September, 2000

In this issue...

* Empathy and emotional functioning in boys with ADHD

* Self-esteem in children with ADHD

Dear Subscriber:

The lead article in this issue -  "EMPATHY AND EMOTIONAL FUNCTIONING IN BOYS WITH ADHD" - presents interesting new data on the empathic capacities and emotional experience of school-age ADHD boys.  The findings indicate that boys with ADHD may have less well-developed abilities to empathize with others than their peers, and may also be prone to experience more negative emotions.  These results have potentially important implications for parents and practitioners that are discussed. The emotional functioning of children with ADHD is a neglected area of study in general, so this paper makes a nice contribution to the literature.

The second article in this issue - "SELF-ESTEEM IN CHILDREN WITH ADHD" - provides a careful look at how self-esteem varies among children with ADHD as a function of the presence of other types of difficulties.  The results of this study highlight the importance of carefully evaluating children suspected of having ADHD for co-occurring internalizing problems such as anxiety or depression, something that is often overlooked in the diagnostic workups that many children receive.

You'll find the details of these studies below.  I hope you enjoy the issue and find it to be useful to you.


David Rabiner, Ph.D.
Senior Research Scientist
Duke University

Although there has been a vast amount of research on ADHD conducted over the years, the vast majority of this work has examined issues related to diagnosis, treatment, or behavioral functioning in children with ADHD.  As a result, we know relatively little about other important aspects of functioning may be affected in children with ADHD.  One very important domain that has been relatively neglected is the role of emotions in children with ADHD.  Related to this general lack of information on emotional characteristics, there is a specific lack of research on empathy in children with ADHD.

Despite the lack of research studies in these important areas, the comprehensive theory of ADHD that was recently proposed by Russell Barkley contains specific predictions about how empathy and emotional responsivity would be affected in individuals with ADHD (Phil - The newsletter had an article on Barkley's theory that would be good to provide a link to here.)  Barkley proposed that because of the deficit in behavioral inhibition that he believes is central to ADHD (e.g. the ability to refrain from immediate responding to stimuli in order to size up the situation and consider alternatives) individuals with ADHD have difficulty regulating their emotions.  One consequence of this difficulty in emotional regulation is lower levels of empathy - i.e. reduced awarenenss/appreciation for the needs, feelings, and opinions of others as well as a reduced ability to evaluate social events from another's perspective.

Because being able to identify what another feels and then put oneself in that person's shoes can help to regulate one's behavior, lower levels of empathy could contribute significantly to the behavioral symptoms displayed by individuals with ADHD.  For example, if a child knows that a certain act will hurt his mother's feelings, and is able to really imagine the hurt his mother will feel, he may refrain from engaging in that behavior.  If this capacity is less well developed in children with ADHD, however, the same hurtful behavior would be more likely.  For this reason, it would be important to know whether children with ADHD are deficient in empathy skills, as these skills may be significant determinants of other behavior.

This question was addressed in an interesting study published recently in the Journal of Consulting and Clinical Psychology (Braaten, E.B. & Rosen, L.A. (2000). Self-regulation of affect in ADHD and non-ADHD boys: Differences in empathic responding. Journal of Consulting and Clinical Psychology, 68, 313-321.)  Participants in this study 24 boys diagnosed with ADHD and 19 comparison boys.  All boys were between the ages of 6 and 12.  During a 2-hour testing session (none of the boys with ADHD were on medication at the time of testing), boys in both groups were individually administered a test that is frequently used to assess children's empathic responding.  In this test, children were read eight short stories about a fictitious child who is experiencing different types of emotions, some of which are positive and some of which are negative.  In addition, several of the stories depict characters who are experiencing conflicting emotions.

After each story, participants were asked how the child in the story was feeling, how the child made them feel, and why he (i.e. the participant) felt that way.  Higher empathy scores were obtained when children consistently indicated that they felt the same as the child in the story (i.e. their feeling matched the feeling they attributed to the story character).  Higher scores were also obtained when participants explained their feelings in relation to the experience of the story character (e.g. "I feel sad because his favorite toy was lost.") rather than providing an egocentric explanation (e.g. "I feel sad because I lost a toy too.")

In addition to this measure of empathic responding, the authors were interested in the frequency with which participants displayed a variety of emotions.  These different emotions included interest, joy, sadness, fear, shame, and guilt.  This was evaluated by having the boys' parents rate how often they observed their sons to display behaviors (e.g. facial expressions, body posture, tone of voice) indicative of each emotion during the prior two weeks.


Results indicated that compared to boys without ADHD, boys with ADHD were significantly less likely to indicate that their own feelings matched those they attributed to the story character (i.e. they obtained lower match scores).  This overall difference occurred primarily because ADHD boys were less likely to match the emotion of the story character when negative emotions were depicted.  In addition, the ADHD boys were significantly less likely to explain their feelings in reference to what the story character was experiencing and instead provided explanations of their feelings that were more egocentric.

On the parent ratings of emotional expression, boys with ADHD were rated as having significantly higher scores for the negative emotions, but did not differ for the positive emotions.  In particular, parents of ADHD boys reported that their sons were significantly more likely to display more outward signs of sadness, anger, and guilt.


Overall, the results of this study suggest that boys with ADHD are less likely than non-ADHD boys to feel bad when they observe others in difficult circumstances, and are also less likely report that their own feelings are directly affected by what happens to others.  In other words, their ability to respond empathically may be deficient relative to other boys.  According to their parents, ADHD boys are also more likely than non-ADHD boys to display behavior indicators of a variety of negative emotions.  What is interesting about this particular combination of findings is the suggestion that although boys with ADHD may be more prone to experience negative emotions themselves, they are apparently less likely to empathize with the negative emotional experience of others. In fact, one possible explanation for the latter finding is that ADHD boys are reluctant to empathize with others negative emotional experience to protect themselves from experiencing even more negative affect.  This, of course, is highly speculative.

These findings are consistent with the predictions about emotional functioning in children with ADHD that emanate from Barkley's theory.  Several practical consequences of these findings are noteworthy as well.  First, because empathizing with others can play an important role in prosocial behavior towards others, helping children with ADHD develop their empathic abilities may need to be included as an essential aspect of social skills training programs.  Second, the parent report data highlights that the emotional experience for many boys with ADHD may be much more negative than that of their peers.  This underscores the need to carefully attend to the emotional experience of children with ADHD rather than focusing solely on working to improve their behavioral and academic functioning.  When children are getting into consistent trouble and acting in aversive ways, this important perspective can be easy to lose sight of.

One concrete way that parents can help with this is to make a concerted effort to spend positive time with their child each and every day.  In many families that I worked with, daily life with an ADHD child could be so filled with struggle that all of parents' time and energy was devoted to discipline and making sure that certain important things got done.  As a result, there was little if any time that was devoted to the essential experience of just trying to have a good time with one's child.  One can easily imagine how this could contribute to a more negative emotional experience for children - and parents. Putting aside even 15 minutes a day to focus solely having fun with your child can play a critical role in helping to build and maintain good parent-child relations and enhancing the emotional experience of both parties.  This can also contribute to children eventually being better able to share some of their negative emotions with parents, thus providing parents with a good opportunity to model empathic skills, which can be helpful in fostering the development of such skills in children.

Despite the interesting and important results from this study, there are several limitations that need to be kept in mind.  First, because the sample was restricted to boys, one can not assume that similar results would have been obtained with girls who have ADHD.  Also, the findings should not be generalized to boys outside of the age range used in this study.  As with any study that employs a relatively small sample, replicating these results would also be important.  Finally, one should not assume that the findings reported would apply to all boys with ADHD even though they may be characteristic of ADHD boys overall.


Because the behavioral and academic difficulties associated with ADHD are often so prominent, it can be easy to overlook the impact that ADHD may have on less obvious areas of children's functioning.  For example, children's peer relations are often adversely affected by ADHD, and despite the importance of good peer relations for long-term development, this area is often neglected in treatment.  Aspects of emotional functioning - i.e. feelings of sadness, worries, etc. - also tend to be adversely affected in many children with ADHD but often go unaddressed.

How a child feels about him or herself - i.e. their self-esteem - is another important area that may be adversely affected by ADHD and which may be overlooked in the face of more obvious behavioral and academic difficulties.  Because a child's  self-esteem depends to a large extent on the success he/she experiences in school and in relationships with parents and peers, it is easy to imagine how the self-esteem in children with ADHD may suffer.  Although effective treatment can mitigate such effects, some parents worry that treatment itself - particularly medication treatment - could negatively impact a child's self-esteem.

These issues were examined in an interesting study published in the Journal of the American Academy of Child and Adolescent Psychiatry (Bussing, R., et al., (2000). Self-esteem in special education children with ADHD: Relationship to disorder characteristics and medication use. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1260-1269.)  In contrast to prior studies in which self-esteem in children with ADHD was compared to self-esteem in non-ADHD peers (the results of such studies have been mixed, with some finding lower self-esteem in ADHD children and other failing to find such differences), Dr. Bussing and her colleagues conducted a more careful examination of this relationship.  Specifically, they recognized that children with ADHD often have other important difficulties, but this varies widely from one child to the next. For example, some children have ADHD alone, others have externalizing problems such as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) in addition to ADHD, while others have mood or anxiety problems (i.e. internalizing disorders).  In addition, there is an unfortunate subset of children with ADHD who have both co-occurring internalizing and externalizing problems.  Clearly, self-esteem in children with these different combination of difficulties would be expected to vary, although this has not been carefully examined in prior research.

Participants in this study were 143 8-12 year old students with ADHD (115 boys and 28 girls) receiving special education services in a medium-sized school district.  (Note: Because this sample was drawn a special education population, the findings do not necessarily generalize to children with ADHD overall.)  Eighty-seven of these children - about 61% - were currently being treated with medication.  All children completed the Piers-Harris Self-Concept Scale, a widely used and well-validated measure of self-esteem in school-age children.  The Piers-Harris provides a total self-concept score as well as specific assessments of children's self-concept in behavioral, academic, social, physical appearance, and general happiness/satisfaction domains.  Children also completed the Child Depression Inventory (CDI) and the Revised Children's Manifest Anxiety Scale (RCMAS) to obtain their reports of depressive and anxiety symptoms respectively.  In addition, children's parents were interviewed to determine whether a co-occurring externalizing disorder (i.e. ODD or CD) was present.  Complete data was obtained on 128 of the 143 participants.


Using the data obtained from children and parents described above, participants were divided into 4 groups: those with ADHD alone (n=52, 41% of sample); those with ADHD and an externalizing disorder (n=40, 31% of sample); those with ADHD and an internalizing disorder (n=18, 14% of the sample); and those who had both an internalizing and externalizing disorder (n=18, 14% of sample).

These data are instructive in and of themselves in that they highlight the frequency with which other important difficulties are often found in children with ADHD.  In this sample, a full 54% had a co-occurring externalizing disorder (i.e. the 40% who had an externalizing disorder alone and the 14% who had both an internalizing and externalizing disorder) while 28% had internalizing problems (i.e. high levels of depressive or anxiety symptoms).  These figures may be slightly elevated because participants were drawn from a special education population, but are not all that discrepant from what has been reported in prior studies.  Clearly, these findings highlight the need for a comprehensive evaluation of children's functioning when attempting to make an ADHD diagnosis rather than focusing on the specific symptoms of ADHD alone.  In particular, the presence of internalizing difficulties can often be missed as parents can be unaware of these problems and many physicians fail to adequately evaluate this aspect of children's functioning in their evaluation.

Participant's self-esteem was found to vary dramatically depending on the presence or absence of these co-occurring problems.  The average scores for each group on the total self-concept scale and the different subscales are shown below (Note E=externalizing; I=internalizing; The results reported below were generally consistent across both genders.):

                          ADHD only     ADHD + E       ADHD + I       ADHD + I & E

Total                      80.1                   71.5              39.7                  39.4

Behavior                 68.9                   56.6              31.8                  27.3

Academics             72.0                   65.5              41.3                  47.4

Appearance             74.5                 69.4              63.4                  54.7

Social                      54.9                  52.7             25.4                  28.7

Happiness                 77.8                   72.7            48.5                  47.3

As can be seen above, apart from the physical appearance scale where differences between the groups were not significant, there are clear differences on all other dimensions as well as the total score.  Children with ADHD alone consistently reported the highest self-esteem, and their scores fell in the normal range for this measure.  Children with externalizing disorders only in addition to ADHD also report generally positive feelings about themselves.  In fact, although their scores look a bit lower than those for children with ADHD alone, these differences are not significant according to statistical test.  This is an interesting finding in and of itself in that it indicates that despite the tremendous distress for others that a child with ADHD and another disruptive behavior disorder can cause, these children tend not to experience much distress themselves, nor do they appear to feel badly about how they are doing.

For children with an internalizing disorder - whether alone or in combination with an externalizing disorder - the results are dramatically different.  These children report consistently less positive feelings about themselves and the differences are really quite substantial.  What is especially striking is that even in the domain of behavior - where children with ADHD and an internalizing problem are likely to be doing objectively better than children with ADHD and an externalizing disorder - they still rated themselves substantially lower.  Thus, the presence of an internalizing disorder along with ADHD greatly increases the likelihood that a child's feelings about him or herself in a variety of important areas are likely to be decidedly negative.

As noted above, once concern that some parents have about the use of medication treatment is that needing to take medication may undermine a child's self-esteem.  The authors examined this issue by computing the average self-esteem scores for medication treated and non-medication treated groups.  No differences between these groups were found.


The most important message from this study is that ADHD alone does not appear to be associated with lower levels of self-esteem in school-age children.  Instead, it is the presence of a co-occurring internalizing problem - either alone or in combination with an externalizing disorder - that is predictive of dramatically lower self-esteem.

The importance of these data is that they clearly highlight the need that children suspected of having ADHD are thoroughly evaluated for the presence of co-occurring internalizing problems.  In this sample, such difficulties were found in almost 30% of the participants.  This is particularly striking because these were all pre-adolescents, and it is in the adolescent years when such difficulties tend to become even more prevalent.

One reason why careful identification of such problems is so important - in addition to the apparent impact on a child's self-esteem - is the implications this can have for treatment.  For example, results from the multi-modal treatment study of ADHD (MTA study), the single largest treatment study of ADHD ever conducted - indicate that psychosocial interventions can be especially helpful and important for these children.  For these children especially, medication treatment alone may often not be an appropriate approach to undertake.

Parents and professionals thus need to pay particularly close attention to the emotional functioning in children with ADHD, and be alert to the possibility that such difficulties may emerge over time in response to the difficulties that having ADHD can cause.  For parents who have questions about these aspects of their child's health, consultation with an experienced child mental health professional is strongly recommended.  Carefully evaluating a child for depressive or anxiety disorders is not something that most pediatricians or family practitioners are typically well equipped to do.

That's all for this issue.

I hope that you enjoyed this issue of Attention Research Update and found it to be informative.  Please feel free to forward this newsletter to others you know who may be interested in receiving it.  The next issue of the newsletter should be sent to you next months.

Take care and be well.

David Rabiner, Ph.D.
Senior Research Scientist
Duke University