Self-Esteem,Self-Efficacy,and Resources in Adults With ADHD

Abstract

Objective: The purpose of this study is to shed light on therapy-relevant factors, such as self-esteem, self-efficacy, and resources in adults with ADHD in comparison with a healthy control group. Method: A total of 43 adults who met Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) criteria for ADHD in adulthood were matched with a nonclinical sample in terms of age and gender. All participants (N = 86) were assessed with self-ratings: Symptom Checklist-90–Revised (SCL-90-R), Rosenberg Self-Esteem Scale, General Perceived Self-Efficacy Scale, and Dick’s Resources Checklist. Results: Adults with ADHD showed lower levels of self-esteem and self-efficacy when compared with the control group. The authors found some, but not all, of the resources of adults with ADHD to be reduced. In other words, people with ADHD seem to possess specific resources. Conclusion: Our results have important implications for the treatment of adult ADHD and suggest that specific therapy programs should include resources-oriented modules for enhancing self-esteem, self-efficacy, and fostering strengths.

Keywords

ADHD self-esteem self-efficacy resources strengths

Introduction

Adults suffering from ADHD are often exposed to a multiplicity of negative life outcomes and underachievement due to their neuropsychological impairments. In particular interpersonal, academic, and vocational difficulties are common in individuals with ADHD (Barkley, 2010; Ramsay & Rostain, 2008; Stieglitz, Nyberg, & Hofecker-Fallahpour, 2011). Furthermore, approximately 70% to 75% of adults with ADHD suffer from psychiatric comorbidity, most prevalently anxiety disorder, depression, or substance use disorder (Biederman, 2004; Shekim, Asarnow, Hess, Zaucha, & Wheeler, 1990; Wilens, Biederman, & Spencer, 2002).

Consequently, numerous negative experiences affect the formation of the individual’s self-esteem and self-efficacy (Philipsen et al., 2007; Ramsay & Rostain, 2008). Negative beliefs about the self and their own competences emerge, and the individuals struggle to deal with stressful events. By developing maladaptive coping strategies (dysfunctional behavior), such as avoidance and procrastination (Young & Bramham, 2007), adults with ADHD maintain and reinforce their negative view of the self but remain incapable of coping with the problem. Captured in this vicious cycle, the individual experiences an ongoing loop of disappointments (Newark & Stieglitz, 2010). Thus, it comes as no surprise that adults with ADHD are often found to have reduced self-esteem (Philipsen et al., 2007; Ramsay & Rostain, 2008) and low self-efficacy (Safren, 2006).

Over the past years, several studies showed predominantly significant improvements on self-efficacy and self-esteem in adults with ADHD through cognitive behavioral therapy (CBT; Bramham et al., 2009; Stevenson, Stevenson, & Whitmont, 2003; Stevenson, Whitmont, Bornholt, Livesey, & Stevenson, 2002). The importance of using strategies to improve self-esteem is highlighted in various cognitive behavioral programs for adult ADHD (Ramsay & Rostain, 2005; Stevenson et al., 2002; Virta et al., 2008).

Despite all the problems people with ADHD have to cope with, they tend to possess various internal resources, such as enhanced creativity (Hallowell & Ratey, 1994; Weiss, 1997) or resilience (e.g., the capacity to try again and hope for a successful outcome after experiencing a disappointment; Young, 2005). Hesslinger et al. (2002) emphasized that adults with ADHD possess curiosity, imaginativeness or flexibility, and resources, which can be used for psychotherapy in a favorable way. At this time, very few studies have been conducted in this field, and our knowledge about the specific resources of adult ADHD still leaves us in the dark.

However, we do know that pointing out resources and making use of them has a highly positive effect on patients in general. Gassmann and Grawe (2006) showed that a successful therapeutic outcome depended considerably on how much the patient was able to activate her resources. But even though therapy studies indicate beneficial effects of focusing on resources (Fiedler, 2007; Klemenz, 2009; Willutzki, 2003), and ambassadors of positive psychology such as Seligman and Csikszentmihalyi (2000) or Snyder and Lopez (2007) stress the importance of a resources-oriented view in psychotherapy, resources have been playing a subordinate role in the treatment of adults with ADHD. Few therapy manuals or guidebooks emphasize the strengths adults with ADHD do possess (Hesslinger et al., 2002; Young & Bramham, 2007).

If adults with ADHD become aware of their resources, it can help them deal with impairments and achieve their goals. Hence, self-esteem and self-efficacy can develop by experiencing strengths and the capability of dealing with difficult situations and to positively influence one’s life. The vicious cycle of negative appraisal could be broken by acknowledging individual resources, believing in oneself and in the capability to influence one’s own life.

The purpose of this study is to shed light on therapy-relevant factors, such as self-esteem, self-efficacy, and resources in adults with ADHD. To this end, the authors want to investigate whether untreated patients suffering from ADHD differ from adults in a healthy control group on these factors.

Self-esteem, self-efficacy, and resources are therapy-relevant factors as they can create positive beliefs about the self and one’s own abilities. Although there are multitudinous significant factors for the psychotherapy of ADHD in adulthood, we only want to point out at those immanent factors that already existed before treatment (for instance, the patients’ inner psychic experiences concerning the image of themselves and their own capabilities). The authors assume that accounting for these therapy-relevant factors is of great importance for the treatment of adults with ADHD. Before specifying this study, we want to give a short theoretical overview of the three therapy-relevant factors that were surveyed.

Self-Esteem

Self-esteem reflects the overall opinion we have of ourselves, how we evaluate ourselves, and the value we attach to ourselves as a person (Fennell, 1999). Considered a personality trait, it is referred to as general self-esteem and has been shown to be a stable variable throughout adulthood (Neiss, Sedikides, & Stevenson, 2002). In Rosenberg’s (1965) definition, self-esteem is specified as a favorable or unfavorable attitude toward the self. Looking for the essence of self-esteem, we come up against the core beliefs about oneself (Beck, 1976, 1995), beliefs that developed out of our life experiences and are fundamental and deeply enrooted. We consider core beliefs to be utterly true and unchangeable, and tend to ignore or devaluate conflicting information, even if evidence therefor is given. Depending on whether our experiences, starting from early childhood, have been generally positive or negative, the view of the self is consolidated. Low self-esteem implies that people have many negative beliefs about themselves.

Self-Efficacy

Perceived self-efficacy is characterized by the individual’s belief in their abilities to perform a specific action needed to attain a desired outcome. Self-efficacy beliefs seem also helpful in dealing with stressful conditions as they influence cognitions, emotions, and behavior (Bandura, 1997). These beliefs appear to be a major factor in influencing behavioral changes (Luszczynska, Scholz, & Schwarzer, 2005). In this article, the term self-efficacy stands for generalized self-efficacy (GSE) that is characterized by a broad and stable sense of personal competence about coping effectively with diverse stressful situations (Luszczynska, Diehl, Gutiérrez-Doña, Kuusinen, & Schwarzer, 2004; Sherer, Maddux, Mercadante, & Prentice-Dunn, 1982). Luszczynska et al. (2005) and Bandura (2002) found GSE to be a universal and transcultural construct, which is characterized by a basic belief that is immanent in all humans.

Resources

By resources we mean “strengths” or “potentials” of either a person (internal resources) or the environment (external resources; Willutzki, 2008). Resources can be perceived either subjectively (perception of the own person) or objectively (perception of one’s resources by an observer), and they can be stable or variable over time (Grawe, 1997). Depending on its validation and disposability, the quality of a resource varies. The perceived subjective resources seem to be decisive for coping with daily hassles as well as with bigger challenges (Frank, 2007; Jerusalem, 1990). At large, all humans are said to have resources and hence the feasibility for personal growth and to favorably influence their environment (Grawe, 1998).

In our study, we compared an untreated clinical sample of adults diagnosed with ADHD with individuals in a healthy control sample to examine the magnitude of self-esteem, self-efficacy, and resources both groups possess. Furthermore, we wanted to examine their general psychological distress level and its potential influence on self-esteem, self-efficacy, and resources.

The following questions were being explored:

Research Question 1: Are there significant differences between adults with ADHD and a healthy control group in matters of self-esteem and self-efficacy?

Research Question 2: Are there significant differences between adults with ADHD and a healthy control group with respect to their resources?

Research Question 3: Is there a significant relationship between the general psychological distress level and factors, such as self-esteem, self-efficacy, and resources?

Research Question 4: Is there a significant relationship between self-esteem, self-efficacy, and resources?

Method

Study Design

Participant characteristics

The study included 36 females and 50 males between the ages of 19 and 60 (ADHD: M = 34.3, SD = 9.47; control group: M = 34.58, SD = 9.88). In total, 43 men and women who met Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) criteria for ADHD in adulthood (experimental group, henceforth EG) were matched with 43 adults from a nonclinical sample (control group, henceforth CG). The EG consisted of patients who came for a clarification of the diagnosis of ADHD in adulthood to the ADHD consultation of the Psychiatric Outpatient Department/Psychiatric University Clinic Basel. For every participant in the EG, a “matching part” was searched, which was to have the same gender and substantial similarities in age. Recruitment of the CG was conducted by searching for an adequate match in the author’s circle of acquaintances.

Sociodemographic information for the sample is depicted in Table 1. There were no significant differences between the groups for age (p = .894) and gender (p = 1.0). The relational status of our sample showed no significant differences between the groups (p = .891). Participants were mostly married or in a relationship (EG = 55.8%, CG = 55.9%), or single (EG = 37.2%, CG = 39.5%), few were divorced/separated (EG = 7%, CG = 4.6%).

Table 1.

Sociodemographic Variables.

	ADHD (n = 43)	CG (n = 43)	t test/χ²	p	df
Age
Age in years: M (SD)	34.3 (9.46)	34.58 (9.88)	t = −0.134	.894	84
Age in years: range	19-60	19-59
Sex			χ² = 0.000	1.0	1
Male	25 (55.8%)	25 (55.8%)
Female	18 (44.2%)	18 (44.2%)
Relational status			χ² = 0.23	.891	2
				.989^a
Single	16 (37.2%)	17 (39.5%)
Married/in a relationship	24 (55.8%)	24 (55.9%)
Divorced/separated	3 (7%)	2 (4.6%)
Education
Total education in years: M (SD)	10.40 (1.71)	12.22 (2.17)	t = −4.294	.000**	84
Total education in years: range	8-14	9-18
Highest completed graduation			χ² = 12.1	.007**	3
				.021*^a
Lower secondary level (Grades 6-9)	20 (46.5%)	6 (14%)
Upper secondary level (Grades 10-13)	13 (30.2%)	14 (34.9%)
Vocational education (final apprentice examination)	8 (18.6%)	18 (41.9%)
University/university of applied sciences	2 (4.7%)	4 (9.2%)
Actual employment situation			χ² = 13.28	.010*	4
				.061^a
Full-time work/housewife/house husband	16 (37.2%)	21 (48.9%)
Part-time work	10 (23.3%)	12 (27.9%)
Unemployed	7 (16.3%)	1 (2.3%)
Student/vocational education	4 (9.3%)	9 (20.9%)
Disability pension/other pension/socioprofessional reintegration	6 (13.9%)	0

p values with Yates’ correction.

p < .05. **p < .01.

Individuals with ADHD featured fewer years of education than individuals in the CG (p < .001; ADHD: M = 10.4 years vs. CG: M = 12.2 years).¹ The highest achieved graduation level among our ADHD sample was 46.5% at the lower secondary level, 30.2% at the upper secondary level, followed by 18.6% with a vocational education, and 4.7% who finished university. In the CG, the majority of the participants completed a vocational education (41.9%) as highest graduation level, followed by 34.9% who finished the upper secondary level. In all, 14% completed the lower secondary level and 9.2% finished university.

Adults with ADHD were more likely to be unemployed (EG = 16.3% vs. CG = 2.3%) or to live from a disability pension (EG = 13.9% vs. CG = 0%). Individuals in the CG were more likely to work full-time or to be a housewife/househusband (CG = 48.9%, EG = 37.2%) and to study or to be in a vocational education (CG = 20.9%, EG = 9.3%).

Consistent with the literature, psychiatric lifetime comorbidity was clearly present in our adult ADHD group. Comorbidity in the 43 adults with ADHD was assessed by a certified psychologist or psychiatrist according to DSM-IV-TR criteria. A total of 36 individuals in the ADHD group suffered from at least one additional psychiatric diagnosis. Predominantly, individuals suffered from mood disorders (34.9%), substance abuse/dependence (20.95%), or anxiety disorders (18.7%). A small part of the group suffered from eating disorders (2.3%) or other not specified psychiatric conditions (2.3%). Our CG was not screened for psychiatric disorders but was to self-report any psychiatric diagnosis received at any time in their lives. Only two individuals in the CG indicated having been diagnosed with a psychiatric diagnosis (in both cases “mood disorder”).

Inclusion criteria for participating in this study were as follows: (a) men and women of 18 to 60 years of age, (b) no current severe comorbid psychiatric disorder or mental retardation, and (c) informed consent given.

To be included, participants in the EG must have had a principal diagnosis of ADHD. The study was approved by the ethics committee of Basel (EKBB).

Adults who came for a clarification of the diagnosis of ADHD to the Psychiatric Outpatient Department were examined by experienced clinical psychologists, through structured clinical interviews and rating scales (see Stieglitz, 2010). All clinical psychologists had been specially trained in the field of adult ADHD. The patients were given a set of questionnaires, which they sent back when completed. The set included the Symptom Checklist-90–Revised (SCL-90-R; Derogatis, 1992), the Rosenberg Scale (Collani & Herzberg, 2003), the General Perceived Self-Efficacy Scale (SWE; Schwarzer & Jerusalem, 1995), and the Resources Checklist (Dick, 2003).

Participants in the CG consisted of a nonclinical sample and were not previously diagnosed with ADHD. Every participant was given the same set of questionnaires as for the ADHD group as well as the ADHD-Screener (World Health Organization [WHO], 2003).

Measures

Because the focus of this article is on self-esteem, self-efficacy, and resources, only associated measures are depicted in more detail. For an extensive overview in screening methods and diagnostics of adult ADHD, see Barkley (2010).

SWE

This scale (Schwarzer & Jerusalem, 1995) is one of the most frequently used self-report measures to determine general perceived self-efficacy. The SWE is a unidimensional scale containing 10 items, which are answered on a 4-point scale (1 = not at all true, 2 = hardly true, 3 = moderately true, 4 = exactly true). Reliability analysis of samples from 23 countries indicated a high internal consistency: Cronbach’s alpha ranged from .76 to .90. The test–retest reliability scores ranged from r = .74 to r = .78. The means for most samples were 29 points with a standard deviation of ±4. For our study, we used raw scores.

Rosenberg Self-Esteem Scale (RSES)

This scale (Rosenberg, 1965) has been revised by Collani and Herzberg in 2003 (German version). Most frequently, this scale is being adopted to measure global self-esteem.

The RSES is a unidimensional scale containing 10 items, which measure “global self-esteem.” Five items (2, 5, 6, 8, and 9) are phrased in a negative way, and 5 items (1, 3, 4, 7, and 10) are positively framed. Each of the 10 items is answered on a 4-point scale (1 = not at all true, 2 = hardly true, 3 = moderately true, 4 = exactly true). Reliability analysis indicated a high internal consistency (Cronbach’s α = .84). The test–retest reliability ranged from r = .85 to r = .82. Although some studies have demonstrated a unidimensional structure to the scale, others found a two-factor structure consisting of self-confidence and self-deprecation (for an overview, see Corwyn, 2000). We used raw scores, and the scale was applied unidimensionally. The mean range was between 25 and 35 points.

Resources Checklist

The Resources Checklist (henceforth RCL; Dick, 2003) comprises an assembly of the most important resources a person features, such as social/environmental resources and personality-related strengths. In this checklist, people are to describe on a scale from 0 = not at all to 4 = very important whether they actually possess this resource (realization) and how important this resource is to them (importance). For the evaluation, the mean values of the importance of each resource are subtracted from the mean values of the actual disposability of the resource. If after subtraction the result is close to 0, we conclude that this specific resource is in balance between importance and disposability. For example, Person A considers the resource relationship as important and is in a satisfying relationship at this time.

A deficient disposability of a resource is given by negative differences. It indicates that this resource needs to be fostered as its importance is higher than the current disposability. For example, Person B considers vocation as very important but is unhappy with his job.

The two main categories environmental/social resources and personality-related resources consist of 14 subcategories: partnership, family, vocation, leisure time, housing, health, self-esteem, confidence, ability to love, courage, creativity, sense of control, composure, and faith.

At this point in time, there is no scientific evaluation of this checklist. Overall, the use of this list has been intended to be a mnemonic for resources-oriented interviews or therapies. Despite these disadvantages, we chose this questionnaire for its clear classification of the resources and due to its relative shortness.

SCL-90-R

This checklist (Derogatis, 1992) is a self-report questionnaire indicating psychological symptoms. In total, 90 items are scored on a 5-point Likert-type scale (from 0 = not at all to 4 = extremely). The questionnaire is designed to measure symptom intensity on nine subscales and on three global indices. The nine subscales are Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Anger-Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. The three global indices consist of the following: (a) Global Severity Index (GSI)—Designed to measure the overall psychological distress. The index is the mean value of all 90 items. High scores reflect high symptomatic distress. (b) Positive Symptom Distress Index (PSDI)—Measures the intensity of symptoms. (c) Positive Symptom Total (PST)—Reports number of self-reported symptoms.

This study only considered the GSI using raw scores. Reliability analysis of the nine scales indicated a high internal consistency: Cronbach’s alpha ranged from .75 to .87. The test–retest reliability ranged from r = .78 to r = .90. For the global indices (GSI, PSDI, and PST), reliability analysis displayed an even higher internal consistency (Cronbach’s α = .96-.98). The t-values for clinical nonrelevant findings were between 40 and 60 points.

Statistical Analyses

Statistical analyses were conducted using SPSS for Windows (Version 19.0). In order to check for the normality of the distribution of demographic and clinical characteristics of the sample we applied Kolmogorov-Smirnov tests. Unless otherwise specified, a p value of .05 was chosen as the criterion of significance.

Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance–covariance matrices, and multicollinearity. No serious violations were noted. We detected possible differences between the groups with respect to sex, age, education, employment situation, and comorbidity via t test or chi-square test, where appropriate. To explore group differences in self-esteem, self-efficacy, and resource, we conducted two-way between-groups ANOVA and one-way between-groups MANOVA. The relationship between the general psychological distress level and self-esteem, self-efficacy, or resource was analyzed with Pearson product–moment correlation coefficient. The strength of the relationship was chosen after Cohen (1988), suggesting the following guidelines: small r = .10 to .29, medium r = .30 to .49, and large r = .50 to 1.0.

Results

To explore significant differences in self-esteem and self-efficacy between adults with ADHD and a healthy CG, we used two-way between-groups ANOVA. We analyzed group and sex differences on levels of self-esteem (as measured by the Rosenberg Scale) and self-efficacy (as measured by the SWE scale). The independent variables were group and sex. We conducted separate analysis for the dependent variables, self-esteem and self-efficacy. Table 2 shows that groups differed significantly in self-esteem, F(3, 82) = 34.7, p < .001, as well as in self-efficacy, F(3, 82) = 39.4, p < .001. Beyond that the results also showed large effect sizes for self-esteem and self-efficacy. No significant gender effects were found for self-esteem, F(3, 82) = 0.018, p = .894, or for self-efficacy, F(3, 82) = 3.35, p = .071. The interaction effect between group and sex was not statistically significant, neither for self-esteem, F(3, 82) = 1.12, p = .291, nor for self-efficacy, F(3, 82) = 0.332, p = .566.

Table 2.

ANOVA: Group Differences on Self-Esteem, Self-Efficacy, and the General Psychological Distress Level (SCL-90-R: GSI).

	ADHD (n = 43)	CG (n = 43)
Variables	M (SD)	M (SD)	F(3, 82)	Significance	η²
Self-esteem (Rosenberg Scale)	15.0 (6.5)	23.2 (6.5)	34.7	.000**	.298
Self-efficacy (SWE scale)	14.7 (4.7)	20.3 (3.5)	39.4	.000**	.325
General psychological distress level (SCL-90-R: GSI)	1.26 (0.67)	0.44 (0.33)	48.7	.000**	.376

Note. SCL-90-R = Symptom Checklist-90–Revised; GSI = Global Severity Index; SWE = General Perceived Self-Efficacy Scale.

p < .05. **p < .01.

Group differences on the level of general psychological distress (SCL-90-R: GSI) were analyzed with a two-way between-groups ANOVA (see Table 2). We found a statistical significant difference between the groups in terms of general psychological distress, F(3, 82) = 48.7, p < .001. Participants in the ADHD group showed a significant higher level of symptom distress (M = 1.26, SD = 0.67) than those in the CG (M = 0.44, SD = 0.33). There were no significant differences found in the symptom distress level of males compared with females, F(3, 82) = 0.198, p = .657. The interaction effect between group and sex was statistically not significant, F(3, 82) = 0.008, p = .930.

We performed a one-way between-groups MANOVA to investigate group differences with respect to the resources they possess (RCL).

According to Dick’s (2003) classification, we analyzed the two main categories, environmental/social resources and personality-related resources, as well as the 14 subcategories. The MANOVA results in Table 3 revealed significant group differences at p < .01 or less with respect to the following variables: environmental/social resources, personality-related resources, partnership, vocation, health, self-esteem, confidence, creativity, sense of control, and composure. Taken as a whole, the ADHD group exhibited a significantly lower level of these resources than the CG. However, there are resources that did not significantly differ between the groups: family, leisure time, housing, ability to love, courage, and faith.

Table 3.

MANOVA: Group Differences on 14 Resources (Resources Checklist).

	ADHD	CG
Variables	M (SD)	M (SD)	F(1, 82)	Significance	η²
Resources main categories
Environmental/social resources	−1.12 (0.77)	−0.45 (0.52)	21.1	.000**	.205
Personality-related resources	−1.06 (0.66)	−0.44 (0.45)	25.0	.000**	.234
Resources subcategories
Partnership^a	−1.50 (1.54)	−0.45 (1.00)	13.3	.000**	.140
Family^a	−0.70 (1.00)	−0.24 (0.55)	6.6	.011	.076
Vocation^a	−1.42 (1.23)	−0.60 (0.78)	13.2	.000**	.139
Leisure time^a	−1.10 (0.90)	−0.78 (0.81)	3.02	.086	.036
Housing^a	−0.53 (0.81)	−0.17 (0.57)	5.5	.021	.064
Health^a	−1.52 (0.87)	−0.63 (0.65)	27.9	.000**	.255
Self-esteem^b	−1.97 (1.50)	−0.60 (0.91)	24.9	.000**	.234
Confidence^b	−1.10 (0.88)	−0.50 (0.78)	10.7	.002*	.116
Ability to love^b	−0.52 (0.77)	−0.32 (0.73)	1.39	.241	.017
Courage^b	−0.97 (0.94)	−0.50 (0.72)	6.56	.012	.074
Creativity^b	−1.36 (1.14)	−0.60 (0.81)	11.9	.001**	.127
Sense of control^b	−1.34 (1.06)	−0.41 (0.70)	22.1	.000**	.213
Composure^b	−1.89 (1.01)	−0.56 (1.68)	19.4	.000**	.192
Faith^b	−0.64 (0.97)	−0.32 (0.52)	3.39	.069	.040

Environmental/social resources.

Personality-related resources.

p < .05 (Bonferroni adjustment alpha level of .0031). **p < .025 (Bonferroni adjustment alpha level of .0015).

Correlations were analyzed to provide more detailed insight into specific relationships among the variables. Particularly, two groups of variables were explored: (a) The general psychological distress level (SCL-90-R: GSI) and self-esteem (Rosenberg Scale) or self-efficacy (SWE scale), respectively. (b) The general psychological distress level (SCL-90-R: GSI) and the resources (14 subcategories of the RCL). Relationships between the variables were investigated using Pearson product–moment correlation coefficient and were calculated for each group separately.

There was a significant and negative correlation between the variables GSI and self-esteem for the ADHD (r = −.44, n = 43, p < .01) as well as for the CG (r = −.50, n = 43, p < .001). The strength of the relationship was moderate in both groups (see Table 4). As for the correlations between the variables GSI and self-efficacy, only the CG revealed a significant relationship at p < .01 suggesting a strong relationship. The ADHD group showed a negative relationship, which was barely not significant at a 5% level (r = −.19, n = 43, p = .072).

Results imply that high levels of general psychological distress are associated with lower levels of self-esteem and self-efficacy in the CG. In the ADHD group, only self-esteem was significantly negatively correlated with high levels of general psychological distress but not self-efficacy. The strength of the relationship for self-esteem was moderate in the ADHD group and strong in the CG.

Higher levels of self-esteem were significantly and positively associated with higher levels of self-efficacy in both groups at p < .01.

The correlations in Table 5 showed significant and negative relationships between the general psychological distress level and following resources: family, vocation, leisure time, health, self-esteem (only ADHD), confidence, courage (only CG), creativity (only CG), composure, and faith. These significant correlations imply that an elevated general psychological distress level is accompanied by a reduced disposability of the aforementioned resources in both groups. The strength of the relationship was large for health and confidence in ADHD, and for leisure time in the CG. All other significant correlations showed a moderate relationship. Conversely, an elevated GSI in the ADHD group did not significantly correlate with a reduced disposability of the resources partnership, housing, ability to love, courage, creativity, and sense of control. For the CG, an elevated GSI did not significantly correlate with a reduced disposability of the resources partnership, housing, self-esteem, ability to love, and sense of control.

Table 4.

Pearson’s Correlations Between the General Psychological Distress Level (SCL-90-R: GSI), Self-Efficacy, and Self-Esteem.

	GSI	Self-efficacy	Self-esteem
Variables	ADHD/CG	ADHD/CG	ADHD/CG
GSI	—	−.19/−.57**	−.44/−.50
Self-efficacy	—	—	.42/.53
Self-esteem	—	—	—

Note. SCL-90-R = Symptom Checklist-90–Revised; GSI = Global Severity Index.

p < .05 (two-tailed). **p < .01 (two-tailed).

Table 5.

Pearson’s Correlations Between the General Psychological Distress Level (SCL-90-R: GSI) and 14 Resources (Resources Checklist).

	GSI
Resources Checklist	ADHD (n = 43)	CG (n = 43)
1. Partnership	−.22	−.14
2. Family	−.33*	−.40**
3. Vocation	−.42**	−.40**
4. Leisure time	−.31*	−.61**
5. Housing	−.22	−.17
6. Health	−.56**	−.49**
7. Self-esteem	−.49**	−.25
8. Confidence	−.52**	−.41**
9. Ability to love	−.08	−.16
10. Courage	−.24	−.32*
11. Creativity	−.15	−.31*
12. Sense of control	−.26	−.17
13. Composure	−.35*	−.43**
14. Faith	−.37*	−.36*

Note. SCL-90-R = Symptom Checklist-90–Revised; GSI = Global Severity Index.

p < .05 (two-tailed).**p < .01 (two-tailed).

Finally, we measured the relationships between self-efficacy, self-esteem, and the 14 resources using the Pearson product–moment correlation coefficient. For each group, we calculated the relationships separately (see Table 6). The ADHD group revealed a highly significant correlation (p < .01) between self-efficacy and confidence. For self-efficacy and family, or self-efficacy and courage, correlations showed significance at p < .05.

Table 6.

Pearson’s Correlations Between Self-Efficacy (SWE Scale), Self-Esteem (Rosenberg Scale), and 14 Resources (Resources Checklist).

	Self-efficacy (SWE)/self-esteem (RSES)
	ADHD (n = 43)	CG (n = 43)
Resources Checklist	SWE/RSES	SWE/RSES
1. Partnership	.05/.24	.21/.−29
2. Family	.32/.34	.54**/.11
3. Vocation	.04/.26	.17/.00
4. Leisure time	.06/.32	.43**/.24
5. Housing	.05/−.023	.17/−.03
6. Health	.20/.37*	.56**/.26
7. Self-esteem	.26/.56**	.36*/.28
8. Confidence	.42/.65	.53*/.30
9. Ability to love	.19/.36*	.24/.14
10. Courage	.35/.52*	.40**/.18
11. Creativity	.14/.39**	.48**/.23
12. Sense of control	.15/.66**	.39**/.07
13. Composure	.20/.54**	.23/.29
14. Faith	.08/.41**	.27/.33*

Note. SWE = General Perceived Self-Efficacy Scale; RSES = Rosenberg Self-Esteem Scale.

p < .05 (two-tailed).**p < .01 (two-tailed).

Table 6 depicts highly significant relationships (p < .01) between self-esteem and self-esteem, confidence, courage, creativity, sense of control, composure, and faith, as well as significant relationships (p < .05) between self-esteem and family, health, and ability to love.

In the CG, we found highly significant correlations (p < .01) between self-efficacy and family, leisure time, health, confidence, courage, creativity, and sense of control, as well as a significant relationship (p < .05) between self-efficacy and self-esteem. The correlations between self-esteem and confidence, or faith showed a significant relationship at p < .05.

Discussion

The primary objective of this study was to explore differences in self-esteem, self-efficacy, and resources in untreated adults with ADHD in comparison with healthy adults in a CG. Relationships between self-esteem, self-efficacy, and resources were surveyed. In addition, the general psychological distress level in both groups was compared, and a possible relationship between the general psychological distress level and self-esteem, self-efficacy, or resources was analyzed. To our knowledge, this is the first study that surveyed resources in adults with ADHD.

Our findings show that adults with ADHD exhibit significantly lower levels of self-esteem and self-efficacy than comparable healthy adults in a CG. These results are consistent with the current literature (Philipsen et al., 2007; Ramsay & Rostain, 2008; Safren, 2006).

As for the resources, we found the ADHD group to have significantly lower values compared with the CG in some but not all of the resources. In particular, the resources partnership, vocation, and health exhibited lower levels. These findings are in line with present studies, which commonly found individuals with ADHD to have interpersonal (Barkley, Murphy, & Fischer, 2008) and vocational difficulties (Barkley, 2010; Biederman & Faraone, 2006) as well as increased health problems (Barkley et al., 2008). Self-esteem and confidence were lower in the ADHD group as measured with both the RCL and the Rosenberg Scale.

Although in our study the ADHD group exhibited a lower level of self-reported creativity compared with a healthy CG, further research is needed as studies on this subject are rare (Hallowell & Ratey, 1994). More knowledge about creativity in ADHD is potentially beneficial for their educational and vocational choices and development.

The ADHD group also seemed to possess an impaired feeling of control (sense of control = “sense of being able to influence one’s life in important areas”). This result is consistent with our findings that ADHD entails lower levels of self-efficacy.

The resource composure was lower in the ADHD group (“having a carefree mind,” “to look into the future in an optimistic way with respect to my dreams and wishes,” “to let go of things I cannot influence”). This could be explained by the multitude of impairments and their long-standing history of negative experiences starting from childhood.

However, the resources that did not significantly differ between the groups are just as telling: family, leisure time, housing, ability to love, courage, and faith. We discuss each point in turn.

The ADHD group was shown to hold the resource family (“feeling loved and accepted the way I am by the family members,” “experiencing an atmosphere of mutual trust”). Furthermore, we found a significant relationship between the resource family and self-efficacy as well as self-esteem. Barkley (2010) pointed out that external resources, such as family or friends, can assist adults with ADHD to manage and improve their work. For psychotherapy, particularly for doing homework and to train new behavior, it could therefore be especially helpful and promising to include family members or close friends as coaches. According to our findings, in using this resource, self-efficacy and self-esteem can be fostered.

Likewise, satisfaction with leisure time (“satisfaction with leisure time activities,” “balance between work and leisure time,” “working in a honorary capacity”) and housing (“satisfaction with domicile”) in adults with ADHD could be a source of energy, helping them to maintain the balance between work, everyday business, and recreation. There seems to be no relationship between leisure time and self-efficacy or self-esteem on one hand, or housing and self-efficacy or self-esteem on the other hand. This suggests that leisure time and housing are less relevant resources with respect to self-efficacy or self-esteem.

Despite the difficulties adults with ADHD have in relationships, their ability to love did not seem to be affected. There is, however, a significant relationship between ability to love and self-esteem. This resource includes aspects, such as “having the capacity to give and accept love,” “being sensitive toward other people’s emotions,” and “being tolerant and open.” Considering the frequent interpersonal difficulties (Barkley et al., 2008) and elevated marital divorce rates (Biederman & Faraone, 2006) in adults with ADHD, the resource “ability to love” could be made use of to foster interpersonal coping strategies and self-esteem, as well as to improve their relationship.

No differences were found between the groups with respect to courage. Courage is characterized by following descriptions: “courage to go into uncertain or dreaded situations,” “endurance when committed to something to hang in until the goal is reached,” and “courage to develop oneself, and to do things that seem right and important.” In a psychotherapeutic setting, courage can have a beneficial effect on patients when making new or uncertain experiences, and it can literally encourage them not to give up easily. Beyond that, courage showed a significant and positive relationship with self-efficacy and self-esteem in our study.

The resource faith was also comparable in both groups. Faith is characterized by statements, such as “believing in the meaningfulness of life,” “believing in a superior power which protects me,” and “believing in being loved and accepted as I am by this power.” To the authors’ knowledge, there are no studies that have analyzed faith in adult ADHD. Yet, in recent years an increasing literature suggests that faith/spirituality might be a protective factor for psychological health in general (Klein & Albani, 2007; Lee, Stacey, & Fraser, 2003; Seybold & Hill, 2001). This opens up yet another resource channel for psychotherapy by virtue of the positive significant relationship between faith and self-esteem.

In comparing the psychological distress level (SCL-90-R: GSI), we found individuals with ADHD to have a significantly higher distress level than individuals in the CG. This result is not surprising as several previous studies (e.g., UMASS study; Barkley, 2010) found individuals with ADHD to have higher elevations on all scales of the SCL-90-R than a clinical group or a CG. An elevated psychological distress level could be explained first and foremost by the ADHD itself, second by the psychiatric comorbidity that is predominant in the ADHD group.

It stands to reason that a greater amount of psychological distress could have impact on self-esteem and self-efficacy. Although the CG exhibited highly significant negative correlations between GSI and both self-efficacy and self-esteem, the ADHD group only showed this relation for self-esteem. This difference could be explained by the fact that the ADHD group exhibited already from the beginning of this study much lower values of self-esteem and self-efficacy. Their values might have hit a lower plateau. What speaks against this hypothesis is that self-esteem showed a negative correlation with psychological distress. If low self-esteem can be reduced further by psychological distress, then self-efficacy should be reduced as well, unless there are protective factors for self-efficacy in ADHD. These potentially protective factors will be discussed in the next intercept.

For the greater part, correlations between the general psychological distress level and the 14 resources showed significant and negative relationships. This relationship was prevalent in both groups. In the first instance, our results indicate that higher levels of psychological distress have a negative relationship with most of the resources. Second, our findings suggest that this relationship is by and large independent of the psychopathology of ADHD, as both groups rated the impact of general psychological distress on their resources in a similar way. There are two noteworthy exceptions: The resources courage and ability to love did not significantly differ between the groups and showed no significant relationship with elevated psychological distress in the ADHD group. Thus, we assume courage and ability to love may be protective resources in ADHD. Theoretically (Hannah, Sweeney, & Lester, 2007) as well as empirically (Kowalski et al., 2006; Pury & Kowalski, 2007), courage has been correlated with efficacy-related states. We found courage to have a positive significant relationship with self-esteem and self-efficacy in our study. This provides us with a potential explanation as to why self-efficacy was not affected by a high GSI.

However, the reason why ability to love impacts on self-efficacy in a protective way seems more cloudy. We could only find a positive significant relationship with self-esteem. The ability to love may be related to experiencing life satisfaction and psychological well-being (Dick, 2003; Seligman, 2002) and as such it may have a general protective effect.

Limitations

One potential weakness of this study is that our groups were not entirely comparable on behalf of years of education, highest achieved graduation, and vocational situation. Nevertheless, it seems to be an inherent problem of ADHD that people suffering from this neurobiological disorder tend to have educational and vocational difficulties. In a nonclinical sample such as ours, the educational and vocational situation is expected to be superior. On account of this, future studies should compare ADHD not only with a healthy control but also with another clinical sample. Nevertheless, our sample was equal with respect to sex and age. Although our groups were not equal with regard to education and profession, they were both highly heterogenic.

One might also argue that the applied resources questionnaire was not being validated. As yet, resources in adult ADHD have not been subject of empirical studies, and we wanted to obtain a first insight and tried to keep the survey as short as possible. In a next step, the resources questionnaire should be validated and applied in a bigger sample of adults with ADHD.

To close with, the relatively small samples size calls for replication with a larger sample to generalize our results.

Despite these potential limitations, our study provides a novel contribution to the current literature on adult ADHD, self-efficacy, self-esteem, and resources. To our knowledge, this is the first study that has surveyed resources in adults with ADHD.

Conclusion and Implications

The present study shows that adults with ADHD have lower levels of self-esteem and self-efficacy when compared with a healthy CG. On closer examination, however, some of the underlying resources do not seem to differ between the groups. In other words, people with ADHD seem to possess the resources family, leisure time, housing, ability to love, courage, and faith, which lend themselves for making use of and being fostered in psychotherapy. Our findings suggest that the resources, family, ability to love, courage, and faith, have a positive relationship with self-esteem. In addition, family and courage show a positive relationship with self-efficacy.

Our results bear important implications for the treatment of adult ADHD and suggest that corresponding therapy programs should include modules for enhancing self-esteem, self-efficacy, and activating/fostering patient’s resources.

A crucial element in psychotherapy for adult ADHD is to break the vicious cycle of negative appraisal and to adopt positive strategies (Bramham et al., 2009; Safren, 2006) when difficulties arise. To make new, positive experiences, adults with ADHD need to become aware of their resources and learn to apply them in everyday life. Once they are able to influence their lives in a favorable way, self-esteem and self-efficacy can grow.

In addition to an inalienable problem-oriented focus, a complementary resources-oriented approach provides the following benefits for adults with ADHD:

experiencing competence, self-esteem (Grawe & Grawe-Gerber, 1999), and hope (Hayes et al., 2007);

motivation for psychotherapy is likely to increase;

fostering coping strategies, through awareness of the own strengths;

protective function of resources assists in coping with recurrent difficulties or stress (Hobfoll, 1988; Rutter, 1990); and

improved problem actuation through the combination with resources activation (Flückiger, Caspar, Grosse Holtforth, & Willutzki, 2009; Gassmann & Grawe, 2006).

Living with a lifelong impairment makes it particularly relevant to shift one’s perspective from deficits to strengths. As little is known about the strengths of people with ADHD, further research is indicated to reveal more knowledge about their specific resources. For instance, empirical studies investigating creativity in adult ADHD are still owing.

From a psychotherapeutical point of view, there is a necessity and eligibility to elaborate resources-oriented modules for adult ADHD. Evaluating their clinical benefit will be the challenge of future research.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Swiss National Science Foundation, Grant 325100-120756/1.

Notes

Author Biographies

Patricia Elizabeth Newark, MA, is a doctoral student in clinical psychology and a psychotherapist at the Psychiatric University Clinic of Basel. Her research interests include the study of psychotherapeutic methods, resources, and self-esteem in adults with ADHD.

Marina Elsässer, MSc, is a doctoral student in clinical psychology and a psychotherapist at the Psychiatric University Clinic of Basel. Her research interests include the study of psychotherapeutic methods and self-regulatory processes in adults with ADHD.

Rolf-Dieter Stieglitz, PhD, is a professor of clinical psychology and psychiatry at the University of Basel. He is also chief psychologist at the Psychiatric University Clinic of Basel. His research interests include psychodiagnostics and psychotherapy in adult ADHD.

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