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Does Stimulant Medication Treatment Improve Self-Esteem in Children with ADHD and Peer Problems?
How Does Treatment With Stimulant Medication Effect A Child’s Self-esteem?
Many parents are concerned that taking medication will cause their child to feel badly about him or herself, and are reluctant to consider medication use because of this concern.
A team of researchers (Frankel, F., Cantwell, D., Myatt, R. & Feinberg, D.) set out to answer this question in an independent study conducted at the UCLA Department of Psychiatry. Their results were recently published in an article of the same name in the Journal of Child and Adolescent Psychopharmacology, 9, pp. 185-194.
The issue that this article addresses is an important one. Children with ADHD often have difficulty making and maintaining friends. Studies have shown that peers of children with ADHD are less likely to endorse them as friends, and frequently these children are the victims of peer teasing. As a consequence of these and other influences, children with ADHD tend to have lower self-esteem compared to children without ADHD. The same is true among adolescents, where a greater number of ADHD symptoms have also been found to be associated with lower self-esteem.
Although stimulant medications - the most common treatment for children and teens with ADHD – has been shown to produce a wide variety of benefits for many children, the impact of medication treatment on self-esteem has not been studied very carefully. Because some researchers believe deficits in self-esteem are among the more enduring problems for children with ADHD, the absence of research on the relation between medication treatment and self-esteem in children with ADHD is an important gap in the literature.
Previous research that is related to this issue has yielded inconclusive results. One study evaluated whether children with ADHD who took medication ascribed their improvement to pills instead of to their own abilities and found some indication that children with ADHD tended to attribute their improvement to their medication. The authors argued that this attribution might lead to feelings of helplessness and lower self-esteem because children were not taking full credit for their own improvement, although they did not measure self-esteem directly.
In a second study on this issue, it was reported that children with ADHD who were prescribed stimulant mediation reported higher academic self-esteem than unmedicated children. However, the majority of children in the study were either receiving special education services or were repeating at least one grade, which is a highly specialized sample. Thus, the results may not necessarily be representative of the majority of children with ADHD. In addition, the study was limited to the assessment of academic self-esteem, which is only one aspect of self-esteem that would be important to examine. For example, it is also important to know how medication treatment may influence not only how a child feels about his or her academic competence, but also their feelings of competence in social and behavioral domains.
The current study was designed to fill in some of these important gaps. The authors attempted to answer two main questions related to the effects of medication in children with ADHD and peer difficulties: 1) Does medication improve self-esteem, and if so 2) does this improvement correspond to the amount of medication taken?
Participants in the study were 39 boys and 17 girls between the ages of 7 and 12 who were in regular school classes without a history of repeated grades. All 56 children were diagnosed with ADHD, with half obtaining the additional diagnosis of Oppositional Defiant Disorder (ODD). All participants were also clinic-referred for peer problems. The most frequent parental complaint was that their child was having difficulty making or keeping friends. Also common were complaints of peer rejection and peer teasing.
In this study, children were divided into two groups. The larger group contained 38 children, and all of these children were prescribed stimulant medication for the study. The smaller group consisted of the remaining 18 children, who were either non-responders to medication, were seeking alternative sources of treatment, or were newly diagnosed in the context of the study. During the study, none of these children received medication.
ADHD diagnoses were made using a structured diagnostic interview completed with the child’s parent(s). The mothers of these children also completed two questionnaires to assess their child’s behavioral and emotional functioning, as well as their ability to establish friendships and get along with their peers. (The specific behavior rating scale instruments used were the Child Behavior Checklist and the Social Skills Rating System (SSRS). The children themselves were administered the Piers-Harris Self- Concept Scale (PHS), one of the most widely used and extensively researched instruments used to measure self-esteem in children. Unfortunately, the amount of time that children were receiving medication prior to the self-esteem assessment was not indicated.
Results
The results of this study indicated that children who received stimulant medication reported mildly higher self-esteem than children who did not take medication. The relationship between self-esteem and medication was complex, however. Medicated children either with or without ODD reported feeling smarter and more accepted by peers then the children who did not receive medication. Only children with ADHD and ODD, however, (i.e. those who demonstrated more behavior problems) reported feeling that they were better behaved. In addition, among all children that were medicated, higher self-esteem in the behavioral academic, peer, and physical domains was associated with higher doses of medication.
The authors suggest two alternative explanations for these results. The first is that children receiving medication reported higher self-esteem because they perceived that their behavior was under better control, thus leading them to feel more positively about themselves. They explained the dose-response relationship by suggesting that children receiving higher doses may have experienced stronger “internal sensations” from the medication, and this may have led them to have greater hope for positive social outcomes. Of course, it higher doses may have resulted in greater improvement, which could also explain the results.
Another possible interpretation for the dose-response relationship is that these improvements may be, in part, a function of the severity of the child’s symptoms. A child with more severe symptoms will generally take higher doses of medication, and will also have greater room for improvement. Greater improvement would be expected to translate into greater gains in self- esteem, thereby accounting for the association found between dosage and self-esteem that was found.
Limitations And Implications
Despite the encouraging findings of this study, you should be aware of several limitations that may have influenced the results. This includes a design that did not randomize children into treatment groups, thereby leaving the possibility that the two groups differed in some ways other than medication status and that these differences could account for the results.
Another important factor not taken into account in this study is what parents tell their children about their medication and how this might effect their children’s self-esteem. It may be that the expectations and interpretations that children on medication make, as well asthe way peers respond to them, vary as a function of the amount of time they have been taking the drug. Future studies should address these concerns to form a more complete and informative understanding of the effects of stimulants on self-esteem in children with ADHD. Finally, this article did not specify the amount of time children had been taking medication before their self-esteem was evaluated. This is an important oversight.
These concerns not withstanding, I think there are several implications of these results are quite important. First, it is important to emphasize that medication is not a “magic pill” that improves a child’s self-esteem. Most psychologists would argue that a child’s self-esteem depends, to a large extent, on how that child is performing in important life areas (i.e. academics, getting along with peers, teachers, and family members) and the feedback the child receives in that area. The fact that medication was associated with improvements in self-esteem thus probably reflected the very real impact that it had on a child’s ability to do better in these different areas. One would expect that any type of intervention – whether that be medical, behavioral, etc. – that yielded significant improvements in child functioning would also result in corresponding self-esteem gains.
A second important implication is that contrary to a concern that has been expressed by many parents and professionals, medication treatment did not seem to be harmful to how children felt about themselves. In fact, the exact opposite was found to be the case. In my own experience, I have worked with a number of parents who were reluctant or unwilling to try medication with their child because they were convinced that this would cause the child to feel badly about him or herself. While this may certainly occur in individual instances, and is a possibility that one should be aware of, the current data would seem to indicate that this would not be expected to occur very often.
Finally, I think it is really important to emphasize again the link between how a child is faring in academic, social, and behavioral domains and how the child feels about him or herself in these different areas. For most children, improving their feelings about themselves in these areas will require helping them to have more consistently successful experiences in school, with peers, and at home. Well-conducted medication treatment is one important way of helping many children experience such success, but other types of interventions can clearly play an important role in accomplishing this as well.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.