One population that often experiences significant and impairing friendship challenges are individuals with ADHD (Blachman and Hinshaw, 2002; Hoza et al., 2005; Marton et al., 2015; McQuade, 2020). Friendship challenges can be defined as having a lack of friendships, poor quality friendships, and having short or unstable friendships (i.e., friendship instability; Rose and Asher, 2000). Children with ADHD have fewer reciprocated friendships than typically developing (TD) peers (Marton et al., 2015; Mikami et al., 2020).
Friendship quality in children and adolescents with ADHD
In addition to having fewer friendships than TD peers, the friendships of children with ADHD are poorer in quality (Blachman and Hinshaw, 2002; Normand et al., 2013, 2019). Rokeach and Wiener (2020) suggest that the friendships of adolescents with ADHD include more conflict than their TD peers and are less supportive, cooperative, close, and satisfying. Children with ADHD mismanage their friendships in several ways. Friendship relations were rated by children and adolescents (7–13 years) with ADHD as being characterized by higher levels of overt aggression toward others and lower levels of mutual intimate exchange, validation, and caring than the friendships of children in the control group (Normand et al., 2011). Normand et al. (2021) suggest that the core symptoms of ADHD (i.e., inattention, hyperactivity/impulsivity) impact friendship quality. Specifically, the severity of inattentive and hyperactive behaviors may inhibit positive friendship features such as intimacy (e.g., bonding) and increase negative features such as conflict (Normand et al., 2021). In a community sample, Haas et al. (2018) reported that externalizing problems rated by teachers correlated with children and adolescents' self-reports of more negative friendship quality. Similarly, Ackermann et al. (2019) found associations between externalizing problems and fewer positive as well as more negative friendship qualities as reported by children and adolescents on questionnaires. An observational study found that the friendships of children and adolescents with ADHD were characterized by less positive features and more negative features (Normand et al., 2011). After observing children and adolescents with ADHD playing with their friends, Normand et al. (2011) characterized these friendships as less intimate and reciprocal, and identified that play behaviors were less associative and cooperative compared to their TD friends. Children and adolescents with ADHD were less sensitive to their friends' needs and preferences as shown by them choosing their own interests and attempting to control the play (Normand et al., 2011).
Time spent with friends impacts friendship quality (Marton et al., 2015). Masten et al. (2012) suggest that friendship quality and friendship intimacy increase as more time is spent with friends in supportive peer relationships. Compared to TD peers, longitudinal research found that the friends of children with ADHD reported deterioration in their friendship quality (i.e., less positive features, more conflict, and less friendship satisfaction) over a 6-month period (Normand et al., 2013). In comparison, TD children showed improved friendship quality and satisfaction over the same time period. Children with ADHD are reported to spend as much time with their friends as comparison peers at school, but less time with friends outside of school (Marton et al., 2015). Similarly, Heiman (2005) found that only 6% of children with ADHD have their friends over to their homes compared to 30% of comparison children. Friendship quality appears to worsen overtime in ADHD samples (Normand et al., 2013), highlighting the need to effectively understand this construct in this population.
Factors associated with friendship quality and stability in children and adolescents with ADHD
Despite these friendship difficulties, many children and adolescents with ADHD have the interpersonal skills to interact with others (Mikami et al., 2010a); consequently, it is important to investigate why it is that they may have trouble making and maintaining friendships. Although numerous studies focus on the features of friendships of children and adolescents with ADHD (Normand et al., 2013, 2019), there is limited research that predicts why they struggle to make and maintain friendships (Mikami and Normand, 2020; Rokeach and Wiener, 2022). However, reviews of research on friendship suggest several factors that may be associated with friendship quality and stability in children and adolescents with ADHD, including ADHD symptomatology (Normand et al., 2021), executive functioning (Barkley, 2014; Kofler et al., 2011; Tarle et al., 2021), social cognition (Parke et al., 2021), and the friends of children and adolescents with ADHD (Marton et al., 2015).
ADHD symptomatology
Normand et al. (2021) suggest that the severity of ADHD symptoms and externalizing problems play a significant role in the friendship quality (i.e., negative) and stability of children with ADHD; the challenges with distractibility, hyperactivity, and impulsivity in children with ADHD may affect their ability to form and maintain friendships (Lee et al., 2021). First, inattentiveness may limit one's ability to encode social cues and understand and follow the fluidity of a conversation (Sibley et al., 2010) that may in turn make it difficult to respond appropriately (Bunford et al., 2018). Kofler et al. (2011) found that adolescents with ADHD respond less frequently, are less organized in structured and unstructured conversation, are less likely to ask questions of their peers, and are more intrusive in conversation. These behaviors can elicit negative reactions from friends and may lead to difficulties in the formation and maintenance of peer relationships (Kofler et al., 2011). Moreover, inattentiveness to the needs and feelings of a friend or a potential friend may impede the reciprocity, sensitivity, and commitment that are necessary to form and maintain friendships (Normand et al., 2007). Inattentiveness is likely linked with all peer problems in general; however, inattentiveness may be more of a pronounced challenge in friendship than peer rejection or victimization. Children with inattentiveness are more often neglected than rejected by peers, and more often ignored than victimized. It is possible they are neglected and ignored more frequently because they are not showing intrusive or disruptive behaviors that turn peers off. Despite this, for friendship, inattention may be impacting their ability to build trust and disclose sensitive information (e.g., intimacy) that friendships require. It is vital that children demonstrate sustained interest in a peer to make a friend, and then positive friend qualities such as trust and intimacy to maintain the friendship and increase friendship quality.
Second, hyperactivity and impulsivity can lead to unrestrained social behaviors (Gardiner and Gerdes, 2015). Children who are restless, talk excessively, interrupt peers, and do not wait their turn may receive negative peer responses that impact social interactions (Bunford et al., 2018). Moreover, hyperactivity and impulsivity are often associated with rule violation, teasing, controlling, hostile, emotionally elevated, and aggressive behaviors that are poorly tolerated by peers (Hoza, 2007). Lee et al. (2021) examined friendships amongst 558 children in grades K-5 and found that greater ADHD symptoms were related to not only fewer reciprocated friends, but also to fewer unchosen friends, more unreciprocated friendships, and more non-friends. The results suggest that ADHD symptoms are associated with a pattern of unilaterally claiming classmates as a close friend without classmates returning the nomination (i.e., fewer unchosen friends and more unreciprocated friends). The longitudinal findings suggested that children's ADHD symptoms at the beginning of the school year negatively predicted their peer relationships nearing the end, after adjusting for peer relationships at the beginning. Elevated initial ADHD symptoms were related to children's reports of greater relational and overt victimization experiences in the classroom, and poorer social preference when evaluated in the spring (Lee et al., 2021). These results show a pattern of losing unilateral friendships over the course of the school year and increasing isolation from peers. These results are in line with previous findings on deterioration in peer relationships of children and adolescents with ADHD, including greater peer rejection, fewer reciprocated friendships, and poorer friendship quality over time (Normand et al., 2013; Rokeach and Wiener, 2020).
Hyperactive and impulsive behaviors are likely to lead to both peer rejection and poor friendship quality/stability. Many individuals with ADHD enter a conversation using negative group entry strategies (e.g., entering a conversation abruptly, off topic, aggressively) with peers who may be potential friends and due to the behavior are not tolerated. Moreover, a child with ADHD-C/HI may respond emotionally to a peer which does not fit the context and is off putting. If children are not getting past the initial introduction than it is harder becoming friends with another child. Impulsive behaviors such as poor sportsmanship (e.g., not following game rules), complaining, insensitivity to others, and poor emotion regulation may impact friendship quality and stability as it may be getting in the way of showing compassion, intimacy, conflict resolution necessary for friendship stability and quality.
Internalizing and externalizing behaviors
Attention-Deficit/Hyperactivity Disorder has long been associated with increased rates of internalizing and externalizing behavior (American Psychiatric Association, 2022; Fogleman et al., 2018). The prevalence of co-occurring internalizing and/or externalizing disorders concomitant with ADHD range between 40% and 80%, with rates being higher in clinical populations (67%−87%) compared to those in the community (Reale et al., 2017). These co-occurring conditions may exacerbate social difficulties seen in children and adolescents with ADHD. Internalizing behaviors, including depression, anxiety, withdrawal, and loneliness (Fogleman et al., 2018), describe a specific pattern of externalizing disorders that are characterized by failing to manage and cope with feelings of negative emotions effectively. Children and adolescents with ADHD and internalizing behaviors likely have poorer quality and unstable friendships as they may ineffectively assert and defend themselves in social situations (Fogleman et al., 2018), struggle to manage negative emotions, and emotionally react to stressful social situations which can be off putting to friends or potential friends.
Externalizing behaviors, such as aggression, disruption, and opposition/defiance (Fogleman et al., 2018), have also been reported to interfere with friendship making and friendship quality in ADHD (Normand et al., 2021). Emotional outbursts and aggression can impact friendship quality and stability as it can disrupt intimacy and create conflict (Normand et al., 2021). In a sample of 165 children and adolescents (aged 6–11 years) with ADHD, the friendships of children with ADHD and a co-occurring diagnosis of an externalizing disorder had poorer quality than the friendships of children with ADHD and no externalizing disorder (Normand et al., 2020). Similarly, Haas et al. (2018) found that externalizing behavior rated by teachers correlated with children and adolescent's self-report of more negative friendship quality. Externalizing problems may interfere with friendship quality because friendships in childhood are built on shared activities, fairness in play, cooperation, and respect for rules of a game (Normand et al., 2020). Mrug et al. (2007) found that children with ADHD tend to violate the rules of competitive games which is an important predictor of peer rejection in children with ADHD. Children with externalizing problems may demonstrate poor sportsmanship, act self-centered, respond insensitively to friends, fail to appropriately manager peer conflict, respond to peer provocation through aggression, and fail to respect the principle of equity in friendship (Normand et al., 2011, 2016). These behaviors are in opposition of characteristics that form and maintain strong friendships; thus, it is likely that individuals who show these behaviors will have difficulty creating new friendships and maintain their current friendships. Kofler et al. (2017) suggest that behavioral symptoms associated with ADHD may be secondary to underlying neurocognitive impairments such as deficient executive functioning (EF).
Executive functioning
A widely researched area in the ADHD literature is EF (Molitor et al., 2019). EF is a set of higher order cognitive processes required to achieve goal-oriented behavior (Baron, 2018). Despite the frequent use of the term EF in the literature, there has yet to be a widely accepted definition, theoretical model, and composite of constructs (Molitor et al., 2019). The literature includes multiple EF constructs such as inhibition, flexibility, working memory, mental switching/set shifting, initiation, reasoning, fluency, and attention capacity (Baron, 2018). EFs allow an individual to attend to a social interaction, monitor their behavior, and inhibit or modify their behavior according to contextual factors (Barkley, 2014). Theories of ADHD suggest that impairments in EF represent a prominent feature of ADHD and a meta-analysis found that EF challenges are significantly associated with ADHD (Willcutt et al., 2005). EF impairments may hinder children socially and contribute to social/emotional difficulties in children and adolescents with ADHD (Parke et al., 2021), even when accounting for the effect of core ADHD symptoms (Kofler et al., 2017).
The most prominent model of EF in children with ADHD is Barkley's (1997) Theoretical Model of EF, which will be used as the guiding EF theory for the purpose of this paper. Barkley (1997) defined EFs as the self-directed behaviors of the individual that are used to self-regulate, which are covert and happen during the delay in responding. The model proposes that behavioral inhibition is a core feature underlying ADHD and children with ADHD have differences in inhibition compared to those without ADHD (Barkley, 1997, 2012). The model states that behavioral inhibition affects four key EF processes: working memory; self-control/regulation of mood (affect); internalization of speech, and reconstitution. Given that EF is a significant area of research in ADHD, and each process could be reviewed in isolation, the next section will provide a brief description of the processes and their impact on friendship challenges in children with ADHD.
Inhibition
Barkley (2014; p.128) defined behavioral inhibition as “(1) inhibiting the initial response to an event, (2) stopping an ongoing response by delaying the choice to respond, and (3) protecting this delay and responses from competing events and potential responses (interference control).” Barkley (2012) suggests that the primary impairment in ADHD is response inhibition, which delays the internalization of behavior that supports EFs; this delay then impedes self-regulation within the individual. Difficulties with inhibition may impact social interactions as children with ADHD may respond before a question is completed, respond without considering all response options, fail to withhold an inappropriate/irrelevant behavioral or cognitive response, act before considering the consequences of a socially offensive or aggressive behavior, or become easily excited, overly aroused, impatient, or frustrated (Barkley, 2014). If a child or adolescent with ADHD is unable to inhibit an inappropriate joke/comment/aggressive response toward a peer, the behavior may be unexpected, embarrassing, or off-putting to the peer, and may subsequently impact their friendship.
Working memory
As described above, Barkley (1997) hypothesized that inhibition in individuals with ADHD leads to secondary impairments in four EFs. The first EF whose function is linked to inhibition is working memory. Working memory refers to the active, top-down manipulation and processing of information temporarily stored in short-term memory either verbally or non-verbally (Kofler et al., 2020). Kofler et al. (2018) report that working memory is impaired in individuals with ADHD and is linked functionally to both inattentive and hyperactive behavior. Recent research found that up to 85% of children with ADHD have working memory impairments (Kofler et al., 2019). Phillips et al. (2007) propose that working memory is involved in social interactions as individuals must simultaneously process complex stimuli and attend to competing interpretations of social cues. Working memory may impact friendship making and keeping through conversation where individuals are expected to use their (1) phonological short-term memory (i.e., temporary storage of verbal/auditory information), (2) visuospatial short-term memory (i.e., temporary storage/rehearsal of visual and spatial information), and (3) “central” working memory to recall information stored in short term memory (Kofler et al., 2020). These concurrent working memory processes may impact an individual's ability to store, recall, and decode non-verbal social and emotional cues accurately (Phillips et al., 2007). Moreover, working memory deficits may impact social challenges indirectly through ADHD symptoms (i.e., inattention, hyperactivity/impulsivity) due to interruptions (i.e., distractibility, inattentiveness) while attempting to store information in working memory. This finding reflects what is often seen in conversations of children and adolescents with ADHD where they speak and act before an intended verbalization or action fades from memory, rather than listening to and observing what others are saying and doing. If a child or adolescent is unable to recall what others are saying in a conversation, they are likely to be off topic and redirection from peers may be irritating, impacting their relationship and ongoing friendship.
Self-control/regulation of affect
Barkley (1997, 2012) hypothesized that impairment in inhibition also negatively contributes to an individual's ability to self-regulate affect (i.e., emotions) and arousal in goal-directed action. Due to difficulties with inhibition, Barkley (2012) suggests that individuals with ADHD have impairment in the self-regulation of affect otherwise known as emotion dysregulation (ED). ED is difficulty inhibiting and self-regulating emotions to accomplish goals when faced with strong emotions (McQuade et al., 2021), and is a significant contributor to the social impairment experienced by children and adolescents with ADHD (Bunford et al., 2018).
Emotion regulation requires an individual to identify how others are feeling, read social cues for context, and modulate one's emotional response (Tarle et al., 2021). ED may manifest in the lack of awareness, understanding, or acceptance of emotions and in difficulties controlling impulsive behavior, reaching goals, and utilizing emotion regulation strategies when emotional (McQuade et al., 2021). Children and adolescents with EF impairments may have trouble with emotional lability (regulating their emotions), resulting in increased emotional reactivity to immediate events (e.g., emotional outbursts, low frustration tolerance, or becoming disproportionately excited when something pleasant occurs), less anticipatory emotional reactions to future emotionally charged events, and negative emotional responses (Barkley, 2014; Tarle et al., 2021). High levels of negative affect (e.g., frustration, nervousness, sadness, anger, aggression) in their interactions with peers (Normand et al., 2016) are troublesome as friendships require cooperation to ensure that the needs of each party are satisfied when faced with potential friendship dissolution. As such, these two factors (i.e., being uncooperative and demonstrating negative affect) may help explain why children and adolescents with ADHD have trouble maintaining their friendships (Marton et al., 2015; Normand et al., 2013). The less sensitive approach of individuals with ADHD is concerning as sensitivity between friends predicts friendship quality and stability (Normand et al., 2019). Further, children and adolescents prefer friends who express fewer negative emotions, and those who regulate their emotions are seen as more socially competent than those who do not (Hubbard and Coie, 1994). ED has been found to mediate the association between child ADHD symptoms and poorer social skills (Bunford et al., 2015), lower peer acceptance (Gardiner and Gerdes, 2015), and greater peer victimization (Bunford et al., 2018).
Internalization of speech
The third EF process in Barkley's (1997) model refers to an individual's internal dialogue that has an important role in self-regulation of cognition and behavior. Inner speech or verbal thinking is believed to allow for reflection, description, understanding of norms, and self-questioning through language, all of which support the process of problem solving (Barkley, 1997). Internal speech is said to work alongside complex EF such as working memory (e.g., recall, forethought), cognitive flexibility, and planning to contribute to the internalization of rules, social norms, and morals (Alderson-Day and Fernyhough, 2015). Alderson-Day and Fernyhough (2015) suggest that internal speech has a role in numerous domains specifically emotional expression and regulation, planning for social interaction, theory of mind, self-discrimination, fantasy, and creativity. Children and adolescents with ADHD often act without use of previous information to prepare for an upcoming response (e.g., forethought) and lack consideration of the rules and norms within settings (Poissant et al., 2016). In social situations, this can manifest in reacting before thinking without first considering one's behavior (i.e., inappropriate behavior for setting) and others' feelings. These situations may be embarrassing, hurtful, and frustrating to friends of children and adolescents with ADHD.
Reconstitution
The last process in Barkley's (1997) model is reconstitution, which refers to one's ability to analyze and synthesize information and behavior productively. Reconstitution is Barkley's alternative to the planning, problem-solving, and fluency components mentioned in other theories of EF (Barkley, 2012). Impairment in reconstitution may manifest in poor behavioral or verbal fluency, poor rule creativity, or less goal-directed behavioral (Barkley, 1997). In social situations, children and adolescents with ADHD may struggle to respond accurately and efficiently in conversation (e.g., verbally or through physical gestures) and shift to alternative rules to adapt to new situations quickly and constructively. Children with ADHD produce less speech in response to confrontational questions or in solving disagreements, are less organized in story narratives and in describing their own strategies, and are less able to communicate task-essential information to peers in cooperative tasks (Barkley, 1997, 2012). Ongoing and stable friendships require perspective taking, compromise, adaptation/flexibility to new situations, negotiating challenging and conflicting goals between peers, negative assertion (i.e., the ability to assert displeasure or stand up for oneself), and conflict resolution (i.e., the ability to work out disagreements and problem solve; Allen et al., 2014). Each of these skills rely on reconstitution, which may be impaired in children and adolescents with ADHD resulting in challenges in situations with peers that require adaptation and problem solving. If children and adolescents with ADHD are unable to communicate effectively to resolve problems with their peers, the problems may be ongoing and result in friendship dissolution.
Social cognition
Social impairments are frequently reported in children and adolescents with ADHD (Parke et al., 2021). Given the EF challenges in those with ADHD, social impairments can be seen in ineffective social cognition and socio-emotional processes (i.e., perception of emotion from facial recognition; Bora and Pantelis, 2016). Parke et al. (2021) define social cognition as a broad domain including distinct but integrated cognitive abilities required for processing social information and successfully navigating social situations. These include affect recognition, pragmatic language, and theory of mind (ToM), which is the ability to infer and understand another's mental state (Uekermann et al., 2010). A dominant theory that describes social cognitive processes in relation to peer interactions and dyadic friendships is the Social Information Processing (SIP) model developed by Crick and Dodge (1994) that includes six steps: (1) encode social cues, (2) interpret cues, (3) clarify goals, (4) generate possible responses, (5) response decision, and (6) enacting the behavior. The model is cyclical in that there are thought to be feedback loops through which positive (or negative) social outcomes impact children's cognitive/emotional processes and social behavior.
To engage in a social interaction appropriately, an individual must encode social cues, which involves attention, perception of cues, peers' motivation, and emotional competence (i.e., accurate understanding of the emotional state using non-verbal cues including facial expressions, prosody, and gestures; Rose-Krasnor, 1997). These social cues are then interpreted in an accurate and meaningful way. Dodge et al. (1986) suggests that understanding the context (i.e., correctly reading the cues) is vital for social competence, as the individual's response can only be deemed effective or ineffective and competent vs. incompetent based on their knowledge of the situation. Once the situation is interpreted, the person generates possible behavioral responses and evaluates the perceived efficacy and consequences of those responses. The individual then responds with the optimal choice, requiring verbal and motor skills. It is assumed that this model of SIP occurs rapidly, on an unconscious level, and repeats itself.
The SIP model suggests that children and adolescents' comprehension and interpretation of a social interaction influences how they will behave and respond (Crick and Dodge, 1994). Inefficient encoding and comprehension of a social interaction can lead to disruption of social cognition. The speed at which an individual encodes and interprets a social interaction has been associated with social outcomes (Uekermann et al., 2010). Children and adolescents with ADHD demonstrate slower cognitive processing that may hinder their ability to follow a changing conversation, keep up with the demands of the social interaction, and respond appropriately (Bora and Pantelis, 2016). Based on the SIP model (Crick and Dodge, 1994), children and adolescents with ADHD show impairments in social cognition, specifically with encoding a social interaction and choosing appropriate responses (Uekermann et al., 2010).
Impairments in social cognitive abilities such as affect recognition and pragmatic language may also contribute to challenges in social interactions and friendship making (Parke et al., 2021). Affect recognition includes understanding emotions through facial expressions and non-verbal communication cues (i.e., prosody). Many children and adolescents with ADHD have difficulty with pragmatic language (i.e., the social use of language) and are unable to detect the underlying meaning in a conversation (e.g., irony, sarcasm) resulting an inappropriate response or a breach of social rules. These responses often lead to poor social performance and negative peer reactions. Moreover, children with ADHD have difficulty decoding subtle differences in prosody (e.g., pitch, loudness, intensity, intonation), which puts them at a disadvantage given its importance for communicating emotion, emphasis, clarification, and contradiction of word meaning (Rapport et al., 2002).
A successful social interaction requires a child's recognition of emotional expressions and ToM to understand the meaning and intentions of others (Bora and Pantelis, 2016; Uekermann et al., 2010). Children with ADHD may struggle to recognize peers' affect (e.g., emotions or mental states) and have poor facial recognition (Bora and Pantelis, 2016). Evidence suggests that the underlying neurology seen in adolescents with ADHD affects learning of non-social information and can interfere with social emotional information processing (Parke et al., 2021). Parents of children with ADHD indicated that their child demonstrated lack of knowledge of the emotions of their peers (Mikami et al., 2010a). Marton et al. (2009) examined social cognitive characteristics such as social perspective taking (SPT) in children and adolescents aged 8–12 years and found that those with ADHD have poorer SPT skills than children without ADHD, meaning that those with ADHD are less able to see multiple perspectives and are less aware of the impact of their emotions on others compared to TD children. Being able to see multiple perspectives supports friendship characteristics such as understanding, compassion, providing help, and sharing, which all foster intimacy and support required for good friendship quality. If children and adolescents with ADHD are unable to read their friends' affect and are unaware of another's thoughts and feelings, they can't respond in an empathetic and supportive manner necessary for the maintenance of a relationship. It may become frustrating to peers if they must continually explain what they mean, how they feel, or redirect the conversation back to a topic if an inappropriate or off topic response was given.
Friends of children and adolescents with ADHD
Children and adolescents with ADHD do have friends. However, it is crucial to understand who these friends are and how that may affect the friendship quality and stability. Normand et al. (2007) suggests the criteria children typically use in the selection of friends represent challenges for children with ADHD. Research suggests that the friends of children with ADHD have higher levels of ADHD symptoms and oppositional behavior than comparison participants (Normand et al., 2011). These findings mirror those by Marton et al. (2015) who found that children with ADHD had a much higher proportion of friends with either learning or behavioral problems compared to TD peers. Based on the similarity-attraction hypothesis that individuals become friends with those like themselves (Rose and Rudolph, 2006), it is possible that children with ADHD are attracted to and spend more time with other children who exhibit learning, attention, and/or activity levels comparable to them. Marton et al. (2015) suggests that the benefit of friendships is not uniformly positive and that the disruptive and/or deviant behavior of a friend may be detrimental to friendship quality. The friends' behaviors could play a role in explaining the displayed problems in friendship quality that are documented in ADHD populations (Normand et al., 2021). As children and adolescents with ADHD may not have experience with multiple friendships, they may have difficulties realizing their peer's behavior is inappropriate or hurtful. Schneider (2016) explains when a friend shows problem behaviors, it may directly result in poorer friendship quality (e.g., a friend is aggressive and the child with ADHD cannot diffuse the situation). Moreover, friends exert bidirectional influences on each other, resulting in greater similarity over time (Rose and Rudolph, 2006). The bidirectional influence has the potential to be detrimental to positive friendship building as children with ADHD may respond more similarly (e.g., aggressively) to their friends over time and not have access to potential friends who show more prosocial behavior. The friends that children with ADHD choose or have impacts friendship quality and stability (Mikami and Normand, 2020); however, having friends with challenging or deviant behaviors may be better than having no friendships at all.