ADHD És ASD Kapcsolata Cikk Angolul

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Clinical Psychology Review 68 (2019) 54–70

Contents lists available at ScienceDirect

Clinical Psychology Review


journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Social functioning in youth with attention-deficit/hyperactivity disorder and T


autism spectrum disorder: transdiagnostic commonalities and differences
Amori Yee Mikamia, , Meghan Millerb, Matthew D. Lernerc

a
University of British Columbia, Vancouver, BC, Canada
b
University of California Davis MIND Institute, Sacramento, CA, USA
c
Stony Brook University, Stony Brook, NY, USA

HIGHLIGHTS

• Youth with ADHD and youth with ASD have transdiagnostic similarities and differences in social problems.
• Shared as well as distinct intervention approaches to address social problems may be needed for youth with each disorder.
• Youth who have both ADHD and ASD may have social problems that reflect features of each disorder.

ARTICLE INFO ABSTRACT

Keywords: Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are both neurodeve-
ADHD lopmental disorders originating in childhood with high associated impairments and public health significance.
ASD There has been growing recognition of the frequent co-occurrence, and potential interrelatedness, between
Social functioning ADHD and ASD without intellectual disability. In fact, the most recent (5th) edition of the DSM is the first to
Social problems
allow ADHD and ASD to be diagnosed in the same individual. The study of transdiagnostic features in ADHD and
Transdiagnostic
ASD is important for understanding, and treating, these commonly co-occurring disorders. Social impairment is
central to the description and prognosis of both disorders, and many youth with some combination of ADHD and
ASD present to clinics for social skills training interventions. However, the aspects of social functioning that are
impaired may have both shared and distinct features between the two disorders, relating to some overlapping
and some diverse etiologies of social problems in ADHD compared to ASD. These findings have implications for
interventions to address social problems in youth with these conditions. We conclude with a discussion about
areas for future research and novel intervention targets in youth with ADHD, ASD, and their comorbidity.

1. Introduction ASD. Social functioning is a major, and central, domain of impairment


in both disorders which significantly affects prognosis. Our review leads
Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism to some shared and also some diverse implications for interventions in
Spectrum Disorder (ASD) are both neurodevelopmental disorders that each disorder. We focus on school-aged children and adolescents be-
originate in childhood. Prior to the 5th edition of the Diagnostic and cause these are the developmental periods during which most research
Statistical Manual (DSM-5; American Psychiatric Association, 2013), has occurred, and for whom the establishment of positive peer re-
ADHD and ASD were not permitted to be diagnosed in the same in- lationships sets the stage for future adjustment (Pedersen, Vitaro,
dividual. However, recently there has been growing awareness of the Barker, & Borge, 2007).
high comorbidity between ADHD and ASD without intellectual dis-
ability, and calls to search for transdiagnostic features between these 2. Distinct disorders, or two manifestations of the same
disorders to explain shared etiologies, associated impairments, and condition?
prognoses (Ameis, 2017).
The purpose of this paper is to compare and contrast the manifes- ADHD affects 5–8% of youth and the corresponding figure for ASD
tation and etiology of social problems that occur in ADHD relative to is 1–2%, with prevalence rates for both disorders having increased


Corresponding author at: University of British Columbia, 2136 West Mall, Vancouver BC V6T 1Z4, Canada.
E-mail address: mikami@psych.ubc.ca (A.Y. Mikami).

https://doi.org/10.1016/j.cpr.2018.12.005
Received 19 June 2018; Received in revised form 12 September 2018; Accepted 31 December 2018
Available online 09 January 2019
0272-7358/ © 2019 Elsevier Ltd. All rights reserved.
A.Y. Mikami et al. Clinical Psychology Review 68 (2019) 54–70

substantially in recent years (Boyle et al., 2011). Approximately 70% of impairment criterion in this disorder; social problems also are linked
children with ASD (and most children with ADHD) do not have an in- closely with the core symptoms of ADHD.
tellectual disability (Christensen et al., 2016) and we target this group. Social impairment is a useful domain in which to explore trans-
Many of the social problems shown by children with ASD and in- diagnostic commonalities and differences between the two disorders. It
tellectual disability are attributable to their intellectual capacity as has been described as a “behavioral cusp”, meaning that impairment in
opposed to, or in addition to, their ASD (e.g., Dyck, Ferguson, & the social domain has wide-reaching effects on development, and that
Shochet, 2001). Therefore, the presence of intellectual disability is a improving social functioning has positive consequences beyond the
confound when disentangling the shared versus unique features of so- change in this domain itself (Matson & Wilkins, 2007). Indeed, social
cial functioning in ASD relative to ADHD. problems augment the risks associated with childhood ADHD alone for
The diagnosis of ADHD has two primary presentations among a variety of negative outcomes in adolescence and adulthood (e.g.,
school-age youth: the Combined presentation, marked by devel- Mrug et al., 2012) – even after statistical control of the earlier, child-
opmentally-inappropriate inattention and hyperactive/ impulsive be- hood levels of adjustment. Similarly, social problems are thought to
havior, and the Inattentive presentation, consisting of predominantly undergird the array of challenges that emerge in ASD, including im-
inattentive symptoms (Baeyens, Roeyers, & Walle, 2006). The diagnosis paired adaptive behavior and achievement (Hillier, Fish, Cloppert, &
of ASD, by contrast, is characterized by difficulties in social interaction Beversdorf, 2007), and even foreshortened lifespan (Hirvikoski et al.,
and social communication, as well as restricted/repetitive interests and 2016). Concern about social impairment motivates many families to
behaviors. Until DSM-5, if a child had symptoms fitting both disorders, seek treatment for this issue in their youth. Yet, the similarities and
the diagnosis was ASD. The thought was that ASD was the more severe differences in social functioning among youth with ADHD versus ASD
disorder, and that inattention displayed by children with ASD could be result in some overlapping and also some diverse treatment implica-
explained by their lack of interest in social relationships (Craig et al., tions. Taken together, these findings underscore the clinical sig-
2015). However, recent findings of similarities between ADHD and ASD nificance of social impairment, and the relevance of understanding
in terms of genetic, environmental, and developmental risk motivated transdiagnostic, as well as diagnosis-specific, processes related to social
the revision in DSM-5 to allow both conditions to be diagnosed in the functioning in ADHD relative to ASD.
same individual (Craig et al., 2015).
Indeed, the comorbidity rate between the two disorders has been 2.2. The current paper
found to be quite high. Many children with a primary diagnosis of ASD
have significant symptoms of ADHD, with estimates ranging from 31 to The first aim of this paper is to descriptively characterize the social
95% (Antshel, Zhang-James, Wagner, Ledesma, & Faraone, 2016). problems found in children and adolescents with ADHD versus ASD
Additionally, 15–25% of youth with primary diagnoses of ADHD de- without intellectual disability, with attention to transdiagnostic simi-
monstrate ASD symptoms (Grzadzinski, Dick, Lord, & Bishop, 2016; larities as well as differences. The second aim is to compare and con-
Kotte et al., 2013). ADHD and ASD may possess a common genetic trast the etiology of social problems in each disorder. Our third aim is to
basis, with shared familial transmission and suggestions that 50–72% of use this information to present empirically-informed and tailored in-
the contributing genetic factors in the disorders overlap (Rommelse, tervention recommendations for each population, with discussion of
Geurts, Franke, Buitelaar, & Hartman, 2011). Research using causal which intervention strategies are likely to be transdiagnostically useful
modelling to identify pathways between co-occurring ADHD and ASD for youth with either ADHD or ASD or their combination, versus which
also reveals substantive ways through which their respective symptoms strategies seem more suitable for youth with one condition but not the
influence one another (Sokolova et al., 2017). Collectively, this evi- other. Throughout this review we emphasize studies that directly
dence has led some researchers to speculate that “both disorders are compare participants with ADHD to participants with ASD, and/or
expressions of one overarching disorder, with ADHD being the milder comorbid ADHD + ASD; methodological details about these com-
expression” (Rommelse, van der Meer, Hartman, & Buitelaar, 2016 p. parative studies are in Table 1.
957). Despite the controversial nature of this stance, the presence of
active discussion about whether ADHD and ASD reflect two manifes- 3. Categories and magnitude of social problems in ADHD and ASD
tations of the same disorder demonstrates the importance of identifying
the transdiagnostic versus diagnosis-specific features and processes In this section we review impairment shown by youth with ADHD
between the two conditions. relative to ASD in three categories of social functioning. Social beha-
Relevant transdiagnostic issues pertain not only to the shared causes vior, social cognition, and peer regard are distinct but interrelated fa-
that lead to a child developing one disorder or the other (or both), but cets of social competence, and problems in any one area incrementally
also to the shared mechanisms that predict adjustment and associated predict maladjustment above and beyond the others (Dirks, Treat, &
impairments in both disorders (Craig et al., 2016; Rommelse et al., Weersing, 2007).
2016). Visser, Rommelse, Greven, and Buitelaar (2016, p. 245) argue
that insights gained from a transdiagnostic approach to ADHD and ASD 3.1. Social behavior
“will inform intervention research and lead to a re-shift in focus away
from rather fixed developmental/diagnostic outcomes to more causal Problems in social behavior are defined as inappropriate or un-
processes.” To achieve this end, a sophisticated understanding of si- skilled verbal or nonverbal actions displayed in peer situations. This
milarities and differences between ADHD and ASD is needed not only in could consist of the presence of negative behaviors, or alternatively, the
terms of etiology, but also in terms of associated impairments and the absence of positive behaviors.
mechanisms behind these impairments. This is a timely topic that has ADHD. Elevated negative social behaviors among youth with ADHD
only recently begun to be explored. are well-documented (Gardner & Gerdes, 2015). Related to the core
hyperactive/impulsive symptoms of the disorder, and particularly
2.1. Social impairment in ADHD and ASD found in children with the Combined presentation of ADHD (Baeyens
et al., 2006), these youth often barge into a game without waiting their
This paper focuses on a central feature of both ADHD and ASD: turn (Ronk, Hund, & Landau, 2011) or show poor sportsmanship
social impairment. In ASD, problems in social communication and in- (Abikoff et al., 2002). In addition to the presence of negative behaviors,
teraction are part of the diagnostic criteria. Although this is not the case children with ADHD also demonstrate the absence of positive beha-
for ADHD, social problems are nonetheless a severe challenge for those viors. Relative to typically developing children, they can lack prosocial
with ADHD and are a common way that symptoms fulfill the skills such as empathetic responding in peer situations (Braaten &

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A.Y. Mikami et al. Clinical Psychology Review 68 (2019) 54–70

Table 1
Summary of comparative studies about ADHD, ASD, and ADHD + ASD.
Study Sample Measures Results

1
Ames & White (2011) 55 ASD, comorbid ADHD symptoms Lab-based tests of Theory of Mind, inhibitory ASD symptom severity, but not ADHD
dimensionally assessed (ages 7–13) control symptom severity, related to Theory of
Mind deficits. ADHD symptom
severity, but not ASD symptom
severity, related to inhibitory control.
Antshel, Zhang-James, Wagner, Review paper Genetics and neurobiology; neuroimaging; Shared features exist in genetics, brain
Ledesma, & Faraone (2016)4 cognitive phenotypes; behavioral phenotypes; structure/function, and executive
treatment implications functioning. ADHD + ASD > ASD in
behavioral impairments. Little is
known about psychosocial
interventions for ADHD + ASD.
Antshel et al. (2011)1 21 ASD, 25 ASD + ADHD, 37 Parent ratings of social skills ASD + ADHD received less benefit
ASD + anxiety (ages 8–12) than ASD, ASD + anxiety from social
skills training.
Baeyens, Moniquet, Danckaerts, 885 portrayals of ADHD and 2071 Observers coded the depiction of ADHD and ASD was portrayed more positively
& van der Oord (2017)5 portrayals of ASD in current Flemish ASD than ADHD in newspapers.
newspapers
Bora & Pantelis (2016)4 Meta-analysis of 44 studies comparing Lab-based tests of facial and vocal emotion ASD < ADHD < typically
ADHD to typically developing participants, recognition, Theory of Mind developing in emotion recognition and
and 17 studies comparing ADHD to ASD Theory of Mind. In ADHD, impairment
(ages 8–37) relative to typically developing
participants was smaller among adults
than among youth.
Cervantes et al. (2013)3 61 ASD, 36 ADHD, 80 “atypical” clinic- Parent ratings of social behaviors ADHD > atypical in hostile behavior
referred but no diagnosis yielded (ages and inappropriately assertive
6–16) behavior. ASD < ADHD, atypical in
adaptive/appropriate behavior.
de Boer & Pijl (2016)3 464 students in general education Self-reports on a vignette measure about Students reported less acceptance of
classrooms; of these, 14 students with acceptance of a hypothetical classmate with the hypothetical classmate with ADHD
ADHD and 14 with ASD (ages 12–14) ADHD or ASD; Peer sociometric nominations of compared to with ASD on the vignette.
real-life classmates. Real-life students with ADHD were
less accepted and more rejected on
sociometric nominations than
comparison students; students with
ASD were in between those with
ADHD and comparison students.
Demurie, Roeyers, Baeyens, & 39 ADHD, 34 ASD, 46 typically developing Lab-based test of temporal discounting ADHD > ASD, typically developing
Sonuga-Barke (2012)1 (ages 8–16) (preferring smaller immediate rewards over in temporal discounting.
larger delayed rewards)
Dyck, Ferguson, & Shochet 35 ADHD Inattentive type, 20 autistic Lab-based tests of emotional empathy, Theory After statistical control of intellectual
(2001)6 disorder, 28 Asperger's, 34 mild of Mind functioning, autistic disorder <
intellectual disability, 14 anxiety, 36 ADHD < typically developing in
typically developing (ages 9–16) empathy; Asperger's did not differ
from any other group. Autistic
disorder < ADHD, typically
developing in Theory of Mind;
Asperger's did not differ from typically
developing but performed worse than
the ADHD group and better than the
autistic disorder group.
Factor, Ryan, Farley, Ollendick, 32 ASD, 25 ASD + elevated ADHD Parent ratings of social problems ASD + elevated ADHD symptoms <
& Scarpa (2017)2 symptoms (ages 3–17) ASD in social communication, social
awareness.
Geurts, Luman, & Van Meel 22 ADHD, 22 ASD, 33 typically developing Response time and accuracy on a Flanker task Children with ADHD and typical
(2008)1 (ages 8–13) across social motivation and control conditions children responded to social
motivation; children with ASD did not.
Geurts, Verte, Oosterlaan, 54 ADHD, 41 ASD, 41 typically developing Lab-based tests of executive functioning; parent ASD < ADHD < typically
Roeyers, & Sergeant (2004)1 (ages 6–12) and teacher ratings of pragmatic language developing in pragmatic language and
in planning/ flexibility. ADHD,
ASD < typically developing in
inhibition and fluency.
Hutchins, Prelock, Morris, 29 ADHD, 67 ASD, 49 typically developing Lab-based tests of Theory of Mind; parent ASD < ADHD, typically developing in
Benner, LaVigne, & Hoza (ages 5–14) ratings of social behaviors related to Theory of lab-based tests of Theory of Mind.
(2016)1 Mind ASD, ADHD < control in parent
ratings of Theory of Mind behaviors.
Kohls et al. (2014)1 15 ASD, 16 ADHD, 17 typically developing Response time and accuracy on a Go-No Go ADHD and ASD both displayed
(ages 9–18) task; fMRI neural activation across social and atypical responsiveness to rewards.
monetary reward conditions ADHD = hyperactivation to social
rewards that are immediately
provided; ASD = lower activation to
all rewards.
Kuijper, Hartman, Bogaerds- 36 ASD, 34 ADHD, 36 typically developing Narrative production observed during Autism ASD, ADHD < typically developing
Hazenberg, & Hendriks (ages 6–12) Diagnostic Observation Schedule; parent in skillful language structure and
(2017)1 ratings of language; lab-based tests of working pragmatic language. Theory of Mind
(continued on next page)

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A.Y. Mikami et al. Clinical Psychology Review 68 (2019) 54–70

Table 1 (continued)

Study Sample Measures Results

memory, Theory of Mind, and response and working memory associated with
inhibition. language proficiency.
Luteijn et al. (2000)1 64 autistic disorder (no intellectual Parent ratings of behavior problems, social PDD-NOS + ADHD, autistic disorder
disability), 190 PDD-NOS, 152 ADHD, 98 problems (no intellectual disability) > ADHD,
PDD-NOS + ADHD, 65 other disorders PDD-NOS in problems in social
(ages 5–12) interaction and social communication.
Miranda, Berenguer, Roselló, 52 ASD, 35 ADHD, 39 typically developing Lab-based tests of Theory of Mind; parent ASD, ADHD < typically developing
Baixauli, & Colomer (2017)1 (ages 7–11) ratings of social behaviors related to Theory of in lab-based test (contextual +
Mind; teacher-reported executive functioning verbal). ASD < ADHD < typically
developing in parent ratings of Theory
of Mind behaviors. Inhibition,
behavioral regulation correlated with
Theory of Mind in ADHD sample, not
ASD sample.
Oerlemans et al. (2014)7 Probands (47 ASD, 43 ASD + ADHD), 79 Lab-based tests of emotion recognition ASD + ADHD < ASD < unaffected
unaffected siblings of probands, 139 siblings < typically developing in
typically developing (ages 6–13) facial emotion recognition and
affective prosody.
Rommelse, Geurts, Franke, Review paper Brain-based endophenotypes (heritable traits Substantial overlap existed in shared
Buitelaar, & Hartman linking genes and behavior) genes and endophenotypes between
(2011)4 ADHD and ASD.
Rommelse, van der Meer, 144 probands with elevated ADHD + ASD Cognitive tests of motor output, working Using cognitive profiling to create
Hartman, & Buitelaar symptoms, 110 unaffected siblings of memory, emotion recognition, attention latent classes, a class existed of
(2016)1 probands, 360 comparison children from a participants with high impairment in
population sample (ages 5–17) cognitive tasks and high parent-rated
symptoms of both ADHD and ASD.
Sinzig, Morsch, & Lehmkuhl 30 ADHD, 19 ASD, 21 ASD + ADHD, 29 Lab-based tests of facial emotion recognition, ASD + ADHD < ASD; ASD + ADHD
(2008)1 typically developing (ages 6–18) executive functioning < typically developing in joy (eyes)
and surprise (faces). ADHD <
typically developing in overall affect
(faces), overall affect (eyes), and joy
(eyes). ASD + ADHD < typically
developing in overall affect (eyes).
Scheeren, Koot, & Begeer 156 ASD, comorbid ADHD symptoms Parent ratings of behavioral style “Active but odd” behavioral style
(2012)1 dimensionally assessed (ages 6–19) associated with both parent and
teacher ratings of comorbid ADHD
symptoms.
Semrud-Clikeman, Walkowiak, 76 ADHD Combined presentation, 77 Lab-based tests of emotion recognition and Asperger's < ADHD (all
Wilkinson, & Butcher ADHD Inattentive presentation, 52 understanding; presentations) < typically developing
(2010)1 Asperger's, 24 nonverbal learning parent, teacher, and self-ratings of behavior in emotion recognition and emotional
disability, 113 typically developing (ages problems understanding. Asperger's > ADHD
9–16) > typically developing on parent and
teacher ratings of social withdrawal.
Sokolova et al. (2017)1 Probands (317 ADHD, 130 ASD, 139 Parent and teacher report of ADHD symptoms; Links existed between impulsivity
ASD + ADHD), 393 unaffected siblings of parent report of ASD symptoms; IQ testing (ADHD) to understanding social
probands, 414 comparison children information (ASD), and hyperactivity
without ASD or ADHD (ADHD) to repetitive behaviors (ASD).
Associations between inattention
(ADHD) and understanding social
information (ASD) were mediated by
IQ.
Sprenger et al. (2013)2 70 ASD, 56 ASD + ADHD (mean age = 12 Parent ratings of behavior problems, social ASD + ADHD > ASD in social
for ASD group and 15 for ASD + ADHD problems interaction problems.
group)
Taurines et al. (2012)4 Review paper Neuropsychological functioning in attention, ADHD and ASD both show impairment
reward processing, and social cognition; brain relative to typically developing
imaging children. ASD is affected by more
severe deficits in social cognition, and
may have more atypical connectivity,
than ADHD.
Visser, Rommelse, Greven, & Review paper Behavioral, affective, and neuropsychological Similarities in behavioral, affective,
Buitelaar (2016)4 functioning in early childhood and neurological impairments exist in
ADHD and ASD, but may manifest
themselves differently in each disorder
and depending on age.

Note.1 Intellectual disability explicitly stated to be an exclusionary criterion. 2 Intellectual disability not specified as exclusionary, but all group mean IQ scores are in
the Average range. 3 Information about intellectual functioning unavailable. 4 Review paper or meta-analysis summarizing varied studies. 5 Not applicable. 6Allowed
comorbid intellectual disability for autistic disorder group, but covaried intelligence in data analysis. 7Exclusionary criterion was IQ less than or equal to 60.

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Rosén, 2000). Perhaps related to the core inattentive symptoms of the conversational inflexibility). However, a tendency to be overly drawn
disorder, they may have trouble with positive behaviors representing to novelty among children with ADHD may manifest in ADHD-related
the pragmatic aspects of language such as keeping up with the pace of a social behavior problems (e.g., moving peers' game pieces when they
conversation and modulating communication to match a partner's are taking too long; see Antshel et al., 2016). For instance, although
needs (Bignell & Cain, 2007). children with ADHD and children with ASD both show negative beha-
In an observational study comparing impairment in positive relative viors on playdates, children with ADHD may most display these beha-
to negative behaviors in a summer camp setting, boys with ADHD were viors when they are losing a game, whereas children with ASD may do
no different than comparison boys in their frequency of prosocial and so when peers deviate from the rules of the game (Frankel, Gorospe,
nonsocial behaviors; however, the boys with ADHD showed more ag- Chang, & Sugar, 2011; Frankel & Mintz, 2011). Therefore, different
gression and noncompliance (Erhardt & Hinshaw, 1994). Similarly, situational triggers may elicit transdiagnostic social behavior problems
Abikoff et al. (2004) found that children with and without ADHD dis- across the two disorders.
played no differences in their observed frequency of initiating positive
or neutral social behaviors to their classroom peers, but children with 3.2. Social cognition
ADHD were over twice as likely to initiate negative social behaviors.
ASD. The social behavior difficulties of children with ASD may in- Social cognition involves the ability to interpret emotional signals
stead most pertain to the absence of positive behaviors (Matson & (emotion recognition) and to perceive others' mental states correctly
Wilkins, 2007). Early descriptions of this disorder focused on a child and as potentially different from one's own (Theory of Mind), and this is
who does not seek peers (Wing & Gould, 1979). Indeed, children with the focus of the current section. Although social cognition can also
ASD demonstrate less social play and initiate fewer social interactions encompass social information processing, and accurate perception of
compared to typically developing children (Corbett et al., 2014). Using one's own behavior, less research has been done directly comparing
naturalistic observations at recess, one study found that children with these areas in ADHD relative to ASD.
ASD spent 30% of their time in solitary activities (the corresponding ADHD. Some research finds a different pattern of neural responses
figure was 9% for classmates without ASD; Locke, Shih, Kretzmann, & to emotional faces in ADHD populations relative to in typically devel-
Kasari, 2016). The significant research documenting pragmatic lan- oping youth (Tye et al., 2014). Children with ADHD may also have
guage impairments may also be characterized as a lack of positive be- trouble identifying emotions in faces (Uekermann et al., 2010) or
havior in social situations. In conversations, youth with ASD often omit matching their affect with that of a character in a story (Braaten &
appropriate gestures and eye contact and may show poor prosody in Rosén, 2000). Problems in emotional understanding appear in youth
language (Peppé, McCann, Gibbon, O'Hare, & Rutherford, 2007). with both the Combined and Inattentive presentations of ADHD (Dyck
However, some children with ASD do display negative social be- et al., 2001; Semrud-Clikeman, Walkowiak, Wilkinson, & Butcher,
haviors. Such children may initiate social interaction, but do so in an 2010), suggesting the relevance of these delays across presentations.
unskilled or unusual way such as by giving a monologue about a per- However, other research finds that children with ADHD perform simi-
sonal intense interest or standing too close to a peer (Bauminger-Zviely larly to comparison children in such lab-based tasks, particularly when
& Agam-Ben-Artzi, 2014). In fact, historically children with ASD have they are basic. For instance, most children with ADHD pass first-order
been classified into subtypes of “active but odd,” compared to “passive” false belief tasks such as Happé's Strange Story Test similar to the
and “aloof,” reflecting the observation that some children with ASD performance of typically developing children (Hutchins et al., 2016),
possess an interaction style characterized predominantly by the pre- although they may fail second-order tasks that require understanding of
sence of negative behavior (see Wing & Gould, 1979). Nonetheless, the complex mental states and irony (Kuijper, Hartman, Bogaerds-
effect size of deficits in the absence of positive behaviors may be larger Hazenberg, & Hendriks, 2017). In another study using eye tracking,
than for the presence of negative behaviors. For example, Wing and children with ADHD and typically developing children were similar in
Gould (1979) estimated the proportion of “active but odd” children where they directed their attention during an emotion knowledge task
with ASD to be 30%, whereas the remainder were primarily withdrawn (Serrano, Owens, & Hallowell, 2018). Further, meta-analytic results
and aloof. find that most children with ADHD outgrow any difficulties they may
Summary. Transdiagnostic commonalties in social behavior pro- show on Theory of Mind or emotion recognition tasks with age (Bora &
blems among children with ADHD relative to ASD exist, in that children Pantelis, 2016).
with both disorders show more negative behaviors and fewer positive ASD. Delays in social cognition are a hallmark characteristic of
behaviors in peer contexts as compared to typically developing chil- youth with ASD (Baron-Cohen, 2000). Group differences between
dren. Nonetheless, within this finding there are differences, whereby children with ASD and typically developing children have been robustly
children with ADHD are more likely to demonstrate the presence of established in interpreting facial expressions (Lozier, Vanmeter, &
negative behaviors (related to acting without thinking or over-re- Marsh, 2014; Tye et al., 2014). These difficulties in emotion recognition
activity). By contrast, children with ASD tend to show the absence of may relate to a different pattern of neural correlates compared to ty-
positive behaviors (related to poor social-pragmatic language or the pical controls (Kang et al., in press). Further, impairments are sig-
appearance of apathy). nificant in Theory of Mind (Baron-Cohen, 2000; Mazza et al., 2017).
Studies comparing children with ADHD, children with ASD, and Children with ASD underperform typically developing children by
typically developing children (summarized in Table 1) confirm this greater than 1 SD on both first order as well as more advanced second
pattern, finding that whereas the ADHD and the ASD groups are both order false belief tasks (Hutchins et al., 2016). Unlike what is found in
impaired relative to controls, the pattern of deficits between the two ADHD, emotion recognition and Theory of Mind impairments fail to
clinical groups is somewhat different. Specifically, children with ASD remit – and may even be exacerbated – with age (Lozier et al., 2014;
less often use skilled pragmatic language (Geurts, Verte, Oosterlaan, Pedreño, Pousa, Navarro, Pàmias, & Obiols, 2017).
Roeyers, & Sergeant, 2004), are less likely to start conversation Summary. There are indications that problems in social cognition
(Cervantes et al., 2013), and show more social withdrawal (Luteijn affect both disorders, suggesting that this may be a transdiagnostic
et al., 2000), than children with ADHD. However, children with ADHD feature. Nonetheless, the severity and consistency of social cognitive
are more likely than children with ASD to show hostility, to brag, or to impairments are thought to be greater in ASD as compared to ADHD.
be bossy in peer situations (Cervantes et al., 2013). Comparative studies about social cognition are listed in Table 1.
Another contrast is that preference for “sameness” and “sticky at- Semrud-Clikeman et al. (2010) found that children with ASD were
tention” in children with ASD may manifest itself in ASD-related in- poorer at understanding emotional cues in a videotaped vignette
appropriate social behaviors (e.g., rigidity when routine is not followed, measure relative to children with ADHD, and both groups performed

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A.Y. Mikami et al. Clinical Psychology Review 68 (2019) 54–70

more poorly than typically developing children. Dyck et al. (2001) re- friendships (Mendelson, Gates, & Lerner, 2016). Difficulties manifest in
ported that empathic ability was more impaired in children with ASD terms of fewer friendships, poorer quality of friendships such as less
relative to ADHD, after covarying intelligence. Additionally, while security or closeness, and lower friendship stability (Bauminger-Zviely
children with ASD as well as children with ADHD showed deficiencies & Agam-Ben-Artzi, 2014; Chamberlain, Kasari, & Rotheram-Fuller,
in some executive functioning processes reflecting social cognition 2007). Chamberlain et al. (2007) reported that on average, children
(Geurts et al., 2004), and in tests of Theory of Mind (Dyck et al., 2001; with ASD received only 2 of 15 possible reciprocated friendship no-
Miranda, Berenguer, Roselló, Baixauli, & Colomer, 2017), the impair- minations; the corresponding figure for randomly selected classmates
ment in the ASD group was broader and more pervasive. Another study was 7 of 12. Still, youth with ASD do make some friends, which differs
found that Theory of Mind problems were uniquely related to ASD from historical depictions of this population as having zero desire or
symptom severity, and not ADHD symptom severity (Ames & White, capability for friendships (Mendelson et al., 2016).
2011). These studies illustrate the conclusion from a recent meta-ana- Children with ASD are also less liked and more disliked by peers
lysis that ASD populations are more impaired than ADHD populations compared to typically developing youth (Chamberlain et al., 2007;
in social cognition, although both groups show more difficulties than Dean et al., 2014). In these studies, effect sizes of peer rejection were
controls (Bora & Pantelis, 2016). medium to large (d = 0.7–1.0; partial eta squared = 0.26). However, the
Notably, the poorer performance of children with ASD relative to data from Chamberlain et al. (2007) and Dean et al. (2014) suggest that
ADHD on Theory of Mind tasks may be most likely to manifest in basic, youth with ASD may have more trouble achieving reciprocated
lab-based tests (where children with ASD, but not children with ADHD, friendship as compared to acceptance.
may differ from typically developing controls). By contrast, in advanced Summary. Problems in peer regard affect youth with ADHD as well
lab-based tests, children with ASD and ADHD may be similarly im- as ASD, suggesting that this is a transdiagnostic feature. However,
paired (Hutchins et al., 2016; Kuijper et al., 2017). In addition, both within this finding, youth with ADHD may have more difficulties in
groups demonstrate social behavior difficulties in real world peer si- being accepted (and not rejected) by the larger peer group. By contrast,
tuations where they can appear unresponsive or nonempathetic to so- youth with ASD may have the greatest impairment in establishing
cial cues that peers are bored or upset – difficulties which are some- friendships. Interestingly, one study found suggestive evidence that
times conceptualized to directly result from a lack of Theory of Mind children ASD were less impaired compared to children with ADHD on
(Hutchins et al., 2016). Yet, it is notable that the majority of children peer sociometric measures of liking and disliking in their general edu-
with ADHD show these deficits in social behaviors but pass social cation classrooms (friendship was not assessed), although both groups
cognition tasks in lab settings. By contrast, the corresponding difficulty were less accepted and more rejected than comparison children (de
on lab-based tests of social cognition in children with ASD may be more Boer & Pijl, 2016; see Table 1). Given that negative social behaviors
consistent with their displayed social behavior problems. This poten- impede peers' initial impressions (liking) more than friendship, but
tially suggests a distinct etiology of social behavior problems in ADHD positive social behaviors are needed to deepen close relationships
versus ASD populations, as discussed later in this paper. (friendship; Erhardt & Hinshaw, 1994), the relative pattern of impair-
ments in social behaviors between ADHD compared to ASD may explain
3.3. Peer regard their corresponding difficulties in distinct aspects of peer regard.

Peer regard refers to the social bonds between children. A common


3.4. Comorbid ADHD + ASD
consideration is whether children are accepted (liked) by their peers,
versus rejected (disliked; Pedersen et al., 2007). Whereas acceptance/
The functioning of youth with comorbid ADHD + ASD is a fairly
rejection refers to peers' social impressions, friendship is a mutual, re-
new topic. In general, individuals with ADHD + ASD may display the
ciprocal relationship between two children (Pedersen et al., 2007).
additive deficits of both disorders, as opposed to representing an en-
ADHD. In the Multimodal Treatment Study of Children with ADHD,
tirely different phenotype (Antshel et al., 2016). Although speculative,
50–80% of children with ADHD were rejected by their classmates, an
the social problems in children with ADHD + ASD may similarly be
effect size of greater than 1.1 relative to comparison children (Hoza
additive. Interestingly, among children with ASD, the presence of both
et al., 2005). A meta-analysis by Waschbusch (2002) concluded that the
negative and positive social behaviors may be associated with comorbid
effect sizes for peer rejection in ADHD populations were large, ranging
ADHD, whereas children with ASD alone more often show only the
from between 0.72 and 1.25 (without versus with comorbid conduct
absence of positive social behaviors (Scheeren, Koot, & Begeer, 2012).
problems). Another meta-analysis recently found the average weighted
We wonder if social behavior patterns that alternate between
effect size of peer regard between children with ADHD and comparison
aloofness (ASD) and intrusiveness (ADHD) may have more ramifica-
children to be r = −0.33, or medium, but larger than the effect sizes for
tions for impaired social cognition, as youth with this pattern may be
problems in social behavior or social cognition (which were both
least likely to gain the peer experiences that teach perspective-taking.
r = 0.27; Ros & Graziano, 2018). The variability in estimates may be
Relatedly, this behavior pattern may be associated with the most peer
partly attributable to children with the Combined presentation of
rejection and lack of friendship, because of its unpredictability.
ADHD being more peer-rejected than those with the Inattentive pre-
Although these are speculations, they potentially explain why results
sentation; however, low peer acceptance affects both presentations of
from several studies (listed in Table 1) find that children with ADHD +
ADHD (Baeyens et al., 2006).
ASD are poorer in social awareness, social cognition, emotion re-
Children with ADHD also display impairments in dyadic friendship,
cognition, and social communication when compared to children with
although these may be less severe than the impairments in peer rejec-
ASD alone (e.g., Factor, Ryan, Farley, Ollendick, & Scarpa, 2017;
tion. In the Multimodal Treatment Study sample, effect sizes for
Oerlemans et al., 2014; Sinzig, Morsch, & Lehmkuhl, 2008; Sprenger
quantity of friends was d = −0.53 relative to comparison children, in
et al., 2013).
contrast to the effect sizes for rejection which were greater than 1.0
(Hoza et al., 2005). Nonetheless, children with ADHD also have poor
friendship quality, whereby their friendships have more conflict and 4. Etiology of social problems in ADHD versus ASD
less closeness as compared to friendships of typically developing chil-
dren (Gardner & Gerdes, 2015; Normand et al., 2013). Friendship sta- This section compares the similarities and differences in etiology of
bility may also be lower for children with ADHD (Gardner & Gerdes, each domain of social problems in ADHD versus ASD, information
2015). which will ideally lead to empirically-informed intervention re-
ASD. Children with ASD demonstrate substantial impairment in commendations.

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4.1. Social behavior into unwillingness to enact prosocial behaviors, or at least a limited
desire to do so when faced with social challenges (Chevallier, Kohls,
Social behavior problems have been conceptualized as either po- Troiani, Brodkin, & Schultz, 2012). Support for this idea comes from
tentially attributable to inadequate knowledge of what to do (knowl- Geurts, Luman, and Van Meel (2008) who found that, whereas com-
edge deficits) versus inability to enact the skills that are known (per- petition with a peer improved the motivation of children with ADHD on
formance deficits; Gresham, 1997). Broadly, a transdiagnostic a game and brought their accuracy closer to that of the typically de-
similarity between ADHD and ASD is that both populations may have veloping group, this manipulation did not affect children with ASD.
performance deficits. However, a difference is that children with ADHD Thus, children with ASD may not be motivated by the same social
are thought to possess intact knowledge about “what to do”, with the contexts that encourage typically developing children and those with
problem being that they “don't do what they know” (Barkley, 2015). By ADHD. In addition, evidence that oxytocin inhalation facilitates social
contrast, knowledge deficits in addition to performance deficits may interactions and eye contact in ASD populations suggests that in-
affect a plurality of children with ASD (Koenig, De Los Reyes, Cicchetti, creasing social motivation (via oxytocin) may help youth with ASD
Scahill, & Klin, 2009; Matson & Wilkins, 2007). display skills that they already know (Parker et al., 2017). Finally, some
Key studies find that, on tests of social knowledge, children with research suggests a lower brain reactivity to social rewards (but not
ADHD perform similarly to typically developing children (Maedgen & monetary rewards) among children with ASD relative to typical chil-
Carlson, 2000), and that parents and teachers report them to have few dren (Delmonte et al., 2012), although other studies find that hypo-
knowledge deficits – but many performance deficits – compared to their sensitivity to reward is not specific to reinforcements that are social in
peers (Aduen et al., in press); of note, this most applies to children with nature, but does differentiate youth with ASD from those with ADHD
the Combined presentation of ADHD (Barkley, 2015). In contrast, (Kohls et al., 2014).
children with ASD sometimes show less knowledge of correct social In addition, recent work in ASD populations suggests that the speed
behavior relative to typically developing children, even when they have or efficiency of initially processing social information may contribute to
intact intellectual abilities (Pedreño et al., 2017). These findings are downstream impairment in social behavior (Lerner, McPartland, &
consistent with the observation that children with ADHD pass basic lab- Morris, 2013). Capacity to capture and process social stimuli in real
based Theory of Mind tests that children with ASD do not, yet both time may be impacted by differential neural processing of those stimuli
groups show demonstrated impairments in social behaviors thought to (Kang et al., in press), providing a gating function that can permit (or
result from Theory of Mind in real world peer situations, such as no- fail to permit) subsequent enactment of known socially skilled beha-
ticing when a peer is bored of the topic of conversation (Hutchins et al., viors. This conceptualization may help explain why the central diffi-
2016). In fact, some work suggests that lack of emotion recognition and culty in ASD is lack of positive social behaviors. The problem in ASD is
other social cognitive skills specifically underlie real world social be- less in inhibiting impulses to do negative actions that are rewarding in
havior problems in ASD (Trevisan & Birmingham, 2016). Nonetheless, the short term but not the long term; rather, it is motivating oneself to
other work finds youth with ASD to have intact knowledge of the be- capitalize on opportunities to do positive actions, and doing so in a
haviors that they are supposed to enact in social situations (Lerner & well-timed manner such that the social context perpetuates and remains
Girard, in press). Therefore, whereas results fairly consistently suggest rewarding.
that social knowledge deficits do not explain social behavior problems We speculate on another potential transdiagnostic mechanism that
in children with ADHD, inadequate social knowledge likely affects some contributes to social behavior problems in both disorders: poor re-
but not all children with ASD. lationship quality with adults. Many children with ADHD have con-
For those children with intact knowledge about correct social be- flictual interactions with parents and teachers, who are often correcting
havior, the impediments to successful performance of that knowledge the child's behavior (Deault, 2010). This type of conflict with adults can
have similarities and differences between each condition. Aberrant re- engender resistance, leading to oppositional or conduct problems, and
ward processing, present in both ADHD and ASD, may be a shared the development of negative social behaviors, in youth with ADHD
feature that affects performance deficits (Taurines et al., 2012). Chil- (Deault, 2010). In contrast, poor relationship quality with adults may
dren with ADHD demonstrate temporal discounting, meaning that, re- also affect social behavior problems in ASD, but for different reasons.
lative to children with ASD and typically developing children, they Rather, some infants who are developing ASD have atypical interac-
prefer small and immediate rewards over larger, delayed rewards tions with parents, perhaps because of these infants' poor social cog-
(Demurie, Roeyers, Baeyens, & Sonuga-Barke, 2012), and demonstrate nitive skills and the diminished reward value of social stimuli. These
heightened neural responsiveness to immediate reinforcement (Kohls altered interactions may lead to increasing loss of motivation for future
et al., 2014). Temporal discounting may relate to the problems in at- socializing (Dawson, 2008). Such processes likely persist across devel-
tentional control (self-monitoring, response inhibition, and self-reg- opment, and thus unrewarding relationships with parents and teachers
ulation) found in this population, in that these executive functions are during childhood and adolescence may also be relevant for explaining
needed to inhibit impulses to procure a reward that is available im- the lack of positive behaviors that characterize school-age youth with
mediately (Patros, Sweeney, Mahone, Mostofsky, & Rosch, 2018). Re- ASD.
levant to social problems, this may pertain to the tendency for children Summary. The barriers to demonstrating positive social behaviors
with ADHD to enact unskilled behaviors in the heat of the moment and inhibiting negative social behaviors have similarities and differ-
(despite knowing the correct thing to do); they fail to restrain impulses ences in ADHD and ASD, as summarized in Table 1. Youth with ASD are
to engage in negative behaviors, even at the cost of missing larger more likely than youth with ADHD to lack adequate knowledge about
benefits later (e.g., better peer regard). These factors may help to ex- the correct behavior to do. Nonetheless, impairment in translating
plain why the salient impairment in social behavior for children with knowledge to performance, specifically related to aberrant reward
ADHD is presence of negative social behaviors as opposed to absence of processing and poor relationship quality with adults, may be a trans-
positive social behaviors. Perhaps the purpose of attentional control is diagnostic feature across the two disorders.
inhibiting competing disruptive impulses, as opposed to motivating
prosocial actions. 4.2. Social cognition
In ASD, by contrast, aberrant reward processing is thought to pre-
dominantly manifest in reduced sensitivity to social rewards (Kohls The conceptualization that children with ADHD (at least the
et al., 2014; Taurines et al., 2012). Low social motivation in ASD, or a Combined presentation) have problems with performance as opposed to
low degree of reward experienced from social interaction as well as knowledge (Barkley, 2015) potentially explains why many children
reduced drive to initiate and persist in social behavior, may translate with ADHD pass emotion recognition or Theory of Mind tasks

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comparable to typically developing children, particularly on lab-based ADHD symptoms (even when, in fact, the peer was typically devel-
or simple tasks (Hutchins et al., 2016). Lab-based tests simulate optimal oping), this expectation alone led children to be less friendly to these
environments where hot executive functioning processes are not taxed, peers as rated by observers (Harris, Milich, Corbitt, Hoover, & Brady,
and children have maximal motivation to perform well. When children 1992). Additionally, typically developing individuals across age groups
with ADHD do fail lab-based tests of social cognition, it is possible this report unwillingness to interact with peers with ASD (Brosnan & Mills,
is attributable to the attentional demands of the task, as opposed to 2016), including after only 10 s of exposure to their real world social
their lack of social cognitive skills; for instance, one study found that behavior (Sasson et al., 2017). We are unaware of any empirical studies
difficulties in inhibition and behavioral regulation were associated with that have directly compared stigma of ADHD to ASD. However, we note
lab-based Theory of Mind performance for children with ADHD but not research finding that adults reported social distance from children with
children with ASD (Miranda et al., 2017). Again, the often successful ADHD (that was greater than toward typically developing children;
performance of children with ADHD on lab-based tests of Theory of Ohan, Visser, Moss, & Allen, 2013), whereas a different sample of adults
Mind and emotion recognition may indicate that children possess intact reported less social distance from children with ASD without in-
skills in these areas. Their failure to enact these skills in real life (e.g., tellectual disability than found in the previous study about ADHD
actual social behavior) may reflect performance deficits. (Ohan, Ellefson, & Corrigan, 2015). Another study coded media por-
Among children with ASD, some youth may lack developmentally- trayals of ADHD as more negative than of ASD in current Flemish
appropriate Theory of Mind or emotion recognition skills fundamen- newspapers (Baeyens, Moniquet, Danckaerts, & van der Oord, 2017; see
tally, suggesting inadequate social knowledge (Baron-Cohen, 2000). Table 1).
Deficiencies in these social cognitive skills may also be attributable to Nonetheless, within the finding that stigma exists against both
slowed or inefficient processing of social stimuli (Kang et al., in press). ADHD and ASD, possible differences in perceptions of personal control
That is, selective attention to salient social stimuli usually produces a over each disorder may influence the manifestation of stigma against
cascade of contextual social learning leading to adaptive social cogni- each condition. The public views ADHD symptoms as generally under
tion over time; lack of such selective attention early in development – personal control and, therefore, ascribes blame to children for their
either as a cause or consequence of such slowed processing of social ADHD behaviors (O'Driscoll et al., 2012). In fact, in the National Stigma
stimuli – may derail this process in ASD (Klin, Jones, Schultz, & Study of Children, even among respondents who correctly identified a
Volkmar, 2003). However, another contributing factor to the failure of child in a vignette to have ADHD symptoms, 19.1% did not consider
children with ASD to pass lab-based social cognition tests may be that ADHD to be a real mental illness (Pescosolido et al., 2007). By contrast,
they are not motivated by aspects of the testing context that typically the recent emphasis on biogenetic explanations for ASD may have led to
developing children and children with ADHD find motivating, such as public perceptions of ASD as a valid disorder that is outside of personal
the social desire to please an examiner (Peterson, Slaughter, Peterson, & control (Ohan et al., 2015).
Premack, 2013). Attributions of controllability are relevant because when the public
Lacking opportunities to learn or practice social cognitive skills is views mental illness as outside of personal control, this may reduce
another potential mechanism explaining social cognition difficulties. social rejection of individuals with mental illness (Lebowitz, Rosenthal,
This factor may apply transdiagnostically to children with ADHD as & Ahn, in press). Crucially, symptoms of ADHD (more so than symp-
well as ASD. For instance, negotiating a conflict with a friend requires toms of depression) are viewed as justifiable grounds for social exclu-
children's perspective taking and accurate emotion reading. Children sion specifically because the child is seen as being able to control the
with ADHD as well as ASD are less likely to have playdates relative to behavior (O'Driscoll, Heary, Hennessy, & McKeague, 2015). On the
typically developing children (Frankel et al., 2011; Frankel & Mintz, other hand, however, views that mental illness is outside of someone's
2011), meaning that children in both clinical groups have fewer op- control may simultaneously increase perceptions of the person as fun-
portunities to learn and practice these skills. Nonetheless, regarding damentally flawed, as well as decrease empathy (Lebowitz et al., in
differences between the two conditions, social cognition may be more press). Therefore, even if the public expresses less overt social distance
facilitated by close dyadic relationships as opposed to superficial social and exclusion toward others who they perceive to have no control over
interactions, because it is in friendship contexts where complex emo- their mental illness, at the same time it may reinforce perceptions of
tion recognition and perspective taking skills are most needed (Hartup, difference from those with mental illness (Hinshaw & Stier, 2008). Al-
1996). This may relate to the finding that children with ASD are more though speculative, perhaps this may explain the differences in peer
impaired in friendship relative to children with ADHD, whereas chil- regard seen in ADHD versus ASD. We wonder if peers currently view
dren with ADHD may be more impaired in peer acceptance relative to ADHD as more under the child's personal control, and therefore per-
children with ASD. Social cognition impairments may have driven, and ceive rejection of children with ADHD to be more acceptable than re-
result from, the unique impairments in peer regard in each disorder. jection of children with ASD. On the other hand, believing that children
Summary. The conceptualization that children with ADHD and with ADHD can control their behaviors may also lead to more will-
children with ASD both possess deficits in performance, but children ingness to befriend them compared to peers' inclinations to befriend
with ASD may have deficits in knowledge as well as in performance, those with ASD.
may explain the similarities and differences in social cognition seen Summary. Stigma against ADHD and ASD is a transdiagnostic
between the two disorders. These comparative studies are listed in feature that contributes to the problems in peer regard seen in youth
Table 1. A shared contributor to social cognition difficulties may be a with both conditions. Nonetheless, potential differences in the type of
lack of playdate opportunities to learn and practice social cognitive stigma associated with each disorder, related to the attribution of
skills among children with ADHD as well as ASD. controllability, may explain distinctions in the pattern of peer regard in
ADHD relative to ASD.
4.3. Peer regard
4.4. Comorbid ADHD + ASD
A transdiagnostic factor contributing to the problems in peer regard
evident in ADHD and ASD may be peers' stigmatizing perceptions of We are unaware of any studies that have examined the etiology of
both conditions. Desire for social distance from children with ADHD has social problems in children with comorbid ADHD + ASD, compared to
been found among typically developing children on explicit and im- children with either condition alone. However, we wonder if children
plicit stigma measures (O'Driscoll, Heary, Hennessy, & McKeague, with ADHD + ASD are at greatest risk for a process by which diverse
2012; Pescosolido, Perry, Martin, McLeod, & Jensen, 2007). When deficits in knowledge and blocks to performance compound social im-
children were told they were going to interact with a peer who had pairment over development. Children with ADHD + ASD may not only

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have reduced social motivation to approach and engage with peers scenarios. By contrast, teaching decision rules to be flexibly applied to
(ASD), but this lack of social motivation may also lead to decreased varied social situations may not lend itself well to social skills training.
impetus to inhibit unskilled competing responses (ADHD) because the However, some researchers have speculated that teaching knowledge
perceived benefits for doing so are less salient. Therefore, the reasons about discrete social behaviors is less useful because it cannot gen-
for social problems in ASD and ADHD may build off one another in eralize to the diversity of social situations that happen, or it inhibits
children who have both conditions. authentic social behavior (Bottema-Beutel, Park, & Kim, 2018).
Another specifier regarding the utility of social skills training for
5. Intervention approaches for social problems in ADHD versus ASD populations is that it is possibly most helpful for the children with
ASD ASD who have substantial knowledge deficits, and not for the children
with ASD who (similar to children with ADHD) have performance
This section provides recommendations for interventions to address deficits in addition to, or instead of, knowledge deficits. Along these
social problems in ADHD versus ASD, with consideration of the trans- lines, Matson and Wilkins (2007) explicitly recommend that the first
diagnostic similarities as well as differences in types of social problems step before beginning intervention in ASD populations should be as-
and the etiologies of problems in each disorder. The goal is for treat- sessing whether social problems in a child stem from lack of knowledge,
ment to be more theoretically- and empirically-informed. or a block to performance (which they predominantly conceptualize as
low social motivation), or both. They suggest that a social skills
5.1. Social behavior knowledge questionnaire or a role-play in a clinic setting be adminis-
tered to determine if children have knowledge of the “correct” things to
Social skills training is a common intervention provided for youth do. Given that social skills training attempts to address insufficient
with ADHD, ASD, or the combination of both disorders, to improve knowledge, it should only be provided for children with ASD who do
social behavior problems. At least as it is typically offered in clinic- show knowledge deficits (Matson & Wilkins, 2007).
based settings, social skills training tends to focus on skills teaching We recommend two intervention approaches that may address
through didactic instruction and role play practice in session (Gates, blocks to performance, based on the aforementioned etiologies of def-
Kang, & Lerner, 2017; Mikami, Smit, & Khalis, 2017). Common topics icits in social behavior in both disorders. Crucially, both approaches
covered are conversation skills, conflict resolution, and emotion re- may have transdiagnostic utility in helping children with ADHD as well
cognition. The general presumption is that children engage in unskilled as those with ASD, but for different reasons. First, positive relationships
social behaviors because they do not know the correct social behavior with adults may improve children's actual performance of social be-
to do, so instruction is mainly tailored to addressing inadequate havior. However, this may be primarily useful for children with ADHD
knowledge. because it reduces defensiveness and defiance against adult instruc-
To the extent that social behavior problems in ADHD are pre- tions. Evidence-based behavioral management interventions for ADHD
dominantly attributable to performance deficits (particularly in the social behavior problems, such as the Summer Treatment Program or
Combined presentation; Barkley, 2015), traditional social skills training behavioral parent training (see Evans et al., 2018) contain emphasis on
approaches may be ill-matched. This may explain why social skills the adult (parent, teacher, or counselor) and the child developing a
training has poor efficacy for children with ADHD, a topic about which positive relationship to encourage the child to follow instructions and
has been extensively written (Evans, Owens, Wymbs, & Ray, 2018). accept adult guidance. Some activities to build the relationship are
Lack of efficacy may directly follow from the mismatch in targets: ad- prescribed, and common recommendations to this end for the adult are
dressing deficient knowledge versus barriers to performance (Mikami increasing labeled praise and “catching the child being good.”
et al., 2017). In fact, scholars have observed children with ADHD to Positive relationships with parents and non-parental adults may also
receive social skills training in a clinic group about “negotiating con- be an important feature in interventions to address social behavior
flicts with friends” where they learn the correct behavior to do, and problems in ASD, but for different reasons. Rather, such a relationship
then fight about seating arrangements on the bus ride home from ses- may bolster the child's desire for social contact. This may operate
sion (Abikoff et al., 2004). through decreasing learned aversion whereby youth have, through re-
By contrast, to the extent that some children with ASD do possess peated experiences of social situations as confusing and overwhelming,
knowledge deficits in terms of not knowing the correct behavior to do understandably learned that social interactions are unrewarding and
in social situations, the emphasis of social skills training may have therefore have become less motivated to engage in them (Dawson,
utility. There is evidence that overall, clinic-based social skills training 2008). A positive bond with an adult may also provide a model for a
is efficacious, with medium effect sizes, for increasing social func- successful social relationship that generalizes to the peer context
tioning in ASD (Gates et al., 2017). Interestingly, the effect sizes are (Lerner, White, & McPartland, 2012). Supporting this idea, among
larger on outcome measures of social knowledge about the correct be- children with ASD, a combination of high Theory of Mind plus high
havior to do or the correct interpretation of a situation, and smaller attachment security with parents was associated with more social re-
(indeed, for some outcomes, null) on measures of actual enactment of sponsiveness with friends (Bauminger, Solomon, & Rogers, 2010).
positive social behaviors in real life situations (Gates et al., 2017). This Socio-dramatic affective relational intervention (SDARI; Lerner &
empirical evidence underscores the idea that social skills training tends Mikami, 2012; Lerner, Mikami, & Levine, 2011) is an approach that is
to focus on instruction in knowledge as opposed to enhancing perfor- aligned with these findings, specifically prioritizing the interpersonal
mance, and consequently may have the most success in increasing connection between counselors and youth in order to demonstrate to
knowledge as opposed to changing enacted social behaviors. youth with ASD how to have a rewarding, positive social bond.
Therefore, an important difference in treatment recommendations A second way to address performance deficits that contribute to
across the two disorders is that whereas traditional, clinic-based social difficulties in enacting socially skilled behaviors is by structuring the
skills training is likely ineffective for ADHD populations, it can be environment to elicit appropriate behavior in real world situations. This
helpful for ASD populations under specific situations. One specifier is technique may also apply transdiagnostically to youth with ADHD as
that social skills training is most useful for children with ASD to the well as ASD, however, different environmental structures may be re-
extent that knowledge about how to behave in a discrete and pre- quired for each disorder. It is probably crucial for youth with ADHD to
dictable situation can be taught. This may be why the Social Stories be provided reminders and incentives at the point of performance (e.g.,
approach (Gray, 1998) provides knowledge about scripts to enact in in the heat of the moment) to enact socially skilled behaviors. For ex-
problematic, but well-defined social scenarios (e.g., going to the den- ample, a child with ADHD may not remember to let the guest choose
tist), and may improve children's social behaviors in these particular the game to play when faced with this situation on a playdate, even if

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the child has talked about this exact scenario in social skills training at a 5.2. Social cognition
different time. It may help for the parent to remind the child during the
time of choosing the game to remember to let the guest pick, and to The treatment implications for addressing social cognition deficits
offer praise (or an immediate tangible reinforcer) for the child per- may be similar to those for social behavior problems. Frequently, social
forming the desired behavior (Mikami, Lerner, Griggs, McGrath, & skills training includes the teaching of perspective taking and emotion
Calhoun, 2010). Reminders at the point of performance may be useful recognition. The presumption is that social cognitive deficits often
because negative behaviors in children with ADHD (particularly the underlie social behavior problems (Trevisan & Birmingham, 2016); that
Combined presentation) are thought to result from their inability to is, children may react poorly in a conflict because they lack the
suppress competing impulses, despite knowing the “correct” behavior knowledge about the peer's perspective or cannot read the peer's social
to do (Barkley, 2015). Further, immediate incentives for socially skilled cues showing anger. However, this intervention model still assumes
behaviors may motivate children with ADHD to enact these behaviors, that children have knowledge deficits in addition to, or as opposed to,
given their accelerated discounting of delayed rewards (Taurines et al., performance deficits. Notably, this may not be true for children with
2012). ADHD who pass social cognitive tests in lab-based settings (at least
Using behavioral principles to reinforce appropriate social beha- when they are simple) at rates matching typically developing children,
viors at the point of performance may similarly be helpful for children yet nonetheless show social behavior problems (Hutchins et al., 2016).
with ASD as it is for children with ADHD, but modifications may be As such, social skills training containing instruction in social cognitive
needed. Applied behavioral analysis approaches for ASD can be used to skills is not indicated for children with ADHD (Evans et al., 2018).
provide immediate reinforcement for children displaying positive ac- In ASD populations, clearly some children demonstrate difficulties
tions in peer situations (Koegel, Werner, Vismara, & Koegel, 2005). in lab-based social cognition tests, unlike children with ADHD, sug-
However, such interventions often encourage simple social behaviors gesting that key social cognition skills may be underdeveloped (Baron-
that are clearly defined (e.g., eye contact, voice volume; Leaf, Dotson, Cohen, 2000). It is possible that the children with poor social cognitive
Oppeneheim, Sheldon, & Sherman, 2010). This differs somewhat from capacities will benefit most from social skills training focused on these
the nature of the in-the-moment reinforcements that children with skills (Matson & Wilkins, 2007). Nonetheless, instruction in skills may
ADHD require. In ASD, some children lack the underlying social cog- not always result in better social cognition, or in performance of better
nitive skills or motivation to enact basic behaviors, so intervention aims social behavior presumed to follow from social cognition. For instance,
to identify and reinforce the most atomistic unit of social behavior, attempts have been made to teach children with ASD the thought
building it from the ground up (Leaf et al., 2010). By contrast, children bubbles that emerge from each character's head in classic Theory of
with ADHD are thought to know, and have the motivation for, engaging Mind tasks such as Sally-Ann. These interventions improve Theory of
in complex socially skilled behaviors, but they cannot suppress com- Mind performance on the tasks to which they are matched, with some
peting impulses. Behavioral reinforcement for ADHD should therefore generalization to other lab-based tasks (Paynter & Peterson, 2013).
focus on altering the contingencies that maintain the child's negative However, they do not necessarily result in improved empathy (pre-
social behaviors, and the behaviors targeted are typically more complex sumed to be a real world manifestation of Theory of Mind skills) or
than in ASD. A reminder by the parent to “think about if your guest social behaviors (Begeer et al., 2011). It has been speculated that some
wants to go first, that's being a good friend” right before a game is more children learn to “hack” the correct solution to a Theory of Mind pro-
likely to be useful for a child with ADHD. Whereas, for a child with blem through rote memorization, but this does not increase actual
ASD, the parent might instead use a more concrete prompt such as mentalizing (Frith, 1994).
“remember, first it's her turn, and then it's your turn, and then it's her Environmental changes may instead be needed to improved social
turn.” cognition, demonstrated at the point of performance, in both ADHD and
There are additional environmental changes that may be more im- ASD populations. However, the specific changes required may be
portant to maximally elicit positive social behaviors (especially com- somewhat distinct in ADHD relative to ASD. It is possible that arranging
plex ones) from children with ASD relative to those with ADHD. a socially motivating setting can encourage youth with ASD to practice
Because a prototypical difficulty in ASD is having the social motivation social cognitive skills in a way that they would not otherwise do. For
to produce effective social behaviors with peers, the environment example, in the SDARI approach (Lerner & Mikami, 2012; Lerner et al.,
should also increase motivation and opportunities for rewarding social 2011), youth with ASD might play a game in which one child has to
interactions. SDARI (Lerner & Mikami, 2012; Lerner et al., 2011) em- demonstrate something that they are doing (e.g., baking a cake)
ploys social games that are non-didactic (i.e., no social rules are taught without any words, while another child watches and describes the
directly) and are entirely open-ended (i.e., children provide the content, child's actions with the goal of deducing the scenario. The latter child
and it can be based on their interests). These features maximize the therefore engages in a Theory of Mind-like task (i.e., understanding
capacity for the games to be intrinsically motivating, while helping what the other child is attempting to convey without knowing the in-
youth experience successful peer interactions. Such an approach is formation), as does the first child (i.e., determining how to modify his
designed to reduce the unique factors in ASD that interfere with per- or her actions to be comprehensible to the peer). This activity is ex-
formance of skilled social behaviors. perienced as a game by the participants, and they may elect to play it
Summary. We recommend shared features to potentially improve independently of the clinician; in doing so, this activity supports de-
the utility of social skills training for both youth with ADHD as well velopment of Theory of Mind without “teaching to the test” in a way
with ASD: encouraging positive relationships with adults, and altering that could impede generalization.
environmental structures to reinforce socially skilled behavior in the By contrast in ADHD, the presumption is that children (particularly
moment. These techniques address transdiagnostic commonalties in the those with the Combined presentation) already know how to recognize
etiology of social behavior problems across the two conditions. emotions or understand peers' perspectives under ideal circumstances
However, the techniques may need to be applied in slightly different (Barkley, 2015). Similar to the techniques to improve social behavior,
ways for youth with each condition, related to differences in what reminders and reinforcements in the heat of the moment may be re-
maintains social behavior problems. In addition, children with ASD, but quired for children with ADHD to demonstrate known social cognitive
not ADHD, are more likely to also benefit from direct instruction to skills at the point of performance.
increase knowledge about the correct behaviors to enact. Summary. To address the transdiagnostic commonality that youth

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with ADHD and ASD experience blocks to performance of social cog- school. Such a discrepancy may reinforce a public view of ASD as a real
nitive skills that they already know, we recommend environmental diagnosis versus ADHD as illegitimate, and have contributed to a po-
changes to improve perspective taking and emotion recognition in real tentially larger reduction in stigma against ASD over time compared to
world peer situations for children with either condition. However, the ADHD.
particular environmental supports needed may differ somewhat in Nonetheless, although this is admittedly speculative, we wonder if
ADHD versus ASD, related to diverse blocks to enacting social cognitive improvements can be made to existing psychoeducation and contact
skills in each condition. Similar to as recommended for addressing so- anti-stigma interventions if the end goal is increasing peer regard.
cial behavior problems, some youth with ASD may benefit from direct Psychoeducation often focuses on the biological basis of disorders
skills instruction about social cognition to address a fundamental lack (Corrigan et al., 2015). Although biological emphases reduce mis-
of knowledge in this area, but this is unlikely to be the case for youth perceptions that the person with the disorder can control symptoms but
with ADHD. chooses not to, thereby lowering blame of the person (which can reduce
rejection and discrimination), it may also lead to public perceptions
5.3. Peer regard that people with mental illness are fundamentally different (which
prevents friendship and connectedness; Lebowitz et al., in press). For
There is a longstanding presumption in the intervention literature this reason, some parts of the neurodiversity movement have rejected
that if children improve their social behaviors and social cognitive the push for biological explanations and cures for ASD, instead em-
skills, peers will respond with liking and friendship. Although there is phasizing celebration and acceptance of the disorder (Kapp et al.,
strong evidence that children who display poor social behaviors en- 2013).
gender peer disliking, the reverse pathway does not necessarily occur We propose an alternative, transdiagnostic approach to improving
(Mikami et al., 2017). Rather, peers selectively remember negative peer regard that includes classroom teachers instructing, and modelling
things that disliked children do while forgetting positive things, and for peers, that students with ADHD and/or ASD have value to en-
they interpret ambiguous actions of disliked children as negative; these courage peers' social inclusion of children with these conditions.
biases are reversed to favor liked children (Mikami, Lerner, & Lun, Specifically, teachers can treat children with mental health conditions
2010). In other words, peers seem cognitively predisposed to retain in ways that demonstrate that they like these children (despite or re-
their initial impressions about a child whom they already dislike, even gardless of these children's behaviors). Also useful may be teachers'
in the face of disconfirming behavioral evidence. To improve peer re- highlighting genuine positive personal attributes in these students that
gard among youth with ADHD and/or ASD, we therefore speculate that are unrelated to their disorder. These teacher practices may help peers
changing social behavior and social cognition may be necessary but not gain favorable impressions of children with ADHD and/or ASD in a
sufficient conditions. Additional efforts may be required to increase naturalistic way. Suggestive evidence supports this approach. Training
peers' inclusiveness, and reduce stigma (Mikami et al., 2017). Despite teachers to undertake these strategies resulted in peers giving higher
the fact that the potential reasons for stigma may be slightly different in liking ratings, fewer negative nominations, and more friendship nomi-
ADHD relative to ASD, there are strong transdiagnostic commonalities nations to children with ADHD (Mikami et al., 2013). Further, en-
in the recommended approaches to address stigma. couraging peers to include children with ASD in play activities led to
Psychoeducation and contact interventions have been found to re- peers giving more friendship nominations to children with ASD (Kasari,
duce stigma toward mental disorders (Corrigan, Michaels, & Morris, Rotheram-Fuller, Locke, & Gulsrud, 2012). Both interventions im-
2015). The aim of psychoeducation is to dispel stereotypes about proved peer regard more than comparison conditions that trained the
mental illness by providing fact-based information. Psychoeducation is child with ADHD or ASD in correct social behaviors; interestingly, the
often paired with contact, in which someone who has lived experience latter approach has been speculated to increase stigma because it
with a mental illness tells a personal story to humanize that disorder, communicates that the child with the disorder needs remediation
reduce fear, and help relatability. Effect sizes for psychoeducation and (Bottema-Beutel et al., 2018; Mikami et al., 2017).
contact approaches tend to be small and may not persist over time; Summary. Similar interventions may address the stigma against
further it is largely unknown whether these interventions improve ADHD as well as ASD, which may potentially lead to improvements in
peers' liking of real life youth with mental disorders as opposed to solely peer regard. These transdiagnostic approaches include psychoeduca-
self-reported inclinations for social distance from hypothetical persons tion, contact, and teachers encouraging peers' social inclusiveness by
with mental disorders (Corrigan et al., 2015). Nonetheless, psychoe- modelling for peers that children with behavioral differences have
ducation and contact are efficacious for reducing stigma against a wide value.
range of disorders as well as “mental illness” generally, without mod-
eration by disorder type (Corrigan et al., 2015). Therefore, these anti- 5.4. Comorbid ADHD + ASD
stigma interventions may be a shared strategy that is useful for im-
proving the peer regard of children with ADHD as well as ASD. Little empirical data exist that inform interventions for children
Of note, we wonder if social customs and policies have facilitated with ADHD + ASD. Interestingly, one study suggested that among
the ability of ASD advocacy groups to disseminate psychoeducation in children with ASD receiving clinic-based social skills training, those
recent years, which may have differentially reduced stigma and im- with comorbid ADHD benefited less from the treatment (Antshel et al.,
proved peer regard for youth with ASD relative to youth with ADHD. 2011; see Table 1). This may have occurred to the extent that social
The neurodiversity movement aims to dismantle negative stereotypes skills training tackles knowledge deficits, and whereas children with
and encourage the public to relate to individuals with ASD (Kapp, ASD are thought to have both knowledge and performance deficits,
Gillespie-Lynch, Sherman, & Hutman, 2013). Although we are not children with ADHD predominantly have performance deficits.
aware of empirical research on the effects of the neurodiversity Other intriguing work suggests that the Program for the Education
movement on stigma, we acknowledge the presence of “Autistic Pride and Enrichment of Relational Skills (PEERS) benefits children with
Day” without a similarly widespread parallel for ADHD. Because ASD ADHD (Frankel, Myatt, Cantwell, & Feinberg, 1997), as well as with
advocacy groups often focus their public relations messages on infants, ASD (Frankel et al., 2010). PEERS involves both social skills training
this may make it easier to pique public empathy, allowing more op- with children, and groups where parents learn to structure the social
portunity to provide psychoeducation about ASD compared to ADHD environment to encourage children to enact skills. This parent com-
advocacy groups. Moreover, educational policy supports differential ponent may tackle performance deficits, which may contribute to the
treatment of children with ASD and ADHD, whereby in the United success of PEERS for children with either disorder. However, existing
States, children with ASD receive more comprehensive services at published research evaluating PEERS has involved children with either

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ADHD or ASD, but not together in the same group, and has excluded child for his or her condition, it may also contribute to peers being
children with comorbid ADHD + ASD. Therefore, the utility of PEERS unwilling to befriend children with ASD – as friendship requires an
for youth with ADHD + ASD has not yet been formally assessed. No- equal partnership between children.
tably, studies evaluating PEERS also emphasize the need to tailor the
topics to be different in groups of children with ADHD (not bragging) 6.1. Clinical implications
versus ASD (being flexible to peers' interests), based on the social be-
havior problems demonstrated in each condition (Gardner, Gerdes, & The Research Domain Criteria initiative (Cuthbert, 2015) has the
Weinberger, 2015). In practice, clinicians may face dilemmas in se- direct aim of influencing future diagnostic classification and treatment,
lecting appropriate topics in a group of children with the combination for example by identifying novel groups of participants across existing
of both disorders. DSM-5 disorders characterized by shared underpinnings, or by finding
tipping points on a continuum of psychopathology that mark the
6. Conclusion transition into disorder (Ameis, 2017). In line with this goal, we re-
commend taking a dimensional approach to characterizing the types of
Given recent changes in DSM-5 to allow ADHD and ASD to be di- social impairments demonstrated when evaluating a child presenting
agnosed in the same individual, and the high comorbidity between with ADHD, ASD, or the combination of the two disorders. To do so, a
these conditions, the study of transdiagnostic processes versus differ- clinician might examine the pattern of subscales on the Social Skills
ences underlying ADHD and ASD is a timely topic. Such study is also in Informant System to identify which particular social behavior problems
line with the National Institute of Mental Health Research Domain the child displays (Gresham & Elliott, 2008); other adult informant
Criteria initiative in the United States (Cuthbert, 2015) to break mental report questionnaires can be used to assess the myriad of relevant social
disorders into their basic constituent components and identify the cognition abilities (e.g., Theory of Mind Inventory; Hutchins, Prelock, &
shared and dissimilar features across disorders. This review focused on Bonazinga, 2012; Hutchins et al., 2016) or the different components of
developing a comprehensive understanding of social functioning in peer regard (e.g., Dishion Social Acceptance Scale; Dishion & Kavanagh,
ADHD relative to ASD without intellectual disability. Social impairment 2003). If feasible, reports from multiple informants and/or observations
is exceedingly common in each condition and represents a frequent of social behaviors in peer situations, or lab-based tasks of social cog-
reason for treatment referrals. nition, would offer the most comprehensive picture of the child's areas
There are both commonalities and distinctions in the manifestation of social strengths and impairments. The information from such an
of social problems between ADHD and ASD without intellectual dis- assessment has the potential to directly inform treatment targets, and
ability. Children with each condition show transdiagnostic impairments will facilitate tracking of the child's progress on specified areas of social
in social behavior, social cognition, and peer regard. Within that deficiency as the child receives intervention.
finding, however, the relative areas of difficulties appear slightly dis- Once the child's pattern of social impairments is identified and
tinct. Many children with ADHD display disruptive, negative behaviors treatment targets chosen, we recommend that clinicians consider the
such as bossiness, aggression, and acting without thinking in peer si- etiology of the social impairment when selecting an intervention ap-
tuations. However, they are less likely to show impaired social cogni- proach. Although it is not always necessary to address the presumed
tion on lab-based tasks. In part because of these negative behaviors, etiology of the problem in order to tackle it, doing so will likely increase
which are off-putting to peers, children with ADHD are highly peer- the probability of success. Because a major consideration is whether
rejected. By contrast, children with ASD may be more likely to lack problems in social behavior/social cognition stem from inadequate
positive or prosocial behaviors, instead omitting social gestures and knowledge, blocks to performance, or both, we recommend that clin-
appearing as if they do not care about social interactions. They may also icians investigate these potential etiologies when devising a treatment
have difficulties with social cognition in lab-based tasks as well as in plan. To this end, it may be possible to create multiple choice tests or
real world peer situations. In part because of their impairment in po- interview the child about the “correct behavior to do” to assess if
sitive social behaviors and social cognition, which are needed to build children have intact social knowledge (Matson & Wilkins, 2007). Ad-
intimate relationships, children with ASD may have the relatively ministering lab-based tests of Theory of Mind or emotion recognition
greatest problems in making and keeping friendships. may provide information about whether the child possesses these social
Transdiagnostic similarities and differences also exist in the etiolo- cognitive skills fundamentally, or under ideal circumstances. Ad-
gies for social problems. Difficulties in performance of skilled behaviors ditionally, some investigators have applied scoring metrics to the Social
presumed to be known may be a shared feature across ADHD and ASD. Skills Informant System to specifically inform the extent to which social
However, a major distinction is that most children with ADHD (parti- behavior problems reflect knowledge versus performance deficits
cularly those with the Combined presentation) are thought to have (Aduen et al., in press).
intact knowledge. That is, they know the correct behavior to do, and Treatment could then follow based on what the presenting social
they have the requisite social cognitive skills, but their difficulty lies in problems and etiologies of these problems may be, with consideration
performing these correct behaviors. By contrast, a plurality of children of the features which are shared between ADHD and ASD relative to the
with ASD may have deficient knowledge in addition to problems in features that are distinct. That is, hypothetically, if inhibiting com-
performance. They may not actually know the correct behavior to do, peting unskilled impulses to engage in negative behavior is identified as
and may fundamentally lack the skills to engage in perspective taking the primary problem (common in ADHD), then interventions could
or emotion recognition. Among children with intact social knowledge, target this performance deficit; however, if lack of social cognitive skills
however, transdiagnostic barriers to performance may include aberrant is the main issue (common in ASD), then interventions might target this
reward processing and poor relationships with adults, in both disorders. knowledge deficit. For children determined to have performance defi-
Finally, stigma against ADHD and ASD likely contributes to the poor cits (in addition to, or instead of, knowledge deficits), the specific ways
peer regard found in each disorder, making this a shared transdiag- to encourage skilled behavior at the point of performance may also
nostic feature. However, nuances in the manifestation of stigma against differ somewhat for children with ADHD versus ASD because of distinct
each condition may, in part, explain the different patterns of peer re- things that children with each condition find motivating. Alternatively,
gard. Perhaps the societal tendency to view ADHD as less of a legitimate another strategy would be to begin with the treatment approaches that
disorder, leading to the assumption that the child can control ADHD are applicable transdiagnostically. For instance, building a more posi-
behaviors, results in peer rejection of children with ADHD. By contrast, tive relationship between children and parental as well as non-parental
stigma about ASD may be more likely to include beliefs that the child is adults may equivalently tackle barriers to performance of known social
fundamentally different. Whereas this may result in less blame of the skills in children with ADHD as well as ASD. Additionally, interventions

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to reduce stigma of mental illness (which may improve peer regard) et al., 2014). In summary, there remains a need for research on dif-
may operate similarly for children across conditions. ferences in manifestations, etiologies, and treatment implications for
In summary, this review highlights the importance of assessing the social problems in girls.
particular social problems of a child, and then delivering a treatment Lifespan issues. The extremely limited amount of longitudinal data
that follows from this assessment, without wasting efforts attending to leaves lingering questions about the way social functioning manifests and
domains or processes where the child does not have deficits. However, changes over time. Whether the same similarities and differences in social
within the existing DSM-5 classification system, treatments are pro- functioning across ADHD versus ASD that exist in childhood continue into
vided (and reimbursed by insurance) based on a child's diagnostic ca- adulthood, versus what new factors emerge, is largely unknown.
tegory. Therefore, at least at the present time, there may be utility in A benefit of adulthood is the ability to find one's own social niche in
devising treatments that are disorder-specific. To that end, the in- ways that are not possible in childhood and adolescence. Although this
formation in the current review potentially suggests that different em- feature may help adults with ADHD as well as with ASD to improve
pirically-supported treatments for social problems could be designed to their social behaviors, social cognition, and peer regard, we wonder if
be specific to ADHD, versus ASD, versus their combination (with each this feature differentially benefits those with ASD. In childhood, in-
treatment containing both overlapping approaches across disorders and dividuals with ASD are more likely to have personalized intense in-
distinct approaches in each disorder). Still, although our synthesis of terests that are not shared by their classmates, as opposed to children
the literature suggests some features that tend to characterize children with ADHD who may enjoy the same activities as their classmates but
with ADHD relative to children with ASD (and vice versa), clearly manifest unskilled social behaviors while they play them (Frankel et al.,
heterogeneity also exists within each disorder. An unanswered question 1997; Frankel et al., 2010). Therefore, freedom to meet a wider range of
concerns how clinicians should balance tailoring services to a child's people may especially help adults with ASD, because they will find
unique profile of needs with maintaining the integrity of an empirically- peers who share their intense interest, and understand them.
supported treatment. An additional implication is that clinicians would On the other hand, it is developmentally appropriate for friendships
need to determine how to proceed when there are children with ADHD, to deepen in adulthood and to rely more upon emotional intimacy, and
ASD, and ADHD + ASD together in a treatment group, such that they successful adult romantic partnerships are viewed as an extension of
cater to the needs of a mixed group. Alternatively, clinicians might being able to establish childhood friendships (Hartup, 1996). Both
prefer to restrict group enrollment to one diagnosis, but this seems adults with ADHD and with ASD are suggested to have poorer quality in
unlikely to be feasible in practice. close relationships relative to adults without these conditions (Orsmond
& Kuo, 2011; VanderDrift, Antshel, & Olszewski, in press). However, to
6.2. Limitations and future research the extent that the social difficulties for individuals with ASD most
pertain to establishing and maintaining close relationships (whereas
Sex differences. There are several limitations of this review in re- this is relatively less true for those with ADHD), it may mean that adult
gards to areas where more research is needed. First, both ADHD and relationships will remain challenging for adults with ASD more so than
ASD are more common in males than females (3:1 gender ratio for for adults with ADHD (Orsmond & Kuo, 2011).
ADHD, and 4:1 for ASD) and girls with ADHD (Quinn & Madhoo, 2014) Manifestations of ADHD and ASD. Most conclusions in this paper
as well as those with ASD (Halladay et al., 2015) are underdiagnosed apply to youth with all presentations of ADHD, as they draw from re-
and undertreated. However, peer problems are a social construct and search that includes children with the Combined as well as the
are inherently influenced by the social context of behaviors and peers' Inattentive presentations. Nonetheless, children with the Combined
interpretation of these behaviors, all of which are affected by gender. presentation comprise the majority of the research literature as they are
Specifically, girls with ADHD may show fewer negative behaviors as most frequently referred for treatment (Baeyens et al., 2006), therefore,
compared to boys with ADHD, despite displaying more negative be- they are over-represented in the findings reviewed (and in the overall
haviors than typically developing girls (Abikoff et al., 2002). This may knowledge base about ADHD). The description of a child with negative,
be attributable to girls with ADHD being less likely to have comorbid disruptive, and intrusive social behaviors who has intact social
disruptive behavior disorders relative to boys (Quinn & Madhoo, 2014). knowledge but significant performance deficits most fits the Combined
Interestingly, the tendency for girls with ADHD to have fewer comorbid presentation (Baeyens et al., 2006; Barkley, 2015). By contrast, some
conduct problems as compared to their male counterparts may lead to investigators speculate that children with the Inattentive presentation
relatively lower peer disliking (Mikami & Lorenzi, 2011). On the other are more likely to have both knowledge and performance deficits, as
hand, some evidence suggests that when girls with ADHD do show opposed to only performance deficits (Pfiffner et al., 2014).
equivalent conduct problems to boys with ADHD, the impact on their The current paper also excludes the approximately 30% of children
peer regard may be more severe (Mikami & Lorenzi, 2011). Perhaps, with ASD who have an intellectual disability (Christensen et al., 2016).
conduct problems in girls are more deviant from female norms, so peers Children with ASD + intellectual disability may show unique patterns
respond with greater disapproval. Therefore, interventions to reduce of social impairment that are distinct from children with ASD and intact
stigma against ADHD are potentially most needed for females, but the intellectual functioning, suggesting that intellectual disability (in ad-
stigma may also be most difficult to address in female peer groups dition to, or instead of, ASD) may be the cause of these social problems.
(Mikami et al., 2013). Further, youth with ASD + intellectual disability are less likely to have
A consistent pattern in recent literature also suggests that girls with comorbid ADHD or to present with diagnostic confusion between ASD
ASD may demonstrate fewer negative social behaviors relative to boys and ADHD. Finally, youth with ASD and intellectual disability are less
with this condition. The “female protective effect” suggests that girls' likely to be in general education classrooms and social skills training
symptoms may, at least in childhood/adolescence, present in more groups enrolling children with ADHD, compared to those with ASD and
peer-appropriate ways (Halladay et al., 2015). That is, girls' perse- no intellectual disability. Therefore, we have focused on children with
verative interests may focus on more normative topics (e.g., dolls and ASD and no intellectual disability because they are most relevant to the
peer networks) and they may have subtler forms of aggression. Further, aim of this paper examining transdiagnostic similarities and differences
girls with ASD may be more likely than their male counterparts to ca- in social functioning and intervention recommendations between
mouflage their social challenges; for instance, because boys play more ADHD and ASD. Nonetheless, the conclusions and recommendations
organized games than girls, it is more obvious when a boy with ASD is from this paper do not generalize to youth with ASD + intellectual
socially isolated (Dean, Harwood, & Kasari, 2017). As a result, boys disability.
with ASD may be more overtly peer-rejected, whereas girls may be Study methodology. As can be seen in Table 1, all of the included
more neglected, meaning that they are neither liked nor disliked (Dean comparative studies of social behavior problems in ADHD relative to

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A.Y. Mikami et al. Clinical Psychology Review 68 (2019) 54–70

ASD and/or ADHD + ASD have relied upon parent report ratings of Author biography
behavior, with infrequent inclusion of teacher report or youth self-re-
port. No comparative studies to date have used observations or peer Amori Mikami is a professor in the Psychology Department at
report to document social behavior patterns in children with each University of British Columbia. Her research focuses on social interac-
condition, despite the existence of many studies using these methods to tions and home- and school-based interventions for social problems in
examine social behaviors in either ADHD or ASD alone. This is a lim- youth with ADHD.
itation, because parents have a unique view of their children's behaviors Meghan Miller is an assistant professor in the Department of
that is largely restricted to the home context, or may be influenced by Psychiatry and Behavioral Sciences at the University of California Davis
their overall perception of their child. By contrast, many comparative MIND Institute. Her work involves transdiagnostic processes between
studies of social cognition between the two disorders have relied upon ADHD and ASD, and early identification of each condition.
observations of children's performance on lab-based tests, supple- Matthew Lerner is an associate professor in the Psychology
mented by parent ratings. Methodologically, the research comparing Department at Stony Brook University. His research focuses on social
social cognition in ADHD relative to ASD and/or ADHD + ASD is the and behavioral functioning in youth with ASD.
most sound of the three areas of social problems examined. Finally,
comparative studies on peer regard in the two disorders are few. This is Author disclosures
the least developed of the three areas of social problems reviewed.
However, the little existing work available has used peer report, so- Role of funding sources
ciometric methods, and observations to compare peer regard and
stigma in ADHD relative to ASD. Funding was provided by the Michael Smith Foundation for Health
Social resilience. Not all children with ADHD have social impair- Research and the Institute of Education Sciences to support the first
ment; in fact, approximately 20% may not (Modesto-Lowe, Yelunina, & author's time in writing the manuscript. The funders had no role in the
Hanjan, 2011). In addition, youth with ADHD as well as with ASD show content of the manuscript.
unique, individualized patterns of social strengths and weaknesses
where they are unlikely to be impaired in all areas across the board, or Contributors
all areas equally. Studies of factors predicting social resilience are rare,
and needed in future work. Further, the extent to which predictors of The first author wrote the first draft of the manuscript and all au-
social resilience may be similar versus distinct for youth with ADHD thors edited the manuscript. All authors participated in discussions
relative to ASD is, to our knowledge, entirely undocumented. None- about manuscript content. All authors have approved the final manu-
theless, it is possible that positive relationships with parental and non- script.
parental adults could be a transdiagnostic feature that foster better peer
relationships in youth with ADHD (Modesto-Lowe et al., 2011) as well Conflict of interest
as ASD (Bauminger et al., 2010).
Comorbid ADHD + ASD. Another priority for future study is how Nothing to disclose.
social impairments develop and manifest in youth with ADHD + ASD
relative to in those with either disorder alone. Given how newly the Acknowledgements
comorbid presentation has been allowed, it is not surprising that there
is little systematic research about it to date. However, the rates of We would like to thank the many graduate students and research
ADHD + ASD diagnoses will likely increase as clinicians and families staff in our labs who contributed to these ideas in discussions over the
adapt to the DSM-5. It may be fruitful to investigate how combinations years, and E. David Klonsky for providing feedback on an earlier ver-
of the relevant symptom dimensions lead to impairment; for example, sion of this manuscript.
how do inattention, hyperactivity/impulsivity, repetitive behaviors,
and restricted interests interact to influence social behaviors, social Author note
cognition, and peer regard on a dimensional level?
We also know virtually nothing about efficacious treatment for so- Amori Yee Mikami, Department of Psychology, University of British
cial problems among youth with ADHD + ASD, even though this group Columbia. Meghan Miller, Department of Psychiatry and Behavioral
presents quite frequently for help. Potentially, the strategy of con- Sciences. Matthew D. Lerner, Department of Psychology, Stony Brook
ducting a thorough assessment to determine areas of impairment and University.
select treatment targets will be most useful for children with ADHD +
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