PSY-07154; No of Pages 7

Psychiatry Research xxx (2012) xxxxxx

Contents lists available at SciVerse ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Association of comorbid anxiety with social functioning in school-age children with

and without attention-decit/hyperactivity disorder (ADHD)
Steve S. Lee a,, Avital E. Falk a, Vincent P. Aguirre b
a
b

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

a r t i c l e

i n f o

Article history:
Received 7 April 2011
Received in revised form 12 January 2012
Accepted 16 January 2012
Available online xxxx
Keywords:
ADHD
Anxiety
Social functioning

a b s t r a c t
Although attention-decit/hyperactivity disorder (ADHD) is frequently comorbid with disruptive behavior
disorders, less is known about ADHD and comorbid anxiety. To improve understanding about the association
of anxiety and social functioning, we studied 223 6 to 9 year-old ethnically diverse boys and girls (M =7.4 years)
with and without ADHD. According to parents, children with ADHD and anxiety (n=46) and ADHD only (n=71)
were consistently less socially competent than comparison children (i.e., no anxiety and ADHD: n =80) and children with anxiety only (n=26), who did not differ from one another. A similar pattern emerged for teacher ratings
where youth with ADHD only and ADHD with anxiety exhibited the most social problems, but they did not differ
from each other. These data suggest that comorbid anxiety does not exacerbate social dysfunction among 6 to
9 year-old children with ADHD. We consider ndings within a developmental psychopathology framework to
further understand social development in children with ADHD and anxiety.
2012 Published by Elsevier Ireland Ltd.

1. Introduction
Attention-decit/hyperactivity disorder (ADHD) is characterized by
an early onset of developmentally aberrant and impairing levels of
inattentive-disorganized behavior and/or hyperactivityimpulsivity.
ADHD prospectively predicts substandard academic achievement,
neuropsychological dysfunction, occupational instability, and substance
problems (Biederman et al., 2006; Lee et al., 2008; Owens et al., 2009; Lee
et al., 2011). Even children who were intensively treated for 14 months
(i.e., careful medication evaluation, integrated parent- and schoolbased interventions) and whose ADHD symptoms improved signicantly,
showed continued impairment into adolescence (Molina et al.,
2008). That is, the clinical signicance of ADHD transcends inattention/
hyperactivity because ADHD persistently compromises socio-emotional
and behavioral functioning over time.
Children with ADHD consistently have higher rates of comorbidity
than typically developing children. The meta-analysis of Angold et al.
(1999) estimated that children with ADHD were 11 times more likely
to have oppositional deant disorder (ODD) or conduct disorder (CD)
than non-ADHD youth and girls with ADHD had more comorbidity
with ODD and CD in childhood and in adolescence than girls without
ADHD (Hinshaw, 2002; Hinshaw et al., 2006). Although comorbid
ODD/CD has been integrated into models of ADHD, there is a gap in
knowledge with respect to the nature of ADHD and comorbid anxiety,
This work was supported by NIH grant 1R03AA020186-01 to Steve S. Lee.
Corresponding author at: Department of Psychology, UCLA, 1285 Franz Hall, Box
951563, Los Angeles, CA 90095-1563, USA. Fax: + 1 310 206 5895.
E-mail address: stevelee@psych.ucla.edu (S.S. Lee).

despite the fact that anxiety frequently co-occurs with ADHD (Biederman
et al., 1991; Schatz and Rostain, 2006). ADHD probands were three times
more likely to have an anxiety disorder than children without ADHD
(Angold et al., 1999) and 33% of the 579 children with combined type
ADHD had an anxiety disorder in the Multimodal Treatment Study
(MTA) of ADHD (MTA Cooperative Group, 1999). In pediatric samples,
ADHD probands were more frequently diagnosed with anxiety than
non-ADHD youth (Bowen et al., 2008) and the proportion of ADHD
probands (27%) exceeded non-ADHD youth (5%) in the prevalence
of multiple anxiety disorders (Spencer et al., 1999). Children with
ADHD and anxiety also show divergent patterns of association, including
sluggish cognitive tempo and response inhibition than children with
ADHD only (Pliszka, 1989, 1992). In the MTA study, children with
ADHD and comorbid anxiety responded more favorably to behavioral
treatment than ADHD children without anxiety (Jensen et al., 2001).
Thus, by virtue of its prevalence and evidence that this group of children
is empirically distinct, further research on children with ADHD and
comorbid anxiety is warranted.
Social dysfunction in children with ADHD is highly intractable to
intervention and it independently predicts and partially mediates
long-term negative outcomes, including later CD and substance problems (Greene et al., 1997; Pelham et al., 2005). There is consistent
evidence that children with ADHD are not only more rejected by
peers (Blachman and Hinshaw, 2002; Hoza et al., 2005), they are perceived by teachers and peers as being less socially competent (DuPaul
et al., 2004), they are prone to positively biased self-perceptions (Hoza
et al., 2002), and they have fewer friendships (i.e., reciprocal dyadic relationship) (Parker and Asher, 1987; Gresham et al., 1998). Further
underscoring its intractability, social dysfunction among children with

0165-1781/$ see front matter 2012 Published by Elsevier Ireland Ltd.

doi:10.1016/j.psychres.2012.01.018

Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018

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

ADHD often persists into adolescence, even if ADHD symptoms improve

(Lee et al., 2008; Owens et al., 2009). Thus, early ADHD catalyzes social
dysfunction that is often more chronic than the constituent symptoms
of ADHD.
Despite evidence that social functioning in children with ADHD and
comorbid aggression is signicantly worse than children with ADHD
only, relatively little is known about whether comorbid anxiety similarly
exacerbates social functioning in children with ADHD (Nijmeijer et al.,
2008). Hoza et al. (2005) observed that studies of social functioning in
children with both ADHD and anxiety [have] not often (if ever) been
studied (p. 11). Similarly, the review of Nijmeijer et al. (2008) on
ADHD and social dysfunction prioritized comorbid ODD/CD and pervasive developmental disorders rather than anxiety. In a recent study of
boys and girls with and without ADHD, child anxiety inversely predicted parent- and teacher-ratings of peer acceptance and social skills
beyond ADHD and ODD, but not according to sociometric nominations
(Mikami et al., 2011). Karustis et al. (2000) found that child- and
parent-rated anxiety signicantly predicted multi-informant ratings of
social problems in a study of school-age children with ADHD. An investigation of 190 children with ADHD and anxiety, anxiety only, ADHD
only, or controls found that comorbid ADHD and anxiety children were
less socially competent according to parent and youth self-report than
each of the other three groups (Bowen et al., 2008). However, this
study utilized a very large age range of participants (817) and limited
comorbid anxiety to panic disorder, generalized anxiety disorder, and
separation anxiety disorder, in addition to social and school phobia.
Further, potential age effects were not accommodated (e.g., covariate,
age predictor interactions), a particularly important consideration
given reliable changes in ADHD over time (Lee et al., 2008). Moreover,
important fear-based anxiety disorders (i.e., obsessive compulsive
disorder (OCD) and post traumatic stress disorder (PTSD)) were not analyzed. Among a subgroup of children with ADHD from the MTA study, comorbid anxiety did not predict social functioning estimated from
sociometric interviews (Hoza et al., 2005). Overall, despite an emerging
literature, methodological differences demand that additional approaches
are required to fully discern critical associations among ADHD, anxiety,
and social functioning. For example, designs that utilize a more narrow
age range of participants would provide an important advance by
circumscribing signicant age-related changes in ADHD, anxiety, and
social functioning. Similarly, rather than use variable-based approaches
(Karustis et al., 2000; Mikami et al., 2011), where clinical signicance is
not readily discerned, studies that utilize diagnostic groups (to complement variable-based approaches) would ensure the clinical relevance of
key constructs (e.g., elevated symptoms plus impairment).
In sum, there is a modest literature on the anxiety and social functioning in children with ADHD with studies to date characterized by important methodological differences (e.g., age range of participants, type of
anxiety disorders ascertained, use of clinical groups versus dimensional
variables). To characterize the precise contribution of anxiety, ADHD,
and their comorbidity on identical measures of social functioning (e.g.,
social problems, negative social preference, social skills) across multiple
informants (i.e., parent and teacher), we rigorously ascertained a large
and ethnically diverse sample of school-age boys and girls with and without ADHD: (1) ADHD and anxiety (ADHD+Anx) (n=46); (2) ADHD
only (n=71), (3) anxiety only (n=26); and (4) comparison youth without ADHD and anxiety (n=80). We hypothesized that the ADHD+Anx
and ADHD only groups would be more socially compromised than
children with anxiety only and comparison youth. In light of the modest
literature, we did not make any directional hypotheses about differences
between ADHD+Anx youth versus children with ADHD only.
2. Methods
2.1. Participants

children (M = 7.4, S.D. = 1.1) with (n = 117) and without ADHD (n = 106) were
recruited through presentations to ADHD self-help groups, referrals from mental
health clinics, and advertisements sent to clinical service providers, pediatric ofces,
and local elementary schools (Table 1). To be eligible for the study, all participants
were required to have a full scale intelligence quotient (IQ) greater than 70, to live
with one biological parent at least half of the time, and to be uent in English.
Exclusion criteria for all participants included a previous diagnosis of an autism
spectrum disorder, seizure disorder, or neurological disorder that prevented full participation in the study.
ADHD diagnostic status (i.e., ADHD versus non-ADHD) was ascertained according to
the Diagnostic Interview Schedule for Children, fourth edition (DISC-IV) (Shaffer et al.,
2000), a fully structured interview with parents keyed to all Diagnostic and Statistical
Manual of Mental Disorders, 4th edition (DSM-IV) criteria (i.e., age of onset, symptom
persistence, cross-situational presence). Families of children with and without ADHD
completed identical screening and testing procedures. To avoid recruiting a non-ADHD
comparison group that may have exaggerated the severity of psychopathology in ADHD
probands, children who met diagnostic criteria for any disorder other than ADHD were
placed in the non-ADHD group. This conservative approach, which is fairly stringent
given that it would likely increase the similarity between the ADHD and non-ADHD
comparison group, has been used in similar studies of childhood ADHD (Lahey et al.,
1998; Hinshaw, 2002).
2.2. Procedures
To determine eligibility, parents completed a telephone screening and eligible
families who were interested in participating were mailed rating scales. After obtaining
parental consent, we mailed the child's primary teacher parallel rating scales. Families
were then invited to our laboratory for in-person assessments. Approximately 85% of
children were unmedicated during the lab visit. Following parental consent and child
assent, parents completed a structured diagnostic interview and rating scales while
children completed tests of cognitive ability, academic achievement, and neuropsychological functioning. Whenever possible, children were assessed without medication.
Similarly, parents and teachers were asked to complete rating scales based on the
child's unmedicated behavior. Interviewers consisted mostly of Ph.D. students in clinical
psychology who had completed graduate coursework in psychological assessment as
well as several BA-level students. All interviewers underwent 2 days of intensive training,
led by the rst author, to standardize administration of measures and interviews. All interviewers were also blind to the child's diagnostic status and the Institutional Review Board
approved all study procedures.
2.3. Measures
2.3.1. Diagnostic Interview Schedule for Children fourth edition (DISC-IV; Shaffer et al.,
2000)
This computer-administered, fully structured parent interview ascertained the
presence of DSM-IV childhood mental disorders. All DSM-IV criteria (e.g., persistence,
age of onset, impairment) were evaluated for each disorder (e.g., anxiety, ADHD). The
DISC-IV is widely used, extensively validated, and psychometrically sound. Testretest
reliability for ADHD from the DISC ranged from 0.51 to 0.64 in the DSM-IV eld trials
(Lahey et al., 1994). A recent review also provided evidence of the DISC-IV's strong
psychometric properties including predictive validity and sensitivity to treatment effects (Pelham et al., 2005). We ascertained eight anxiety disorders with the DISC-IV:
social phobia (n = 6, 2.7%), obsessive compulsive disorder (OCD) (n = 6; 2.7%), generalized anxiety disorder (GAD) (n = 7; 3.1%), post-traumatic stress disorder (PTSD)
(n = 3; 1.3%), separation anxiety disorder (SAD) (n = 14; 6.3%), specic phobia
(n = 55; 16.1%), agoraphobia (n = 1; b 1%), and panic disorder (0.0%). Children were
considered to have an anxiety disorder if they met full diagnostic criteria for at least
one of the eight anxiety disorders we assessed for using the DISC.
2.3.2. Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) for ages 618
(Achenbach and Rescorla, 2001)
The CBCL and TRF are both 113-item rating scales of child psychopathology, competence, and impairment. Each item is scored on a 02 metric. Based on normative data

Table 1
Demographic and clinical characteristics of diagnostic groups.
Variable

Non-ADHD
(n=80)

Anxiety only
(n=26)

ADHD only
(n=71)

Anxiety and ADHD F/Wald

(n=46)

Age
Male (%)
Caucasian
(%)
WISCa
FSIQb

7.41 (1.02)
65
59

7.62 (1.02)
65
57

7.30 (1.13)
70
48

7.20 (1.09)
78
62

3.07
2.63
2.11

108.52
(15.32)

108.83
(14.75)

103.53
(15.06)

107.74 (13.53)

1.43

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

WISC-IV = Wechsler Intelligence Scale for Children, fourth edition.

FSIQ = IQ.
p b 0.05.
b

Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018

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

from 3210 618 year-old children, the CBCL and TRF yield developmentally sensitive
scales of externalizing and internalizing problems as well as competence and impairment.
We specically focused on the social problems narrow band scale (alpha=0.82 and 0.79
for the CBCL and TRF, respectively), which consists of 11 items including Complains of
loneliness and Doesn't get along with other kids.
2.3.3. Dishion Social Preference Scale (Dishion, 1990)
This is a three-item (ve-point metric) measure of peer acceptance, rejection, and
being ignored with parallel parent and teacher forms. Social preference was predicted
from initial sociometric ratings and was signicantly correlated with antisocial behavior
(ASB), depression, and deviant peer association (rs = 0.60, 0.30, and 0.51, respectively)
(Dishion, 1990). We subtracted the reject from the accept rating and then reverse scored
the difference to estimate negative social preference and to approximate Poisson distributions for statistical analyses (alpha= 0.78). This method has been sensitive to group
differences in other studies of ADHD and social preference (e.g., Lahey et al., 2004).
2.3.4. Impairment Rating Scale (IRS; Fabiano et al., 2006)
A total of ve items were completed by parents and teachers to assess children's
need for treatment due to problems in relationships with playmates, siblings, academic
progress, self-esteem, and family using a seven point metric ranging from No problem/
denitely does not need treatment or special services to Extreme problem/denitely
needs treatment or special services. We utilized a single item evaluating how the child's
problems affected his/her relationship with peers. Previous studies reported adequate
1 year testretest stability with different teachers rating the same child (r = 0.39 to
0.63) and acceptable concurrent validity with other impairment scales (Fabiano et al.,
2006).
2.3.5. Social Skills Rating SystemTotal Social Skills Scale (SSRS; Gresham and Elliott,
1990)
Across 20 items, parents and teachers rated children's cooperation, self-control, assertiveness, and responsibility. Based on the normative sample, we analyzed designations of
social skill as being: below average, average, or above average. The SSRS total score has
been used in similar ADHD samples (Lee et al., 2008; Owens et al., 2009) and it demonstrated good discriminant validity (i.e., children with versus without behavior problems)
(Antshel and Remer, 2003).
2.4. Data analytic procedures
To review, our goal was to evaluate social functioning in four groups of children based
on their ADHD and anxiety diagnostic status. To supplement the frequent use of variablecentered strategies in clinical research, our approach reected an increasing recognition
on the value of person-centered methods in developmental psychopathology (Bergman et
al., 2006). We examined the following four groups (note that some children had more
than one anxiety disorder): (1) ADHD plus anxiety (n = 46; 13.0% OCD, 6.5% PTSD,
19.6% SAD, 8.7% social phobia, 15.2% GAD, 78.3% specic phobia), (2) ADHD only
(n = 71), (3) anxiety only (n = 26; 3.8% agoraphobia, 19.2% SAD, 7.7% social phobia,
73.1% specic phobia), and (4) comparison youth (n = 80). Eleven percent (n = 9) and
1% (n = 1) of comparison youth (i.e., neither anxiety nor ADHD) met diagnostic criteria
for ODD and major depression, respectively, according to the DISC. No other diagnoses
were made in this group. First, age and sex, but not race-ethnicity, were correlated significantly with outcome (see Table 2). Consequently, we included age and sex as covariates
for all relevant models. Race-ethnicity was correlated with the SSRS and it was also
included as a covariate. Further, medication status of the child was not covaried in
our analysis given that medication status is likely to reect severity of psychopathology

rather than actual treatment effects due to the intervention selection bias (Larzelere
et al., 2004). That is, without random assignment, treatment effects cannot be rigorously discerned. To accommodate the skewed distributions of several social functioning measures, we utilized Poisson regression using generalized estimating equations
and ordinal logistic regression for the SSRS. For example, skewness statistics included 1.1
for the parent Dishion and 1.8 for the TRF. Third, to evaluate the overall model t for each
social functioning measure, we entered age and sex as covariates and entered diagnostic
group status (ADHD plus anxiety, ADHD only, anxiety only, comparison youth) as a
main effect.

3. Results
3.1. Social problems
Controlling for age and sex, we observed a signicant main effect
for diagnostic group and CBCL social problems (Wald 2 = 102.06,
d.f. = 3, p b 0.001). Pairwise comparisons among the four diagnostic
groups suggested that comparison youth (B = 0.98, SE = 0.11,
p b 0.001) and children with anxiety only (B = 0.82, SE = 0.14,
p b 0.001) had signicantly fewer social problems than children with
ADHD and comorbid anxiety. Both comparison youth and children with
anxiety only had fewer social problems than children with ADHD only
(B=0.73, SE=0.10, pb 0.001 and B = 0.58, SE = 0.14, p b 0.001,
respectively). The ADHD + Anx group had signicantly more social
problems than children with ADHD only (B = 0.25, SE = 0.09,
p b 0.01) (see Table 3).
TRF social problems were also sensitive to diagnostic group differences (Wald 2 = 11.76, d.f.= 3, p b 0.01) whereby children with
ADHD only had signicantly more social problems than children with
anxiety only (B = 0.40, SE = 0.16, p = 0.01) and children with ADHD
and comorbid anxiety had more social problems than comparisons
and anxiety only children (B = 0.27, SE= 0.12, p b 0.05 and B = 0.53,
SE = 0.17, p b 0.01, respectively) (Table 3). No other signicant pairwise
comparisons were observed among the four diagnostic groups.
3.2. Negative social preference
We observed a signicant main effect of diagnostic group for parent
rated negative social preference (Wald 2 = 43.62, d.f. = 3, p b 0.001).
Post-hoc tests revealed that comparison youth (B = 1.04, SE = 0.19,
p b 0.001) and children with anxiety only (B = 1.17, SE = 0.29,
p b 0.001) were less negatively regarded than the ADHD + Anx group
and less negatively regarded than ADHD only youth (B = 0.61,
SE = 0.13, p b 0.001 and B = 0.57, SE= 0.21, p b 0.01, respectively).
Children with ADHD only were similarly negatively regarded by peers
as ADHD + Anx youth (B = 0.11, SE = 0.14, p = 0.42) (Table 2).

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

Age
Sex
Race
ADHD status
Anxiety status
CBCL social problems
Neg. social pref.
SSRS (P)
IRS (P)
TRF social problems
Neg. social pref. (T)
SSRS (T)
IRS (T)

Age

Sex

Race

1
0.06
0.02
0.09
0.01
0.16
0.04
0.03
0.05
0.13
0.13
0.03
0.14

1
0.04
0.10
0.06
0.12
0.16
0.01
0.01
0.09
0.01
0.03
0.12

1
0.03
0.05
0.07
0.02
0.09
0.03
0.11
0.01
0.22
0.01

ADHD
status

Anxiety
status

CBCL social
problems

Neg. social
pref.

1
0.16
0.44
0.36
0.35
0.26
0.13
0.14
0.26
0.17

1
0.20
0.09
0.11
0.02
0.01
0.01
0.01
0.02

1
0.50
0.49
0.56
0.44
0.36
0.26
0.46

1
0.39
0.45
0.29
0.36
0.23
0.44

SSRS (P)

IRS

1
0.48
0.29
0.32
0.25
0.37

1
0.33
0.28
0.31
0.44

TRF social
problems

Neg. social
pref. (T)

1
0.69
0.49
0.63

1
0.52
0.66

SSRS (T)

IRS (T)

1
0.54

Note: ADHD = attention-decit/hyperactivity disorder. CBCL = Child Behavior Checklist. SSRS = Social Skills Rating System. Neg. social pref. = negative social preference.
TRF = Teacher Report Form. (T) denotes teacher version of indicated measure. ADHD status indicates presence or absence of ADHD diagnosis. Anxiety status indicated presence
or absence of an anxiety disorder.
p b 0.05.
p b 0.01.

Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018

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

Table 3
Parent-rated social functioning by diagnostic group.
Variable

A. Non-ADHD
(n = 80)

B. Anxiety only
(n = 26)

C. ADHD only
(n = 71)

D. ADHD + anxiety
(n = 46)

Walda

Contrasts

CBCL social problems

Negative social preference
Impairment Rating Scale
Social Skills Rating System
Non-ADHDb
Anxiety onlyb
ADHD onlyb

2.02 (0.17)
0.62 (0.09)
1.51 (0.15)

2.36 (0.30)
0.54 (0.15)
1.57 (0.30)

4.19 (0.27)
1.53 (0.16)
2.77 (0.24)

5.38 (0.36)
1.74 (0.21)
2.47 (0.27)

A, B b C b D
A, B b C, D
A, B b C, D

2.08

2.99
6.36

8.77
11.43
1.88

102.06
43.63
24.81
23.75

a
b

Signicance based on Poisson regression for dimensional outcomes and logistic regression for Social Skills Rating Scale ordinal data, controlling age and sex.
Pearson chi-square estimates contrasting proportion of children in SSRS low versus average/high group (unadjusted).
p b 0.01.
p b 0.001.

Teacher rated negative social preference was also sensitive to diagnostic group differences (Wald 2 =8.00, d.f.=3, pb 0.05). Interestingly,
children with ADHD only and ADHD and comorbid anxiety were each
more negatively regarded by peers, but only relative to children with
anxiety only (B = 0.45, SE = 0.21, p b 0.05 and B = 0.57, SE = 0.22,
p b 0.01), although a marginal association was also observed for children with ADHD and anxiety relative to comparison youth (B = 0.28,
SE = 0.16, p = 0.08). No other signicant pairwise comparisons were
observed for teacher rated negative social preference (Table 4).
3.3. Social impairment
Parent ratings of children's social impairment showed signicant
variability as a function of diagnostic group (Wald 2 = 24.81, d.f. = 3,
p b 0.001). Once again, comparison youth and children with anxiety
only had less impaired peer relationships than children with ADHD
and anxiety (B = 0.50, SE = 0.15, p b 0.001 and B = 0.46, SE= 0.22,
p b 0.05, respectively). A similar pattern was observed relative to children with ADHD only (B = 0.61, SE= 0.13, p b 0.001 and B = 0.57,
SE = 0.21, p b 0.01, respectively). However, no signicant differences
were observed for the comorbid group versus children with ADHD
only (Table 2). There was no signicant association between diagnostic
group and teacher ratings of social impairment (Wald 2 = 6.30,
d.f.= 3, p = 0.10). To avoid type I error, we did not conduct post-hoc
comparisons among the four groups.
3.4. Social skills
Finally, we evaluated the association of diagnostic group on social
skills using ordinal designations (low, average, high) derived from

the SSRS normative sample. There was a signicant main effect for diagnostic group (Wald 2 = 23.8, d.f. = 3, p b 0.001) where comparison
youth and children with anxiety only (B = 1.73, SE = 0.41, p b 0.001
and B = 1.65, SE = 0.50, p b 0.001, respectively) were more likely to
have average or high social skills than children with ADHD and anxiety. Comparison youth and children with anxiety only were also more
likely to be socially competent (i.e., average or high) than children
with ADHD only (B = 1.24, SE = 0.35, p b 0.001 and B = 1.17,
SE = 0.45, p b 0.01, respectively). No signicant differences were observed between children with ADHD only and the comorbid group,
however (B = 0.49, SE = 0.39, p = 0.21). No signicant association between diagnostic group and teacher ratings of social skills was observed (Wald 2 = 6.16, d.f. = 3, p = 0.10) and no post-hoc
comparisons were made.

4. Discussion
Although children with ADHD exhibit signicant anxiety problems, anxiety has yet to be integrated into theoretical/empirical
models of ADHD to an extent that is commensurate with ODD/CD
(see Schatz and Rostain, 2006 for an exception). We rigorously ascertained 223 ethnically diverse 6 to 9 year-old children using structured
diagnostic interviews and multi-informant ratings of social functioning. Across all parent ratings of social functioning, children with
ADHD + anxiety and children with ADHD only were less socially competent and more socially impaired than comparison youth and children with anxiety only, who did not differ from each other. Findings
were less uniform according to teacher ratings, although children
with ADHD and ADHD + anxiety were the most consistently socially
impaired and there was no difference between the two groups.

Table 4
Teacher-rated social functioning by diagnostic group.
Variable

A. Non-ADHD
(n = 53)

B. Anxiety only
(n = 24)

C. ADHD only
(n = 49)

D. ADHD + Anxiety
(n = 28)

Walda

Contrasts

TRF social problems

2.99 (0.24)

2.33 (0.32)

3.48 (0.27)

3.94 (0.37)

11.76

Negative social preference

Impairment Rating Scale
Social Skills Rating System
Non-ADHDb
Anxiety onlyb
ADHD onlyb

1.75 (0.19)
2.17 (0.21)

1.32 (0.24)
2.48 (0.33)

2.08 (0.21)
2.94 (0.25)

2.33 (0.29)
2.81 (0.33)

8.00
6.30
6.16

A b D;
B b C, D
B b C, D
AbC

0.85

1.37
3.39

1.78
3.80
0.75

a
Signicance based on Poisson regression for dimensional outcomes, controlling for age and sex and logistic regression for Social Skills Rating Scale ordinal data, controlling age,
sex and race.
b
Pearson chi-square estimates contrasting proportion of children in SSRS low versus average/high group (unadjusted).
p b 0.05.
p b 0.01.
p b 0.001.

Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018

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

These results further substantiate that early ADHD strongly predicts

social dysfunction such as peer rejection (Blachman and Hinshaw,
2002) and fewer social skills (Mikami et al., 2007). However, unlike
some previous studies which reported comorbid anxiety negatively
affected social functioning in children with ADHD (Karustis et al.,
2000; Bowen et al., 2008; Mikami et al., 2011), Hoza et al. (2005)
did not nd this association.
Several reasons may have explained the primacy of ADHD versus
the incremental contribution of comorbid anxiety on social functioning. First, unlike previous studies where anxiety mitigated aggressive
behavior and improved inhibitory control among children with ADHD
(Walker et al., 1991; Epstein et al., 1997), our study found that anxiety did not meaningfully affect social functioning in children with
ADHD. That is, anxiety neither exacerbated nor improved social functioning in children with ADHD. Second, ADHD may have explained
substantial variance and thus limited the putative role of anxiety.
Similar effects were observed in two independent samples where
ASB and social information processing decits predicted delinquency
severity and aggression, respectively, more robustly in controls than
in children with ADHD (Lee and Hinshaw, 2004; Mikami et al., 2008).
This pattern was also suggested by Mikami et al. (2011) where anxiety
negatively affected social functioning more robustly in controls than in
ADHD youth. Third, although we employed a reasonably large sample,
we were unable to adopt more rened distinctions among anxiety disorders. For example, all eight anxiety disorders were analyzed equivalently, although this approach may betray important differences
overall and with respect to social functioning specically (Kendall
et al., 2010). Whereas specic phobia is typically characterized by
onset in early childhood, social phobia is associated with a postpubertal onset (Albano et al., 2003), suggesting that different factors
may be implicated in the onset of each disorder. Recent evidence also
identied important structural differences between social phobia,
which was optimally characterized by a single factor, and GAD, which
consisted of two factors (i.e., worry and somatic complaints) (HigaMcMillan et al., 2008). Finally, Hinshaw and Lee (2003) reviewed inconsistent evidence on the role of anxiety in the development of serious
ASB (i.e., exacerbating versus protective role). Beyond diagnostic differences among anxiety disorders, important dimensions of anxiety, including withdrawn/isolated behavior may exacerbate aggression whereas
inhibition/fear may diminish aggression. Overall, the multi-dimensional
and developmentally sensitive nature of anxiety necessitates that future
studies adopt more rened approaches to its measurement in studies of
childhood ADHD (Nigg, 2001).
Given relatively few studies on ADHD and anxiety, methodological
inuences may be salient. First, to prioritize clinical signicance and
person-centered approaches, we evaluated ADHD and anxiety based
on a structured diagnostic interview whereas previous studies used a
variable-centered approach (i.e., incremental contribution of anxiety
beyond ADHD) (Mikami et al., 2011). Although diagnostic ascertainment of anxiety is based on evidence of functional impairment, they
can sacrice statistical power whereas variable-based methods estimate
associations across the entire sample for the average child. Second,
Bowen et al. (2008) utilized a wide age-range of participants (8 to
17 years), but they did not control for age. Prospective longitudinal
studies of ADHD show aggregate stability, but reliable age-related
decreases in ADHD in adolescence as well as important individual
differences in outcome among ADHD youth. Indeed, recent studies of
ADHD have distinguished persistent ADHD from remitters based on
neuropsychological differences (Halperin et al., 2008). That is, as
ADHD is a disorder of development, inferences from cross-sectional
studies, particularly those with wide age ranges, must be done cautiously. Nevertheless, using variable-based approaches, Mikami et al. (2011)
did nd a signicant association of anxiety with social dysfunction in
children with ADHD at a similar age in development with the participants in this study. Similarly, childhood OCD has a mean age of onset
of 10 years and it is chronic as evidenced by the fact that 40% of youth

still met diagnostic criteria for OCD in a 9 year prospective follow-up

(Micali et al., 2010). However, the median age of onset for specic phobia is 7 years (Kessler et al., 2005) and SAD is noted for its early onset
(Albano et al., 2003). Thus, the age of children may inuence the pattern
of anxiety relative to comorbidity, prognosis, and etiology (Chabane et
al., 2005).
Developmental inuences must also be considered when appraising
potential patterns of association for ADHD, anxiety, and social functioning.
This is particularly true given recent work on the role of developmental
cascades for competence and psychopathology (Masten and Cicchetti,
2010). Dened as the accumulation of interactions and transactions
resulting in dispersed effects across multiple systems, anxiety may
interact with childhood ADHD in distinct ways across development.
Lahey et al. (2002a, 2002b) found that increases in CD prospectively
predicted growth in ADHD, ODD, anxiety, and depression. Therefore,
prospective longitudinal designs are necessary to rigorously discern
the timing of effects of anxiety on social dysfunction, including interactive effects with ADHD. This is particularly true given that the negative,
cumulative effects of signicant anxiety may not have been realized at
the early stage in development in this study. That is, children with
ADHD and anxiety may exhibit more social dysfunction than children
with ADHD as the burden of comorbidity increases over time. Coupled
with evidence that ADHD and ODD/CD may be more consequential in
girls than in boys (Loeber and Keenan, 1994), the role of ADHD and
anxiety on social functioning may differ according to sex and developmental period.
We emphasize several important limitations of our study. First,
our limited sample size precluded theoretically relevant tests of interactions with gender and did not allow for alternative methods to
grouping children with anxiety, an important limitation given the
heterogeneity of the latent factor structure of common child anxiety
disorders (Higa-McMillan et al., 2008; Kendall et al., 2010). Second,
although we incorporated a broad array of social functioning measures, our approach may have lacked sufcient specicity for children
with ADHD and anxiety at this stage in development. Future studies
should consider using sociometric interviews and structured interaction
tasks between the target child and peers that may provide additional insight into the nature of peer interactions. Third, our study was unable to
assess whether anxiety differentially affected social functioning in children with combined versus inattentive type ADHD. Solanto et al. (2009)
found that ADHD combined type children exhibited specic dysfunction in cooperation and self-control (relative to inattentive type youth
and controls) whereas inattentive type children lacked assertiveness
relative to combined type youth and controls. Thus, future studies
must consider that the different aspects of social dysfunction may be
differentially distributed among ADHD subtypes. Fourth, medication effects on the variables of interest could not be rigorously discerned given
the non-experimental nature of this study design. For example, potential biases secondary to our instructions to parents and teachers to
rate the children's unmedicated behavior could have inuenced our results. Indeed, given that interventions in non-experimental designs
often correlate positively with psychopathology due to the intervention
selection bias (Larzelere et al., 2004), strong inferences about treatment
effects in this study cannot be made. Finally, some of the psychometric
properties of our instruments were only in the acceptable range, thus
necessitating that future studies consider alternative methods as well,
and our data analytic procedures did not yield estimates of effect size,
potentially limiting the clinical interpretability of our ndings.
Results from this large and ethnically diverse sample of children
with and without ADHD revealed evidence that children with ADHD
only and children with ADHD and comorbid anxiety, who did not differ from one another, were consistently more socially impaired than
children with anxiety only and comparison youth (who also did not
differ from one another). Future research must utilize more rened
approaches to phenotypic classication including ADHD and anxiety
disorder subtypes as well as prospective longitudinal designs to uncover

Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018

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

the timing of potential effects. Clinically, these ndings underscore the

powerful contribution that ADHD makes on social dysfunction, even
relative to other children with clinically signicant psychopathology
(i.e., anxiety disorder). Given the independent and interactive effect
of social dysfunction to negative outcome, particularly among children
with existing psychopathology, interventions must be developed and
delivered that target specic decits in social competence.
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Please cite this article as: Lee, S.S., et al., Association of comorbid anxiety with social functioning in school-age children with and without
attention-decit/hyperactivity disorder (ADHD), Psychiatry Res. (2012), doi:10.1016/j.psychres.2012.01.018