Self Concept in Children and Adolescents

with ADHD
Gail Houck, PhD, RN, PMHNP, Judy Kendall, PhD, RN, Aaron Miller, MS, RN, Piper Morrell,
MS, RN, and Gail Wiebe, MS, RN
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The publisher's final edited version of this article is available at J Pediatr Nurs
See other articles in PMC that cite the published article.

Attention deficit hyperactivity disorder (ADHD) is the most common mental health disorder of
childhood, affecting approximately 3%-8.7% of children and adolescents in the U.S. (NIMH,
2008). ADHD is a chronic and stigmatizing neurobiological disorder with deficits in the
neurotransmitter systems that effect executive functioning. Etiology is primarily genetic, with
only 7% of cases related to head trauma, lead poisoning, or low birth weight. Seven genes have
been shown to have statistically significant evidence of association with ADHD (the dopamine 4
and 5 receptors, the dopamine transporter gene, dopamine –hydroxylase gene, the serotonin
transporter gene, the serotonin 1B receptor, and the synapt osomal associated protein 25 gene)
(Faraone, Perlis, Doyle, Smoller, Goralnick, Holmgren & Sklar, 2005). Although ADHD is
considered an environmentally-dependent disorder, with symptoms increasing and decreasing in
relation to environmental demands and expectations, there is no evidence to suggest that ADHD
is caused by poor parenting practices or diet (Barkley, 2006).

People with ADHD have impairments in adaptive functioning which is often manifested in
difficult behaviors such as aggression, poor rule-regulated behavior, inability to delay
gratification, behavioral disinhibition, learning difficulties, poor impulse control, and low
motivation. Children and adolescents with ADHD are at significant risk for numerous emotional
and social problems, including academic and occupational underachievement, increased suicide
and risk-taking behavior, depression, addiction, interpersonal difficulties, and family disruption
(Barkley, 2006). Symptoms of ADHD are pervasive, affecting an individual’s cognition,
behavior, and affect resulting in academic, social, and interpersonal relationship challenges. On a
systemic level, ADHD significantly influences multiple social units including the family,
neighborhoods, schools, community organizations, workplaces, and the larger society.

Much discussion exists in the research literature about the short- and long-term effects of this
behavioral disorder on individual children and their families. Findings from previous studies on
the relationship between ADHD and self-concept are mixed, with some studies indicating that
self-concept scores are higher in children with ADHD than those without ADHD (Treuting &
Hinshaw, 2001), others reporting that scores are lower in children with ADHD, (Barber, Grubbs,
& Cottrell, 2005), and still others reporting no difference between children with or without
ADHD (Bussing, Zima, & Perwien, 2000). Further research is needed to clarify under what
circumstances differences in self-concept scores exist in children with ADHD. Understanding
more specifically how self-concept and behavioral problems are related, given the behavioral
disruption that accompanies ADHD, is important in order to support a child’s social and
emotional development. Furthermore, an understanding of such a relationship may be different
based on gender, age, and ethnicity. Gaining an increased understanding of these relationships
can better guide best practices in the assessment and treatment of children with ADHD disorder.
The aim of this study was to examine the relationship between behavior problems and self-
concept in children and adolescents with ADHD. In addition, the prediction of self-concept
scores by gender, age, ethnicity, and behaviors problems was also examined.

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Background
Symptoms of ADHD, pharmacological treatment of ADHD, comorbid disorders, and the
developmental course of the disorder are well studied. Nonetheless, a paucity of research exists
in other important areas. More specifically, there is a lack of studies examining the differences in
how children of different gender, ages, and ethnic groups experience ADHD and how those
differences are expressed in relation to self-concept and behavior problems. Few studies are
published and research results that are available report conflicting findings.

ADHD and Self-concept

Self-concept is the totality of the individual’s cognitive image of him or herself; it is the
cognitive component of the self (Houck & Spegman, 1999). It includes a descriptive definition of
the self and the ideas, beliefs, and attitudes about the self and one’s competencies in various
domains. A positive self-concept in children has been associated with improved academic
performance, effective use of coping skills, safe and healthy social relationships, and dynamic
movement through successive developmental stages (Houck, 1999). Self-esteem is differentiated
from self-concept as the expression of one’s self-concept, and the value and significance one
places on one’s self – the way one feels about who they are. One kind of perceived competence
that develops over time may be a sense of self-efficacy (Houck, 1999), which refers to the
experience of the self as able to produce specific social interactive outcomes (Connell, 1990). It
is similar to “social competency” - the perceived competence to produce social outcomes.
Whereas self-concept is an individual’s cognitive image of self and one’s competencies, self-
efficacy is the experience of self as able to produce these competencies

Self-concept and self-esteem have been found to be impaired in children with ADHD (Graetz,
Sawyer, & Baghurst, 2005; Demaray & Elliot, 2001). Pisecco (2001) found that poor self-
concept, specifically in relation to academic competence, contributed directly to the development
of disruptive, antisocial behaviors in early adolescence. Others found that children with the
inattentive type of ADHD tended to engage in more internalizing behavior and had lower self-
esteem than the hyperactive type who exhibited externalizing behaviors and had a higher self-
esteem (Graetz, et al., 2001). Concurrently, this same research found that children with ADHD
who were both inattentive and exhibited externalizing behavior had lower self-esteem than
children who were solely inattentive or were hyperactive-externalizing (Graetz et al., 2001).

A Canadian study sampled 165 children with ADHD when they were, on average, 10 years old
(Klassen, Miller, & Fine, 2004). Although physical health in children with ADHD was deemed
comparable to the control group, psychosocial health scores were significantly impacted across
all domains. Children with more symptoms of ADHD had worse psychosocial health-related
quality of life (HRQL) scores. The negative impact on self-esteem was substantial, with a large
effect size of −0.90. Furthermore, children with two or more co-morbid disorders had poorer
HRQL scores across a range of domains compared to those with no or only one comorbid
disorder. Oppositional defiant disorder and conduct disorder co-morbidities were correlated with
lower HRQL scores, yet co-morbid learning disabilities were not. This suggests that
identification and differentiation of co-morbid processes in children with ADHD has clinical
significance when determining appropriate treatment (Klassen, Miller, & Fine, 2004). Given the
finding that children with ADHD self report the belief that their “real” selves are persistently
“bad” (Kendall, Hatton, Beckett, & Leo, 2003) despite treatment with medication, these
psychosocial consequences and co-morbidities may well contribute to diminished self-concept.
This is supported by a study of 143 students with ADHD, eight to twelve years old, that even
though self-esteem scores were normal, independent predictors of lower self-esteem again
included having a diagnosed co-morbid internalizing condition and having a high level of
functional impairment (Bussing, et al, 2000). Medication use was not predictive although being
Caucasian was.

Self-concept and Age

Little research exists specifically comparing the self-concept of children with ADHD at different
ages. In this study, interest in age as a factor stems from the implications of the research findings
described above. To the extent that ADHD symptoms, co-morbidities, and internalizing behavior
problems negatively impact self-esteem and self-concept, a finding for behavior problems to be
related to self-concept is anticipated for the current study. There is evidence that there is little
change in a child’s level of aggressive/externalizing behavior from kindergarten through eighth
grade (Vazsonyi & Keiley, 2007) and for there to be relative stability of behavior problems over
time, especially aggression and social withdrawal, from toddlerhood to preschool, and from
preschool to grade school and adolescence (Houck & Spegman, 1999). Therefore, a concern is
raised about whether such stability of behavior problems may have a negative cumulative effect
on self-concept as children age. Thus, in this study of children and adolescents with ADHD, age
will be examined in relation to self-concept.

Self-concept and Gender

Much of the current ADHD research on gender differences has limited applicability to females
because study samples included mostly males. Females tend to present less frequently in clinics
for evaluation of ADHD, and therefore are represented less in clinical research. Clinically
referred males could be more numerous due to their greater likelihood of disruptive behaviors.
The reasons behind fewer female referrals to clinics may be numerous and complex.
Nonetheless, this circumstance has implications for the diagnosis and treatment of ADHD in
females (Gershon, 2002).

Gershon’s (2002) meta-analytic review of gender differences in ADHD revealed females to be

rated significantly less impaired than males on hyperactivity, inattention, and impulsivity
whereas a more recent study (Rucklidge, 2008) found that ADHD symptoms were not gender
specific. However, both the Geshon (2002) meta analysis and the Rucklidge study (2008) found
that females with ADHD manifested fewer externalizing problems (Geshon) or aggression and
externalizing behavior (Rucklidge), and were found to have more internalizing problems
(Geshon), with higher rates of depression and anxiety (Rucklidge) compared to boys with
ADHD. Adolescent girls were additionally found to have lower self-efficacy and poorer coping
strategies than adolescent boys with ADHD (Rucklidge), and efficacy and coping strategies are
thought to be linked to self-concept (Houck, 1999).

These findings—that females had more internalizing problems, depression, and anxiety as well
as diminished self-efficacy and coping, and had less aggression and externalizing behavior than
males—together support a hypothesis that aggression and externalization may not negatively
impact self-concept as much as internalizing behaviors. Yet, not all studies agree with these
findings and often show similar rates of coexisting psychiatric disorders and symptoms
(Rucklidge). The relationships among gender, behavior problems, and self- concept are not well
understood and require further research.

Self-concept, Behavioral Problems, and Ethnicity

One teacher-based study assessed children without ADHD from low SES families, and found
that ethnicity, specifically being African American, and the primary caretaker’s single marital
status were the only variables significantly associated with teachers’ assessment of externalizing
behavioral problems (Horwitz, Bility, Plichta, Leaf,& Haynes, 1998). This same study found that
Hispanic children were more likely to experience internalizing and attention behavioral
problems.

In a study of parents of African American children with ADHD, researchers found that African
American children were half as likely to receive pharmacotherapy compared to Caucasians
(Olaniyan, dos Reis, Garriett, Mychailyszyn, Anist, Rowe, & Cheng, 2007). Interestingly, a
Turkish randomized controlled study on methylphenidate treatment of ADHD in children found
that the children treated pharmacologically had significantly higher self-esteem than those who
were not treated pharmacologically (Ozturk, Sayar, Tuzun, & Kandil, 2000). Furthermore, an
American study found that treatment with stimulants and self-esteem were positively correlated
in children with ADHD (Frankel, Cantwell, Myatt, & Feinberg, 1999). It may be that medication
facilitates behavioral regulation thereby promoting more positive self-esteem. This potential
warrants further study. Additionally, these findings suggest that African American children, who
are less likely to be treated pharmacologically for their ADHD, may be at risk for lower self-
esteem. More research is necessary, however, to further our understanding about how children
and adolescents with ADHD from various ethnic groups differentially manifest self-concept.

Purpose

Existing research reveals links between behavior problems and self-concept, as well as behavior
problems and ADHD, gender, and ethnicity, respectively. The purpose of this study was to
examine the relationship between behavior problems and self-concept in children and
adolescents with ADHD. In addition, the relationships among gender, age, and behavior
problems with self-concept were explored, and ethnic differences with respect to behavior
problems and self-concept were examined.
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Method
Using a descriptive correlational design, this study is a secondary analysis of data drawn from
the NIH-funded study, ADHD, Ethnicity, and Family Environment (Kendall, 2000). Previous
results from the larger study have been published (Kendall, Hatton, Beckett, & Leo, 2003;
Kendall, Leo, Perrin, & Hatton, 2005a; Kendall, Leo, Perrin, & Hatton, 2005b; Perry, Hatton, &
Kendall, 2006). The original sample included 157 caregivers of at least one child living in the
home and diagnosed with ADHD. During the screening process mothers were asked how the
diagnosis of ADHD was made and by whom. To be included in this study, the diagnosis had to
be made by a health care provider legally allowed to make such a medical diagnosis, such as a
physician, clinical psychologist, psychiatric-mental health nurse practitioner, or licensed clinical
social worker. Those who reported that their children were diagnosed by their teachers or
through their school, or that they were self-diagnosed, were referred to clinicians for a formal
diagnostic assessment. If an ADHD diagnosis was given to the child, then subsequently, that
family was invited to participate in the study. Our success in using this screening procedure in a
previous study (Kendall, 1998; 1998) warranted using self-report of diagnosis in the current
study. Furthermore, we interviewed all the children with ADHD and their mothers which further
solidified that self-report of ADHD was accurate.

A thrust of the larger parent study was to examine the disability burden from unmet mental
health needs that typify ethnic minorities relative to Caucasians. Thus, about a third of the
participating families were African American, a third were Hispanic, and a third were Caucasian
(see Kendall et al., 2005b for details). Families were recruited through informational flyers
posted at schools, clinics, and social service and cultural support agencies in the Portland,
Oregon and San Diego areas. Those interested in participating in the study contacted recruitment
coordinators to schedule an initial interview with the family in their home, unless the family
specified otherwise. Once informed consents were signed and questions answered,
questionnaires were administered and private interviews were conducted with individual family
members. At the conclusion of the data collection session, the caregivers were provided $100 in
appreciation for the time and effort contributed to the project. The current study focuses on the
data collected from self-reports of caregivers regarding child behavior problems and children and
adolescents with ADHD self-reporting on their self-concept.

Measures

Demographic Questionnaire

Caregivers were asked to complete a demographic form, consisting of questions related to age,
gender, and ethnicity of the ADHD child, family ethnicity, and household income. In addition,
we asked caregivers to report the ADHD – diagnostic type of their child (inattentive,
hyperactive/impulsive or combined), the number of existing diagnosed psychiatric co-
morbidities of their child, and to rate their perception of severity of ADHD symptoms (not a
problem, mild, moderate, extremely severe) and their perception of disruptiveness of symptoms
(not a problem, mild, moderate and extremely severe). (For further information on the perception
of severity of ADHD symptoms perception scale and the perception of disruptiveness of
symptoms scale see Kendall, et al, 2005b).

Child Behavior Checklist (CBCL)

The Child Behavior Checklist (CBCL; Achenbach, 1991) was administered to parents of
children and adolescents to assess the severity of ADHD symptoms. The behavioral/emotional
problems of the target child were assessed through 118 behavioral descriptors that the parents
rated as not true of the child (0), somewhat or sometimes true (1), or very true or often true (2).
Parental reports were obtained separately from caregivers and fathers; maternal scores were
analyzed for this report.

The CBCL data yielded a total problem score in addition to two major dimensions of child
behavior, Internalizing and Externalizing. Substantial reliability and validity study has been
conducted, and normative data were drawn from the 48 contiguous states for SES, ethnicity,
region, and urban-suburban, and urban-suburban-rural residence. In the current study, internal
consistency estimates (alpha coefficients) were: Internalizing Problems, α = .90 (32 items);
Externalizing Problems, α = .93 (33 items); and Total Problems α = .95 (118 items). Internal
consistency estimates of the scale and subscales were fairly high and more than adequate. For
this sample, the mean scores and standard deviations for the subscales and total scale were in the
clinical range for gender and age categories; see Table 1.

Table 1

CBCL Means and Standard Deviations

Sample Normsa
M (SD) M (SD)
Internalizing Scale
Boys 6–11 years (n = 71) 13.42 (9.13) 5.6 (4.7)
Girls 6–11 years (n = 26) 14.77 (9.87) 6.3 (5.5)
Boys 12–18 years (n = 52) 13.92 (9.10) 6.4 (5.5)
Girls 12–18 years (n = 8) 22.38 (10.76) 7.5 (6.6)
Externalizing Scale
Boys 6–11 years (n = 71) 23.59 (11.04) 9.8 (7.1)
Girls 6–11 years (n = 26) 21.27 (9.48) 8.2 (6.1)
Boys 12–18 years (n = 52) 22.19 (12.84) 8.7 (7.6)
Girls 12–18 years (n = 8) 29.25 (15.36) 7.1 (6.6)
Total Problems Scale
Boys 6–11 years (n = 71) 61.51 (28.21) 24.3 (15.6)
Girls 6–11 years (n = 26) 61.84 (24.27) 23.1 (15.5)
Boys 12–18 years (n = 52) 57.59 (28.95) 22.5 (17.0)
 Sample Normsa
M (SD) M (SD)
Girls 12–18 years (n = 8) 82.13 (35.66) 22.0 (17.7)
a
Achenbach, T. M. (1991). Manual for the child behavior checklist/4–18 and 1991 profile.
Burlington, VT: University of Vermont Department of Psychiatry.

Children’s Self-Concept Scale: The Way I Feel about Myself

The Piers-Harris Children’s Self-Concept Scale (CSC; Piers, 1986) was completed by children
and adolescents with ADHD, aged six to eighteen years, to assess self-concept. The self-report
measure was administered to younger children (age 6–8) individually by a research assistant. The
CSCS has 80 items that are self-declarative statements, such as “I have many friends.” The
children respond to each statement with “yes” (1) or “no” (0); the item scores are summed to
yield a total score and factor scores, including physical appearance and attributes, anxiety,
intellectual and school status, behavior, happiness and satisfaction, and popularity. Higher scores
for total self-concept and factor scores reflect a more positive self-concept. Previous test-retest
reliability estimates range from .71-.96 (Piers), reflecting relative stability in children’s report on
the CSCS. Internal consistency estimates have been more than adequate, ranging from .78-.93
for the total scale. In the current study, the internal consistency estimate (alpha) for the total scale
was .92 for the entire sample of children. The total scale score, with a possible range from 0 to
80, was used in the current study. For the total self-concept scores, the sample in this study
yielded M = 56.52 (SD = 13.12), a somewhat lower average score than found for the normative
sample (M = 61.16, SD = 11.04; Piers, 1986).

Data Analysis

Descriptive statistics were used to describe the characteristics of the children’s ADHD. The
associations between gender and these characteristics and ethnicity and these characteristics were
also assessed. The first aim of this study, to examine the relationship between behavior problems
and self-concept, was analyzed using correlation analysis and linear regression. It was
hypothesized that more behavior problems would be related to lower self-concept. The second
aim of the study was to explore the relationship among gender, age, and behavior problems with
self-concept. Correlation analyses between gender, age, behavior problems, and self-concept
were conducted; subsequently, multiple regression analysis was conducted to assess the
prediction of self-concept scores by gender, age, and behavior problems. Finally, MANOVA was
carried out with ethnicity serving as the grouping variable and behavior problems and self
concept scores serving as the dependent variables.

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Results
Sample
A complete data set was available for 145 children and adolescents, who ranged from 6 to 18
years of age, with an average age of nearly 11 years (M = 10.92, SD = 2.99). Mothers were the
primary caregivers of these children and adolescents, although the sample also included seven
grandmothers and one great-grandmother, ranging in age 21 to 79 years of age (M = 38.3, SD =
8.7). Caregivers were educated, with 85% (n = 122) having at least a high school education and
two thirds (67.2%, n = 96) having at least some college. Most caregivers (88%, n = 128) reported
having family health insurance. Families averaged 4 members in size (M = 4.01, SD = 1.38). See
Table 2 for additional characteristics of the children/adolescents and their families.

Table 2

Sample Characteristics

Children/Adolescents n %
Age
6–12 years 100 69.0
13–18 years 45 31.0
Gender
Males 114 78.6
Females 31 21.4
Ethnicity
African American 46 31.7
Hispanic American 45 31.0
Caucasian 47 32.4
Other or mixed 7 4.8
Family/Caregiver n %
Annual Income
< $10,000 36 25.
2
$10,000–40,000 66 44.
7
>$40,000 43 30.
1
Partner Status
Single-parent 74 51.
0
Partnered 71 49.
0

Characteristics of ADHD
Descriptive statistics were calculated for the children’s type, severity, and disruptiveness of
ADHD. In this sample, all of the children (100%; n = 145) were identified as having ADHD. The
type of ADHD was reported for 143 of the child participants: over two thirds (68.3%, n = 99)
were reported to have a combination of inattention and hyperactivity, 15% (n = 22) had
inattention and 15% (n = 22) had hyperactivity. Using a subjective rating scale for severity of
ADHD symptoms, most of the children were rated by their caregivers as having at least a
moderate level of ADHD severity (51.7%, n = 75) and nearly one third were rated as having
extremely severe ADHD (32.4%, n = 47). Caregivers were also asked to rate their perception of
the disruptiveness of their children’s ADHD behavior. Accordingly, 95% (94.5%, n = 137) of the
children were viewed as having ADHD that was at least a little disruptive, with two thirds
(64.1%, n = 93) perceived as having ADHD that was moderately or extremely disruptive.

Over two thirds (69.7%, n = 101) of the ADHD participants were currently on medication for
their ADHD. Of those, nearly half (48.5%, n = 49) found the medication extremely helpful and
another third (37.6%, n = 38) reported the medication as moderately helpful. A few found the
medication to be only a little helpful or not helpful at all (6.9%, n = 7, respectively).

The associations between gender and the type, severity, and disruptiveness of ADHD were
separately assessed using Chi Square, as were the associations between ethnicity and these
variables. Gender was not significantly associated with the type of ADHD, χ2 (3, N = 145) =
4.11, p = .25, the severity of the child’s ADHD, χ2 (3, N = 145) = 1.54, p = .67, or the
disruptiveness of the child’s ADHD, χ2 (3, N = 145) = 4.08, p = .25. Ethnicity also was not
significantly associated with the child’s ADHD characteristics: type, χ2 (9, N = 145) = 2.54, p =
.98; severity, χ2 (9, N = 145) = 6.38, p = .70; and disruptiveness, χ2 (9, N = 145) = 7.28, p = .61.

Behavior Problems and Self-Concept

The first aim of this study, to examine the relationship between behavior problems and self-
concept, was analyzed using correlation analysis and linear regression. It was hypothesized that
more behavior problems would be related to and predict lower self-concept. According to
correlation analysis, the CBCL total problem score yielded a moderate negative correlation with
the total score on the Pier Harris Self-Concept Scale (r = −.20, p = .01). When the major
dimensions of the CBCL were correlated with the self-concept total score, analysis revealed a
negative relationship between the internalizing problem score and the self-concept total score (r
= −.29, p = .001); more internalizing problems were related to lower self-concept scores. See
Table 3.

Table 3

Correlations among Child Gender, Age, Behavior Problem (CBCL) Scores and Self-Concept
(PSC) Scores (N = 145)

Child Variables 1 2 3 4 5 6

Total Self-Concept 1
Internalizing Behavior Problems −.29** 1
Child Variables 1 2 3 4 5 6

Externalizing Behavior Problems −.11 .61** 1

Total Behavior Problems −.20** .85** .88** 1
Gender .08 .17* .03 −.13 1
Age −.23** .06 .01 .03 −.13 1
**
p = .01 (1-tailed)
*
p = .05 (1-tailed)

A linear multiple regression analysis was then performed with the total self-concept score as the
dependent variable and internalizing behavior problems and externalizing behavior problems as
the independent variables. Refer to Table 3 for the correlations between the variables; Table 4
displays the results of the regression analysis. The overall regression equation was significant, F
(2, 145) = 7.18, p = .001. Altogether, 9% (8% adjusted) of the variability in self-concept scores
was predicted by knowing the scores on the two behavior problem variables. Only the
internalizing behavior problem score predicted self-concept scores, with higher internalizing
problems predicting lower self-concept (β = −.36, t = −3.53, p < .01).

Table 4

Standard Multiple Regression of Behavior Problem Scores on Self-Concept Scores

Predictor Variables B β t

CBCL Internalizing Problems −.488 −.356 −3.53**

CBCL Externalizing Problems .118 .108 1.07
Intercept 60.73
2
R = .09
Adjusted R2 = .08
R = .30**
**
p ≤ .01
*
p ≤ .05

Relationships between Gender, Age, Behavior Problems and Self-Concept

The second aim of the study was to explore the relationship between gender, age, and behavior
problems with self-concept. Correlation analyses between gender, age, internalizing and
externalizing behavior problem scores, and self-concept were conducted. Subsequently, multiple
regression analysis was conducted to assess the prediction of self-concept by gender, age, and
behavior problem scores.

The correlation analyses (see Table 3) revealed a small but significant correlation between
gender and internalizing behavior problems, with females yielding higher scores (r = .17, p =
.02); gender was not related to externalizing behavior problem scores. Age was not correlated
with internalizing, externalizing, or total behavior problem scores. Whereas gender was not
related to the self-concept score, age yielded a significant negative relationship with the total
self-concept score (r = −.23, p = .01), with older children having lower self-concept scores.

Linear multiple regression analysis was performed between the total self-concept score as the
dependent variable and gender, age, and internalizing and externalizing behavior problem scores
as the independent variables. Table 5 displays the results of the multiple regression analysis. The
overall regression equation was significant, F (4, 145) = 5.96, p = .001. Altogether, 15% (12%
adjusted) of the variability in self concept scores was predicted by knowing the scores on the
four predictor variables. Two independent variables uniquely contributed to the prediction of
self-concept scores: age and internalizing behavior problem score. The child’s age was predictive
of self-concept (β = −.19, t = −2.34, p < .05) after taking into account child gender, with older
children having a diminished self-concept score. The child’s CBCL internalizing score was
moderately predictive of self-concept (β = −.36, t = −3.61, p < .01), after taking into account the
child’s gender and age.

Table 5

Standard Multiple Regression of Child Gender, Age, and Behavior Problem Scores on Self-
Concept Scores (N = 145)

Predictor Variables B β t

Gender 3.73 .117 1.45

Age −.816 −.186 −2.34*
CBCL Internalizing Problems −.499 −.364 −3.61**
CBCL Externalizing Problems .117 .107 1.08
Intercept 68.99
2
R = .15
Adjusted R2 = .12
R = .38**
**
p ≤ .01
*
p ≤ .05

Ethnicity and Child Behavior Problems and Self-concept

Separate ANOVA’s were carried out with ethnicity serving as the grouping variable and
internalizing behavior problems, externalizing behavior problems, and self-concept scores as the
respective dependent variables. There were no significant differences between ethnic groups on
CBCL internalizing scores, F (3, 141) = 1.055, p = .37, or CBCL externalizing scores, F (3, 141)
= .378, p = .77. Although ANOVA revealed only a slight trend for differences between ethnic
groups on self-concept scores, F (3, 141) = 2.106, p ≤ .10, the mean scores by ethnic group were
of interest: other/mixed (n = 7) m = 60.71 (sd = 4.90); African American (n = 46) m = 59.85 (sd
= 1.91); Hispanic American (n = 45) m = 55.44 (sd = 1.93); and Caucasian (n = 47) m = 53.68
(sd = 1.89). The lowest mean scores on self-concept were obtained by Caucasian children.

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Discussion
The study explored several factors that potentially contributed to low self-concept in children
with ADHD. After analyzing the results for this report, age and internalizing behaviors were
found to negatively influence the child’s self-concept.

Within the study’s sample, 84% of the caregivers identified the child as having at least a
moderate severity of ADHD and one third said their child had ADHD of extreme severity. Also,
94.5% said the child’s ADHD was at least a little disruptive, with two thirds reporting moderate
to severe disruptiveness. These characteristics of ADHD certainly put the subjects of the study at
higher risk for negative behavior and correlated low self-concept. This limitation could have
affected the following findings of the study.

The older children with ADHD had the lower self-concept scores. This finding suggests that the
duration of ADHD perhaps has an adverse cumulative effect on self-concept and intervention for
self-concept and/or -esteem may be needed. It may be beneficial to reassess needs of children
with ADHD with a focus on self-concept as they mature and enter new developmental stages.

In this study, more internalizing problems were correlated with lower self-concept scores. Past
studies have shown that females tend to have more internalizing behaviors and fewer
externalizing behaviors than males, and thus may be more susceptible to poor self-concept than
males. Because of a tendency toward internalization, females tend to be diagnosed with ADHD
later than males. Therefore, there is a need for earlier diagnosis of girls and screening for
internalizing problems and diminished self-concept as a part of the diagnostic process and
management of ADHD.

However, gender did not predict self-concept. This indicates that it is more important to
determine whether a child exhibits internalizing or externalizing behavior problems regardless of
the patient’s gender in assessing risk for poor self-concept. Given that females were
underrepresented in this study (21.4%, n = 31), more research is necessary to definitively
determine whether there is a correlation between gender and self-concept.

Post hoc exploratory analysis suggested that the self-concept of Caucasians is lower than that of
African-Americans and Hispanics. Although only a trend for difference in this regard was found,
the trend is supported by the findings of other studies indicating that minorities may have better
underlying self-concept and self-esteem (Negy, Shreve, Jensen, & Uddin, 2003). This is
especially interesting considering that, while research has shown that stimulant treatment of
ADHD leads to higher self-esteem scores, African-Americans particularly are less likely to
receive psychopharmacotherapy for their ADHD and experience such benefits (Frankel et al.,
1999; Ozturk et Al., 2000; Olaniyan et Al., 2007). Nonetheless, although our study had an
adequate sample size, each ethnic group was relatively small. Moreover, our study included West
Coast African Americans and Hispanics, which may not be a good representation of these groups
in other areas of the United States.

Furthermore, our study was not longitudinal. Thus, self-concept was not assessed at baseline to
determine if the lower mean self-concept score seen in Caucasians was a more severe and
precipitous decline by age than for Blacks and Hispanics. In addition, self-concept scores were
not measured before the ADHD diagnosis. It is therefore impossible to speculate whether self-
concept scores declined from the mere diagnosis of ADHD, from the symptoms of ADHD, or
from the experience of the symptoms and their consequences over time. Additional research is
needed to identify factors that may precipitate a decline in self-concept over time in children
with ADHD and protective cultural factors that may exist in minority communities protecting
self-concept.

The link between age and self-concept suggests the importance of assessing and treating ADHD
early, given that ADHD seems to have a progressive negative effect on children’s self-concept.
Further, those children with internalizing behavioral problems are at higher risk for poorer self-
concept. Nonetheless, unidentified cultural factors may offer protection from ADHD’s assault on
a child’s self-concept. Thus, identifying the patient’s specific needs based on family and social
context is an important aspect in the treatment of ADHD.

In conclusion, self–concept generally decreases with age and those with internalizing problems
are at greater risk for poor self-concept. Thus, screening and treating low self-concept should be
considered, even when medication is resulting in a good response for managing the symptoms of
ADHD.

Applications for Clinical Practice

The problems that children with ADHD experience, particularly in relation to peer relationships,
school performance, and acceptance, are highly specific domains that influence self-concept sand
self-esteem. If functioning in these areas is impaired, then self-esteem plummets, and, since self-
esteem mediates functioning, as self-concept is diminished, so too is functioning, which furthers
reinforces a negative view of self, continuing a downward spiral. Early intervention is essential if
we are to prevent secondary emotional injuries to children and adolescents with ADHD.
Clinicians need to keep in mind that ADHD and ADHD symptoms are not always associated
with dysfunction. If treated and managed, children with ADHD can grow to be happy and
productive members of society. Early intervention in addressing both the ADHD symptoms
directly, as well as addressing issues in relation to self-concept—such as identifying personal
strengths, sharing success stories, providing peer support—may be key to optimizing outcomes
for children and adolescents. Therefore, screening and treating low self-concept is an important
aspect of the care needed for these children.

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Acknowledgments
Extramural Funding: The writing of this article was funded, in part, by a grant from the
National Institute of Nursing Research (NIH/NINR R01-NR05004).

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Footnotes
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No previous presentations of this data. No commercial financial support provided.

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Contributor Information
Gail Houck, Professor, School of Nursing, Oregon Health and Sciences University, Portland,
OR.

Judy Kendall, Professor, School of Nursing, Oregon Health and Sciences University, 3455 SW
US Veterans Hospital Rd., Mail code: SN-5S, Portland, OR 97239-2941, 503-494-3890 (office),
503-494-3878 (FAX)

Aaron Miller, Oregon Health and Sciences University, Portland, OR.

Piper Morrell, Oregon Health and Sciences University, Portland, OR.

Gail Wiebe, Oregon Health and Sciences University, Portland, OR.

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A Comparison between Children with ADHD

and Children with Epilepsy in Self-Esteem
and Parental Stress Level
Antonella Gagliano,1,*# Marco Lamberti,1,2,*# Rosamaria Siracusano,1 Massimo Ciuffo,1 Maria
Boncoddo,1 Roberta Maggio,1 Simona Rosina,1 Clemente Cedro,3 and Eva Germanò1
Author information ► Article notes ► Copyright and License information ► Disclaimer
This article has been cited by other articles in PMC.
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Abstract
Attention-deficit/hyperactivity disorder (ADHD) is frequently associated with negative
psychological outcomes. This study explores the relationship between self-esteem, ADHD
symptoms and parental stress. It compares children with ADHD, children with epilepsy (E) and
typical developmental controls (TD). Participants included 65 children (aged 9-12 yrs) and their
parents. The assessment was conducted by Multidimensional Self-Concept Scale (MSCS), Parent
Stress Index (PSI) and Conners' Parent Rating Scales–Revised. Significant differences were
found in Social, Competence and Academic areas of self-esteem between children with ADHD,
with E and TD. Moreover, parents of children with ADHD showed a higher overall stress than
both other groups. In conclusion, it seems important to evaluate the psychological aspects of
ADHD con-dition, both in children and in parents, in order to suggest an individual multimodal
treatment.

Keywords: Attention-deficit/hyperactivity disorder, children, epilepsy, parental stress, self-

esteem.
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INTRODUCTION
Several syndromes and developmental disorders are commonly associated with low levels of
self-esteem. Conversely, a low self-esteem may be a signal of distress associated with serious
impairments in psychological development. Attention-deficit/hyperactivity disorder (ADHD), a
common child and adolescent disorder, is frequently associated with low self-esteem and low
self-perception, negative outcomes and emotional and behavioural problems [1, 2]. ADHD
makes it difficult to achieve success and fulfillment at school [3], at home and during free time.
Increasingly, the literature suggests that affected children are more likely to experience school
failure, poor peer relationships, and familial conflict [4-6]. In particular, lower scores in sub-
domains of self-esteem such as “skills and talents” and “psychological well-being” in children
with high scores of ADHD symptoms have been reported [7]. On the whole, low self-esteem has
been associated with feelings of inadequacy and frustration which in turn can result in the
worsening of behavioural symptoms. Indeed, a poor self-concept related to academic
competence can directly contribute to the development of disruptive, antisocial behaviors in
early adolescence [8].

However, findings from previous studies investigating the relationship between Attention-
deficit/hyperactivity disorder (ADHD) and self-esteem are inconsistent. Some studies indicate
that self-esteem scores are lower in children with ADHD than typical developmental children
(TD) [2, 8, 9], others report that self-esteem scores are higher in children with ADHD [10]. In
particular elementary-age children with ADHD display overly positive self-perceptions, a
condition described as a “positive illusory bias” (PIB) [11-13]. The PIB has been defined in the
following way: “children with ADHD unexpectedly provide extremely positive reports of their
own competence in comparison to other criteria reflecting actual competence” [14]. Current
literature supporting the presence of the PIB in individuals with ADHD has been conducted
primarily with elementary-age students. However, academic and social problems associated with
ADHD may become more prominent during adolescence due to the increasing academic
demands and the increased emphasis on peer acceptance [15]. Interestingly, self–concept seems
to decrease with age in children with ADHD and those with internalizing problems are at greater
risk for poor self-esteem [16]. ADHD adolescent’s sense of self can also be affected by both the
core symptoms and environmental factors, such as parental difficulty in managing their children
[17]. Some authors, using twin methodology [18] have argued for the existence of a long-term
relationship between ADHD symptoms reported by parents, measured at 8 years of age, and a
self-report of low self-esteem measured at 13 years. They suggested that children with ADHD
may experience heightened risk of developing clinically low self-esteem in early adolescence.
The current study examines the relationship between ADHD and self-esteem, and observes how
self-esteem impacts on the relation between parental stress and ADHD symptoms. We
hypothesized that children with ADHD have a self-esteem even lower than children with a
chronic and severe condition as epilepsy. In fact, children with epilepsy do not always show
lower self-esteem than their peers [19-21] and some studies indicate that children with physical
impairments are not always impaired as regards their self-esteem [22]. However, epilepsy is
commonly considered a very debilitating disease that could have a strong impact on self-esteem
because of the clear perception of the illness, the need for long-term drug therapy, the social
stigma attached to the illness and other resulting problems [23]. In a certain sense the
characteristics of the epileptic condition could be considered very close to of ADHD
characteristics. Moreover, parents of patients with epilepsy are directly involved in the
management of children’s condition just as the parents of children with ADHD. Taking into
consideration these similarities, we decided to compare children with ADHD to children with
epilepsy.

An additional goal of the current study was to determine the extent to which perceived parental
stress is related to the management of children with ADHD symptoms. It is well known that
parents of children with ADHD experience elevated levels of caregiver stress. Many studies have
reported very high parent stress levels related to the severity of children's ADHD symptoms,
aggression, emotional liability, and executive functioning difficulties [24]. Recent research has
shown that the perceived impairments in children's self-regulation across emotional, cognitive,
and behavioural domains are what parents report as stressful, not simply the severity of ADHD
symptoms [25]. As a matter of fact, the link between child behaviours and maternal distress
seems strengthened by maternal risk and attenuated by child behavioural self-esteem [26]. Thus,
we planned to exam the correlation between child self-esteem and parental stress.

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METHODS
Sample

Subjects attending our programs in the Unit of Child Neurology and Psychiatry of the University
Clinic were considered for the study. The study was approved by the local Ethics Committee.

Participants included 65 children and their parents: 22 children with a diagnosis of ADHD
(according to DSM-IV- TR criteria; 17 combined subtype and 5 inattentive subtype) aged 9-12
years (M = 10,14, SD = .990), 20 children with Epilepsy (Idiopathic epilepsy with partial or
secondarily generalized seizures) aged 9-12 years (M = 10,85, SD = .813), and 23 typically
developing children (TD) recruited in two different schools in Messina and examined within
their school environment. The groups were comparable for gender, age of patient and parents,
level of education, number of siblings and socio-economic background. Demographic features
are reported in Table 11.

Table 1.
Demographic characteristics of children with Attention-Deficit/Hyperactivity Disorder (ADHD),
epilepsy and typical developmental.

ADHD EPILEPSY th
Mean SD Mean SD Mean SD
Age children 10,14 ,990 10,85 ,813 10,61 1,08
Male 100% 100% 100%
Siblings 1,14 1,16 1,33 ,594 1,22 ,671
Age mother 40,4 3,95 41,20 5,1 42,39 5,0
Age father 43,50 4,091 43,84 4,2 45,9 6,5

p < 0,05 p < 0,01

We excluded subjects with low IQ (total IQ below 85 at WISC-III scale), specific learning
disorders (such as dyslexia), major neurological signs and sensory deficits.

At the moment of evaluation, 10/22 patients with ADHD were on pharmacological treatment
with stimulants, and 12/20 patients with epilepsy were on antiepileptic drugs (5 with acid
valproic, 4 with carbamazepine, 3 with levetiracetam).

Measures

Multidimensional Self Concept Scale [27] SCS, Bracken, 1993; MTA Italian version Beatrice
& Bracken,2005) was used to investigate the participants’ global level of self-esteem.

MSCS is a self-report instrument, which consists of 150 items exploring six areas by six
subscales: Social, Competence, Affect, Academic, Family and Phisical. MSCS subscales analyze
some personal traits and social characteristics (see Table 22). The information about the
person/individual in several domains of varying contexts is used to create multidimensional
personal profiles [28]. Therefore, an individual value profile consists of the values in the
variables constituting the profile, described by the subscales of the questionnaire. The multiple
answering options are: Absolutely True, True, False, Absolutely False.

Table 2.

MSCS subscales.

Social subscale: social competence related to interactions with others;

Competence subscale: success/failure in attainment of goals:
Affect subscale: recognition if affective behaviors
Academic subscale: academic achievement and competence in other school-related activities:
Family subscale: competence related to interaction with family members
Physical subscale: physical attractiveness and prowess.
Parenting Stress Index [29] is used to measure parental stress level. This self-report instrument
is aimed to explore the stress levels of parents or caregivers. It consists of 36 items that describe
feelings and behaviours related to parental stress. Five answering options are proposed for each
item: Absolutely Agree (AA), Agree (A),Not Sure (NS), Disagree (D), Absolutely Disagree
(AD).

The instrument is based on the assumption that parental stress originates not only from
characteristics of children and parents but also from socio-demographic features.

It analyzes three subscales:

 Parental Distress (PD)

 Parent-Child Dysfunctional Interaction (P-CDI)
 Difficult Child (DC)

Conners' Parent Rating Scales–Revised, [30] is commonly used to quantify ADHD symptoms.
We asked the parents to complete the Conners’ Parents Rating Scales Revised, Short Form
(CPRS-R:S , Conners, 1989). The CPRS-R:S contains 27 items and covers a subset of the
subscales and items on the long parent form.

It provides the following sub-scores:

- Oppositional : probes like children are “ predisposed “ to break rules,

- Cognitive Problems/Inattention: probes like subject may experience learning difficulties, of

difficulty in organizing school work,

- Hyperactivity : probes like subject finds it difficult to sit in the classroom or pay attention for a
long-time,

- ADHD Index: probes to identify children / adolescents "at risk" of ADHD.

Statistical Analyses

Descriptive analyses were used to analyze demographic and clinical characteristics of the whole
sample. Chi-square analyses were performed on categorical variables and unpaired t-test on
continuous variables. Bonferroni multiple comparison method was performed to compare the test
variables between each group. Effect size was calculated for relevant differences by Hedge
method. Furthermore, correlation analyses were performed between variables for each group
using Pearson’s correlation coefficients.

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RESULTS
Significant differences were found across the explored domains between children with ADHD,
and typically developing children. Table 33 and Fig. (11) show the means and SD of the
differences in MSCS domains between the three groups.

Fig. (1)

Comparison between the three groups in MSCS.

Table 3.

Mean scores, SD and bonferroni multiple comparison method for all parameters of
Multidimensional self concept scale (MSCS): comparison between children with attention-
deficit/hyperactivity disorder (ADHD), epilepsy and typical developmental. Effect size by g of
hedge.

ADHD EPILEPSY th P value Effect Size

MSCS Domains
Mean SD Mean SD Mean SD A/E A/C E/C t
 ADHD EPILEPSY th P value Effect Size
MSCS Domains
Mean SD Mean SD Mean SD A/E A/C E/C t
Social 91,7 12,0 100 13,8 104,1 11,5 ,109 ,004** ,847 >1
Competence 90,2 14,5 94,1 13,9 102,9 12,1 1 ,008** ,115 >1
Affect 97,0 12,7 102,6 12,2 103,0 9,1 ,356 ,260 1
Academic 93,1 14,3 102,4 15,2 103,6 10,0 ,083 ,032* 1 >1
Family 97,1 9,7 103,2 9,4 99,0 10,5 ,153 1 ,527
Physical 105,1 12,1 102,1 14,8 103,6 10,5 1 1 1
MSCS tot 95,4 11,4 101,6 10,5 102,5 10,6 ,212 ,094 1

* p < 0,05 ** p < 0,01

There are statistically significant differences in MSCS subscales between the ADHD group and
TD group in the Social area (p ,004), in the Competence area (p ,008) and in the Academic area
(p ,032). Even if the mean overall MSCS scores of children with ADHD is not greatly impaired,
some subjects out of the whole group obtained very low scores, as shown in Fig. (22). Notably,
patients with ADHD obtained higher scores in “Physical” subscale compared to the other two
groups (see Fig. 22). Conversely, no statistical differences emerged between children with
epilepsy and typically developing controls in any of the MSCS areas and between ADHD and
children with epilepsy. In one out the MSCS subscales (Family) children with epilepsy showed a
higher level of self-esteem than typically developing children.
Fig. (2)

Comparison between the three groups in PSI.

Analysing the PSI scores, we observed that parents of children with ADHD had significantly
higher scores than parents of typically developing children. Parent Stress Index (PSI) mean
scores, analysed by Bonferroni multiple comparison for all parameters, between ADHD group,
epilepsy group and TD group, were significantly different (see Table 44). ADHD group and TD
group differ significantly in P-CDI (Parent-Child Dysfunctional Interaction, p ,000), DC
(Difficult Child, p ,000) and PSI -TS (Parental stress index total score sub-scores, p,000) sub-
scores.

Table 4.

Mean scores, SD and bonferroni multiple comparison method for all parameters of parent stress
index (PSI): comparison between Attention-Deficit/Hyperactivity Disorder (ADHD), epilepsy
and typical developmental children’s parents.
 ADHD EPILEPSY th P value
PSI Domains Effect Size
Mean SD Mean SD Mean SD A/E A/C E/C
PD 66,8 30,0 58,5 27,1 47,1 26,7 1 ,065 ,574
P-CDI 82,5 21,4 60,5 29,4 43,5 23,9 ,018* ,000** ,090 >1
DC 80,2 25,2 57,7 25,8 41,7 27,1 ,028* ,000** ,150 >1
PSI TS 79,4 27,1 59,5 25,7 42,4 26,2 ,064 ,000** ,115 >1

[PD = Parent Distress; P-CDI= Parent-Child Dysfunctional Interaction; DC= Difficult Child; PSI
TS = Parental stress index total score].

*p < 0,05 ** p < 0,01

But also the difference between Epilepsy group and ADHD group was statistically significant in
P-CDI (Parent-Child Dysfunctional Interaction, p ,018) and DC (Difficult Child, p ,028) sub-
scores. Therefore, parents of children with ADHD showed a higher overall stress than both the
parents of TD and epilepsy groups (see Fig. 22).

In order to examine the sources of parental stress, we analysed the statistical relationship
between PSI scores and other variables. Specifically, we described the correlations between PSI
scores and children’s age (as continuous variables), drug treatment (as dichotomous variable
describing if the child was or was not on drug treatment), the Conners’ rating scale scores (as
continuous variables describing symptoms) and the MSCS scores (as continuous variables
describing self-esteem level). Only some demographic and behavioural variables seem related to
parental stress: Table 55 shows the significant correlations. No significant correlations emerged
between MSCS and PSI scores.

Table 5.

PSI domains and several variable correlation. The table shows only the significant correlations
(p< 0,01).

Children Age Drug Conners Opp.

PSI TS .516 .614
DC (PSI) .727 .498
P-CDI .514 .516

[PSI TS = Parental stress index total score; DC= Difficult Child; P-CDI= Parent-Child
Dysfunctional Interaction]

Conversely, it appears that higher scores in CPRS oppositional subscale are closely related to
higher scores in parental stress level, as measured by “PSI total score”, “Difficult Child” and
“Parent-child dysfunctional interaction” scores. Furthermore, higher age of children appears
related to “PSI total score” and “Difficult Child” sub-scale scores.
Instead, there were no significant correlations between MSCS scores and other CPRS
behavioural sub-domains scores (inattention and hyperactive/impulsive). Finally, the parents of
treated children with ADHD show higher stress levels than parents of non-treated children with
ADHD, as expressed by the significant correlation between “parent-child dysfunction
interaction” and the dichotomous variable describing whether the child was or was not on drug
treatment.

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DISCUSSION
In accordance with literature supporting the relationship between clinically-diagnosed children
with ADHD and low levels of self-esteem, the first purpose of this study was to compare the
levels of self-esteem in children with ADHD compared to typically developing and epileptic
children. Results suggest that children with ADHD actually have a different level of self-esteem
compared to children without ADHD. Self-esteem is both a cognitive and emotional concept that
describes the individual’s idea and values about him/herself. Self-esteem is also related to
cognitive strategies that lead to successful problem-solving, which is a crucial issue in children
with ADHD [28]. It is correct to regard self-esteem as a multidimensional concept and to
describe different domains of the self-image in different contexts. Low scores in internal
domains of self-esteem, such as “psychological well-being” and “skills and talents”, have been
previously reported in subjects with ADHD [7]. Our results are consistent with the conclusions
of a recent paper [31] that describes a significant difference between boys with ADHD and
typically developing children on some domains of self-esteem. By the Harter Self-Esteem
Questionnaire, reduced scores were found in “Global Self-Esteem Subscale”, “Social Acceptance
Subscale” and “Scholastic Performance Subscale”.

Thus, on an individual level, children with problems related to ADHD seem to have very
different profiles of self-esteem, in line with the idea that self-esteem is a multidimensional
concept [32]. In this respect, some authors suggest that there is no clear link between ADHD and
profiles of self-esteem [7]. They argue that the individual patient with ADHD could have low
self-esteem in some domains of self-esteem, but on the whole self-esteem could be quite good.
Also in our study, the mean overall MSCS scores of children with ADHD is not greatly
impaired, but some subjects out of the whole group showed very low scores. In more details,
children with ADHD exhibited lower self-esteem scores in three domains (“Social”,
“Competence” and “Academic”) rather than a global decrease in all areas.

These findings suggest that children’s concerns can be focused on developing friendships and
good family interactions and school achievements as well. This can be considered a likely
consequence of the social and academic failures that children with ADHD commonly have. It is
usual for children with ADHD to be criticized and reproached due to their maladaptive
behaviours. This condition can lead to develop the idea that nobody appreciates and regards
them. Given that children with ADHD lack expertise in most domains, their overly positive self-
views of competence promote learning or persistence on difficult tasks that might otherwise
prove too discouraging [33].
The only domain in which children with ADHD exhibited a higher self-esteem level than the
other two groups was the physical subscale that describes the children’s perception of their body
and their ability in physical activities. This is a somewhat expected finding since children with
ADHD can show good self-confidence in their physical ability due to their high levels of energy
and strength. The relatively good self-esteem in physical competence in children with ADHD is
in some way consistent with the “positive illusory bias”, that is to say that the children have a
tendency to overestimate their abilities [12]. In this model it has been argued that the self-
enhancement could be a way of neglecting the individual’s lack of skills that he/she does not
want others to know about [34]. Actually it seems likely that children with ADHD have a really
strong perception of their physical power due to their dynamic behavioural pattern and to their
get-up-and-go when dealing with peers or older persons.

By examining the mean MSCS score differences between children with ADHD and similar-aged
epileptic children, we were able to compare the self-esteem pattern in both social and
behavioural domains. As previous studies have reported [19] , our results confirm that children
with epilepsy do not have a significantly lower self-esteem than the control group even though
they have a relatively compromised well-being and comprehensive care needs which go beyond
the attempt of controlling seizures. Epilepsy can significantly affect quality of life [21, 35] not
only because of its chronicity, the necessity for medication, and their side effects [36], but also
due to the prejudices and social conventions that still surround the condition [37].

It is noteworthy that our children with ADHD seem less capable than children with epilepsy to
protect themselves from the emotional negative impact of their symptoms on the self-esteem
level. Conversely, children with epilepsy showed an even better self-esteem than the typically
developing controls in subscale “family “ of MSCS. We can assume that the parents of children
with epilepsy are more prone to develop reciprocity in the parent-child relationship than the
parents of children with ADHD. In fact, they have no reason to feel frustrated and angry because
of their “sick” children. Instead, the functional and behavioural problems encountered by
children with ADHD can be very disruptive for their families and often lead to conflictive
parent–child relationships which can in turn impact children’s self-esteem. In fact, when a child
displays hyperactivity, inattention, and/or oppositional behaviour, even parents with a high level
of care, may respond with dissatisfaction, anger and intolerance. This can lead to a high degree
of frustration in children. It is therefore not surprising that the presence of ADHD in children is
associated with reduced parenting self-efficacy, lower parental satisfaction and increased levels
of parental stress, as indicated by several studies [24, 25]. These suggestions, taken as a whole,
propose a possible protective effect on self-esteem as a result of a positive, caring and not
frustrated parent-child relationship.

Our study also confirms the relationship between high levels of parental stress and ADHD [38]
but does not sustain the relationship between parental stress and child self-esteem. The lack of
significant correlations between MSCS and PSI scores suggests that children’s self-esteem is not
directly influenced by parental stress. This counterintuitive finding could be explained
considering that the children’s self-esteem level is mostly based on social and academic
reinforcements, not only on the well-being of family environment. We could argue that the
parental stress have a more modest impact on children’s self-idea than the social stigma and the
scholastic failure. Given that children build their self-esteem during childhood, and especially
during preadolescent and adolescent stage, it is arguable that the behavioral problems could lead
to poor peer relations, aggression, and learning problems which are in turn associated with
academic failure and a low self-esteem. Previous reports underline how this vicious circle can
even have effects on increasing of developing psychiatric disorders, such as depression [39].

Nevertheless, it seems particularly important to understand which variables are more closely
related to parental stress. Interestingly in our study, parents of children with ADHD showed
higher scores in PSI than parents of children with epilepsy. As correlation analysis reveals, the
parental stress levels are mainly associated with oppositional symptoms rather than to inattentive
and hyperactive/impulsive behaviours. Children with oppositional defiant disorder (ODD) have
frequent run-ins with authority figures and oppositional behaviours, far more often than other
children their age. When associated with ODD, ADHD may predispose affected children to the
subsequent development of conduct disorders (CDs), delinquent behaviour, and substance
misuse [5, 40, 41]. Moreover, children with ODD experience disturbances in peer and family
relationships, as well as poor academic achievement [42, 43]. According to other reports, the role
of ODD symptoms must be considered of greatest interest is the comorbidity with depression
[44] and self-concept weakening [45].

Another interesting figure is that parents stress level increases with the children’s age. This
finding can be explained considering that adolescents with ADHD usually experience an
increasing gap between their functional level and social and academic requirements. The
difficulty to cope with this increased demand could consecutively increase parental discomfort
and worsen the family relationships.

Finally, an unexpected result showed a higher parental stress level associated with drug
treatment. We argue that most parents in Italy still have concerns regarding the safety of
medication for treating ADHD and, more in general, a current adverse view of stimulants.
Therefore, Italian parents experience stress due to the choice of medication option, even when
the treatment shows efficacy in improving symptoms. This evidence is in contrast with a
previous North American study [46] that revealed no differences among children on medication
and children without medication on measures of family distress (eg, parenting stress, depressive
symptoms among parents, marital adjustment).

Go to:

CONCLUSION
Children with ADHD may be relatively more impaired in self-esteem than other children
affected with severe chronic diseases. They can have low self-esteem in some domains of self-
esteem, even when the whole self-esteem is not impaired. Thus, the evaluation of self-esteem
level in children and adolescents with ADHD can be helpful in guiding psycho-educational
interventions that should be individualized and based on a “person-oriented approach” [7].
Timely and targeted treatment for ADHD is associated with improvement of self-esteem and
consequently better outcomes [47].
At the same time, it is important to develop intervention programs designed to help parents in the
identification and management of their own parenting stress. This seems mostly related to ODD
symptoms that cause disturbances in peer and family relationships.

These findings emphasize the psychological aspects of ADHD condition, both in children and in
parents and strongly suggest an additional focus on self-esteem problems and on parental stress
in the context of a multimodal treatments for children with ADHD.

Fig. (3)

Scatter Diagram of MSCS subscales in ADHD group.

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ACKNOWLEDGEMENTS
Declared none.
Go to:

LIMITATIONS AND IMPLICATIONS FOR RESEARCH

The current study is limited by cross-sectional data and by a rather restricted sample. Moreover,
our findings in a health care-based sample could describe the characteristics of a more severe
form of ADHD with a strong prevalence of combined subtype and of male patients. This is most
likely due to the reliance on parents for diagnosis, as teachers identify more problem behaviours
in boys, which may contribute to higher numbers of boys treated in clinical settings [48].
Furthermore this paper includes a clinically referred males sample because they are more
numerous due to their greater likelihood of disruptive behaviours. Thus, we decided to include
only male subjects because females had more internalizing problems, depression, and anxiety as
well as diminished self-efficacy and coping, and had less aggression and externalizing behaviors
than males [49]. There are few studies addressing the issue of sex differences in self-esteem in
children with ADHD. Gershon’s (2002) [50] meta-analytic review of gender differences in
ADHD revealed females to be rated significantly less impaired than males on hyperactivity,
inattention, and impulsivity. This meta analysis found that females with ADHD manifested fewer
externalizing problems, and were found to have more internalizing problems. Thus, the
relationships among gender, behavior problems, and self-esteem are not well understood and
require further research.

Go to:

CONFLICT OF INTEREST
The authors confirm that this article content has no conflict of interest.

Go to:

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