Self-Esteem in Special Education Children With ADHD: Relationship to Disorder Characteristics and Medication Use

Self-Esteem in Special Education Children With ADHD: Relationship to Disorder Characteristics and Medication Use REGINA BUSSING, M.D., BONNIE T. ZIMA, M.D., AND AMY R. PERWIEN, B.S.

ABSTRACT Objectives: To describe the level of self-esteem among the study population, to examine how self-esteem ratings may vary by disorder characteristics and medication use, and to identify predictors of low self-esteem while adjusting for sociodemographic factors. Method: In a school district–wide sample of children in special education programs, the authors assessed self-esteem with the Piers-Harris Self-Concept Scale among 143 students at high risk for attention-deficit/hyperactivity disorder (ADHD) in the school year 1995, with an interview participation rate of 73%. Disorder characteristics and medication use were assessed using multiple informants and standardized measures. Results: Self-esteem scores, on average, were in the normal range. However, across ADHD comorbidity profiles, children with ADHD and internalizing symptoms had significantly lower self-esteem scores, especially in the areas of anxiety and popularity, than children with ADHD alone or those with comorbid disruptive behavior disorders. Independent predictors of lower self-esteem were being white, high functional impairment, and comorbid internalizing conditions, but not medication use. Conclusions: Findings suggest that interventions for ADHD should be culturally sensitive as well as aimed at improving a child’s functional level and associated internalizing symptoms. Medication use among this younger patient group was not related to self-esteem scores. J. Am.

Acad. Child Adolesc. Psychiatry, 2000, 39(10):1260–1269. Key Words: self-esteem, attention-deficit/hyperactivity disorder, comorbidity, special education.

Attention-deficit/hyperactivity disorder (ADHD) may adversely affect a child’s developmental trajectory, placing him or her at greater risk for impaired functioning and diminished well-being in adulthood (Cantwell, 1996; Mannuzza et al., 1991, 1993; Szatmari et al., 1989). Of particular concern has been the role of poor self-esteem in this pathway, because it is thought to mediate other adverse outcomes, such as depression, deviant peer choices, or substance abuse, among children with ADHD Accepted April 13, 2000. Dr. Bussing is Associate Professor and Chief, Division of Child and Adolescent Psychiatry, University of Florida, Gainesville. Dr. Zima is Associate Professor and Training Director, Division of Child and Adolescent Psychiatry, University of California at Los Angeles. Ms. Perwien is completing her internship in Clinical and Health Psychology at the University of Miami. This research was supported by NIMH grants K12 MH00990, R24 MH51846, and MH57399. The authors express their gratitude to Kathleen McNaughton and Elena Schuhmann for their excellent research assistance; to Thomas Belin, Ph.D., for his statistical consultations; to Steve Wieland for his editing and proofreading services; and to school professionals and parents for their support that made this study possible. Correspondence to Dr. Bussing, Box 100177 UFHC, Gainesville, FL 326100177. 0890-8567/00/3910–1260䉷2000 by the American Academy of Child and Adolescent Psychiatry.

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(Emery et al., 1993; Gordon and Caltabiano, 1996; Moore et al., 1996; Reinherz et al., 1989). Self-esteem, defined as one’s global regard for oneself as a person (Harter, 1993), is proposed to be internalized during the same developmental period as when ADHD is commonly diagnosed and treated (Rappley et al., 1995; Zarin et al., 1998a). By 8 years of age, children have developed both global and domain-specific evaluations of their self-worth (Harter, 1982). Further self-esteem development may follow 4 main pathways, characterized as consistently high, moderate and rising, steadily decreasing, and consistently low (Zimmerman et al., 1997). The direction of such trajectories are reported to be related to domains highly relevant to children with ADHD, such as peer relationships, school performance, and behavior problems (Zimmerman et al., 1997). To date, research addressing the relationship between ADHD and self-esteem has yielded conflicting results. Some studies report lower self-esteem levels among adolescents with ADHD diagnosed in childhood compared with matched controls (Slomkowski et al., 1995), while others note no differences (Hoza et al., 1993; Wilson et al., 1996). In addition, few if any conceptual models of

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self-esteem development in children with ADHD are available. Previous studies, nevertheless, have explored potential predictors of self-esteem among children with ADHD, including child age (Alston and Romney, 1992), psychostimulant use (Cohen et al., 1982; Frankel et al., 1996; Hechtman et al., 1984), and treatment duration (Kelly et al., 1989). Based on these earlier findings, this study adapts Wallander and Varni’s stress-coping model of adjustment to chronic health conditions (Wallander and Varni, 1992) to examine how disorder characteristics and medication treatment may affect self-esteem levels among children with ADHD. The following disorder and treatment factors are hypothesized to be influential. Disorder Characteristics

For this study, disorder characteristics are conceptualized to include ADHD symptoms, comorbid conditions, functional impairment, and perceived family burden. The role of these factors in self-esteem development of children with ADHD is largely unexplored. Previous studies compared clinical samples to controls without specifying condition severity, symptom patterns, family burden, or comorbidity in affected children (Hoza et al., 1993; Slomkowski et al., 1995). Given that ADHD symptoms have been found to impact social relationships and school performance (Greene et al., 1996), this study anticipates that children who exhibit greater symptoms in multiple settings and more functional impairment are at increased risk for lower self-esteem. Self-esteem also is expected to be negatively influenced by the effects of cooccurring externalizing and internalizing conditions. Studies have suggested disproportionately high rates of comorbid disruptive behavior, depressive, and anxiety disorders in children with ADHD (Biederman et al., 1991). Special education placement for learning disabilities or emotional handicaps also can be thought of as a proxy for comorbid conditions that may place a child at risk for lower self-esteem (Beltempo and Achille, 1990). Treatment Status

Treatment may facilitate improved self-esteem in children with ADHD by ameliorating functional disabilities and improving social relations. Conversely, treatment could be expected to promote a negative self-concept if, for example, an intervention makes the child feel defective or different from his or her peers (Sandoval et al., 1980). The most frequently used treatment modality for children with ADHD is stimulant medication (Swanson et al., 1993; Wolraich et al., 1990; Zarin et al., 1998b). J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 3 9 : 10 , O C TO B E R 2 0 0 0

Studies examining the relationship between selfesteem and ADHD medication use have suggested a complex interplay of sociodemographic and treatment factors. Cohen et al. (1982) noted that children treated for ADHD with medication reported a positive shift in feelings of internal control and self-acceptance. Frankel et al. (1996), using a cross-sectional research design, and Hechtman et al. (1984), in a longitudinal study, found that stimulant-treated children with ADHD reported higher self-esteem than those not receiving medication. Age also may have an interactive effect on self-esteem. Compared with their unmedicated counterparts, young children had higher academic self-esteem and adolescents had lower self-esteem (Alston and Romney, 1992). Furthermore, the relationship between medication and self-esteem in children may be related to duration of treatment, as Kelly et al. (1989) demonstrated that improvements in self-esteem levels were related to long-term, but not short-term, treatment. The generalizability of these studies’ findings, however, is limited by the use of the clinic-based study populations and the underrepresentation of ethnic minority children. This study expands upon earlier research in several ways. It is based on an epidemiological sample of special education students with ADHD, including children who did not access clinical treatment as well as those from minority and lower socioeconomic backgrounds. Furthermore, data from multiple informants and measures are used to evaluate how self-esteem levels relate to clinically significant behavior problems in home and classroom settings, comorbidity, family burden, functional impairment, and medication use. The objectives of this study are to describe the level of self-esteem among the study population, to examine how selfesteem ratings may vary by disorder characteristics and medication use, and to identify predictors of low selfesteem while adjusting for sociodemographic factors. It is hypothesized that children with more symptoms, comorbid conditions, and greater functional impairment are more likely to have lower self-esteem. METHOD Participants This study includes an epidemiological sample of special education students (N = 143) from a medium-sized school district in north Florida who had screened positive for ADHD risk during a parent telephone interview and subsequently completed a face-toface diagnostic interview. The diagnostic interview indicated that

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129 of the 143 children met DSM-IV criteria for ADHD or were receiving stimulant medications and that 14 children had screened ADHD risk-positive but did not meet full diagnostic criteria. For comparison purposes, these 14 screen-positive children were included in some of the analyses presented in this report. Briefly, the study sample was derived as follows. Of the total eligible school district special education student population (N = 722), more than two thirds of the parents participated in the screening interview (n = 499; 69% participation rate). The screening process, based on parental responses to the Abbreviated Symptom Questionnaire (ASQ) and the Attention Deficit Disorder Evaluation Scale (ADDES) (Conners, 1990; McCarney, 1989), identified 204 children as being at high risk for ADHD. Children were classified as being at high risk for ADHD if their parent ASQ score was 1.5 SD above the normative reference group mean (T score ≥ 65) and their parent ADDES score fell below the 10th percentile. Children receiving medication treatment for ADHD also were included in the high-risk category. Subsequently, parents of 148 of the 204 children deemed at high risk for ADHD agreed to a personal interview, yielding a 73% participation rate. Piers-Harris self-esteem ratings scores were available on the 143 children included in this study. Teacher ratings were available on 88 children because only two thirds of the school principals permitted the teachers at their schools to complete teacher questionnaires. Special education services ranged in intensity from part-time (80%, n = 115) services to self-contained classrooms (20%, n = 28) for specific learning disabilities (63%, n = 91) or emotional handicap (39%, n = 56). Four children qualified for special education services for emotional handicap and specific learning disabilities; for purposes of this analysis, they were included in the emotional handicap category. Procedures The study design and informed consent procedures were approved by the university institutional review board and the school district research office to ensure human subject protection. The interview team consisted of 3 clinical psychology graduate students, 6 psychology undergraduate students, and a board-certified child and adolescent psychiatrist (R.B.). Interviewers completed 40 hours of training. All child self-report measures were read aloud by the psychology undergraduate students. Details of the study methods are reported elsewhere (Bussing et al., 1998). Measures Self-Esteem. Self-esteem was evaluated with the Piers-Harris SelfConcept Scale (Piers-Harris), an 80-item self-report measure designed for children and adolescents aged 8 through 18 years. The Piers-Harris provides a total self-concept score and 6 cluster scores in the areas of behavior, intellectual and school status, physical appearance and attributes, anxiety, happiness and satisfaction, and popularity. Total raw scores are converted to percentiles, based on a Pennsylvania school district–wide sample of children (N = 1,183) in grades 4 through 12 (Piers, 1984). For this normative population, the mean total score was 51.84 (SD = 13.87). The normative sample used to derive the subscale score consisted of 485 public school students, including elementary, junior high, and high school students. The mean subscale scores were 11.44 (SD = 3.22) for behavior, 11.62 (SD = 3.57) for intellectual/school status, 8.31 (SD = 3.05) for physical appearance/ attributes, 9.54 (SD = 3.11) for anxiety, 8.05 (SD = 2.04) for happiness/ satisfaction, and 8.27 (SD = 2.70) for popularity (Piers, 1984). Since the development of this measure, the mean total raw score based on an accumulated sample of normal school children (N = 3,692) has been found to be somewhat higher (mean = 55.2; SD = 12.6) (Piers,

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1984). The reliability and validity in general public school–based populations (Piers, 1984) and learning disabled elementary school student samples (Smith and Rogers, 1978) is high (general: r = 0.72–0.77, Cronbach α = .90; learning-disabled: r = 0.62, Cronbach α = .89). Nevertheless, the psychometric properties of this measure for children from predominantly minority backgrounds who are enrolled in special education programs have not been established. Sociodemographic Factors. Child age, gender, and ethnicity were evaluated by parent report. Socioeconomic status (SES) was rated on a scale of 1 through 5, with the Hollingshead 4-factor index, a measure based on the educational level and occupational category of the child’s caregivers (Hollingshead, 1975). High SES was defined as level 1 through 2 and low SES was classified as levels 3 through 5. Disorder Characteristics. Behavior problems were assessed during a telephone interview using ASQ and the ADDES. The ASQ is a 10-item instrument assessing behavioral problems frequently exhibited by children with ADHD, based on a large normative sample (Conners, 1990). Raw scores are converted to age- and gender-specific T scores, such that the normative sample mean is 50 (SD = 10), with higher scores indicating greater problems. The ADDES examines the frequency of ADHD target symptoms and yields a total score as well as subscale scores for hyperactivity, impulsivity, and inattention (McCarney, 1989). Raw scores were transformed into standard scores and percentile ranks. High problem counts translate into low standard scores and percentile ranks. The ADDES has been standardized and validated with representative reference groups (McCarney, 1989). Reliability and validity for the ASQ and the ADDES are high based on large samples including minority populations (McCarney, 1989; Zelko, 1991). Diagnoses of ADHD and comorbid externalizing conditions were made using the Diagnostic Interview Schedule for Children Version 3.0 (DISC-3.0) based on DSM-IV criteria (American Psychiatric Association, 1994). Diagnoses were generated from parent interviews, because previous studies aggregating data from parents and children found that parents alone were effective informants for ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) (Bird et al., 1992). Consistent with DSM-IV diagnostic criteria, the DISC3.0 inquires about symptoms and impairment across school and home settings. In its earlier versions, the DISC has been shown to have moderate to high test-retest reliability and internal consistency (Fisher et al., 1993; Jensen et al., 1995b; Piacentini et al., 1993; Schwab-Stone et al., 1994). Level of depressive and anxiety symptoms were assessed with the Children’s Depression Inventory (CDI) and the Revised Children’s Manifest Anxiety Scale (RCMAS), respectively. The CDI, a 27-item measure of depressive symptoms including anhedonia, neurovegetative signs, and interpersonal behavior, is appropriate for children aged 7 to 17 years (Kovacs, 1985). Internal consistency and test-retest reliability have been reported to be high in a large sample of elementary school children (Smucker et al., 1986). Children with scores at or greater than 16, a cutpoint corresponding to 1 SD above the normative mean data (Smucker et al., 1986), were identified as having significant depressive symptoms. The RCMAS is a 37-item anxiety measure for children and adolescents that also includes a Lie scale. Internal consistency and test-retest reliability coefficients are high (Reynolds and Richmond, 1985). A cutpoint at the 90th percentile of the normative sample was used to indicate clinically significant anxiety symptoms (Reynolds and Richmond, 1985). Children who scored at or above the cutpoint on the CDI or the RCMAS were classified as having comorbid internalizing symptoms. Using these assessment approaches, we grouped comorbid disorder profiles into 4 categories: (1) ADHD only; (2) ADHD with ODD or CD (ADHD + externalizing); (3) ADHD with depressive or anxiety symptoms (ADHD +

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internalizing); and (4) ADHD with an externalizing disorder and internalizing symptoms (ADHD + externalizing + internalizing). Level of functional impairment was evaluated using the parent version of the Columbia Impairment Scale (CIS) (Bird et al., 1993). A 13-item measure, the CIS assesses multiple areas of functioning, including interpersonal relations, school, and leisure time, and has been found to have high internal consistency and test-retest reliability (Bird et al., 1993). Based on discriminatory function analysis, a parent CIS score of 15 or greater yielded optimal sensitivity and specificity (Bird et al., 1993). Family burden associated with caring for children with mental disorders was assessed using the Child and Adolescent Burden Assessment (Angold et al., 1996; Messer et al., 1996). This 20-item measure includes the domains of economic burden, impact on family relationships, restriction on personal activities, and impact on parental psychological adjustment. Good internal consistency and adequate test-retest reliability have been reported (Angold et al., 1996; Messer et al., 1996). A cutpoint of 15 or greater was selected to indicate significant family burden, based on previous discriminant validity research (Angold et al., 1996; Messer et al., 1996). Medication Use. Medication use was assessed by using the Services Use in Children and Adolescents-Parent Interview (SCA-PI), a measure developed at the National Institute of Mental Health (Jensen et al., 1995a). Questions include systematic inquiry into the type and doses of medication prescribed for ADHD. The SCA-PI was modified to include inquiry into lifetime and use of medications and services in the previous year. Data Analysis Mean raw scores and percentile scores based on the original normative sample were calculated for the total sample. For Table 2, raw scores were selected to describe the relationship between the proposed predictor variables and self-esteem ratings. These analyses were conducted with analysis-of-variance procedures. For Table 3, Piers-Harris percentile scores were selected to ease the interpretation of the relationship between self-esteem scores (total and subscale) and ADHD comorbidity type (ADHD alone, + externalizing, + internalizing, + both). Pairwise comparisons using the Scheffé estimation technique were conducted (α = .05). This procedure was selected because multiple comparisons can be made simultaneously, and it remains valid under a wide range of conditions (StataCorp, 1997). To examine the independent contribution of predictor variables on the total self-

esteem percentile score, multivariate regression analyses were performed. The independent variables were sociodemographic factors (gender, ethnicity, SES), disorder characteristics (level of symptoms, ADHD comorbidity including special education category, impairment, family burden), and medication treatment status. To improve the model’s parsimony, a stepwise backward elimination procedure with an F-to-stay of 3.92 was used to eliminate nonsignificant predictor variables in the final model. For these latter 2 analyses, the sample was restricted to children who met ADHD diagnostic criteria or who were receiving medication treatment for ADHD and for whom all data points were available (n = 127; 89%). The level of behavior problems per teacher report also was excluded from the regression model because these data were available on only 88 children. All analyses were performed using STATA-5 (StataCorp, 1997).

RESULTS Self-Esteem

The mean total and subscale self-esteem raw and percentile scores are presented in Table 1. These scores did not significantly vary from those based on normative samples. Distribution of Potential Predictors

Sociodemographic Factors. Children were evenly distributed across grade levels, such that 28% (n = 41), 36% (n = 51), and 36% (n = 51) were in the second, third, and fourth grades, respectively. Most of the children (n = 115; 80%) were boys. Forty-five percent of the children (n = 65) were from minority backgrounds and, of these, the majority (n = 62; 95%) were African American. More than one half of the children (n = 90; 63%) came from low-SES families, and 49% (n = 70) lived in a household headed by a single parent. Disorder Characteristics. Thirty percent of the children (n = 26) were rated by their teachers as having significant

TABLE 1 Total and Subscale Piers-Harris Raw and Percentile Mean Scores

Total score Subscales Behavior Intellectual/School Performance Physical Appearance/Attributes Anxiety Popularity Happiness/Satisfaction

Raw Score

SD

Percentile a

SD

59.2

12.8

66.1

29.8

12.5 13.1 9.8 10.1 7.9 8.6

3.1 3.2 3.0 3.0 2.9 1.8

54.3 62.9 68.2 61.4 45.9 67.3

28.3 26.9 29.2 28.5 29.1 25.6

Note: Sample consists of 143 special education students in second through fourth grades at high risk for attention-deficit/ hyperactivity disorder in a north Florida school district. a Percentile scores are based on a normative sample of 1,183 Pennsylvania public school children for the total score and on a sample of 485 public school children for the subscale scores.

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behavior problems on the ASQ, compared with 78% (n = 112) by their parents. Seventy-one percent (n = 102) met DSM-IV diagnostic criteria for ADHD and, of those who did not, 66% (n = 27) were being treated with medication. Forty-three percent of the children also met diagnostic criteria for ODD or CD (n = 61), and 29% endorsed a clinically significant level of depressive or anxiety symptoms (n = 41). The mean percentile scores on the CDI and RCMAS were 46.3 (SD = 9.6) and 55.4 (SD = 31.9), respectively. The mean Lie scale score on the RCMAS was 3.9, which corresponds to the 55th percentile of the normative sample. When we used the child’s special education category, 61% of the children (n = 87) were identified as having a learning disability and the remainder (n = 56; 39%) were classified as being emotionally handicapped. Many of the children (n = 100; 70%) were severely functionally impaired, and almost one half of their families (n = 70; 49%) reported a significant level of burden related to the child’s mental health problems. Medication Treatment Status. More than 60% of the children (n = 87) received medication treatment in the previous year. Nearly three fourths of these children (n = 63) were receiving stimulant medication (methylphenidate: n = 59; dextroamphetamine: n = 4), 10% (n = 9) were taking a stimulant and clonidine, and 17% (n = 15) were receiving other medications, such as antidepressants (fluoxetine, clomipramine, imipramine) and/or other α2adrenoreceptor agonists (guanfacine). The average daily dose was 27 mg of methylphenidate (SD = 16.8; range 5–120), 24 mg of dextroamphetamine (SD = 11.4; range 10–45), and 0.2 mg of clonidine (SD = 0.10, range 0.05–0.40). Relationship of Sociodemographic, Disorder, and Treatment Factors With Level of Self-Esteem

The variation in the level of raw self-esteem scores by sociodemographic factors, disorder characteristics, and medication treatment status is summarized in Table 2. Children from minority backgrounds had higher total self-esteem scores than their white counterparts. Level of self-esteem did not vary by child age, SES, or teacher ratings of behavior problems. In contrast, compared with children whose parents did not report significant behavior problems, children viewed as having a clinical behavior problem had lower total self-esteem scores. Diagnostic criteria and comorbidity status also differentiated those children with lower levels of self-esteem. Children meeting DSM-IV ADHD criteria had significantly lower self1264

esteem total scores than children not meeting such criteria. In addition, total self-esteem scores varied significantly by type of associated disorders and were lowest for children with comorbid internalizing symptoms. Compared with less impaired children, those with severe functional impairment had lower total self-esteem scores. Likewise, children of families who attributed a high level of burden to the child’s mental health problem had lower total selfesteem than children of less impacted families. Total selfesteem scores did not vary by medication treatment status. Placement in self-contained classrooms versus receipt of special education services on a part-time basis was not associated with variations in self-esteem scores (not shown in Table 2). Relationship Between ADHD Comorbidity and Self-Esteem Percentile Scores

The relationships between ADHD comorbidity and self-esteem percentile scores are more fully described in Table 3 for the 129 children meeting DSM-IV diagnostic criteria or receiving stimulant medication treatment. The presence of internalizing symptoms in the clinical range was associated with lower total and subscale selfesteem scores in the domains of behavior, intellectual/ school performance, anxiety, happiness/satisfaction, and especially popularity. Predictors of Self-Esteem

The results of the full and final multivariate regression models are presented in Table 4. Minority status was associated with increased self-esteem scores, and greater functional impairment was related to lower selfesteem. Using children with ADHD only as a reference group, comorbid internalizing symptoms and internalizing symptoms plus externalizing conditions were independent predictors of lower self-esteem scores. Child gender, SES, special education category, parent behavior ratings, family burden, ADHD plus externalizing condition, and medication use did not have significant independent effects. DISCUSSION

Overall, the children in this study reported self-esteem scores in the normative reference range. This finding is especially remarkable because children in this study qualified for special education services due to emotional handicaps or learning disabilities, considered additional risk J . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 3 9 : 10 , O C TO B E R 2 0 0 0

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TABLE 2 Total Piers-Harris Raw Scores by Sociodemographic Factors, Disorder Characteristics, and Medication Treatment Status

Sociodemographic Age 8 Years (n = 26) 9 Years (n = 45) 10 Years (n = 51) 11 Years (n = 20) 12 Years (n = 1) Gender Male (n = 115) Female (n = 28) Ethnicity White (n = 78) Minority (n = 65) SES Low (n = 90) High (n = 52) Disorder Teacher behavior ratingsa T-ASQ ≥ 65 (n = 26) T-ASQ < 65 (n = 62) Parent behavior ratings P-ASQ ≥ 65 (n = 112) P-ASQ < 65 (n = 31) DSM-IV ADHD criteria Yes (n = 102) Nob (n = 41) Comorbidityc ADHD alone (n = 52) ADHD + externalizing (n = 40) ADHD + internalizing (n = 18) ADHD + externalizing + internalizing (n = 18) Special education category Learning disability (n = 87) Emotional handicap (n = 56) Impairment CIS ≥ 15 (n = 100) CIS < 15 (n = 43) Family burden CABA ≥ 15 (n = 70) CABA < 15 (n = 73) Medication treatment status Yes (n = 87) No (n = 56)

Mean

SD

56.9 58.2 61.6 57.7 68.0

11.8 12.5 13.7 12.5 0

59.0 60.1

13.0 12.2

56.9 61.9

13.9 10.8

59.4 58.9

13.2 12.2

55.7 60.5

12.5 12.4

57.3 65.9

13.1 8.9

57.7 62.8

13.1 11.3

65.4 61.9 46.8 47.7

8.8 9.2 14.3 13.1

60.1 57.7

11.8 14.2

56.7 61.5

13.8 11.3

56.7 61.5

13.8 11.3

59.8 58.2

12.1 13.8

F

p

0.9

NS

0.17

NS

5.5

<.05

0.04

NS

2.77

NS

11.88

<.001

4.72

<.05

22.47

<.001

1.26

NS

8.48

<.01

5.23

<.05

0.57

NS

Note: The sample consisted of 143 special education students at high risk for ADHD in a north Florida school district. Significance testing was done with analysis-of-variance procedures. ADHD = attention-deficit/hyperactivity disorder; SES = socioeconomic status; T-ASQ = Abbreviated Symptom Questionnaire-Teacher Version; P-ASQ = Abbreviated Symptom Questionnaire-Parent Version; CIS = Columbia Impairment Scale; CABA = Child and Adolescent Burden Assessment; externalizing = oppositional defiant or conduct disorder diagnosis; internalizing = Children’s Depression Inventory raw score ≥ 16 or Revised Children’s Manifest Anxiety Scale score ≥ 90th percentile; NS = not statistically significant. a Available for 88 students. b Included 27 receiving stimulant medications. c Restricted to 129 children who met DSM-IV ADHD diagnostic criteria or were receiving stimulant medications.

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TABLE 3 Total and Subscale Piers-Harris Percentile Scores by Comorbidity Status ADHD Only (n = 52)

+Externalizing (n = 40)

a,b

Total Subscales Behavior Intellectual/School Performance Physical Appearance/Attributes Anxiety Popularity Happiness/Satisfaction

c,d

+Internalizing (n = 18) a,c

+Both (n = 18) a,c

p

80.1

71.5

39.7

39.4

<.0001

68.9 a,b 72.0a,b 74.5 74.1a,b 54.9 a,b 77.8 a,b

56.6c,d 65.5c 69.4 68.3c,d 52.7c,d 72.7c,d

31.8a,c 41.3a,c 63.4 32.3a,c 25.4a,c 48.5a,c

27.3b,d 47.4b 54.7 41.2b,d 28.7b,d 47.3b,d

<.0001 <.0001 NS <.0001 <.0001 <.0001

Note: The sample consisted of 128 special education students meeting ADHD criteria. Pairwise comparisons were made using the Scheffé estimation procedure. Results of these comparisons are indicated by superscript letters, such that ADHD categories sharing the same letter have statistically significant mean score differences at p < .05. The p values were derived using analysis-of-variance procedures. ADHD = attention-deficit/hyperactivity disorder; externalizing = oppositional defiant or conduct disorder diagnosis; internalizing = Children’s Depression Inventory raw score ≥ 16 or Revised Children’s Manifest Anxiety Scale score ≥ 90th percentile; NS = not statistically significant. TABLE 4 Independent Predictors of Total Piers-Harris Percentile Scores Coefficient Full Model

Final Modela

Sociodemographic factors Female 2.1 Minority 9.4* 8.2* High SES 0.05 Disorder characteristics Parent behavior rating P-ASQ ≥ 65 –7.7 Comorbidityb +Externalizing –4.2 +Internalizing –36.8*** –36.1*** +Externalizing + internalizing –36.8*** –35.6*** EH special education category –0.7 CIS ≥ 15 –8.4 –12.3** CABA ≥ 15 –0.6 Medication use –0.7 Adjusted R 2 0.39 0.40 F (11, 115) = 8.25 (4, 122) = 22.3 p <.0001 <.0001 Note: The sample consisted of 128 special education students meeting ADHD criteria. Coefficients are derived from multiple regression analysis. ADHD = attention-deficit/hyperactivity disorder; SES = socioeconomic status; P-ASQ = Abbreviated Symptom Questionnaire-Parent Version; EH = emotional handicap; CIS = Columbia Impairment Scale; CABA = Child and Adolescent Burden Assessment; externalizing = oppositional defiant or conduct disorder diagnosis; internalizing = Children’s Depression Inventory raw score ≥ 16 or Revised Children’s Manifest Anxiety Scale score ≥ 90th percentile. a Derived from backward elimination procedures with F-to-stay value of 3.92. b Reference group for comorbidity is ADHD only. * p < .1; ** p < .01; *** p < .001.

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factors for lower self-esteem (Beltempo and Achille, 1990). Furthermore, these findings are in contrast to several previous reports of lower self-esteem levels in children with ADHD (Hechtman et al., 1980; Slomkowski et al., 1995), but they are consistent with others (Hoza et al., 1993). There are several possible explanations for why children in this study had mean self-esteem scores within normal limits. First, the participants may have been too young to internalize negative self-images related to ADHD, because of immature self-observational skills or because they had not struggled with the consequences of ADHD for an extended period of time. Age effects on self-esteem development have been reported among children with ADHD (Alston and Romney, 1992), lending support for this hypothesis. Second, the children may have underreported self-esteem problems because they attempted to present themselves in a positive light. Although the Piers-Harris itself does not contain an indicator for social desirability, the RCMAS Lie scale scores were in the average normative range. Overestimation of self-esteem levels due to high social desirability therefore seems less likely. Third and last, the self-esteem measure may be of questionable validity for children at risk for ADHD and enrolled in special education programs. The validity of the Piers-Harris, however, has been found to be acceptable among normal, special education, and chronically ill child populations, making this explanation less plausible (Piers, 1984). In the present study, the level of ADHD symptoms was weakly related to lower self-

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esteem. The mean self-esteem ratings of children identified as having ADHD were slightly lower than that of their peers not meeting such criteria, further supporting the ability of this measure to discriminate between such groups. Considering these points together, findings from this study suggest that young special education students with ADHD did not experience, on average, significant self-esteem problems. While self-esteem scores were overall within the normal range, severe functional impairment was an independent predictor of lower self-esteem. This relationship is consistent with theoretical conceptualizations of selfconcept development (Zimmerman et al., 1997). In addition, children who experience repeated difficulty getting along in home, school, or social settings would be expected to rate themselves less favorably on personal attributes reflected in self-esteem scores. Because functional impairment was rated by parent report, these findings cannot be attributed to method variance. These findings therefore suggest that interventions for ADHD should be aimed at raising a child’s functional level and evaluations of ADHD programs should include selfesteem as a clinical outcome. Internalizing comorbid symptoms also were found to be independent predictors of self-esteem, lowering self-esteem ratings by more than 30 percentiles. As a cautionary note, the association between self-esteem and internalizing disorders may reflect informant bias because they were assessed by child self-report measures. This issue is difficult to tease out because parents are less likely to report the presence of internalizing disorders (Klein, 1991). Despite this common methodological problem, our findings should be considered carefully because the validity of the CDI, RCMAS, and Piers-Harris is reportedly good. This finding also is clinically intuitive, as low self-worth is considered an integral part of the cognitive mindset associated with depression and represents a main focus of cognitive behavioral therapies (Evans and Murphy, 1997). In addition, given that a large proportion of ADHD treatment is rendered by primary care providers whose treatment patterns typically do not include screening for internalizing problems (Wolraich et al., 1990), these findings underscore the importance of identifying comorbid internalizing symptoms among children with ADHD. In contrast to disorder characteristics, this study found little evidence that lower self-esteem was related to the use of medication to treat ADHD. This finding should

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be reassuring to parents who worry about the psychological consequences of giving medication to their children with ADHD. This study, however, did not find that medication treatment by itself improved child selfesteem, as reported by Frankel and colleagues (1996). Of interest, Kelly et al. (1989) did not find immediate enhancement in self-esteem despite behavioral improvement on medication, but positive changes in self-esteem were noted at long-term follow-up (mean treatment time of 16 months; range 7–27 months). Taken together, these findings suggest that the relationship between self-esteem and medication treatment may be mediated by other factors, such as treatment duration and efficacy. The ethnicity effects on self-esteem scores in this study are intriguing and merit further investigation. The normative sample did not show a relationship between ethnicity and self-esteem; thus Piers-Harris scores are not adjusted for this domain (Piers, 1984). The finding of higher self-esteem levels in minority children (predominantly African American) compared with their white counterparts may represent a time cohort effect, as it is consistent with other recent publications (Richman et al., 1985; Tashakkori, 1993) but is contrary to findings from studies conducted before the 1960s (Spurlock, 1986). It has been suggested that societal changes and the increased presence of positive minority role models have contributed to the development of higher self-esteem in AfricanAmerican children (Spurlock, 1986). Study Limitations

In light of several study limitations, these findings should be interpreted cautiously. The study population was restricted to one school district. Furthermore, data are not generalizable to the larger population of children with ADHD in regular classroom settings because this study was restricted to students with ADHD who qualified for special education programs. In addition, this study did not include middle or high school students, which limits any conclusions about the relationship between age and self-esteem. To avoid excessive respondent burden, this study did not include a full diagnostic assessment of anxiety or affective disorders, relying instead on child selfreport questionnaires. This may result in overestimating the level of comorbid internalizing disorders and their impact on self-esteem. Finally, the cross-sectional design of the study precludes comments about the direction of the observed relationships or the long-term consequences of having ADHD and poor self-esteem. 1267

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Clinical Implications

Although self-esteem among elementary special education students with ADHD in the study fell within the normal range, child ethnicity, functional impairment, and comorbid depression and anxiety symptoms were predictive of lower self-esteem. Assessment and treatment guidelines for ADHD should therefore take into account cultural variation in self-esteem and be targeted at a child’s functioning and comorbid internalizing symptoms. In addition, greater priority should be placed on reliable assessment methods for comorbid depressive and anxiety symptoms during an ADHD evaluation, particularly because primary care providers conduct the majority of these assessments. Internalizing symptoms, for example, could easily be missed if ADHD evaluations using standardized parent and teacher questionnaires were limited to disruptive behavior problems. In addition to emphasizing the need for accurate detection, our study findings also have implications for treatment. A child and adolescent psychiatrist’s approach to ADHD treatment may be influenced by the presence of comorbid internalizing disorders. Practicing child and adolescent psychiatrists have become sensitized to potentially higher rates of stimulant medication side effects among youngsters with such comorbid disorders (Vance et al., 1999), increasing the likelihood for selecting other medications as first-line treatment or recommending additional psychosocial treatments. The latter treatment strategy is supported by recently released findings of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) (MTA Cooperative Group, 1999a,b). For ADHD children with comorbid anxiety disorders, reduction of hyperactivity and impulsivity among youths receiving psychosocial treatment alone approached that of children receiving medication treatment only and combined medication and psychosocial treatments (MTA Cooperative Group, 1999b). These findings are especially remarkable because MTA behavioral treatment was targeted to ADHD symptoms and not for specific internalizing disorder symptoms. The important role of behavioral interventions for these children is thus strongly evidenced by the MTA study findings. An additional benefit from such psychosocial interventions also may be improved self-esteem among children with ADHD and comorbid internalizing disorders—a problem that differentiated them from youngsters with ADHD alone in our study. 1268

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