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How did you make your first friend? If someone were to ask you this question, where would you begin? As children we often aren’t aware of the skills required to commence a friendship – yet for most, friendships are such an integral of childhood, as well as development. Building relationships is a complex process of interpreting and reacting to social situations, and can be challenging for anyone, especially a child. Whether it is in the classroom, at home, or on the playground children are continuously thrown into social situations and often struggle to understand the social mores, which can have ramifications on relationships with parents, teachers and peers.
For some children making friends can be a struggle, and failing to adapt to the normative patterns of peer behavior may result in greater intrapersonal conflict and rejection by peers. One population that often struggles socially is those with Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a childhood-onset neurodevelopmental disorder characterized by symptoms of inattention and impulsivity/hyperactivity that interfere with functioning or development. Children with ADHD often have more difficulty with social skills and peer relations. Current research has suggested that Theory of Mind (ToM) may partially explain some of the social difficulties for children with ADHD. ToM is a skill that entails gaining another person’s perspective actions through an understanding of their mental state. Previous research has identified that poor sleep is negatively associated with poor performance on tasks for Theory of Mind and other executive functioning skills in typically developing children. As 50-80% of children with ADHD experiencing sleep difficulties, the current research seeks to identify if sleep quality has an impact on theory of mind in children with ADHD.
Attention Deficit/Hyperactivity Disorder (ADHD) is a childhood-onset neurodevelopmental disorder characterized by symptoms of inattention and impulsivity and/or hyperactivity that are interfering with functioning or development with these problems often persisting into adulthood. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ADHD has an incidence of 5% of the school-aged population making it one of the most common psychological disorders in childhood.
Primary signs of ADHD are often noted by parents when the child is a toddler, by displays of excessive motor activity. However, it is often hard to distinguish symptoms from typical development, at least until early school years. ADHD begins in childhood and symptoms must be present before the age of 12 years for a clinical diagnosis. Specific symptoms that are characteristic to the disorder include: Inattention which is characterized by getting off task and difficulty remaining focused – something that becomes more impairing and noticeable by teachers and parents alike. Hyperactivity; which refers to excessive motor activity when not appropriate this can appear as excessive fidgeting, tapping or talking; and impulsivity which refers to acting without thinking – something that can put the individual or others at risk.
The DSM-5 provides specific criteria examples of inattention and hyperactivity/ impulsivity of which the child must have at least six or more present for at least six months to a degree that not only is not in line with what is expected at their developmental age, but that also has a significant negative impact on social and academic or occupational activities. For children over the age of 17, the criterion decreases to requiring five or more of the listed symptoms.
There are three classifications of ADHD, the first is Combined presentation where six or more symptoms of both inattention and hyperactivity/ impulsivity are present for a time period greater than six months. The second presentation is Inattentive, where greater than six symptoms of inattention are present but fewer than six hyperactive/ impulsive are present. Finally, Hyperactive/ impulsive presentation requires greater than six symptoms of hyperactive/ impulsive but fewer than six for the inattentive symptoms. Symptoms must be present in more than one setting, such as both home and school; however, there is acknowledgment that context can influence how, and which symptoms are being displayed. Further everyday consequences of ADHD include struggling academically and socially, something that can persist into adulthood and can be reflected in difficulty finding and maintaining employment as well as greater interpersonal conflict.
From an epidemiological perspective, ADHD is much more frequent in boys than girls with a ratio of approximately 2:1 in children. Comorbidity with other disorders is extremely prevalent, including Autism Spectrum Disorder, Oppositional Defiant Disorder, Conduct Disorder, Specific learning disorder, along with others. Developmental problems are also highly comorbid, including Developmental Coordination Disorder (DCD) which increases the risk of childhood obesity and is characterized by delayed development of motor skills, or a difficulty coordinating movements.
For now, the primary treatment of impairing symptoms of ADHD in school-aged children is pharmacotherapy. There are multiple advantages to this course of treatment that targets the neurobiological component of the disorder. Stimulant medication increases dopamine and norepinephrine in the prefrontal cortex as well as enhances activity in the central nervous system. As a result, there has been noted decreases in aggressive and impulsive behaviours and an increase in alertness. However, there are also some negative side-effects that can come along with pharmaceutical treatments such as a loss of appetite, difficulty sleeping and gastrointestinal problems. Furthermore, less frequent but more severe side effects can occur such as cardiac problems and the stunting of the child’s growth. The use of stimulants often results in reduction of symptoms however there are continued concerns of the harmful long-term effects of stimulant medication. ADHD has been further associated with a variety of neurodevelopmental deficits including impaired executive functioning skills as well as social emotional functioning, working memory tasks, interpersonal difficulties and persistent sleep problems.
Children with ADHD have been found to struggle in social environments, with 52-82% reporting social difficulties. Social impairments are documented by parents, teachers and peers as early as preschool aged. Further, children with ADHD are reported to have fewer reciprocal friendships than their typically developing peers. Despite increases in research surrounding ADHD, the developmental mechanisms responsible for the impairments in social functioning, continue to be poorly understood. The long-term consequences of the peer rejection include substance abuse, school dropout, delinquency, and academic problems in school aged children and mature into difficulty maintaining a job and higher divorce rates for adults with ADHD.
The social deficits in children with ADHD have been attributed to impulsivity, inattention, a lack of social knowledge, and deficits in social cognition. Social cognition is the ability to understand the thoughts and feelings of others, in order to successfully engage in social interactions. This overarching process includes the ability to interpret social cues, body language, prosody as well as the skill of perspective taking also called Theory of Mind (ToM). For children with ADHD there is deficient processing at each stage of the model of social problem solving first erected by Dodge in 1986. This information-processing model outlines six processing steps to social problem solving, of which the first two steps are responsible for social cognition. The first step is the encoding of cues and the second step is the interpretation of cues. This is followed by the clarification of goals, responses access or construction, response decision and finally behavioural enactment. For children with ADHD, Crick and Dodge (1994) theorize that the first two steps of social information processing are prejudiced, and thus the entire social interaction can be misdirected. Children with ADHD are often lacking the social cognitive skill of perspective taking which impedes the successful encoding and interpreting of social cues.
Although the route of the deficits in social cognition is not fully understood, as a neurodevelopmental disorder, ADHD is associated with a slight impairment in the growth and development of the brain. Neuroimaging studies have shown that this cognitive process of encoding and interpreting a person’s social cues is processed through the complex network that involves the prefrontal cortex. ADHD has been shown to have dysfunction in the prefrontal cortex which thus leads to further difficulties in social cognition. Children and adults with ADHD often suffer from social and interpersonal problems which may be the result of hyperactive, impulsive or inattentive behaviours but additionally, may be the result of social cognitive deficits as a result of neurodevelopmental brain dysfunction.
Apart from generalized social deficits, little is known as to where the breakdown in social cognition occurs for children with ADHD, and which part of encoding and perception precisely is responsible. Current research has suggested that deficits in Theory of Mind (ToM) may partially explain some of the social difficulties for children with ADHD.
Theory of Mind (ToM) is the cognitive skill of being able to understand the beliefs, desires, thoughts and intentions of others. This skill entails the ability to gain perspective of another person’s actions through an understanding of their mental state. Originally labeled as a narrow construct, ToM is now defined as the ability to comprehend that others have their own thoughts, feelings, desires and motivations that are different than one’s own and can be used to predict or explain behaviour. Children with Attention Deficit Hyperactivity Disorder (ADHD) often experience challenges in social situations, including difficulty applying ToM in a social context which can impede peer interactions.
The development of ToM is a normal part of sociocognitive development that occurs between the ages of two and six years and continues to develop throughout early childhood and adolescence. ToM can be demonstrated in a laboratory setting through a false belief task: a child makes the transition from identifying what an object actually is, to what another individual might think that object is, requiring the understanding of their knowledge for the other person’s individual mental state as different from their own. At the beginning, most two to three year olds will fail false belief tasks, but by the age of five, most typically developing children are able to complete false belief tasks. Despite this, children who are able to demonstrate the conceptual theory of ToM in a laboratory setting may not necessarily be competent in applying this skill in a social context.
This ability to apply perspective taking in social situations continues to develop as children interact more and more with their peers, particularly through their early elementary years, culminating in what is considered second order understanding. Second order understanding is the ability to understand what a person feels or believes regarding another person’s feelings or beliefs. Advanced ToM skills are related to understanding the causal associations between desires and emotions with respect to their influence on physical and mental traits. Although ToM is considered a neurocognitive skill that occurs in normal development, McAlister and Peterson (2013) argue that faster development of ToM is linked to the richness of social experiences at home (e.g. number of siblings, parent involvement) or general life experience. Parents who model perspective-taking by referring to their own mental states (thoughts, desires and feelings) can help develop ToM in their child.
The development of ToM in children in an applied setting is demonstrated as a child begins to refer to their own mental states (thoughts, feelings etc.) in a social context. Once a child enters school and begins to interact with a peer group, they are given opportunities to learn and practice the integration of ToM within a social setting on a day-to-day basis. These early schooling experiences aid children in adapting to new social situations, understanding the perspective of others which directly utilizes ToM. Children with low ToM have difficulty navigating social situations, something that may have long-term implications for their ability to positively integrate into their social and academic settings. This critical period in social development is heavily reliant on the development of cognitive skills.
Examining the building block of ToM, there are major changes in the development of social understanding in preschool children. Research has strongly associated the development of socially appropriate behaviours as being dependent on the development of cognitive abilities. These cognitive abilities include not only ToM but also Executive Functioning (EF), something else that is maturing during this same period of development.
EF is a skill of higher order cognitive control which is required for goal-directed behaviour. It is the ability to control one’s cognition, attention and behaviour through cognitive flexibility and shifting and entails skills such as inhibitory control and working memory. EF has been identified as having a strong to moderate correlation with ToM skills. The relationship between ToM and EF is bi-directional in nature; however, there is a stronger relationship between early EF development predicting later ToM development, suggesting that in order for ToM to develop, EF is required. This relationship between EF and ToM suggests that for a child to be able to understand mental states and perspective-taking, they must be able to demonstrate higher order cognitive control in terms of mental set shifting, and the maintenance and manipulation on of information.
The developmental progress of sociocognitive skills becomes very apparent within a social context. ToM is related to social competence as children are able to interpret and predict the behaviour of others as well as be able to consider the beliefs and desires of others different than their own. Further, more advanced ToM skills are correlated to greater social competence and prosocial behaviour. This relationship between social skills and ToM can be explained through the development and coordination of perspective taking and the ability to understand predict other’s thoughts and feelings in a social setting.
The development of ToM and EF is associated with an increase in cognitive control, and self-monitoring actions can help increase the insight into other people’s intentions and behaviours. ToM is a necessary skill for children to integrate into social groups, as well as navigate social situations and ToM is a positive predictor of socializing skills. The ability to navigate social interactions helps the development of appropriate behaviors which contributes to positive peer relationships, and academic success. Further, social interactions play a significant role in the development of ToM, indicating a directional relationship between ToM and social competence. Such findings suggest that children that lack ToM skills and as a consequence, are less able to form meaningful peer relations, will fall further behind in terms of social competence.
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