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Self-Esteem in Children with ADHD
Because the behavioral and academic difficulties associated with ADHD are often so prominent, it can be easy to overlook the impact that ADHD may have on less obvious areas of children’s functioning. For example, children’s peer relations are often adversely affected by ADHD, and despite the importance of good peer relations for long-term development, this area is often neglected in treatment. Aspects of emotional functioning – i.e. feelings of sadness, worries, etc. – also tend to be adversely affected in many children with ADHD but often go unaddressed.
How a child feels about him or herself – i.e. their self-esteem – is another important area that may be adversely affected by ADHD and which may be overlooked in the face of more obvious behavioral and academic difficulties. Because a child’s self-esteem depends to a large extent on the success he/she experiences in school and in relationships with parents and peers, it is easy to imagine how the self-esteem in children with ADHD may suffer. Although effective treatment can mitigate such effects, some parents worry that treatment itself – particularly medication treatment – could negatively impact a child’s self-esteem.
These issues were examined in an interesting study published in the Journal of the American Academy of Child and Adolescent Psychiatry (Bussing, R., et al., (2000). Self-esteem in special education children with ADHD: Relationship to disorder characteristics and medication use. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1260-1269.) In contrast to prior studies in which self-esteem in children with ADHD was compared to self-esteem in non-ADHD peers (the results of such studies have been mixed, with some finding lower self-esteem in ADHD children and other failing to find such differences), Dr. Bussing and her colleagues conducted a more careful examination of this relationship. Specifically, they recognized that children with ADHD often have other important difficulties, but this varies widely from one child to the next. For example, some children have ADHD alone, others have externalizing problems such as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) in addition to ADHD, while others have mood or anxiety problems (i.e. internalizing disorders). In addition, there is an unfortunate subset of children with ADHD who have both co-occurring internalizing and externalizing problems. Clearly, self-esteem in children with these different combination of difficulties would be expected to vary, although this has not been carefully examined in prior research.
Participants in this study were 143 8-12 year old students with ADHD (115 boys and 28 girls) receiving special education services in a medium-sized school district. (Note: Because this sample was drawn a special education population, the findings do not necessarily generalize to children with ADHD overall.) Eighty-seven of these children – about 61% - were currently being treated with medication. All children completed the Piers-Harris Self-Concept Scale, a widely used and well-validated measure of self-esteem in school-age children. The Piers-Harris provides a total self-concept score as well as specific assessments of children’s self-concept in behavioral, academic, social, physical appearance, and general happiness/satisfaction domains. Children also completed the Child Depression Inventory (CDI) and the Revised Children’s Manifest Anxiety Scale (RCMAS) to obtain their reports of depressive and anxiety symptoms respectively. In addition, children’s parents were interviewed to determine whether a co-occurring externalizing disorder (i.e. ODD or CD) was present. Complete data was obtained on 128 of the 143 participants.
Results
Using the data obtained from children and parents described above, participants were divided into 4 groups: those with ADHD alone (n=52, 41% of sample); those with ADHD and an externalizing disorder (n=40, 31% of sample); those with ADHD and an internalizing disorder (n=18, 14% of the sample); and those who had both an internalizing and externalizing disorder (n=18, 14% of sample).
These data are instructive in and of themselves in that they highlight the frequency with which other important difficulties are often found in children with ADHD. In this sample, a full 54% had a co-occurring externalizing disorder (i.e. the 40% who had an externalizing disorder alone and the 14% who had both an internalizing and externalizing disorder) while 28% had internalizing problems (i.e. high levels of depressive or anxiety symptoms). These figures may be slightly elevated because participants were drawn from a special education population, but are not all that discrepant from what has been reported in prior studies. Clearly, these findings highlight the need for a comprehensive evaluation of children’s functioning when attempting to make an ADHD diagnosis rather than focusing on the specific symptoms of ADHD alone. In particular, the presence of internalizing difficulties can often be missed as parents can be unaware of these problems and many physicians fail to adequately evaluate this aspect of children’s functioning in their evaluation.
Participant’s self-esteem was found to vary dramatically depending on the presence or absence of these co-occurring problems. The average scores for each group on the total self-concept scale and the different subscales are shown below (Note E=externalizing; I=internalizing; The results reported below were generally consistent across both genders.):
As can be seen above, apart from the physical appearance scale where differences between the groups were not significant, there are clear differences on all other dimensions as well as the total score. Children with ADHD alone consistently reported the highest self-esteem, and their scores fell in the normal range for this measure. Children with externalizing disorders only in addition to ADHD also report generally positive feelings about themselves. In fact, although their scores look a bit lower than those for children with ADHD alone, these differences are not significant according to statistical test. This is an interesting finding in and of itself in that it indicates that despite the tremendous distress for others that a child with ADHD and another disruptive behavior disorder can cause, these children tend not to experience much distress themselves, nor do they appear to feel badly about how they are doing.
For children with an internalizing disorder – whether alone or in combination with an externalizing disorder – the results are dramatically different. These children report consistently less positive feelings about themselves and the differences are really quite substantial. What is especially striking is that even in the domain of behavior – where children with ADHD and an internalizing problem are likely to be doing objectively better than children with ADHD and an externalizing disorder – they still rated themselves substantially lower. Thus, the presence of an internalizing disorder along with ADHD greatly increases the likelihood that a child’s feelings about him or herself in a variety of important areas are likely to be decidedly negative.
As noted above, once concern that some parents have about the use of medication treatment is that needing to take medication may undermine a child’s self-esteem. The authors examined this issue by computing the average self-esteem scores for medication treated and non-medication treated groups. No differences between these groups were found.
Summary And Implications
The most important message from this study is that ADHD alone does not appear to be associated with lower levels of self-esteem in school-age children. Instead, it is the presence of a co-occurring internalizing problem – either alone or in combination with an externalizing disorder – that is predictive of dramatically lower self-esteem.
The importance of these data is that they clearly highlight the need that children suspected of having ADHD are thoroughly evaluated for the presence of co-occurring internalizing problems. In this sample, such difficulties were found in almost 30% of the participants. This is particularly striking because these were all pre-adolescents, and it is in the adolescent years when such difficulties tend to become even more prevalent.
One reason why careful identification of such problems is so important – in addition to the apparent impact on a child’s self-esteem – is the implications this can have for treatment. For example, results from the multi-modal treatment study of ADHD (MTA study), the single largest treatment study of ADHD ever conducted – indicate that psychosocial interventions can be especially helpful and important for these children. For these children especially, medication treatment alone may often not be an appropriate approach to undertake.
Parents and professionals thus need to pay particularly close attention to the emotional functioning in children with ADHD, and be alert to the possibility that such difficulties may emerge over time in response to the difficulties that having ADHD can cause. For parents who have questions about these aspects of their child’s health, consultation with an experienced child mental health professional is strongly recommended. Carefully evaluating a child for depressive or anxiety disorders is not something that most pediatricians or family practitioners are typically well equipped to do.
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.