Picture a child with attention-deficit/hyperactivity disorder (ADHD) in school, doing what kids with ADHD do: fidgeting, blurting out answers, jumping out of the chair, or zoning out because of some distraction during the science lesson.
It's not too much of a stretch to assume that such a child might receive a negative or corrective comment from the teacher, say, three times an hour “Pay attention!” “Sit still!” “Get back on task!” Let's say the child is in class 6 hours a day for 180 days of school each year. That's more than 3,200 nonpositive comments directed at a child each year and does not include a single annoyed comment from a coach or an angry scolding from a parent.
In school alone, a child with ADHD could receive 20,000 corrective or negative comments by the time he or she is age 10.
Medication does help many of these children, but even if it reduces behaviors that elicit negative comments by 50% or 75%, the child still is left with a heavy burden of criticism and a message that a lot of what he's about is not OK.
Even medication carries its own challenge to self-esteem if family members question its benefits, or siblings taunt the child for taking a pill.
Learning disabilities are common comorbidities in children with ADHD, so they might feel “stupid” and receive lackluster grades even if they're working harder than their peers. They might have difficulty reading social cues so they might not be very popular on the playground or on the bus.
All of this leads, quite predictably, to low self-esteem in children with ADHD, although their other symptoms draw so much attention that this very corrosive but hidden damage is overlooked by adults in their lives.
Children with low self-esteem suffer from the pain of being themselves. They learn to expect to fail rather than to succeed. They recoil from the idea of trying new things–even things they might be terrific at, like sports, or music, or dance–because they figure the odds of being naturally talented at something, or being able to patiently develop the skills to be a winner, are pretty low.
When we look at statistics on how children with ADHD fare down the line, in terms of lower-than-average educational achievement, employment, and marriage stability, one wonders how much is the disorder itself holding people back, versus how the disorder made them feel about themselves and their capabilities from earliest childhood.
The way to approach this important issue with parents and teachers is to emphasize that in treating ADHD, we should do all we can to respect the child, 24 hours a day. Beyond medication and behavior modification, we need a new sensitivity to preserving and enhancing self-esteem.
My guidelines begin with these suggestions:
▸ Set reasonable expectations for all children, but especially children with ADHD. When we set goals too high, they will ensure a sense of failure. In some ways, I think it is better to err slightly on the side of setting low expectations with a high probability of success.
▸ Expect normal variations in a child's performance. Again, all kids (like adults!) have great days of peak performance, and not-so-great days, but for kids with ADHD, the variability might be more dramatic. If we get too excited about a child with ADHD having a wonderful day of achievement and control, we risk resetting the bar too high and setting the stage for a disappointing tomorrow.
▸ Consider other factors. When evaluating the performance of a child with ADHD, take other factors into account: comorbidities, problems in the family, and chronic illness. See whether improvements in those other areas might boost their accomplishments.
▸ Focus on building strengths rather than remediating weaknesses whenever possible. An extra 2-3 hours of math tutoring is not likely to make a child with ADHD a great success at math. The same 2-3 hours after school honing a skill, whether it's a computer game or karate or ice hockey, might give the child an avenue in which to excel and provide a genuine source of pride. Keep in mind that in the long term, most people choose a career based on a strength, not a weakness they've tried to overcome.
▸ Think about summer as a time to take the pressure off and cultivate successes. Ask families to consider an energetic camp, one with activities suited to the individual child, rather than endless hours of academic skills building or remediation.
▸ Encourage play! Remind families that kids with ADHD crave moments of senseless fun with their parents. Swimming lessons are important, but so is splashing in the pool. I like to brainstorm with families about ideas for rituals in which there is no lesson to be learned or skill to be practiced, like watching a favorite (noneducational!) television show each week. Even better is to ask the child to pick an activity he or she does well–like playing computer games–and using “fun” time to teach parents how to play.