Running head: DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 1

Does being diagnosed with ADHD impact childrens self-esteem?

Dana V. Comer
University of North Carolina at Greensboro







DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 2
Abstract
With ADHD being one of the more common diagnoses made in children, research in this
area is imperative. More often than not, fluctuating levels of self-esteem coincide with the
diagnosis of ADHD in children. In attempts to test whether ADHD causes high or low self-
esteem, researchers use various methods such as questionnaires given to children and parents, as
well as administering a common method known as the I think I am Scale to the children. A
positive illusory bias and a self-protective hypothesis may be attributed to causing those children
with ADHD to have high self-esteem. However, according to other researchers, ADHD may
cause low self-esteem. This literature review focuses on the differing views of whether children
with ADHD present high or low levels of self-esteem. A study of how peer relationships with
children who have ADHD is impacted and its effects on self-esteem is included also.

DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 3
Does being diagnosed with ADHD impact childrens self-esteem
According to the American Psychiatric association, ADHD has a prevalence of affecting
approximately 3%-7% of all children (Edbom, Granlund, Lichtenstein, & Larsson, 2008).
Individuals make the assumption that children who are diagnosed with ADHD experience low
self-esteem, however, recent research may suggest otherwise. Presently, research findings are on
the fence as to whether this is true. For some, children experience low self-esteem (Ek,
Westerlund, Holmberg, & Fernell, 2008) and for others, they experience high self-esteem (Ohan
& Johnston, 2011). The purpose of this paper is to evaluate studies that support children with
ADHD as having high or low self-esteem.
Nevertheless, it is important to understand both concepts of what ADHD and self-esteem
are. Children who are diagnosed with ADHD experience behavioral impairment (Hoza, Mrug,
Gerdes, Hinshaw, Bukowski, Gold, Kraemer, Pelham, Wigal, & Arnold, 2005). ADHD is a
prevalent disorder and it is characterized by its higher levels of hyperactivity as well as
hyperactivity-impulsivity. The affects of this disorder are far from simple and can be wide-
ranging (Ohan & Johnston, 2011). ADHD affects children in the areas of the childs home,
school, and community life (Edbom et al., 2008). For most children with ADHD, the
consequences are serious and lead to poor relationships with peers. On the other hand, self-
esteem is both cognitive and emotional. It refers to the concept of the way an individual views
him/herself. Contributing factors include the way an individual holds ideas or values about
themselves and the way in which they accept themselves with those ideas. Self-image is a strong
feature that leads to an individuals self-esteem (Edbom et al., 2008).
Low Self-Esteem
DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 4
Studies documenting low self-esteem is shown when Ek et al. (2008) hypothesized
children diagnosed with ADHD and those with subthreshold ADHD (displaying symptoms of
inattention or behavior problems, but not meeting the criteria for diagnosis of ADHD) would
report lower levels of self-esteem. Children who did not fit into the ADHD or subthreshold
group were clustered together by placing these children in a group that displayed much milder
forms of inattention and behavioral or learning difficulties (BLD). Using 591 children and their
parents, The Conners scale, was given to the parents and teachers which assesses the executive
functions and aids to gain insight on how the parents and teachers rate the childs behavior or
learning difficulties (Ek et al., 2008). For the children, the I think I am scale (ITIAS), a self-
report scale on which children rate themselves was used to reflect self-esteem. It is comprised of
five scales: physical appearance, scholastic competence and talents, mental well-being,
relationship to parents and family, and relationships to others (peers) (Ek et al., 2008).
The main findings for Ek et al.s (2008) study show in support of the hypothesis that the
children with ADHD and the subthreshold ADHD children revealed significant reports of low
self-esteem as opposed to the BLD group. The ADHD/subthreshold ADHD group results
illustrate the low self-esteem in their mental well-being, relationship to parents, and relationship
to others on the ITIAS categories. By separating the responses from boys and girls, gender was
another factor analyzed and when taken into account, results for the boys showed higher self-
esteem in physical appearance, but lower self-esteem in all other categories of the ITIAS. For
girls, results concluded that they also showed low self-esteem in mental well-being which may
trigger mood and anxiety disorders later in life. Therefore, both boys and girls show an
increased risk for having low self-esteem if they are diagnosed with ADHD or have subthreshold
ADHD (Ek et al., 2008).
DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 5
To further show how ADHD leads to lower self-esteem, a study by Edbom et al. (2008)
took a longitudinal approach evaluating how ADHD is related to self-esteem using twins. The
aim of the study was used to analyze what profiles of self-esteem at 13 years of age are related to
high scores of ADHD symptoms and if children with persistent ADHD from age 8-13 have
specific self-esteem profiles. This study used 1,714 children who were evaluated twice, once at
age 8 and again at age 13 (Edbom et al., 2008). At age 8 the childrens parents completed a
questionnaire assessing the childrens behavioral problems. Five years later, parents completed
another questionnaire used to assess the twins ADHD symptoms, behavior problems, and health
status. At age 13 the twins completed a questionnaire using the ITIAS revealing their health
status and self-conception (Edbom et al., 2008).
Like the results form Ek et al. (2008), the findings from Edbom et al. (2008) confirm that
the twins with ADHD experienced low self-esteem in the categories (on the ITIAS) of skills and
talents and mental well-being. However, those twins that displayed lower self-esteem in skills
and talents and mental well-being, showed relatively high scores of self-esteem in the domains of
relation to family and relation to others. This brings attention to a possible explanation that those
children with ADHD who express good self-esteem in some domains attribute their self-esteem
to a positive illusory bias (Edbom et al., 2008).
High Self-Esteem and Peer Interactions
While some researchers claim that children with ADHD experience low self-esteem,
other researchers have differing opinions. Ohan and Johnston (2011) attribute the childs good
self-esteem to a positive illusory bias (PIB) and the self-protective hypothesis. The PIB
refers to children having a tendency to overestimate his/her own skills relative to his/her true
capabilities and the self-protective hypothesis suggests that children over-estimate their skills
DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 6
in order to hide their true abilities and put on a front for others (Ohan & Johnston, 2011). Using
42 girls with ADHD, 40 girls without ADHD and their mothers, their experiment took place by
having the child, parent and teachers use a self- and teacher-report scale to measure social
competence. Another method used was the Revised Childrens Manifest Anxiety Scale (Lie
Scale) which is used to measure socially desirable responding that contains yes/no questions
describing desirable but unrealistic characteristics. For example, I never get angry (Ohan &
Johnston, 2011).
Results for Ohan and Johnstons (2011) study indicate that those girls in the ADHD
group displayed higher self-esteem. According to the RCMAS-Lie scale, positive correlations
were found with the child-mother, child-teacher, and child-lab task discrepancies. Childrens
combination of the self-protective hypothesis and the PIB allows children with ADHD to present
a positive front to the world maintaining their self-esteem (Ohan & Johnston, 2011). Thus,
despite the failures that children with ADHD go through, the self-esteem of these children are
still more positive.
More research has been completed to see if children with ADHD can be motivated to
reduce positive bias in their own self-perceptions which may alter their self-esteem (Hoza,
Vaughn, Waschbush, Murray-Close, & McCabe, 2012). With the PIB and the self-protective
hypothesis still in mind, participants and teachers completed the Self-Perception Profile for
Children (SPPC) used to evaluate the childs self-perceived competence in the scholastic, social
acceptance, athletic, physical appearance and behavioral conduct domains. After completion of
the SPPC by the children and teachers, a match game with and without an incentive was
administered. In an effort to test whether children could match their own SPPC responses to
their teachers SPPC responses, an incentive of 50 cents was paid to the child for each match
DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 7
made (Hoza et al., 2012). With this, the effects from the self-perception match game with and
without the incentive could be separated and analyzed for the results.
Results concluded that for children with ADHD the matching manipulation significantly
reduced the amount of positive bias in both academic and behavioral domain. The money
manipulation significantly reduced the amount of bias in children with ADHD, but these
manipulations were only partially effective in reducing the bias. This goes to show that based on
these results, on average, children who have ADHD cannot fully view themselves in an unbiased
fashion (Hoza et al., 2012). With this, the self-protective hypothesis and PIB plays a prominent
role in promoting high self-esteem in children who have ADHD.
Other research has looked at how children with ADHD interact with peers to help
understand causes for the varying levels of self-esteem they express (Hoza et al., 2005). In Hoza
et al.s (2005) study, researchers recognized that boys were more likely to rate their behavior and
social interactions more positively than boys without ADHD after blatantly experiencing failure.
It has been suggested that this lack of insight and poor social perception may contribute to peer
problems which lead to fluctuating levels of self-esteem. Hoza et al. (2005), found that after 165
children with ADHD and 165 comparison children (without ADHD) positively and negatively
nominated peers on a questionnaire, results of this study concluded that 56% of children with
ADHD had no dyadic friends and only 33% had one dyadic friend. This means that more than
half of the children with ADHD did not have two best friends and a little over one-third had only
one best friend. Moreover, results indicated that 52% of the children with ADHD were rejected
as compared with only 14% of the comparison children. Given these results, it is safe to say that
children with ADHD are disliked to a greater extent and rejected more often than other children
which further suggest impairment in the level of self-esteem they obtain (Hoza et al., 2005).
DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 8
As with all the current research that has been studied, future data is needed to be
assessed. Because ADHD is more common in boys than girls, one limitation is that boys and
girls are never equally represented in a study (Hoza et al., 2005; Ohan & Johnston, 2011; Ek et
al., 2008). Another limitation to be mentioned is more research needs to be evaluated to see if
children with ADHD have good self-esteem as an outcome of cognitive or executive functioning
deficits. Problems in these areas distort childrens ability to accurately express self-perception
(Hoza et al., 2012). In addition to this, one question still unanswered in many research articles is
whether good self-esteem is related to delayed development in children with ADHD (Ohan &
Johnston, 2011). A concern brought up in Edbom et al.s (2008) article was children with long-
term ADHD may have good self-esteem only because they have developed strategies for coping
with their symptoms of ADHD. Further research in this area would be beneficial. Lastly, for
future research, studies evaluating children with different ADHD sub-types could be useful
(Ohan & Johnston, 2011).
In conclusion, there have been no theories set in stone for whether children with ADHD
are predestined to have high or low self-esteem. With the current research, researchers are on the
fence as to whether children with ADHD express low or high levels of self-esteem. Some
studies suggest low (Edbom et al., 2008; Ek et al., 2008) while others suggest high (Hoza et al.,
2012; Ohan & Johnston, 2011). Increased knowledge on how being diagnosed with ADHD
impacts self-esteem in children is such an intriguing and important area for study due to the fact
that ADHD is a fairly common disorder diagnosed in children. Ongoing research with the PIB
and the self-protective hypothesis should be continued to further see what other factors may
contribute to the varying levels of self-esteem in children with ADHD.

DIAGNOSIS OF ADHD IMPACTING SELF-ESTEEM 9
References
Edbom, T., Granlund, M., Lichtenstein, P., & Larsson, J. (2008). ADHD symptoms related to
profiles of self-esteem in a longitudinal study of twins: A person-oriented approach. Journal
of Child and Adolescent Psychiatric Nursing, 21(4), 228-237.
Ek, U., Westerlund, J., Holmber, K., & Fernell, E. (2008). Self-esteem in children with attention
and/or learning deficits: the importance of gender. Acta Paediatrica, 97(8), 1125-1130.
Hoza, B., Mrug, S., Gerdes, A.C., Hinshaw, S.P., Bukowski, W.M., Gold, J.A., Kraemer, H.C.,
Pelham, W.E., Wigal, T., & Arnold, L. (2005). What aspects of peer relationships are
impaired in children with attention-deficit/hyperactivity disorder?. Journal of Consulting and
Clinical Psychology, 79(3), 411-423.
Hoza, B., Vaughn, A., Waschbusch, D. A., Murray-Close, D., & McCabe, G. (2012). Can
children with ADHD be motivated to reduce bias in self-reports of competence?. Journal of
Consulting and Clinical Psychology, 80(2), 245-254.
Ohan, J.L., & Johnston, C. (2011). Positive illusions of social competence in girls with and
without ADHD. Journal of Abnormal Child Psychology, 39(1), 527-539.