The self-esteem of adults diagnosed with attention-deficit/hyperactivity disorde...

The subjective measure of one’s own value or self-worth has been of concern to theorists dating back to James (1890), who stated:

Our self-feeling in this world depends entirely on what we back ourselves to be and do. It is determined by the ratio of our actualities to our potentialities (p. 310).

The pivotal role of self-esteem has remained of great theoretical and empirical interest (e.g. Allport 1943; Maslow 1954; Mruk 1999). Much information in daily life bears upon self-esteem; everyday occurrences may lead individuals to believe that they are lovable, intelligent or incompetent; and it appears critically important to adaptive functioning. Many psychiatric diagnoses are associated with lower levels of self-esteem (e.g. Silverstone and Salsali 2003). In line with this, individuals with attention-deficit/hyperactivity disorder (ADHD) often grow up with negative messages surrounding their abilities (e.g. Young et al. 2008) and may experience adverse outcomes throughout their lives (e.g. Mannuzza and Klein 2000), potentially impacting on the development of self-esteem.

Attention-deficit/hyperactivity disorder

The diagnostic and statistical manual of mental disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association; APA 2000) posits three potential diagnostic subtypes: inattentive (ADHD-IA), hyperactive/impulsive (ADHD-HI) and combined type (ADHD-C). For a diagnosis of ADHD, symptoms must meet DSM-IV-TR (APA 2000) or ICD-10 (World Health Organisation; WHO 1992) criteria, be present from childhood and persistently interfere with functioning in multiple domains of an individual’s life (National Institute of Clinical Excellence; NICE 2008).

Whether diagnosed as an adult or as a child, and whether currently symptomatic or not, identifiable ADHD in adulthood implies the life-time presence of this developmental disorder to greater or lesser extents. There is now increasing evidence to suggest that ADHD symptoms do not diminish with increasing age (Barkley 1998). However, such symptoms may appear more subtle and heterogeneous in adulthood (De Quiros and Kinsbourne 2001; Wender et al. 2001). Indeed, research has found that inattentive symptoms tend to persist into adulthood (Barkley 1997; Friedman et al. 2003; Hervey et al. 2004), whereas the hyperactive/impulsive symptoms, typically associated with childhood ADHD, tend to be less persistent (Biederman et al. 2010, 2011, 2012).

Additionally, NICE (2008) guidance highlights difficulties in service provision for these individuals as they reach adulthood, despite being relatively well served in childhood by institutions such as the educational system and the National Health Service (NHS; e.g. child and adolescent mental health services). However, ages of transition to adult services vary between the ages of 16 and 19, and there are geographical differences in thresholds for referral to adult mental health services; only a small number of adult ADHD clinics exist in the UK. Adults with ADHD are therefore often left without adequate support from services.

Concerns relating to the label of ADHD

The diagnosis of ADHD is controversial; its validity has been questioned (e.g. Asherson et al. 2010; Moncrieff 2010), as has the utility of a diagnostic category that encompasses such a heterogeneous group (Zwi and York 2004). In addition to the contentious nature of the diagnosis, ADHD is often experienced as being stigmatising. For instance, there is evidence to suggest that children with ADHD are less likely to tell their friends that they are taking medication than those with epilepsy (McElearney et al. 2005). A qualitative study by Singh et al. (2007, as cited in NICE guidelines 2008) identified experiences of stigma as a result of taking tablets, ADHD diagnosis and symptomatic behaviours in children. These included feelings of being different and alienated, alongside experiences of others’ negative assumptions, name-calling and being treated differently.

Furthermore, Young et al. (2008) found that adults with ADHD who have undergone the process of diagnosis in adulthood report that they feel different from others and experience negative judgements. Indeed, this stigma carries over to others’ perceptions of those with ADHD. In one study, participants rated the likelihood that they would want to interact with a peer described as having ADHD, a general medical problem or an ambiguous flaw such as perfectionism. Peers labelled with ADHD were rated as significantly less socially desirable than peers with the other identified difficulties (Canu et al. 2008).

Cognitive difficulties, social rejection and failure

Negative outcomes and underachievement can result from chronic hyperactivity, impulsivity, inattention or a combination of these. Neuropsychological impairments can act as additive factors to compound problems, such as attentional difficulties, reduced self-regulation, poor working memory and disinhibition (e.g. Barkley 1997). Knouse and Safren (2010) posit that these neuropsychological difficulties give rise to functional impairments. In particular, interpersonal, academic and occupational difficulties are common in individuals with ADHD (e.g. Ramsay and Rostain 2008). These impairments often lead the individual with ADHD to experience multiple failures and receive negative social feedback from those around them. Experiences such as these lead to the development of negative cognitions that exacerbate problems through increased avoidance and decreased motivation, therefore becoming cyclic in nature (Knouse and Safren 2010). Furthermore, approximately 70–75 % of adults with ADHD have co-morbidities including depression, substance use disorder or anxiety (e.g. Biederman 2004; Wilens et al. 2002; Shekim et al. 1990). Such difficulties serve to reinforce the aforementioned cycle and render it less likely that individuals with ADHD will utilise adaptive compensatory strategies (Knouse and Safren 2010).

While longitudinal studies are required to indicate causal links, it has been suggested that underachievement, coupled with numerous negative experiences or negative messages about one’s abilities, as often experienced by those with ADHD, affects the formation of self-esteem. For instance, Young and Bramham (2007) state that the “negative experiences of adults with ADHD (whether symptomatic or not) are long-term and deep-rooted” (p. 258). Furthermore, in accord with Knouse and Safren (2010), these authors posit that adults with ADHD may develop unhelpful coping styles in which they respond to difficult or stressful situations with avoidance and procrastination. As a result, self-esteem is unlikely to improve, and low self-esteem may indeed be reinforced because these individuals remain unable to cope, thus leading to continual disappointments (Newark and Stieglitz 2010).

Social rejection is also problematic for those with ADHD. For instance, Paulson et al. (2005) found that social rejection was higher for peers exhibiting symptoms of ADHD than those demonstrating no psychopathology, as measured by undergraduates’ ratings of liking and willingness to interact. Social rejection of those with ADHD was comparable with that of those with depression.

Summary

Thus far, ADHD has been described as a difficulty that is longstanding, associated with difficulties in numerous areas of daily life and, in adulthood, inadequate service provision. It is a contentious diagnosis with questionable validity, which is often experienced as stigmatising, either by the individual or through the resulting perceptions of the eye of the beholder. It is associated with neuropsychological difficulties alongside significant comorbidities and social rejection. It is reasonable to propose, then, that these numerous and often lifelong concerns might be associated with reduced self-esteem in adults with ADHD.

Self-esteem: theoretical concerns

The definition of self-esteem remains contentious. Following on from James’ (1890) definition, theorists have emphasised that self-esteem is the evaluative component of self-concept (Zeigler-Hill and Jordon 2010); the emotional valence of the beliefs one holds about themselves and their personal characteristics (Wells and Marwell 1976). Campbell and Lavallee (1993) identify this as ‘how I feel about who I am’. This definition contrasts with generalised self-concept; the manner in which we view ourselves or ‘who am I?’

An additional issue in the literature surrounds whether self-esteem should be considered a state or trait. The unidimensional approach defines self-esteem as stable and global; an ‘individual’s positive or negative attitude toward the self as a totality’ (Rosenberg et al. 1995, p. 141). This general feeling of self-worth, or global self-esteem has been the most common conceptualisation in research, and is related to diverse outcomes such as depression and criminality (Salmivalli 2001). Another approach to self-esteem is the multidimensional approach; the idea that it fluctuates across different contexts. For instance, Swann et al. (2007) argue that global measures may be effective at predicting global outcomes, but are likely to be less effective at predicting more specific outcomes; leading to a need for more contextually based measures of self-esteem. Both conceptualisations tend to be measured via self-report (Greenwald and Farnham 2000). The Rosenberg Self-Esteem Questionnaire (RSEQ; Rosenberg 1965), a measure of global self-esteem, is the most commonly used.

Self-esteem pathway in ADHD

Authors postulate different conceptions of self-esteem difficulties in children with ADHD. Children with ADHD tend to have few friends, poor social skills and problems interacting with individuals of the opposite sex (Weiss and Hechtman 1993). However, a recent critical review by Owens et al. (2007) identified that self-esteem tends to be relatively preserved in children with ADHD, despite their histories; holding a ‘positive-illusory bias’. Owens et al. (2007) suggest that this dearth of self-awareness may render children with ADHD more susceptible to failure, preventing recognition of difficulties and concomitant needs for improvement (e.g. Hoza et al. 2002). Conversely, this lack of self-awareness may protect their self-esteem in the short term as a coping mechanism (Evangelista et al. 2008). Indeed, Hoza et al. (2004) found that children with ADHD had the most inflated self-perceptions in symptom domains in which they experienced the greatest deficit. Nevertheless, impairments have been observed in psychosocial quality of life scores, which negatively impacted upon self-esteem (Bussing et al. 2000) in children with ADHD, and self-esteem tends to be lower than that of age-matched children without ADHD despite their actual level of ability (Foley-Nicpon et al. 2012).

Regardless of the aetiology of self-esteem difficulties, long-term negative consequences may result from having either low self-esteem or unrealistically high self-esteem (Hoza et al. 2002). Individuals with heightened self-esteem relative to actual ability may develop through childhood without the ability to recognise and thus remedy their deficits (Owens et al. 2007). As a result, these children may have more negative experiences and outcomes throughout their development into adolescence and adulthood, eventually leading to a reduction in self-esteem.

Aims and scope of the current review

The goal of this literature review was to systematically evaluate the research regarding self-esteem in relation to adults with ADHD. The operational definition of self-esteem in the current review is as above; the emotional component of self-evaluation, i.e. ‘how I feel about who I am’ (Campbell and Lavallee 1993).

It was anticipated that this goal could be achieved by retaining broad search criteria to encompass an inclusive review, which might include both observational and intervention studies. However, it was considered important to exclude studies where a clinically significant level of ADHD symptomatology had never (previously or currently) been identified or where conceptualisations of ADHD do not map on to relatively current diagnostic frameworks (from 1980 onwards, e.g. DSM-III, APA 1980), as this could lead to erroneous conclusions. A systematic review was considered the most appropriate and holistic approach, allowing for a less constrained discussion around this subject than, for example, a meta-analysis.

Although this review was relatively exploratory due to the absence of previous reviews investigating this topic, there were two aims:

1. 1.

   Examine the evidence regarding the relationship between ADHD and self-esteem in adulthood.

2. 2.

   Evaluate the efficacy of any interventions that have been utilised to target self-esteem in adults with ADHD with regard to clinical implications.

It was anticipated that this review would highlight the nature and impact of self-esteem problems in adults with ADHD, with a view to outlining needs and potential opportunities in terms of service provision.