Effectiveness of Social Skills Interventions Incorporating Peer Interactions for Children With Attention Deficit Hyperactivity Disorder: A Systematic Review

Impact of Social Skills Deficits

The symptoms and social characteristics associated with ADHD often result in social dysfunction and lead to peer rejection and less meaningful friendships (Mrug et al., 2012). Children with ADHD were found to be twice as likely as TD children to have no friends (Hoza et al., 2005); of those who reported having friends, 56% of those friends did not consider these children to be their friends. Even when children with ADHD have friends, the friendships tend to be of lower quality and less stable than those of their TD peers (Hoza et al., 2005) and to last a shorter time than friendships of TD children (Normand et al., 2011).

Social dysfunction, peer rejection, and poor friendship quality can persist over time if not resolved. Constant social difficulties and peer rejection have been associated with adverse outcomes later in life (Mrug et al., 2012). In an 8-yr follow-up of children with ADHD, Mrug et al. (2012) found that symptoms of ADHD were correlated with higher levels of substance abuse and depressive symptoms. Peer rejection was positively associated with delinquency, smoking, anxiety, and social impairment, whereas friendship was associated with lower delinquency and lower depressive symptoms.

Need for Peer Involvement

Because problems with peer relationships are likely a causal factor in persistent long-term impairments, approaches that address peer relationships are important (Mrug et al., 2012). Of the currently accepted interventions targeted at social skills improvement, those involving TD peers in treatment have been shown to result in improved generalization (Ang & Hughes, 2002; DuPaul & Weyandt, 2006). This outcome was especially true when the same peers engaged in social interactions outside of treatment sessions in an environment where practice, corrections, and reinforcement could occur organically (Ang & Hughes, 2002; DuPaul & Weyandt, 2006). Incorporation of peers in parent training interventions also has demonstrated the potential to improve positive social behaviors and friendship development (Antshel, 2015).

Few studies examining the use of peers during interventions have been published, and no systematic review has been conducted to evaluate the available literature. A systematic review is warranted to clarify the effectiveness of peer inclusion during social interventions for children with ADHD. The objective of this systematic review, therefore, was to evaluate whether social skills interventions incorporating peers are effective in improving social skills in children with ADHD. The knowledge gained from the studies included in this review can be implemented in practice to improve social participation in children with ADHD while reducing peer rejection and the negative long-term outcomes resulting from social dysfunction.

Search Strategy

Intervention studies from peer-reviewed journals were selected for this systematic review on the basis of a topic and search protocol agreed on by members of the research team (the authors). Databases searched were CINAHL, PubMed, Web of Science, Google Scholar, and PsycINFO. Other sources included to ensure a comprehensive search of the literature were reference lists from published literature and hand searches of electronic journals. The aim of our review was to examine the effects of social skills interventions for children with ADHD that included some type of interaction with peers and outcome measures within the domain of occupational therapy.

Selection Criteria

To meet inclusion criteria, studies had to have participants younger than age 18 yr with any ADHD pattern, provide a social skills training intervention with peer involvement, use outcome measures within the domain of occupational therapy, and be published in English. Studies needed to use a peer as the sole or primary component at some point in the social skills intervention (search terms are listed in Table 1). Peers were defined as TD children, children with ADHD, playmates, schoolmates, or siblings who were similar in age to the children with ADHD. Initially, only publications in the past 10 yr were included, yielding 10 articles, so search criteria were expanded to the past 20 yr to provide more comprehensive coverage of the available literature, yielding 15 articles. All review databases, including the Cochrane database, were screened for systematic reviews on social skills interventions for children with ADHD that included peers to ensure that the systematic review had not already been completed.

Studies that addressed adults with ADHD and articles written in a language other than English were excluded. Additionally, studies that used participants with comorbidities or multiple conditions, such as autism spectrum disorder and conduct disorder, were excluded to prevent characteristics that were not consistent with ADHD diagnoses from affecting the results of the interventions.

Procedure

Each member of the research team performed comprehensive searches and screened the results on the basis of the inclusion criteria. From there, the team, with the guidance of additional experienced researchers, discussed and analyzed the full-text articles to determine which studies to include in this systematic review. Each article was reviewed by at least two team members to ensure accuracy of data. Disagreements were addressed by involving the rest of the research team and outside researchers until a consensus was reached (for a diagram of the flow of articles through the selection process, see Figure 1). Finally, the data were compiled into an evidence table (Table A.1 in Appendix A) and classified by level of evidence on the basis of the American Occupational Therapy Association’s (2017) Guidelines for Systematic Reviews, which are based on Sackett (1989).

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Figure 1.

Flow diagram for inclusion and exclusion of peer-reviewed studies in the systematic review.

Risk of Bias

We used Higgins et al.’s (2011) methods to assess for risk of five types of bias: selection bias, performance bias, detection bias, attrition bias, and reporting bias (Table A.2). Blinding of outcome assessment for objective outcomes occurred in 7 of the 15 studies reviewed. Six studies had high risk for attrition bias because of incomplete outcome data. None of the studies had high risk of selective reporting bias. Avoiding most of these types of bias is often impractical and problematic in studies with Level II–IV designs. In spite of these risks, we deemed the findings useful and valuable to inform the use of interventions to support the social skills development of children with ADHD. Several researchers participated in multiple studies included in this systematic review, although different participants were included in each of the studies.

Interventions Incorporating Peers Without Attention Deficit Hyperactivity Disorder

Of the 15 articles, 11 involved interventions incorporating peers without ADHD. We classified these studies into two subcategories: play-based interventions and school-based interventions.

Interventions Incorporating Peers With Attention Deficit Hyperactivity Disorder

Four studies assessed the influence of social skills interventions involving interactions with peers with ADHD in a group therapy setting. In a Level II study, Frankel et al. (1997) explored the efficacy of a social skills training intervention that involved role-play and coached play with a peer. Compared with the wait-list control group, the intervention group had significantly better scores on the teacher-reported Aggression scale of the Pupil Evaluation Inventory (PEI; p < .05; Pekarik et al., 1976) and the parent-reported Assertion and Self-Control subscales of the Social Skills Rating System (SSRS; p < .05; Gresham & Elliott, 1990). No significant difference was found between groups in performance on the Hyperactivity and Inattention scales of the PEI (p > .25).

In a Level III study, Corkum et al. (2010) examined the effectiveness of the Working Together Program, which focuses on a range of social skills including making conversation, giving introductions, making positive statements to others, speaking assertively, using courtesy words, asking for help, offering and giving help, giving and accepting criticism, joining a play activity, and negotiating conflict. The intervention included role-play and group activities with peers that targeted the social skills. Parent and teacher ratings of overall social skills on the SSRS improved significantly (ps = .05 and .04, respectively). Student self-ratings at posttreatment were slightly higher than at pretreatment but did not reach statistical significance.

Hoza et al. (2003) conducted a Level III study of the effects of a summer treatment program that consisted of a behavioral point system, peer-oriented interventions, dyadic peer interventions, sports skills training, academic remediation, participation in recreational activities, and weekly parent trainings. Each child was paired with a buddy to promote friendship skills while participating in program activities. The buddy’s antisocial behavior was significantly predictive of the children’s academic improvement and normalization. Children paired with a less antisocial buddy were viewed as more normalized (p < .001), showed more improvement in academic performance, and had higher quality friendships (p < .001). Parental compliance with the buddy system was predictive of the children’s perception of companionship (p < .001) and was marginally predictive of positive adaptation (p < .10).

In a Level III study, Hansen et al. (2000) examined the Kids Together program, which uses play therapy, role-playing, board games, and expressive arts to enhance social skills in a group therapy setting. Children practiced emotion identification, nonverbal communication, self-image and others’ perceptions of them, self-monitoring and organization, impulse control, conflict resolution, and responsibility with their peers. After the intervention, the children demonstrated significant improvements in internalizing behavior problems (p = .008) and total behavior problems (p = .011). Externalizing behaviors decreased, but not significantly (p = .051).

Strengths and Limitations

Strengths of the 15 studies include statistically significant improvements after implementation of a social skills intervention and promotion of interactions with peers. In addition, a majority of the studies (9 of 15) used multiple outcome measures, providing more data to qualify results. Involvement of parents during the intervention process demonstrated a positive influence on outcomes and increased generalizability of skills across environments. Finally, 5 studies reported maintenance of improvements at follow-ups of previously conducted intervention studies, suggesting that children with ADHD were able to maintain improved skills over time, even though outcomes were not always significantly different between postintervention and follow-up assessments.

Limitations across the 15 studies included the lack of a control group (13 studies), participant dropout (6 studies), lack of blinding of researchers scoring assessments (7 studies), small sample sizes and limited generalizability to pediatric populations (5 studies), and insufficient evidence regarding generalizability of skills across environments and long-term outcomes. In addition, discussion was limited regarding medication use and its effects on children’s social interactions during interventions. Only 1 study demonstrated Level I evidence; the remaining 14 studies provided lower evidence because randomized groups were not used, indicating that groups were not blinded to intervention, which may have influenced performance outcomes. Finally, many studies had small sample sizes (<20 total participants).

The primary limitation of this review is that the studies did not always use peers as the primary intervention. Many modalities were used in addition to peer involvement, making it difficult to clearly identify the incorporation of peers as the reason for improvements in social skills. Additionally, peers were often siblings or of the opposite gender, possibly resulting in different social expectations for the interactions. Inclusion only of studies available in English and published in peer-reviewed journals was a limitation of the study selection process.

Future Research

Further research is needed to provide additional support for incorporating peers in social skills interventions for children with ADHD. Higher level studies are needed that strive to create specific intervention guidelines and that include control groups, blinding of researchers, randomization of participants, and larger sample sizes. Future research should also include longitudinal studies to track long-term outcomes.