Impairments in social functioning are associated with childhood ADHD, and this can lead to adverse outcomes in adolescence and adulthood. Treatments for ADHD, including psychostimulants and adult-mediated interventions, have limited success in reducing social impairments linked to ADHD. The aim of this study was to assess the effects of a sibling-mediated intervention on positive and negative social behaviours of young children with ADHD. The implementation, integrity and acceptability of this intervention was also assessed for the children with ADHD as well as their typically developing siblings and their parents.
Families that met the inclusion criteria* were recruited through local paediatrician offices and community pre-schools in the United States. The study was conducted in the living room of the participants’ home, and play toys, materials and activities (no video games or electronics), based on the interests of the children and siblings, were used for the purpose of facilitating play interactions. The following screening measures were used in the study: Conners Early Childhood Rating Scale (CERS),† the ADHD Rating Scale V home version (ADHD-RS-V-HV),‡ a structured diagnostic interview and a social communications questionnaire (SCQ).§ Demographic information relating to family income, current employment, education level, race/ethnicity of parents and children, and marital status was also obtained. Social behaviours between the child with ADHD and their sibling were measured to assess the effects of the intervention. The primary dependent variable was positive social behaviour which included sharing, giving/requesting assistance and compromising; however, negative social behaviours (e.g. pushing, hitting, screaming or teasing) were also measured. The intervention phase included intervention training sessions for the sibling,|| and post-training sessions in which the social behaviours of the child with ADHD were assessed during the play interactions.
Participants (pseudonyms used throughout)
- The first sibling dyad included Elizabeth (aged 6 years, 2 months old), who had predominantly inattentive ADHD, and her sister Jessica (aged 11 years, 9 months old).
- The second sibling dyad included Robert (5 years, 1 month old), who had predominantly hyperactive/impulsive ADHD and a speech disability, and his sister Lauren (8 years, 4 months old).
- The third sibling dyad included Jake (6 years, 6 months old), who had combined ADHD and oppositional defiant disorder, and his brother Zach (10 years, 8 months old).
Child social behaviours
- Positive social behaviours: compared with baseline, all children with ADHD showed immediate increases in targeted positive social behaviours following introduction of the sibling-mediated intervention (Elizabeth: M = 2.8% [range 0.0–7%] vs 17.3% [range 6.7–33.3%]; Robert: M = 5.0% [range 0.0–13.3%] vs 19.0% [range 10.0–36.7%]; Jake: M = 0.3% [range 0.0–3.3%] vs 12.1% [range 3.3–33.3%], respectively). Visual analysis indicated a significant effect size for the comparisons between baseline and intervention phases in all three children (Tau-U = 0.9531, p < 0.001).
- Negative social behaviours: from baseline and throughout the intervention, all children continued to demonstrate negative behaviours at similar levels (Elizabeth: M = 6.7% [range 3.3–0%] vs 5.0% [range 0.0–13.3%]; Robert: M = 12.5% [range 3.3–30.0%] vs 5.0% [range 0.0–16.7%]; Jake: M = 24.3% [range 0.0–53.3%] vs 16.7% [range 0.0–36.7%], respectively). Across all three children, there was a minimal decrease in negative behaviour from baseline to the intervention phase but this effect was not significant (Tau-U = 0.1634, p = 0.061).
Sibling social behaviours
Positive social behaviours increased from baseline as a result of the intervention (Jessica: M = 9.4% [range 6.7–13.3%] vs 29.3% [range 10.0–63.3%]; Lauren: M = 11.4% [range 3.3–20.0%] vs 31.0% [range 20.0–76.7%]; Zach: M = 2.2% [range 0.0–10.0%] vs 34.2% [range 10.0–76.7%], respectively), and this effect was significant across all three siblings (Tau-U = 0.943, p < 0.001).
Maintenance of positive social behaviours as a result of the sibling-mediation intervention was assessed between the children with ADHD and their siblings (Elizabeth: 13.3% vs Jessica: 20.0%; Robert: 13.3% vs Lauren: 16.67%; Jake: 0.0% vs Zach: 0.0%). Although some children maintained their positive social behaviours, neither Jake not Zach used any of their target positive strategies during the maintenance phase of the study.
All parents indicated that they thought the intervention was acceptable, suitable and effective at improving the problem behaviour of their child with ADHD. The parents also thought that this sibling-mediated intervention would be applicable to similar children with ADHD and their families, and they agreed that they would like to see the sibling continue to use the strategies learned in the intervention. All three siblings felt that the strategies they had learned were fair, helped them and their sibling with ADHD become better playmates, and were easy to use.
This study has several study limitations. First, since the sample size is small and the participants were recruited from the same location, the generalisability of the results is limited. Second, novelty effects (e.g. children’s initial excitement to participate in the study and adult attention) may have influenced how the children played with their sibling with ADHD. Third, volunteers were used to complete the sibling adherence checklists, which may have led to experimental bias. Fourth, the variability in the siblings’ implementation of all social strategies was high which reflects the need for constructing a checklist that only includes steps fundamental to the strategy implementation. Fifth, the follow-up period of one month may have been too short to adequately assess long-term maintenance of the intervention. Sixth, the types of toys that were used during the play sessions were not recorded and this may have explained the variability in patterns of observed social behaviour. Finally, history effects cannot be ruled out and having play sessions without the use of electronics for 30 minutes may not be generalisable to typical play sessions.
The authors conclude that by using this sibling-mediated intervention, children with ADHD and their siblings increased their use of targeted positive social behaviours and these effects were maintained over time. These are preliminary data that sibling-mediated intervention can potentially improve social behaviours in children with ADHD.
*Children with ADHD must have had the following: a chronological age between 4 and 0 and 6 and 11; a sibling aged ≥7 years old (although the age gap could not have exceeded 6 years); a parent-rating score at or above the 90th percentile on ≥1 subscales pertaining to ADHD on the CERS; a diagnosis of ADHD based on the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5TM) based on parent interview; and parent-reported social difficulties
†The parent version of the CERS includes six behaviour scales containing 190 items. For this study, the inattention/hyperactivity scale was the main interest, and parent ratings were collected for both the child with ADHD and their sibling (≤6 years) to confirm the presence or absence of ADHD symptoms, respectively
‡The ADHD-RS-V-HV contains 18 items that correspond to the diagnostic symptoms of ADHD specified in DSM-5TM. Parents were asked to complete the ADHD-RS-V-HV for siblings aged ≥6 years.
§The SCQ is a 40-item screening questionnaire that is completed by parents and used to assess a child’s risk for an autism spectrum disorder. Parents were asked to complete the SCQ in both children and if either the child with ADHD or their sibling had a score ≥15 then the family was not included in the study
||The intervention training sessions lasted 15–30 minutes and were conducted twice a week. Siblings were taught three lessons: sharing; giving/asking for help; and compromising which focused on specific social behaviour strategies to help their sibling with ADHD in play or social interactions.
Daffner MS, DuPaul GJ, Kem L, et al. Enhancing social skills of young children with ADHD: effects of a sibling-mediated intervention. Behav Modif 2020; 44: 698-726.