Self-Esteem in Adults With ADHD Using the Rosenberg Self-Esteem Scale: A Systematic Review

Objective: To summarize and analyze recent articles investigating self-esteem in adults with ADHD, focusing on the impact of demographic and clinical characteristics, and methodological issues. Method: Following PRISMA guidelines, a systematic search for literature published between 2010 and 2022 was conducted in the Web of Science, Ovid, Pubmed, and EBSCO databases. Results: Eleven studies met inclusion criteria. Five of the six studies including healthy controls reported lower self-esteem in participants with ADHD. ADHD symptoms correlated negatively with self-esteem. Gender differences were not observed. Self-esteem mediated several outcomes associated with ADHD. There was a lack of studies that examined potential mechanisms behind the reduced self-esteem, and studies controlling for confounding variables. Conclusion: A robust association between ADHD and low self-esteem in adults emerged, but the lack of control of confounding variables is critical to consider when interpreting the findings. Longitudinal studies addressing the limitations of the current studies are needed.


Introduction
ADHD is a neurodevelopmental disorder with core symptoms of inattention, hyperactivity, and impulsivity (American Psychiatric Association [APA], 2013).ADHD is characterized by three different presentations; pre dominantly inattentive, predominantly hyperactive/impul sive, and combined.The worldwide prevalence rate of ADHD in childhood is reported to be between 5% to 7% (Polanczyk et al., 2007;Thomas et al., 2015).At least two thirds of childhood cases are reported to show persistent symptoms of the disorder into adulthood (Faraone et al., 2006), and the estimated worldwide prevalence of ADHD in adulthood is approximately 2,5% (Kooij et al., 2016;Simon et al., 2009;Song et al., 2021).Boys are diagnosed with ADHD more frequently than girls.However, the gen der distribution in adulthood is more balanced, with inat tention being the most prevalent presentation (Hinshaw et al., 2022;Willcutt, 2012).A higher prevalence of ADHD is reported in the white American population compared to the African American, Hispanic, and Asian American pop ulation (Chung et al., 2019).
ADHD in adulthood is associated with a wide array of challenges in everyday life, including problems affecting social and emotional function (Kooij et al., 2019;Paulson et al., 2005), emotional regulation (Groves et al., 2022), educational attainment (Gjervan et al., 2016;Henning et al., 2022), employment level (Gjervan et al., 2016), qual ity of life (Kazda et al., 2022;Pinho et al., 2019), and the presence of chronic fatigue (Kooij et al., 2019), somatic dis eases (Instanes et al., 2018), neuropsychological deficits (Halleland et al., 2012;Lundervold et al., 2019;Munro et al., 2018;Weyandt et al., 2017), and psychiatric disorders (Franke et al., 2018;Kooij et al., 2019;Nutt et al., 2007;Schiweck et al., 2021;Torgersen et al., 2006).The most common cooccurring psychiatric disorders in adult ADHD are depression, anxiety disorders, bipolar disorder, sub stance use disorders, and personality disorders (Katzman et al., 2017).Beyond these symptoms and challenges, ADHD is associated with impaired selfesteem in both childhood and adulthood (Çelebi & Ünal, 2021;Cook et al., 2014;Kooij et al., 2010).The interplay between ADHD and selfesteem is complex, and stigma toward individuals with ADHD may add to the burden of the disorder (Halleröd et al., 2015).While empirical evidence regarding casual impacts on selfesteem in ADHD may be scarce, it has been theoretically suggested that the negative life experiences and failures associated with ADHD, and the consecutive negative feedback, may have detrimental effects on self esteem (Young & Bramham, 2006).Recognizing challenges and stigma faced by adults with ADHD may therefore be an important first step to help promote a more positive self esteem in these individuals.
Selfesteem is a core construct in the psychological literature that is theoretically and empirically associated with life quality and psychological wellbeing (Kashdan, 2004;Robins et al., 2001).Morris Rosenberg (1979, p. 23) describes the self as "one of the objects toward which one has . . .feelings," and states that selfesteem "refers to a positive or negative evaluation of the self " (Rosenberg, 1979, p. 31).Low selfesteem is thought to manifest as negative attitudes toward the self, with low selfacceptance and selfrespect, and feelings of low selfworth (Rosenberg, 1979;Rosenberg & Simmons, 1972).Rosenberg devel oped the Rosenberg SelfEsteem Scale (RSES) (1965).According to Donnellan et al. (2015), RSES is the most frequently used questionnaire to assess selfreported self esteem, accounting for more than 50% of the citations of studies using selfesteem measures.The tool was originally developed using a Guttman scale, with four options for each item (Rosenberg, 1965).RSES consists of ten items, where five are formulated positively (e.g., "I feel that I am a person of worth, at least on an equal plane with others.")and five negatively (e.g., "All in all, I am inclined to feel that I am a failure.").Due to the complexity of the Guttman scale, the RSES is often modified to a Likert scale of 4 points (Jordan, 2020), and a score below 50% has been suggested as a cutoff for low selfesteem (Isomaa et al., 2013).RSES has shown high crosscultural validity (Schmitt & Allik, 2005).
Numerous important factors have been associated with the development of selfesteem.Age seems to be one criti cal factor, based on metaanalytic findings of the develop mental trajectory of selfesteem (Orth et al., 2018;Orth & Robins, 2014).In the general population, selfesteem has been found to steadily increase from childhood through adolescence and adulthood, peaking at 50 or 60 years of age.After peaking, selfesteem has been found to decline, with a rapid decline starting around age 70 years.These dif ferences can be attributed to varying challenges, cognitive, emotional, and social.A recent metaanalysis (Betancourt et al., 2024) suggests that children and adolescents with ADHD have reduced global, academic, and social self esteem compared to those without ADHD.As children with ADHD progresses to adolescence and adulthood, the com parison to peers and demands from society increases, poten tially inflicting harm to their selfesteem (Richman et al., 2010, p. 112).Increased academic and social demands could elucidate findings suggesting that the inattentive pre sentation of ADHD appears to have the most devastating effect on selfesteem in adolescents (Kita & Inoue, 2017).Throughout adulthood, males are shown to display slightly higher selfesteem compared to females (Orth et al., 2010), but gender does not appear to significantly impact the developmental trajectory of selfesteem (Orth et al., 2018).Metaanalyses have found differences in levels of self esteem between different ethnic populations, with African Americans scoring higher than white Americans, and Asian Americans scoring even lower (Twenge & Crocker, 2002).Others have found associations between selfesteem and education level (Orth et al., 2010(Orth et al., , 2012;;Twenge & Campbell 2002;von Soest et al., 2018), employment status (Kuster et al., 2013;Orth et al., 2012;von Soest et al., 2018), and job satisfaction (Kuster et al., 2013;Orth et al., 2012).These studies were based on longitudinal prospective designs, where in most instances no reciprocal effects of these outcomes on selfesteem were detected.Low self esteem is also associated with various psychiatric disorders such as depression, anxiety, premorbid psychosis, border line and avoidant personality disorders, and eating disor ders (Bemrose et al., 2021;Colmsee et al., 2021;Lynum et al., 2008;Šare et al., 2021;Sowislo & Orth, 2013).Furthermore, low selfesteem has been associated with the development of poor physical health (Byth et al., 2022;Trzesniewski et al., 2006).
Knowing that adults with ADHD are at risk for several of the outcomes associated with reduced selfesteem (including lower educational attainment, lower employ ment level, comorbid psychiatric disorders, and reduced quality of life), the purpose of the present systematic review is to examine the literature from the past decade regarding selfesteem in adults with ADHD with a goal to uncover associated factors potentially impacting selfesteem.Specifically, this study aimed to (a) identify and summarize the peerreviewed literature analyzing selfesteem in adults with ADHD, and (b) present findings regarding the level of selfesteem and the potential impact of demographic (age, gender, race/ethnicity, education level, and employment status) and clinical characteristics (presentation of ADHD, symptom severity, and comorbid disorders).An additional aim of the systematic review was to identify methodologi cal issues and shed light on crucial gaps in the literature, specifically those raised in a previous review by Cook et al. (2014).

Methods
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines (Page et al., 2021).A literature search was conducted in the databases Web of Science, Ovid, Pubmed, and EBSCO over the period 2010 to 2022.The time frame was set with the intention to build upon previous findings based primarily on literature before 2010 (Cook et al., 2014), and thus to ensure relevance to the contemporary context.The search consisted of the follow ing terms: ("ADHD" OR "Attention Deficit Hyperactivity Disorder" OR "hyperactiv*") AND ("Adult*" OR "Grown up*" OR "Student*") AND ("selfesteem" OR "RSES" OR "Rosenberg Self Esteem Scale").
A flow diagram according to the PRISMA guidelines for the identification of studies is presented in Figure 1.Studies were included if they (1) defined selfesteem by responses on the RSES, (2) reported or analyzed self esteem in adults with ADHD, (3) operationalized ADHD according to DSM4 or DSM5, (4) were peerreviewed, and (5) published after 2010.
Studies were excluded if they were (1) treatment studies, (2) systematic reviews, (3) book chapters, (4) dissertations, (5) case studies, (6) not written in English, or (7) included participants below the age of 18 years.The first four authors were responsible for the selection process.The authors screened titles and abstracts independently from each other, before reaching a consensus.Further, some studies were excluded based on fulltext review.
Only studies using RSES to define selfesteem were included, due to the dominant use of RSES in psychologi cal literature and to maintain consistency between studies.For each study, the following data were retrieved: RSES scores in individuals with ADHD and controls, demo graphics (age, gender, ethnicity, education, and employ ment status), symptom severity, presentation of ADHD, and comorbidities.Data were extracted using the data extraction tool developed by Cook et al. (2014).The tool includes the following parameters: description of the sub jects, the phenomenon of interest, context, outcome, and study design.The data were extracted independently by the first four authors, and the process was supervised by one of the senior authors (AJL).
To assess the quality and identify possible sources of bias, we applied the quality assessment tool developed by Cook et al. (2014).The quality of each study was expressed in terms of percentage and is presented in Table 1.Questions were rated with yes (score = 2), partially (score = 1), no (score = 0), can't tell (score = 0), or "not applicable" (item subtracted from the total score).The authors discussed and established a shared understanding of how to employ the assessment tool.Two of the authors independently assessed all articles, and the interrater reliability for each study was calculated with Cohens' Kappa (mean κ = .83,median = 0.87).When a discrepancy in rating occurred, four of the authors met and reached a consensus through discussion.
All studies reporting scores on the 10item version of RSES within an ADHD group are presented in Table 2. Scores in control groups were included when available.Since the RSES is most frequently reported on a scale from 0 to 30, studies reported RSES scores on other scales were converted to a standard of 0 to 30, to facilitate comparability, using Equation (1).
Where n RSES = New standardized RSES score; o RSES = Original reported mean RSES; L min = Likert minimum on original scale; and L max = Likert maximum on original scale.Means that were reported on a scale that did not start at zero, were subtracted by the minimum level score on the Likert scale, to start at zero.The new maximum Likert level score was calculated by subtracting the original minimum Likert level from the original maximum level.Thereafter, the new mean was divided by the new maximum level score of the Likert scale.Lastly, to convert the numbers to a stan dardized mean, ranging from 0 to 30, the transformed mean was multiplied by 30.
Although this transformation could imply methodological concerns that are of serious risk to the validity of the trans formed RSES means, it provides an indication of the levels of selfesteem across the samples.The RSES scores that were transformed, are highlighted by an asterisk in Table 2.

Study Selection
The search procedure is described in Figure 1, showing that the initial literature search returned 387 records.After removing duplicates (190) and noneligible articles (186), five articles were excluded after fulltext screening (Babinski et al., 2011;Davtian et al., 2012;Gudjonsson et al., 2014;Kirino et al., 2015;Romo et al., 2015).A total of eleven studies were included in this review.

Quality Assessment
The quality assessment scores ranged from 55% to 77%, with a mean of 67% (see Supplemental Table 1 for detailed descriptions).Four studies obtained a quality score of 70% or above (Arsandaux et al., 2021;Chamberlain et al., 2017;Michielsen et al., 2014;Pawaskar et al., 2020), while the quality scores for five studies ranged from 55% to 64% (Bae et al., 2019;Dan & Raz, 2015;Evren et al., 2021;Jhambh et al., 2014;Newark et al., 2016) due to insuffi cient identification, justification, and control of potentially confounding variables.Regarding methodology, most studies did not conduct power analysis (n = 3), adjusted for multiple comparisons (n = 3), and compared characteristics of excluded and included participants (n = 1).No study stated to have implemented measures to avoid recall bias.

Study Characteristics
All studies were published between 2014 and 2021 and included participants from countries across Europe (n = 4), North America (n = 3), Middle East (n = 2), and Asia (n = 2).Most studies (nine) used crosssectional designs and eight of those included either a healthy control group (n = 7) or a symptomatic undiagnosed control group (n = 1).Self esteem in adults with ADHD was explicitly described as a main research focus in five of the included studies (Arsandaux et al., 2021;Evren et al., 2021;Dan & Raz, 2015;Newark et al., 2016;Pawaskar et al., 2020), while the remaining studies investigated ADHD and selfesteem as part of a broader research question related to psychological and psychosocial factors.(Masuch et al., 2019).No studies included information regarding nonbinary participants.Race/ethnicity was only reported in the study by Pawaskar et al. (2020) and education level and employment status were reported in nine of the studies.Five studies included participants with a clinical ADHD diagnosis, while six stud ies defined ADHD based on selfreport.Only one study reported the distribution of ADHD presentation within their sample (Dan & Raz, 2015).

Level of Self-Esteem Among Adults With ADHD
Seven studies reported mean RSES scores for the ADHD groups (diagnosed or symptomatic).The six studies that used the 10item version are presented in  2020) study obtained the second lowest mean score on RSES, while their group of adults formerly diagnosed with ADHD at a clinical ward obtained one of the highest mean scores among the included studies.The highest selfesteem was reported in two samples of young (mean age 22.3 and 23.4) nontreatmentseeking adults with symptomatic ADHD (Chamberlain et al., 2017;Turel & Bechara, 2016).
Two studies reported the proportion with a score below the threshold for low selfesteem (RSES ≤ 15) in their ADHD groups.The proportion was 53.8% in Jhambh et al.'s (2014)

Diagnosed ADHD Groups Versus Controls
Three studies compared the selfesteem level in a group of adults diagnosed with ADHD and a group of healthy con trols.In a study of the relationship between ADHD, self esteem, and test anxiety, Dan and Raz (2015) showed that the selfesteem in 25 female undergraduate students with ADHD (M = 4.10 ± 0.95) was significantly lower than in a group of 30 agematched female controls (M = 5.10 ± 0.76, p = .001).Michielsen et al. (2014) performed a study of the relationships between ADHD, selfesteem, and depres sion in a group of older adults with ADHD (n = 23, M age = 68.0 ± 4.9) and controls (n = 208, M age = 72.0 ± 7.9).The differences in selfesteem between the ADHD (M = 13.87 ± 3.22) and control group (M = 14.85 ± 2.19) were nonsignificant (p = .17).However, when age was included as a covariate, the association between ADHD diagnosis and selfesteem became statistically significant r = −.20,p = .024).Lower selfesteem in an ADHD than in a control group (M = 15.0 ± 6.5 vs. M = 23.2 ± 6.5, p < .01)was also found in Newark et al.'s (2016) study.

Symptomatic ADHD Versus Controls
Three studies compared the selfesteem level of adults with symptomatic ADHD to healthy controls.Chamberlain et al. (2017) investigated selfesteem in a symptomatically defined ADHD group (n = 86, M age = 22.3) and a healthy control group (n = 33.7 M age = 22.3), recruited based on gambling behavior.The group with symptomatic ADHD displayed significantly lower selfesteem compared to healthy controls (M = 20.2 ± 6.0 vs. M = 22.4 ± 6.3, p = .005,d = 0.36).Jhambh et al. (2014) investigated the prevalence of ADHD and its relationship to low selfesteem (RSES ≤ 15) in students (age range = 18-25, M age = 19.5)and found that a symptomatic ADHD group (n = 13) showed significantly lower selfesteem than students without ADHD (n = 224; p = .008).Turel and Bechara (2016) inves tigated whether selfesteem could partly mediate the rela tionship between ADHD symptoms and the use of social network sites while driving (M age = 23.4).The students in the ADHD symptomatic group (n = 110) showed signifi cantly lower selfesteem than students in a healthy control group (n = 347, M = 19.7 vs. M = 21.2, p < .05).Pawaskar et al. (2020) sought to explore the effects of diag nosis in adults with symptoms of ADHD.When comparing adults with symptomatic (n = 867, M age = 43.5)and diag nosed ADHD (n = 436, M age = 42.5), the latter group reported significantly higher selfesteem ratings (M = 19.3 ± 6.6 vs. M = 15.2 ± 6.3, p < .001).

Association Between Symptoms of ADHD and Self-Esteem
Three studies showed negative correlations between the presence or severity of ADHD symptoms and selfesteem.Bae et al. (2019) found a weak negative correlation between the presence of ADHD symptoms and selfesteem (r = −.27,p < .01.) in students with high caffeine consumption (n = 92, M age = 22.7), and controls (n = 419, M age = 23.0).Michielsen et al. (2014) found a significant negative correlation between selfesteem in the presence of an ADHD diagnosis (r = −.20,p = .02)and between ADHD symptoms and selfesteem (r = −.25, p = .002)regardless of group status, while Turel and Bechara (2016) found a weak, but statistically signifi cant negative correlation between ADHD symptoms and selfesteem in a student sample (n = 457, r = −.26,p < .01).In addition, Evren at al. (2021) reported a moderate correla tion between ADHD symptoms and selfesteem (r = .421,p < .001) in a sample consisting of individuals with alcohol use disorder.

Impact of Demographic and Clinical Characteristics
The few studies analyzing the impact of gender reported no differences between men and women (Chamberlain et al., 2017;Newark et al., 2016).The differences were also non significant for the inattentive and combined ADHD presen tations in the female sample included in Dan and Raz's (2015) study, where 52% were classified with an inatten tive, 44% with a combined, and 4% with a hyperactive impulsive presentation.Notably, Evren et al. (2021) showed that selfesteem was associated with inattentive symptoms (r = .44,p < .001)and hyperactivity/impulsivity symptoms (r = .30,p < .001) in a sample of inpatients with alcohol use disorder.However, it was only the inattentive dimension that was predicted by selfesteem in a MANCOVA analysis.Newark et al. (2016) highlighted psychological distress as a potential contributor to group differences in selfesteem.When analyzing the effect of psychological distress on self esteem, they found a higher level of psychological distress in the ADHD group than in a group of healthy controls, but the correlation between general psychological distress and level of selfesteem was statistically significant in both groups (r = −.44,p < .01, vs. r = −.50, p < .01).

Self-Esteem as a Mediator or Moderator
Five studies investigated selfesteem as a mediator between ADHD symptoms and various life outcomes.With age as a covariate, Michielsen et al. (2014) found that mastery and selfesteem partly mediated the relationship between ADHD symptoms and depressive symptoms (R 2 = .27)in a single mediation analysis.Arsandaux et al. (2021), who analyzed three different pathways from ADHD symptoms to suicidal ideation, found a mediating effect of selfesteem accounting for 45% of the association, compared to 25% through depression.A third pathway, through selfesteem and then depressive symptoms, accounted for an additional 19%.Their model adjusted for several covariates including age, gender, education level, conditions during college years, and substance consumption.Dan and Raz (2015), who analyzed the mediating effect of selfesteem on the relationship between ADHD and test anxiety using the Sobel test, found that the level of selfesteem functioned as a full mediator between ADHD and the social derogation facet of test anxiety (Sobel = −3.46,p = .0005)and as a par tial mediator between ADHD and the cognitive obstruction facet of test anxiety (Sobel = −2.62,p = .008).The mediating role of selfesteem and harm avoidance on the relationship between symptoms of ADHD and symptoms of social anxi ety was also studied by Evren et al. (2021).They found that selfesteem and harm avoidance together fully mediated the association between ADHD symptoms and symptoms of social anxiety [F(3,147) = 19.63,p < 0.001; Adjusted R 2 = .27].Finally, the study by Turel and Bechara (2016) should be mentioned.They investigated the potential medi ating effects of stress and selfesteem on the relationship between ADHD symptoms and the use of social network sites (SNS) while driving.The relationship between ADHD and craving to use SNS was partially mediated by stress (R 2 = .35)and selfesteem (R 2 = .19),supporting that the level of selfesteem in ADHD may be a risk factor for use of SNS while driving.

Discussion
The present systematic review aimed to identify and sum marize the empirical literature analyzing selfesteem in adults with ADHD, with a focus on the potential impact of demographics (age, gender, race/ethnicity, education level, and employment status) and clinical characteristics (presen tation of ADHD, symptom severity, and comorbid disor ders).Methodological issues in this body of work were also identified as well as crucial gaps that exist in the literature.In sum, all studies in the current review support reduced selfesteem in adults with ADHD.The results also sup ported that selfesteem acts as a mediator in numerous negative life outcomes associated with adult ADHD.How ever, several methodological constraints were identified that limit firm conclusions.
In alignment with findings in the review by Cook et al. (2014), findings from the present study support a relation ship between ADHD and reduced selfesteem in adults.This finding was well supported by the controlled studies, where four of five studies that compare an ADHD group to healthy controls found significantly lower selfesteem in the ADHD groups (Chamberlain et al., 2017;Dan & Raz, 2015;Newark et al., 2016;Turel & Bechara, 2016).Additionally, when controlling for age as a covariate, Michielsen et al. (2014) found that the participants with an ADHD diagnosis had significantly lower selfesteem than healthy controls.Overall, our findings strongly suggest that individuals with diagnosed ADHD, or who have symptoms indicative of ADHD, have lower selfesteem than in the general population.Furthermore, the severity of ADHD symptoms was negatively associated with selfesteem (Bae et al., 2019;Evren et al., 2021;Michielsen et al., 2014;Turel & Bechara, 2016), which further strengthening that adults with ADHD are at greater risk for low selfesteem.
Notably, low selfesteem was not restricted to adults with a formal ADHD diagnosis.Selfesteem was also impaired in adults with symptomatic ADHD (Chamberlain et al., 2017;Pawaskar et al., 2020;Turel & Bechara, 2016).This suggests that a diagnosed sample is not necessary to find group differences in selfesteem compared to healthy controls.Surprisingly, Pawaskar et al. (2020) found that adults diagnosed with ADHD were more likely to display higher selfesteem than symptomatic adults, potentially implying that living with the core symptoms of ADHD, not living with the diagnostic effect (e.g., stigma), is inflicting the most harm on selfesteem.
The review also supported an influencing role of demographic and clinical characteristics on selfesteem in adults with ADHD.For example, Michielsen et al. (2014) studied an older sample and observed no selfesteem dif ferences between ADHD and a younger control group.After including age as a covariate, however, the ADHD group showed significantly lower selfesteem.This pat tern is in accordance with studies showing that higher age is associated with reduced selfesteem (Orth et al, 2018;Orth & Robins, 2014).
Interestingly, gender differences appeared to be of minor importance regarding selfesteem in adults with ADHD (Chamberlain et al., 2017;Newark et al., 2016).By this, the literature review supported findings in previous reviews (Cook et al., 2014;Harpin et al., 2016) showing that males and females are more similar than different when it comes to selfesteem.The lack of observed gender differences is interesting, because men in the general population display slightly higher selfesteem than females (Orth et al., 2010), possibly explained by wordingeffects where women tend to agree more easily with negatively worded selfstatements (Magee & Upenieks, 2019).Based on two other studies, our findings suggest that all ADHD presentations are at risk of reduced selfesteem (Dan & Raz, 2015;Evren et al., 2021), but that the inattentive presentation may be at slightly higher risk (Evren et al., 2021).However, future research on demographic and clinical characteristics is needed given the limited number of studies.
It is also important to note that the relationship between selfesteem and ADHD is expected to be bidirectional: while low selfesteem can exacerbate difficulties related to ADHD symptoms (e.g., depression, social anxiety, and suicidal ideation), level of ADHD symptoms may also con tribute to low selfesteem.This is supported by studies repor ting negative correlations between severity level of ADHD symptoms and selfesteem (Bae et al., 2019;Evren et al., 2021;Michielsen et al., 2014;Turel & Bechara, 2016).This highlights the complexity of ADHD's impact on selfesteem and vice versa, and the importance of addressing self esteem in a therapeutic and clinical relationship.
Research unequivocally supports that ADHD is com monly associated with comorbid conditions like anxiety and depression (Katzman et al., 2017), each capable of inde pendently influencing selfesteem (Sowislo & Orth, 2013).Conversely, selfesteem may influence the onset of these conditions in ADHD.However, given the correlational design of the reviewed studies, causal inferences or clarifi cation of the nature of these relationships was not possible.Newark et al. (2016) found a moderate negative correlation between psychological distress and selfesteem in adults with ADHD, suggesting that psychological distress could moderate or mediate the negative correlation with self esteem in adults with ADHD.Additionally, selfesteem has been explored as a mediator in the relationship between ADHD and associated mental health issues, such as depres sion (Michielsen et al., 2014), test anxiety (Dan & Raz, 2015), and social anxiety (Evren et al., 2021), with some evidence that selfesteem may play a more significant role than depression in the link between ADHD symptoms and suicidal ideation (Arsandaux et al., 2021).
The present systematic review has highlighted the reciprocal relationship between selfesteem and overall functioning in adults with ADHD, and thus the vital role of recognizing selfesteem in both mental health research and clinical practice.Furthermore, treatment programs may benefit from including selfesteem interventions, as out lined by U. de la Barrera et al. (2022).The importance of this issue is further highlighted by studies linking self esteem to selfharm and suicidal ideation (Lippo et al., 2022), and by studies showing the impact of suicidal ide ation on core aspects of the life of an adult with ADHD (Austgulen et al., 2023).Future studies should thus focus on designing studies that substantiate the significance of self esteem on the overall functioning of adults with ADHD.

Methodological Issues and Gaps in the Literature
In the present review, the results indicate a general lack of reporting and controlling of important demographic and clinical variables such as employment status, ethnicity, pre sentation and severity of ADHD, and comorbid disorders.Given that previous research supports that these factors are associated with selfesteem, future research would benefit from addressing these variables.Considering the widespread usage of medication in the ADHD population and the possible influence of medication on selfesteem (Biederman et al., 2004), it is a concern that only one study reported medication usage among ADHD participants.It is also noteworthy that zero studies reported on nonbinary gender, as nonbinary adults may suffer from reduced life satisfaction (Kennis et al., 2022).The heterogeneity of the ADHD population, the varied methods of assessing ADHD, and the frequent use of student samples, pose challenges to generalizability.Furthermore, few studies adhere to rigor ous methodological standards such as conducting power analysis, reporting effect sizes, correcting for multiple com parisons, or preventing recall bias.These methodological shortcomings leave the validity and generalizability of our findings open for questions.
Information about potential mediating or moderating factors with impact on the relationship between different presentations of ADHD and selfesteem is also still limited, and few studies have investigated why adults with ADHD exhibit lower selfesteem.It thus seems essential to develop and empirically evaluate theoretical frameworks (e.g., Young & Bramham, 2006) that can elucidate the relation ship between ADHD and selfesteem.Such work will be critical both when assessing and personalizing intervention strategies.Taken together, there are still crucial gaps in the literature that restrict our understanding of the nature of the relationship between adult ADHD and selfesteem.

Strengths and Limitations
The application of the PRISMA approach and the use of a quality assessment tool are strengths of the present study.Limiting our review to studies using RSES enhances com parability but also excludes other relevant studies.In that RSES assesses general selfesteem rather than domain specific selfesteem, the included studies may also have missed the complexity of selfesteem dynamics in indi viduals with ADHD.The exclusion of treatment studies may also have led to the omission of potentially relevant research.Further, the psychometric properties of RSES for adults with ADHD are underexplored, raising concerns about possible wording effects.Converting RSES scores for consistency may lead to information loss.Lastly, the restriction to Englishlanguage articles introduces potential publication and cultural biases.

Future Directions
In light of the findings of the present study, future research should continue to explore the relationship between self esteem and ADHD.At present, most studies are correlational and crosssectional, and longitudinal designs are crucial for understanding casual relationships and informing inter vention strategies.Given the noted methodological issues, future studies should attempt to account for both demo graphic and clinical variables.It is essential that research include a broader range of demographic factors (e.g., gen der, presentation, and comorbidity), and explore selfesteem among individuals formally diagnosed with ADHD and those with ADHD symptomatology.Furthermore, the appli cability and validity of the RSES for adults with ADHD are unexplored and warrant investigation.

Conclusion
The results of this study underscore a strong association between low selfesteem and ADHD, aligning with results from prior reviews.The synthesis of the literature not only supported the presence of low selfesteem in adults with an ADHD diagnosis, but also in those with symptom severity indicative of ADHD.Selfesteem was also found to be clin ically important by being a mediator in the association between adult ADHD and several adverse outcomes, inclu ding depression, social anxiety, and suicidal ideation.Notably, several methodological issues characterize this body of research, which strongly encourage future research to identify mediating and moderating factors on selfesteem in adults with ADHD.The present systematic review also highlights the importance of the intersection between self esteem, psychosocial functioning, and ADHD symptoms that may keep adults with ADHD in a vicious behavioral and emotional cycle.These findings support that self esteem may be an important target for intervention for qual ity of life and to help diminish the severity of negative ADHDrelated outcomes.
Bergen, Norway.He received a bachelor's degree in renewable energy engineering at the University of Agder, Grimstad, Norway.
Bernhard Vestby Edvardsen is a fifthyear clinical psychology student at the University of Bergen, Norway.He is a research assistant at the Department of Psychosocial Science.Salvatore Matias Messina is a fifthyear clinical psychology student at the University of Bergen, Norway.
Maria Rudjord Volden is a fifthyear clinical psychology student at the University of Bergen, Norway.She is a research assistant at Bergen Center for Brain Plasticity at Haukeland University Hospital, Bergen, Norway.
Lisa L. Weyandt is a Full Professor III at the University of Rhode Island, Department of Psychology.She is also the Director of the URI Interdisciplinary Neuroscience Programs, including the graduate and undergraduate programs, and a licensed psychologist.Dr. Weyandt is nationally recognized for her research concerning the assessment and treatment ADHD.She specializes in appropriate use and misuse of prescription stimulant medication among college students with and without ADHD.Dr. Weyandt is the author of five books concerning ADHD and clinical neuroscience.
Astri J. Lundervold is a clinical specialist and a professor of clinical neuropsychology at the University of Bergen.With a multi disciplinary approach, her interest as a clinician and researcher covers topics related to the assessment and treatment of everyday challenges associated with ADHD, cognitive aging, and disorders of the gut-brain interaction.

Table 1 .
Table 1 provides an overview of the sample size, gender distribution, definition of ADHD, and age.A total of 6,085 Overview of Included Studies.ADHD symptomatic = self-reported symptom severity level indicative of ADHD diagnosis; OCPT = online continuous performance test.

Table 2
Table 2 reflects the large heterogeneity in reported levels of selfesteem between the studies, in the ADHD and the control groups.The lowest mean level of selfesteem was found in the diagnosed ADHD group included in Newark et al.'s (2016) study.The ADHD group in that study con sisted of treatmentseeking individuals who were diagnosed at site and characterized by a high mean age, as well as a high frequency of mood disorders and psychological dis tress.The symptomatic control group in Pawaskar et al.'s ( , which also includes two studies with converted means (marked with an asterisk).The mean RSES scores in the diagnosed ADHD groups varied between 15.0 and 19.3 (mean = 17.48 ± 1.91), while the mean RSES scores in the symp tomatic ADHD groups varied between 15.