12. Social problems with ADHD
Author: Ulrich Brennecke
Review: Dipl.-Psych. Waldemar Zdero
People with ADHD often show impulsive behavior by interfering in the conversations and activities of others without being asked. Impulsiveness goes hand in hand with hyperactivity (in adults: inner restlessness). The disregard for social norms and rules often leads to social rejection.
Social withdrawal is a common symptom of ADHD. It arises for various reasons, e.g. because no positive feedback is expected or the need for security and control is too great. Girls with ADHD are more likely to show social withdrawal and have more difficulty being recognized. Adult people with ADHD have difficulty solving problems in social situations, especially due to fears of social interaction.
ADHD can lead to reduced ability to recognize the emotions of others as well as increased social anxiety, which naturally exacerbates social problems.
Loneliness often occurs as a consequence of social withdrawal and is associated with increased introverted symptoms.
ADHD is associated with an increased risk of social exclusion.
- 12.1. Impulsive disregard of social rules in ADHD
- 12.2. Problems with friendships
- 12.3. Social withdrawal / social phobia in ADHD
- 12.4. Loneliness as an ADHD symptom
- 12.5. Social jet lag due to shifted daily rhythm
- 12.6. Problems with social cognition (recognition of social signs)
12.1. Impulsive disregard of social rules in ADHD
People with ADHD are more likely to interfere in the conversations / activities of others without being asked. This correlates with impulsivity and therefore occurs more frequently with ADHD-HI and ADHD-C
Impulsive disregard for social norms and rules leads to social rejection.
Children with ADHD often exhibit inappropriate social behavior.1
12.2. Problems with friendships
12.2.1. Problems with mutual friendships
People with ADHD often suffer from social problems in interpersonal relationships.234
This symptom usually persists throughout the lifetime of the Disorder.5
Adults with ADHD often have problems with friendships and poorer social interaction.6
12.2.2. Relationship problems
Adults with ADHD are more likely to have poorer intimate relationships and show poorer marital adaptability.78
12.2.3. Problems with empathy and theory of mind
Children with ADHD show impairments in empathy.9
Children with ADHD showed significantly poorer Theory of Mind (ToM) performance, which appears to correlate with executive functions problems.10 MPH normalized ToM performance to the level of non-affected individuals.11 MPH also improves empathy in people with ADHD.12
Adults with ADHD were also found to have impairments in empathy, but no impairments in ToM.13
12.2.4. Problems of constancy of connectedness and permanence of connectedness
The term object constancy refers to the development of a constant (emotional) attachment to the (maternal) caregiver in young children. It describes the child’s ability to maintain a relationship that is relatively independent of need satisfaction. This is to be distinguished from the concept of object permanence, which in young children refers to the development of (cognitive) knowledge that people or objects that leave the field of perception nevertheless continue to exist.
The development of object permanence (from 8 months) and object constancy (from 2 years) are general development phases.
The following description is not backed up by studies. However, it is a perception that is shared by many people with ADHD.14
Similar to empathy, which is divided into cognitive empathy (knowing what moves another) and emotional empathy (sympathizing with what another feels), we see an emotional and a cognitive problem of object constancy / object permanence in ADHD.
By problems of object constancy in ADHD, we mean that many people with ADHD report losing the feeling for an attachment figure (friends, partner) if they are not present (for a longer period of time). The feeling of affection and attachment for a loved one is lost if they are absent for one or more days. This can be so pronounced that people with ADHD begin to doubt their ability to love.
This is to be distinguished from the fact that many people with ADHD forget things more easily or have difficulty finding things again if they are stored in closed containers, cupboards or other rooms. They report a very immediate “out of sight, out of mind”. In contrast to object permanence in young children, the understanding that things that are out of sight continue to exist is not impaired. Rather, the things are forgotten and thus disappear from consciousness.
A classic ADHD meme is the story of cleaning an apartment. It starts with a cleaning bucket and mop in the first room. Something is noticed that belongs in another room and is taken there. Something is found there that belongs in a third room. From there, something else is taken to the basement. Typical of ADHD is the surprise when re-entering the first room that there is a cleaning bucket and a mop. This phenomenon can be explained by the impairment of working memory in ADHD as a neurophysiological correlate.
Closer to the problem of object constancy, on the other hand, are the frequent reports that things that are stored out of sight are no longer remembered, as this affects long-term memory rather than short-term memory. It can therefore help people with ADHD to use open shelves or transparent storage boxes.
However, in our opinion, an impaired working memory cannot explain the loss of emotional attachment to absent persons. It remains to be seen to what extent this correlates with an impairment of long-term memory.
In order to differentiate from the developmental psychology terms object permanence and object constancy, we propose the terms attachment constancy (emotional attachment) and attachment permanence (cognitive attachment) for the ADHD context.
12.3. Social withdrawal / social phobia in ADHD
12.3.1. Social withdrawal as an ADHD symptom
Social withdrawal is a restriction in social contacts because either no positive or even negative feedback is expected (⇒ Rejection sensitivity) or the need for security and control is too great (too much closeness, ambivalence, closeness-distance pendulum).1516 Other studies suggest a link between an increased desire for withdrawal and loneliness and internalizing symptoms.17
Social withdrawal of people with ADHD, which can go as far as social phobia in front of people, apparently correlates only in girls with an increased feeling of being an outsider18 and has several mechanisms as its cause.
Adult people with ADHD performed equally well on Theory of Mind, generating the “best” solution to problematic social situations and selecting the optimal solution from a range of alternatives in a study of social problem solving ability. The general ability to generate problem solutions fluently and freely was not linked to executive functions or the trait of empathy. It was only impaired by fear of social interaction.19
Fear of social contact (social phobia) significantly inhibits social skills.
In contrast, other studies found reduced ability to recognize the emotions of others (theory of mind problems) in adults with ADHD, which correlated with executive problems.2021
In addition, the negative reactions of the environment to one’s own symptoms lead to a negative evaluation of social contacts.
According to the results of our symptom test, the symptom of social phobia occurs with approximately the same frequency in 73% of people with ADHD-HI (with hyperactivity) and 70% of people with ADHD-I, but its severity is significantly weaker in people with ADHD-HI at 0.63 than in people with ADHD-I at 0.73 (on a scale of 0 to 1). Only 15% of those not affected reached the symptom threshold. In addition, 98% of people with ADHD-I reached the cut-off of the symptom anxiety (with a severity of 0.89), compared to 93% of people with ADHD-HI with a severity of 0.84.
In addition, the overly open stimulus filter with the resulting increased sensitivity is likely to reduce the limits of tolerable stimuli to such an extent that withdrawing from the perceived stressful influences of third parties is a plausible and necessary defense mechanism. Many people with heightened sensitivity report that they flee from parties after a certain time or withdraw to quieter rooms (kitchen, balcony, toilet).
Neurophysiologically, the activation of oxytocin receptors in the ventral tegmentum is essential for a reward-driven interest in social contact.22
Interestingly, social skills appear to be higher in girls and women (as everywhere) than in boys and men with ADHD. In autism spectrum disorders, this correlation was reversed and age-dependent.23
ADHD is associated with an increased risk of social exclusion.24 This could be independent of a tendency towards social withdrawal on the part of the person with ADHD themselves and could add up to this effect.
12.3.2. Social withdrawal as a symptom of stress
Social withdrawal is known to be a typical symptom of severe stress.2526 A restriction of social contacts during stress is attributed to the fact that:1516
- No positive or even negative response is expected (avoidance or aggression, ⇒ rejection sensitivity) Rejection Sensitivity)
- The need for security and control is too great (too much closeness, ambivalence, closeness-distance pendulum)
Increased withdrawal behavior is a direct effect of the stress hormone CRH.2728
An increasing restriction of social contacts is a typical symptom of burnout.29
12.4. Loneliness as an ADHD symptom
Loneliness is an ADHD symptom30 and often a consequence of social withdrawal and tends to be associated with increased introverted symptoms in ADHD.31 Loneliness is therefore more likely to occur in ADHD-I than in ADHD-HI.
12.5. Social jet lag due to shifted daily rhythm
As up to 80% of people with ADHD have a circadian rhythm that is shifted backwards32, the entire biological daily routine is shifted compared to most other people. Consequences of this often lead to social problems (for which lack of sleep is only one of several causes), which are referred to as social jet lag. The term social jet lag was first coined by Roenneberg et al. in 2013 and refers to the mismatch between biological and social time rhythms.33
More on this under Sleep problems with ADHD in the following article.
12.6. Problems with social cognition (recognition of social signs)
ADHD is associated with more frequent deficits in social cognition. This includes impairments in social cognition related to the perception of faces and prosody (subtleties in the meaning of stress, intonation and relative duration of sounds and syllables in spoken language). These recognition deficits can further impair the quality of social functioning and exacerbate social problems.34353637 In FASD, this mechanism appears to be even more pronounced.38
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