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Because
the behavioral and academic difficulties associated with ADHD are often so
prominent, it is easy to overlook the impact that ADHD may have on less obvious
areas of children's functioning. For example, children's peer relationships
are often adversely affected by ADHD. Despite the importance of good peer
relations for long-term development, this area often is neglected in
treatment. Aspects of emotional functioning, such as feelings of sadness or
anxiety, also tend to be adversely affected in many children with ADHD. Yet,
these difficulties often go unacknowledged.
How a child feels about himself or herself (their self-esteem) is another key
area that may be adversely affected by ADHD, but 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 or 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., pp. 1260-1269, 2000). 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 others
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 key 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 (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 combinations of difficulties would be expected to vary,
although this has not been carefully examined in prior research.
Participants in this study included 143 students with ADHD between the ages
of 8 and 12 (115 boys and 28 girls) who were receiving special education
services in a medium-sized school district. (Note: Because this sample was
drawn from a special education population, the findings do not necessarily
generalize to children with ADHD overall.) Out of this group, 87
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 the areas of behavior, academics,
social life, 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, the children’s
parents were interviewed to determine whether a co-occurring externalizing
disorder (such as 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 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 (the 40% who had an externalizing
disorder alone and the 14% who had both an internalizing and externalizing
disorder) while 28% had internalizing problems (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 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.
Participants' self-esteem was found to vary dramatically depending on the
presence or absence of 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 and I=internalizing. The results reported
below were generally consistent across both genders.)
ADHD only
ADHD + E ADHD + I
ADHD + I & E
Total
80.1 71.5 39.7 39.4
Behavior 68.9 56.6 31.8 27.3
Academics 72.0 65.5 41.3 47.4
Appearance 74.5 69.4 63.4 54.7
Social 54.9
52.7 25.4 28.7
Happiness 77.8 72.7 48.5 47.3
As 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 only ADHD
consistently reported the highest self-esteem, and their scores fell in the
normal range for this measure. Children with only externalizing disorders in
addition to their 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 tests. This is an interesting finding, as 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. The
differences are 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 himself or herself in
a variety of important areas are likely to be decidedly negative.
As noted above, one 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, which is predictive
of dramatically lower self-esteem.
These data clearly highlight the need for children suspected of having ADHD
to be 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 they were all
pre-adolescents, and it is in the adolescent years when such difficulties
tend to become even more prevalent.
In addition to the apparent impact on a child's self-esteem, careful
identification of such problems is so important because of its impact on
treatment measures. For example, results from the multi-modal treatment study
of ADHD (MTA study)—the single largest treatment study of ADHD ever
conducted—indicates that psychosocial interventions can be especially helpful
and important for these children. For these children especially, medication
treatment alone often may not be an appropriate approach.
Parents and professionals thus need to pay particularly close attention to the
emotional functioning of children with ADHD, and be alert to the possibility
that such difficulties may emerge over time in response to the obstacles
sometimes caused by ADHD. Consultation with an experienced child mental health
professional is strongly recommended for parents who have questions about
these aspects of their child’s health. Carefully evaluating a child for
depressive or anxiety disorders is not something that most pediatricians or
family practitioners typically are well equipped to do.
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