Systematic Evaluation of Self-Esteem, Internalizing Symptoms, and Theory of Mind in Youth with ASD, ADHD, and Typical Development

Background:  Although self-esteem is a robust indicator of a wide range of clinically significant mental health outcomes in youth with typical development (TYP) and with Attention Deficit Hyperactivity Disorder (ADHD), little is known about these relations in youth with autism spectrum disorder (ASD). Self-esteem reports from youth with ASD may provide a new barometer of mental health within the population. Although, impairments in social-cognitive skills thought to be requisite for self-assessment, such as theory of mind (ToM), may compromise the validity of these reports.

Objectives:  The objectives of the current study were to: (1) describe how individuals with ASD rate their self-esteem compared to age-matched individuals with ADHD, and TYP; (2) test how self-esteem relates to anxiety and depression in all three groups; and (3) examine if ToM performance moderated these associations.

Methods:  98 children and adolescents, aged 9 to 17 (See Table 1), were administered a battery of questionnaires and assessments as part of a longitudinal study of academic functioning. Participants completed two measures of self-esteem -- the Marsh SDQ (Marsh, 1992), and the Lifespan Self-esteem questionnaire (LSE; Harris, 2015) -- along with measures of depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D; Radloff 1977]), and anxiety symptoms (Multidimensional Anxiety Scale for Children, 2^ndedition [MASC-2; March 1997]). Furthermore, participants were administered two tasks of ToM capabilities, the Strange Stories (Happe, 1994), and the Silent Films (Devine & Hughes, 2013) tasks. ANOVAs, correlations, and multiple regressions were performed using SPSS 22.

Results:  There were no significant differences between the ASD, ADHD, and TYP group ratings of self-esteem assessed on both the Marsh SDQ, F(2, 94) = 2.25, p=.11, and the LSE, F(2, 94)=2.10, p=.13. As predicted, self-esteem ratings were negatively correlated with depressive symptoms across all three groups (Pearson’s r’s ranged from -.62 to -.47). Self-esteem was negatively associated with anxiety symptoms in the ADHD (r(23)=-.56)  and TYP groups (r(32)=-.60), but had a positive association in the ASD group (r(37)=.31) that was driven by the Obsessions and Compulsions and Harm Avoidance subscales of the MASC-2, suggesting that endorsing items on these scales, emphasizing following rules and insistence on sameness, may be closely related to self-worth for individuals with ASD. Furthermore, there was no evidence that ToM moderated the relations between self-esteem and both depressive symptoms and anxiety symptoms in the ASD and ADHD groups.

Conclusions:  All three groups demonstrated comparable self-esteem ratings that were negatively associated with depression. There were inconsistencies between the groups’ reports of the relations between self-esteem and anxiety symptoms. The ASD group reported that self-esteem was positively associated with anxiety symptoms involving following rules and compulsive behaviors, suggesting they may be interpreting some anxiety symptoms idiosyncratically. Finally, there was no evidence that ToM moderated the relations between self-esteem and internalizing symptoms in the ASD and ADHD groups, indicating that ToM abilities are not impacting the validity of these reports. Consequently, these results indicate that children and adolescents with ASD can report self-esteem relatively accurately and may provide insights to mental health functioning across groups.