Academic journal article Cognitie, Creier, Comportament

The Independent Contributions of Negative Peer Functioning and Social/familial Risk Factors to Symptoms of Adhd among Italian Primary School Children

Academic journal article Cognitie, Creier, Comportament

The Independent Contributions of Negative Peer Functioning and Social/familial Risk Factors to Symptoms of Adhd among Italian Primary School Children

Article excerpt

Attention-deficit/hyperactivity disorder (ADHD) is currently one of the most prevalent disorders seen in childhood (Merikangas et ak, 2010) affecting 6 to 7 percent of school-aged children (Willcutt, 2012). The Diagnostic and Statistical Manual (DSM-V) classifies it as age inappropriate behavioral symptoms of inattention and/or hyperactivity/ impulsivity (American Psychiatry Association, 2013). Among the main challenges for this syndrome is the fact that it appears to occur in presence of various social and behavioral comorbidity factors (Jensen et al., 2001; Newcom et al., 2001), including negative peer functioning and aversive behaviors to peers (Biederman, Faraone & Monuteaux, 2002) and low levels of social competence (Biederman et al., 2004; Maedgen & Carlson, 2000). In addition, several studies have shown that ADHD is associated with low socio-economic status, family disturbance and various social risk factors (Counts, Nigg, Stawicki, Rappley, & Von Eye, 2005; DuPaul, McGoey, Eckert, & VanBrakle, 2001). These facts, together with the absence of an adequate diagnosis, favor the probability of both under-diagnosing and over-diagnosing children with ADHD (Cuffe, Moore, & Me Keown, 2005).

Indeed, previous research has demonstrated that children who suffer from ADHD symptoms but haven't been formally diagnosed with ADHD report equally academic, social, emotional difficulties and other impairments as diagnosed children (Barry, Lyman, & Klinger, 2002; Polderman, Boomsma, Bartels, Verhulst, & Huizink 2010). Overall, this raises several questions concerning possible independent contributions of behavioral and relational factors and how environmental risk factors contribute to the expression of ADHD symptoms. Specifically, despite the established link between ADHD symptoms and impaired peer functioning, a number of limitations remain in the literature. First, very few studies have showed that peer relationship problems may exacerbate ADHD symptoms (Tseng, Kawabata, Shur-Fen Gau, & Crick, 2014) moreover, relatively little is known regarding the unique relationship of children's peer functioning and inattention versus hyperactivity/impulsivity. The two groups of symptoms may each be linked to specific peer problems (Hoza, 2007). Last, since maladaptation is a result of reciprocal transactions between individuals and their socio-ecological contexts (Cicchetti & Rogosch, 2002) considering social/familial risk factors and peer functioning together will contribute to our knowledge regarding specific pathways trough which symptoms of ADHD occur. Indeed, a better understanding of these issues would facilitate our understanding and treatment of ADHD. Accordingly, in the current study, we examined the association of negative and positive peer functioning and the presence or absence of social risk factors with the onset of ADHD symptoms among a group of Italian primary school children.

Peer functioning, social risk factors and ADHD symptoms

It has been documented that early childhood manifestations of negative peer functioning and aversive behaviors to peers are usually associated with ADHD's symptomatologies (Loeber, Burke, Lahey, Winters, & Zera, 2000), while several studies found that aggression or conduct problems in childhood contributed to the persistence of ADHD well beyond childhood (Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Loney, Kramer, & Milich, 1981; Taylor, Sandberg, Thorley, & Giles, 1991). In fact, negative peer experiences, such as dislikes, friendlessness, and peer rejection may deprive a child of important developmental opportunities to interact with peers and friends and to learn social knowledge or practice social skills (Murray-Close et al. 2010), which may lead him or her to continue behaving in maladaptive ways (e.g., being inattentive, hyperactive, or impulsive) during peer interactions (Parker, Rubin, Erath, Wojslawowicz, & Buskirk, 2006). However, past research has demonstrated an association between ADHD symptoms and children's peer relationship problems through a "symptom-driven" perspective. What remains unknown is the reciprocal influences that impaired peer functioning can have on children's development or maintenance of ADHD symptoms. If we agree that inattention and hyperactivity/impulsivity may invite rejection or low acceptance from peers, then it seems reasonable to argue that peer problems may give rise to more inattentive or hyperactive/impulsive behaviors or may exacerbate symptoms of ADHD. We know that the quality of the relationship among peers during childhood are better predictors of later psychological functioning than teacher ratings, grades, IQ, or absenteeism (Hamre & Pianta, 2001; Woodward, 2000) . Accordingly, here we focused on both positive and negative peer functioning among primary school children by looking at conflictual and affective friendship quality (Weimer, Kerns, & Oldenburg, 2004), aggressive and prosocial behaviors (Caprara & Pastorelli 1993; Pastorelli, Mazzotti, & Prezza, 1988), and emotional and behavioral instability (Pastorelli, Caprara, Barbaranelli, Cermak, & Rozsa, 1997).

In relation to social risk factors, despite the fact that studies have shown that ADHD is associated with low socio-economic status, family disturbance and parents' marital conflict (Counts, Nigg, Stawicki, Rappley, & Von Eye, 2005; Biederman, Faraone & Monuteaux, 2002; DuPaul, McGoey, Eckert, & VanBrakle, 2001) their role in the onset of ADHD has been less studied than other aspects of the disorder (Johnston & Mash, 2001). Nevertheless, research findings have shown that social risk factors contribute to the difficulties in children and adolescents who already experience behavioral problems (Mathijssen Koot & Verhulst, 1999) or lead to an earlier occurrence of the problems (Nigg, 2006). Therefore, it is plausible to assume that environmental risk factors also play an important role in the expression of ADHD symptoms as problems in the social environment are a universal risk factor for the development and onset of mental disorder (Biederman, 2005; Johnston & Mash, 2001; Sandberg, Rutter, Pickles, McGuinnes, & Angold, 2001). Specifically, research has shown that it is the aggregate of risk factors rather than the presence of a single factor alone that impairs cognitive development (Institute of Medicine, 1988; Rutter, 1988). Accordingly, as adverse risk factors accumulate the degree of impaired outcome may increase proportionally (Cohen, 1968). Previous studies that found an association between psychosocial adversity and the occurrence of ADHD have adopted measures of social risk such as Rutter's indicators of adversity (e.g., Biederman, Faraone & Monuteaux, 2002; Mick, Biederman, Faraone, Sayer, & Kleinman, 2002). This set of indicators includes family conflict, socio-economic status, family size, maternal psychopathology, and paternal criminality (Rutter, Cox, Tupling, Berger, and Yule, 1975). In the current study, we partially draw from such previous set of indicators for social risk by taking into account individual cultural differences. In fact, research findings point out possible differences by race and ethnicity in the prevalence of psychiatric disorders in general and ADHD in particular (Cuffe, Moore, & Me Keown, 2005). Moreover, the lack of resources in schools and of bilingual mental health services can result in obstacles to diagnosis and management of ADHD (Boshert, 2007). Now, reading from research literature on risk factors that are, in various degrees, related to child development, the following were accounted as indicators of adversity: family composition (Rydell, 2009; Vollebergh et ak, 2005), maternal age at birth (Roberts et ak, 2008; Treyvaud et ak, 2009), parents' nationality (Cuffe, Moore, & Me Keown, 2005), child's years of residence in Italy (Vollebergh et ak, 2005) and teachers' reports regarding the presence of discomfort in children lacking family support (Boshert, 2007).

Gender differences

Research findings on the moderator role of gender on the relations between peer functioning and ADHD and between social risk factors and ADHD remain controversial. One reason for this current state of affairs may be the lack of previous studies that include large numbers of diagnosed female participants (see Hoza, 2007). The limited available evidence based on peers' perspectives, suggests that both boys and girls with ADHD are impaired in their peer relationships relative to non-ADHD children. However, results on specific gender differences regarding peer-perceived impairment are not univocal (Mikami, 2010; Hoza, et ak 2005; Pelham, & Bender, 1982). For instance, in a recent study by Zucchetti, Ortega, Schölte, and Rabaglietti (2014) emerged that boys and girls differed in the relationship between ADHD symptoms and best friend conflict. In boys, best friend conflicts were related to the presence of HYP symptoms but not ADD symptoms, whereas in girls best friend conflicts were associated only with ADD symptoms. Anyhow, although this recent study confirms other research on ADHD children friendship (e.g., Blachman & Hinshaw 2002) the gender manifestation of friendship among ADHD children is not completely established.

Low SES/parental education has been associated with ADHD symptoms particularly for boys (Cuffe, Moore, & McKeown, 2005; Rydell, 2009; Sauver, et ak 2004). Furthermore, a broad measure of social disadvantage showed similar patterns for boys and girls regarding ADHD (Rowe, Maughan, Pickles, Costello, & Angold, 2002). Moreover, there have been no investigations, to our knowledge, of gender effects in relations of ethnicity/immigrant background to ADHD problems. Thus, whether peer functioning and social risk factors are similarly related to ADHD symptoms for boys and girls is a relatively open question. In order to shed light on this phenomenon, our study will explore the association among these factors considering the moderating role of gender.

Aims and hypotheses

Therefore, the purpose of this study was to examine the association of negative and positive peer functioning and social/familial adversity on the occurrence of ADHD symptoms among primary school children. Based on previous research literature, we expected to observe a positive association between the presence of problematic and conflictual peer relationship (Loeber, Burke, Lahey, Winters, & Zera, 2000; Taylor, Sandberg, Thorley, & Giles, 1991) and social/familial adversity (Biederman, Faraone & Monuteaux, 2002; Mick, Biederman, Faraone, Sayer, & Kleinman, 2002) with ADHD symptoms. Specifically, we hypothesized that maladjusted peer functioning and the cumulative number of indexes of adversity would be independently associated to ADHD. Last, reading from research findings pointing out to possible gender differences regarding peer-perceived impairment and its relationship with the occurrence of ADHD symptoms (Hoza, et al. 2005; Pelham, & Bender, 1982), we also tested for gender moderate effects of both peer functioning and social/familial risk factors.


Samples and procedures

103 children were sampled for the present study (48 girls, 46.6%; Mage = 8.25; SI) = .62). Parents' countries of origin included various geographical areas, from European, Asian, African, and South-American locations. Table 1 reports descriptive statistics regarding sample's characteristics and measures. The only criterion for inclusion was the informed consent from parents. In addition, we also involved primary school teachers in the study who filled out questionnaires regarding each child.

Questionnaires were submitted in class during school hours in the presence of the teachers and of professional researchers. The latter read each item of the questionnaires to the children, who responded verbally, and indicated their answers. Teachers' questionnaires were submitted individually on a separate occasion. As reported by the teachers, no child was diagnosed with ADHD or any other serious psychopathological disorders at the time the questionnaires were submitted.


Peer functioning

Friendship Quality Scale (FQS; Bukowski, Hoza. & Boivin, 1994). The FQS is a 22-item questionnaire based on a 5-point Likert scale, ranging from 0 = "not true" to 5 = "really true". Children were asked to rate how true each item was for their friendship. The authors originally identified 5 dimensions: Companionship (e.g., "We spend our time together"); Conflict (e.g., "We can argue a lot/my friend and I disagree"); Help (e.g., "My friend helps me if I need it"); Closeness (e.g., "I feel happy when I am with my friend"); and Security measured with two sets of items, one regarding transcending problems (e.g., "If my friend and I have a fight or argument, we can say T am sorry' and everything will be all right"), and the other regarding the reliability of the alliance (e.g., "If I have a problem at school or at home I can talk to my friend about it"). However, a review of the recent literature provides clear evidence for a 2 factorial solution: affection and conflict (Lecce, Primi, Pagnin, & Menzione, 2006; Weimer, Kerns, & Oldenburg, 2004). Internal consistency of these two factors was found to be acceptable in the present study (Cronbach's alpha Conflict = .68; Cronbach's alpha Affection = .81).

Prosocial behavior (Caprara & Pastorelli, 1993). To measure prosocial types of behaviors, children completed a 10-item scale (e.g., "I try to help the others") with answers ranging from 1 (almost never) to 3 (many times). This type of scale has been used elsewhere in populations of primary school children (Pastorelli, Mazzotti, & Prezza, 1988). The scale yielded good internal consistency (Cronbach's alpha =.79).

Aggressive behavior (Caprara, Pastorelli, Barbaranelli, Incatasciato, & Rabasca, 1997). To measure aggressive behavior, children completed a 15-item Likert scale ranging from 1 (almost never) to 3 (many times) to rate how often they engaged in each of the listed behaviors - e.g. non-play fighting, kicking, punching, teasing others and hurting. The scale yielded good internal consistency (Cronbach's alpha =.94).

Emotional and behavioral instability (Caprara & Pastorelli, 1993). To measure emotional and behavioral instability, children completed a 15-item scale (e.g., "I interrupt someone when he/she is talking", "I play noisy games") with answers ranging from 1 (almost never) to 3 (many times). This type of measure has been adopted in previous studies (Caprara, Pastorelli, Barbaranelli, Incatasciato, & Rabasca, 1997) as one overall indicator of these proposed behaviors. The scale yielded good internal consistency (Cronbach's alpha =.90).

Social risk

An overall familial social risk score was calculated based on a composite measure assessing five social risk factors in various degrees related to child development. Each domain was scored on a 3-point scale where 0 represented lowest risk, and 2 represented highest risk to give a total scores 0-10: family composition (0 - two caregivers; 1 - separated parents with shared custody, or cared for by other family members; 2 - single caregiver), parents' nationality (0 - both parents from Italy; 1 - one parent with a different original nationality than Italian; 2 - both parents not originally from Italy), child's years of residence in Italy (0 - bom in Italy; 1 - more than three years; 2 - less than three years), maternal age at birth (0 - more than 21 years old; 1 - 18-21 years old; 2 - less than 18 years old), and teachers' reports regarding the presence of discomfort in children that lacking family support (0 - absence of discomfort; 1 - presence of discomfort; 2 - presence of discomfort and lack of family support). Regarding this latter factor, it was specified to the teachers to indicate those children that they considered in need of specific individual support in class without already receiving it and to further specify whether their families were acknowledging such situation, for example attending parents/teachers meetings at school. Finally, based on these factors, children were categorized as at a lower social risk (total score < 2) or at a higher social risk (total score > 2). This cut-point was based on other composite social risk scales that have been used in previous studies focusing on samples of primary school children and adopting similar categories of social risk (see Roberts et ak, 2008; Treyvaud et al., 2009).


To measure ADHD symptoms we used the ADHD Rating Scale for Teachers (SDAI) (Marzocchi & Comoldi, 2000). The SDAI Scale was designed for use in screening but not for clinical diagnosis. It includes 18 items based on the 18-item ADHD symptoms list from the fourth edition of the Diagnostic and Statistic Manual of Mental Disorder (American Psychiatry Association, 1994). Nine of these items are about inattention (ADD) (e.g., "Has difficulty sustaining attention in tasks or play activities") while the rest are about hyperactivity (HYP) (e.g., "Is on the go or acts as if driven by a motor "). The questionnaire was administered to teachers who were then asked to assesses the frequency of the appearance of the proposed behavior, scoring these answers using Likert scale values from 0 to 3, considering "0" to signify if the child never has a certain behavior, "1" if the child sometimes has a certain behavior, "2" if the child often has this behavior, and "3" if it appears very often. The 18 items were summed up to calculate the total score of the ADHD symptoms. A higher score indicates that the given behavior occurs more frequently therefore no cut-offs were adopted to distinguish among children with higher or lower symptomatology expressions (see Zucchetti, Ortega, Schölte, & Rabaglietti, 2014). Cronbach's alpha for the ADD and HYP subscales were .93 and .94 respectively.


All the scores of the items for each scale were examined for accuracy of data entry, detecting and replacing missing values, identifying univariate and multivariate outliers and dealing with the question. We also examined the data for detecting non normal distribution among dependent variables. Subsequently, correlations were calculated to assess the relations between input variables (age, gender, friendship conflict, friendship affection, pro-social behavior, aggressive behavior, emotional and behavioral instability and social risk) and symptoms of ADHD. The main analyses consisted of multiple hierarchical regressions. The two symptom subscales (ADD and HYP) were used as output variables in separate analyses. Age and gender were covariates in all models and were entered in the first step, friendship conflict, friendship affection, pro-social behavior, aggressive behavior and emotional and behavioral instability, were entered in the second step, and social risk, categorized as at a lower social risk (total score < 2) or at a higher social risk (total score > 2), was entered in step three. In a fourth step we entered the interaction terms between gender and social risk and between gender and each measure of peer functioning. As covariates, age and gender where entered in the first step to control for the portion of explained variance they accounted for ADHD scores since we were specifically interested in the effects of the sets of variables at the second (i.e., peer functioning) and third (i.e., social risk) step. This analytical strategy allowed us to determine whether peer functioning and social risk contributed with unique variance to the two ADHD symptom measures by examining the AR2 statistic. A significant effect of the block of measures in the second step (after the covariates) indicates that the block of measures contributes to the outcome. A significant effect in the third step indicates that the block of measures contributes independently, provided that the block in the second step is also significant. This strategy also gave us the opportunity to examine whether social risk explained additional variance after the measures on peer functioning had been entered, also by examining the AR2 statistic.


Preliminary analysis

No transformation of the distributions was found that could accommodate the model well. Given the significant low rates of missing values on each item of the scales (less than 5%), we performed total mean substitution for each missing value. This decision was also made as no systematic correlation between these missing values and the scores of other variables among these subjects was detected (r<|.20|) (see Raaijmakers, 1999). Prior to the analysis, data was carefully examined for univariate outliers (classified as scores more than three standard deviations above or below the mean; see Hoaglin & Iglewicz, 1987). As a result, no case was excluded from further analysis.

As can be seen in Table 2, correlations among studied variables ranged from .03 to .69. Specifically, the highest negative correlation was found between aggressive behavior and pro-social behaviour (r = -.63, p < .01), whereas the highest positive correction was found between emotional and behavioral instability and aggressive behaviour (r = .69, p < .01). Accordingly, children with high scores on aggressive behavior were more likely to have low scores on pro-social behavior, and children with high scores on emotional and behavioral instability were more likely to have also high scores on aggressive behavior.

Descriptive statistics

The mean of the aggregated score of social risk - based on the sum of the 0 to 2 scores for each of the five risk factors - was equal to 1.59 (SD = 1.47). According to its categorization (i.e., total score <2 = lower social risk; total score >2 = higher social risk), 46 children (44.7%) were categorized as being at a lower social risk while 57 children (55.3%) were categorized as being at a higher social risk. Chi-square test and t-test for independent samples did not show significant differences between the two sub-groups of risk as related to gender composition, X2 (1, 103) = 2.00,/) > .05, and age, ?(103) = -1.48,p > .05.

Results of hierarchical regression models

Multiple hierarchical regression analyses were performed for each ADHD symptom - inattention (ADD) and hyperactivity/impulsivity (HYP) - to evaluate the contributions of peer functioning and social risk factors, controlling for age and gender. The results when peer functioning variables were entered in the second step, social risk (categorized "0" for lower social risk and "1" for higher social risk) in the third step and their interaction terms with gender in the fourth step are presented in Table 3. No interaction term between gender and any of the variables describing peer functioning were found to be significant in explaining scores on ADD and HYP, therefore we decided to not include them in our models of multiple hierarchical regressions.

Together, age and gender at Step 1 contributed significantly to explain variance of both symptoms of ADD (AR2 = .10; F( 1, 102) = 1.91, p > .05 for age effect, and F(1, 102) = 1.92, p < .05 for gender effect respectively), and HYP (AR2= .08; F( 1, 102) = 2.89, p < .01, and F(l, 102) = 3.05, p < .01). Older participants had lower HYP scores, while boys had more chances to have higher scores on both ADHD's symptoms than girls.

Overall, peer functioning variables contributed with significant variance to symptoms of ADD when they were entered in the second step (AR2 = .18,/) < .001; ßs ranging between -.18 and .30). In particular, conflict was found to be the main source of explained variance in ADD's scores among peer functioning variables, F( 1, 102) = 3.43, p < .001. Accordingly, higher scores on friendship conflict increased the probability of having higher scores on ADD. Regarding HYP, only aggressive behavior significantly explained variance in symptoms' scores, /*( 1. 102) = 2.07, p < .05, at Step 2 (AR2 = .08, p > .05; ßs ranging between .Oland .31). Accordingly, higher scores on aggressive behavior increased the probability of having higher scores on HYP.

Regarding social risk, it demonstrated independent contributions to scores on HYP's symptoms, (AR2 = .01,/) > .05; F( 1, 102) = 2.27,p < .05), indicating that higher social risk increased the probability of having higher scores on HYP's symptoms. Lastly, the interaction term between gender and social risk significantly explained variance in HYP's scores, (AR2 = .01,/) < .05; F(1, 102) = -2.27,p < .05). As suggested by (Aiken & West, 1991) the significant interaction was plotted in order to facilitate interpretation (Figure 1). Reading from this last result, we can say that the positive relationship between social risk and HYP scores was especially evident for girls in comparison to boys.


Results from the current study confirmed the presence of a positive association between negative peer functioning and social/familial adversity with the occurrence of ADHD symptoms during primary school years (Biederman, Faraone & Monuteaux, 2002; Loeber, Burke, Lahey, Winters, & Zera, 2000). Specifically, the main contribution of our study was to evidence the independent contributions of relational and environmental risk factors for the occurrence of ADHD symptoms and to point out to gender differences of such relationship.

Our hypotheses about the independent contributions of maladjusted peer functioning and the cumulative number of indexes of adversity, were supported by the findings from this study that showed how both negative peer functioning and social risk factors were associated with ADHD symptoms. Specifically, in the present sample the result of the hierarchical regression models pointed out to the independent contributions of conflictual friendship quality for ADD symptoms and aggressive conduct behaviors for what concerning HYP symptoms. These results are aligned with prior work (Biederman, Petty, Clarke, Lomedico, & Faraone, 2011; Sandberg, Thorley, & Giles, 1991) that showed conduct/aggressive symptoms were associated with the persistence of ADHD well beyond childhood. Children showing symptoms of ADD might also exhibit difficulties regarding their peer relationships due to a degree of inattention towards the needs and feelings of others (Pelham & Bender, 1982). In turn, this may become an obstacle to build positive relationships and a cause of conflict between friends. Indeed, children who take part in daily conflicts and disputes with peers may be more exposed to the risk of inattention and lack of concentration. Moreover, ADD symptoms are linked to social withdrawal and disinterest that are responsible behaviors for less positive friendship engagement and more peer disagreements, especially among girls (Blachman, & Hinshaw 2002). Finally, the association between aggressive behavior and HYP symptoms found in this study confirms the existence of a link between aggression, anti-social behaviors and ADHD (Biederman, Petty, Clarke, Lomedico, & Faraone, 2011; Gillberg et al. 2004).

In addition, our findings add support to previous studies that have found a relationship between the social/familial environment and ADHD (Counts et al., 2005; Biederman, Faraone, & Monuteaux, 2002; DuPaul, McGoey, Eckert, & VanBrakle, 2001; Pressman et al., 2006). In particular, social risk was found to be independent contributors of HYP symptoms especially among females. In general, previous research findings showed that the association between environmental adversity and the risk for ADHD does not differ by gender (e.g., Biederman, Faraone, & Monuteaux, 2002; Faraone et al., 2000). However, despite the fact that ADHD is much more common in males than in females according to all clinical studies published to date, recent studies suggest that ADHD may often be missed in girls (Gillberg et al., 2004). For example, the marked overrepresentation is less pronounced in population studies (Gillberg et al., 2004). Indeed, in our sample we found boys to be significantly more affected than girls for both symptoms of ADD and HYP. However, we did not include children with an existing history of diagnosis regarding any form of psychopathology, therefore our results are limited to non-clinical groups. Also, these results could be related to the specificity of our sample and adopted measures of social risk. Specifically, our findings could be better interpreted by the "gender stereotype" response to different situations and difficulties (Fisher, & Dubé, 2005). For example, Keenan and Shaw (1997) showed that socialization efforts influence the development of girls' psychopathology by channeling early problems into predominantly internalizing and externalizing problems. Moreover, it is possible that girls, especially with an immigrant background, due to their high level of "fragility and sensibility" could experience more stressful feelings connected to their family environments than boys. In turn, such a source of stress may favour the occurrence of higher levels of hyperactivity and instability. Indeed, Short and Johnston (1997) showed that in a population of children from immigrant families living in England lower levels of maternal support were associated to higher adjustment problems only among girls. Thus, our results regarding these specific gender differences should be read in light of the specific risk indexes that were taken into account in order to build an overall assessment of social risk and regarding which specific prior research might lack.

In conclusion, it necessary to remind that this study had several limitations. First, the strict correlational nature of our data does not allow us to report on any specific effects between the variables but it rather represents a descriptive attempt to draw on the relationship between peer functioning and environmental variables from a side and ADHD symptoms from another side. Second, being that only teachers provided ratings we do not know to what extent the behavior problems penetrated out-of-school contexts. This is a specific problem with regard to ADHD, for which the manifestation of symptoms in multiple contexts is important (American Psychiatric Association, 2013). Third, the cross-sectional design precluded proper mediation analyses, which could have shed light on pathways in the associations. Finally, there are numerous important family factors we did not include, such as parental psychopathology, parents' educational level and domestic violence.

Nevertheless, our results not only confirm once again the existence of a relationship between peer problem behaviours and environmental risk factors with the occurrence of ADHD symptoms during childhood, but evidence how relational and environmental factors may both play an independent role for the onset of such psychopathology.

Implications for future research

Overall, the results of the current study highlight the importance of working on the behavioral correlates of ADHD syndrome already in childhood. Indeed, for prevention and early intervention strategies in potentially affected children, possible negative social and familial influences should be taken into account. However, further research is needed to assess the association between peer functioning, social risk and ADHD among children with a formal diagnosis. For example, our results need to be confirmed by future research that will examine possible mediation effects (e.g., psychological feelings) between social risk and ADHD symptoms, according to the gender and other socio-demographic characteristics of the children.



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[Author Affiliation]


University of Turin, Department of Psychology

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E-mail: beatrice.sacconi(S?

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