Social Skills in Adults with AD/HD
By: the National Resource Center on AD/HD
Individuals with AD/HD 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. This information and resource sheet will:
- describe the ways in which the core symptoms of AD/HD can result in social and interpersonal relationship problems
- summarize research on children's social skills and AD/HD
- describe the implications of this research for adult AD/HD
- suggest approaches to assessing social and interpersonal difficulties in adults with AD/HD
- suggest ways to treat social and interpersonal problems in adults with AD/HD
Because very little research has been published regarding social skills in adults with AD/HD, the suggestions given in this information and resource sheet are based primarily upon sound clinical practices and upward extrapolations from the research on children's social skills and AD/HD.
Overall Impact of AD/HD on Social Interactions
It is not difficult to understand the reasons why individuals with AD/HD 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 AD/HD have difficulty with peer relationships.1 Over 25 percent of Americans experience chronic loneliness.2 One can only speculate that the figure is much higher for adults with AD/HD.
To interact effectively with others, an individual must be attentive, responsible and able to control impulsive behaviors.3 Adults with AD/HD are often inattentive and forgetful and typically lack impulse control. Because AD/HD is an "invisible disability," often unrecognized by those who may be unfamiliar with the disorder, socially inappropriate behaviors that are the result of AD/HD 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 AD/HD. Social rejection causes emotional pain in the lives of many of the children and adults who have AD/HD 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 AD/HD, who may eventually "burn out" and give up on the relationship or marriage.
Educating individuals with AD/HD, their significant others, and their friends about AD/HD 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 AD/HD needs to learn strategies to become as proficient as possible in the area of social skills. With proper assessment, treatment and education, individuals with AD/HD can learn to interact with others effectively in a way that enhances their social life.
AD/HD 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 AD/HD 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 AD/HD, 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 AD/HD and Social Skills
Researchers have found that the social challenges of children with AD/HD include disturbed relationships with their peers, difficulty making and keeping friends, and deficiencies in appropriate social behavior.4,5,6,7 Long-term outcome studies suggest that these problems continue into adolescence and adulthood and impede the social adjustment of adults with AD/HD.8
At first, these difficulties of children with AD/HD 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, AD/HD has been re-conceptualized as an impairment of the executive or controlling functions of the brain.9 It follows from this conceptualization that the social deficits of the individual with AD/HD 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 AD/HD more reliably use newly acquired social skills. Researchers have also added components to social skills training that help children with AD/HD reliably apply what they have learned in various settings. To accomplish this goal, parents and teachers are trained to prompt and reinforce children with AD/HD 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 AD/HD. 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.7,10,11,12 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.13 There is no research yet that addresses the question of whether children with AD/HD 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 AD/HD Symptoms and Social Skills
Tips for identifying subtext:14
- Look for clues in your environment to help you decipher the subtext. Be mindful of alternative possibilities. Be observant.
- Be aware of body language, tone of voice, behavior, or the look of someone's eyes to better interpret what they are saying.
- Look at a person's choice of words to better detect the subtext. ("I'd love to go" probably means yes. "If you want to" means probably not, but I'll do it.)
- Actions speak louder than words. If someone's words say one thing but their actions reveal another, it would be wise to consider that their actions might be revealing their true feelings.
- Find a guide to help you with this hidden language. Compare your understanding of reality with their understanding of reality. If there is a discrepancy, you might want to try the other person's interpretation and see what happens, especially if you usually get it wrong.
- Learn to interpret polite behavior. Polite behavior often disguises actual feelings.
- Be alert to what others are doing. Look around for clues about proper behavior, dress, seating, parking and the like.
A momentary lapse in attention may result in the adult with AD/HD missing important information in a social interaction. If a simple sentence like "Let's meet at the park at noon," becomes simply "Let's meet at noon," the listener with AD/HD misses the crucial information about the location of the meeting. The speaker may become frustrated or annoyed when the listener asks where the meeting will take place, believing that the listener intentionally wasn't paying attention and didn't value what they had to say. Or even worse, the individual with AD/HD goes to the wrong place, yielding confusion and even anger in the partner. Unfortunately, often neither the speaker nor listener realizes that important information has been missed until it is too late.
A related social skills difficulty for many with AD/HD involves missing the subtle nuances of communication. Those with AD/HD 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 AD/HD may act before thinking through their behavior. Making decisions based on an "in the moment" mentality often leads to poor decision-making. Those with AD/HD 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 AD/HD leaves little room for others who might want to participate in the conversation. Monologues rather than dialogues leave many with AD/HD 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 AD/HD. 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 AD/HD. During the course of a diagnostic evaluation for AD/HD, 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 AD/HD and reports by spouses, significant others, and friends on a comparable version of the questionnaire. The questionnaire may include the following types of items:
- Difficulty paying attention when spoken to, missing pieces of information
- Appears to ignore others
- Difficulty taking turns in conversation (tendency to interrupt frequently)
- Difficulty following through on tasks and/or responsibilities
- Failure to use proper manners
- Missed social cues
- Disorganized lifestyle
- Sharing information that is inappropriate
- Being distracted by sounds or noises
- Become flooded or overwhelmed, shutting down
- Disorganized or scattered thoughts
- Rambling or straying off topic during conversations
- Ending a conversation abruptly
Readers who wish to self-assess their social skills in depth should see the resource list at the end of this paper for further information.
When the social skill areas in need of strengthening have been identified, obtaining a referral to a therapist or coach who understands how AD/HD affects social skills is recommended (see the coaching information and resource sheet for further discussion of coaching [coming soon]). Medications are often helpful in the management of AD/HD symptoms; in many cases, an effective dose of medication will give the adult with AD/HD 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 the medication information and resource sheet for further discussion of medication [coming soon]).
As discussed earlier, social skills training for children and adolescents with AD/HD 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 AD/HD 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?14, ADD and Romance,15 or You, Your Relationship, & Your ADD 16 can provide some of that knowledge.
- Attitude. Individuals with AD/HD 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 AD/HD 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 AD/HD 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 AD/HD 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 AD/HD 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 AD/HD 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 AD/HD 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. 3 Developing or improving any of the likeability characteristics should help one's social standing.
Although AD/HD certainly brings unique challenges to social relationships, information and resources are available to help adults with AD/HD improve their social skills. Most of this information is based upon sound clinical practice and research on social skills and AD/HD in children and adolescents; there is a great need for more research on social skills and AD/HD in adults. Seek help through reading, counseling, or coaching and, above all, build and maintain social connections.
1. Gresham, F., & Elliott, S. (1993). Social skills intervention guide: Systematic approaches to social skills training. Binghamton, NY: The Haworth Press, Inc.
2. Taylor, S., Peplau, L., & Sears,Ã?Â? D. (1997). Social Psychology (9th ed.). Upper Saddle River, NJ: Prentice Hall.
3. Anderson, N.H. (1968). Likeableness ratings of 555 personality-trait words. Journal of Social Psychology, 9, 272-279.
4. Landau, S., & Moore, L.A. (1991). Social skill deficits in children with attention-deficit/ hyperactivity disorder. School Psychology Review, 20, 235-251.
5. Pelham, W.E., & Milich, R. (1984). Peer relations in children with attention deficit hyperactivity disorder. Journal of Learning Disabilities, 17, 560-567.
6. Whalen, C.K. & Henker, B. (1985). The social worlds of hyperactive (AD/HD) children. Clinical Psychology Review, 5, 447-478.
7. Pelham, W. E., & Bender, M. (1984). Peer relationships in hyperactive children: Description and treatment. In K. Gadow & I. Bailer (Eds.), Advances in learning and behavioral disabilities (Vol. 1, pp.365-436). Greenwich, CT: JAI Press.
8. Weiss, G., & Hechtman, L.T. (1986). Hyperactive children grown up. New York: Guilford Press.
9. Barkley, R. (1997). ADHD and the Nature of Self-Control. New York: Guilford Press.
10. Pfiffner, L.J., & McBurnett, K. (1997). Social skills training with parent generalization: Treatment effects for children with attention deficit disorder. Journal of Consulting & Clinical Psychology, 65, 749-757.
11. Antshel, K.M., & Remer, R. (2003). Social skills training in children with attention deficit hyperactivity disorder: A randomized controlled clinical trial. Journal of Clinical Child & Adolescent Psychology, 32, 153-165.
12. Hinshaw, S.P., Henker, B., & Whalen, C.K. (1984). Cognitive-behavioral and pharmacologic interventions for hyperactive boys: Comparative and combined effects. Journal of Consulting & Clinical Psychology, 52, 739-749.
13. Pelham, W.E., & Hoza, B. (1996). Intensive treatment: A summer treatment program for children with ADHD. In E. Hibbs & P. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 311-340). New York: American Psychological Association Press.
14. Novotni, M. (2000). What Does Everybody Know That I Don't? Plantation, FL: Specialty Press, Inc.
15. Halverstadt, J.C. (1998). A.D.D. & romance: Finding fulfillment in love, sex, and relationships. Dallas, TX: Taylor Publishing Company.
16. Bell, M.T. (2002). You, your relationship, and your ADD. Oakland, CA: New Harbinger Publishing Company.
Novotni, M. (2000). What Does Everybody Know That I Don't?. Plantation, FL: Specialty Press, Inc.
Halverstadt, J.C. (1998). A.D.D. & romance: Finding fulfillment in love, sex, and relationships. Dallas, TX: Taylor Publishing Company.
Bell, M.T. (2002). You, your relationship, and your ADD. Oakland, CA: New Harbinger Publishing Company.
This information & resource sheet was developed for the National Resource Center on AD/HD under CDC grant R04/CCR321831-01-1 by the Attention Deficit Disorder Association. It was approved by CHADD's Professional Advisory Board in August 2003. Permission is hereby granted to reproduce this document in its entirety as long as the NRC name, contact information, and logo are included.
For further information about AD/HD or CHADD, please contact:
National Resource Center on AD/HD
Children and Adults with Attention-Deficit/Hyperactivity Disorder
8181 Professional Place, Suite 150
Landover, MD 20785
Please also visit the CHADD Website at http://www.chadd.org/.