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Perceptions of risk among children with and withoutattention deficit/hyperactivity disorderB. S. Bruce a , M. Ungar b & D. A. Waschbusch ca Faculty of Health Professions , Dalhousie University , Canadab School of Social Work, Dalhousie University , Canadac Department of Pediatrics , University at Buffalo – SUNY , New York, USAPublished online: 13 Nov 2009.

To cite this article: B. S. Bruce , M. Ungar & D. A. Waschbusch (2009) Perceptions of risk among children with and withoutattention deficit/hyperactivity disorder, International Journal of Injury Control and Safety Promotion, 16:4, 189-196, DOI:10.1080/17457300903306914

To link to this article: http://dx.doi.org/10.1080/17457300903306914

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ORIGINAL PAPERS

Perceptions of risk among children with and without attention deficit/hyperactivity disorder

B.S. Brucea*, M. Ungarb and D.A. Waschbuschc

aFaculty of Health Professions, Dalhousie University, Canada; bSchool of Social Work, Dalhousie University, Canada; cDepartmentof Pediatrics, University at Buffalo – SUNY, New York, USA

(Received 28 September 2008; final version received 12 August 2009)

Traditionally, health professionals have positioned injury prevention strategies from their own perspective with littleacknowledgement or understanding of the perspective of those who experience risk taking: specific populations ofchildren with differing approaches to risk perception and problem-solving. The present study addresses this oversightby engaging children with and without attention deficit/hyperactivity disorder (ADHD) to explore the meaning ofrisk from their perspective. Although both groups of children reported similar processes of assessing risk, unique tochildren with ADHD was the overestimation of their physical abilities, intentional risk taking and anticipation ofpositive or no consequences of their risk taking. These findings also advance our knowledge of potentiallyappropriate strategies to effect change in risk taking that could influence risk of injury. Specifically, findings suggestthat prevention efforts that incorporate both cognitive and social interventions are the most promising approaches.Integrating this understanding of children’s perception of risk builds our knowledge about the contribution of riskperception to injury events and may help to inform future injury prevention initiatives with children with ADHD.

Keywords: risk perception; ADHD; injuries; overestimation; photo elicitation

1. Background

There is evidence that children who have a behaviourdisorder, such as attention deficit/hyperactivity disor-der (ADHD) are more likely to suffer an injury(Brehaut, Miller, Raina, & McGrail, 2003; Bruce,Kirkland, & Waschbusch, 2007; Pastor & Reuben,2006; Rowe, Maughan, & Goodman, 2004). Despitestrong evidence of an association, we have no clearunderstanding of the mechanism by which this occurs.Children’s assessment of risk is one possible mechanismunderlying the increased number of injuries experi-enced by children with ADHD. In this article, wepresent findings from a study that explored the meaningof risk taking among children with and withoutADHD. Using photo elicitation methods (Clark-Ibanez, 2004), children were interviewed regardingphotographs they had taken that were intended toelicit their perceptions of risk. The present study isbased on the argument that the perception of risk isassociated with engagement in risky events, though noassumption is made that injury necessarily results.

2. The literature

Deficits in information processing have been aprincipal position for examining behaviour patterns

in children with ADHD and may also have implica-tions for investigating risk perceptions of thesechildren. Barkley’s model (1997) is among the mostwell-known information processing models for exam-ining behaviour patterns in children with ADHD. Themodel describes a disruption in the internal processingof information, and specifically with a disorder ofinhibition control, as the central problem amongchildren with ADHD. One implication of Barkley’smodel is that disinhibition may impact how childrenwith ADHD perceive risk. A recent qualitative studylends support to this possibility. Researchers inter-viewed 39 children with ADHD with respect to howthey perceived the meaning and experiences of ADHDin the context of their everyday lives (Kendall, Hatton,Beckett, & Leo, 2003). Consistent with Barkley’s(1997) theory, the investigators reported that childrenwith ADHD perceived their experiences in ways thatwere characterised by disinhibition, not understandingcircumstances, failure to follow rules and diminishedability to control behaviour. Other research has shownthat deficits on several social information processingskills, such as attending to cues, assigning attributesand generating potentially unsuitable or inappropriateresponses, are common among children with beha-viour disorders, including children with ADHD

*Corresponding author. Email: bsbruce@dal.ca

International Journal of Injury Control and Safety Promotion

Vol. 16, No. 4, December 2009, 189–196

ISSN 1745-7300 print/ISSN 1745-7319 online

� 2009 Taylor & Francis

DOI: 10.1080/17457300903306914

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(King et al., 2009; Matthys, Cuperus, & Van Engeland,1999; Milich & Dodge, 1984). That is, research hasshown that children with ADHD tend to ignore ordistort cues from their peers during social interactions,which often leads to misinterpretation of other’sbehaviours and inappropriate behaviour in response.

In addition to Barkley’s model (1997) of disinhibi-tion, other researchers have found impaired cognitiveabilities in children with ADHD, including a tendencyto overestimate their own abilities. Researchers havereported consistent evidence of overestimation of theirown abilities and behaviours among children withADHD (Deiner & Milich, 1997; Hoza, Pelham,Dobbs, Owens, & Pillow, 2002; Hoza, Waschbusch,Pelham, Molina, & Milich, 2000; Ohan & Johnson,2002; Owens, Goldfine, Evangelista, Hoza, & Kaiser,2007; Owens & Hoza, 2003). For example, Hoza et al.(2000) found that boys with ADHD overestimatedtheir social performance more so than boys withoutADHD. Further research demonstrated that boys withADHD tend to overestimate scholastic competence,social acceptance and behaviour conduct more thantheir controls, referred to as a positive illusionary bias(Hoza et al., 2002). In these studies, overestimation istheorised as a self-protective coping mechanism. Otherresearchers suggest that children with ADHD whooverestimate their abilities do so because they areunable to process feedback necessary to be self-evaluative (Kendall et al., 2003).

These findings suggest that children with ADHDmay not accurately evaluate their abilities and beha-viours in risky situations, but there is little empiricalevidence of how children with ADHD assess risk and ifthe assessment differs from children without ADHD.Only one study to date has examined risk assessmentamong children with ADHD. Farmer and Peterson(1995) reported that children with ADHD anticipatedfewer negative consequences of risk-taking and hadlower expectations of personal risk than children with-out ADHD. This study suggests that children withADHD may process risk differently than do childrenwithout ADHD, but further research is needed,especially research evaluating what process childrenwith ADHD use to assess risk.

3. The study

This study seeks to better understand the perception ofrisk among children with and without ADHD. Thestudy is based on the assumption that children possessknowledge of abstract phenomena and can articulatetheir lived experience when given the opportunity to doso. Being sensitive to a child’s level of development,Scott (2000) suggests the use of individual or groupinterviews with children of age 7 years and above and

proposes that visual stimuli may be useful for childrenunder the age of 11 years. With this in mind, aqualitative research approach called photo elicitationwas selected (Clark-Ibanez, 2004). This method isuseful for soliciting children’s impressions of placesand things that are representative of their position inthe world. Using photographs taken by childrenthemselves as a medium of communication, photoelicitation provides a useful method for children tocommunicate even when they may not have acquiredthe skills or ability to communicate their under-standing of abstract ideas (Cappello, 2005; Clark-Ibanez, 2004). Using this method, one elicits a richdescription of a child’s understanding of his or her ownbehaviour and context (Dell Clark, 1999). Thetechnique also allows adults to understand howchildren make meaning of their world through thenarratives they construct about the visual images theyhave gathered. Although this method has been mostlyused with adult participants, some researchers havereported successful engagement of children usingvisual methods (Berman, Ford-Gilboe, Moutry, &Cekic, 2001; Rich, Lamola, Amory, & Schneider,2000). Researchers have reported that the mostcommon applications of visual methods have been todocument and promote understanding of phenomenaand in participatory action research to empowerparticipants (Riley & Manias, 2004; Wang & Burris,1997). Engaging children with and without ADHD inparticipatory research to promote a better under-standing of their sense of risk is the primary goal of thepresent study, suggesting that photo elicitation (avisual method) is an appropriate choice.

3.1. Participants

Participants were 20 children who were 10 to 12 yearsold, including 10 children with a physician-madediagnosis of ADHD and 10 children without anADHD diagnosis. Children were randomly recruitedfrom a larger group of 57 children who participated ina study to measure overestimation of physical abilitiesamong children with and without ADHD. As is typicalin samples of children with ADHD, one half of thechildren with ADHD also met criteria for oppositionaldefiant disorder (ODD) (Pliszka, Carlson, & Swanson,1999; Waschbusch, 2002). Children were from diversesocioeconomic backgrounds. About one-half of thechildren had two parents in the home and one half ofthe children were in single parent families. Themajority of children were living in urban areas withabout one-third of the children living in suburban/rural communities. Seventeen children were white andthree children were African Canadians. Most of thechildren interviewed were male, particularly in the

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ADHD group (9 out of 10). This reflects the typical sexdistribution of children with ADHD (Gaub & Carlson,1997; Waschbusch & King, 2006). Because of thechallenges of recruiting non-ADHD participants, thesample was one of convenience and in the non-ADHDgroup, both sexes were equally represented.

3.2. Data collection

Each child was given a disposable camera with 27exposures and instructed in the correct use of thecamera. Children were asked to take 12 or morephotographs of things or places in their world that helpthem think about risk and safety. They were instructedthat the pictures could be of their place of play, homeor sports activities. Minimal direction was given toencourage creativity and to discourage imparting theresearcher’s own bias about risk and safety to thechild. They were advised that there is no wrong pictureto take except taking a picture that could put thempersonally in danger of an injury. Parents were presentduring the instructions and asked to provide super-vision of photography sessions to reinforce instruc-tions with respect to danger.

After children completed taking pictures, pictureswere developed (by the first author) and thenindividual interviews were scheduled with each childwithin 2 weeks of completing picture taking. Childrenwere asked to reflect on their photographs in an effortto learn how they construct a meaning of risk.Interviews were audiotaped to ensure that the descrip-tions were captured accurately and in the children’sown words. All interviews were transcribed verbatim.Interviews lasted from 30 to 60 min. Although theinterviews were unstructured, a set of verbal probeswere used such as ‘Tell me about this picture?’ followedby ‘What do you find interesting about this picture?’and ‘How does it make you think about risk?’ Promptssuch as ‘What makes it good or bad?’ were also used toencourage the children to present their own criticalperspectives (Wang & Redwood-Jones, 2001).

A variety of pictures were taken but some weremore common than others. Among the commonpictures were those of road safety signs, cars andtrucks, safety gear, bikes, skateboards, trees, heights,knives, poisons, fire, water and electricity. The mostunique pictures were those of guns or bullets, woods,graveyards, school bathrooms and a train. Althoughthe pictures were often similar, the stories about apicture of the same thing were often quite distinctlydifferent. Children were very articulate in their inter-pretations of the pictures. They spoke of personalexperiences in relation to the picture, sometimes theirown experience but often it was about an observationof others who were engaged in an activity such as

riding a bike, climbing a tree or playground equip-ment, crossing at an intersection, using a sharp knife,swimming, skate boarding or using protective gear.

The constructivist approach to this study wasaimed at understanding children’s perceptions of riskand looking for patterns and connections whileoffering an interpretation (Charmaz, 2006). Themeswere identified through a constant comparative analy-sis with further clarification and exploration with eachsubsequent interview (Charmaz, 2000). The first 13interviews (7 from the ADHD group and 6 from thenon-ADHD group) provided data to develop a modelof risk perception through exploration of new conceptsand clarification of evolving themes. All interviewswere conducted in similar format with the exception ofthe last seven in which more in-depth inquiry about thedeveloping model was explored once each child hadfully explored their own concepts using their photo-graphs. Children were asked to confirm or denydeveloping theory such as ‘Other children have toldme . . . how does that fit with what you are telling me?’Every attempt was made to give initial priority to thechild’s story with further exploration of developingconcepts at the end of the interviews.

3.3. Data analysis

Initially, the first few transcripts were read in theirentirety several times allowing the development of anoverall sense of the rich descriptions that were in thedata. A journal of impressions, developing ideas,context, observations and interactions during inter-views was kept. Memos provided a record of develop-ing ideas and perceptions of themes. Interviewtranscripts were reread for reoccurring themes andadditional expansion of initial themes. Themes fromeach transcript were compared to each other forconsistency of themes or the identification of newemerging themes. The comparative analysis permittedthe development and refinement of emerging themes.

Data collection proceeded simultaneously withdata analysis. Data were examined to seek conditionsthat gave rise to strategies and consequences. Assessingrisk revolved around thinking or not thinking abouttheir ability, about wearing the safety gear or respect-ing the rules, about the likelihood of the personalconsequences or the implications of those conse-quences, both positive and negative. Attending tocognitive appraisal of risk was integral to theirconsideration of risk, sometimes clearly evident andother times notably absent. When thinking aboutconsequences, the children described positive conse-quences in terms of achievement, keeping safe, andhaving fun. Negative consequences were seen aspersonal injury, punishment, hurt or even death.

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Initially, each transcript was coded independentlyusing these themes. An initial matrix of codes wasdeveloped but soon became an evolving documentas categories emerged from the expansion of codesthrough further probing in the interviews. Conceptswere developed that best explain what was happeningin the data using the properties that children attachedto risk and how they understood risk to develop aframework. All interviews were coded using thisframework.

3.4. The findings

The general patterns of assessing risk as described byall children in the study will be presented in the nextsection followed by the experiences specific to childrenwith ADHD to provide insight into their uniquelynuanced perception of risk.

3.4.1. Risk appraisal for all children

Through the rich data collected, the meaning childrenascribed to risk and their process of assessing riskbecame apparent. The basic process emerging was oneof attending or not attending to thinking about risk.Both groups of children, those with and withoutADHD, described conditions of thinking or notthinking in relation to intentions and consequencesof their actions. Some children described that notattending to thinking was associated with their sense ofhaving no control over behaviour or outcomes: thingsjust happen that way. Other children who talked aboutthinking about risk also considered the consequencesof risk-taking. Although thinking or not thinking waspresent for both groups of children, there were someunique strategies among children with ADHDthat included overestimation of abilities, intention(breaking the rules), descriptions of positive outcomesand a perception of having no consequences to theiractions.

Attending to thinking or not thinking about riskassessment was a theme present in the interviews withall the children, both with and without ADHD. Forsome children who described thinking about risk, theyalso described assuming responsibility for their actionsand considered options and consequences whenapproaching a risk. One boy explained that; ‘It isgoing to really hurt if you don’t do it right.’ Whenasked, ‘And how do you know if you are going to do itright?’ he replied, ‘I have no idea. It’s just you have tothink. You have to think how to do it . . . . And itmakes it less risky.’

Thinking revolved around several key factors thatinfluenced the children’s decisions about whether anactivity represented a risk or not and whether they

would plan to take that risk. Some risky situationsthat the children described included playing unsuper-vised in a playground, swimming in an unfamiliarplace, riding a bike without a helmet, recognition ofpoisons and jumping on a trampoline with friends.Most of the assessment was at an individual level.The children spoke about their consideration of theirown abilities and limits, demonstrated an awarenessof how to accomplish the task independently, feltresponsible for their success or failure, knew the rulesand decided whether to attend to or ignore the rules,evaluated the situation and decided whether or not towear safety gear, and demonstrated agency in theirdecision to accept supervision when it was expected.For example, one boy without ADHD, referred to hislimited level of physical ability several times duringthe interview. He described the adventures of hisfriends who routinely climbed a tree that was in hispicture. When asked about why he did not climb thistree, he commented, ‘I am crap at climbing trees.’ Inother interviews, children talked about thinking abouthurting themselves as a possible consequence (thusdemonstrating acceptance or rejection of the possibleoutcomes from their personal choices). One boywithout ADHD who shared his picture of a shiny,new helmet explained, ‘The risk you can take withyour bike is you, is like biking on the road with carsand stuff and not wearing a helmet could be a bigrisk. Because if you crash you could do a lot ofdamage.’

On the other hand, children who described notthinking about risk often spoke of having no controlover their behaviour or taking no responsibility forconsequences. As one boy with ADHD explains whenasked about how he would describe risk, ‘Risk is likeyou go out to do something, and just do it, and theydon’t really care what the consequences.’ Linked tothis understanding of responsibility and consequenceswas the theme of unintentionality which referred toevents that the children were aware of but that theydescribed as if there was nothing they could have doneto stop or prevent them from occurring. It was as if,they said, something just went wrong. The childrenimplied that their actions were neither intentional nordid they have any control over the specific event, eitherbecause it would occur anyway or they were just notpaying attention. Likewise, some children describedsituations in which they felt they had little control. Oneboy with ADHD, in reference to being out bicyclingwith his friends, said: ‘I just think of somethingpushing me to do it and something holding me back,and something telling me what to do. Like sometimes Idon’t feel like I am in charge, something will justhappen.’ When talking about how things can be risky,one girl who did not have ADHD told stories of how

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her younger brother who had ADHD did not thinkabout risk: ‘Because, they really don’t think thatpeople could hurt themselves or like they really don’tknow and they don’t think of what could happen.’ Sheshared a picture of her brother swinging from a tree intheir backyard and another of him hanging from thefixtures in their basement. She explained that somechildren with ADHD ‘don’t really think about the risk,and they just do it. They just do it without thinking atall.’ Those children who described not thinking aboutrisk also told stories about adults whom they believedwere responsible for supervision and ensuring theirsafety. One boy with ADHD used a picture of thelifeguard at his community pool to illustrate his point:‘Now this one is the lifeguard at the pool. In casesomeone is drowning and that, they can get in thereand save them . . . if you like accidentally start drown-ing, they can help . . . [or] if older people were there sothen they really couldn’t drown.’

Although children with and without ADHDdescribed similar experiences with respect to cognitiveappraisal, there were strategies unique to children withADHD in their assessment of risk that included:overestimation of abilities; intentional risk taking; andanticipation of positive or no consequences. Thesepatterns are described below for the subsample ofchildren with ADHD.

3.4.2. Risk appraisal for children with ADHD

3.4.2.1. Overestimation of physical abilities. Althoughseveral but not all children with ADHD describedoverestimation of abilities, no children without ADHDdescribed overestimation. One boy with ADHDrelated a story as he showed a picture of dark waterswirling in a pond outside his church, ‘We were in ahotel, and then there was a swimming pool. We alwayswent there. And then my Mom always told me to stayin the shallow end and not to go to the deep end. But Iwould always go to the deep end with a life jacket. Butthen I took the life jacket off. And then I couldn’tswim, and then I almost drowned. But then I got to theshallow end in time.’ When asked, ‘Why do yousuppose you did that?’ he replied, ‘Because I thought Icould swim, and I couldn’t.’

Another child with ADHD talked very openly abouthis ADHD, many of the boy’s pictures were ofoutdoor activities with his friends. As he describedriding his trick bike over jumps with his friends heshowed a picture of his friends taking jumps on theirbikes in the street:

Kids with ADHD are more competitive and also theyare very, very, very, show-offy, way more than kidsthat don’t have ADHD. And like they can kind of getangrier quickly. Also, like they don’t think as fast too.

And like they are not as afraid of stuff too. Like kidsthat don’t have ADHD, they will go and they will dojumps until they get more practice. Some kids withADHD just go wooph, right up the big jump. And thatis how they practice instead of going from the little tothe big. I kind of started off in the medium to the biginstead of going little, medium, big.

Although overestimation was apparent with someof the children with ADHD, other children withADHD were clear about assessing their limits. Oneboy with ADHD spoke about taking precautions andbeing aware as the key to minimising risk. Many of hispictures focused on safety and things that couldenhance safety or illustrate how he knew the limits ofwhat he could do. For example, he shared a picture ofhis father’s tool chest in their garage, saying: ‘I don’twant to use the tools. I don’t know how to use them. Iget my Dad.’ He was clear that he assessed his abilityto successfully accomplish tasks and negotiate his wayaround danger. Like some of his peers, there wasevidence in his narrative of the search for alternativeswhen risks were present. This child was an exception tothe group of ADHD children who spoke of over-estimation. It is not clear why not all children withADHD expressed overestimation although with thischild, his parents were very engaged and placedsignificant emphasis on attending to safety in his day-to-day activities.

3.4.2.2. Intentional risk taking. Some children withADHD purposefully chose to take a risk, even whenthey knew there were rules against doing so or whenthey knew their parents would not approve. Several ofthese children reported that they do not wear ‘the gear’such as their bike helmets, knee and elbow pads whenskateboarding unless they know their mother or fatherwere watching. They were very aware that they wereintentionally taking a risk. This was predominantamong children with ADHD and not so amongchildren without ADHD. One boy with ADHDproudly shared a picture of his skateboard and whiledescribing that he was recognised by his peers for hissuperior skateboarding skills, he explained, ‘Bad risk issomething that you know will hurt yourself, you knowthat it will hurt but you do it anyway.’ Another childdescribed his experiences at school with a friend andthat despite thinking he would get caught disobeyingthe rules at school, he said: ‘Yes, I do it all the time. Iget caught. I got sent to the principal’s office. My momdoesn’t know this but I got sent to the principal’s officeonce for doing it. Well, I almost did. I talked myselfout of it. That is . . . I talked myself out of fourdetentions. Me and my friend, when we both get introuble for doing something, I talk us both out of it. Ithappens all the time.’

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3.4.2.3. Positive or no consequences. Both groups ofchildren with and without ADHD described negativeconsequences although children with ADHD tended todismiss the relevance of negative consequences. Inaddition, unique to children with ADHD was the senseof not worrying about any consequences or thepossibility of positive consequences, includingdemonstration of their physical ability and socialacceptance. One boy described his risk-taking strategyas, ‘Goahead, do it. Forget about the consequences, do itnow. Worry about the consequences later.’ Whileanother boy with ADHD talked about how heunderstood he was different from children withoutADHD describing children with ADHD as ‘wireddifferently’. He described the competitive differences inchildrenwithADHDand thosewithoutADHDwhenheshared a picture of his friends riding their bikes on thestreet:

If they [ADHD children] are in a competitive mood,they are not thinking straight anyway. Like a kid withcompetitive mood, it is just like a dial-up internet and ahigh speed internet. Theirs just goes wooph, somethingis going to happen to me . . . ADHD, they are like:‘Come on I can do this’ and then go fly. I am going tofly high and I am going to show them that I am betterthan them . . . but a kid, like a normal kid would justbe like ‘something is going to happen. If I don’t landthis jump right, I am going to get hurt real bad.

4. Discussion

Risk-taking is a complex set of processes that childrenengage in relative to the context of their situation,using a diverse set of strategies. Those strategies maybe employed with or without consideration forpotential consequences, whether those are positive ornegative. Although there are some similar cognitiveprocesses among children with and without ADHDthat are associated with perceptions of risk andsubsequent behaviour, the two groups of childrendescribed several different themes. These includedoverestimating their abilities and intentionally break-ing the rules. Furthermore, while both groups ofchildren anticipated negative consequences, childrenwith ADHD also anticipated positive consequences ordismissed consequences altogether. Moreover, negativeconsequences did not seem to deter risk-taking amongchildren with ADHD whereas it did among thosechildren without ADHD.

Children with ADHD may be at particular risk forengaging in dangerous behaviour if one considers theirrisk perception in the context of Barkley’s (1997)disrupted information processing model. That modelsuggests that disinhibition affects self-regulation ofmotivation, arousal and reconstitution. Consistent

with Barkley’s (1997) model, the children withADHD in this study described some unique informa-tion processing styles as compared to children withoutADHD, especially with respect to evaluating theirabilities, intentions and presumed consequences oftheir behaviours. These findings are also congruentwith previous research demonstrating that childrenwith ADHD tend to overestimate their abilities (Hozaet al., 2000, 2002) and to contemplate fewer negativeconsequences (Farmer & Peterson, 1995).

Children with ADHD described overestimatingtheir ability to successfully manage risky situations.Similar to previous research, this present study showsthat children with ADHD may overestimate theirphysical abilities in addition to social and academicdomains (Hoza et al., 2000, 2002). The question thatremains is whether it is a self-protective copingmechanism described as positive illusionary self(Hoza et al., 2002) that compensates the child withADHD for potential social stigmatisation/exclusion oran inability to process social cues that contributes tothe overestimation (Kendall et al., 2003; Matthys et al.,1999). Understanding the underlying mechanism couldhave implications for intervention strategies.

For those children with ADHD, there wereapparently positive, negative and no consequencesperceived to risk-taking whereas for children withoutADHD, there were only descriptions of negativeconsequences. This is consistent with findings reportedby Farmer and Peterson (1995) who found thatchildren with ADHD reported fewer and less severenegative consequences of risk-taking behaviour. How-ever, the present study extends what Farmer andPeterson (1995) found by suggesting that positiveconsequences are also uniquely associated with risk-taking as identified by children with ADHD. That is,the children in this study make mention of how riskalso presents a potential opportunity to demonstratephysical abilities and gain peer acceptance. Thechildren in this study may perceive that successfulperformance when taking risks can influence theiracceptance by their peers. This finding supports thetheory of positive illusionary self-concept in relation tosocial acceptance previously reported (Hoza et al.,2002). If positive illusionary self-concept is an under-lying construct then our data suggest that there areopportunities for a child to enhance his or her self-esteem, self-evaluation of abilities and strengthen hisor her ability to accurately attend to the demands ofsocial situations.

It is noteworthy that in the present study, notthinking about risk was common between both groupsof children. On the other hand, children with ADHDwere more likely to be the children who intended totake a risk, and who consciously reported they would

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take a risk if they had the opportunity, regardless ofconsequences. In contrast, children without ADHDthought about the risk and consequences, oftendeclining to take a risk if negative consequences wereprobable. Children with ADHD explained that theircontemplation of engaging in dangerous behaviourwas part of the process of assessing risk but did notdissuade them from the challenge. A helpful model ofrisk-taking that could assist with interpreting thesecognitive processes is one of social reaction theory(Gerrard, Gibbons, & Gano, 2003). Social reactiontheory argues ‘the assumption that reasoned thoughtor intentions necessarily precede risky and precau-tionary behaviour is not accurate’ (p. 75). Instead,Gerrard et al. (2003) describe two paths to risk-taking:intentional (planned risk taking) and behaviouralwillingness (not consciously planning to take a riskbut not planning to avoid one). In support of thistheory, research has demonstrated that adolescents donot plan risky behaviour but rather risky behaviour isa reaction to a social situation in which risk is present.Both intentional and behavioural willingness appear tobe present in the pre-teens with and without ADHDwho were interviewed in this study.

Further research is needed to discover whetherthose children with ADHD who intentionally takerisks, and who prepare for those risks and anticipateconsequences, are any less likely to experience anegative outcome than their peers who are lessprepared in their approach to risky situations. Like-wise, further research is needed to determine whetherchildren with ADHD who have no premeditated planof action but are willing to take the risk anyway, havean accurate perception of risks and consequences.Taking all these factors together suggests a verycomplex picture of risk assessment and how themotivation for risk-taking might be different forchildren with ADHD.

5. Implications for injury prevention

These results have implications for an injury preven-tion intervention strategy that differs from moreconventional approaches. Children in this age grouptend to experience falls, sports related injuries andpedestrian and traffic injuries. These types of injuriesare often associated with some degree of individualassessment of risk either in attempting to indepen-dently approach a task with or without supervision,wear the appropriate safety gear and obey the rules/signs. In addition, it is a time of developing compe-tence in social interactions. Traditional injury preven-tion work has drawn attention to potential negativeconsequences of risk-taking. Such an approach isproblematic in children with ADHD who may not be

deterred by negative consequences or may associaterisk-taking with positive or no potential consequencesthat may result in an injury. An alternative interven-tion strategy may be to help children consider potentialrisk-taking situations and develop strategies forapproaching the situation in ways that ensure a moreaccurate assessment of risk and successful completionof tasks. Although the adolescent brain is developingthere are researchers who suggest that this develop-mental phase of brain function may be moderated bysocial interactions (Crone, Bullens, van der Plas,Kijkuit, & Zelazo, 2008; Fareri, Martin, & Delgado,2008), and the individual’s predisposition to engage inrisky behaviour (Galvan, Hare, Voss, & Casey, 2007).Gerrard et al. (2003) suggest there is a time sensitiveeffect to such an approach in that it should occur onceyouth are willing, but not necessarily intending, totake the risk. For example, those children who mightbe willing to climb to the top of the monkey bars in theplayground but have not planned a strategy whenencountering this task as they have no intention ofclimbing to the top.

Another issue that is equally important is therecognition that children in this age group are naturallycurious and need to explore. It would be helpful tofurther examine what contributes to the development ofchildren who establish limits on their ability to master agiven situation versus children who tend to over-estimate their abilities. One possible factor is parentingas positive parenting can have a significant role toplay in assisting children to recognise risk, theirwillingness to participate in risk situations, andpreparing them to manage the demands of socialsituations (Ungar, 2007).

Risk perception may be conceived as requiringboth cognitive and social strategies and may haveparticular relevance for children with ADHD whoexperience more injuries than children withoutADHD. Important to consider is the opportunity toequip children with the capacity to think about theiroptions and take responsibility for their choices.Acknowledging that risk-taking is an inevitable andimportant part of growth and development suggeststhat children can make ‘smart choices’.

Acknowledgements

This study was funded by the Nova Scotia Health ResearchFoundation.

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