ArticlePDF AvailableLiterature Review

A Review of Factors that Promote Resilience in Youth with ADHD and ADHD Symptoms

Authors:
  • George Washington University & Children's National Research Institute

Abstract

The vast majority of research on youth with ADHD has focused on risk factors and describing the types of impairment individuals with ADHD experience. However, functional outcomes associated with ADHD are heterogeneous, and although many youth with ADHD experience significant negative outcomes (e.g., school dropout), some are successful in multiple domains of functioning (e.g., pursue and graduate college). There is a growing body of literature supporting the existence of factors that protect youth with ADHD from experiencing negative outcomes, but there is no published synthesis of this literature. Accordingly, the goals of this review are to conceptualize risk–resilience in the context of ADHD using a developmental psychopathology framework and to systematically review and critique evidence for promotive and protective factors in the context of ADHD. The literature search focused specifically on resilience in the context of ADHD symptoms or an ADHD diagnosis and identified 21 studies, including clinic, school, and community samples. Findings of promotive and/or protective factors are summarized across individual, family, and social–community systems. Overall, we know very little of the buffering processes for these youth, given that the study of promotive and protective factors in ADHD is in its infancy. The strongest evidence to date was found for social- and family-level systems. Specifically, multiple longitudinal studies support social acceptance as a protective factor, buffering against negative outcomes such as poor academic performance and comorbid depressive symptoms for youth with ADHD. There was also compelling evidence supporting positive parenting as a promotive factor. In terms of individual-level factors, positive or modest self-perceptions of competence were identified as a promotive factor in multiple studies. Future directions for research that will catalyze the study of resilience with ADHD are provided, and the potential for targeting protective mechanisms with intervention and prevention is discussed.
A Review of Factors that Promote Resilience in Youth with ADHD
and ADHD Symptoms
Melissa R. Dvorsky
1
Joshua M. Langberg
1
Published online: 17 October 2016
ÓSpringer Science+Business Media New York 2016
Abstract The vast majority of research on youth with
ADHD has focused on risk factors and describing the types
of impairment individuals with ADHD experience. How-
ever, functional outcomes associated with ADHD are
heterogeneous, and although many youth with ADHD
experience significant negative outcomes (e.g., school
dropout), some are successful in multiple domains of
functioning (e.g., pursue and graduate college). There is a
growing body of literature supporting the existence of
factors that protect youth with ADHD from experiencing
negative outcomes, but there is no published synthesis of
this literature. Accordingly, the goals of this review are to
conceptualize risk–resilience in the context of ADHD
using a developmental psychopathology framework and to
systematically review and critique evidence for promotive
and protective factors in the context of ADHD. The liter-
ature search focused specifically on resilience in the con-
text of ADHD symptoms or an ADHD diagnosis and
identified 21 studies, including clinic, school, and com-
munity samples. Findings of promotive and/or protective
factors are summarized across individual, family, and
social–community systems. Overall, we know very little of
the buffering processes for these youth, given that the study
of promotive and protective factors in ADHD is in its
infancy. The strongest evidence to date was found for
social- and family-level systems. Specifically, multiple
longitudinal studies support social acceptance as a protec-
tive factor, buffering against negative outcomes such as
poor academic performance and comorbid depressive
symptoms for youth with ADHD. There was also com-
pelling evidence supporting positive parenting as a pro-
motive factor. In terms of individual-level factors, positive
or modest self-perceptions of competence were identified
as a promotive factor in multiple studies. Future directions
for research that will catalyze the study of resilience with
ADHD are provided, and the potential for targeting pro-
tective mechanisms with intervention and prevention is
discussed.
Keywords Attention-deficit/hyperactivity disorder
Protective factors Resilience Promotive factors Risk
Adaptive outcomes Competence Developmental
psychopathology Adjustment
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is char-
acterized by developmentally inappropriate and impairing
inattention and/or hyperactivity and impulsivity (American
Psychiatric Association 2013). ADHD is one of the most
common mental health disorders in childhood, with
prevalence rates of 3–9 % in the USA and worldwide
(Merikangas et al. 2010; Polanczyk et al. 2007). Children
and adolescents with ADHD often experience clinically
significant impairment across multiple domains of func-
tioning (see Barkley 2014, for a review). Numerous studies
have found that ADHD predicts adverse functional out-
comes for youth, including academic failure, delinquency,
conduct problems, family conflict, impaired peer relation-
ships, and chronic health problems (DuPaul and Langberg
&Melissa R. Dvorsky
dvorskymr@vcu.edu
Joshua M. Langberg
jlangberg@vcu.edu
1
Department of Psychology, Virginia Commonwealth
University, 806 W. Franklin Street, Richmond, VA 23284,
USA
123
Clin Child Fam Psychol Rev (2016) 19:368–391
DOI 10.1007/s10567-016-0216-z
2014; Johnston and Mash 2001; Molina et al. 2007; Man-
nuzza et al. 2004; Hoza et al. 2005). Compared to their
non-ADHD peers, adolescents and young adults with
ADHD exhibit higher rates of risky sexual behaviors,
personal injury, risky driving behavior, incarceration,
unemployment, substance use problems, and relationship
impairments (e.g., Barkley et al. 2006; Lee et al. 2011;
Molina and Pelham 2014). Decades of research have
explored risk factors that increase the probability of youth
with ADHD experiencing these negative outcomes, and
multiple risk factors have been identified, such as comorbid
anxiety or depression, executive functioning deficits, par-
ental psychopathology, and conduct problems (e.g., see
Barkley 2014; Becker et al. 2012; Waschbusch 2002 for
reviews).
Although a majority of youth with ADHD experience
social, academic, and family difficulties, a focused look
reveals wide heterogeneity. As a group, youth with ADHD
display considerable variation in the severity and onset of
functional impairment and in the development of comorbid
psychological disorders (Barkley 2014;Wa
˚hlstedt et al.
2009). In fact, a minority of individuals with ADHD lar-
gely avoid these long-term negative outcomes and are
successful in multiple domains of functioning (Biederman
et al. 1998; Lee et al. 2008). For example, longitudinal
studies following youth with ADHD into young adulthood
have found 20–50 % successfully graduate from high
school and pursue college (Barkley et al. 2006; Hechtman
1999; Kuriyan et al. 2013). Indeed, a small body of liter-
ature suggests that there is a subgroup of individuals with
ADHD who function well in some domains despite
impairment in other domains (Lee et al. 2008; Modesto-
Lowe et al. 2011). For example, in a sample of adolescents
with ADHD, Biederman et al. (1998) found that approxi-
mately 20 % were functioning well (i.e., defined as scores
above the 5th percentile of scores in comparison with a
non-ADHD group) across the school, social, and emotional
domains, 20 % were performing poorly in all three
domains, and 60 % displayed mixed outcomes. Recogniz-
ing this heterogeneity has fueled interest in identifying
potential protective mechanisms that contribute to resilient
outcomes for a minority of youth with ADHD.
The goal of this review is to better understand why and
how some youth manifest positive outcomes in the context
of having ADHD or elevated symptoms of ADHD. Within
the developmental psychopathology framework, there is
emphasis on the identification of risk and protective factors
within the youth, family, or social–community systems that
contribute to adjustment over time (see Cicchetti and Curtis
2007; Cicchetti and Toth 2009; Masten 2014). Whereas
risks factors increase vulnerability for negative outcomes,
protective factors serve to buffer a child from negative
outcomes by promoting positive adaptation, even in the
context of risk (Luthar et al. 2000). Investigators studying
resilience examine dynamic pathways to successful as well
as maladaptive outcomes (Wright and Masten 2015).
Findings about protective factors and resilience in the
context of ADHD can be used to promote effective man-
agement of ADHD by building positive assets and
improving contexts that support positive outcomes. How-
ever, presently, we know very little about what distin-
guishes resilient and non-resilient trajectories among youth
with ADHD as research has historically emphasized risk
factors. Considerably less attention has been dedicated to
clarifying how and what protective factors buffer against or
modify the course of ADHD. Understanding protective
factors for positive adjustment in the context of ADHD
may provide a window into processes to be targeted and
enhanced in prevention or intervention efforts to promote
resilient development among this high-risk population.
Objectives of the Empirical Review
This paper will review and integrate the literature on
resilience among youth with ADHD or ADHD symptoms.
Specifically, this review will (1) evaluate empirical studies
that report findings regarding putative promotive and pro-
tective mechanisms when exposed to risk of ADHD or
associated problems among youth with ADHD; (2) identify
key protective mechanisms for different risk contexts that
garner empirical support; (3) synthesize the mechanisms
identified as promotive and protective against ADHD and
associated risk contexts across differential functional out-
comes; and (4) discuss weaknesses of the current state of
the literature as well as promising avenues for future work
that advance our understanding of resilience in the context
of ADHD. Further, this paper will discuss implications for
prevention and intervention efforts aimed at guiding public
policy and social programs to improve outcomes for youth
with ADHD.
Developmental Psychopathology as a Guiding
Framework
This review utilizes a developmental psychopathology
framework (e.g., Cicchetti and Toth 2009;Masten2014)in
order to draw attention to relevant promotive/protective pro-
cesses and methodological considerations. Accordingly, this
next section focuses on briefly defining the developmental
framework terms that will be used to guide this review.
Resilience
Resilience is a broad term that reflects ‘‘positive patterns of
adaptation in the context of adversity’’ (Masten and
Obradovic 2006, p. 14). By definition, resilience requires
Clin Child Fam Psychol Rev (2016) 19:368–391 369
123
both (1) experiencing risk or adversity and (2) having
positive adjustment outcomes despite risk experiences
(Luthar et al. 2000). Resilience is conceptualized within a
dynamic ecological systems framework, encompassing
interactions of many systems across levels, both within and
outside the individual (Masten 2014; Wright et al. 2013).
Resilience has increasingly been recognized as central to
the promotion of mental health, but efforts to identify
factors that promote resilience have been complicated by
differing views regarding the theoretical and methodolog-
ical applications of their effect (Farrell et al. 2011; Luthar
et al. 2006). Initially described in the literature broadly as
‘protective factors,’’ the field has since adopted the terms
promotive effects (also referred to as ‘‘compensatory’’) to
describe main effects and reserves the term protective
effects to describe interactive processes (Masten 2014;
Mikami and Hinshaw 2003). Promotive factors are bene-
ficial to all individuals (i.e., predict positive outcomes
similarly for those at both high and low levels of risk),
whereas protective factors are particularly important at
high levels of risk for mitigating or reducing the effects of
risk on adaptive outcomes (Wright et al. 2013). The key
difference in these two concepts is being whether the factor
had an effect under the context of risk (e.g., presence of
ADHD). Luthar et al. (2000) and Masten and Tellegen
(2012) provide thorough conceptual reviews as well as
illustrative figures to describe the key differences between
promotive and protective effects. As such, for the purpose
of this review, protective will be defined as an interaction
with risk and promotive will be defined as those demon-
strating a main effect.
The very notion of protective mechanisms depends on the
presence of some risk (Obradovic et al. 2012). By definition,
risk signifies an elevated probability of a negative develop-
mental outcome for individuals of a designated risk group
(e.g., youth with ADHD), but it does not indicate the precise
nature of the threat to an individual or differentiate which
individuals with the risk will experience a negative outcome.
Risk is often multifaceted and risk factors frequently co-
occur, often measured by assessments of ‘‘cumulative risk’
(Evans et al. 2013). The examination of multiple risk and
protective factors has been increasingly used by investiga-
tors, beginning with Rutter (1987), who found that it was not
any particular risk factor, but the number of risk factors in a
child’s background that led to disorder and dysfunction. It
should also be noted that risk and protective factors are often
inversely related to each other and in some cases reflect
opposite ends of the same continuum (e.g., poor versus
effective self-regulation skills, low versus high IQ). For the
purposes of this review, risk factors are variables that
demonstrate negative effects on developmental outcomes.
Specifically, risk factors included the presence of an ADHD
diagnosis (i.e., in samples with ADHD and controls), ADHD
symptom severity, and associated problems (e.g., opposi-
tional behavior, depressive symptoms, peer rejection, and
academic failure) in the context of youth diagnosed with
ADHD.
Methodology
The study of resilience comprises decades of research, which
offers several key methodological considerations for studying
protective processes. Most often, investigators test moderat-
ing effects, where a potential moderator variable serves to
buffer, ameliorate or in some other way protect youth from the
full effects of a potential risk factor (Masten 2014). Sometimes
the same construct can function as a promotive and protective
factor, in which case a main effect and an interaction effect
would be present (Luthar et al. 2000). Resilience research has
increasingly recognized the role of developmental systems in
causal explanations of protective processes (Cicchetti and
Curtis 2007; Masten and Tellegen 2012). As such, more
sophisticated modeling strategies have been used to consider
the interactional, transactional, and multiple-level models of
development (Kaplan et al. 2009;Masten2014). These
models allow for testing cross-domain effects of specific
domains for both within-time covariance and across-time
continuity within domains (e.g., see Obradovic et al. 2010;
Masten and Tellegen 2012). Findings from models such as
these have significantly informed treatment approaches aimed
at breaking coercive interactions between parents and their
children and promoting adaptive longitudinal outcomes
(Patterson et al. 2010).
Findings support that a variety of protective processes
across ecological systems should be examined simultane-
ously and longitudinally to better understand individual
differences in developmental pathways and contextual
variation. Longitudinal data assessing multiple time points
are essential for understanding how protective factors
change the developmental trajectories of high-risk youth
(Masten and Tellegen 2012). Cross-sectional studies are an
important initial step in highlighting constructs of interest
and yielding hypotheses about potential processes and
relationships. However, understanding pathways, ‘‘turning
points,’’ and processes related to change require longitu-
dinal data (Masten 2014). Longitudinal models capture the
capacity for change that exists throughout development and
provide valuable insight into the possible processes that
may operate to produce stability or change in functioning.
Fundamental Promotive and Protective Systems
Through their widespread study over the past 50 years, there
are several core protective factors that have universally and
consistently demonstrated promotive and protective effects
across diverse risks, ethnic groups, geographic, and
370 Clin Child Fam Psychol Rev (2016) 19:368–391
123
sociocultural contexts (Masten 2014; Wright et al. 2013).
Masten (2014) has nicknamed this recurrent list of factors
associated with resilience, ‘‘the short list,’’ and posited that
these factors represent fundamental adaptive systems. These
processes have been identified across three broad levels of
influence: (1) individual mechanisms, (2) family systems,
and (3) socialcommunity mechanisms including peers,
teachers, and other adults (see Wright and Masten 2015, for a
review of these constructs). At the most proximal, individual
level, these include intellectual ability, temperament,
autonomy, self-regulation, social skills, self-esteem, coping
strategies, motivation, and cultural beliefs (e.g., Masten et al.
2005; Wills et al. 2007). Family-level protective factors
include family warmth, cohesion, structure, emotional sup-
port, positive styles of attachment, and a close bond with
caregivers (e.g., Farrell et al. 2011; Masten and Obradovic
2006). Other systems involve the broader social–community
context and consist of positive peer relations, social accep-
tance, positive school experiences, religious organizations,
and relationships with prosocial adults in the wider com-
munity (Masten et al. 2005; Vaughan et al. 2010). Each of
these is likely to exert a beneficial influence for youth with
ADHD, but research efforts are needed to evaluate whether
the benefits are due to promotive direct effects, interactions
that buffer the negative effects of risk factors, or meditational
processes in the variability of outcomes. Given these con-
siderations, this review focuses on identifying individual,
family, and social–community promotive and protective
factors in the context of ADHD in order to draw attention to
relevant processes and offer promising avenues for future
work.
Method
Search Procedure and Review Parameters
Pertinent peer-reviewed studies were identified through
keyword searches in major publication databases (e.g.,
PsycINFO, PubMed, and Google Scholar). Search terms
(or word stems) consisted of (ADHD, ADD, attention-
deficit disorder, attention-deficit hyperactivity disorder,
attention problems, inattention, hyperactivity, impulsivity)
and (resilience, resilient, protective factors, competence,
buffer, promotive effects, promote, variable- and person-
focused, positive outcomes). Search terms were also added
to the base terms for each area of developmental domain
assessed (e.g., family, social, and academic). After the
initial search, specific examples of protective and promo-
tive mechanisms (e.g., social support and parenting) were
searched based on the previous findings to ensure com-
prehensiveness. Manual searches of prominent relevant
journals (i.e., Child Development, Developmental
Psychology, Development and Psychopathology, Journal
of Abnormal Child Psychology, Journal of Abnormal
Psychology, Journal of Attention Disorders, Journal of
Clinical Child and Adolescent Psychology, Journal of
Child Psychology and Psychiatry, Journal of Consulting
and Clinical Psychology) were also conducted. Finally, the
reference sections of identified manuscripts were screened
for additional studies. Studies in print or online publication
in English in a peer-reviewed journal between January
1980 and February 2016 were included.
Studies in the present review satisfied the following
inclusion criteria: (1) examined promotive or protective
factors in relation to the risk of ADHD symptom severity
or associated problems in the context of ADHD; (2) par-
ticipants were from a clinical sample (i.e., a diagnosis of
ADHD) or school and community samples where symp-
toms of ADHD
1
(i.e., inattention and/or hyperactivity/im-
pulsivity) were specifically examined as risk factors and
non-ADHD samples were only included if studies specifi-
cally examined interactions between ADHD and other
predictors; (3) all participants aged 18 or younger at
baseline; (4) the study of potentially malleable factors (i.e.,
excluded those limited to fixed factors that may not be
malleable to intervention including IQ, family status, par-
ent education); (5) examined factors outside of those rep-
resenting ‘‘lack of risk’’ (e.g., ‘‘lower symptoms’’ or
‘absence of parent–child conflict’’) or ‘‘lack of ADHD’
(i.e., studies that examined ADHD as an outcome were
excluded); and (6) use of non-intervention data (see Hin-
shaw 2007, for a review of moderators of intervention
outcomes). The only exception was studies that specifically
evaluated and documented that treatment effects were no
longer present and did not demonstrate effects on the
variables examined in the study (e.g., McQuade et al.
2011).
These specific review criteria were selected in order to
examine potential promotive and protective factors across
all levels of the social–ecological model including indi-
vidual and contextual/environmental factors (Bronfen-
brenner 1979). The primary rationale for the systematic
study of resilience is to inform practice, prevention, and
policy efforts directed toward fostering resilience when it is
not likely to occur naturally. As such, only studies of
clearly malleable factors were included, whereas more
fixed factors (e.g., IQ, family status, and parent education
level) were excluded. Importantly, studies examining
1
As highlighted by others (e.g., Fergusson and Horwood 1995), it is
important to note the distinction between categorical and dimensional
approaches to symptoms. Although a focus of this issue is beyond the
scope of this paper, careful language is used throughout the text and
tables to indicate whether studies examined participants with
psychiatric diagnoses, clinical cutoffs, or continuous measures of
symptomatology.
Clin Child Fam Psychol Rev (2016) 19:368–391 371
123
ADHD as the outcome were excluded as they address
different questions about the etiology of ADHD and may
not inform potential intervention strategies. Additionally,
studies that measured the ‘‘absence of risk’’ were not
considered, given that the lack of problems is not sufficient
to describe resilience mechanisms (Masten et al. 2008).
Lastly, for consistency in defining ADHD (i.e., diagnosis
and symptomatology), studies before 1980 were not con-
sidered given the significant changes in symptom criteria
for ADHD with the third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III) in 1980
(American Psychiatric Association 1980).
The first author screened the abstracts of all identified
articles for relevance to the current review, and full-text arti-
cles of pertinent studies were obtained. A total of 179 full-text
articles were obtained and screened by the first author, of
which 158 were excluded for the following reasons: did not
examine promotive or protective factors (n=102); com-
prised of community-based or general population samples,
and did not examine interactions between ADHD and other
predictors (n=13); included adult samples at baseline
(n=4); only studied non-malleable factors (n=19); only
examined absence of risk or lack of ADHD as an outcome
(n=9); and were in the context of interventions (n=11).
In presenting the results in the subsequent section, research
design and representativeness of the samples are specifically
considered. Regarding design, it is important to note whether
the studies are cross-sectional or longitudinal, as well as the
specific developmental period covered (e.g., childhood to
adolescence and adolescence to emerging adulthood). As
described above, longitudinal data are optimal and important
for studying resilience in order to best capture the individual
and context over time. However, given that the study of pro-
tective factors in ADHD is in its infancy, cross-sectional
studies remain informative for some purposes such as high-
lighting constructs of interest and yielding hypotheses about
potential processes and relationships for further longitudinal
research. In reviewing study findings, we also consider how
different sample characteristics might impact the inter-
pretability of the results. Some of the factors considered
include sample composition (e.g., sample of youth diagnosed
with ADHD vs. sample of youth with and without ADHD),
diversity (with respect to race and gender), location (country),
and sample size. Detailed information about sample charac-
teristics and study design is provided in Table 1.
Results
Twenty-one studies met all of the inclusion criteria. Table 1
provides details on the research design, sample composition
and demographics, measures, risk context, promotive/pro-
tective factors, covariates, and results of these studies.
Consistent with developmental frameworks for resilience
(e.g., Luthar et al. 2000;Masten2014), the results are sum-
marized in the text below organized by the three levels of
promotive/protective factors that are central across resilience
work: (a) individual factors, (b) family mechanisms, and
(c) social–community factors. Six studies examined factors
across multiple domains (e.g., individual and family levels); in
these cases,the studies are listed again under each domain. For
each domain, the empirical support for protective and pro-
motive effects is discussed separately, and evidence from
longitudinal studies is presented first given the above noted
limitations associated with cross-sectional research.
Individual Factors
As listed in Table 1, 12 studies examined individual-level
promotive and protective effects against ADHD, ADHD
symptoms, or associated problems. The strongest evidence
to date is for the promotive effect of self-perceptions of
competence, with three studies demonstrating promotive
effects (McQuade et al. 2011; Mikami and Hinshaw 2006;
Schei et al. 2015). There is also preliminary evidence from
cross-sectional studies demonstrating the promotive effects
of academic enabling behaviors and skills (e.g., Martin
2014; Volpe et al. 2006).
Protective Effects
Out of six studies that examined protective effects, only one
cross-sectional study (i.e., Mikami and Hinshaw 2003)
demonstrated the buffering role of an individual mechanism
against ADHD. Mikami and Hinshaw (2003) found that
goal-directed solitary play buffered against ADHD status for
predicting decreased depressed/anxious behavior in a cross-
sectional sample of girls (aged 6–13) with (n=91) and
without (n=58) ADHD. However, when examined in the
follow-up longitudinal study (Mikami and Hinshaw 2006)
5 years later, the same variable actually predicted increased
problem behaviors (internalizing, externalizing, substance
use) in adolescence (aged 11–18), controlling for ADHD
status and childhood (baseline) levels of outcomes in the
model. To explain this contradictory finding, Mikami and
Hinshaw (2006) suggest that goal-directed play may be
adaptive in childhood but becomes increasingly maladaptive
in adolescence as the peer domain becomes increasingly
salient. However, it remains unclear whether solitary play
has a promotive or protective role against ADHD.
Promotive Effects
For promotive effects, one important theme that arose
across individual-level studies was that positive self-per-
ceptions of competence in the context of ADHD promoted
372 Clin Child Fam Psychol Rev (2016) 19:368–391
123
Table 1 Studies examining promotive or protective factors in relation to ADHD
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Individual
Arnold
et al.
(2012)
School-based sample:
N=467 children in pre-
K, Mage =4.66 years,
58 % Black, 29 % White
Cross-
sectional;
variable-
focused
TR Attention
problems (TRS)
TR Aggression
(TRS)
Promotive and
Protective
TR social skills (SSRS)
SR feelings about
school (FAS)
Gender, race/
ethnicity
Preliteracy (WJ-III)
Language (PPVT)
Mathematics (WJ-III)
Promotive effect of social
skills to academics after
controlling aggression and
IA. NS protective effects for
SSRS and FAS when
interacted with IA. Thus,
those with elevated attention
problems were no more or
less protected by SSRS or
FAR than comparisons
Biederman
et al.
(1998)
ADHD and non-ADHD:
N=153 boys, aged
6–17, all White, n=85
persistent ADHD,
n=68 non-ADHD
Longitudinal
(2 waves,
4 years);
person-
focused
Persistent ADHD
diagnostic status
(KSADS)
Promotive
PR T1 emotional
functioning (CBCL)
PR/SR T1 social
functioning (SAI)
Family size, SES,
comorbidity, and
maternal
psychopathology
T2 PR and SR social
functioning (SAI)
T2 PR Emotional (CBCL)
T2 School functioning
Among those with persistent
ADHD, normalized
emotional functioning at
baseline predicted
normalized school
functioning at follow-up, and
normalized social
functioning at baseline
predicted normalized
emotional functioning at
follow-up
Dvorsky
et al.
(2016)
a
ADHD sample: N =93
middle school students
with ADHD ages 10–14,
72 % Male, 78 % White,
16 % Black
Longitudinal
(2 waves,
18 months);
variable-
focused
PR/TR IA (DBD)
PR/TR HI (DBD)
PR/TR ODD
(DBD)
Promotive and
Protective
PR and SR social skills
(SSIS)
Gender,
medication
status, age,
grade, IQ; T1
GPA and T1
impairment
Follow-up School grades
(GPA)
Follow-up TR academic
impairment
NS promotive or protective
effects for SR or PR social
skills for predicting either
follow-up GPA or TR
academic impairment
Latimer
et al.
(2003)
a
ADHD and non-ADHD:
N=174, aged 7–11 at
T1 and 13–17 at T3,
93 % White, 76 % Male,
n=115 ADHD, n=59
non-ADHD
Longitudinal
(3 waves,
6 years);
variable-
focused
ADHD status
(DICA)
Parental
psychopathology
(SCID)
Promotive
Achievement (WRAT,
WJ)
PR, TR, and SR
adjustment (BASC,
PCSC)
Gender, parental
marriage status
Global functioning
Achievement
PR behavioral adjustment
Promotive effect of
achievement for positively
influencing adjustment.
Indirect effect of ADHD
status on global functioning
through latent factor of
emotional/behavioral
adjustment
Clin Child Fam Psychol Rev (2016) 19:368–391 373
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Martin
(2014)
ADHD and non-ADHD:
N=3915 from
Australian junior and
senior high schools, aged
11–18, n=136 ADHD,
n=3779 non-ADHD
peers
Cross-
sectional;
variable-
focused
ADHD diagnostic
status (based on
SR of prior
diagnosis)
Promotive
Prior achievement
Motivation (MES)
Personality (IEBM):
Open, Extravert,
Neurotic, Agreeable,
Conscientious
Specific LD,
parent’s job and
education,
gender, age
SR Failed grade/
repetition (ARRS)
SR School refusal (ARRS)
SR Changing
classes (ARRS)
SR Expulsion/
Suspension (ARRS)
SR Uncompleted
work (ARRS)
Direct effect of motivation on
reduced school refusal.
Direct effect of
agreeableness for decreased
grade repetition, changed
classes, suspensions, and
expulsions. Direct effect of
conscientiousness for
academic failure and
uncompleted work. All
promotive effects present
after controlling for ADHD.
Did not examine interaction
effects
McQuade
et al.
(2011)
ADHD sample: N =88
boys with ADHD, aged
8–12 at T1 and 11–15 at
T2 86 % White, 8 %
Black, 5.6 % other or
mixed
Longitudinal
(2 waves,
3 years);
variable-
focused
ADHD sample
T1 depression
(CDI)
Baseline attribution
styles (CASQ)
Promotive
Change (T1–T2) in SR
competency in
scholastic, social, and
behavioral domains
(SPPC)
TR competency at
T1 and T2
Depression (CDI)
Attribution of negative
events (CASQ)
Attribution of positive
events (CASQ)
SR scholastic, social, and
behavioral competence
promoted decreased
depression controlling for T1
depression. In simultaneous
model, change in social was
the sole predictor of
decreased depression.
Positive changes in SR social
competence promoted T2
attribution of positive and
negative events
Mikami
and
Hinshaw
(2003)
a
ADHD and non-ADHD:
N=149 girls, aged
6–13, 53 % White,
n=91 ADHD, n=58
non-ADHD
Cross-
sectional;
variable-
focused
ADHD diagnosis
Peer rejection
(sociometric, PR
popularity, TR
DSP)
Promotive and
Protective
b
Observations of goal-
directed solitary play
Aggression (TRF)
Depressed/Anxious (CDI,
TRF, CBCL)
Substance Use (SAQ)
Promotive effect of goal-
directed play for decreased
depressed/anxious behavior.
Protective effect for goal-
directed play against ADHD
for predicting depressed/
anxious behavior. All 3-way
interactions ns
Mikami
and
Hinshaw
(2006)
a
ADHD and non-ADHD:
N=209 girls, aged
6–13 at T1 and 11–18 at
T2, 50 % White,
n=127 ADHD, n=82
non-ADHD
Longitudinal
(2 waves,
5 years);
variable-
focused
Childhood ADHD
diagnosis
Peer rejection
(sociometric, PR
popularity, TR
DSP)
Promotive and
Protective
Self-perceived
scholastic
competence (SPPC)
Observations of goal-
directed solitary play
Achievement
(WIAT), T1
externalizing,
T1 internalizing
Externalizing (TRF)
Internalizing (CBCL)
Eating pathology (EDI)
Substance use (SAQ)
When baseline levels of
outcomes were controlled,
promotive effect of self-
perceived scholastic
competence for internalizing,
externalizing and substance
use. Solitary play predicted
greater problem behavior
longitudinally. All
interactions ns
374 Clin Child Fam Psychol Rev (2016) 19:368–391
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Mikami
et al.
(2015)
ADHD sample: N =63
with ADHD, aged 6–10,
67 % male, 81 % White,
9 % Black
Cross-
sectional;
variable-
focused
PR and TR ADHD
symptom severity
Promotive
PR child’s social skills
(SSRS)
PR and TR ADHD
(CSI)
Parental negativity
(observed)
Parental affiliate stigma
After controlling for PR and
TR ADHD, PR social skills
had a promotive effect on
reducing parental affiliate
stigma and parental
negativity. Mediation model
ns
Schei et al.
(2015)
a
ADHD sample: N =194
with ADHD, aged
13–18, 55 % White;
from Norwegian hospital
Cross-
sectional;
variable-
focused
Emotion/conduct
(SDQ)
ADHD symptoms
(PRS, SDQ)
Promotive and
Protective
Individual
competencies (i.e.,
Personal
Competence, Social
Competence,
Structured Style)
(READ)
Age, medication
status
Quality of life (ILC) Latent factor of individual
competencies promoted
quality of life. Indirect
effects for individual
competences mediating the
relation between
emotion/conduct problems
with quality of life. All
interactions ns
Vitaro et al.
(2005)
a
School-based sample:
N=4340, aged 5–6, in
kindergarten at T1, 95 %
Canadian whites,
N=879 used in
analyses
Longitudinal
(2 waves,
15 years);
variable-
centered
Aggression (PBQ)
IA/HI symptoms
(PBQ)
Anxiety (PBQ)
Promotive and
Protective
TR Prosociality (PBQ)
Sex, SES High school diploma
attainment
Promotive effects for PBQ in
predicting high school
completion, with
compensatory role after
controlling for risks of
ADHD symptoms,
aggression, anxiety, and
sociofamily adversity. All
interaction effects were ns.
Thus, those with elevated
ADHD were no more or less
protected by PBQ than
comparisons
Volpe et al.
(2006)
ADHD and non-ADHD:
N=146 grades 1–6,
72 % White, 19 %
Latino, 9 % Black;
n=103 ADHD, n=43
comparison
Cross-
sectional;
variable-
centered
TR ADHD
symptoms (TRS)
TR Conduct
Problems
(BASC)
Promotive
TR engagement,
Interpersonal skills,
motivation and study
skills (ACES)
Control: grades as
measure of prior
achievement
Math and reading
achievement (WJ)
Interpersonal skills and
motivation indirect
(promotive) effects
mediating the relation from
ADHD to math and reading
achievement. Promotive
effects of study skills for
math and reading, and
engagement for predicting
math
Clin Child Fam Psychol Rev (2016) 19:368–391 375
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Family
Chronis
et al.
(2007)
ADHD sample: N =108
with ADHD, aged 4–7 at
baseline and 12–15 at
follow-up, 81.5 % Male,
67 % White/Non-
Hispanic, 27 % African-
American, 6 % Other
Longitudinal
(8 waves,
8 years);
multi-level;
variable-
and person-
focused
PR and TR ADHD
symptoms (DBD)
PR and TR overall
impairment (IRS)
Maternal
depression and
APD (SCID)
Negative parenting
and commands
(DPICS)
Promotive and
Protective
Positive parenting
(praise, positive
affect, physical
positive) from
structured task and
play situation
(DPICS)
Family income,
informants
available (PR
and/or TR),
race/ethnicity,
age, gender, IQ,
and maternal
education
PR and TR conduct
problems at trajectories
and follow-up (DBD)
Positive parenting (during
structured task) promoted
decreased conduct problems.
NS protective effect of
positive parenting in the
context of maternal
depression. For course of
conduct problems over years
2–8: those with highest
positive parenting at T1 had
the lowest conduct over time.
Correlations show positive
parenting via structured task
significantly negatively
associated with conduct at
waves 3–7
Healey
et al.
(2011)
ADHD sample: N =138
with ADHD, aged 3–4,
76 % male, 41 % White,
20 % Hispanic 14 %
Black, 6 % Asian, 19 %
Other
Cross-
sectional;
variable-
focused
PR and TR ADHD
symptoms (ARS)
TR impulsivity
(TABC)
Parent stress (PSI)
PR Inconsistent
and Punitive style
(APQ)
Promotive and
Protective
b
PR Positive parenting
(APQ-P)
Gender, age, SES Global child functioning
(CGAS)
Positive parenting style
promoted global functioning
after controlling for negative
parenting style, ADHD
severity, impulsivity, and
parenting stress (the latter 3
significant). Positive
parenting demonstrated
significant protective effect
with ADHD in predicting
child functioning, after
controlling for inconsistent
and punitive parenting
Hinshaw
et al.
(1998)
ADHD and non-ADHD:
N=133 boys, aged
6–12, 56 % White, 17 %
Black, 11 % Latino,
n=73 with ADHD,
n=60 comparisons
Cross-
sectional;
variable-
focused
ADHD status
Aggression,
isolation
Antisocial behavior
(LCAB)
SR depression
(CDI)
Promotive and
Protective
PR Maternal
authoritative
parenting (IAP)
IQ, reading,
parental psych,
authoritarian,
and permissive
(IAP)
Peer sociometric
nominations
Peer-rated social preference
Maternal authoritative
parenting beliefs had
promotive effect on peer
social preference, after
controlling for ADHD,
aggression, social isolation,
and antisocial behavior.
Authoritativeness 9ADHD
interactions ns
376 Clin Child Fam Psychol Rev (2016) 19:368–391
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Kawabata
et al.
(2012)
School-based sample:
N=2463 students in
grades 1–9 in northern
Taiwan, aged 6–16
Cross-
sectional;
variable-
focused;
multi-level
TR IA, HI, and
opposition
(CTRS)
PR overprotection
(PBI)
Promotive and
Protective
b
PR Maternal
affection/care (PBI)
Age, gender,
maternal
education
PR Academics (SAI)
PR School social problems
(SAI)
PR Negative peer relations
(SAI)
Main effect for IA and
maternal affection on all
outcomes. All moderations
ns, with exception of 3-way
interaction of age, maternal
affection, and IA for school
social problems, such that
maternal affection buffered
IA to social problems for
older children
Latimer
et al.
(2003)
a
ADHD and non-ADHD:
N=174, aged 7–11 at
T1 and 13–17 at T3,
93 % White, 76 % Male,
n=115 ADHD, n=59
non-ADHD
Longitudinal
(3 waves,
6 years);
variable-
focused
ADHD status
(DICA)
Parental
psychopathology
(SCID)
Promotive
Maternal
adjustment/parenting
skill (BASC, BMSA,
FOC)
Gender, parental
marriage status
Global functioning
Achievement
PR behavioral adjustment
For all: maternal
adjustment/parenting skill
(i.e., communication coping
skills, management, parental
control, and family cohesion)
promotes child’s emotional/
behavioral adjustment
Ostrander
and
Herman
(2006)
ADHD and non-ADHD:
N=362, grades 1–4,
79 % male, 95 % White
n=232 ADHD and
n=130 comparisons
Cross-
sectional;
variable-
focused
ADHD status
SR external locus
of control
(BASC)
Promotive
PR parent management
(BMSA)
SR external locus of control
(BASC)
SR/PR depression (BASC,
CDI, CBCL)
Parent management
demonstrated a small direct
(promotive) effect in for
predicting lower depression
for all ages. Parent
management partially
mediated the relationship
between ADHD and
depression
Schei et al.,
(2015)*
ADHD sample: N =194
with ADHD, aged
13–18, 55 % White;
from Norwegian hospital
Cross-
sectional;
variable-
focused
SR
emotion/conduct
problems (SDQ)
ADHD symptoms
(PRS, SDQ)
Promotive and
Protective
SR Family cohesion
(READ)
Age, medication
status
SR Quality of Life (ILC) Promotive effects of family
cohesion for quality of life.
Family cohesion mediates
the relation between ADHD
symptoms, emotional and
conduct problems with
quality of life. All
moderating effects were ns
Theule
et al.
(2011)
ADHD and non-ADHD:
N=95, children aged
8–12, n=50 ADHD
and n=45 comparison
Cross-
sectional;
variable-
focused
ADHD symptoms
and Opposition
(PRS, TRS)
Parental ADHD
Promotive
PR family social
support (FSS)
Gender, age,
parent
education,
marital status
PR Parental stress (PSI) In teacher-rated model, social
support promotes decreased
parent stress, controlling
ADHD symptoms and parent
ADHD. All interactions
effects ns
Clin Child Fam Psychol Rev (2016) 19:368–391 377
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Vitaro et al.
(2005)
a
School-based sample:
N=4340, aged 5–6 at
T1, 95 % Canadian
whites, N=879 used in
analyses
Longitudinal
(2 waves,
15 years);
variable-
centered
PR aggression and
IA/HI symptoms
(PBQ)
PR Anxiety (PBQ)
Promotive and
Protective
PR Parent pleasure,
discipline, and
stimulation (PCRA)
Sex High school diploma
attainment
Parent pleasure discipline had
promotive (main) effects for
high school completion,
demonstrating compensatory
role after controlling for
risks. All interaction effects
were ns
Social/community
Becker
et al.
(2013)
Community-based sample:
N=131, aged 5–13,
53 % Male, 66 %
African-American, 21 %
White
Longitudinal
(2 waves,
1 year);
variable-
focused
TR ADHD
symptoms (DBD)
Promotive and
Protective
b
SR friendship intimacy
exchange (FQQ)
Baseline social
problems (TRF),
age, and sex
(moderator)
Social problems (TRF) Friendship intimacy
demonstrated protective
effect to ADHD for
decreased social problems.
The relation between ADHD
and social problems was ns
for those with high
friendship intimacy
Cardoos
and
Hinshaw
(2011)
ADHD and non-ADHD:
N=228 Girls at
summer day camp, aged
6–12, 53 % White,
n=140 ADHD and
n=88 comparison
Longitudinal
(3 waves,
5 weeks);
variable-
focused
ADHD diagnosis
(DISC)
Externalizing
(CBCL and TRF
composite)
Internalizing
(CBCL and TRF
composite)
PR social (CBCL)
Promotive and
Protective
Peer-rated friendship
presence (i.e.,
presence of at least
one friend)
Friend status (i.e., all
friends with ADHD
vs. at least one
comparison friend)
Peer-rated peer
victimization
For all: friendship presence
promoted decreased
victimization, protective
effects for friendship
presence against
internalizing, externalizing,
and social problems for
victimization. All 3-way
interactions with ADHD and
friendship were ns. Thus,
girls with ADHD were no
more or less protected by a
friendship than comparison
girls
Dvorsky
et al.
(2016)
a
ADHD sample: N =93
middle school students
with ADHD aged 10–14,
72 % Male, 78 % White,
16 % Black
Longitudinal
(2 waves,
18 months);
variable-
focused
PR/TR IA (DBD)
PR/TR HI (DBD)
PR/TR ODD
(DBD)
Promotive and
Protective
b
PR and SR social
acceptance (SPPC)
Gender,
medication
status, age,
grade, IQ; T1
GPA and T1
impairment
Follow-up School grades
(GPA)
Follow-up TR academic
impairment
Promotive effect of SR and PR
social acceptance for
predicting follow-up GPA
and TR academic
impairment. Parent- and
student-rated social
acceptance demonstrated
protective effects to
inattention and increased
grades after controlling for
baseline grades and
intelligence
378 Clin Child Fam Psychol Rev (2016) 19:368–391
123
Table 1 continued
Authors Sample Design Risk context(s) Promotive/protective
factor(s)
Covariates Outcomes Key findings
Mikami
and
Hinshaw
(2003)
a
ADHD and non-ADHD:
N=149 girls, aged
6–13, 53 % White,
n=91 ADHD, n=58
non-ADHD
Cross-
sectional;
variable-
focused
ADHD diagnosis
Peer rejection
(sociometric, PR
popularity, TR
DSP)
Promotive and
Protective
Popularity with adults
(nominated by staff)
Achievement
(WIAT)
Aggression (TRF)
Depressed/anxious (CDI,
TRF, CBCL)
Promotive effect of popularity
with adults for aggression,
but ns effect for depressed/
anxious behavior. Ns
protective effects against
ADHD status
McQuade
et al.
(2014)
ADHD and non-ADHD:
N=349 from MTA
study, aged 8–13 at T1,
78 % male, 65 % White,
15 % Black,
n=226 ADHD and
n=123 comparisons
Longitudinal
(2 waves,
1 year);
variable-
focused
ADHD group
status
Low peer-rated
social preference
T1 depression
(CDI)
Promotive and
Protective
b
Self-perceived social
acceptance (SPPC)
Gender Follow-up SR child’s
depression (CDI)
Follow-up aggression and
conduct (DSM-IV)
Promotive effect of SR social
acceptance on T2 depression
after controlling for effect of
ADHD. NS interactions of
social acceptance and
ADHD. Significant 3-way
interaction: SR social
acceptance protected against
ADHD and predicted
reduced depression for those
with lower peer preference
Mikami
and
Hinshaw
(2006)
a
ADHD and non-ADHD:
N=209 girls, aged
6–13 at T1 and 11–18 at
T2, 50 % White,
n=127 ADHD, n=82
non-ADHD
Longitudinal
(2 waves,
5 years);
variable-
focused
Childhood ADHD
diagnosis
Peer rejection
(sociometric, PR
popularity, TR
DSP)
Promotive and
Protective
Popularity with adults
(nominated by staff)
Achievement
(WIAT),
baseline
externalizing
and internalizing
Externalizing (TRF)
Internalizing (CBCL)
Achievement (WIAT)
Eating pathology (EDI)
Substance use (SAQ)
No significant promotive or
protective effects found
against ADHD status for any
outcomes. Popularity with
adults had ‘‘marginally
significant’’ main effect
(p=.08) and interaction
effect (p=.06) with peer
rejection for achievement
Schei et al.
(2015)
a
ADHD sample: N =194
with ADHD, aged
13–18, 55 % White;
from Norwegian hospital
Cross-
sectional;
variable-
focused
SR emotion and
conduct (SDQ)
PR and SR ADHD
(PRS, SDQ)
Promotive and
Protective
SR Social resources
(READ)
Age, medication
status
SR Quality of Life (ILC) Positive direct (promotive)
effects for social resources
predicting QoL. Indirect
effects of social resources
mediating the relation
between emotional and
conduct problems with QoL.
All interactions ns
Constructs listed under risk context and promotive/protective factor(s) include all those examined in the study. Specific measures/assessment tools are included in parentheses; please see
reference for full measurement descriptions. ADHD sample, samples of participants that were all classified as having an ADHD diagnosis; ADHD and non-ADHD, samples of participants that
include both those who were and were not diagnosed with ADHD; school-based sample and community-based sample, general population samples that were not diagnosed with ADHD; Mage,
mean age of participants, which is only reported when the sample age range is not provided by the authors (e.g., Arnold et al. 2012); ADHD, Attention-deficit/hyperactivity disorder; ns, non-
significant; SR, self- or student-rated/ratings; PR, parent-rated/ratings; TR, teacher-rated/ratings; IA, inattention or attention problems; HI, hyperactivity/impulsivity; SES, socioeconomic status;
LD, specific learning disability; IVs, independent variables; APD, Antisocial Personality Disorder; T1, Time 1 or baseline; T2, Time 2; T3, Time 3; FSIQ, Full-scale Intelligence Quotient;
AUD, alcohol use disorder; NS, non-signficant or no signficant; DUD, drug use disorder
a
Studies that are listed under multiple table headings
b
Studies that demonstrate significant protective effects
Clin Child Fam Psychol Rev (2016) 19:368–391 379
123
against the development of depression or internalizing
symptoms (e.g., McQuade et al. 2011; Mikami and Hin-
shaw 2006) as well as promoted overall quality of life
(Schei et al. 2015). This was demonstrated in studies of
middle childhood to early adolescence (i.e., aged 8–12;
McQuade et al. 2011) and later adolescence (i.e., aged
11–18; Mikami and Hinshaw 2006; Schei et al. 2015). The
strongest evidence for these promotive effects was
demonstrated in two longitudinal studies of adolescents
(McQuade et al. 2011; Mikami and Hinshaw 2006). First,
in a longitudinal sample of boys with ADHD (N=88,
aged 8–12), McQuade et al. (2011) demonstrated the pro-
motive effects of social, scholastic, and behavior/conduct
domains of self-perceived competence against depression,
controlling for baseline levels of the outcomes and teach-
ers’ perceptions of boys’ competency. When these pro-
motive effects were evaluated simultaneously in a single
model, only self-perceived social competence was pro-
motive against depressive symptoms. Another longitudinal
study demonstrated the promotive effects of competence
with a sample of adolescent girls (aged 11–18) with and
without ADHD (Mikami and Hinshaw 2006). Mikami and
Hinshaw (2006) demonstrated promotive effects of self-
perceived scholastic competence for predicting not only
decreased internalizing symptoms, but also externalizing
behaviors and substance use after controlling for actual
levels of academic achievement, ADHD status, baseline
impairment, and peer rejection. An important strength
across each of these promotive studies is the multi-method
and multi-informant design, which included parent, tea-
cher/staff, and youth ratings, as well as behavioral obser-
vations and sociometric nominations.
The only other study to examine the promotive effects
of competence in a sample of youth diagnosed with ADHD
was a cross-sectional study of adolescents (aged 13–18)
with ADHD (N=194; Schei et al. 2015). Specifically, a
latent measure of competence (i.e., self-report of social
competence, personal competence and structured style)
demonstrated a direct effect on quality of life as well as an
indirect effect, mediating the relationship between emotion
and conduct problems with quality of life. These models
controlled for the effects of age, sex, ADHD symptom
severity, medication status, and family variables.
Preliminary evidence from three cross-sectional studies
also supports the promotive effects of several ‘‘academic
enabling’’ behaviors or skills (e.g., motivation, study skills,
engagement, interpersonal skills, and social behavior) for
promoting positive academic performance after controlling
for ADHD (Arnold et al. 2012;Martin2014;Vitaroetal.
2005; Volpe et al. 2006). However, findings were mixed
across studies with some academic factors demonstrating
promotive effects for a particular outcome, but not others, and
no studies finding protective effects against ADHD. For
example, motivation demonstrates promotive effects for math
and reading achievement among elementary school-aged
children with (n=103) and without ADHD (n=43; Volpe
et al. 2006), but not against more ecological outcomes such
academic failure, repeating a grade, and uncompleted work
among middle and high school-aged adolescents with
(n=136) and without ADHD (n=3779; Martin 2014).
Importantly, all these studies were cross-sectional, with the
exception of one that included two data points (Vitaro et al.
2005). Further, these studies included combined samples of
youth with and without ADHD (Martin 2014; Volpe et al.
2006) as well as general school-based samples (Arnold et al.
2012; Vitaro et al. 2005). Overall, there was mixed support for
academic enablers as promotive factors, depending on the
sample characteristics and area of academic adjustment
examined.
Interestingly, across all of the studies identified in this
review, no study demonstrated protective effects for social
skills, and several studies found either no effect or a small
effect for the promotive role of social skills (Mikami et al.
2015; McQuade et al. 2014; Dvorsky et al. 2016) when
examined across a variety of risk contexts and outcomes.
Only two studies (Arnold et al. 2012; Vitaro et al. 2005)
found promotive effects of social skills, and these were in
general school-based samples of preschool children. Further,
when examined in a sample of youth diagnosed with ADHD
(Dvorsky et al. 2016), parent- and adolescent-rated social
skills did not demonstrate promotive or protective effects
with follow-up academic outcomes. As such, there is no
evidence that social skills serve as a protective or promotive
factor for children or adolescents diagnosed with ADHD.
Family Factors
Nine studies examined family-level promotive and pro-
tective effects. The strongest evidence to date is for posi-
tive parenting, with seven studies demonstrating the
promotive effects of positive attitudes, parenting behaviors/
style, emotional support/intellectual stimulation, and
affection (Chronis et al. 2007; Healey et al. 2011; Hinshaw
et al. 1998; Kawabata et al. 2012; Latimer et al. 2003;
Ostrander and Herman 2006; Vitaro et al. 2005) and two of
these studies demonstrating protective effects (Healey et al.
2011; Kawabata et al. 2012). Preliminary evidence from
cross-sectional studies also supports the promotive effects
of family environment factors for promoting positive
adjustment after controlling for ADHD symptom severity
(Schei et al. 2015; Theule et al. 2011).
Protective Effects
Out of six studies that examined protective effects of
family mechanisms, only two cross-sectional studies
380 Clin Child Fam Psychol Rev (2016) 19:368–391
123
(Healey et al. 2011; Kawabata et al. 2012) demonstrated
the buffering role of positive parenting against ADHD.
First, in a sample of pre-K children (N=138; aged 3–4)
diagnosed with ADHD, positive parenting protected
against parent- and teacher-rated ADHD symptom severity
in predicting participants’ overall functioning, after con-
trolling for inconsistent and punitive parenting (Healey
et al. 2011). In contrast to evidence supporting positive
parenting in early childhood, Kawabata et al. (2012) found
a significant three-way interaction between maternal
affection, inattention, and age such that maternal affection
buffered the association between inattention severity and
social problems only for older children (grades 4–6).
Importantly, this finding is in the context of a large school-
based sample of Taiwanese youth (N=2463; grades 1–9)
and may not generalize to other samples of youth diag-
nosed with ADHD.
Promotive Effects
The majority of evidence for positive parenting is in the
context of early childhood samples (aged 3–7), with one
exemplar longitudinal study examining latent develop-
mental trajectories of behavior spanning from early child-
hood to adolescence (Chronis et al. 2007). Specifically, in a
longitudinal study of young children diagnosed with
ADHD, positive parenting behaviors during a structured
observation task (at aged 4–7) significantly promoted
against the development of comorbid conduct problems
over the course of 8 years into adolescence (Chronis et al.
2007). Importantly, this model controlled for medication
status, demographic characteristics (i.e., family income,
race/ethnicity, age, gender, IQ, and maternal education),
maternal depression as well as baseline levels of ADHD
symptoms, conduct problems, and overall impairment. A
significant strength of this study is the use of objective
observation measures of parenting behaviors as opposed to
subjective parent ratings. Two other longitudinal studies
demonstrate the promotive role of positive parenting con-
trolling for the risk of ADHD, including one comprised of
youth with and without ADHD (Latimer et al. 2003) and
one general population sample of preschool-aged youth
(Vitaro et al. 2005). Both studies found that regardless of
the presence of risk of ADHD symptoms, positive parent-
ing was promotive of positive adjustment for all youth (i.e.,
with and without ADHD), after controlling for the effects
of ADHD diagnostic status or symptom severity.
Four additional cross-sectional studies found support for
the promotive effects of positive parenting (Healeyet al. 2011;
Kawabata et al. 2012; Hinshaw et al. 1998; Ostrander and
Herman 2006). First, in a cross-sectional sample of young
children (aged 3–4) diagnosed with ADHD (N=180), par-
ent-rated positive parenting promoted global child
functioning after controlling for negative parenting style,
parent- and teacher-rated ADHD symptom severity, teacher-
rated impulsivity, and parent stress. Two additional cross-
sectional studies found evidence for the promotive effects of
parenting style in children with and without ADHD (Hinshaw
et al. 1998; Ostrander and Herman 2006). Maternal authori-
tative parenting promoted peer-rated social preference after
controlling for the risk effects of ADHD diagnostic status,
social isolation, aggression, and antisocial behavior as well as
relevant covariates (i.e., IQ, achievement, and parental psy-
chopathology) in a sample of boys (aged 6–12) with (n=73)
and without ADHD (n=60; Hinshaw et al. 1998). The
authors examined interactions with ADHD status and
authoritative parenting; however, no significant interactive or
protective effects were found. In another cross-sectional study
of youth (grades 1–4) with (n=232) and without ADHD
(n=130), a broad measure of parent management demon-
strated a small promotive effect against depression and par-
tially mediated the relationship from ADHD diagnostic status
to depression (Ostrander and Herman 2006). Lastly, Kawa-
bata et al. (2012) found a promotive effect for parent-rated
maternal affection in predicting decreased concurrent aca-
demic problems, school social problems, and negative peer
relations, after controlling for the risk of ADHD in school-
based sample of Taiwanese students (N=2463).
Preliminary evidence from two cross-sectional studies
also supports family environment factors, including family
cohesion and support, in promoting positive adjustment for
adolescent samples across a variety of risk contexts
including youth with ADHD (Schei et al. 2015) and sam-
ples comprised of youth with and without ADHD (Theule
et al. 2011). The strongest evidence is from Schei et al.
(2015), who demonstrated that in a sample of adolescents
with ADHD (N=194; aged 13–18), family cohesion not
only had a direct effect for promoting adjustment after
controlling for ADHD symptoms, age and medication
status, but also mediated the relations between ADHD
symptom severity and quality of life. Family cohesion also
mediated the association between self-reported emo-
tion/conduct problems and quality of life, controlling for
ADHD symptoms, age, and medication status (Schei et al.
2015). In another study of children (aged 8–12) with
(n=50) and without ADHD (n=45), family social
support promoted decreased parental stress in the context
of controlling for parent- and teacher-rated ADHD symp-
toms and oppositional behavior as well as relevant demo-
graphic characteristics (i.e., gender, age, parent education,
and marital status) in the model (Theule et al. 2011).
Social–Community Factors
Across the seven studies identified, the most compelling
evidence comes from four longitudinal studies
Clin Child Fam Psychol Rev (2016) 19:368–391 381
123
demonstrating the role of friendship presence, friendship
quality, and peer acceptance for protecting or promoting
positive adjustment in the context of ADHD symptoms
(Becker et al. 2013; Cardoos and Hinshaw 2011; Dvorsky
et al. 2016; McQuade et al. 2014).
Protective Effects
All seven studies included analyses to examine protective
mechanisms in the context of ADHD or ADHD symp-
toms; however, only three found protective effects
(Becker et al. 2013; Dvorsky et al. 2016; McQuade et al.
2014). The strongest evidence for social protective factors
was found for social acceptance, demonstrating protective
effects in a sample of adolescents diagnosed with ADHD
(i.e., Dvorsky et al. 2016) as well as a sample of ado-
lescents with and without ADHD (i.e., McQuade et al.
2014). First, in a longitudinal sample of 93 adolescents
(aged 10–14) diagnosed with ADHD, Dvorsky et al.
(2016) demonstrated that the relationship between inat-
tention symptom severity and low grades was attenuated
for adolescents with high social acceptance, even after
controlling for baseline grades and intelligence. Models
examined both parent and adolescent ratings of social
acceptance and demonstrated ‘‘protective-enhancing’
effects (e.g., Luthar et al. 2000) such that adolescents’
competence in grades is augmented by social acceptance
even with increasing risk of inattention. Social acceptance
also demonstrated protective effects in longitudinal sam-
ple comprised of youth (aged 8–13) with (n=226) and
without (n=123) ADHD from the Multimodal Treat-
ment of ADHD (MTA) study (McQuade et al. 2014).
Specifically, a significant three-way interaction arose for
peer preference 9self-perceived social accep-
tance 9ADHD in predicting depression and aggres-
sion/conduct, controlling for gender and baseline levels of
depression and aggression/conduct. Specifically, for youth
with ADHD and low peer preference, higher self-per-
ceived social acceptance protected against increases in
depression; however, for predicting aggression/conduct,
high peer preference and having a more modest percep-
tion of competence were protective for those with ADHD.
Interestingly, self-perceived social acceptance did not
demonstrate protective effects against ADHD status via
two-way interactions for predicting depression or
aggression/conduct. Lastly, a longitudinal study using
community-based sample of youth at risk for disruptive
behavior disorders (aged 5–13) demonstrated that high
friendship intimacy buffers against ADHD symptom
severity in predicting future teacher-rated social problems,
after controlling for baseline social problems (Becker
et al. 2013). This model also controlled for differences
across age and sex of participants.
Promotive Effects
Three longitudinal studies demonstrate the promotive
effects of social mechanisms (Dvorsky et al. 2016; Cardoos
and Hinshaw 2011; McQuade et al. 2014). First, in longi-
tudinal sample of adolescents with ADHD, parent- and
adolescent-rated social acceptance promoted increased
grades and decreased teacher-rated academic impairment at
follow-up, after controlling for ADHD symptom severity,
oppositional behavior, IQ, and baseline functioning of the
outcomes in each of the models (Dvorsky et al. 2016).
Second, in a sample of youth with and without ADHD,
McQuade et al. (2014) demonstrate that self-perceived
social acceptance promoted decreases in subsequent
depression after considering the direct effect of ADHD and
baseline depression. Third, Cardoos and Hinshaw (2011)
also demonstrated the promotive effects of friendships in a
longitudinal sample of girls (aged 6–12) from a summer
day camp (n=140 with ADHD, n=88 comparison).
Specifically, friendship presence promoted decreased peer
victimization after controlling for internalizing symptoms,
externalizing behaviors, and social problems; however, no
significant interactions between friendship and ADHD
status were found (Cardoos and Hinshaw 2011). Although
this was a short-term longitudinal study (5 weeks),
friendships were measured via sociometric and peer nom-
ination methods, which are considered the gold standards
for assessing these domains.
Two additional cross-sectional studies provide evidence
for broad social support and resources promoting positive
outcomes (Schei et al. 2015; Mikami and Hinshaw 2003).
The strongest of these comes from a study of adolescents
diagnosed with ADHD (aged 13–18), which found direct
and indirect promotive effects of a self-reported latent
construct of social resources for predicting quality of life
(Schei et al. 2015). Another study by Mikami and Hinshaw
(2003) demonstrated mixed effects for popularity with
adults, measured using nominations from summer camp
staff in a sample of youth with and without ADHD.
Specifically, in the cross-sectional study (Mikami and
Hinshaw 2003), after controlling for ADHD status, popu-
larity with adults demonstrated promotive effects for
reducing aggression, but not for depressed/anxious behav-
ior. However, in the follow-up longitudinal study (Mikami
and Hinshaw 2006), no significant promotive or protective
effects of popularity with adults were found at aged 11–18.
Discussion
The purpose of this review was to evaluate the extant lit-
erature regarding the role of promotive and protective
factors in relation to the functioning of youth with ADHD
382 Clin Child Fam Psychol Rev (2016) 19:368–391
123
or dimensional ADHD symptoms. The number of studies
that were relevant to this particular review was limited
(N=21), qualifying the strength of any conclusions that
can be drawn. Further, differing findings were sometimes
observed across various risk contexts, promotive/protective
mechanisms, and outcome domains. Nevertheless, a num-
ber of interesting trends emerged that have important
implications for future research. The strongest evidence to
date for promotive and protective factors in the context of
ADHD was found across social and family systems.
Specifically, several longitudinal studies demonstrate the
protective effects of social–community factors. Further,
while only two cross-sectional studies demonstrate pro-
tective effects of family-level factors, several longitudinal
studies found promotive effects.
For social–community-level factors, the strongest lon-
gitudinal evidence was for social acceptance. Specifically,
social acceptance buffered against inattention in predicting
higher school grades in a sample of adolescents with
ADHD (Dvorsky et al. 2016) and buffered against a
diagnosis of ADHD in predicting reduced depressive
symptoms in a sample of youth with and without ADHD
(McQuade et al. 2014). Becker et al.’s study (2013) was the
only other longitudinal study to find a protective effect for
a social–community factor. In that study, friendship inti-
macy buffered against ADHD symptoms in predicting
decreased social problems (Becker et al. 2013). There is
also preliminary cross-sectional evidence for friendship
presence, social support, and quality relationships pro-
moting positive adjustment in the context of ADHD
symptoms. Social–community factors such as social com-
petence and positive peer relationships are significantly
related to youth’s ability to adapt to life stressors (Masten
and Coatsworth 1998). Friendships provide support sys-
tems that can foster positive emotional, social, and aca-
demic adjustment (Rubin 2002). Decades of research also
support important elements of effective community envi-
ronments, including positive role models from prosocial
adults in the community, participation in community
organizations, and supportive teacher relationships as
having a protective influence on youth (Karapetian and
Gradoes 2005). Interestingly, the majority of studies
examining social mechanisms included samples of middle
childhood, with only three studies examining adolescent
samples (Dvorsky et al. 2016; Mikami and Hinshaw 2006;
Schei et al. 2015). Given the increased saliency of peer
relationships during adolescence (Lerner and Castellino
2002), it is important to study the role of these mechanisms
with older adolescent samples as well. Social–community
mechanisms were also limited to peer relationships or
support, with fewer studies evaluating the role of rela-
tionships with adults such as teachers (Mikami and Hin-
shaw 2003,2006). Future research should examine other
social–community mechanisms in the context of ADHD,
such as teacher–student relationships, school environment,
neighborhood, and community factors, all of which have
been identified as promotive or protective in the general
population (Masten 2014; Wright et al. 2013).
Although evidence for protective effects of family-level
factors is limited to two cross-sectional studies (Healey et al.
2011; Kawabata et al. 2012), there is compelling longitudinal
evidence for the promotive effects of positive parenting for
youth diagnosed with ADHD (e.g., Chronis et al. 2007;Hin-
shaw et al. 1998). Preliminary cross-sectional evidence is also
available for family cohesion and support for promoting
positive outcomes for adolescents with ADHD (Schei et al.
2015;Theuleetal.2011). Overall, these findings suggest that
specific positive parenting mechanisms are critical during
early ages, and family cohesion/support may be especially
relevant during adolescence. These findings are consistent
with decades of research, demonstrating that positive par-
enting is one ofthe most important resources for helping youth
overcome adversity (Masten 2001; Steinberg and Morris
2001). For example, an authoritative parenting style has been
found to promote adolescents’ academic success (Glasgow
et al. 1997) and to protect adolescents from problem behavior
(Baumrind 1991). In the context of the present review specific
to youth with ADHD, it seems likely that positive parenting
and family cohesion foster a sense of attachment and com-
mitment to parental values, which helps youth avoid risky
situationsand behavior (e.g., substance use and delinquency).
Another possibility is that for youth with ADHD or ADHD
symptoms, positive parenting may be an important source of
social support and social modeling, leading to reduced prob-
lems in their interactions with peers and teachers. This
assertion is consistent withthe studies in this review thatfound
that parental support and authoritative parenting promote
higher levels of social competence for youth with ADHD
(e.g., Hinshaw et al. 1998). In sum, with the exception of a few
studies (Chronis et al. 2007; Latimer et al. 2003; Vitaro et al.
2005), the majority of evidence for family mechanisms is
limited to cross-sectional designs. This permits investigating
cohort or age differences across samples as a measure of
temporal change (e.g., see Kawabata et al. 2012), but does not
allow for developmental models to be explicitly tested.
Additional research should evaluate other family factors, such
as positive interparental relationships, sibling relationships,
and parental involvement in child’s education, which have
been identified as promotive or protective in the general
population (e.g., Wright et al. 2013)
Lastly, there is minimal evidence supporting any indi-
vidual-level factors as protective, with only one cross-
sectional study demonstrating protective effects for solitary
play among young girls (Mikami and Hinshaw 2003);
however, a follow-up longitudinal study with the same
participants found that it was no longer protective and
Clin Child Fam Psychol Rev (2016) 19:368–391 383
123
instead was associated with negative outcomes in adoles-
cence (Mikami and Hinshaw 2006). The strongest evidence
for individual factors comes from longitudinal studies
demonstrating the promotive effects of positive and modest
self-perception (i.e., self-perceptions of social, scholastic,
behavior, and overall competencies). Specifically, positive
self-perceptions of competence in the context of ADHD
promoted again the development of depression and inter-
nalizing symptoms (e.g., McQuade et al. 2011; Mikami and
Hinshaw 2006), as well as promoted overall quality of life
(Schei et al. 2015). These findings align with the large body
of literature supporting positive self-concept and self-effi-
cacy as promotive of positive adjustment and protective
against risk across heterogeneous populations and envi-
ronments (e.g., Masten 2014; Rutter 1987; Wyman et al.
1993). Indeed, self-concept, or the way youth and adoles-
cents think and feel about themselves, influences their
reaction and subsequent adjustment to difficult life events
(Rutter 1987). For example, individuals with positive self-
concept are hopeful about their future, believe in their
ability to impact their situation, are confident in their
abilities to overcome obstacles, and make use of resources
in their lives (Werner and Smith 2001; Werner 1993).
Further, individuals with a realistic, positive sense of self
are more likely to adopt active coping strategies, whereas
low self-concept has been associated with unsuccessful
coping strategies, depression and anxiety as well as
delinquency (e.g., Dumont and Provost 1999; Levy 1999;
Youngstrom et al. 2003). Interestingly, findings supporting
promotive effects of positive self-perceptions of compe-
tence would seem to be counter to research, suggesting that
children with ADHD and a ‘‘positive illusory bias (PIB)’
experience negative outcomes (e.g., Hoza et al. 2010).
However, studies of PIB are traditionally focused on youth
with ADHD who have inflated, or ‘‘biased’’ self-percep-
tions, as compared to other raters such as parents or
teachers. Importantly, there is a strong body of literature,
suggesting that self-perceptions and ‘‘reality’’ have differ-
ent, but equally important, implications for adjustment
(Harter 1985; Harter and Whitesell 1996). As such, there
may be an important difference between youth with ADHD
who have realistic positive self-appraisals, and youth with
ADHD who have inaccurate self-appraisals (e.g., Swanson
et al. 2012). This highlights the importance of a multi-
informant approach for evaluating promotive and protec-
tive factors in the context of ADHD.
Limitations and Considerations for Future Research
Across all individual, family, and social systems examined,
several promotive effects were observed across a variety of
risk contexts and outcomes, but relatively less evidence is
available for protective factors with only six studies
demonstrating significant protective effects of the 13 that
included analyses for such effects. One potential implica-
tion of these findings is that tests of statistical interactions
in non-experimental research are greatly underpowered
(McClelland and Judd 1993). Indeed, many studies were
restricted to small sample sizes and effect sizes, although
rarely reported, were often small. This is a common chal-
lenge in research on protective mechanisms (Scott et al.
2015). Importantly, this does not mean that such protective
factors are not relevant. In fact, the lack of consistency in
predicting positive outcomes across domains and time
suggests that total resilience is rare, if not non-existent for
youth with ADHD. It is likely that multiple pathways exist
(i.e., equifinality; Luthar et al. 2000) and that the presence
of multiple pathways in any given sample at least partly
explains the divergent findings reported to date. Integration
efforts are also qualified by the fact that many studies have
relatively small samples of high-risk youth (e.g., Bieder-
man et al. 1998; Mikami et al. 2015; Theule et al. 2011),
single-informant measurement approaches (e.g., Martin
2014; Volpe et al. 2006), cross-sectional and correlational
designs (e.g., Ostrander and Herman 2006; Schei et al.
2015), or longitudinal studies that examine a promotive/
protective construct at only one occasion (e.g., Latimer
et al. 2003; Vitaro et al. 2005). Further, the extant literature
has very little to say about the processes through which
promotive and protective factors have their influence. For
example, we hypothesize that adolescents’ social accep-
tance may buffer against ADHD in predicting academic
outcomes through mediating mechanisms of keeping youth
connected in school and away from deviant peer groups.
Large-scale studies using prospective longitudinal designs
that address multiple outcomes of functioning as well as
multiple risk and promotive/protective variables will help
to improve our understanding of the heterogeneity and
specifically resilient outcomes of youth with ADHD.
Future investigations of resilience in ADHD would also
benefit from a more thorough grounding in developmental
science. Although there are several commendable studies
that follow the developmental psychopathology framework
(e.g., Chronis et al. 2007; Dvorsky et al. 2016; Mikami and
Hinshaw 2003,2006), many studies included this review
did not have specific aims or hypotheses related to pro-
motive or protective mechanisms in the context of ADHD.
Indeed, only 16 studies in the review described intention-
ally examining resilience mechanisms, of which only 5
included samples of youth diagnosed with ADHD and 7
included samples of youth with and without ADHD. The
remaining 4 studies examined promotive and protective
effects for school-based or community samples of youth in
relation to ADHD symptoms in predicting adjustment.
Further, some studies even describe or interpret findings
384 Clin Child Fam Psychol Rev (2016) 19:368–391
123
through a negative lens (e.g., lack of competence predicts
increased impairment); however, they evaluate positive
constructs such as family support (Theule et al. 2011).
Indeed, despite being one of the most studied childhood
mental health disorders, the developmental pathways
linking ADHD to adaptive or successful outcomes are not
well understood. This underscores the importance of future
investigations of resilience in ADHD including a clearly
delineated theoretical framework within which hypotheses
about salient protective processes are considered in respect
to the specific risk of the sample under study.
Age Differences
It has been suggested that different mechanisms (e.g.,
family and social) may be related to functional outcomes
at different stages of development (e.g., Masten and
Obradovic 2006). In the context of ADHD, it seems likely
that protective effects will vary for individuals who have
experienced chronic ADHD (e.g., older adolescents with
persistent ADHD) compared to younger children recently
diagnosed with ADHD. Further, symptoms of hyperac-
tivity and impulsivity tend to decline as youth with
ADHD age, meaning that the risk variables/profile may
also change across development. However, relatively little
research on resilience in the context of ADHD has
adopted a developmental framework, which makes it
difficult to understand how these mechanisms fit into the
progression of adaptive functioning among youth with
ADHD. Further, inconsistencies in this research also arise
from the failure to measure or control for age differences,
which have the potential to confound results. Most of the
studies in this review focused specifically on middle
childhood (13/21; aged 6–12), followed by samples of
adolescence (4/21; aged 12–18) and samples of early
childhood (4/21; aged 2–6). Some studies grouped diverse
ages of youth together (e.g., aged 6–17), with minimal
regard to potential developmental differences (e.g., Bie-
derman et al. 1998). One study identified variables that
appear to be protective at one age (Mikami and Hinshaw
2003), but are later found to be risk factors in longitudinal
work. Another study specifically examined age effects
(Kawabata et al. 2012) and found maternal affection to
only be protective among older children (grades 7–9), but
not younger children (grades 1–6). Future studies that
examine ADHD and protective mechanisms should be
explicit as to which stage of development is the focus and
why, to help clarify whether different mechanisms are
important for different developmental contexts. It may
also be informative to take into account the develop-
mental progression and change in risk and protective
mechanisms over time.
Cultural Context
Future research on resilience in ADHD must include racial/
ethnic minority populations of youth in sizeable enough
numbers to support analyses that can inform about racial/
ethnic differences. A protective factor in one context or
culture may not be as protective in another (Lerner and
Castellino 2002). For example, in the parenting literature,
harsh and authoritarian parenting was a risk for later con-
duct problems among European American but not African-
American youth (Deater-Deckard and Dodge 1997).
Although a number of the studies included in this review
had diverse samples, few specifically examined racial/
ethnic differences. Further, cultural factors including tra-
ditions, beliefs, and community support services undoubt-
edly provide a wide variety of protective functions, though
these have not been studied in research on resilience in
ADHD.
Risk Contexts
The promotive and protective mechanisms in this review
have been examined in a variety of risk contexts. As such,
caution is warranted for generalizing across levels of risk.
Studies vary greatly in how they operationalize high-risk
status, which has ranged from ADHD symptom severity
(on a dimensional scale), ADHD diagnostic status (by a
categorical definition), or presence of comorbid problem
with ADHD (e.g., Chronis et al. 2007). When symptom
severity is examined as the risk context, individuals are
often sampled from ADHD only samples or community-
based samples and classified according to arbitrary cutoff
thresholds of symptom severity (e.g., Becker et al. 2013;
Arnold et al. 2012). These dimensional classification
methods are used as proxy measures of severity of ADHD
symptoms, which may be subject to measurement error,
rater bias, and information bias. However, when ADHD
diagnostic status is examined as the risk context (e.g., in
samples of those with and without ADHD), ADHD
symptom severity may be subject to restriction of range or
ceiling effects. As such, it is plausible that protective
mechanisms may have differing effects across each of
these groups. Overall, some of the reported effects (or lack
thereof) may be due to the risk context examined rather
than the promotive/protective mechanism. Unfortunately,
the same protective mechanism is rarely examined across
different risk contexts (e.g., at-risk and diagnosed samples),
and this can lead to inconsistent findings when taken out of
context. For example, it is unknown whether friendship
quality mechanisms shown to buffer against ADHD
symptom severity in a sample of at-risk youth (e.g., Becker
et al. 2013) would also buffer against other risks commonly
associated with ADHD such as oppositional behaviors,
Clin Child Fam Psychol Rev (2016) 19:368–391 385
123
anxiety, or substance use behaviors in a sample of youth
diagnosed with ADHD. It is important for future work to
collect groups of youth with and without ADHD within a
single study in order to identify whether unique protective
mechanisms exist.
Considerations for Future Avenues of Research
In addition to the recommendations above regarding
research designs and sample characteristics, below are five
promising areas for future research rooted in the frame-
work of developmental psychopathology that will lead to a
better understanding of the potential resilience pathways
associated with ADHD: (1) measurement, (2) develop-
mental cascades, (3) multiple levels of analysis, (4) person-
centered approaches, and (5) the role of genes and bio-
logical mechanisms.
Measurement
Improvements in the measurement of promotive and pro-
tective constructs are needed including (a) broadening the
scope of risks and protective variables examined and
(b) giving careful consideration of specificity of risk and
protective constructs, in order to fully understand the
effects of promotive and protective mechanisms in the
context of ADHD. For example, as recently highlighted by
McQuade et al. (2011), more research is needed that
examines the protective effect of self-perceived compe-
tence in addition to the broader constructs of inflated self-
perceptions that have received the bulk of attention to date.
Also, in line with Bronfenbrenner’s (1979) ecological
systems theory, exploration of the interdependence and
reciprocal interactions between micro-level (e.g., school,
family, and friends) and macro-level (e.g., neighborhood
and culture) factors is an important avenue for future
research. In fact, support for the bidirectional child–family
influences with ADHD families (e.g., Deault 2010)
demonstrates such interactions and is a promising launch-
ing place for resilience study. Developmental research also
suggests that there is a cumulative effect of multiple risk or
promotive/protective indicators within the individual per-
son and their various systems of development (Evans et al.
2013). Only a few studies in this review examined inter-
actions across multiple risks (e.g., Mikami and Hinshaw
2003,2006), but no studies examined combinations of
protective factors including cumulative promotive/protec-
tive indicators or how different factors may interact with
each other to create especially strong protection or resi-
lience. Another approach to studying resilience in the
context of ADHD is to evaluate strengths using measures
that have been established for other at-risk populations or
examine standardized measures of resilience (e.g.,
Resiliency Scales for Children and Adolescents; Prince-
Embury 2010), which allow for examining assets and
strengths within ADHD populations relative to normative
samples.
Developmental Cascades
It has long been recognized that problem behaviors asso-
ciated with ADHD can spread across domains over time
through interactions of the individual child, their family
and other social systems. For example, when a child’s
inattention, hyperactivity, or impulsivity negatively impact
academic performance, this impacts relationships with
teachers, self-concept, and parent–child conflict, which
then leads to increased risk of internalizing symptoms (e.g.,
Humphreys et al. 2013). Studying which protective factors
may reduce this negative chain or pathway of behavior
(e.g., via moderated mediation) is another important ave-
nue of exploration. It is likely that positive behavior also
spreads such that competence builds competence, which
may prevent the negative pathways to impairment often
associated with ADHD. For example, cross-lagged analy-
ses could model how high parental support predicts
improvement academic performance for youth with ADHD
through mediators of motivation for school and imple-
menting planning and organization skills. Others have
hypothesized that through positive social interactions and
high-quality friendships, children with ADHD may gain
instrumental and emotional support from peers and friends,
providing a context for youth with ADHD to learn positive
behaviors or practice skills that subsequently lead to
improvement in functional outcomes (e.g., Becker et al.
2013). However, longitudinal data with several data points
and transactional analyses are needed to evaluate such
hypotheses. Transactional cascade models will likely pro-
vide the most fruitful avenues for understanding the
intersection of development and psychopathology (see
Masten et al. 2005; Masten and Cicchetti 2010). No study
to date has used a longitudinal cross-lagged design to
evaluate promotive or protective mechanisms for ADHD.
Multiple Levels of Analysis
Most of what is known about the correlates and pathways
of ADHD has been gleaned from investigations that
focused on relatively narrow domains of variables. Several
leaders in developmental psychopathology (Cicchetti and
Curtis 2007; Cicchetti and Toth 2009; Wright and Masten
2015) have argued that a comprehensive research agenda is
needed, spanning biological, cognitive, psychological,
social, and environmental factors. To successfully test
theories of various systems of influence affecting youth’s
resilience, multiple levels of analysis are needed (Wright
386 Clin Child Fam Psychol Rev (2016) 19:368–391
123
and Masten 2015). The majority of studies reviewed here
used multiple regressions to analyze their data; however,
multi-level modeling (MLM) approaches can properly
assess the interrelation between variables, across systems,
and account for nesting (e.g., youth nested in classrooms),
without violating the assumption of independence of errors
or overestimating the association among aggregated vari-
ables (Kaplan et al. 2009). Further, MLM can be applied in
conjunction with growth curve modeling such that intra-
individuals differences in an outcome over time are cap-
tured at level 1; individual differences in change over time
are at level 2; and a third level can represent changes over
time among individuals nested in systems such as schools
or classrooms (Grimm et al. 2011; Kaplan et al. 2009). As
such, the MLM framework approaches risk and promotive
or protective mechanisms from the perspective of a hier-
archal structure such that repeated measures are naturally
nested within individuals (e.g., Bryk and Raudenbush
1987). For example, MLM analyses could model growth
trajectories for risk and promotive mechanisms at the
individual level (e.g., biological, cognitive, or psycholog-
ical) as well as the association of being to particular peer
groups, nested within schools or communities. Others have
hypothesized that growth in positive developmental tra-
jectories is associated with individual characteristics (e.g.,
genotype and cognitive mechanisms) nested within family
environments, which are characterized by their own level
of risk and promotive mechanisms (e.g., Jester et al. 2005;
Nigg et al. 2007). Research in resilience against ADHD
should examine both risks and protective mechanisms at
multiple levels, because biological, psychological, and
social factors are integral for the development and main-
tenance of ADHD and associated impairment (Barkley
2014).
Person-Focused Approaches
Many of the studies in this review use a variable-focused
approach to analyses utilizing continuous measures of
outcomes, risk, promotive, and protective variables, and
not comparing groups based on risk status or outcome.
These variable-focused studies are valuable for providing
information on protective factors that are associated with
positive outcomes in the context of ADHD; however, they
do not permit examination of unique group differences or
fluctuations in outcomes across domains over time. Person-
focused approaches seek to distinguish between adaptive
youth and maladaptive youth, who are similar in risk but
have different developmental outcomes. This often
involves classifying groups of high-risk individuals
according to their competence or adaptive behavior and
subsequent analyses attempt to determine the moderating
and mediating factors that differentiate these groups of
individuals (Magnusson 2003; Masten 2014). More
recently, person-focused approaches have used latent
growth modeling to explore resilient developmental tra-
jectories (e.g., Grimm et al. 2011; Murray et al. 2014).
These models examine individual patterns of behavior over
time in a group of individuals who share a common risk
factor. Although person-focused approaches are widely
used in the social sciences (Magnusson 2003), such models
have rarely been applied to research on resilience in ADHD
with only two studies utilizing these methods in this review
(Biederman et al. 1998; Chronis et al. 2007). In an exem-
plar of the person-focused approach, Chronis and col-
leagues (2007) found that decreases in individual growth
trajectories in conduct problems were promoted by positive
parenting behaviors. Overall, person-focused models that
utilize latent growth modeling and models that combine
both person- and variable-focused approaches (see Muthe
´n
and Muthe
´n2000) are needed to explore individual and
group differences in resilient trajectories in the context of
ADHD.
The Role of Genes and Biological Mechanisms
The vast majority of what is known about the correlates
and pathways of resilience in the context of ADHD has
been gleaned from studies focusing on psychosocial fac-
tors. Given that the causal mechanisms of ADHD are
multifaceted, involving complex interactions between
biological and environmental factors, there is a need for
research examining the role of biological and genetic fac-
tors. Some researchers have examined genetic and psy-
chosocial interactions, but these have focused on negative
mechanisms such as inconsistent parenting and family
conflict (e.g., Martel et al. 2011). Some of the leading
developmental psychopathology researchers have pointed
out that important gains could be made by studying bio-
logical and psychological systems simultaneously for
exploring pathways to resilience (e.g., Wright and Masten
2015). The role of genetic and environmental contributions
to resilience in youth with ADHD likely represents an area
of expanding research and may generate new ideas about
intervention targets.
Clinical Implications of Findings
A compelling rationale for the study of resilience in ADHD
is to inform practice, prevention, and policy efforts directed
toward creating resilience when it is not likely to occur
naturally. The practice and policy implications of these
review findings are preliminary but exciting. With respect
to assessment screenings, they point to the importance of
integrating strength-based assessments to provide a more
complete picture of the individual. However, there are
Clin Child Fam Psychol Rev (2016) 19:368–391 387
123
inherent challenges related to measuring strengths, perhaps
most importantly is the field’s relative absence of assess-
ment tools that focus on constructs such as developmental
strengths, adaptive behavior, resiliency, competence, or
protective factors. These findings could also be used to
inform prevention strategies at the primary, secondary, and
tertiary levels. The connections between positive parenting
and positive self-perceptions with decreased comorbid
conduct problems and internalizing symptoms, respec-
tively, suggest that broader interventions including both
positive parenting strategies and cognitive–behavioral
strategies to increase self-efficacy or self-perceptions of
competence may help address the risk associated with
ADHD.
One important consideration in light of findings sup-
porting positive self-perceptions in the context of ADHD is
that some youth with ADHD provide elevated ratings of
their own functioning (referred to as positive illusory bias;
Owens et al. 2007). This may influence whether self-per-
ceived competence reflects true well-being or predicts
long-term adjustment for youth with ADHD. Although this
elevated self-concept has been proposed as potentially
serving a self-protective function (Owens et al. 2007), it is
also possible that it prohibits learning from experiences and
adjusting behaviors, thereby increasing long-term risks and
negative outcomes. Alternatively, it could be that self-
perceptions are most relevant for predicting perceptions of
resilient outcomes such as decreased depressive symptoms.
A key issue in implementing an early or preventative
intervention for ADHD is deciding which children are
targeted. Many argue that early interventions are most
critical for young children (e.g., DuPaul et al. 2015). In a
review of early interventions for ADHD, Sonuga-Barke
and Halperin (2010) recommend that intervening early may
be more successful than waiting until outcomes or trajec-
tories are formed and then trying to intervene on the neg-
ative pathways. As such, early interventions can be applied
before the disorder becomes complicated by the experience
of repeated failure and impairment. Alternatively, this
review also suggests that unique protective factors may
operate during middle childhood and adolescence. This
finding indicates that preventive interventions should be
targeted not only toward young child populations, but also
during key developmental transitions throughout adoles-
cence. Finally, if we are to meet the multidimensional
needs of children with ADHD across the various systems, it
seems clear that no ‘‘one size fits all’’ approach will work.
Rather, treatments must be individually tailored and tar-
geted at the points of performance, be it a deficient aca-
demic skill or ineffective parent–child communication. As
such, research designs and analytic models need to account
for individual differences across youth in treatment
response (DuPaul et al. 2015).
Conclusions
This review examined the applicability of a developmental
psychopathology resilience framework for understanding
the heterogeneity associated with ADHD by synthesizing
findings about promotive and protective mechanisms.
Important work in the area of resilience in youth with
ADHD has been completed, although a great deal of work
remains. We know very little of the processes by which
positive adjustment and developmental competence occur
for these youth. Given the multitude of interdependent and
reciprocal influences, mechanisms, and processes involved
in the etiology and course of ADHD, there is a clear need
for more complex theories, research designs, and data-an-
alytic strategies. Overall, there is solid evidence for social
acceptance as protective in youth with ADHD. There was
also compelling evidence supporting positive parenting as
a promotive factor. However, the study of other individual,
family, and social mechanisms remains in its infancy. In
the next stage of ADHD resilience research, a focus on
longitudinal trajectories as well as interacting and under-
lying developmental processes should be prioritized. As
described above, measurement, developmental cascades,
multiple levels of analysis, person-focused approaches, and
the role of genetic and biological mechanisms are five
promising avenues that can guide future work in this area.
Together, ongoing and cross-fertilizing intervention and
developmental process research can contribute to devel-
opmentally sensitive intervention approaches that promote
competence and adaptation.
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... 4 Children with ADHD often experience persistent depressive episodes into adolescence. 21 Protective factors buffer a child from adverse outcomes by promoting positive adaptation; 22 resilience can help at-risk children move from adversity to positive adaptation. The core value of resilience is "prevailing when faced with difficult and negative situations" (p. ...
... Consistent with previous findings, higher selfperceived resilience with promotive or protective factors protected against the development of depression in children with ADHD. 22 Our finding indicates that increased resilience may significantly correlate with decreased depression in children with ADHD. ...
... 25 Previous studies emphasized the facilitation of resilience among children with ADHD. 22 It appears that learning to be resilient may help children with ADHD overcome associated symptoms and improve their QoL. Based on our present findings, resilience was a significant mediator in the relationship between MVPA and depression among children with ADHD. ...
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Purpose This study investigated the mediating role of resilience in the association between moderate-to-vigorous physical activity (MVPA) and psychological ill-being, as well as the moderating role of age in the direct and indirect relationship between MVPA and psychological ill-being in children with attention-deficit/hyperactivity disorder (ADHD). Methods Eighty-five children aged 6–12 years (Mage = 8.41 ± 1.44 years) diagnosed with ADHD were recruited. Participants wore an accelerometer on their non-dominant wrist for seven consecutive days to record MVPA. Resilience and psychological ill-being were assessed using self-reported questionnaires. Results MVPA was positively associated with resilience but negatively related to depression and stress. Resilience was negatively correlated with depression and stress. Using the bootstrapping method, the indirect effect of resilience was found between MVPA and depression (-0.006, 95% confidence interval [CI] = [-0.060, -0.020]) in children with ADHD, supporting partial mediation. Moderated mediation analysis further demonstrated that the indirect effect of MVPA on depression via resilience was stronger in older children (-0.008, 95% CI = [-0.023, -0.001]) than in younger children with ADHD. Conclusion The findings may inform future empirical studies on designing exercise interventions with MVPA levels that help to improve resilience and depression in children with ADHD.
... On the other hand, aspects of positive parenting practices seem to act as protective factors regarding the development of different types of externalizing behavior. For example, positive parenting practices have been associated with fewer future conduct problems [6] and were found to have a positive impact on ADHD symptoms [34]. In a longitudinal study, warm parenting by adoptive mothers predicted lower levels of later child externalizing problems [35], and a study of clinic-referred families reported an association between higher parental involvement and lower levels of later hyperactivity and inattention [32]. ...
... In other words, with more pronounced positive parenting behavior, more severe ADHD symptoms were observed in the child. This second path contradicts the results of previous studies, which reported that lower levels of aspects of positive parenting behavior were associated with higher ADHD symptom severity [31,34]. ...
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This study analyzes whether the association between parental internalizing symptoms (depression, anxiety, stress) and child symptoms of attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) is mediated by positive and negative parenting behaviors. Cross-sectional data of 420 parents of children (age 6–12 years) with elevated levels of externalizing symptoms were collected in a randomized controlled trial. Measures included parent ratings of their internalizing symptoms and parenting behaviors and of their child’s externalizing symptoms. Two mediation models were examined, one including ADHD symptoms and one including ODD symptoms as the dependent variable. Parental internalizing symptoms were modeled as the independent variable and positive and negative parenting behaviors were modeled as parallel mediators. Regression analyses support negative parenting behavior as a mediator of the association between parental internalizing symptoms and child ODD symptoms. For the ADHD model, no significant mediator could be found. Future studies should use prospective designs and consider reciprocal associations.
... The individual's functioning and health consist of the interactions between these three components with personal and developmental factors [44]. The ICF model was implemented in previous studies of ADHD [22,45,46]. The present study adds to the existing literature by implementing the ICF model in the context of ADHD symptoms and antisocial behavior. ...
... The findings call for the application of the ICF model in the domain of ADHD and antisocial behavior, suggesting that the antisocial behavior stemming from ADHD is a product of the interaction between ADHD symptoms and a personal factor (SOC). This finding is consistent with the growing trend in the research literature calling for examining resilience factors for the risks for functional impairments associated with ADHD [12,21,22,[45][46][47][48][49][50][51]. ...
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Numerous studies have established the link between ADHD and antisocial behavior, one of the most serious functional impairments caused by the disorder. However, research on protective factors that mitigate this link is still lacking. The Salutogenic Model of Health offers the “Sense of Coherence” (SOC), establishing that individuals who see their lives as logical, meaningful, and manageable are more resistant to various risk factors and diseases. The present study examines for the first time whether SOC is also a protective factor against different ADHD-related types of antisocial behaviors (severe/mild violent behavior, verbal violence, property crimes, public disorder, and drug abuse). A total of 3180 participants aged 15–50 completed online questionnaires assessing the level of ADHD symptoms, antisocial behaviors, and SOC. Structural equation modeling was applied to examine the research hypothesis. An interaction between ADHD symptoms and SOC was found in predicting each type of antisocial behavior (beta = −0.06–−0.17, p < 0.01). The link between ADHD symptoms and antisocial behavior was significantly weaker for high than low SOC participants, regardless of age group. The current study found that people with high SOC are protected against the effect of ADHD symptoms on one of the most serious functional impairments, antisocial behavior. These findings suggest that SOC is a protective factor from the adverse effects of ADHD symptoms, justifying further prospective and intervention studies.
... The individual's functioning and health consist of the interactions between these three components with personal and developmental factors [44]. The ICF model was implemented in previous studies of ADHD [22,45,46]. The present study adds to the existing literature by implementing the ICF model in the context of ADHD symptoms and antisocial behavior. ...
... The findings call for the application of the ICF model in the domain of ADHD and antisocial behavior, suggesting that the antisocial behavior stemming from ADHD is a product of the interaction between ADHD symptoms and a personal factor (SOC). This finding is consistent with the growing trend in the research literature calling for examining resilience factors for the risks for functional impairments associated with ADHD [12,21,22,[45][46][47][48][49][50][51]. ...
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Numerous studies have established the link between ADHD and antisocial behavior, one of the most serious functional impairments caused by the disorder. However, research on protective factors that mitigate this link is still lacking. The Salutogenic Model of Health offers the “Sense of Coherence” (SOC), establishing that individuals who see their lives as logical, meaningful, and manageable are more resistant to various risk factors and diseases. The present study examines for the first time whether SOC is also a protective factor against ADHD-related different types of antisocial behaviors (severe/mild violent behavior, verbal violence, property crimes, public disorder, and drug abuse). 2260 participants aged 15-50 completed online questionnaires assessing the level of ADHD symptoms, antisocial behaviors, and SOC. An interaction between ADHD and SOC was found in predicting each type of antisocial behavior. The link between ADHD and antisocial behavior was significantly weaker for high than low SOC participants, regardless of age group. The current study found that people with high SOC are protected against the effect of ADHD on one of the most serious functional impairments, antisocial behavior. These findings suggest that SOC is a protective factor from the adverse effects of ADHD, justifying further prospective and intervention studies.
... An understanding of what family factors contribute to more positive outcomes, as protective (buffer against risks) and/or promotive factors, in children with ADHD could be used to promote resiliency in children with ADHD. As Dvorsky and Langberg [36] observed, the study of resilience in ADHD is "in its infancy" (p. 372), their systematic review identified familial factors, especially positive parenting, parental mental health, and cohesive family environments. ...
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If having one child with Attention Deficit Hyperactivity Disorder (ADHD) contributes to family stress and dysfunction, then what happens when more than one family member has ADHD? This paper explores this question by drawing on findings from a multi-case study that explored the voices of stakeholders (child and parent/carer) affected by ADHD in Ireland. There were eight case studies (families) included. Each case had one parent/carer with ADHD and a child with ADHD. Eight children (aged 7–17 years; Mean = 12.6; S.D. = 3.4) and ten parents (2 males) participated. Four parentw/carers reported a diagnosis of ADHD themselves (2 females) and 6 mothers participated who had a spouse with ADHD. Triangulation was achieved using multiple interviews (parent/carers and child), a demographic survey, and creative methods with the children to contribute to a highly contextualised understanding of stakeholders’ experiences. Research findings demonstrated that there may be positive and negative consequences when both parent and child have ADHD. On the one hand, it may contribute to greater dysfunction, when parents with ADHD struggle to stick to routines and remain calm and organised. On the other hand, children with ADHD may feel a sense of belonging and less different, parents believe they have greater understanding, and shared interactional preferences may have benefits. Findings will be discussed in terms of their implications for practice with families and future research.
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Chapter
This chapter provides an overview of key resilience concepts, controversies, and perspectives. It delineates a variety of types of research models that examine resilience processes over time, including person-focused, variable-focused, and hybrid models focused on understanding developmental pathways and trajectories. The importance of qualitative and quantitative approaches to understanding the human capacity for adaptive responses to challenges is emphasized. Resilience is conceptualized within a dynamic, embedded, ecological systems framework, encompassing interactions across multiple levels, from genes, to person, family, community, and cultural group. The importance of a life-span ecologically informed perspective is illustrated through highlights from the past half century of research on diverse pathways to resilience.