The Role of Self-Esteem on the Relationship Between ADHD and Depression Symptoms in College Students

Introduction: Individuals with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of developing comorbid depression symptoms (Anastopoulos et al., 2018). One explanatory variable for this relationship may be self-esteem (i.e., one’s cognitive and emotional concept of self which involves feelings of competence, achievement, and self-worth; Mazzone et al., 2013). Research has linked ADHD symptoms with poor social skills (e.g., difficulty listening, missing social cues) and emotion dysregulation (e.g., anger problems, internal restlessness), both of which increase the frequency of unsuccessful interpersonal interactions and contribute to poor self-esteem (Shaw-Zirt et al., 2005). Additionally, low self-esteem has been shown to predict depressive symptoms across the lifespan and is linked to low mood, hopelessness, suicidal ideation, and suicide attempts (Orth et al., 2014). Although self-esteem’s relationship with each type of psychopathology independently is well-established, its role in the relationship between ADHD and depression symptoms, especially during the college years, is unclear and warrants further investigation. In addition to understanding whether self-esteem moderates the relationship between ADHD and depression, it is important to understand if the relationship between ADHD and self-esteem is augmented by demographic variables (i.e., gender, race), as well as protective variables such as social support. For instance, females with ADHD are more likely than males to be underdiagnosed and endorse internalizing symptoms, rendering them more vulnerable to poor self-esteem (Young et al., 2020). BIPOC youth are more likely than white youth to experience social and economic inequities that negatively impact self-esteem (Bradley & Corwyn, 2002). Finally, having ample social support is believed to protect against poor self-esteem in youth with ADHD (Wilmshurst et al., 2011). Given the harm related to comorbid ADHD and depression in college students, it is crucial that the field examine self-esteem for its impact on this relationship and its potential as an intervention target. Method: Secondary data was analyzed from a cross-sectional study of college students conducted across seven universities in the United States. These universities differed in geography (e.g., urban vs. rurally located campuses) and student demographics (e.g., majority-white vs. majority-minority student bodies). Participants (n = 2,146, 60% female, 40% non-white) were students 18 years or older, and were recruited through an online human subject recruitment platform during the Fall 2021 and Spring 2022 semesters. Participants completed the DSM-5 Symptom Checklist for ADHD (American Psychiatric Association, 2013) and Depression Anxiety Stress Scale (i.e., depression subscale; DASS; Henry & Crawford, 2005), which were used to derive continuous measures of ADHD and depression symptom severity, respectively. To assess for the first moderator (i.e., self-esteem) on the relationship between ADHD and depression symptom severity, participant responses on the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965) were used to derive a continuous measure of self-esteem. To assess for the second set of moderators (i.e., gender, race, social support) on the relationship between ADHD and self-esteem, participants completed the Interpersonal Support Evaluation List (ISEL-12; Cohen et al., 1985) and a demographic form. The ISEL-12 was used to derive a continuous measure for social support and the demographic form was used to derive dichotomous variables for gender (male/female) and race (white/non-white). Results. Results of the Pearson correlation aligned with current literature, indicating that ADHD and depression symptom severity were moderately positively correlated, r(2144) = .53, p < .001. To accommodate mean differences found between universities during preliminary analysis, Hierarchical Linear Modeling (HLM) was chosen for moderation analyses. Models were developed using the intentional and stepwise fashion described by Bates and his colleagues (2015). As predicted, results indicated that self-esteem moderated the relationship between ADHD symptom severity and depression symptom severity. As self-esteem decreased, the influence of ADHD symptom severity on depression severity increased, β = –0.01, p < .001. Contrary to expectations, results indicated that neither gender, race, nor social support moderated the relationship between ADHD symptom severity and self-esteem. Discussion. Results indicate that low self-esteem in college students exacerbates the relationship between ADHD symptomology and depression severity. This finding supports self-esteem as a meaningful target for interventions to reduce depression in the context of ADHD. Analyses also revealed that ADHD symptoms are associated with self-esteem regardless of demographic variables or levels of social support. This indicates that interventions for self-esteem should be made accessible to individuals at high risk of comorbid ADHD and depression regardless of these factors. Improving self-esteem among children and adolescents high in ADHD symptoms through empirically supported treatments (e.g., cognitive behavior therapy, compassion-focused therapy) could be protective against high levels of depressive symptoms during the college years.