Individuals with ADHD often experience social difficulties, social rejection, and interpersonal relationship problems as a result of their inattention, impulsivity and hyperactivity. Such negative interpersonal outcomes cause emotional pain and suffering. They also appear to contribute to the development of co-morbid mood and anxiety disorders.
Because very little research has been published regarding social skills in adults with ADHD, the suggestions given in this sheet are based primarily upon sound clinical practices and upward extrapolations from the research on children's social skills and ADHD.
Overall impact of ADHD on social interactions
It is not difficult to understand the reasons why individuals with ADHD often struggle in social situations. Interacting successfully with peers and significant adults is one of the most important aspects of a child's development, yet 50 to 60 percent of children with ADHD have difficulty with peer relationships. Over 25 percent of Americans experience chronic loneliness. One can only speculate that the figure is much higher for adults with ADHD.
To interact effectively with others, an individual must be attentive, responsible and able to control impulsive behaviors. Adults with ADHD are often inattentive and forgetful and typically lack impulse control. Because ADHD is an "invisible disability," often unrecognized by those who may be unfamiliar with the disorder, socially inappropriate behaviors that are the result of ADHD symptoms are often attributed to other causes. That is, people often perceive these behaviors and the individual who commits them as rude, self-centered, irresponsible, lazy, ill-mannered, and a host of other negative personality attributes. Over time, such negative labels lead to social rejection of the individual with ADHD. Social rejection causes emotional pain in the lives of many of the children and adults who have ADHD and can create havoc and lower self-esteem throughout the life span. In relationships and marriages, the inappropriate social behavior may anger the partner or spouse without ADHD, who may eventually "burn out" and give up on the relationship or marriage.
Educating individuals with ADHD, their significant others, and their friends about ADHD and the ways in which it affects social skills and interpersonal behaviors can help alleviate much of the conflict and blame. At the same time, the individual with ADHD needs to learn strategies to become as proficient as possible in the area of social skills. With proper assessment, treatment and education, individuals with ADHD can learn to interact with others effectively in a way that enhances their
ADHD and the acquisition of social skills
Social skills are generally acquired through incidental learning: watching people, copying the behavior of others, practicing, and getting feedback. Most people start this process during early childhood. Social skills are practiced and honed by "playing grown-up" and through other childhood activities. The finer points of social interactions are sharpened by observation and peer feedback.
Children with ADHD often miss these details. They may pick up bits and pieces of what is appropriate but lack an overall view of social expectations. Unfortunately, as adults, they often realize "something" is missing but are never quite sure what that "something" may be.
Social acceptance can be viewed as a spiral going up or down. Individuals who exhibit appropriate social skills are rewarded with more acceptance from those with whom they interact and are encouraged to develop even better social skills. For those with ADHD, the spiral often goes downward. Their lack of social skills leads to peer rejection, which then limits opportunities to learn social skills, which leads to more rejection, and so on. Social punishment includes rejection, avoidance, and other, less subtle means of exhibiting one's disapproval towards another person.
It is important to note that people do not often let the offending individual know the nature of the social violation. Pointing out that a social skill error is being committed is often considered socially inappropriate. Thus, people are often left on their own to try to improve their social skills without understanding exactly what areas need improvement.
Research on children with ADHD and social skills
Researchers have found that the social challenges of children with ADHD include disturbed relationships with their peers, difficulty making and keeping friends, and deficiencies in appropriate social behavior. Long-term outcome studies suggest that these problems continue into adolescence and adulthood and impede the social adjustment of adults with ADHD.
At first, these difficulties of children with ADHD were conceptualized as a deficit in appropriate social skills, such that the children had not acquired the appropriate social behaviors. Based upon this model, social skills training, which is commonly conducted with groups of children, became a widely accepted treatment modality. In the typical social skills training group, the therapist targets specific social behaviors, provides verbal instructions and demonstrations of the target behavior, and coaches the children to role-play the target behaviors with one another. The therapist also provides positive feedback and urges the group to provide positive feedback to one another for using the appropriate social behavior. The children are instructed to apply their newly acquired skills in their daily lives.
More recently, ADHD has been re-conceptualized as an impairment of the executive or controlling functions of the brain. It follows from this conceptualization that the social deficits of the individual with ADHD may not be primarily the result of a lack of social skills, but rather a lack of efficiency in reliably using social skills that have already been acquired. Social skills training addresses the lack of skills, but does not address inefficient use of existing skills. Medication produces direct changes in the executive function of the brain and may therefore help children with ADHD more reliably use newly acquired social skills. Researchers have also added components to social skills training that help children with ADHD reliably apply what they have learned in various settings. To accomplish this goal, parents and teachers are trained to prompt and reinforce children with ADHD to use newly acquired social skills at home and in school.
Only a small number of controlled investigations have studied the effectiveness of social skills training for children with ADHD. These studies have found that social skills training improves the children's knowledge of social skills and improves their social behavior at home as judged by parents, and these positive changes last up to the 3 or 4 month follow-up periods in the studies. However, these changes only partially generalize to school and other environments.
Researchers have also found that embedding social skills training within an intensive behavioral intervention, such as a specialized summer camp program, is a highly effective way of increasing the chances that the children will maintain and generalize the gains that they have made. There is no research yet that addresses the question of whether children with ADHD who benefit from social skills training have more friends, are better accepted by their peers, and have better interpersonal relationships as they move into adolescence and adulthood. Clearly, this is an area where more research is necessary.
Specific ADHD symptoms and social skills
Tips for identifying subtext:
A related social skills difficulty for many with ADHD involves missing the subtle nuances of communication. Those with ADHD will often have difficulty "reading between the lines" or understanding subtext. It is difficult enough for most to attend to the text of conversations without the additional strain of needing to be aware of the subtext and what the person really means . Unfortunately, what is said is often not what is actually meant.
Impulsivity negatively affects social relationships because others may attribute impulsive words or actions to lack of caring or regard for others. Failure to stop and think first often has devastating social consequences. Impulsivity in speech, without self-editing what is about to be said, may appear as unfiltered thoughts. Opinions and thoughts are shared in their raw form, without the usual veneer that most people use to be socially appropriate. Interruptions are common.
Impulsive actions can also create difficulties as individuals with ADHD may act before thinking through their behavior. Making decisions based on an "in the moment" mentality often leads to poor decision-making. Those with ADHD often find themselves lured off task by something more inviting. Impulsive actions can include taking reckless chances, failure to study or prepare for school- or work-related projects, affairs, quitting jobs, making decisions to relocate, financial overspending, and even aggressive actions, such as hitting others or throwing items.
Rapid and excessive speech can also be a sign of impulsivity. The rapid-fire speech of an individual with ADHD leaves little room for others who might want to participate in the conversation. Monologues rather than dialogues leave many with ADHD without satisfying relationships or needed information.
Physical hyperactivity often limits the ability to engage in leisure activities. Failure to sit still and concentrate for concerts, religious ceremonies, educational events, or even leisure vacations and the like may be interpreted by others as a lack of caring or concern on the part of the person with ADHD. In addition, difficulties looking attentive leave others feeling unattended.
Assessment of social skills
Interviews and self-report questionnaires are the primary tools for assessing social skill deficits and interpersonal interaction problems in adults with ADHD. During the course of a diagnostic evaluation for ADHD (see What We Know #9, "Diagnosis of ADHD in Adults"), a mental health professional will thoroughly assess the social interactions of the adult. When questionnaires are used, it is important to include both a self-report by the individual with ADHD and reports by spouses, significant others, and friends on a comparable version of the questionnaire. The questionnaire may include the following types of items:
When the social skill areas in need of strengthening have been identified, obtaining a referral to a therapist or coach who understands how ADHD affects social skills is recommended (see Coaching). Medications are often helpful in the management of ADHD symptoms; in many cases, an effective dose of medication will give the adult with ADHD the boost in self-control and concentration necessary to utilize newly acquired social skills at the appropriate time. However, medications alone are usually not sufficient to help gain the necessary skills (see Medication Management).
As discussed earlier, social skills training for children and adolescents with ADHD usually involves instruction, modeling, role-playing, and feedback in a safe setting such as a social skills group run by a therapist. In addition, arranging the environment to provide reminders has proven essential to using the correct social behavior at the opportune moment. These findings suggest that adults with ADHD wishing to work on their social skills should consider the following elements when seeking an effective intervention. It is important to note that these treatment strategies are suggestions based on clinical practice, rather than empirical research.
Knowledge. Oftentimes social skills can be significantly improved when there is an understanding of social skills as well as the areas in need of improvement. Reading books such as What Does Everybody Know That I Don't, ADD and Romance, or You, Your Relationship & Your ADD can provide some of that knowledge .
Attitude. Individuals with ADHD should have a positive attitude and be open to the growth of their social skills. It is also important to be open and appreciative of feedback provided by others.
Goals. Adults with ADHD may want to pick and work on one goal at a time, based on a self-assessment and the assessments of others. Tackling the skill areas one at a time allows the individual to master each skill before moving on to the next.
The echo. Those who struggle with missing pieces of information due to attentional difficulties during conversation may benefit from developing a system of checking with others what they heard. "I heard you say that. Did I get it right Is there more " Or an individual with ADHD could ask others to check with them after providing important information. "Please tell me what you heard me say." In this way, social errors due to inattention can be avoided.
Observe others. Adults with ADHD can learn a great deal by watching others do what they need to learn to do. They may want to try selecting models both at work and in their personal lives to help them grow in this area. Television may also provide role models.
Role play. Practicing the skills they need with others is a good way for individuals with ADHD to receive feedback and consequently improve their social skills.
Visualization. Visualization can be used to gain additional practice and improve one's ability to apply the skill in other settings. Those who need practice in social skills can decide what they want to do and rehearse it in their minds, imagining actually using the skill in the setting they will be in with the people they will actually be interacting with. They can repeat this as many times as possible to help "overlearn" the skill. In this manner, they can gain experience in the "real" world, which will greatly increase the likelihood of their success.
Prompts. Adults with ADHD can use prompts to stay focused on particular social skill goals. The prompts can be visual (an index card), verbal (someone telling them to be quiet), physical (a vibrating watch set every 4 minutes reminding them to be quiet), or a gesture (someone rubbing their head) to help remind them to work on their social skills.
Increase "likeability." According to social exchange theory, people maintain relationships based on how well those relationships meet their needs. People are not exactly "social accountants," but on some level, people do weigh the costs and benefits of being in relationships. Many with ADHD are considered to be "high maintenance." Therefore, it is helpful to see what they can bring to relationships to help balance the equation. Investigators have found that the following are characteristics of highly likeable people: sincere, honest, understanding, loyal, truthful, trustworthy, intelligent, dependable, thoughtful, considerate, reliable, warm, kind, friendly, happy, unselfish, humorous, responsible, cheerful, and trustful. Developing or improving any of the likeability characteristics should help one's social standing.
Although ADHD certainly brings unique challenges to social relationships, information and resources are available to help adults with ADHD improve their social skills. Most of this information is based upon sound clinical practice and research on social skills and ADHD in children and adolescents; there is a great need for more research on social skills and ADHD in adults. Seek help through reading, counseling, or coaching and, above all, build and maintain social connections.