Attention-deficit/hyperactivity disorder (ADHD) is consistently associated with elevated screen use during childhood and adolescence (Liu et al. Reference Liu, Chen, Huang, Yu, Gan, Wang, Chen, Nie and Ge2024). Most explanations for this relationship emphasize impulsivity, reward sensitivity, and deficits in self-regulation. However, ADHD is also characterized by substantial social difficulties, including loneliness, peer problems, friendship deficits, and reduced participation in offline activities (Jong et al. Reference Jong, Odoi, Lau, Hollocks and Disord2024). These observations raise an alternative possibility: screen engagement may partly function as a social substitute for children who experience difficulties establishing or maintaining social connections, consistent with compensatory models of internet use (Kardefelt-Winther Reference Kardefelt-Winther2014).

We analyzed data from 204 children and adolescents aged 7– 16 years, including 94 participants with ADHD and 110 controls. Measures included loneliness, peer difficulties, feelings of exclusion, number of close friends, extracurricular participation, and multiple domains of screen engagement. The primary outcome was social substitute screen time, defined as the combined duration of social and gaming screen use. Regression and mediation analyses were performed to evaluate the contribution of social vulnerability to ADHD-associated screen engagement.

Compared with controls, participants with ADHD reported greater loneliness (36.5 vs 28.6), peer difficulties (5.7 vs 2.3), and feelings of exclusion (11.8 vs 6.2), alongside fewer close friends (2.3 vs 4.1) and lower extracurricular participation (1.4 vs 2.3 days/week) (all p < 0.001). Differences in passive screen use were comparatively modest (1.66 vs 1.40 h/day; p = 0.002). In contrast, larger differences emerged for social screen use (1.53 vs 0.55 h/day) and gaming (1.95 vs 0.79 h/day), resulting in substantially greater social substitute screen engagement among participants with ADHD (3.48 vs 1.34 h/day; p < 0.001). In unadjusted analyses, ADHD was strongly associated with social substitute screen engagement (β = 2.15, p < 0.001). After adjustment for age, sex, socioeconomic status, loneliness, and peer difficulties, the ADHD coefficient decreased by 68.4% (β = 0.68, p < 0.001). Mediation analyses further suggested substantial indirect effects through loneliness and peer difficulties, accounting for approximately 47% and 49% of the adjusted association, respectively.

These findings suggest that elevated screen engagement in ADHD may reflect social vulnerability as much as behavioral dysregulation. Children experiencing loneliness, peer difficulties, and reduced opportunities for offline participation may increasingly rely on digital environments for interaction, recreation, and social connection. Notably, loneliness, peer difficulties, friendship deficits, and extracurricular participation independently predicted social substitute screen engagement, whereas ADHD symptom severity showed a comparatively smaller association. This pattern is broadly consistent with compensatory internet use theory, which proposes that online engagement may emerge in response to unmet psychosocial needs (Kardefelt-Winther Reference Kardefelt-Winther2014).

Our findings extend previous evidence linking ADHD and screen exposure (Liu et al. Reference Liu, Chen, Huang, Yu, Gan, Wang, Chen, Nie and Ge2024) and are consistent with broader evidence demonstrating adverse consequences of loneliness for health and functioning across populations (Zheng et al. Reference Zheng, Qualter, Rollano, Hu, Martin, Nukui, Walibhai and Maes2026). Together, these findings suggest that social vulnerability may represent an important and often overlooked pathway linking ADHD and digital media use. Rather than viewing elevated screen engagement solely as a manifestation of impulsivity or poor self-regulation, our results indicate that loneliness and peer difficulties account for a substantial proportion of the association between ADHD and social screen use. This interpretation is further supported by the observation that extracurricular participation, friendship deficits, and loneliness independently predicted social substitute screen engagement. Viewing screen engagement as a potential marker of unmet social needs may therefore provide a more complete explanation for digital media use in children with ADHD than behavioral models alone.

Interventions aimed at reducing screen engagement in ADHD may benefit from addressing social functioning alongside behavioral management. For some children with ADHD, screen engagement may reflect loneliness as much as behavioral dysregulation.