder and problems in peer relations: Predictions from childhood to adolescence. Journal of American Academy of Child and Adolescent Psychiatry, 40, 1285-1292. Barkley, R.A. (1997). Defiant children: A clinician's manual for assessment and parent training (2nd ed.), New York: Guilford Press. Barkley, R. (2001). The executive functions and self-regulation: An evolutionary Peer Functioning 28 neuropsychological perspective. Neuropsychology Review, 11, 1-29. Barkley, R. A. (2006). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.). New York: Guilford Press. Barkley, R. A., & Biederman, J. (1997). Towards a broader definition of the age of onset criterion for attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1204-1210. Barkley, R. A., Fischer, M., Edelbrock, C., & Smallish, L. (1991). The adolescent outcome of hyperactive children diagnosed by research criteria. III. Mother-child interactions, family conflicts and maternal psychopathology. Journal of Child Psychology and Psychiatry, 32 (2), 233-255. Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2004). Young adult follow-up of hyperactive children: Antisocial activities and drug use. Journal of Child Psychology and Psychiatry, 45, 195-211. Blachman, D. R., & Hinshaw, S. (2002). Patterns of friendship among girls with and without attention-deficit/hyperactivity disorder. Journal of Abnormal Child Psychology, 30, 625-640. Biederman, J., Faraone, S. V., Millberger, S., Curtis, S., Chen, L., Marrs, A., et al. (1996). Predictors of persistence and remission of ADHD into adolescence: Results from a four-year prospective follow-up study. Journal of the American Academy of Child and Adolescent, 35, 343–351. Bierman, K. L., & Greenberg, M. T. (1996). Social skills training in the Fast Track Program. In R. D. Peters & R. J. McMahon (Eds.), Preventing childhood disorders, substance abuse, and delinquency (pp.65-89). Thousand Oaks, CA: Sage. Bierman, K. L., Miller, C. L., & Stabb, S. D. (1987). Improving the social behavior and peer acceptance of rejected boys: Effects of social skills training with instructions and prohibitions. Journal of Consulting and Clinical Psychology, 55, 194–200. Bor, W., Sanders, R. M., & Markie-Dadds, C. (2002). The effects of the Triple P-Positive Parenting Program on preschool children with co-occurring disruptive behavior and attentional\hyperactive difficulties. Journal of Abnormal Child Psychology, 30, 571- 587. Bowen, M. (1978). Family therapy and clinical practice. New York: Jason Aronson. Peer Functioning 29 Campbell, S. B., & Ewing, L. J. (1990). Follow-up of hard to manage preschoolers: Adjustment at age 9 and predictors of continuing symptoms. Journal of Child Psychology and Psychiatry, 31, 871-889. Carbone, E. (2001). Arranging the classroom with an eye (and ear) to students with ADHD. Teaching Exceptional Children, 34(2), 72-81. Carlson, C. M., & Bunner, M. R. (1993). Effects of methylphenidate on the academic Performance of children with attention-deficit hyperactivity disorder and learning disabilities. School Psychology Review, 22, 184-198. Choronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E., Jr. (2004). Enhancement to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child and Family Psychology Review, 7, 1-27. Cole, P. M., Michel, M. K., & Teti, L. O. (1994). The development of emotion regulation and dysregulation: A clinical perspective. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations (pp. 73-100). Monographs of the Society for Research in Child Development, 59 (2-3, Serial No. 240). Cole, P. M., Zahn-Waxler, C., & Smith, D. (1994). Expressive control during a disappointment: Variations related to preschoolers’ behavior problems. Developmental Psychology, 30, 835-846. Conner, D. F., & Steingard, R. J. (2004). New formulations of stimulants for attention-deficit hyperactivity disorder: Therapeutic potential. CNS Drugs, 18(14), 1011-1030. Cook, V. J., & Plas, J. M. (1984). Intervention with disturbed children: The ecological viewpoint. In M. J. Fine (Ed.), Systematic intervention with disturbed children (pp. 157- 178). Boston: Spectrum, SP Medical & Scientific Books. Dawson, M. M. (2007). The ideal versus the feasible when designing interventions for students with attention deficit hyperactivity disorder. School Psychology Review, 36(2), 274- 278. Dodge, K. A., & Feldman, E. (1990). Issues in social cognition and sociometric status. In S. R. Asher & J. D. Coie (Eds.), Peer rejection in childhood (pp.119-155). New York: Cambridge University Press. Peer Functioning 30 Dodge, K. A., Pettit, G. S. (2003). A biopsychosocial model of the development of chronic conduct problems in adolescence. Developmental Psychology, 39 (2), 349-371. Dodge, K. A., & Tomlin, A. M. (1987). Utilization of self-schemas as mechanism of interpretational bias in aggressive children. Social Cognition, 5, 280-300. DuPaul, G. J. (2007). School-based interventions for students with attention deficit hyperactivity disorder: Current status and future directions. School Psychology Review, 36 (2), 183- 194. DuPaul, G. J., & Eckert, T. L. (1994). The effects of social skills curricula: Now you see them, now you don’t. School Psychology Quarterly, 9, 113-132. DuPaul, G. J., & Eckert, T. L. (1997). School-based interventions for children with attention- deficit hyperactivity disorder: A meta-analysis. School Psychology Review, 26, 5-27. DuPaul, G. J., Guevremont, D. C., & Barkley, R. A. (1991). Attention-deficit hyperactivity disorder. In T. R. Kratochwill & R. J. Morris (Eds.), The practice of child therapy (pp. 115-144). Needham Heights, MA: Allyn and Bacon. DuPaul, G. J., McGoey, K. E., Eckert, T. L., & Van Brakle, J. (2001). Preschool children with attention deficit\hyperactivity disorder: Impaırments in behavioral, social, and school functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1036-1045. DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools: Assessment and intervention strategies (2nd ed.). New York: Guilford Press. DuPaul, G. J., & Weyandthb, L. L. (2006). School-based interventions for children with attention deficit hyperactivity disorder: Effects on academic, social, and behavioral functioning. International Journal of Disability, Development and Education, 53 (2), 161-176. Durlak, J. A. (1997). Successful prevention programs for children and adolescents. Thousand Oaks, CA: Sage. Eisenberg, N. (2001). The core and correlates of affective social competence. Social Development, 10, 120-124. Eisenberg, N., Cumberland, A., Spinrad, T. L., Fabes, R. A., Shepard, S., Reiser, M., Murphy, B. C., Losoya, S. H., & Guthrie, I. K. (2001). The relations of regulation and emotionality to children’s externalizing and internalizing problem behavior. Child Peer Functioning 31 Development, 72, 1112-1134. Eisenberg, N., Fabes, R. A., Bernzweig, J., Karbon, M., Poulin, R. & Hanish, L. (1993). The relations of emotionality and regulation to preschooler’s social skills and sociometric status. Child Development, 64, 1418-1438. Erhardt, D., & Hinshaw, S. (1994). Initial sociometric impressions of attention-deficit hyperactivity disorder and comparison boys: Predictions from social behaviors and from nonbehavioral variables. Journal of Consulting and Clinical Psychology, 62, 833-842. Faraone, S. V., Biederman, J., Lehman, B., keenan, K., Norman, D., Seidman, L. J., et al. (1993). Evidence for the independent familial transmission of attention deficit hyperactivity disorder and learning disabilities: Results from a family genetic study. American Journal of Psychiatry, 150, 891-895. Faraone, S. V., Biederman, J., Weber, W. & Russell, R. L. (1998). Psychiatric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention- deficit\hyperactivity disorder: Results from a clinically referred sample. Journal of American Academy of Child and Adolescent Psychiatry, 37, 185-193. Fiore, T. A., Becker, E. A., & Nero, R. C. (1993). Educational interventions for students with ADD. Exceptional Children, 60, 771-773. Fletcher, K.E., Fisher, M., Barkley, R. A., & Smallish, L. (1996). A sequential analysis of the mother-adolescent interactions of ADHD, ADHD/ODD, and normal teenagers during neutral and conflict discussions. Journal of Abnormal Child Psychology, 24, 271- 297. Goldstein, S., & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children (2nd ed.), New York: John Wiley & Sons, Inc. Gresham, F. M. (2002). Teaching social skills to high-risk children and youth: Preventive and remedial strategies. In M. R. Shinn, H. M. Walker, & G. Stoner (Eds.), Interventions for academic and behavioral problems II: Preventive and remedial approaches (2nd ed., pp. 403-432). Washington, DC: National Association of School Psychologists. Gross, J. J., & Munoz, R. F. (1995). Emotion regulation and mental health. Clinical Psychology: Science and Practice, 2, 151-164. Grossman, D., Neckerman, H. J., Koepsell, T. D., Liu, P., Asher, K. N., Beland, K., et al. (1997). Peer Functioning 32 The effectiveness of a violence prevention curriculum among children in elementary school. Journal of the American Medical Association, 277, 1605-1611. Guevremont, D. C., & Dumas, M. C. (1994). Peer relationship problems and disruptive behavior disorders. Journal of Emotional and Behavioral Disorders, 2, 164-173. Hinshaw, S. P. (1987). On the distinction between attentional deficits/hyperactivity and conduct problems/aggression in child psychopathology. Psychological Bulletin, 101, 443- 463. Hinshaw, S. P. (1992). Interventions for social competence and social skill. Child and Adolescent Psychiatric Clinics of North America, 1 (2), 539-552. Hinshaw, S. P. (2002). Preadolescent girls with attention-deficit\hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functions, and parenting practices. Journal of Consulting and Clinical Psychology, 70, 1086-1098. Hisnhaw, S. P., Lahey, B. B., & Hart, E. L. (1993). Issues of taxonomy and comorbidity in the development of conduct disorder. Development and Psychopathology, 5, 31-49. Hinshaw, S. P., & Melnick, S. M. (1995). Peer relationship in boys with attention-deficit hyperactivity disorder with and without comorbid aggression. Development and Psychopathology, 7, 627-647. Hodgens, J. B., Cole, J., & Boldizar, J. (2000). Peer-based differences among boys with ADHD. Journal of Clinical Child Psychology, 29, 443-452. Hoza, B., Mrug, S., Gerdes, A. C., Hinshaw, S., Bukowski, W. M., et al. (2005). What aspects of peer relationships are impaired in children with attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology, 73 (3), 411-423. Hubbard, J. A., Dodge, K. A., Cillessen, A. H. N., Coie, J. D., & Scwartz, D. (2001). The dyadic nature of Social Information Processing in boys’ reactive and proactive aggression. Journal of Personality and Social Psychology, 80 (2), 268-280. Johnston, C., Pelham, W. E., & Murphy, H. A. (1985). Peer relationships in ADHD and normal children: A developmental analysis of peer and teacher ratings. Journal of Abnormal Child Psychology, 13, 89-100. Kavale, K. A., Mathur, S. R., Forness, S. R., Rutherford, R. G., & Quinn, M. M. (1997). The effectiveness of social skills training for students with emotional or behavioral disorders: A meta analysis. In T. E. Scruggs & M. A. Mastropieri (Eds.), Advances in Peer Functioning 33 learning and behavioral disabilities (Vol. 11, pp. 1-26). Greenwich CT: JAI Press. Kern, L., Dupaul, G. J., Volpe, R. J., Sokol, N. G., Lutz, J. G., Arbolino, L. A., et al. (2007). Multisetting assessment-based intervention for young children at risk for attention deficit hyperactivity disorder: Initial effects on academic and behavioral functioning. School Psychology Review, 36 (2), 237-255. Kollins, S. H., & Greenhill, L. (2006). Evidence base for the use of stimulant medication in preschool children with ADHD. Infants and Young Children, 19 (2), 132-141. Landau, S., & Milich, R. (1988). Social communication patterns of attention-deficit-disordered boys. Journal of Abnormal Child Psychology, 16, 69-81. Landau, S., & Milich, R. (1990). Assessment of social status and peer relations. In A.M. La Greca (Ed.), Childhood assessment: Through the eyes of a child (pp.259-291). New York: Allyn & Bacon Landau, S., & Milich, R. (1998). Social communication patterns of attention-deficit-disordered boys. Journal of Abnormal Psychology, 16, 69-81. Landau, S., Milich. R., & Diener, M. B. (1998). Peer relations of children with attention deficit hyperactivity disorder. Reading & Writing Quarterly: Overcoming Learning Difficulties, 14, 83-105. Landau, S., & Moore, L. A. (1991). Social skills deficits in children with attention-deficit hyperactivity disorder. School Psychology Review, 20, 235-251. Lemery, K., Essex, M.J., & Smider, N.A. (2002). Revealing the relation between temperament and behavior problem symptoms by eliminating measurement confounding: Expert ratings and factor analyses. Child Development, 73, 867-882. Maag, J. W. (1999). Behavior Management. San Diego, CA: Singular Publishing Group. MacDougall, P., Hymel, S., Vaillancourt, T., & Mercer, L. (2001). The consequences of childhood peer rejection. In M. R. Leary (Ed.), Interpersonal rejection (pp. 213-247). Oxford, England: Oxford University press. Maedgen, J. W., & Carlson, C. L., (2000). Social Functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Child Psychology, 29, 30-42. Mannuzza, S., Gittelman-Klein, R., Bessler, A., Malloy, & LaPadula, M. (1993). Adult outcome of hyperactive boys: Educational achievement, occupational rank, and psychiatric Peer Functioning 34 status. Archives of General Psychiatry, 50, 565-576. Mannuzza, S., Klein, R. G., Bessler, A. Malloy, P., & LaPadula, M. (1998). Adult psychiatric status of hyperactive boys grown up. American Journal of Psychiatry, 155 (4), 493-498. Mannuzza, S., Klein, R., Bonagura, N., Konig, P., & Shenker, R. (1988). Hyperactive boys almost grown up. II. Status of subjects without a mental disorder. Archives of General Psychiatry, 45, 13-18. Maughan, B., Rowe, R., Messer, J., Goodman, R., & Meltzer, H. (2004). Conduct disorder and oppositional defiant disorder in a national sample: Developmental epidemiology. Journal of Child Psychology and Psychiatry, 45, 609-621. Matthys, W., Cuperus, J. M., & Van Engeland, H. (1999). Deficient social problem solving in boys with ODD\CD, with ADHD, and with both disorders. Journal of American Academy of Child and Adolescent Psychiatry, 38, 311-321. McBurnett, K., Pfiffner, L. J., Willcutt, E., Tamm, L., Lerner, M., Ottolini, Y. L., et al.(1999). Experimental cross validation of DSM-IV types of attention-deficit\hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 17-24. McGoey, K. E., Eckert, T. L., & DuPaul, G. J., (2002). Early intervention for preschool-age children with ADHD: A literature review. Journal of Emotional and Behavioral Disorders, 10 (1), 14-28. McGoey, K. E., & DuPaul, G. J. (2000). Total reinforcement and response cost procedures: Reducing the disruptive behavior of preschool children with attention- deficit\hyperactivity disorder. School Psychology Quarterly, 15 (3), 330-343. Melnick, S. M., & Hinshaw, S. P. (1996). What they want and what they get: The social goals of boys with ADHD and comparison boys. Journal of Abnormal Child Psychology, 24, 169–185. Melnick, S. M., & Hinshaw, S. P. (2000). Emotion regulation and parenting in AD/HD and comparison boys: Linkages with social behaviors and preference. Journal of Abnormal Child Psychology, 28, 73-86. Mikami, A. Y., & Hinshaw, S. P. (2003). Buffers of peer rejection among girls with and without ADHD: The role of popularity with adults and goal-directed solitary play. Journal of Peer Functioning 35 Abnormal Child Psychology, 31, 381-397. Mrug, S., Hoza, B.,& Gerdes, A.C. (2001). Children with attention-deficit/hyperactivity disorder: Peer relationships and peer oriented interventions. In D. Nangle, & C. Erdley (Eds.), New directions for child and adolescent development: Friendship and psychological adjustment (pp. 51-77). San Fransisco, CA: Jossey-Bass. Murphy, K. R., Barkley, R. A., & Bush, T. (2002). Young adults with attention deficit hyperactivity disorder: Subtype differences in comorbidity, educational, and clinical history. The Journal of Nervous and Mental Disease, 190, 147-157. Noam, G., & Hermann, C. A. (2002). Where education and mental health meet: developmental prevention and early intervention in schools. Development and Psychopathology, 14, 861-875. Ozdemir, S. (2006). First Step to Success program: Implementation effectiveness with Turkish children with attention deficit hyperactivity disorder. Unpublished doctoral dissertation, Arizona State University, Phoenix. Ozdemir, S. (2009). Peer relationship problems of children with AD/HD: Risk factors and new directions in interventions. Australian Journal of Special Education. (DOI: 10.1375). Parker, J.G., & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low- accepted children at risk? Psychological Bulletin, 102, 357-389. Pelham, W. E., & Fabiano, G. A. (2007). Evidence-based treatment for children and adolescents with ADHD: An update. Journal of Clinical Child and Adolescent Psychology, 37, 184-214. Pelham, W. E., Wheeler, T., & Chronis, A. (1998). Empirically supported psychosocial treatment for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190-205. Peterson, B. S., Pine, D. S., Cohen, P., & Brook, J. S. (2001). Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit\hyperactivity disorders in an epidemiological sample. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 685-695. Pfiffner, L. J., Calzada, E., & McBurnett, K. (2000). Interventions to enhance social competence. Child and Adolescent Psychiatric Clinics of North America, 9, 689-709. Pfiffner, L. J., McBurnett, K., Lahey, B. B., Loeber, R., Green, S., Frick, P. J., et al. (1999). Peer Functioning 36 Association of parental psychopathology to the comorbid disorders of boys with attention –deficit hyperactivity disorder. Journal of Consulting and Clinical Psychology, 67, 881-893. Rappley, M. D. (2006). Actual psychotropic medication use in preschool children. Infants and Young Children, 19(2), 154-163. Reid, J. (1993). Prevention of conduct disorder before and after school entry: Relating interventions to developmental findings. Development and Psychopathology, 5, 243- 262. Reid, R. & Maag, J. (1998). Functional assessment: A method for developing classroom-based accommodations for children with ADHD. Reading and Writing Quarterly, 14, 9-42. Rowland, A. S., Umbach, D. M., Stallone, L., Naftel, J., Bohlig, M., & Sandier, D. P. (2002). Prevalence of medication treatment for attention-deficit/hyperactivity disorder among elementary school children in Johnston County, North Carolina. American Journal of Public Health, 92, 231-234. Saarni, C. (1999). The development of emotional competence. New York: Guilford. Sandstrom, M., & Cramer, P. (2003). Defense mechanisms and psychological adjustment in childhood. Journal of Nervous and Mental Disease, 191, 487-495. Shelton, T. L., Barkley, R. A., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., et al. (2000). Multimethod psychoeducational intervention for preschool children with disruptive behavior: Two-year post-treatment follow-up. Journal of Abnormal Child Psychology, 28, 253-266. Sheridan, S. M. (1998). Social skills training for ADHD children. In S. Goldstein, & M. Goldstein, (Eds.), Managing attention deficit hyperactivity disorder in children (pp. 592-612). New York: John Wiley & Sons, Inc. Southam-Gerow, M. A. & Kendall, P. C. (2002). Emotion regulation and understanding: Implications for child psychopathology and therapy. Clinical Psychology Review, 22, 189-222. Stormont, M. (2001). Social outcomes of children with AD/HD: Contributing factors and implications for practice. Psychology in the Schools, 38 (6), 521-531. Stormont-Spurgin, M., & Zentall, S. S. (1995). Contributing factors in the manifestation of aggression in preschoolers with hyperactivity. Journal of Child Psychology and Peer Functioning 37 Psychiatry, 36, 491–509. Stroes, A., Alberts, E., & van der Meere, J. J. (20030). Boys with ADHD in social interaction with a nonfamiliar adult: An observational study. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 295-302. Tannock, R., & Schachar, R. (1996). Executive dysfunction as an underlying mechanism of behavior and language problems in attention deficit hyperactivity disorders. In J. H. Beitchman, N. J. Cohen, M. M. Konstantareas, & R. Tannock (Eds.), Language learning and behavior disorders: Developmental, biological, and clinical perspective (pp.128-155). New York: Cambridge University Press. Taylor, J. F. (1994). Helping your hyperactive/attention deficit child. CA: Prima. Treuting, J. J., & Hinshaw, S. P. (2001). Depression and self-esteem in boys with attention- deficit/hyperactivity disorder: Associations with comorbid aggression and explanatory attributional mechanisms. Journal of Abnormal Child Psychology, 29, 23-39. Vitaro, F., Tremblay, R. E., Gagnon, C., & Pelletier, D. (1994). Predictive accuracy of behavioral sociometric assessments of high-risk kindergarten children. Journal of Clinical Child Psychology, 23, 272-282. Young, S. (2000). ADHD children grown: An empirical review. Counseling Psychology Quarterly, 13, 191-200. Waschbusch, D. A., Pelham, W. E., Jennings, J. R., Greiner, A. R., Tarter, R. E., & Moss, H. B. (2002). Reactive aggression in boys with disruptive behavior disorders: Behavior physiology, and affect. Journal of Abnormal Child Psychology, 30, 641-656. Weiss, G., & Hechtman, L. (1993). Hyperactive children grown up (2nd ed.). New York: Guilford Press. Wells, K. C., Epstein, J. N., Hinshaw, S. P., Conners, C. K., Klaric, J., Abikoff, H. B., et al. (2000). Parenting and family stress treatment outcomes in attention deficit hyperactivity disorder (ADHD): An empirical analysis in the MTA Study. Journal of Abnormal Child Psychology, 28, 543-553. Whalen, C. K., & Henker, B. (1985). The social worlds of hyperactive (ADHD) children. Clinical Psychology Review, 5, 447-478. Whalen, C. K., & Henker, B. (1991). The social impact of stimulant treatment for hyperactive Peer Functioning 38 children. Journal of Learning Disabilities, 24, 231-241. Wheeler, J. & Carlson, C. L. (1994). The social functioning of children with ADD with hyperactivity and ADD without hyperactivity. Journal of Emotional and Behavioral Disorders, 2, 2-11. Wigal, T., Greenhill, L., Chuang, S., McGough, J., Vitiello, B., Skrobala, A., et al. (2006). Safety and tolerability of methylphenidate in preschool children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 1294-1303. Wilens, T. E., Biederman, J., Brown, S., Tanguay, S., Monuteaux, M. C., Blake, C., et al. (2002). Psychiatric comorbidity and functioning in clinically-referred preschool children and school-age youth with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 262-268. Zentall, S. S. (1988). Production deficiencies in elicited language but not in the spontaneous verbalizations of hyperactive children. Journal of Abnormal Child Psychology, 16, 657-673. Zito, J. M., Safer, D. J., DosReis, S., Magder, L. S., Gardner, J. F., & Magder, L. S., Soeken, K., et al., (2003). Psychotropic practice patterns for youth: A 10-year perspective. Achieves of Pediatrics and Adolescent Medicine, 157, 17-25.