Social thinning and stress generation in childhood ADHD: a systematic review
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Background
Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition whose social challenges can be as impairing as its core symptoms. Social thinning (reduction in the number and quality of relationships) and stress generation (increased likelihood of experiencing interpersonal stressors) are key mechanisms underlying psychiatric vulnerability, and might be central to the social challenges in childhood ADHD. We aim to map the existing longitudinal evidence on the interplay between ADHD, these two social processes, and the subsequent psychopathological risk.
Methods
This systematic review was conducted in line with PRISMA guidelines (PROSPERO: CRD42023467876). We searched Embase, Medline, CINAHL, and APA PsycINFO from inception to 23 April 2025 for longitudinal observational studies enrolling participants younger than 18 with a formal ADHD diagnosis. The primary outcomes were quantitative associations between ADHD and social thinning or stress generation. Methodological quality was appraised using the Joanna Briggs Checklist for Cohort Studies.
Findings
Eleven studies, including 26,177 participants, met inclusion criteria. The overall methodological quality was high, with risk of bias rated as low-to-minimal for ten of the eleven studies. ADHD was consistently associated with social thinning, demonstrated by lower peer acceptance (OR = 5.1) and indirectly by poorer social competence (OR = 7.3), and to stress generation, showing positive associations with aggression ( β = 0.28) and involvement in bullying (OR = 3.6). These social challenges were associated with a higher incidence of psychiatric disorders, including conduct disorder and major depression.
Interpretation
The extant evidence indicates that childhood ADHD is prospectively associated with persistent social thinning and stress generation, from childhood into early adulthood. These mechanisms likely compound the psychosocial impairment from core ADHD traits, contributing to the heightened vulnerability for psychiatric disorders across the lifespan. Clinical interventions for ADHD should adopt a holistic approach that targets social functioning to mitigate long-term adverse outcomes.
Funding
None
