Studies have indicated that ADHD not only affects the patient, but can also have a detrimental effect on the family unit as a whole. Reduced interaction and loyalty between those with ADHD and surrounding family members can lead to conflict and have a negative impact on family functioning. As such, these strained relationships can lead to low self-esteem and high expressed emotion (EE) in those with ADHD. This study assessed the perception of family environments by adolescents with ADHD based on self-esteem and perceived EE.
Adolescents diagnosed with ADHD attending Uludag Medical Faculty Children and Adolescent Psychiatry Outpatient Clinic (April to July 2015) were enrolled into the study, along with volunteer students without ADHD. Using the Wechsler Intelligence Scale for Children (WISC-R),* participants with scores of <85 and/or chronic diseases were excluded from the study. Completion of a sociodemographic form† was requested of those deemed eligible for study participation. Following this, participants were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL). The Shortened Level of Expressed Emotion Scale (SLEES; 33 items measuring lack of emotional support [LES; 15 items], irritability [12 items] and intrusiveness [6 items]) was used to assess the EE of the participants’ perceived most important person over the previous 3 months.‡ Self-esteem was measured using the first subtest (10 items) of the Rosenberg Self-Esteem Scale (RSS).§ Higher numbers indicate higher self-esteem levels.
The study included 41 adolescents with ADHD (age, 13.6 ± 1.3 years; male, 68.3%) and 35 without ADHD (age, 13.5 ± 1.2 years; male, 54.3%).
No significant difference was observed in the total WISC-R scores between those with and without ADHD. However, ADHD was associated with lower family income (p=0.032), divorced (rather than married) parents (p=0.006) and a lower level of paternal education (p=0.007).
The K-SADS-PL semi-structured diagnostic interview identified 11 (26.8%) adolescents with predominantly inattentive ADHD, 5 (12.2%) with predominantly hyperactive/impulsive ADHD and 25 (61.0%) with combined type ADHD. A high percentage of participants with ADHD had ≥1 comorbid disorder (68.3%), the most common being conduct disorder (27.5%), depressive disorders (17.5%) and anxiety disorders (10.0%).
Significant differences in total and subscale SLEES scores were also observed between those with and without ADHD (total score, 63.2 vs 53.9, p=0.005; LES, 28.8 vs 24.5, p=0.039; irritability, 19.9 vs 16.5, p=0.013; intrusiveness, 14.4 vs 12.7, p=0.026). Furthermore, a significant difference in RSS scores indicated lower levels of self-esteem in those with ADHD compared with those without ADHD (29.6 vs 32.2, p=0.031). Analysis indicated a correlation between low self-esteem and high perceived EE scores when considering total EE scores (with ADHD, p=0.003; without ADHD, p=0.008), LES subscale score (with ADHD, p=0.010; without ADHD, p=0.011) and irritability subscale score (with ADHD, p=0.015; without ADHD, p=0.040); however, there was no significant correlation for intrusiveness.
A major limitation of this study is the small sample sizes enrolled. Additionally, parental psychopathology was not assessed by psychiatrists.
The results indicate that familial relationships and wider social support are important for adolescents with ADHD, and that consideration of these relationships may be integral for treatment of both the disorder and associated comorbidities.
*The WISC-R consists of six verbal and six performance-based subtests for each subtest group
†This form collected the following participant information: age, gender, parental level of education, parental employment, number of siblings and the order of birth and economic status
‡Items were measured on a Likert-type scale with four units ranging from ‘1=not true’ to ‘4=true’, with a higher number indicating higher levels of EE
§The RSS consists of 12 subtests, the first 10 of which evaluate self-esteem. In the present study, answers were recorded using a 4-point scale of strongly disagree (1 point), disagree (2 points), agree (3 points) and strongly agree (4 points)
Uçar HN, Eray Ş, Vural AP, et al. Perceived family climate and self-esteem in adolescents with ADHD: a study with a control group. J Atten Disord 2017; Epub ahead of print.