Lee et al., 2012

Psychiatry Research xxx (2012) xxx–xxx

PSY-07154; No of Pages 7

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Psychiatry Research

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Association of comorbid anxiety with social functioning in school-age children withand without attention-deficit/hyperactivity disorder (ADHD)☆

Steve S. Lee a,⁎, Avital E. Falk a, Vincent P. Aguirre b

a Department of Psychology, University of California, Los Angeles (UCLA), 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, USAb Department of Psychology, California State University, Fresno, Fresno, CA, USA

☆ This work was supported by NIH grant 1R03AA020⁎ Corresponding author at: Department of Psycholog

951563, Los Angeles, CA 90095-1563, USA. Fax: +1 310E-mail address: [email protected] (S.S. Lee).

0165-1781/$ – see front matter © 2012 Published by Eldoi:10.1016/j.psychres.2012.01.018

Please cite this article as: Lee, S.S., et al., Aattention-deficit/hyperactivity disorder (AD

a b s t r a c t
a r t i c l e i n f o
Article history:Received 7 April 2011Received in revised form 12 January 2012Accepted 16 January 2012Available online xxxx

Keywords:ADHDAnxietySocial functioning

Although attention-deficit/hyperactivity disorder (ADHD) is frequently comorbid with disruptive behaviordisorders, less is known about ADHD and comorbid anxiety. To improve understanding about the associationof anxiety and social functioning, we studied 223 6 to 9 year-old ethnically diverse boys and girls (M=7.4 years)with andwithout ADHD. According to parents, childrenwith ADHD and anxiety (n=46) and ADHD only (n=71)were consistently less socially competent than comparison children (i.e., no anxiety and ADHD: n=80) and chil-drenwith anxiety only (n=26),whodid not differ fromone another. A similar pattern emerged for teacher ratingswhere youth with ADHD only and ADHDwith anxiety exhibited the most social problems, but they did not differfrom each other. These data suggest that comorbid anxiety does not exacerbate social dysfunction among 6 to9 year-old children with ADHD. We consider findings within a developmental psychopathology framework tofurther understand social development in children with ADHD and anxiety.

© 2012 Published by Elsevier Ireland Ltd.

1. Introduction

Attention-deficit/hyperactivity disorder (ADHD) is characterized byan early onset of developmentally aberrant and impairing levels ofinattentive-disorganized behavior and/or hyperactivity–impulsivity.ADHD prospectively predicts substandard academic achievement,neuropsychological dysfunction, occupational instability, and substanceproblems (Biederman et al., 2006; Lee et al., 2008;Owens et al., 2009; Leeet al., 2011). Even children who were intensively treated for 14 months(i.e., careful medication evaluation, integrated parent- and school-based interventions) andwhoseADHDsymptoms improved significantly,showed continued impairment into adolescence (Molina et al.,2008). That is, the clinical significance of ADHD transcends inattention/hyperactivity because ADHD persistently compromises socio-emotionaland behavioral functioning over time.

Children with ADHD consistently have higher rates of comorbiditythan typically developing children. The meta-analysis of Angold et al.(1999) estimated that children with ADHD were 11 times more likelyto have oppositional defiant disorder (ODD) or conduct disorder (CD)than non-ADHD youth and girls with ADHD had more comorbiditywith ODD and CD in childhood and in adolescence than girls withoutADHD (Hinshaw, 2002; Hinshaw et al., 2006). Although comorbidODD/CD has been integrated into models of ADHD, there is a gap inknowledge with respect to the nature of ADHD and comorbid anxiety,

186-01 to Steve S. Lee.y, UCLA, 1285 Franz Hall, Box206 5895.

sevier Ireland Ltd.

ssociation of comorbid anxieHD), Psychiatry Res. (2012)

despite the fact that anxiety frequently co-occurswith ADHD (Biedermanet al., 1991; Schatz and Rostain, 2006). ADHD probands were three timesmore likely to have an anxiety disorder than children without ADHD(Angold et al., 1999) and 33% of the 579 children with combined typeADHD had an anxiety disorder in the Multimodal Treatment Study(MTA) of ADHD (MTA Cooperative Group, 1999). In pediatric samples,ADHD probands were more frequently diagnosed with anxiety thannon-ADHD youth (Bowen et al., 2008) and the proportion of ADHDprobands (27%) exceeded non-ADHD youth (5%) in the prevalenceof multiple anxiety disorders (Spencer et al., 1999). Children withADHD and anxiety also show divergent patterns of association, includingsluggish cognitive tempo and response inhibition than children withADHD only (Pliszka, 1989, 1992). In the MTA study, children withADHD and comorbid anxiety responded more favorably to behavioraltreatment than ADHD children without anxiety (Jensen et al., 2001).Thus, by virtue of its prevalence and evidence that this group of childrenis empirically distinct, further research on children with ADHD andcomorbid anxiety is warranted.

Social dysfunction in children with ADHD is highly intractable tointervention and it independently predicts and partially mediateslong-term negative outcomes, including later CD and substance prob-lems (Greene et al., 1997; Pelham et al., 2005). There is consistentevidence that children with ADHD are not only more rejected bypeers (Blachman and Hinshaw, 2002; Hoza et al., 2005), they are per-ceived by teachers and peers as being less socially competent (DuPaulet al., 2004), they are prone to positively biased self-perceptions (Hozaet al., 2002), and they have fewer friendships (i.e., reciprocal dyadic re-lationship) (Parker and Asher, 1987; Gresham et al., 1998). Furtherunderscoring its intractability, social dysfunction among children with

ty with social functioning in school-age children with and without, doi:10.1016/j.psychres.2012.01.018

http://dx.doi.org/10.1016/j.psychres.2012.01.018

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Table 1Demographic and clinical characteristics of diagnostic groups.

Variable Non-ADHD(n=80)

Anxiety only(n=26)

ADHD only(n=71)

Anxiety and ADHD(n=46)

F/Waldχ²

Age 7.41 (1.02) 7.62 (1.02) 7.30 (1.13) 7.20 (1.09) 3.07Male (%) 65 65 70 78 2.63Caucasian(%)

59 57 48 62 2.11

WISCa

FSIQb108.52(15.32)

108.83(14.75)

103.53(15.06)

107.74 (13.53) 1.43

a WISC-IV=Wechsler Intelligence Scale for Children, fourth edition.b FSIQ=IQ.⁎ pb0.05.

2 S.S. Lee et al. / Psychiatry Research xxx (2012) xxx–xxx

ADHD often persists into adolescence, even if ADHD symptoms improve(Lee et al., 2008; Owens et al., 2009). Thus, early ADHD catalyzes socialdysfunction that is often more chronic than the constituent symptomsof ADHD.

Despite evidence that social functioning in children with ADHD andcomorbid aggression is significantly worse than children with ADHDonly, relatively little is known aboutwhether comorbid anxiety similarlyexacerbates social functioning in children with ADHD (Nijmeijer et al.,2008). Hoza et al. (2005) observed that studies of social functioning in“children with both ADHD and anxiety [have] not often (if ever) beenstudied” (p. 11). Similarly, the review of Nijmeijer et al. (2008) onADHD and social dysfunction prioritized comorbid ODD/CD and perva-sive developmental disorders rather than anxiety. In a recent study ofboys and girls with and without ADHD, child anxiety inversely pre-dicted parent- and teacher-ratings of peer acceptance and social skillsbeyond ADHD and ODD, but not according to sociometric nominations(Mikami et al., 2011). Karustis et al. (2000) found that child- andparent-rated anxiety significantly predicted multi-informant ratings ofsocial problems in a study of school-age children with ADHD. An inves-tigation of 190 children with ADHD and anxiety, anxiety only, ADHDonly, or controls found that comorbid ADHD and anxiety children wereless socially competent according to parent and youth self-report thaneach of the other three groups (Bowen et al., 2008). However, thisstudy utilized a very large age range of participants (8–17) and limitedcomorbid anxiety to panic disorder, generalized anxiety disorder, andseparation anxiety disorder, in addition to social and school phobia.Further, potential age effects were not accommodated (e.g., covariate,age×predictor interactions), a particularly important considerationgiven reliable changes in ADHD over time (Lee et al., 2008). Moreover,important fear-based anxiety disorders (i.e., obsessive compulsivedisorder (OCD) and post traumatic stress disorder (PTSD)) were not ana-lyzed. Among a subgroup of childrenwith ADHD from theMTA study, co-morbid anxiety did not predict social functioning estimated fromsociometric interviews (Hoza et al., 2005). Overall, despite an emergingliterature,methodological differences demand that additional approachesare required to fully discern critical associations among ADHD, anxiety,and social functioning. For example, designs that utilize a more narrowage range of participants would provide an important advance bycircumscribing significant age-related changes in ADHD, anxiety, andsocial functioning. Similarly, rather than use variable-based approaches(Karustis et al., 2000; Mikami et al., 2011), where clinical significance isnot readily discerned, studies that utilize diagnostic groups (to comple-ment variable-based approaches)would ensure the clinical relevance ofkey constructs (e.g., elevated symptoms plus impairment).

In sum, there is amodest literature on the anxiety and social function-ing in children with ADHD with studies to date characterized by impor-tant methodological differences (e.g., age range of participants, type ofanxiety disorders ascertained, use of clinical groups versus dimensionalvariables). To characterize the precise contribution of anxiety, ADHD,and their comorbidity on identical measures of social functioning (e.g.,social problems, negative social preference, social skills) across multipleinformants (i.e., parent and teacher), we rigorously ascertained a largeand ethnically diverse sample of school-age boys and girlswith andwith-out ADHD: (1) ADHD and anxiety (ADHD+Anx) (n=46); (2) ADHDonly (n=71), (3) anxiety only (n=26); and (4) comparison youthwith-out ADHD and anxiety (n=80). We hypothesized that the ADHD+Anxand ADHD only groups would be more socially compromised thanchildren with anxiety only and comparison youth. In light of the modestliterature, we did not make any directional hypotheses about differencesbetween ADHD+Anx youth versus children with ADHD only.

2. Methods

2.1. Participants

Two hundred twenty-three ethnically diverse [n=124 Caucasian; n=18 African-American; n=22 Hispanic; n=8 Asian; n=44 Mixed; n=7 Other] 6 to 9 year-old

Please cite this article as: Lee, S.S., et al., Association of comorbid anxieattention-deficit/hyperactivity disorder (ADHD), Psychiatry Res. (2012)

children (M=7.4, S.D.=1.1) with (n=117) and without ADHD (n=106) wererecruited through presentations to ADHD self-help groups, referrals from mentalhealth clinics, and advertisements sent to clinical service providers, pediatric offices,and local elementary schools (Table 1). To be eligible for the study, all participantswere required to have a full scale intelligence quotient (IQ) greater than 70, to livewith one biological parent at least half of the time, and to be fluent in English.Exclusion criteria for all participants included a previous diagnosis of an autismspectrum disorder, seizure disorder, or neurological disorder that prevented full par-ticipation in the study.

ADHD diagnostic status (i.e., ADHD versus non-ADHD) was ascertained according tothe Diagnostic Interview Schedule for Children, fourth edition (DISC-IV) (Shaffer et al.,2000), a fully structured interview with parents keyed to all Diagnostic and StatisticalManual of Mental Disorders, 4th edition (DSM-IV) criteria (i.e., age of onset, symptompersistence, cross-situational presence). Families of children with and without ADHDcompleted identical screening and testing procedures. To avoid recruiting a non-ADHDcomparison group that may have exaggerated the severity of psychopathology in ADHDprobands, children who met diagnostic criteria for any disorder other than ADHD wereplaced in the non-ADHD group. This conservative approach, which is fairly stringentgiven that it would likely increase the similarity between the ADHD and non-ADHDcomparison group, has been used in similar studies of childhood ADHD (Lahey et al.,1998; Hinshaw, 2002).

2.2. Procedures

To determine eligibility, parents completed a telephone screening and eligiblefamilies who were interested in participating were mailed rating scales. After obtainingparental consent, we mailed the child's primary teacher parallel rating scales. Familieswere then invited to our laboratory for in-person assessments. Approximately 85% ofchildren were unmedicated during the lab visit. Following parental consent and childassent, parents completed a structured diagnostic interview and rating scales whilechildren completed tests of cognitive ability, academic achievement, and neuropsycho-logical functioning. Whenever possible, children were assessed without medication.Similarly, parents and teachers were asked to complete rating scales based on thechild's unmedicated behavior. Interviewers consisted mostly of Ph.D. students in clinicalpsychology who had completed graduate coursework in psychological assessment aswell as several BA-level students. All interviewers underwent 2 days of intensive training,led by thefirst author, to standardize administration ofmeasures and interviews. All inter-viewers were also blind to the child's diagnostic status and the Institutional Review Boardapproved all study procedures.

2.3. Measures

2.3.1. Diagnostic Interview Schedule for Children — fourth edition (DISC-IV; Shaffer et al.,2000)

This computer-administered, fully structured parent interview ascertained thepresence of DSM-IV childhood mental disorders. All DSM-IV criteria (e.g., persistence,age of onset, impairment) were evaluated for each disorder (e.g., anxiety, ADHD). TheDISC-IV is widely used, extensively validated, and psychometrically sound. Test–retestreliability for ADHD from the DISC ranged from 0.51 to 0.64 in the DSM-IV field trials(Lahey et al., 1994). A recent review also provided evidence of the DISC-IV's strongpsychometric properties including predictive validity and sensitivity to treatment ef-fects (Pelham et al., 2005). We ascertained eight anxiety disorders with the DISC-IV:social phobia (n=6, 2.7%), obsessive compulsive disorder (OCD) (n=6; 2.7%), gener-alized anxiety disorder (GAD) (n=7; 3.1%), post-traumatic stress disorder (PTSD)(n=3; 1.3%), separation anxiety disorder (SAD) (n=14; 6.3%), specific phobia(n=55; 16.1%), agoraphobia (n=1; b1%), and panic disorder (0.0%). Children wereconsidered to have an anxiety disorder if they met full diagnostic criteria for at leastone of the eight anxiety disorders we assessed for using the DISC.

2.3.2. Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) for ages 6–18(Achenbach and Rescorla, 2001)

The CBCL and TRF are both 113-item rating scales of child psychopathology, com-petence, and impairment. Each item is scored on a 0–2 metric. Based on normative data



3S.S. Lee et al. / Psychiatry Research xxx (2012) xxx–xxx

from 3210 6–18 year-old children, the CBCL and TRF yield developmentally sensitivescales of externalizing and internalizing problems as well as competence and impairment.We specifically focused on the social problems narrow band scale (alpha=0.82 and 0.79for the CBCL and TRF, respectively), which consists of 11 items including “Complains ofloneliness” and “Doesn't get along with other kids.”

2.3.3. Dishion Social Preference Scale (Dishion, 1990)This is a three-item (five-point metric) measure of peer acceptance, rejection, and

being ignored with parallel parent and teacher forms. Social preference was predictedfrom initial sociometric ratings and was significantly correlated with antisocial behavior(ASB), depression, and deviant peer association (rs=0.60, 0.30, and 0.51, respectively)(Dishion, 1990). We subtracted the reject from the accept rating and then reverse scoredthe difference to estimate negative social preference and to approximate Poisson distribu-tions for statistical analyses (alpha=0.78). This method has been sensitive to groupdifferences in other studies of ADHD and social preference (e.g., Lahey et al., 2004).

2.3.4. Impairment Rating Scale (IRS; Fabiano et al., 2006)A total of five items were completed by parents and teachers to assess children's

need for treatment due to problems in relationships with playmates, siblings, academicprogress, self-esteem, and family using a seven point metric ranging from “No problem/definitely does not need treatment or special services” to “Extreme problem/definitelyneeds treatment or special services.”We utilized a single item evaluating how the child'sproblems affected his/her relationship with peers. Previous studies reported adequate1 year test–retest stability with different teachers rating the same child (r=0.39 to0.63) and acceptable concurrent validity with other impairment scales (Fabiano et al.,2006).

2.3.5. Social Skills Rating System—Total Social Skills Scale (SSRS; Gresham and Elliott,1990)

Across 20 items, parents and teachers rated children's cooperation, self-control, asser-tiveness, and responsibility. Based on the normative sample, we analyzed designations ofsocial skill as being: below average, average, or above average. The SSRS total score hasbeen used in similar ADHD samples (Lee et al., 2008; Owens et al., 2009) and it demon-strated good discriminant validity (i.e., children with versus without behavior problems)(Antshel and Remer, 2003).

2.4. Data analytic procedures

To review, our goalwas to evaluate social functioning in four groups of children basedon their ADHDand anxiety diagnostic status. To supplement the frequent use of “variable-centered” strategies in clinical research, our approach reflected an increasing recognitionon the value of person-centeredmethods indevelopmental psychopathology (Bergmanetal., 2006). We examined the following four groups (note that some children had morethan one anxiety disorder): (1) ADHD plus anxiety (n=46; 13.0% OCD, 6.5% PTSD,19.6% SAD, 8.7% social phobia, 15.2% GAD, 78.3% specific phobia), (2) ADHD only(n=71), (3) anxiety only (n=26; 3.8% agoraphobia, 19.2% SAD, 7.7% social phobia,73.1% specific phobia), and (4) comparison youth (n=80). Eleven percent (n=9) and1% (n=1) of comparison youth (i.e., neither anxiety nor ADHD) met diagnostic criteriafor ODD and major depression, respectively, according to the DISC. No other diagnosesweremade in this group. First, age and sex, but not race-ethnicity, were correlated signif-icantly with outcome (see Table 2). Consequently, we included age and sex as covariatesfor all relevant models. Race-ethnicity was correlated with the SSRS and it was alsoincluded as a covariate. Further, medication status of the child was not covaried inour analysis given that medication status is likely to reflect severity of psychopathology

Table 2Correlation matrix for demographic, predictor, and outcome variables.

Age Sex Race ADHDstatus

Anxietystatus

CBCL socialproblems

Age 1Sex 0.06 1Race −0.02 −0.04 1ADHD status −0.09 −0.10 −0.03 1Anxiety status −0.01 −0.06 −0.05 0.16⁎ 1CBCL social problems 0.16⁎ −0.12 −0.07 0.44⁎⁎ 0.20⁎⁎ 1Neg. social pref. 0.04 −0.16⁎ 0.02 0.36⁎⁎ 0.09 0.50⁎⁎

SSRS (P) 0.03 0.01 −0.09 −0.35⁎⁎ −0.11 −0.49⁎⁎

IRS (P) −0.05 −0.01 −0.03 0.26⁎⁎ 0.02 0.56⁎⁎

TRF social problems −0.13 −0.09 −0.11 0.13 −0.01 0.44⁎⁎

Neg. social pref. (T) −0.13 −0.01 −0.01 0.14 −0.01 0.36⁎⁎

SSRS (T) 0.03 0.03 −0.22⁎ −0.26⁎⁎ −0.01 −0.26⁎⁎

IRS (T) −0.14 −0.12 −0.01 0.17⁎ 0.02 0.46⁎⁎

Note: ADHD=attention-deficit/hyperactivity disorder. CBCL=Child Behavior Checklist.TRF=Teacher Report Form. (T) denotes teacher version of indicated measure. ADHD statuor absence of an anxiety disorder.⁎ pb0.05.⁎⁎ pb0.01.


rather than actual treatment effects due to the intervention selection bias (Larzelereet al., 2004). That is, without random assignment, treatment effects cannot be rigor-ously discerned. To accommodate the skewed distributions of several social function-ing measures, we utilized Poisson regression using generalized estimating equationsand ordinal logistic regression for the SSRS. For example, skewness statistics included 1.1for the parent Dishion and 1.8 for the TRF. Third, to evaluate the overall model fit for eachsocial functioning measure, we entered age and sex as covariates and entered diagnosticgroup status (ADHD plus anxiety, ADHD only, anxiety only, comparison youth) as amain effect.

3. Results

3.1. Social problems

Controlling for age and sex, we observed a significant main effectfor diagnostic group and CBCL social problems (Wald χ2=102.06,d.f.=3, pb0.001). Pairwise comparisons among the four diagnosticgroups suggested that comparison youth (B=−0.98, SE=0.11,pb0.001) and children with anxiety only (B=−0.82, SE=0.14,pb0.001) had significantly fewer social problems than children withADHD and comorbid anxiety. Both comparison youth and children withanxiety only had fewer social problems than children with ADHD only(B=−0.73, SE=0.10, pb0.001 and B=−0.58, SE=0.14, pb0.001,respectively). The ADHD+Anx group had significantly more socialproblems than children with ADHD only (B=−0.25, SE=0.09,pb0.01) (see Table 3).

TRF social problems were also sensitive to diagnostic group differ-ences (Wald χ2=11.76, d.f.=3, pb0.01) whereby children withADHD only had significantly more social problems than children withanxiety only (B=0.40, SE=0.16, p=0.01) and children with ADHDand comorbid anxiety had more social problems than comparisonsand anxiety only children (B=−0.27, SE=0.12, pb0.05 and B=0.53,SE=0.17, pb0.01, respectively) (Table 3). No other significant pairwisecomparisons were observed among the four diagnostic groups.

3.2. Negative social preference

We observed a significant main effect of diagnostic group for parentrated negative social preference (Wald χ2=43.62, d.f.=3, pb0.001).Post-hoc tests revealed that comparison youth (B=−1.04, SE=0.19,pb0.001) and children with anxiety only (B=−1.17, SE=0.29,pb0.001) were less negatively regarded than the ADHD+Anx groupand less negatively regarded than ADHD only youth (B=−0.61,SE=0.13, pb0.001 and B=−0.57, SE=0.21, pb0.01, respectively).Children with ADHD only were similarly negatively regarded by peersas ADHD+Anx youth (B=0.11, SE=0.14, p=0.42) (Table 2).

Neg. socialpref.

SSRS (P) IRS TRF socialproblems

Neg. socialpref. (T)

SSRS (T) IRS (T)

1−0.39⁎⁎ 10.45⁎⁎ −0.48⁎⁎ 10.29⁎⁎ −0.29⁎⁎ 0.33⁎⁎ 10.36⁎⁎ −0.32⁎⁎ 0.28⁎⁎ 0.69⁎⁎ 1−0.23⁎⁎ 0.25⁎⁎ −0.31⁎⁎ −0.49⁎⁎ −0.52⁎⁎ 10.44⁎⁎ −0.37⁎⁎ 0.44⁎⁎ 0.63⁎⁎ 0.66⁎⁎ −0.54⁎⁎ 1

SSRS=Social Skills Rating System. Neg. social pref.=negative social preference.s indicates presence or absence of ADHD diagnosis. Anxiety status indicated presence



Table 3Parent-rated social functioning by diagnostic group.

Variable A. Non-ADHD(n=80)

B. Anxiety only(n=26)

C. ADHD only(n=71)

D. ADHD+anxiety(n=46)

Walda χ² Contrasts

CBCL social problems 2.02 (0.17) 2.36 (0.30) 4.19 (0.27) 5.38 (0.36) 102.06⁎⁎⁎ A, BbCbDNegative social preference 0.62 (0.09) 0.54 (0.15) 1.53 (0.16) 1.74 (0.21) 43.63⁎⁎⁎ A, BbC, DImpairment Rating Scale 1.51 (0.15) 1.57 (0.30) 2.77 (0.24) 2.47 (0.27) 24.81⁎⁎⁎ A, BbC, DSocial Skills Rating System 23.75⁎⁎⁎

Non-ADHDb – 2.08 2.99 8.77⁎⁎

Anxiety onlyb – – 6.36⁎⁎ 11.43⁎⁎⁎

ADHD onlyb – – – 1.88

a Significance based on Poisson regression for dimensional outcomes and logistic regression for Social Skills Rating Scale ordinal data, controlling age and sex.b Pearson chi-square estimates contrasting proportion of children in SSRS “low” versus “average”/“high” group (unadjusted).

⁎⁎ pb0.01.⁎⁎⁎ pb0.001.


Teacher rated negative social preference was also sensitive to diag-nostic group differences (Waldχ2=8.00, d.f.=3, pb0.05). Interestingly,children with ADHD only and ADHD and comorbid anxiety were eachmore negatively regarded by peers, but only relative to children withanxiety only (B=0.45, SE=0.21, pb0.05 and B=0.57, SE=0.22,pb0.01), although a marginal association was also observed for chil-dren with ADHD and anxiety relative to comparison youth (B=0.28,SE=0.16, p=0.08). No other significant pairwise comparisons wereobserved for teacher rated negative social preference (Table 4).

3.3. Social impairment

Parent ratings of children's social impairment showed significantvariability as a function of diagnostic group (Wald χ2=24.81, d.f.=3,pb0.001). Once again, comparison youth and children with anxietyonly had less impaired peer relationships than children with ADHDand anxiety (B=−0.50, SE=0.15, pb0.001 and B=−0.46, SE=0.22,pb0.05, respectively). A similar pattern was observed relative to chil-dren with ADHD only (B=−0.61, SE=0.13, pb0.001 and B=−0.57,SE=0.21, pb0.01, respectively). However, no significant differenceswere observed for the comorbid group versus children with ADHDonly (Table 2). There was no significant association between diagnosticgroup and teacher ratings of social impairment (Wald χ2=6.30,d.f.=3, p=0.10). To avoid type I error, we did not conduct post-hoccomparisons among the four groups.

3.4. Social skills

Finally, we evaluated the association of diagnostic group on socialskills using ordinal designations (low, average, high) derived from

Table 4Teacher-rated social functioning by diagnostic group.

Variable A. Non-ADHD(n=53)

B. Anxiety only(n=24)

TRF social problems 2.99 (0.24) 2.33 (0.32)

Negative social preference 1.75 (0.19) 1.32 (0.24)Impairment Rating Scale 2.17 (0.21) 2.48 (0.33)Social Skills Rating SystemNon-ADHDb – 0.85Anxiety onlyb – –

ADHD onlyb – –

a Significance based on Poisson regression for dimensional outcomes, controlling for age asex and race.

b Pearson chi-square estimates contrasting proportion of children in SSRS “low” versus “⁎ pb0.05.⁎⁎ pb0.01.⁎⁎⁎ pb0.001.


the SSRS normative sample. There was a significant main effect for di-agnostic group (Wald χ2=23.8, d.f.=3, pb0.001) where comparisonyouth and children with anxiety only (B=1.73, SE=0.41, pb0.001and B=1.65, SE=0.50, pb0.001, respectively) were more likely tohave average or high social skills than children with ADHD and anxi-ety. Comparison youth and children with anxiety only were also morelikely to be socially competent (i.e., average or high) than childrenwith ADHD only (B=1.24, SE=0.35, pb0.001 and B=1.17,SE=0.45, pb0.01, respectively). No significant differences were ob-served between children with ADHD only and the comorbid group,however (B=0.49, SE=0.39, p=0.21). No significant association be-tween diagnostic group and teacher ratings of social skills was ob-served (Wald χ2=6.16, d.f.=3, p=0.10) and no post-hoccomparisons were made.

4. Discussion

Although children with ADHD exhibit significant anxiety prob-lems, anxiety has yet to be integrated into theoretical/empiricalmodels of ADHD to an extent that is commensurate with ODD/CD(see Schatz and Rostain, 2006 for an exception). We rigorously ascer-tained 223 ethnically diverse 6 to 9 year-old children using structureddiagnostic interviews and multi-informant ratings of social function-ing. Across all parent ratings of social functioning, children withADHD+anxiety and children with ADHD only were less socially com-petent and more socially impaired than comparison youth and chil-dren with anxiety only, who did not differ from each other. Findingswere less uniform according to teacher ratings, although childrenwith ADHD and ADHD+anxiety were the most consistently sociallyimpaired and there was no difference between the two groups.

C. ADHD only(n=49)

D. ADHD+Anxiety(n=28)

Walda χ² Contrasts

3.48 (0.27) 3.94 (0.37) 11.76⁎⁎ AbD;BbC, D

2.08 (0.21) 2.33 (0.29) 8.00⁎ BbC, D2.94 (0.25) 2.81 (0.33) 6.30 AbC

6.161.37 1.783.39 3.80⁎

– 0.75

nd sex and logistic regression for Social Skills Rating Scale ordinal data, controlling age,

average”/“high” group (unadjusted).




These results further substantiate that early ADHD strongly predictssocial dysfunction such as peer rejection (Blachman and Hinshaw,2002) and fewer social skills (Mikami et al., 2007). However, unlikesome previous studies which reported comorbid anxiety negativelyaffected social functioning in children with ADHD (Karustis et al.,2000; Bowen et al., 2008; Mikami et al., 2011), Hoza et al. (2005)did not find this association.

Several reasons may have explained the primacy of ADHD versusthe incremental contribution of comorbid anxiety on social function-ing. First, unlike previous studies where anxiety mitigated aggressivebehavior and improved inhibitory control among children with ADHD(Walker et al., 1991; Epstein et al., 1997), our study found that anxi-ety did not meaningfully affect social functioning in children withADHD. That is, anxiety neither exacerbated nor improved social func-tioning in children with ADHD. Second, ADHD may have explainedsubstantial variance and thus limited the putative role of anxiety.Similar effects were observed in two independent samples whereASB and social information processing deficits predicted delinquencyseverity and aggression, respectively, more robustly in controls thanin children with ADHD (Lee and Hinshaw, 2004; Mikami et al., 2008).This pattern was also suggested by Mikami et al. (2011) where anxietynegatively affected social functioning more robustly in controls than inADHD youth. Third, although we employed a reasonably large sample,we were unable to adopt more refined distinctions among anxiety dis-orders. For example, all eight anxiety disorders were analyzed equiv-alently, although this approach may betray important differencesoverall and with respect to social functioning specifically (Kendallet al., 2010). Whereas specific phobia is typically characterized byonset in early childhood, social phobia is associated with a post-pubertal onset (Albano et al., 2003), suggesting that different factorsmay be implicated in the onset of each disorder. Recent evidence alsoidentified important structural differences between social phobia,which was optimally characterized by a single factor, and GAD, whichconsisted of two factors (i.e., worry and somatic complaints) (Higa-McMillan et al., 2008). Finally, Hinshaw and Lee (2003) reviewed incon-sistent evidence on the role of anxiety in the development of seriousASB (i.e., exacerbating versus protective role). Beyond diagnostic differ-ences among anxiety disorders, important dimensions of anxiety, includ-ing withdrawn/isolated behavior may exacerbate aggression whereasinhibition/fear may diminish aggression. Overall, the multi-dimensionaland developmentally sensitive nature of anxiety necessitates that futurestudies adopt more refined approaches to its measurement in studies ofchildhood ADHD (Nigg, 2001).

Given relatively few studies on ADHD and anxiety, methodologicalinfluences may be salient. First, to prioritize clinical significance andperson-centered approaches, we evaluated ADHD and anxiety basedon a structured diagnostic interview whereas previous studies used avariable-centered approach (i.e., incremental contribution of anxietybeyond ADHD) (Mikami et al., 2011). Although diagnostic ascertain-ment of anxiety is based on evidence of functional impairment, theycan sacrifice statistical powerwhereas variable-basedmethods estimateassociations across the entire sample for the average child. Second,Bowen et al. (2008) utilized a wide age-range of participants (8 to17 years), but they did not control for age. Prospective longitudinalstudies of ADHD show aggregate stability, but reliable age-relateddecreases in ADHD in adolescence as well as important individualdifferences in outcome among ADHD youth. Indeed, recent studies ofADHD have distinguished persistent ADHD from remitters based onneuropsychological differences (Halperin et al., 2008). That is, asADHD is a disorder of development, inferences from cross-sectionalstudies, particularly thosewithwide age ranges,must be done cautious-ly. Nevertheless, using variable-based approaches, Mikami et al. (2011)did find a significant association of anxiety with social dysfunction inchildren with ADHD at a similar age in development with the partici-pants in this study. Similarly, childhood OCD has a mean age of onsetof 10 years and it is chronic as evidenced by the fact that 40% of youth


still met diagnostic criteria for OCD in a 9 year prospective follow-up(Micali et al., 2010). However, the median age of onset for specific pho-bia is 7 years (Kessler et al., 2005) and SAD is noted for its early onset(Albano et al., 2003). Thus, the age of childrenmay influence the patternof anxiety relative to comorbidity, prognosis, and etiology (Chabane etal., 2005).

Developmental influences must also be considered when appraisingpotential patterns of association for ADHD, anxiety, and social functioning.This is particularly true given recent work on the role of developmentalcascades for competence and psychopathology (Masten and Cicchetti,2010). Defined as the accumulation of interactions and transactionsresulting in dispersed effects across multiple systems, anxiety mayinteract with childhood ADHD in distinct ways across development.Lahey et al. (2002a, 2002b) found that increases in CD prospectivelypredicted growth in ADHD, ODD, anxiety, and depression. Therefore,prospective longitudinal designs are necessary to rigorously discernthe timing of effects of anxiety on social dysfunction, including interac-tive effects with ADHD. This is particularly true given that the negative,cumulative effects of significant anxiety may not have been realized atthe early stage in development in this study. That is, children withADHD and anxiety may exhibit more social dysfunction than childrenwith ADHD as the burden of comorbidity increases over time. Coupledwith evidence that ADHD and ODD/CD may be more consequential ingirls than in boys (Loeber and Keenan, 1994), the role of ADHD andanxiety on social functioning may differ according to sex and devel-opmental period.

We emphasize several important limitations of our study. First,our limited sample size precluded theoretically relevant tests of inter-actions with gender and did not allow for alternative methods togrouping children with anxiety, an important limitation given theheterogeneity of the latent factor structure of common child anxietydisorders (Higa-McMillan et al., 2008; Kendall et al., 2010). Second,although we incorporated a broad array of social functioning mea-sures, our approach may have lacked sufficient specificity for childrenwith ADHD and anxiety at this stage in development. Future studiesshould consider using sociometric interviews and structured interactiontasks between the target child and peers thatmay provide additional in-sight into the nature of peer interactions. Third, our studywas unable toassess whether anxiety differentially affected social functioning in chil-drenwith combined versus inattentive type ADHD. Solanto et al. (2009)found that ADHD combined type children exhibited specific dysfunc-tion in cooperation and self-control (relative to inattentive type youthand controls) whereas inattentive type children lacked assertivenessrelative to combined type youth and controls. Thus, future studiesmust consider that the different aspects of social dysfunction may bedifferentially distributed among ADHD subtypes. Fourth,medication ef-fects on the variables of interest could not be rigorously discerned giventhe non-experimental nature of this study design. For example, poten-tial biases secondary to our instructions to parents and teachers torate the children's unmedicated behavior could have influenced our re-sults. Indeed, given that interventions in non-experimental designsoften correlate positively with psychopathology due to the interventionselection bias (Larzelere et al., 2004), strong inferences about treatmenteffects in this study cannot be made. Finally, some of the psychometricproperties of our instruments were only in the acceptable range, thusnecessitating that future studies consider alternative methods as well,and our data analytic procedures did not yield estimates of effect size,potentially limiting the clinical interpretability of our findings.

Results from this large and ethnically diverse sample of childrenwith and without ADHD revealed evidence that children with ADHDonly and children with ADHD and comorbid anxiety, who did not dif-fer from one another, were consistently more socially impaired thanchildren with anxiety only and comparison youth (who also did notdiffer from one another). Future research must utilize more refinedapproaches to phenotypic classification including ADHD and anxietydisorder subtypes as well as prospective longitudinal designs to uncover




the timing of potential effects. Clinically, these findings underscore thepowerful contribution that ADHD makes on social dysfunction, evenrelative to other children with clinically significant psychopathology(i.e., anxiety disorder). Given the independent and interactive effectof social dysfunction to negative outcome, particularly among childrenwith existing psychopathology, interventions must be developed anddelivered that target specific deficits in social competence.

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Lee et al., 2012