1.       Abbreviations       

ADHD    :               Attention Deficit Hyperactivity Disorder

HNT       :               Helse-Nord Trondelag

QoL        :               Quality of Life

Rek         :               Research Ethics

STC        :               Strategy for Analysis

2.       Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequently diagnosed conditions in child and adolescent psychiatry. The prevalence rate for this diagnosis varies, studies indicate prevalence from 1% to 5% in children and adolescents [1-3]. The impact of ADHD often goes beyond the effects of the core symptoms and comorbidity with other conditions is often present in children and adolescents with the diagnosis of ADHD [4-8]. The symptoms change in the transition from childhood to adulthood, occasionally symptoms of ADHD may decrease during adolescence [8]. Anyway, there is evidence that ADHD is known to persist into adulthood in two-thirds of individuals [9-10]. Indeed, adolescents with ADHD often report lower health-related Quality of Life (QoL) [5] and ADHD symptoms affect school functioning, family functioning, psychosocial functioning, social life and self-esteem [11-14].

Impairments in self-esteem and sociability are often present in adolescents with ADHD and, compared to children, adolescents are more impaired at baseline according to satisfaction with self [8]. These feelings of low self-esteem may continue into adulthood [15]. Indeed, older children and adolescents report lower self-esteem scores - perhaps a product of the internalizing behaviors often associated with adolescents within ADHD populations [6]. Despite the apparent link between ADHD and levels of self-esteem, Houck points out that international research investigating the relationship between ADHD and self-esteem shows contradictory results, or no difference at all, [16] and that further research is needed to identify and resolve the gap in this knowledge [6]. Comorbidity (among other reasons) may explain these differences [16]. To this point of view some studies indicating low self-esteem [6,12,17] and others high self-esteem [16,18] in individuals with ADHD. Cleary then, further research is needed to crystalize the relationship between ADHD and self- esteem levels.

The role of gender may also be important when living with a diagnosis of ADHD, especially in the development and maintenance of self-esteem. Females with ADHD display fewer externalizing problems than males, but more internalizing problems [6]. Schei notes: “better self- esteem in adolescence, younger age, and male gender were associated with better psychosocial functioning in early adulthood” [19]. This raises the question of whether females are more likely to suffer low self-esteem than males [6]. Houck writes that adolescent girls were found to have lower self-efficacy and poorer coping strategies than adolescent boys with ADHD, and that efficacy and coping strategies are thought to be linked to self-concept [6,20]. These gender differences may be considered in future research.

Young adults and adolescents want to be like everybody else, and feelings of wanting to fit in are a natural part of growing up. For young people with ADHD, this transition into adulthood may be particularly challenging: there is significant stigma attached to an ADHD diagnosis and such stigma may restrict their feelings of fitting in [21].

The majority of research tends towards the problems associated with ADHD symptomatology and ADHD treatment methods e.g. medication [22,23]. What is largely unknown then is how the individual experiences a diagnosis of ADHD, and how the diagnosis relates to feelings of self-esteem. Also relatively unexplored is young individuals qualitative experience of ADHD treatment methods e.g. medication.

In their 2008 qualitative study of adults receiving a diagnosis and treatment for ADHD, Young found that internalized blame from childhood influenced and increased the participants’ future expectations of failure, and found that those expectations of failure related to increased risk of depression and low self-esteem [24]. The present study used the same interview structure as Young and colleagues but, rather than to examine the impact of diagnosis and treatment in adulthood, we examined the impact of diagnosis and treatment in children with an ADHD diagnosis.

To the best of our knowledge, the qualitative experience of adolescents and young people with ADHD has rarely been investigated, particularly regarding their feelings of self-esteem. The present study is thus necessary to develop our understanding of such an experience, and to fill the gap in the literature concerning the relationship between living with a diagnosis of ADHD and self-esteem.

3.       Aim

The primary aim of this study was to investigate how adolescents and young adults experience life with an ADHD diagnosis (and treatment with medication) over an eight-year period. We wanted to examine the complexity of growing up with a diagnosis of ADHD and how this affected their self-esteem.

4.       Method

4.1.  Participants

The participants were selected from Helse-Nord Trøndelag (HNT), Child and Adolescent Psychiatric services, Hospital of Nord Trøndelag. Diagnoses were established by a clinical psychologist or a child psychiatrist. The clinic follows standardized procedures for the assessment and diagnosis based on the Norwegian national guideline for assessment and treatment of ADHD (Norwegian Directorate of Health, 2007).

Informant selection was based on a strategic sampling strategy. Ten patients were invited to this study, then eight patients volunteered to participate, three females and five males, age range: 14 - 20. All participants were subject to treatment between the years 2007 and 2014.

Participants Characteristics, is being presented in Table 1.

4.2.  Ethical Considerations

Written informed consent was obtained from these patients and all participants were followed up with a telephone call. Approval was granted by the Norwegian Regional Committee for Medical and Health Research Ethics (REK) in February 2015 (ref. no: 2015/178). Research ethics principles are upheld with regards to policy, security, and internal quality checks, and conducted in accordance with the Declaration of Helsinki. Data materials are stored in according to guidelines by REK. Further use of data materials must be approved by REK. All work has been conducted in accordance with the Declaration of Helsinki.

4.3.  Data Collection

Semi-structured interviews were adapted from the interview developed for use with adults with ADHD by Young and colleagues (2008), with consent from Young [24]. The interview contained 5 main areas, 15 different themes and 39 specific questions. The 5 main areas were as follows: (a) how the adolescents felt about themselves before the diagnosis, (b) how they coped with difficulties before the diagnosis, (c) the diagnosis itself and their experience of attending the clinic for medication, (d) how the adolescents felt about themselves after receiving the diagnosis and whether this had changed, and (e) their perception of their self-esteem during this 8-year period.

The first six interviews were carried out late in 2015, and the last two were completed in 2016. All interviews were audio-recorded and transcribed. The interviews lasted up to 1 hour and 50 minutes. The interviews were conducted in clinics nearest to the participants. The lead author completed all the interviews for the current study.

4.4.  Data Analysis

This study is a qualitative retrospective study. In qualitative research, knowledge is developed from experiences by interpreting and summarizing organized empirical data [25]. This approach aims to illuminate the lived experiences of the adolescent’s post-diagnosis. The criteria for reporting qualitative research (COREQ) were applied in the writing process [26]. Systematic Text Condensation (STC) was applied, a technique inspired by the principles of Giorgi’s phenomenological approach [27,25]. This method represents a pragmatic approach inspired by phenomenological ideas [25].

STC is a Strategy for Analysis developed from traditions shared by most of the methods of qualitative data analysis. STC is considered to be intersubjective, reflexive, and feasibile - while maintaining a responsible level of methodological rigor. This method is a descriptive approach in which the conscious experience of the participant is explored at face-value, rather than its underlying meaning. STS implies analytic reduction and contextualization of data, like Giorgi`s method, and theoretical perspectives are applied in editing analysis style [25]. Using STC we have followed four steps of analysis.

Step 1. From raw data to themes: In the first step the researcher brackets the preconceptions, taking the meta position, which means taking the bird's eye view, finds an overall impression of the material, and selects preliminary themes [25]. The preliminary analysis at step one was conducted by the researcher, and transcribed. Transcribed text was read and commented by the supervisors. Several themes were identified during the early stages of this process.

Step 2. From themes to code groups: At this stage a systematic review of the transcript commenced (Malterud, 2012) [25]. The meaning units; a text fragment with information about the research question, representing different aspects of the themes, were identified and marked with different colours in the text. They became elements for coding. Having identified meaning units on level two, four codes were identified. Names and features of the code groups were developed from the themes from the first step. One of the co-authors read the interviews during this process. These codes represented the empirical findings, and were not identified in advance. It is important to state that the researcher had an eye on the theoretical framework and preconception during the process (Malterud, 2001) [27]. Examples of code groups included: 1) Importance of self-esteem. 2) Wanted to be treated as normal. 3) Learning to cope with the diagnosis. 4) Knowledge about ADHD in the society and environment.

Step 3. From code to meaning: Condensation through systematic abstraction, meaning: the topics that have emerged from steps 1 and 2 have been reduced to four codes. The researcher took every separate code and conducted sub coding, condensation and synthesizing [25]. Each code was an analytic unit for further abstraction by condensation of content. During this process four codes were reduced to three codes. Each of the three code groups was then the analytic unit in the further abstraction, by condensation of content.

Subgroups were developed under each of the codes, with focus on the main aim of the study and the interpretative perspectives. The codes were sorted into several subgroups. These subgroups became subject to the further analysis towards condensate. Then, the content was reduced into a condensate (an artificial quotation), trying to maintain the original terminology of the participants, alongside a final production of a coherent story supported by "gold quotes".

Step 4. From condensation to descriptions and concepts: At this final step, synthesis was used to develop descriptions and concepts [25]. We had to choose what to present for the readers; each subgroup got its own section. Subgroups were put forward as analytic text. Each subgroup was given a description and “gold titles” was added to each by the researcher. After reading the raw data all over again, all the categories got final names.

To ensure validity, the informants were asked to give feedback on a summary from the findings after the analysis.

5.       Results

Three themes emerged from the analysis: (1) The importance of being themselves. The participants shared the importance of being a unique person regardless of the diagnosis, and their self-esteem was stronger than suggested by previous literature. (2) To be treated equally. Normalization and being treated like others was important for the participants. They were concerned about the stigma and labelling associated with the diagnosis but, at the same time, did not want to receive special treatment. (3) Learning to live with the diagnosis. Maturation and psychological development made it easier to understand themselves despite diagnosis and medical treatment. The results are presented under these themes with verbatim quotes to illustrate the findings.

5.1.  The Importance of Being Themselves

The desire ‘to be myself’ was a strong signal communicated by the participants.

During the interviews, they emphasized that they were individual persons: they wanted to be accepted as themselves, not as a person with ADHD. Some of the informants had thoughts like “what will the others think about me having an ADHD diagnosis", whilst also thinking “I do not care, it is just a couple of letters”. One of the young men claimed that he felt no different after receiving a diagnosis.

No, I thought....it was not like; the world goes under. I did not actually think like that. Yes, I have got ADHD but, actually it does not change me as a person, it is just a couple of letters.

(ip_2)

One of the boys who was diagnosed in his first school year, explained his feelings of excitement when he was told he had ADHD; “at first…. I was quite proud, Yeey! I have been diagnosed, I have to use medicine, I was cool”. He also explained that when other children were told about his diagnosis they responded with surprise; he said they did not believe that he had ADHD because they thought he was completely ‘normal’.

The participants said that, with the passage of time, they all accepted the diagnosis - but for some of the participants it took longer to process the experience than it did for others. During childhood, they had negative thoughts about themselves and their ADHD symptoms. They thought that the diagnosis led to difficulties, and reported experiencing difficulty concentrating and sitting quietly. Several respondents also remarked that their ADHD may have been related to difficulty making friends when they were growing up; some also said that they were reluctant to talk openly about their ADHD diagnosis and only told the people they were close to. Others believed it was ok to disclose their diagnosis and talk about it.

In the gymnastics class it was a conflict between me and another pupil, and then he shouted out to me, that I should keep my mouth shout because I got ADHD, this made me very sad

(ip_1)

It was essential to participants to be a unique person regardless of the diagnosis. One female participant explained that "people with ADHD are not their ADHD", but are themselves. She said that she does not immediately tell her peers that she has ADHD because she prefers to wait for them to get to know her first. She explained that she wanted them to get to know her as a person rather than be defined as ‘the person with ADHD’. She feared that the stigma associated with the diagnosis would lead them to make negative assumptions about her or judge her in some way.

It is not the first thing I tell another person when we meet; hello I got ADHD!....it is important to me that my friends get to know me before they got to know about my ADHD, I feel that it is me they are going to get familiar with and not my ADHD

(ip_8)

One of the girls expressed relief when she was diagnosed in elementary school and felt as though her diagnosis explained her past troubles. The diagnosis explained the problems; it was the ADHD symptoms and not the person who was the problem. And that being diagnosed maybe was a good thing, because it rather explained her problems instead of the problems becoming a part of herself as a person.

I was a bit relieved because I knew that there actually was something, that it was not just me being the problem somehow….

(ip_4)

During his childhood, one of the young men recalled overhearing people from his village talking about him and saying they did not think that he would be successful and get a job in adulthood. He later proved them wrong and expressed pride in his achievements, emphasizing how self-esteem and self-efficacy had been important motivating factors in his success.

I do not walk around thinking I am better than everybody else, but I think that I have managed to come this far, and that I have managed to reach a goal, unlike many others

(ip_2)

It was probably when I first learned that I must have faith in myself that I can achieve something, and then it began to circulate in to my head, it actually happened, I started to understand that I must have believe in myself. It is not important how many people who have faith in me; if I do not have faith in myself.... I must have faith in myself

(ip_1)

Despite experiencing difficulties and challenges, participants expressed a positive attitude to their ADHD diagnosis. They talked about having humour, energy, being fearless, and daring to try new things, as positive traits that they possess. This positivity was shared by their peers also; several of the boys said they had been told by friends that they are fun to be with, creative, and imaginative. One of the boys said that ADHD gives him an extra "boost" that he would not be without, and described how he harnesses his creativity to turn challenges into successful outcomes.

Well, not having the ADHD diagnosis…. I would not actually think about it at all, I really want that boost it gives me…. I am creative in different way. There have been different things that has been difficult for me, but I know exactly how I can turn it in to the right direction

(ip_3)

5.2.  To Be Treated Equally

To be treated in the same way as their peers was an important issue for all participants. They did not like special treatment, and said this made them feel excluded and different from others. The Norwegian education system aims to provide special education measures for individuals with learning disabilities, behavior problems, language problems, or other diagnosis/difficulties. As such, some of our sample took part in lessons outside of mainstream education and received additional teaching support and/or individual learning plans. The participants in this study explained that, if they were taken out of the class or given books aimed at an alternative educational level, they believed that their non-ADHD peers would perceive them in a qualitatively different way. They did not want ‘special education’ at all - they wished to be treated in the same manner as other pupils in the class. Several participants said that they would never use their ADHD as an excuse of way to avoid schoolwork.

I have seen that friends of mine who have been in an argument or dispute....and both had to go to the principal in elementary school….and then the guy with the ADHD diagnosis did not have to take responsibility for his actions….then when the other guy asked why, the principal said ‘he has ADHD, he can be hurt’.…So, the reason why I stopped going out of the classroom to receive special education, is that I discovered that friends….they treated me....more different. They looked at me as a special person who needs special treatment

 (ip_6)

Some of the participants had significant reading and language difficulties and felt as though the school system highlighted those difficulties in a maladaptive way. For example, two members of the sample reported having a teaching assistant to support them in primary school, and did not feel comfortable receiving that type of support. The girl recalled that it was an awful experience to be isolated with the assistant while the other pupils went on in their usual way in another part of the classroom.

So, I did not feel smart, and I was often angry with the assistant. I would not receive help even if I needed it…. because I was the only one. I would not be the only one with a handicap somehow.… I would not be the one who needed help and who failed everything. I knew this was not the truth, but I felt that the others looked at me that way.…I felt it would have been better if the teacher had come to me when I needed help, it was awful to sit alone behind a corner with an assistant and working with math, while the others sat on the other side and worked together.…It would have been better if the teacher could have taught me to take some responsibility to ask for help instead of getting it served.

(ip_8)

One of the girls said that getting special treatment caused her to feel that others looked differently at her, and she did not like that. One of the boys said that he refused to accept special education in High School: he asked for his name to be removed from the system because he wanted to prove that he could succeed without being treated differently to other pupils.

When I started High School, I got a letter since I had special help in Secondary School. So, I got this letter that I had to sign, and confirm that I had this and this diagnosis and that I needed special education in High School. Then I said to my teacher; I do not want to sign it….I would not be stuck in this, me being something else, me being something different. Well I would take part in things equally, to get the same difficulty as the others in school, get the same challenges.…it was not like.…I would not be who I am….but I would not have special treatment

(ip_3)

As they grew older, it became more important to our sample to not disclose their diagnosis to their peers. It seems that several participants invested time and energy into keeping the diagnosis hidden; they felt as though receiving special treatment would mark them out, and thus put in a concerted effort to avoid it. One of the boys said that, when he received the ADHD diagnosis in Primary School, he was proud and thought it was exiting (and openly told other children that he had ADHD) but as he got older he became more cautious.

I really did not like to disclose it, because I discovered that people were so negative about it I discovered….when I told them, they said, ‘is that why you click’ because sometimes I became very angry.…and they said,’ oh my God, you’ve got ADHD’, and then started to tease me about it”

(ip _6)

When participants talked about being treated differently, they expressed sadness, and a feeling of incompetence. Some of them said that this affected their self-esteem, and made it harder to maintain a positive self-perception. Looking back, one of the boys talked with sorrow about when he attended first grade of Elementary School: he said that he was not able to grasp school subjects like the others and instead he played with toys (lego bricks). He did not learn to read when the others learned to read.

I cannot remember one day I sat on my desk and did schoolwork. I remember sitting at the back of the classroom and playing with lego-brics and other toys….so in second class the other pupils had learned mathematics and learned to read, I could not do any of it I remember

(ip_6)

5.3.  Learning to Live with the Diagnosis

Learning to live with ADHD was another important outcome from the findings. As participants matured they learned about themselves, about how to behave, and how to overcome difficulties. The participants had a common feeling that maturation brought with it an increased ability to reflect on past behavior and to control their feelings and emotions, and so helped them to live with their diagnosis.

Children with ADHD often struggle to express and reflect on their thoughts and feelings about their diagnosis. This can, as referenced previously, go on to impact upon their self-esteem and self-image. As they mature however, they become better able to reflect and, as one of the participants said, learning about rules and norms can support their insight into their own behavior. This requires resilience and confidence though: the individual has to have the strength to persevere and motivation to challenge their negative feelings about their diagnosis. Indeed, interview participants said that it requires strength and self-confidence to be a young person with ADHD.

Several participants gave reference to this process of maturation, increased insight, and resilience. Overall, the participants perceived themselves to have changed socioemotionally since childhood, and seemed able to reflect on their past behavior. One participant commented that when he was younger, he was so hyperactive that he had no time to reflect.

It was much harder to get friends, I had few friends…. I was not popular....just before I started in Middle School, I started to think about the things that I had done, and that I had made some bad choices.…the behavior I had, had ruined it for myself…all the stupid things I did. I could not take it back… did not think about it while it was happening. But now, I have started to do that thinking while it happens.

(ip_7)

Some commented that it was difficult to make friends when they were younger, as they lacked control over their behavior and emotions. One of the participants said that he developed insight following his diagnosis and realized that he must “sharpen up”.

I have taught myself how to deal with it, and then realized that there is nothing to whine over, so this is the way it is; Okay I got ADHD, that is okay. There is nothing I can do about it rather than to live the life….

(ip_1)

Adapting to the challenge of having ADHD (both once diagnosed and during treatment), learning to live with these circumstances and accepting them, was a theme shared by all participants. As highlighted previously, resilience seems to be an important factor that is facilitated by early diagnosis and treatment. One of the boys, who was diagnosed at the beginning of elementary school, described a lot of difficulties with negative thinking during childhood. Pleasingly however, by the time he started High School, he had started to manage those feelings and looked forward to future successes.

Well…it is just something you have to learn to live with….yes it is the way things work, and there are not much I can do about it.…many people use the diagnosis as an excuse, I would never use it as an excuse.…I think it's okay to live with it, I do not have to struggle in the dark anymore.…it was a period when I was very sad about having ADHD, and I thought this happens to me only because I got the diagnosis

(ip_6)

Another girl reported experiencing difficulties from a young age; difficulties she attributed to feeling different from others because of receiving special education. However, she said that things began to improve when she entered High School. Whilst this might reflect a good response to treatment and/or remitting symptoms, it is also an illustration of how individuals with ADHD begin to live with their diagnosis and become resilient in doing so. 

….well I think it is a bit easier now.…I can concentrate a bit better

(ip_ 5)

Some participants had experienced bullying at school but felt that, as they got older, they were better able to reflect on the bullies’ behavior. For example, one girl recalled that older pupils used to look at and judge her, and knew that they talked about her negatively behind her back.

Most of the things do not affect me in the way they did before, if someone sends me “the eye” then I don’t care about it the way I use to do…. it’s much easier now, because now I can understand, I’ve got more experience with it, so now I actually know how to do stuff

(ip_8)

Several said that they would not have reached where they are today without their diagnosis of ADHD and reflected that, in spite of the difficulties and challenges they had experienced, they were pleased that their condition had been properly identified and treated at a younger age. They felt that receiving a diagnosis was a crucial step in their recovery and felt that they may have been hampered in reaching their achievements had they not received a diagnosis and subsequent treatment e.g. medication.

Participants discussed the different ways in which ADHD medication had helped them e.g. increase concentration in school. All participants reported using ADHD medication frequently but, at the time of interview, two had stopped using their medication. One of those that had stopped using their medication commented that he had stopped because he had finished school, and that he did not need medicine in the same way at work. He did say that he would use it again if he went back to school. He also said that medicine changed him into a boring person.

I become an entirely different person, I did not want to take it....you become more, I see myself as a very fun person….and a lot of people like me for it, while when I take medicine I get so boring….

(ip_2)

Another participant was considering stopping their medication due to side-effects. She said that the side-effects included flattened affect and that she was not feeling joy in the same way. She did however suggest that medication helped her when she was younger.

Very good to have medicine when you need it, before you get older… .there were side effects, I did not eat enough, I lost the appetite….I was not happy.…even though I was hyper, and smiled very often, but I was not completely satisfied with my mood.

(ip_8)

Most of the participants however perceived medication to be helpful.

If I take medication one day and another day I do not, there is a big difference, and everyone around me take notice of that …especially in the classroom…they ask me; why are you like that, you didn’t used to be like this…If I had not been diagnosed and receiving medication, I would not be sitting here today. I don’t think that I would have passed my driving license either. I don’t think that I could have done my job or drive my motorbike….

(ip_ 6)

6.       Discussion

This study investigated the childhood and adolescent experiences of individuals with a diagnosis of ADHD. More specifically, qualitative analysis has been used to examine attitudes to diagnosis and treatment, and how it may have impacted on user experience and lifestyle. Three core themes emerged. First, self-esteem and personal identity helped individuals to understand themselves and their symptomatology in the context of their diagnosis, but the respondents were keen to emphasize that they are not to be defined by their diagnosis and disapprove of the stigma associated with the diagnosis. Second, they wished to be treated equally to their peers, especially in the school system. The third theme related to maturation: they wanted to succeed in life despite their diagnosis. Like with previous research in adults (S. Young et al., 2008) receiving medication in childhood seemed to have a protective effect on their self-esteem [24].

6.1.  To Maintain a Positive Self-Esteem

Participants strongly indicated that they wanted to be accepted as individuals. The diagnosis affected how they felt about themselves and seemed to be a motivating factor in the respondents’ pursuit of success: very much in the image of the idiom "adversity makes you stronger". College students with a diagnosis of ADHD may represent a resilient group with high levels of self-esteem [18]. In their study Wilmshurst et al. found that there was no statistical difference in self- concept between college students diagnosed with and without ADHD. They speculated that perhaps they achieve the same outcome because they are motivated by values and priorities based on life lessons, and that they have “achieved success against the odds”. Our study supports this possibility.

ADHD individuals with less symptom severity or individuals without comorbidity have better prognosis [28]. In a recent study examining the role of self-esteem in a clinical sample of adolescents, Henriksen et.al. found that individuals with high self-esteem demonstrate fewer attentional difficulties and report less symptoms of anxiety/depression, and that self-esteem may function as a resilience factor [29]. In Young`s study: “Coping strategies used by adults with ADHD” (2005) they found an unexpected outcome: “The ADHD group positively reappraised stressful situations, which is a constructive response, although this will clearly depend on the context of the situation” [30].

The participants in this present study described themselves as unique persons, and as a resilient group with a strong desire and determination to deal with their difficulties. As one of the young men said, that he had managed to come this far, and managed to reach a goal.

The respondents' resilience may be a product of maturation but also medication [12]. A positive influence of treatment with medication has previously been reported in the literature; a Turkish randomized controlled study on methylphenidate treatment of ADHD in children found that the children who were treated pharmacologically had significantly higher self-esteem than those who were not treated pharmacologically [6]. Houck and colleagues theorize that medication facilitates behavioral regulation and thereby promotes positive self-esteem [6]. Dittman et al. investigated self-esteem in adolescent patients with ADHD during open-label atomoxetine treatment, and found that self-esteem may be an important individual patient outcome [31]. Further research is needed in this area.

What a child thinks and believes about his or her competencies may have implications for adjustment, and some children with ADHD overestimate their competencies in academic, behavioral and social domains [28]. This “positive illusory bias” may serve as a protective function to preserve self- esteem [28]. In the Modesto-Lowe study, some of the male participants had an attitude to school which may have had a protective function on their self-esteem.

Impairments in self-esteem often occur in adolescents with ADHD [15,8], although there is debate about whether ADHD symptomatology is related to lower or greater feelings of self-esteem: some international studies assessing the relationship between ADHD and self-esteem indicate low self-esteem [6,12,17] whereas others indicate high self-esteem [16,18]. Thaulow and Jozefiak found in their study that children in the ADHD group reported higher QoL than children in the Anxiety/Depression group [32]. In the discussion they pointed out that these results can be interpreted in the way that “children with ADHD often tend to be active, creative and “funny” children, although they often get into trouble. In general, they might have a more positive way of looking at their lives than children with anxiety/depression- related problems”. The findings of Thaulow and Jozefiak very much mirror those of the present study, in that both highlight how much young people with ADHD value how their ADHD contributes to their creative and energetic outlook [32]. Having said that, the present study also suggests that self-esteem levels vary depending on respondent age and context, and thus more research is needed to tease these constructs apart from one another and clarify the relationship between ADHD and self-esteem.

Gender may be a factor in the development of self-esteem. In the present study, females seemed less confident than the males: several of the boys talked about having humour and energy, being creative, being fearless, and that they had been told by friends that they were fun to be with. Whereas, females were more affected by feeling different and receiving negative feedback from others and they were perhaps affected more by difficulties in school. A handful of studies have explored the differences between females and males with ADHD in this respect [6,16,33]. For example, adolescent girls have been found to have lower self-efficacy and poorer coping strategies than adolescent boys with ADHD, and self-efficacy and coping strategies are thought to be linked to self-concept [6]. These variations have a tendency to disappear by adulthood [20], Rucklidge points as well that rates of depression and anxiety may be higher in girls (especially in adolescence). On the other hand, externalizing behaviors may be lower in girls and women with ADHD [20]. As mentioned earlier, previous research points that some children and adolescence with ADHD exhibit a “positive illusory bias” (PB) in their self-perception [16,34,35], and positive illusory self- perceptions may function as a self-protective function in coping with deficits [16,36]. Boys expressing depressive symptoms are more likely to report lower self-esteem, but when positive illusory self-perceptions are evidence aggressive boys with ADHD inflate their self-perceptions [16]. In this present study none of the boys expressed having conduct problems or aggressive problems, but still they expressed positive self- esteem. This present study cannot answer to this question, but it may be a very important hypothesis to explore. Alongside the findings of the present study, it does seem as though the ADHD experience is different for boys and girls, and further research is needed to explore these differences.

The participants in Young and colleagues (2008) study reported that stimulant medication had a positive impact on their lifestyle and life satisfaction as they had previously lived a life of struggle without treatment and without knowing the reason they were experiencing difficulties [24]. One of the participants commented: “I suppose I’ve got more confidence, simply because I know that if I say something I am more likely to do it”. In childhood they had been told that they were stupid, lazy and disruptive, and subsequently felt different to others. This frustration and confusion often led to low self- esteem and low feelings of self-worth. They talked how "their lives would have been different with an earlier diagnosis". One participant said, "I think that I could have done much better at school....and made a little more of myself". The outcomes differ in the present study because participants received their diagnosis and treatment much earlier on in childhood and this early intervention seems to have had a protective effect on their self-esteem.

6.2.  Normalization and Equality

As referenced above, adolescents have a strong desire to be accepted as ‘normal’ by their peers and may discard the ‘ADHD patient role’ and distancing oneself from the socially imposed stereotypes, previously assigned by parents, the school system and treatment providers to achieve this goal [37]. The participants in Young’s study (2008) reported a certain degree of stigma, and said that this made it difficult to be open about their diagnosis. Likewise, the participants in this study experienced labelling and feelings of stigma; usually within school situations [24].

It seems that the environment, especially school, affected participants’ self- concept and self-perception. Despite the difficulties associated with such environments, the present study suggests that individuals with ADHD actively stand up for themselves and hold on to their position of being themselves regardless of what others thought: “To be me and not my ADHD”. This suggests that, whilst not distancing themselves from their diagnosis, respondents drew on the uniqueness of their position, but endeavoured to be treated the same as their peers. It was important that young people with ADHD prove that they can be independent and cope, even in the face of challenges and difficulties.

Having received a diagnosis and subsequent treatment from a young age, the participants’ experiences seem to have been driven by their ADHD. For example, we were pleased to hear about the young man who claimed to go through High School without special education - even though he had a history of struggling in school, he refused to be treated differently to his peers. He also said that he would not want to be without his diagnosis and the boost it gives him. This example captures the importance of early diagnosis, and how treatment can facilitate the development of positive attitudes, and their related opportunities, in children and young people with ADHD.

During the interviews, the participants expressed a strong desire to be treated as their peers in the school system and said that they were not comfortable receiving special interventions e.g. a classroom assistant. Although largely unanticipated, these findings are supported by the qualitative analysis from Bussing`s study [39] where adolescents identified a feasibility barrier related to the equality and fairness of individualized academic interventions. In keeping with Bussing (2016), the present study emphasizes the importance of being treated with the same interventions as the rest of the class [39].

In his review article, Lebowitz (2016) purports that people with ADHD are reluctant to engage in social interaction in preference for maintaining a social distance [21]. Whereas, in the present study, adolescents with ADHD described stigma as an undesirable effect of academic interventions in school and commented that special interventions made them feel embarrassed and uncomfortable. The adolescents want basic education [39].

6.3.  Learning to Live with the Diagnosis in Shifting Perspectives

The participants in Young’s study reached a point of acceptance in which the ADHD diagnosis became a part of their identity. The participants in the current study grew up knowing about the diagnosis, and thus their perception of their diagnosis can be interpreted as a product of their experience and the environments in which they have associated e.g. school. This raises the question of whether adolescents with an illness or a chronic condition mature differently from others, and whether/how people can learn to accept and to live with chronic conditions.

Receiving a diagnosis in childhood may have strengthened the self-esteem of the participants and will have given them the opportunity to understand themselves.

However, the label of the diagnosis is too a factor, and respondents wanted to be seen as just being an ordinary kid, and not an “ADHD kid”. This means that they must shift from one perspective to another, from wellness to illness and vice versa [40].

6.4.  Strengths and Limitations

The study has several limitations. The sample is small, and there was a difference in age between participants, both at age of interview and age at diagnosis. However, the differences in age also gave us the opportunity to capture the differences associated with getting a diagnosis early or late in childhood. Time since diagnosis may also be a methodological concern. At the time of the interview, eight years had passed since the participants were first diagnosed. The participants’ memory of their experiences and attitudes may have decayed over time and there is thus the possibility that their accounts may be inaccurate or biased. This is unlikely however, as all respondents were animated whilst telling their story, and gave spontaneous and honest accounts.

In respect of experimenter influence, the primary researcher did conduct the interviews on her own and thus there is the possibility that reflexivity may have been undermined. To strengthen the validity, the supervisors read several of the transcriptions and discussed main themes with the primary researcher, and the researcher also read all transcripts several times during the process. During the writing process, the primary researcher discussed the findings with other clinicians, with the user organization (ADHD Norge) and with other researchers. To strengthen validity, the researcher also had a dialog with some of the participants to discuss the findings of the study.

6.5. Implications

The findings illustrate the protective effect of early intervention and treatment programs. It is important to note, however, that adolescents do not like to be treated with special interventions in school; they like to be treated like everybody else.

Interventions that draw attention to the child’s problems and needs may serve to mark them out and thus may be counter-productive. Such interventions may too have a negative impact on the self-esteem of users. Medication should be supplemented by psychological treatments that improve a child’s cognitive, emotional, behavioral and social functioning and reduce the impact of stigma. Indeed, adolescents with ADHD perceived stigma to have an undesirable influence on academic outcomes in adolescence; it made them feel embarrassed and uncomfortable. These findings are important when considering interventions in the school setting.

7.       Conclusion

This study aimed to investigate how adolescents and young adults experience living with ADHD following a diagnosis and treatment in childhood. Further research is needed; our findings indicate that adolescents and young people diagnosed with ADHD have strong self-esteem. They express themselves as individual persons independent of their diagnosis and the diagnosis motivated them to show that they could manage to achieve as much as their peers. The participants in this study presented themselves as a resilient group who had a strong desire and determination to deal with their difficulties autonomously and independently. Receiving a diagnosis of ADHD in childhood may have strengthened their self-esteem compared with those who are first diagnosed as adults. Receiving ADHD medication early in childhood seems to protect their self- esteem. Nevertheless, participants also felt that the diagnosis put a label on them. This was perceived negatively as it affected the perception of others and their reputation.

8.       Acknowledgments

The authors would like to thank all the participants for taking part in this study, and for their willingness to share their views and experiences.

9.       Funding 

We will like to thank Namsos Hospital, Nord-Trøndelag Hospital Trust, and The Central Norway Regional Health Authority for supporting this study.

10.   Declaration of Conflicts of Interest

The authors have no financial, professional or personal conflict of interest.

 Appendix

Step. 3: Subgroups were developed under each of the codes from step 2, with focus on the study questioning and the interpretative perspectives. The codes were sorted in to several subgroups. 

The subgroups at this state was: 

1.Will be treated like others. Feeling sorrow about having ADHD. Believe in the future.

2.Being like everyone else. Want to learn like everybody else.

3.Life experience. To cope challenges better. Treatment with medication helped. 

These subgroups became subject to the further analysis towards condensate.

Table 1: Participants Characteristics.

1.                   Dopfner M, Breuer D, Wille N, Erhart M, Ravens-Sieberer U (2008) How often do children meet ICD-10/DSM-IV criteria of attention deficit-/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample--results of the BELLA study. Eur Child Adolesc Psychiatry 17: 59-70.

2.                   Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA (2007) The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 164:  942-948.

3.                   Singh A, Yeh CJ, Verma N, Das AK (2015) Overview of Attention Deficit Hyperactivity Disorder in Young Children. Health Psychol Res 3: 2115.

4.                   Booster GD, Dupaul GJ, Eiraldi R, Power TJ (2012) Functional impairments in children with ADHD: unique effects of age and comorbid status. J Atten Disord 16: 179-189. 

5.                   Danckaerts M, Sonuga-Barke EJ, Banaschewski T, Buitelaar J, Dopfne M, et al. (2010) The quality of life of children with attention deficit/hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry 19: 83-105.

6.                   Houck G, Kendall J, Miller A, Morrell P, Wiebe G (2011) Self-concept in children and adolescents with attention deficit hyperactivity disorder. J Pediatr Nurs 26: 239-247. 

7.                   Schei J, Jozefiak T, Novik TS, Lydersen S, Indredavik MS (2016). The Impact of Coexisting Emotional and Conduct Problems on Family Functioning and Quality of Life Among Adolescents with ADHD. J Atten Disord 20: 424-433. 

8.                   Wehmeier PM, Schacht A, Escobar R, Savill N, Harpin V (2010) Differences between children and adolescents in treatment response to atomoxetine and the correlation between health-related quality of life and Attention Deficit/Hyperactivity Disorder core symptoms: Meta-analysis of five atomoxetine trials. Child Adolesc Psychiatry Ment Health 4: 30. 

9.                   Kooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugue M, et al. (2010) European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. BMC Psychiatry 10: 67.

10.                Young S, Murphy CM, Coghill D (2011) Avoiding the 'twilight zone': recommendations for the transition of services from adolescence to adulthood for young people with ADHD. BMC Psychiatry 11: 174.

11.                Cussen A, Sciberras E, Ukoumunne OC, Efron D (2012) Relationship between symptoms of attention-deficit/hyperactivity disorder and family functioning: a community-based study. Eur J Pediatr 171: 271-280. 

12.                Mazzone L, Postorino V, Reale L, Guarnera M, Mannino V, et al. (2013) Self-esteem evaluation in children and adolescents suffering from ADHD. Clin Pract Epidemiol Ment Health 9: 96-102.

13.                Riley AW, Spiel G, Coghill D, Dopfner M, Falissard B, et al. (2006) Factors related to health-related quality of life (HRQoL) among children with ADHD in Europe at entry into treatment. Eur Child Adolesc Psychiatry 15: I38-145.

14.                Schei J, Nøvik TS, Thomsen PH, Lydersen S, Indredavik MS, et al. (2018) What Predicts a Good Adolescent to Adult Transition in ADHD? The Role of Self-Reported Resilience. J Atten Disord 22: 547-560.

15.                Cook J, Knight E, Hume I, Qureshi A (2014) The self-esteem of adults diagnosed with attention-deficit/hyperactivity disorder (ADHD): a systematic review of the literature. Atten Defic Hyperact Disord 6: 249-268.

16.                Hoza B, Gerdes AC, Hinshaw SP, Arnold LE, Pelham WE, et al. (2004) Self-perceptions of competence in children with ADHD and comparison children. J Consult Clin Psychol 72: 382-391. 

17.                Michielsen M, de Kruif JT, Comijs HC, van Mierlo S, Semeijn EJ, et al. (2015) The Burden of ADHD in Older Adults: A Qualitative Study. J Atten Disord 22: 591-600.

18.                Wilmshurst L, Peele M, Wilmshurst L (2011) Resilience and well-being in college students with and without a diagnosis of ADHD. J Atten Disord 15: 11-17. 

19.                Schei J, Novik TS, Thomsen PH, Lydersen S, Indredavik MS, et al. (2015) What Predicts a Good Adolescent to Adult Transition in ADHD? The Role of Self-Reported Resilience. J Atten Disord 22: 547-560.

20.                Rucklidge JJ (2008) Gender differences in ADHD: implications for psychosocial treatments. Expert Rev Neurother 8: 643-655. 

21.                Lebowitz MS (2016) Stigmatization of ADHD: A Developmental Review. J Atten Disord 20: 199-205.

22.                Rothenberger A, Rothenberger LG (2012) Updates on treatment of attention-deficit/hyperactivity disorder: facts, comments, and ethical considerations. Curr Treat Options Neurol 14: 594-607.

23.                Wells KC, Pelham WE, Kotkin RA, Hoza B, Abikoff HB, et al. (2000) Psychosocial treatment strategies in the MTA study: rationale, methods, and critical issues in design and implementation. J Abnorm Child Psychol 28: 483-505.

24.                Young S, Bramham J, Gray K, Rose E (2008) The experience of receiving a diagnosis and treatment of ADHD in adulthood: a qualitative study of clinically referred patients using interpretative phenomenological analysis. J Atten Disord 11: 493-503. 

25.                Malterud K (2012) Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health 40: 795-805.

26.                Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 19: 349-357.

27.                Malterud K (2001) Qualitative research: standards, challenges, and guidelines. Lancet 358: 483-488.

28.                Modesto-Lowe V, Yelunina L, Hanjan K (2011) Attention-deficit/hyperactivitydisorder: a shift toward resilience? Clin Pediatr (Phila) 50: 518-524.

29.                Henriksen IO, Ranoyen I, Indredavik MS, Stenseng F (2017) The role of self- esteem in the development of psychiatric problems: a three-year prospective study in a clinical sample of adolescents. Child Adolesc Psychiatry Ment Health 11: 68. 

30.                Young S (2005) Coping strategies used by adults with ADHD. Personality and Individual Differences, 38: 809-816.

31.                Dittmann RW, Wehmeier PM, Schacht A, Lehmann M, Lehmkuhl G, et al. (2009) Self-esteem in adolescent patients with attention-deficit/hyperactivity disorder during open-label atomoxetine treatment: psychometric evaluation of the Rosenberg Self-Esteem Scale and clinical findings. Atten Defic Hyperact Disord 1: 187-200. 

32.                Thaulow CM, Jozefiak T (2012) A comparison between child psychiatric outpatients with AD/HD and anxiety/depression. Nord J Psychiatry 66: 396-402.

33.                Hoza B, Pelham WE Jr, Dobbs J, Owens JS, Pillow DR (2002) Do boys with attention-deficit/hyperactivity disorder have positive illusory self-concepts? J Abnorm Psychol 111: 268-278.

34.                Hoza B, McQuade JD, Murray-Close D, Shoulberg E, Molina BS, et al. (2013) Does childhood positive self-perceptual bias mediate adolescent risky behavior in youth from the MTA study? J Consult Clin Psychol 81: 846-858. 

35.                Owens JS, Goldfine ME, Evangelista NM, Hoza B, Kaiser NM (2007) A critical review of self-perceptions and the positive illusory bias in children with ADHD. Clin Child Fam Psychol Rev 10: 335-351.

36.                Hoza B, Vaughn A, Waschbusch DA, Murray-Close D, McCabe G (2012)Can children with ADHD be motivated to reduce bias in self-reports of competence? J Consult Clin Psychol 80: 245-254.

37.                Honkasilta J, Vehmas S, Vehkakoski T (2016) Self-pathologizing, self- condemning, self-liberating: Youths' accounts of their ADHD-related behavior. Soc Sci Med 150: 248-255.

38.                Williamson P, Koro-Ljungberg ME, Bussing, R. (2009) Analysis of critical incidents and shifting perspectives: transitions in illness careers among adolescents with ADHD. Qual Health Res 19: 352-365.

39.                Bussing R, Koro-Ljungberg M, Gagnon JC, Mason DM, Ellison A, et al. (2016). Feasibility of School-Based ADHD Interventions: A Mixed-Methods Study of Perceptions of Adolescents and Adults. J Atten Disord 20: 400-413.

40.                Paterson BL (2001) The shifting perspectives model of chronic illness. J Nurs Scholarsh 33: 21-26.