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. Author manuscript; available in PMC: 2020 Sep 1.
Published in final edited form as: J Clin Child Adolesc Psychol. 2018 May 1;48(5):765–780. doi: 10.1080/15374416.2018.1443460

Trajectories of Global Self-Worth in Adolescents with ADHD: Associations with Academic, Emotional, and Social Outcomes

Melissa R Dvorsky 1, Joshua M Langberg 2, Stephen P Becker 3, Steven W Evans 4
PMCID: PMC6287970  NIHMSID: NIHMS1512489  PMID: 29714502

Abstract

Objective

Resilience models suggest that there are likely to be multiple trajectories of self-worth, and that despite experiencing impairment, some youth with attention-deficit/hyperactivity disorder (ADHD) may maintain a positive self-worth, which could buffer them against negative outcomes. The present study used a cohort-sequential longitudinal design to evaluate developmental trajectories of global self-worth in a sample of 324 middle school-aged adolescents (71% male) diagnosed with ADHD between ages 11 and 14 in predicting outcomes at age 15.

Method

Sex, medication status, and ADHD/oppositional defiant disorder symptom severity were included as covariates in the models.

Results

Using Growth Mixture Modeling (GMM), three distinct self-worth trajectory groups were identified: (1) high and increasing (44.4% of participants); (2) moderate and decreasing (48.8%); and (3) low and decreasing (6.8%). Participants with high and increasing global self-worth were less likely to exhibit co-occurring depressive symptoms and had better social functioning and higher grades at age 15 relative to those in either decreasing trajectory.

Conclusions

Implications of these findings for monitoring and supporting positive global self-worth for adolescents with ADHD are discussed.

Attention-deficit/hyperactivity disorder (ADHD) is a chronic and stigmatizing mental health condition that persists into adolescence for the majority of individuals (Copeland et al., 2013). Adolescents with ADHD frequently experience failure and impairment in multiple domains (Barkley, 2015), which in turn are often associated with the development of low or negative self-worth (Eddy et al., 2015; Houck et al., 2011; Knouse & Safren, 2010). Self-worth has been hypothesized to play an important role in the outcomes of individuals with ADHD, predicting the development of depression, emotional problems, and overall adjustment (e.g., Cook et al., 2014; Major et al., 2013; McQuade et al., 2011; Slomkowski, Klein, & Mannuzza, 1995). Such difficulties also render increased avoidance/procrastination and decreased motivation for individuals with ADHD to utilize adaptive compensatory strategies, which further reinforces low self-worth (Knouse & Safren, 2010; Newark & Stieglitz, 2010).

Given the presence of multi-domain impairment, it may be expected that most individuals with ADHD would experience low self-worth. However, there is some evidence that heterogeneity in patterns of self-worth exists, as well as in associated outcomes such as depression, anxiety, and social impairment (e.g., Cook et al., 2014; McQuade et al., 2011; Hoza et al., 2010). A developmental psychopathology approach that evaluates both risk and resilience is needed to understand the heterogeneity of self-worth and outcomes seen in adolescents with ADHD (Dvorsky & Langberg, 2016). However, ADHD research has largely focused on symptom severity and impairment over time, and our knowledge about positive trajectories and outcomes is limited. Accordingly, the present study longitudinally evaluates heterogeneity in trajectories of global self-worth and evaluates how these trajectories influence the development of internalizing symptoms, grades, and social functioning in young adolescents with ADHD.

Self-worth is defined as a person’s overall sense of their worth and how much one likes oneself as a person, which includes an affective component (i.e., the degree that one is generally happy with the way one is; Kuzucu et al., 2014; Sowislo & Orth, 2013). Self-esteem, self-image, self-perception, self-concept, and self-efficacy are closely related terms, referring to the way people view and evaluate themselves (Erol & Orth, 2011). Global self-worth represents a general perception of the self, in contrast to domain- or context-specific sense of ability or adequacy in specific areas of one’s life (Harter, 2012). Self-worth is regarded as both a risk factor and protective factor with meaningful implications across development for both adaptive and maladaptive functioning (e.g., Erol & Orth, 2011; Preckel et al., 2013; Sowislo & Orth, 2013). Indeed, over the last two decades, research on self-worth has accumulated to provide substantial support for the developmental dynamics of self-worth and the existence of individual differences in trajectories of stability and change (see Wagner & Gerstorf, 2017 for a review). In school- and community-based samples of youth, self-worth has been linked to positive outcomes such as life satisfaction, happiness, physical health, and academic achievement (Birkeland et al., 2012; Erol & Orth, 2011; Marsh, 2009). Evidence from typically developing samples of youth suggests that positive self-worth is associated with greater social abilities, including teacher-rated prosocial skills (Scharf & Mayseless, 2009) and positive peer relationships including peer-rated companionship (Preckel et al., 2013). Conversely, low self-worth predicts a number of maladaptive outcomes such as depression, anxiety, and interpersonal problems (Preckel et al., 2013; Sowislo & Orth, 2013). Further, longitudinal studies with typically developing samples have demonstrated a causal relation between self-worth and internalizing symptoms, indicating that low self-worth functions as a risk for internalizing symptoms, but not vice versa (Orth & Robins, 2013).

Theoretical Underpinnings for Examining Self-Worth in Youth with ADHD

Several theoretical models outline the potential causal pathways of global self-worth for youth with ADHD. Cognitive-behavioral (Safren, Sprich, Chulvick & Otto, 2004), competency-based (Cole, 1990), and interpersonal (Ybrandt, 2008) models each theorize that self-worth plays an important role in the development of socio-emotional and academic functioning. The cognitive-behavioral model of ADHD emphasizes the role of repeated failure experiences with specific tasks (e.g., homework completion) in youth developing negative thought patterns and self-schemas, such as viewing themselves as incompetent (Barber et al., 2005; Knouse & Safren, 2010; Wehmier et al., 2010). Competency-based and interpersonal theories add to this model by hypothesizing that the negative appraisals of others (particularly peers) combines with the impact of failure experiences to cascade into negative self-worth for youth with ADHD, which leads to peer rejection and social withdrawal (Mrug et al., 2012), as well to as to the development of anxiety and depression (Cook et al., 2014; Houck et al., 2011) and academic impairment (Marsh, 2009).

Self-Worth Change and Development in Adolescence

Early adolescence and the transition to middle school is a sensitive period for the development of self-worth (Birkeland et al., 2012; Harter, 2012; Kuzucu et al., 2014). When examined at the aggregate level, several longitudinal studies have found that on average youth become less positive in their self-worth between 5th and 9th grades (e.g., Birkeland et al., 2012; Orth et al., 2012; Robins & Trzesniewski, 2005). Using person-focused methods, other studies have demonstrated evidence of heterogeneity and individual differences in trajectories of self-concept during the middle school, early adolescent period (e.g., Steiger et al., 2014; Kuzucu et al., 2014; Zimmerman, Copeland, Shope, & Dielman, 1997). These studies have helped shift the study of developmental psychopathology and behavior away from what has been termed “variable-focused”, describing broad predictors of behavior variance, toward more “person-focused”, emphasizing discretely distinct individual differences in development. Specifically, although self-worth becomes more negative over the course of adolescence for some (Robins & Trzesniewski, 2005), others demonstrate positive or stable trajectories (e.g., Zimmerman et al., 1997). Multiple studies in typically developing youth have found support for distinct trajectories of self-worth characterized as “consistently high”, “moderate and rising”, “steadily decreasing” and “consistently low” (e.g., Hirsch & DuBois, 1991; Zimmerman et al., 1997). However, it is unknown whether this heterogeneity is also evident in young adolescents with ADHD who often experience significant increases in impairment following the transition to middle school (Langberg et al., 2008; Sibley, Evans & Serpell, 2010).

Heterogeneity of Self-Worth in Adolescents with ADHD and Associated Outcomes

The majority of studies evaluating self-worth in samples of youth with ADHD have used cross-sectional group approaches, comparing global self-worth scores between youth with and without ADHD (e.g., Barber et al., 2005; Hoza et al., 1993; Ostrander, Crystal, August, 2006). Overall, the evidence suggests that youth with ADHD have significantly lower global self-worth or self-concept compared to their peers (e.g., Barber et al., 2005; Mazzone et al., 2013; Treuting & Hinshaw, 2001), though some conflicting findings have also been reported that found no group differences (e.g., Hoza, Dobbs, Owens, Pelham, & Pillow, 2002). Nevertheless, self-worth tends to be lower than that their same-aged peers without ADHD despite their actual level of ability (Foley-Nicpon et al., 2012) and is associated with increased functional impairment (Bussing et al., 2000). Cross-sectional studies suggest that low self-worth is associated with increased anxiety and depressive symptoms (Hoza et al., 2002; Houck et al., 2011) and interpersonal problems (Becker, Mehari, Langberg, & Evans, 2016). These mixed findings demonstrate that there is likely heterogeneity in self-worth among adolescents with ADHD, though we are unaware of any study that has directly examined this possibility. Presently there is a dearth in longitudinal research examining the long-term negative consequences that may result from having low self-worth among youth with ADHD.

The few existing longitudinal studies of the developing self and ADHD (e.g., Hoza et al., 2010; McQuade et al., 2012) have been limited to examining discrepancies between youth’s self-perceptions of competence across multiple domains (e.g., social, academic, behavior) and parent or teacher ratings on parallel domains of competence using the Self-Perception Profile for Children (SPPC; Harter, 2012). Importantly, none of these studies examined global self-worth or general self-esteem. This is a crucial distinction to make, since Harter’s model of self, based on the early work of William James (1894) and others, views global self-worth as a “superordinate construct [whereby] competence judgements represent one type of lower-order evaluative dimension” (Harter, 1982, p. 88). Thus, on the SPPC “the global self-worth is not a measure of general competence” (Harter, 1985, p. 6, italics in original) or “the summation of responses to items tapping a wide array of specific abilities and attributes” (Harter, 1982, p. 88). Moreover, self-worth is an overarching self-evaluative and subjective process, for which there is no criterion for accuracy. As such, only the self-report version of the SPPC has items assessing global self-worth since these items “do not translate into attributes which an objective observer can rate” (Harter, 1985, p. 12). This distinction is highly relevant to the study of ADHD, because although self-perception of competence in specific domains (e.g., social) has garnered significant research attention, almost nothing is known about global self-worth and how it changes across the critical developmental period of adolescence. In particular, heterogeneity in global self-worth during this period may be important in helping to explain the high rates of internalizing comorbid conditions (>50%) that develop in late adolescence and emerging adulthood for individuals with ADHD (Anastopoulous et al., 2016).

Person-focused approaches are needed to capture inter and intra individual differences in the development of self-worth and we are aware of only one study that has used person-focused analyses to examine heterogeneity in self-worth in the context of ADHD. Edbom and colleagues (2008) formed profiles of self-esteem across several domains (e.g., physical, family relations, skills and talents, well-being) and evaluated whether these profiles were predicted by elevated ADHD symptoms in a population-based twin sample of Swedish adolescents (N=1,480, age 13). Although youth with elevated ADHD were more likely to be in cluster profiles characterized by lower scores in the “skills and talents” and “psychological well-being” domains of self-worth, some youth with ADHD were in the positive self-worth profiles. Further, this study was cross-sectional and developmental trajectories could not be evaluated.

Present Study

The present study sought to identify trajectories of global self-worth from early adolescence through mid-adolescence – across the duration of middle school – for adolescents with ADHD. This study builds upon prior work by using a large, well-characterized sample of adolescents with ADHD. We used well-established measures of global self-worth, depression, anxiety, academic and social functioning. Although academics are a particularly important domain of impairment for adolescents with ADHD (Langberg et al., 2008), studies have not examined whether trajectories of self-worth are associated with academics. Importantly, we applied a person-focused approach to analyze trajectories of self-worth while controlling for sex, ADHD and oppositional defiant disorder (ODD) symptom severity, and medication status. Prior research on self-worth in youth with ADHD has not controlled for potentially important covariates such as sex, symptom severity, and medication status. It is possible that the development of self-worth and its association with depression, anxiety, academics, and social functioning is different for male or female adolescents with ADHD (e.g., Meier et al., 2011; Orth et al., 2012). Further, others have noted the potential impact of ADHD and ODD symptom severity and medication use on trajectories of self-worth as well as internalizing symptoms, academic impairment and social problems in adolescence (e.g., Frankel, Cantwell, Myatt, & Feinberg, 1999; Treuting & Hinshaw, 2001). However, none of the studies reviewed above controlled for ADHD or ODD symptom severity or medication use in predicting self-worth.

Using a person-focused approach we expected to identify trajectory classes similar to those found in prior research with typically developing youth (i.e., consistently high, moderate and rising, steadily decreasing, and consistently low self-worth). However, given the impairment associated with ADHD, especially during the middle school period, we hypothesized some key differences. Specifically, we expected that the majority of youth would be in two decreasing classes, differentiated by where they start. Further, unlike typically developing youth, we did not expect to find a class that increases across middle school, but we expected a class that holds stable at moderate to high levels of self-worth. A secondary aim was to identify clinically relevant outcomes at age 15 as a function of trajectory membership. Outcomes selected for this study align with developmental theory and theoretical models of internalizing symptoms as well as academic and social functioning, including cognitive-behavioral, interpersonal, and competency-based models (Cole, 1990; Safren et al., 2004). We hypothesized that members of a stable moderate or high self-worth trajectory class would display significantly few internalizing symptoms and better academic and social functioning at age 15 as compared to members of the two decreasing self-worth trajectory classes. To test these hypotheses, we applied growth mixture modeling (GMM; Muthén & Muthén, 2001) to (a) identify subgroups corresponding to distinct patterns of growth in longitudinal self-worth and estimate the prevalence of the patterns as well as (b) examine the predictive validity of these patterns for adolescent outcomes.

Methods

Participants

Data for this study were collected as part of a three-wave longitudinal study spanning 18-months with a 12-month interval between the first and second waves and six-months between the second and third waves. Students and their families were recruited from two sites that together represented nine rural, urban, and suburban middle schools across in two states in the Midwest United States. Participants included 324 middle school adolescents (230 boys and 94 girls) diagnosed with ADHD who were between the ages of 11 and 14 at the first wave (Mage = 12.32, SD = .89). Using an accelerated or cohort-sequential longitudinal design, seven cohorts based on age at the first wave (i.e., rounded to the nearest six months by two decimal places) of youth were assessed across three waves. These age cohorts were staggered and partly overlap with adjacent cohorts in subsequent waves. Thus, due to the cohort sequential study design, data for this study span the ages 11 to 15.5 years. Approximately three quarters of the participants were non-Hispanic White (n = 243), with the remaining participants Black (n = 39), multiracial (n = 26), Asian (n = 2), Hispanic/Latino (n = 9), other (n = 3), or not reported (n = 11). Sixty-five percent of the sample was taking medication for ADHD at the start of the study. Mean family income was $52,800 (SD = $46,700). To further describe the sample, the counties in which the schools reside are classified by the 2013 Rural-Urban Continuum Codes, as ranging from metropolitan (Code 1: Counties in metro areas of 1 million population or more) to non-metropolitan (Code 6: Urban population of 2,500 to 19,999, adjacent to a metro area).

Procedures

This was a two-site study, which was reviewed and approved by the Institutional Review Board (IRB) at each site. Participants were recruited as part of a school-based randomized controlled intervention study. A two-step assessment strategy was used to determine eligibility. Participants were recruited by way of study announcement letters, flyers, and direct referrals from school staff. Interested parents who contacted study personnel were provided with a comprehensive description of the study. Parents were also asked to complete an eligibility screen regarding their children; those who endorsed the presence of at least four of nine DSM-IV-TR (American Psychiatric Association, 2000) symptoms of inattention and/or a prior diagnosis of ADHD were scheduled for an evaluation to assess eligibility. Children were eligible to participate in the study if they (a) attended a participating school; (b) met full DSM-IV-TR diagnostic criteria for ADHD- on the Children’s Interview for Psychiatric Syndromes—Parent Version (P-ChIPS; Weller, Weller, Rooney, & Schecter, 2000) or parent interview combined with teacher-reported symptoms on the Disruptive Behavior Disorder Rating Scale (DBD; Pelham, Gnagy, Greenslade, & Milich, 1992); (c) had clinically significant impairment due to ADHD symptoms on the parent or teacher versions of the Impairment Rating Scale (IRS; scores of ≥ 3 demonstrate impairment; Fabiano et al., 2006); and (d) had an estimated IQ of at least 80 as assessed using the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV; Wechsler, 2003). There had to be evidence of cross-setting symptoms and impairment on the P-ChIPS for symptoms to count and supplementation only occurred when parents endorsed 4 or 5 symptoms in a domain on the P-ChIPS and teachers endorsed at least 4 symptoms in the supplementation domain. Children were ineligible if they had a pervasive developmental disorder or met diagnostic criteria for bipolar disorder, psychosis, or obsessive–compulsive disorder on the P-ChIPS. Two doctoral-level psychologists reviewed assessment data to determine eligibility status and diagnoses. The P-ChIPS (Weller et al., 2000) is a structured parent interview assessing the presence of symptoms of 20 disorders in children and adolescents based on DSM-IV-TR criteria. The P-ChIPS demonstrates adequate psychometric properties (Weller et al., 2000). At baseline, 51% of the sample met DSM-IV criteria for ADHD-Inattentive Type and 49% for Combined Type. In addition, 53.4% of the participants met criteria for ODD, 12.2% for CD, 27% for an anxiety disorder, and 13% for a depressive disorder.

Eligible participants were randomly assigned to one of three treatment conditions and received the intervention over the course of one academic year. The first treatment condition (Challenging Horizons Program—After School) was a school-based intervention delivered afterschool and targeted organization, planning, study skills, and personal goals, through a mix of group and individual meetings. The second condition (Challenging Horizons Program—Mentoring) involved the delivery of a subset of interventions via weekly individual meetings with a teacher or school staff member (i.e., a mentor) supervised by study staff. The third condition (community control) received no intervention, but was provided with an evaluation report and a list of resources in the community. For additional information about the study design and treatment conditions, see Evans et al. (2016). Importantly, the interventions being evaluated primarily targeted academic functioning, such as materials organization and homework completion, and did not directly target self-worth or internalizing symptoms. Second, in the intent-to-treatment outcome analyses, no treatment effects were found for participants’ social functioning (Evans et al., 2016). Regardless, to examine whether being randomized to one of the three treatment conditions (i.e., community care and two treatment conditions) had an effect on variables examined in this study, analyses of variance (ANOVAs) were conducted to compare participants across the three groups on the primary measures of self-worth, depression, anxiety, grades and social functioning. ANOVA results indicated that the groups did not significantly differ on any of these variables at all waves in this study (all ps > .05), indicating that treatment did not significantly influence the variables examined in the current study. Nevertheless, to be conservative, condition was included as dummy-coded covariates in the models. In order to provide further validity for the design, we examined whether the trajectories identified in the results had similar rates of participants from each of the treatment conditions. Conditions were evenly represented ranging from 29.3 to 37.0% for each condition in each of the three trajectory classes.

Measures

Self-worth.

Youth completed the global self-worth subscale of the SPPC (Harter, 2012). As described in the Introduction, this global self-worth score is not the sum of the domain-specific scores of self-perceptions of competence of the SPPC and is instead an overarching self-evaluative construct (Harter, 2012). This scale comprises six items using a “Some Kids”/”Other Kids” format (e.g., “some kids are usually happy with themselves as a person, but other kids are often not happy with themselves”; “some kids are very happy being the way they are, but other kids wish they were different”). Youth select one of four boxes to indicate their response (the participant first decides whether the “some kids” or “other kids” statement fits them best, and then chooses whether that is “sort of true” or “really true”), which are then scored on a 4-point scale with higher scores indicating greater self-esteem. The SPPC has demonstrated acceptable reliability and validity (Harter, 2012; Muris, Meester, & Fijen, 2003). Specifically, convergent validity has been established other measures of self-worth such as the Self-Description Questionnaire (rs from .56-.69; Harter, 2012), construct validity has been supported with measures of global self-esteem and self-concept (Harter, 2012), and internal consistency indices have been in the acceptable range across multiple samples (αs from .78-.85 for the global self-worth scale; Harter, 2012). In the present study, mean scores on the global self-worth at all waves were used in the analyses (αs from .80 to .85). The mean global self-worth score at the first wave was 3.11 (SD = .65), which is comparable with normative samples of adolescents (e.g., Kuzucu et al., 2014).

ADHD and ODD symptoms.

Parents completed the DBD (Pelham et al., 1992) a well-validated measure of DSM-IV ADHD (18 items), ODD (8 items), and CD (15 items) symptoms, with items rated on a 4-point scale from 0 (not at all) to 3 (very much). The DBD has demonstrated good reliability and validity in studies of youth with ADHD (Pelham et al., 1992; Wright, Waschbusch, & Frankland, 2007). Sum scale scores on the parent-report DBD were used in the present study as continuous measures of total ADHD (α = .90) and ODD (α = .89) symptoms. ADHD and ODD severity were evaluated as possible covariates in the primary analyses.

Internalizing symptoms.

Parents completed the Anxious/Depressed subscale of the Child Behavior Checklist for Ages 6–18 (CBCL/6–18; Achenbach 2001). The CBCL/6–18 is a caregiver-report measure of emotional and behavioral problems for children ranging from 6 to 18 years of age. Respondents rate on a 3-point scale (0 = not true, 1= somewhat or sometimes true, 2= very true or often true) how true each item is for their child. This scale has demonstrated good internal consistency (e.g., αs>0.80) as well as convergent and discriminant validity with other parent- and self-report scales (Achenbach, 2001). The participant’s total T-score (based on age and sex norms from a norming sample of over 3,000 youth) assessed at age 15 to 15.5 (M = 56.83, SD = 8.34) was used as a distal outcome in analyses.

Youth completed the Reynolds Adolescent Depression Scale, Second Edition (RADS-2), a well-validated measure of depressive symptoms (Reynolds, 2002). The RADS-2 includes 30 items that measure youths’ depressive symptoms (including dysphoric mood, anhedonia/negative affect, negative self-evaluation, and somatic complaints). Each item is rated on a 4-point scale (1 = almost never, 4 = most of the time), with some items reverse-coded before summing the items to create subscale. Higher scores indicate greater levels of depressive symptoms. Internal consistency and test–retest reliability across both school-based and clinical samples demonstrated alphas ranging from .80 to .93 for the subscale and total scores (Reynolds, 2002). The participant’s total T-score (based on age and sex norms from a norming sample of over 9,000 adolescents) assessed at age 15 to 15.5 (M = 47.84, SD = 12.75) was used as a distal outcome.

Youth also completed the Multidimensional Anxiety Scale for Children (MASC; March, 1997; March, Parker, Sullivan, Stallings, & Conners, 1997) as a measure of their anxiety. The MASC is a 39-item self-report measure of anxiety symptoms in youth (including physical symptoms, harm avoidance, social anxiety, separation/panic). Item responses range from 0 (never true about me) to 3 (often true about me). Internal consistency for the subscales is adequate (>.70), and concurrent, convergent, and divergent validity has been established (Baldwin & Dadds, 2007; March et al., 1997). Total anxiety T-score (based on age and sex norms from a norming sample of over 2,500 youth) assessed at age 15 to 15.5 (M = 48.65, SD = 11.22) was used as a distal outcome.

School Grades

Report cards were collected for all participants at each wave. As reviewed in the informed consent/assent process, grades for each participant in the study were collected from the school offices at the end of each academic year. All grades were converted into grade point averages (GPA) for core subject areas (English, Social Studies, Math, Science) with a range from 0.0 to 4.0 (0 = F; 4.0 = A). Completion of parent and adolescent ratings at follow-up corresponded with fourth quarter grades. Fourth quarter grades assessed at age 15 and 15.5 (M = 2.15 SD = .98) was used as a distal outcome.

Social functioning

Adolescents and parents reported on youths’ general social skills using the Social Skills Improvement System (SSIS; Gresham & Elliott, 2008). On both versions, items are rated on a 4-point scale from 0 (never/not true) to 3 (almost always/very true), and standard scores are calculated with higher scores indicating better social skills. Social skills items on the SSIS include a wide range of child behaviors, including communication, cooperation, assertion, responsibility, empathy, engagement, and self-control. Most items on the SSIS focus on broad social skills that apply to social relationships generally (i.e., relationships with parents, teachers, siblings, and peers). Only four of the 46 items are specific to peer relationships, with three of these items focused on how the individual behaves in the peer group (i.e., ‘‘starts conversations with peers,’’ ‘‘interacts well with other children,’’ ‘‘tolerates peers when they are annoying’’) and only one item focused on how well the individual is regarded in the peer group (i.e., ‘‘makes friends easily’’). Internal and test–retest reliability of the SSIS are good and adequate criterion, convergent and discriminant validity have been established using samples of elementary and middle school-aged youth (Gresham & Elliot, 2008; Gresham et al., 2011). Standard scores (αs = .94 and .95 for the parent- and youth-report versions, respectively) assessed at age 15 to 15.5 (M = 85.00, SD = 16.67 and M = 92.44, SD = 19.65 for parent and youth-reports) were used as distal outcomes.

Analytic Approach

Preliminary Analysis.

The analytic approach was based on an accelerated longitudinal or cohort sequential design (Miyazaki & Raudenbush, 2000) which entailed restructuring the data to use age as the unit of time instead of data collection wave. Specifically, by linking seven staggered overlapping age cohorts (ages 11 to 14 based on age in six month increments at Wave 1), we were able to evaluate developmental patterns of self-worth from ages 11 to 14 years and examine distal outcomes at age 15–15.5. Because of the overlap between ages across cohorts, it was possible to test the assumption that a common developmental trajectory existed for self-worth from ages 11 to 14. Using procedures described by Miyazaki and Raudenbush (2000), we tested whether or not it was justified to converge the separate cohort groups in a common growth model by testing age by cohort interactions. First, we conducted multiple group multiple cohort growth modeling in Mplus to test the assumptions of invariance of growth parameters across cohorts by constraining growth parameters to be equal across groups (cohorts). In a second model, these constraints were relaxed and the growth parameters were estimated separately for each cohort. Chi-square difference tests revealed that an accelerated approach was justified, since the fit of a model with equality constraints did not significantly differ from the fit of a model where parameters were freely estimated, Δχ2(18) = 39.91, p = .15. As a result, we were able to collapse data across the cohorts and use age as the unit of time instead of data collection wave in all subsequent analyses. The intercept was set at the first measurement, age 11. The factor loadings for the linear slope factor were spaced such that a one-unit increase would represent six months in time. We examined the relative fit of this model using comparative and absolute fit indices including comparative fit indices (CFI), tucker-lewis indices (TLI), and root mean square error of approximation (RMSEA) using value threshold criteria recommended by Hu and Bentler (1999). Acceptable fit was determined in the CFI and TLI values approached or exceeded .95 and the RMSEA value approached or fell below .06. Second, we also tested for cohort effects on the trajectory of self-worth by estimating a conditional growth curve model in which the growth factors were regressed on birth cohort. Birth cohort did not significantly predict any of the growth factors (ps > .05). We concluded that there were no systematic birth cohort changes in the level and shape of the self-worth trajectory across the birth cohorts included in the present sample. This further supports that modeling a converged trajectory across the observed age range was appropriate. These findings are consistent with results of previous cohort-sequential longitudinal studies (Orth, Maes & Schmitt, 2015; Orth et al., 2012).

Missing Data.

Given the cohort-sequential longitudinal design, each cohort has a different pattern of intentional attrition, or “planned missing data.” Given this design, there were a different number of participants with a valid response on the self-worth measure in each age cohort: ages 11, n=43; 11.5, n=51; 12, n=49; 12.5, n=43; 13, n=42; 13.5, n=45; 14, n=51. Thus, missing data meet the assumption of missing-completely-at-random (Enders, 2010) and full-information maximum likelihood was used for handling missing data. We also examined missing data according to the number of missing responses at each wave on our primary variable, self-worth. The number of participants with at least 1, 2, or 3 valid responses was 324, 260, and 244, respectively. Two regression analyses were conducted: (a) a logistic regression with a valid response at wave 3 versus no response at wave 3 as a dichotomous outcome variable, and (b) a multiple regression with total number of missing responses across all waves as a continuous outcome variable. These analyses showed that missing data were not associated with wave 1 age and self-worth, as well as all other variables used in this study (χ2 (13)=10.14, p = .43; F(13) = .88, p =.55).

Primary Analyses.

Growth mixture modeling (GMM; Muthén, 2004) was used to identify classes of self-worth trajectories and to assess whether these classifications are associated with key covariates as well as later outcomes (i.e., depression, anxiety, social functioning, school grades) assessed at age 15 to 15.5. GMM attempts to capture sample heterogeneity by representing the population distribution by two or more distinct classes of developmental trajectories with random variability around the mean trajectories within each class (Muthén & Muthén, 2000). Muthén and colleagues (e.g., Muthén & Muthén, 2000; Lubke & Muthén, 2007) stress that to support interpretation, one should consider not only the growth trajectories, but also covariates and distal outcomes (i.e., predictive validity). In line with these recommendations and similar to other accelerated cohort-sequential longitudinal studies (e.g., Costello et al., 2008; Miers et al., 2013; Oshri et al., 2017), we performed the GMM analyses in three steps. First, we evaluated an unconditional GMM with classes K (in which K = 1, 2, 3, 4). Second, building on the model described in the first step, we evaluated a conditional GMM incorporating key covariates. Third, building on the model described in step 2, we examined a conditional GMM involving later distal outcomes of either internalizing symptoms, grades, or interpersonal functioning at ages 15–15.5.

GMMs were estimated using Mplus version 8 (Muthén & Muthén, 1998–2017). The models were estimated using the maximum likelihood estimator with robust standard errors (MLR), which is robust to non-normality in the data. This estimator, based on full information maximum likelihood (FIML), addresses missing data by using all available data to maximize the information available for data analysis. By using MLR, all adolescents with at least one wave of data were retained in the analytical sample. Different types of growth models were considered including no growth (i.e., intercept only), linear (i.e., intercept and slopes) and non-linear (i.e., quadratic). The validity and number of trajectory classes were determined by examining the available indicators of goodness of fit for one-, two-, three-, and four-class solutions (Muthén et al., 2002). As each class was added to the model we examined model indices including the Bayes Information Criterion (BIC), sample-size adjusted BIC (SSBIC), and the Akaike Information Criterion (AIC) with smaller values suggesting better fit. We also examined the Vuong-Lo-Mendell-Rubin test (VLMR-LRT) and the bootstrapped likelihood ratio test (BLRT), which compares a particular model to a model with one fewer classes. A significant p value indicates that the estimated model provides a better fit to the data than the more parsimonious model with fewer classes (Lubke & Muthén, 2007; Muthén & Muthén, 2000). Entropy and average classification probabilities indices provided a summary of classification accuracy with values above .70 indicating adequate accuracy and greater power to predict class membership (Jung & Wickrama, 2008; Lubke & Muthén, 2007). We also examined class sizes, considering classes with no less than 5% of the total count (Jung & Wickrama, 2008; Lutz, Hofmann, Rubel, Boswell et al., 2014). Finally, we examined plots of each class to identify areas of misfit and the most appropriate shape as well as the interpretability of classes.

Follow-up analyses examined conditional models. In these models, covariates (i.e., sex, medication status, ADHD and ODD symptom severity, condition, cohort) were allowed to influence latent growth parameters (e.g., intercept, slope) as well as class membership. In an effort to ensure that trajectories were based solely on the heterogeneity of self-worth and not also the heterogeneity of the covariates, we constrained the effects of the covariates on growth parameters (i.e., intercept, slope) to be the same across classes. Finally, the auxiliary function in Mplus was used to compare the probability-based latent classes on the distal outcomes of depression, anxiety, and social functioning at age 15 to 15.5. This approach is similar to other longitudinal growth studies (e.g., Oshri et al., 2017; Steiger et al., 2014; Yaroslavsky, Pettit, Lewinsohn, Seeley, & Roberts, 2013), where distal outcomes were entered directly into the conditional model (as auxiliary variables) that included covariates of trajectory class membership. This approach produces a Wald chi-square test based on random pseudo-class draws and tests the equality of outcome means across latent classes (see Muthén & Muthén, 2000).

Results

Visual inspection of raw individual plots and preliminary growth curve analyses suggested that the linear model was adequate to describe intra-individual change in self-worth across time (χ2(26) = 45.44, p =.001, CFI = .98, TLI = .96, RMSEA = .04). Next, unconditional GMMs that estimated 1–4 classes were examined (see Table 1). The fit criteria to determine the optimal number of latent classes in GMM suggested three latent classes as the most accurate solution (see Table 1). The AIC and SSBIC evidenced diminishing gains in estimating classes beyond a 3-class model. A non-significant Adjusted LRT statistic for the 4-class model and a significant Adjusted LRT and bootstrapped LRT for the 3-class model provide further support the 3-class model. Additionally, the smallest class size for the 3-class model represented 6.8% of the sample; however in the 4-class model there were two classes representing less than 5% of the sample. We retained the 3-class model solution as the preferred unconditional model. This model was estimated with a fully independent within-class solution (i.e., no constraints were placed on variance within classes). This solution yielded clearly distinct and interpretable trajectories that had high average probabilities for class membership (range = .90-.96) and consisted of sufficient percentages of the analysis sample. Specifically, the three trajectory classes, displayed in Figure 1, were labeled high-increasing (n = 144, 44.4%), moderate-decreasing (n = 158, 48.8%), and low-decreasing (n = 22, 6.8%). The final solution specified three latent trajectory classes and included the six covariates. To investigate the stability of this solution, we re-estimated the model with different starting values for the growth parameters. The solution proved robust to differences in starting values, suggesting that optimization was not achieved through identification of a local maximum (Hipp & Bauer, 2006).

Table 1.

Fit Indices, Entropy, and Model Comparisons for Growth-Mixture Models

Growth-Mixture
Models		 LL AIC BIC SSABIC Entropy Adjusted
LRT		 BLRT
One-class −667.89 1407.22 1456.73 1415.49 -- -- --
Two-class −640.69 1381.48 1419.56 1387.84 .56 43.84*** 45.10***
Three-class −623.85 1285.70 1358.06 1297.79 .80 145.24*** 150.24***
Four-classa −613.17 1285.35 1383.17 1297.53 .74 24.25 24.25**
Three-class with covariates −513.24 1076.47 1164.81 1085.55 .80 -- --
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Note. N = 324. LL = log likelihood; AIC = Akaike information criterion; BIC = Bayesian information criterion; SSABIC = sample-size adjusted Bayesian information criterion; Adjusted LRT = Lo-Mendell-Rubin Adjusted Likelihood Ratio Test. BLRT = Bootstrap likelihood ratio test.

*

p < .05

**

p <.01

***

p <.001.

a

Non-significant negative growth factor variances were observed in the second and third class of the 4-class model, and required constraints to zero values in order to reach a positive definite psi matrix.

Figure 1.

Figure 1.

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Observed and predicted growth trajectories of self-concept across middle school

Figure 1 and Table 2 demonstrate that two of the three classes exhibit linear decreases in self-worth over the period of adolescence. Those in the third class (high-increasing) began their trajectories at higher levels of self-worth and demonstrated a slight and steady increase from age 11 to 14. Significant differences in intercept parameters (starting points) were found across classes, with the exception of comparisons between the high-increasing and moderate-decreasing classes, Wald χ2 (1) = .30, p = .44; b = 3.00 and 3.44. Significant differences in slope parameters were found across all the classes, Wald χ2 (2) = 42.56, p < .0001. Members of the high-increasing class maintained moderately high levels of self-worth that continued to increase over time (b = .04, p <.0001). Slope parameters for the high-increasing trajectory significantly differed from the moderate-decreasing (Wald χ2 (1) = 20.24, p <.0001) and low-decreasing (Wald χ2 (1) = 33.94, p <.0001) trajectories. Slope parameters for the moderate-decreasing and the low-decreasing classes evidenced similarly declining trajectories that were more similar, although still significantly different from one another in magnitude of change, (b = −.05 to −.10, ps <.0001, Wald χ2 (1) = 5.67, p = .02. These findings demonstrate that for those with moderate to low self-worth in early adolescence, regardless of initial level, self-worth declines throughout adolescence. In contrast to the high-increasing class, self-worth continued to decrease during adolescence for the moderate-decreasing and the low-decreasing classes.

Table 2.

Growth Factor Parameter Estimates for the 3-Class Unconditional and Conditional Models

Intercept Slope
Unconditional Model Est. SE Est. SE
Low-Decreasing Self-Concept 1.92*** .10 −.10*** .02
Moderate-Decreasing Self-Concept 3.00*** .08 −.05** .01
High-Increasing Self-Concept 3.44*** .06 .04*** .01
Conditional Model Est. SE Est. SE
Low-Decreasing Self-Concept 2.00*** .13 −.15*** .04
Moderate-Decreasing Self-Concept 3.05*** .07 −.05** .02
High-Increasing Self-Concept 3.37*** .08 .08*** .02
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Note. Unconditional Model does not include covariates whereas the Conditional Model includes covariates estimated in the model. Est. = Estimate. SE = standard error.

Direct inclusion of the covariates in the GMM is recommended for a more precise estimation of their effects and more accurate classifications (Lubke & Muthén, 2007). Further, it is assumed that substantive interpretation of the latent classes should be qualitatively similar when predictors are omitted and that causal ordering is from the predictors to the latent classes (Marsh et al., 2009). In line with these recommendations, after class enumeration, we examined the associations between key covariates by estimating their effects in a conditional GMM. As shown in Tables 1 and 2, the conditional model resulted in improved model fit and importantly, no substantive changes in the model classes occurred after the covariates were included.

Table 3 shows the multinomial logistical regressions and odds ratios examining the association between identified covariates in predicting trajectory membership. In support of the validity of the distinction between the three classes, the covariates of sex, ADHD symptoms, and ADHD medication status did not significantly differ across any of the classes. However, compared to those in the low decreasing and moderate decreasing classes, those in the high increasing class were more likely to have lower levels of ODD symptoms. Interestingly, those in the low decreasing and moderate decreasing classes did not differ across any of the covariates. Given the design of this study, we also examined condition and cohort as covariates in the conditional model to determine if latent class membership differed across cohorts or condition status. Both condition and cohort did not significantly differ across the latent classes, further strengthening our use of the cohort-sequential design.

Table 3.

Baseline Demographics by Self Self-Worth Trajectory Class Membership

Class Specification Means Vs. High-Stable/Increasinga Vs. Low-Decreasingb
Low-Decreasing Moderate-Decreasing Moderate-Decreasing
Predictor High
M (SE)		 Moderate
M (SE)		 Low
M (SE)		 Coeff (SE) OR Coeff (SE) OR Coeff (SE) OR
Sex .76 (.05) .65 (.04) .51 (.13) 1.01 (.66) 2.76 .52 (.40) 1.69 −.49 (.61) .61
ADHD 30.43 (.95) 31.95 (.93) 33.92 (1.42) −.03 (.03) .97 −.02 (.02) .99 .01 (.03) 1.02
ODD 8.44 (.56) 10.70 (.49) 13.29 (1.53) .19 (.06)** 1.21 .10 (.05)* 1.10 −.09 (.05) .91
Medication .75 (.05) .72 (.04) .69 (.13) −.75 (.66) .47 −.19 (.42) .83 .56 (.63) 1.71
Cohort 12.07 (.08) 12.20 (.06) 12.29 (.07) .69 (.45) 1.03 −.30 (.96) .31 −.99 (.66) 1.09
Condition .34 (.05) .29 (.04) .35 (.13) .45 (.31) .68 .49 (.61) .82 .54 (.83) .65
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Note. Coefficients represent results from the multinomial logistic regressions predicting global self-worth trajectory class membership. OR = Odds Ratio. Coeff = Standardized Coefficient. SE = Standard Error. Condition, Sex and Medication Status were dummy coded and cohort was centered for the analyses. Sex = Percent Male. Condition = Participants in the control condition as the reference group.

*

p < .05

**

p <.01

***

p <.001.

a

High Increasing Class is the reference class.

b

Low Decreasing Class is the reference class.

Means and associations between the three trajectory classes and distal outcomes of internalizing symptoms, grades, and social skills at ages 15 to 15.5 are reported in Table 4. Members of the high increasing class significantly differed from members of the moderate decreasing and low decreasing class on every outcome. As compared to members of the high increasing class, those in the moderate decreasing and low decreasing classes displayed poorer adjustment, experiencing higher levels of self-reported depression, parent-reported depression and anxiety, as well as lower levels of self- and parent-reported positive social skills. Members of the low-decreasing class were also more likely to have increased anxiety and lower grades compared to those in the high-increasing and moderate-decreasing classes. Interestingly, those in the high-increasing and moderate-decreasing classes demonstrated similar levels of anxiety and grades. Members of the two decreasing classes did not differ across social functioning and parent-rated anxiety/depression.

Table 4.

Results from the Wald Chi-Square Tests of Mean Equality of the Auxiliary (DESTEP) Analyses of Developmental Outcomes

Class Specification Means Wald χ2 Tests of Mean Equality


Outcomes at age 15
High SW
M (SE)
Mod. SW
M (SE)
Low SW
M (SE)
High SW
vs Mod SW		 High SW
vs. Low
SW		 Mod SW
vs. Low
SW
SR Depression 37.54 (.74) 52.17 (2.26) 65.46 (3.12) 38.53*** 75.26*** 11.20***
SR Anxiety 45.56 (1.53) 48.40 (1.91) 60.10 (6.31) 1.22 4.99* 2.86+
PR Anxious/Depressed 54.03 (.84) 108.34 58.21 (.99) 64.91 (3.92) 7.40** 9.61** 2.15
SR Social Skills (2.84) 85.01 (3.29) 79.53 (8.24) 27.17*** 10.98*** .37
PR Social Skills 95.53 (2.77) 81.69 (2.03) 77.42 (3.29) 14.33*** 17.84*** 1.21
Grades 2.39 (.12) 2.09 (.10) 1.33 (.25) 2.77 17.98*** 10.61***
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Note. SW = global self-worth. SR = Self-rated. PR = Parent-rated. M. Wald = multivariate Wald χ2 (df = 1) and represents differences in the likelihood of having higher (or lower) levels of depression, anxiety and social functioning. Significance level of independent contrasts presented after Benjamin-Hochberg correction (α = .05).

+

p = .06

*

p < .05

**

p <.01

***

p <.001.

Discussion

This was the first study to evaluate heterogeneity in trajectories of self-worth for adolescents with ADHD during the middle school period and the importance of these trajectories for predicting outcomes. We found support for three distinct classes that differed on starting points (intercepts), as well as direction and degree of change (slopes). Similar to prior research with typically developing samples (e.g., Smokowski et al., 2010; Steiger et al., 2014; Zimmerman et al., 1997), the majority of adolescents with ADHD in the present study fell into one of two trajectories that demonstrated a pattern of declining global self-worth (i.e., low-decreasing and moderate-decreasing classes) during middle school. Importantly, we found no differences in self-worth trajectories across sex, medication status or ADHD symptom severity, which is consistent with studies of normative adolescents (Meier et al., 2011; Orth et al., 2012) as well as studies of adolescents with ADHD (Houck et al., 2011). In line with previous research conducted with younger children with ADHD (Treuting & Hinshaw, 2001), adolescents in the moderate-decreasing and low-decreasing classes did have higher rates of ODD symptoms relative to the high-increasing self-worth trajectory. Contrary to our hypotheses given the challenges and impairments faced by adolescents with ADHD, 44% of the sample demonstrated moderately high and gradually increasing self-worth. This unique finding highlights the importance of a focus on resilience and heterogeneity within ADHD, and supports movement away from a reliance on group (ADHD versus peers) comparisons.

This study also extends previous research by longitudinally evaluating how each of the self-worth trajectories was associated with later depression, anxiety, grades, and social functioning. Adolescents with high-increasing self-worth were more likely to have lower depressive symptoms and social problems and higher social skills at age 15 relative to those in the moderate-decreasing and low-decreasing trajectories. Specifically, those in the moderate-decreasing class showed normative levels of internalizing symptoms (T-scores ranging from 48.40 to 58.21), which may indicate that this group is a typical variant, whereas those in the high-increasing class showed lower than average internalizing symptoms (T-scores ranging from 37.54 to 54.03) and those in the low-decreasing class had internalizing symptoms approaching the clinical range (T-scores ranging from 60.10 to 65.46). These findings are consistent with the hypothesis that high and stable self-worth serves as a source of resiliency or positive adaptation in adolescents with ADHD, lowering the likelihood of the development of comorbid mental health, academic problems, and social impairment and increasing the likelihood of developmental gains such as social skills.

These findings are also consistent with cognitive-behavioral, competency-based, and interpersonal theories, which together suggest that self-worth plays an important role in the development of mental health and social outcomes (Safren et al., 2004; Cole, 1990; Ybrandt, 2008). One potential explanation for self-worth as a protective factor is that adolescents with a positive self-worth may manage stress in more constructive ways, instead of blaming themselves and developing a sense of inadequacy (e.g., Eddy et al., 2015). Further, adolescents who have positive self-perceptions may be enabled to approach future challenges in constructive and self-affirmative ways. An alternative explanation may be that some adolescents with ADHD develop strategies for coping and adjusting their life according to their symptoms (Synder & Lopez, 2010), which helps them adapt and to minimize future failure experiences. For example, Bjorklund (1997) posited that positive self-perceptions despite low competence helps children persist in difficult tasks, which provides a greater opportunity to try new behaviors and master skills. Of course, positive global self-worth and low perceptions of competence may not be a common combination given that in Harter’s model global self-worth is viewed as a superordinate construct with domain specific competence representing low-order self-evaluative perceptions. Nevertheless, the benefit of a positive global self-worth among those with ADHD or low competence may be achievable, if the youth has experienced the benefits of persistence and integrated those successes into their perceptions of self. Additional research is needed to evaluate the mechanisms through which positive global self-worth contributes to improved outcomes. On a broader level, these findings highlight the utility of taking a positive, resilience focus, to studying adolescents with ADHD, rather than solely focusing on negative outcomes and group comparisons with typically developing youth.

As noted above, there is a body of research suggesting that some youth with ADHD may exhibit an overly positive view of their functioning when compared to other raters, a phenomenon referred to as a “positive illusory bias” (PIB; e.g., Hoza et al., 2002). The PIB was not evaluated in this study, and it is possible that some adolescents in the increasing trajectory would fall into that category. This is relevant as some have argued that an awareness of poor competence may be necessary for individuals to alter future behavior and learn from mistakes (e.g., Colvin & Block, 1994). However, recently the validity of the PIB construct has been called into question in multiple studies (Bourchtein et al., 2016; Jiang & Johnston, 2017; Swanson et al., 2012). Further, an important distinction of this study is the examination of the concept of global self-worth as opposed to specific domains of self-perceptions of competence. Harter (2012) argues that by definition, global self-worth “is its own judgment, rated by its own set of items, and scored separately” and recommends against using other informants as a measure of validity (e.g., discrepancy analyses). Distinguishing between a maladaptive illusory bias (which is domain-specific) and a healthy positive self-worth (which is global) is an important topic for future research and may be especially important for those with ADHD.

Clinical Implications

Our findings are clinically relevant as they suggest the potential for focusing on self-worth as a promotive or protective factor by helping adolescents to develop realistic and adaptive thoughts when they experience failure. It is important to be clear that we believe the focus of interventions for adolescents with ADHD should continue to be on skills building and enhancement, with the hopes of reducing failure experiences (Evans, Langberg, Egan, & Molitor, 2014). However, it is also important to be realistic, and to recognize that ADHD is a chronic condition and that most adolescents will continue to experience impairment, especially as they transition to new settings (e.g., high school and college). The findings from this study suggest that in addition to skills enhancement, the field should also be helping adolescents with ADHD learn and practice adaptive coping thoughts and strategies, to increase the likelihood that failure is not internalized. Interventions focused on improving the functioning of adolescents with ADHD do not often target adolescents’ self-esteem or self-worth. Consistent with the present study, findings from interventions for emerging adults with ADHD show that self-worth and self-esteem are important predictors of student improvement (Anastopoulos & King, 2015; Eddy et al., 2015). As such, it may be that interventions for adolescents with ADHD should focus not only on teaching and reinforcing positive behavior and skills, but also on building a positive self-worth. Specifically, existing interventions could be adapted to include components that would more directly teach adolescents with ADHD strategies to incorporate successes into a positive self-schema. There is emerging evidence that cognitive-behavioral interventions may be effective in adolescents with ADHD (Sprich et al., 2016), and such interventions may be especially poised to target maladaptive thoughts and reinforce positive strategies related to self-worth. Further, intervention researchers may want to evaluate changes in self-worth as a potential mechanism through which adolescents maintain skills and strategy use across time. Finally, since ODD symptoms were the only significant antecedent variable that distinguished the high-increasing class from the two decreasing classes, comorbid ODD is clearly an important marker of risk that warrants unique attention in ADHD interventions.

Limitations and Future Directions

Although the current study has many strengths, there are a number of limitations that need to be acknowledged. Given that this is the only published study of self-worth trajectories in an ADHD sample, replication is needed as a number of factors may limit the generalizability of the findings. For example, although we controlled for condition and evaluated the association between group assignment and trajectories, it is important to acknowledge that this study used an intervention seeking sample. Future work is need with naturalistic longitudinal samples. Further, this study focused on the middle school years as an important developmental period and the findings may not generalize to later adolescence as self-worth and its associations with adjustment may appear different in other developmental stages (e.g., Bracey, Bamaca, & Umana-Taylor, 2004; Gaylord-Harden et al., 2007). Future studies could consider use of a multiple cohort design similar to this study as a practical method for understanding the patterns of self-worth stability and change across multiple windows of development. Although our study included students across nine rural, urban, and suburban middle schools, the sample was disproportionately White. In the broader developmental literature, there is growing evidence that heterogeneity in self-worth exists among different racial and ethnic groups and these differences tend to increase with age (e.g., Bracey et al., 2004; Harris et al., 2017). Future research should examine whether these trajectories hold in other cultural contexts, such as in other geographic areas, among different racial and ethnic groups, and other socioeconomic stratums.

Another important limitation to acknowledge is that this study did not include a comparison group of adolescents without ADHD. As such, we were unable to evaluate whether our trajectories of self-worth and/or associated outcomes were unique in middle school students with ADHD as compared to their peers. It will also be important for future research to use a multi-method and multi-informant approach to assess the associations between self-worth and adjustment among adolescents with ADHD. For example, the present study relied on school grades as measure of academic functioning and did not include parent or teacher ratings of academic outcomes or standardized assessments of academic achievement. Additionally, the ratings used for social functioning were skills based, which may not capture qualitatively important information about peer functioning in adolescents (e.g., quality friendships, acceptance). Using peer informants (e.g., sociometric ratings) or more objective ratings of social functioning such as time spent with peers would improve understanding of the impact of self-worth on social functioning for those with ADHD.

Conclusion

This study examined trajectories of self-worth in adolescents with ADHD and is the first study to longitudinally examine latent growth trajectories of self-worth and how these trajectories differentiate between adjustment outcomes of depression, anxiety, grades, and social skills. A key finding of this study is that a sizeable minority of youth with ADHD (44.4%) experience generally high self-worth that increases from early to mid-adolescence. This study contributes to a small but growing literature examining the potential positive mechanisms that may prevent the development of further impairment and maladjustment in youth with ADHD. Overall, findings suggest that differences in trajectories of self-worth exist across adolescence and that high and stable or increasing self-worth may be important for preventing the development of comorbid depression, anxiety, and social problems in adolescents with ADHD. Further, declining self-worth is an important factor in explaining the comorbid internalizing symptoms, academic problems and social impairment common in adolescents with ADHD. Our findings support the need for future work that focuses on the development of self-worth. Specifically, these findings support the need for interventions focused on addressing self-worth and strategies to help build healthy self-perceptions in order to persevere through challenges. Additional research is needed to evaluate the efficacy of bolstering existing cognitive-behavioral interventions with a self-worth component in an effort to prevent the development of depression, anxiety, academic problems, and social impairment in adolescents with ADHD.

Contributor Information

Melissa R. Dvorsky, Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, 3333 Burnet Ave MLC 10006, Cincinnati, OH 45229, (melissa.dvorsky@cchmc.org, dvorskymr@vcu.edu)

Joshua M. Langberg, Virginia Commonwealth University, Department of Psychology, 806 W Franklin St PO Box 842018, Richmond, VA 23284-2018, (jlangberg@vcu.edu)

Stephen P. Becker, Cincinnati Children’s Hospital Medical Center, Division of Behavioral Medicine and Clinical Psychology, 3333 Burnet Ave MLC 10006, Cincinnati, OH 45229, (stephen.becker@cchmc.org)

Steven W. Evans, Ohio University, Department of Psychology, Porter Hall, Athens, OH 45701, (evanss3@ohio.edu)

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