Social Issues
When the child with ADHD does not receive proper treatment, or if the treatment is not fully effective, the child may not only fail in schoolwork, but also in social scenarios.An inability to cooperate with peers at play or other social activities makes it hard for friendships to develop. Impulsiveness, difficulty in awaiting one's turn in a group situation, and an inability to play games for the same length of time as other children of the same age are all characteristics of ADHD. These characteristics may make it difficult for the child to be a good team member and to maintain friendships.

Children have great difficulty being patient or delaying gratification. They may therefore often speak out of turn or interrupt others. They may also engage in what looks like—but is not—intentionally risk-taking behavior. The child with ADHD may climb to the top of a tall structure or tree, may run into traffic without looking, or may leap on or off a moving vehicle. And, after the behavior has occurred, such children may be surprised to find themselves in a dangerous situation and not be able to get out of it. The behavior is risky—but the child is not risk-taking—simply impulsive. Psychiatrically, impulsivity and hyperactivity are not considered to be separate features of ADHD. They are a pattern that stems from an overall difficulty in inhibiting behavior.

Other associated features of ADHD can cause social problems at school and with peers outside of school. The features, which may change depending on the age and the developmental stage of the child, include outbursts of temper, bossiness, difficulty following rules, and disorganization.

Most children with ADHD have some social difficulties. Children who are not socially functional have a higher rate of coexisting psychiatric disorders and experience more problems at school, with peers, and at home.

Emotional Issues
Emotionally, the child with ADHD may experience social rejection and poor self-esteem. Many children with ADHD show signs of being depressed—feelings that stem from the child's sense of personal failure. Children with ADHD—especially those who are undiagnosed or untreated—receive constant negative feedback. They are punished or blamed for things they cannot help doing. They are frequently told: "Sit down," "Don't interrupt," "Stop that," "Wait your turn," "You are acting badly"—or worse, "You are bad." To avoid the issues of poor self-esteem, the child with ADHD must be helped to recognize personal strengths and develop them. As feelings of competency improve, so will feelings of self-esteem.

The child should be praised as often as possible when behaving appropriately—or when clearly trying to follow instructions. The child needs encouragement, recognition, and positive attention. Reasonable expectations should be set for the child—and the child should be rewarded for meeting those expectations. Ridicule will never help; punishment is seldom useful. The impulsive, hyperactive child can also be helped if adults are less impulsive in their responses to the child's behavior. The adult needs to act rather than react. The adult who considers his or her actions before responding will be less likely to respond with blame and anger towards the child. Children with ADHD are not incapable-it's not that they can't or even won't behave as expected. It's just that everything comes harder for them. As self-esteem improves, the child with ADHD will be more likely to work harder.

Emotional problems may not only be caused by ADHD, or complicate its course, but may also coexist with ADHD and, although independent of ADHD, mimic its features. Depression and anxiety may be secondary features of ADHD, or they may appear independently. Conduct disorder may coexist with ADHD. Children with mania or bipolar disorder may also have ADHD. A complete psychological examination should permit an understanding of primary and secondary emotional disturbances associated with ADHD.

Family Issues
The brothers and sisters of children with ADHD have about twice the risk of having the disorder as does the general population. The biological parents of a child with ADHD have a higher risk for having the condition than do adoptive parents. And, when a conduct disorder coexists with ADHD, the parents are more likely than the general population to have disorders associated with alcohol use and antisocial personality disorder. The socioeconomic status of the family does not seem to predispose a child to ADHD, but emotional deprivations, and anxiety-stressful psychic events and a disruption of the family equilibrium-do tend to play a role in ADHD.

Children with ADHD respond best to an environment that is structured and predictable. The rules need to be clear, expectations consistent, and consequences-positive and negative-need to be described ahead of time and delivered in immediate relationship to the behavior. The demands on the child should be limited in frequency and time-but rewards and praise should not be.

These behavior management tools may be easier to achieve at school, which is already structured with frequently clear and consistent rules, than at home. Structure and predictability may also be more difficult to achieve in a home that is disruptive or stressful. The school personnel involved with a child with ADHD can make sure that the family understands-without blame-the diagnosis and behavioral management tools of ADHD. By providing information on how the child is doing in school, and asking questions about home management, the teacher may provide help for the child and support for the family. The school personnel need to know if the family is, or is becoming destabilized, or is otherwise under stress. If the family has access to the Web, the school personnel can help the family receive information through this and other Web sites. The more the family, including siblings, knows about ADHD, the better able they will be to understand the child's actions, reactions, and daily problems.