ADHD, or Childhood Narcissism?

In a typical American classroom, there are nearly as many diagnosable cases of ADHD as there are of the common cold. In 2008, researchers from the Slone Epidemiology Center at Boston University found that almost 10 percent of children use cold remedies at any given time. The latest statistics out of the Centers for Disease Control and Prevention estimate that the same proportion has ADHD.

The rising number of ADHD cases over the past four decades is staggering. In the 1970s, a mere one percent of kids were considered ADHD. By the 1980s, three to five percent was the presumed rate, with steady increases into the 1990s. One eye-opening study showed that ADHD medications were being administered to as many as 17 percent of males in two school districts in southeastern Virginia in 1995.

With numbers like these, we have to wonder if aspects of the disorder parallel childhood itself. Many people recognize the symptoms associated with ADHD: problems listening, forgetfulness, distractibility, prematurely ending effortful tasks, excessive talking, fidgetiness, difficulties waiting one’s turn, and being action-oriented. Many also may note that these symptoms encapsulate behaviors and tendencies that most kids seem to find challenging. So what leads parents to dismiss a hunch that their child may be having difficulty acquiring effective social skills or may be slower to mature emotionally than most other kids and instead accept a diagnosis of ADHD?

The answer may lie, at least in part, with the common procedures and clinical atmosphere in which ADHD is assessed. Conducting a sensitive and sophisticated review of a kid’s life situation can be time-consuming. Most parents consult with a pediatrician about their child’s problem behaviors, and yet the average length of a pediatric visit is quite short. With the clock ticking and a line of patients in the waiting room, most efficient pediatricians will be inclined to curtail and simplify the discussion about a child’s behavior. That’s one piece of the puzzle. Additionally, today’s parents are well versed in ADHD terminology. They can easily be pressured into bypassing richer descriptions of their kid’s problems and are often primed to cut to the chase, narrowly listing behaviors along the lines of the following:

All too often, forces conspire in the doctor’s office to ensure that any discussion about a child’s predicament is brief, compact, and symptom-focused instead of long, explorative, and developmentally focused, as it should be. The compactness of the discussion in the doctor’s office may even be reassuring to parents who are baffled and exasperated by their kid’s behavior. It is easy to understand why parents may favor a sure and swift approach, with a discussion converging on checking off lists of symptoms, floating a diagnosis of ADHD, and reviewing options for medication.

Childhood Narcissism

In my experience, the lack of a clear understanding of normal childhood narcissism makes it difficult for parents and health-care professionals to tease apart which behaviors point to maturational delays as opposed to ADHD.

What is normal childhood narcissism? It can be boiled down to four tendencies: Overconfident self-appraisals; craving recognition from others; expressions of personal entitlement; and underdeveloped empathy.

Let’s start with overconfident self-appraisals. The veteran developmental psychologist David Bjorklund says the following of young children:

It is normal for preschoolers to think big and engage in magical thinking about their abilities, relatively divorced from the nature of their actual abilities. Even first graders, according to research by psychologist Deborah Stipek of the University of California at Los Angeles, believe they are “one of the smartest in the class,” whether this self-assessment is valid or not. The play of young children is full of references to them being all-powerful, unbeatable, and all-knowing. As most parents intuit, this overestimation of their abilities enables young children to take the necessary risks to explore and pursue activities without the shattering awareness of the feebleness of their actual abilities. For maturation to occur, kids need to get better at aligning their self-beliefs about personal accomplishments with their actual abilities. They also need to get better at realizing how a desired outcome is fundamentally connected to how much effort and commitment they put into a task. The ways in which caregivers deal with kids’ successful and not-so-successful demonstrations of supposed talents have a bearing on how well kids form accurate beliefs about their true abilities. This brings us to the next ingredient of normal childhood narcissism—recognition craving.

The eminent psychoanalyst Dr. Heinz Kohut had much to say about kids’ showiness and its role in the acquisition of self-esteem. He was the one who brought the concept of narcissism into the spotlight during the 1980s. He proposed that adequate handling of a kid’s “grandiose-exhibitionistic needs” is one pathway toward establishing a kid’s basic sense of self-worth. Consider, for example, a toddler who discovers for the first time that she can run across the living room unassisted. She brims with pride and is delighted by her masterful display. Her mood is expansive. She turns to caregivers for expressions and gestures that mirror back her sense of brilliance. Appreciation and joy shown by caregivers during these moments of exhibitionistic pride are absorbed like a sponge and become part of the child’s self-experience. Such praise becomes the emotional glue that she needs to hold together a basic sense of aliveness and self-worth.

Disappointment, of course, always lurks around the corner. Kids cannot always flawlessly swing across the monkey bars or execute a perfect cartwheel. Parents are not always able to pay undivided and sensitive attention to their kids’ efforts. And parents cannot, and should not, be constant sources of unqualified praise. They only need to be good enough in their recognizing efforts. It is also important that parents do not emotionally rescue their kid when his or her pride gets injured. Gushy statements aimed at putting Humpty Dumpty back together again should be avoided. When a narcissistically needy seven-year-old loses in a footrace with Joey, a neighbor, it’s better to avoid saying, “You are a great runner. Your dad and I even think you’ll be a wide receiver one day. Come on now. Wipe off those tears.” What his emerging sense of self needs is something more like this: “Honey, I’m so sorry you lost. ... I know how bad you must feel. ... It feels so great to win. ... But you know Joey is on the all-star soccer team and has been practicing his running for months. It’s gonna be tough to race against him anytime soon. You can always jog with your dad on Saturday mornings. That will surely make your legs stronger, and who knows what might happen?” This sort of measured response ensures that kids will develop realistic self-appraisals. It also aids with the sort of self-talk that kids need to acquire to help them restore their self-esteem in the face of failures and setbacks, without crumbling in shame or lashing out at others because their pride has been injured.

Caregivers usually find kids’ exaggerated claims of what they can perform and witness-my-brilliance moments tolerable, if not cute and amusing. However, when encountering kids’ expressions of personal entitlement, most caregivers bristle. It is tempting for most caregivers to think that something is morally or medically wrong with their six-year-old when he or she stubbornly refuses to eat pasta for dinner as everyone around the table chows down with gusto, or when their five-year-old defiantly runs down the driveway rather than files into the minivan with the rest of the family to see a movie at the mall. What are we to make of such extreme attempts on the part of kids to stubbornly insist upon things going their way or to act like they deserve special attention or treatment?

One way of thinking about this involves kids’ need for autonomy. They need to have a measure of control over what happens to them and around them, to have access to sources of pleasure that arouse and enliven them, and to have the means to avoid sources of pain. Throughout their childhood, kids also need a measure of control over the pace of life to which they are required to adapt, without becoming excessively understimulated or overstimulated much of the time. The proverbial “morning rush to get out the door” often sets the stage for kids’ most bothersome displays of personal control. A sudden “fashion crisis” necessitating a last-minute dash to the clothes hamper, or a refusal to turn off the television and leave for school, can signify how exasperated a kid is over the mandate that he or she move at a pace that may be convenient for grown-ups but is immensely stressful for him or her. These types of defiant behaviors can also signify how effective a kid has been at pressing his or her agenda in the past, knowing parents will ultimately surrender to his or her wishes.

The final dimension of normal childhood narcissism I will discuss is empathy underdevelopment. Empathy is fundamentally an emotional experience. It involves “feeling along with others.” It entails a capacity to join with others and be sensitized to their emotions. Young preschoolers often hover nearby a crying friend and make awkward attempts to be comforting. This shows a rudimentary emotional connection that is the basis of empathy. By the time kids reach age four or five, caring behaviors become much more refined. By this age, most kids are well on their way to naming and verbally elaborating upon the feelings others are manifesting. Of course, the greater the spectrum of emotions a kid is allowed to experience—and allows him-or-herself to experience—the more fully he or she is able to empathize with others across a range of feeling states in a variety of emotional situations.

Maintaining a healthy degree of empathy is a balancing act. Often the struggle for young children is to be sensitized to another person’s distress, anger, or excitement without becoming oversensitized or desensitized by it. When children become overly upset in the face of another kid’s negative feelings, they experience what developmental psychologist Nancy Eisenberg calls a “personal distress reaction.” These types of reactions tend to make kids more self-focused because, once distressed, a kid is more concerned about his or her own self-comfort instead of how to be a friend to someone in need.

Empathic concern for others and feeling connected to them makes a kid “ruthful.” It dissuades a kid from engaging in “ruthless” acts of aggression. Where there is empathy, there is the experience of another’s suffering as being one’s own to some degree. In conflicts, the emotional pain caused by aggressive actions reverberates back to the child via empathic connection. It acts as a deterrent against wilder acts of aggression. It spurs the motivation to back off, make up, and make amends. Empathy maturation, more often than not, is something that needs to be coaxed along by parents, caregivers, and educators. Kids should be prodded into elaborating on how they think a friend might be feeling: “Marissa has a frown on her face. How do you think calling her a witch made her feel?” They need to be reminded of the importance of sometimes putting their needs aside for the time being. At Bob’s birthday party, for example, it is Bob’s time to be the focus of everybody’s enjoyment.

Childhood Narcissism and ADHD-Like Behavior

When I listen carefully to how parents describe their kid’s ADHD-like behavior, their descriptions often touch upon normal and not-so-normal levels of childhood narcissism of the sort I have just discussed:

Evidence of childhood narcissism—overconfident self-appraisals, attention-craving, a sense of personal entitlement, empathy struggles—are nestled in these snippets I have collected over the years in my work with kids who have been brought to me because of suspected ADHD. In my book Back to Normal: Why ordinary childhood behavior is mistaken for ADHD, bipolar disorder, and autism spectrum disorders, I painstakingly go through most of the core symptoms of ADHD and show how closely they resemble aspects of childhood narcissism. For now, let me give you a flavor of this approach by analyzing a few of the above examples.

Take Jonah’s situation. He falls apart emotionally when unable to immediately master a task. One hypothesis is that this is a symptom of ADHD (not that a single indicator is positive proof of a disorder). Difficulties with retention of information needed to successfully execute a task—say, learning his multiplication tables—may predispose Jonah to tear up his math sheet and storm out of the room. However, another hypothesis is that he demonstrates a good dose of magical thinking. He believes mastering tasks should somehow be automatic—not the outcome of commitment, perseverance, and effort. Jonah’s self-esteem may also be so tenuous that it fluctuates greatly. For instance, when Jonah anticipates success, he productively cruises through work, eager to receive the recognition that he expects from parents and teachers. He is on a high. He definitely feels good about himself. But in the face of challenging work, he completely shuts down, expects failure, outside criticism, and wants to just give up. He feels rotten about himself. His life sucks. Wild swings in productivity like this are sometimes evidence of nothing other than shaky self-esteem in kids. These are kids whose feeling about themselves is overly dependent on outside praise and criticism. When they experience success, they believe they are outstanding individuals, and when they experience failure, they believe they are worthless individuals.

Similarly, does Samantha exhibit the disorganization commonly seen in ADHD children or a sense of entitlement whereby she resists accommodating others, believing that others should accommodate her by giving her special dispensations?

And does Ernesto have impulse-control problems or are his emotional boundaries underdeveloped? Does he absorb the feelings of those he comes into contact with in ways that unhinge and frazzle him?

When we truly listen to parents and refrain from shoehorning their descriptions into nifty behavioral phrases, overlaps begin to emerge between what is often described as ADHD phenomena and normal childhood narcissism.

Turning to the Research

I don’t expect readers to be entirely satisfied with my informal proposals linking ADHD phenomena with childhood narcissism. These days, scientific findings have an exalted status—especially with ADHD. This disorder is widely considered to be neurological in nature, perhaps best left to the brain specialists to investigate with modern imaging technology. If I leave out scientific findings demonstrating linkages of the sort I am proposing, I run the risk of being perceived as just another naysayer who naively equates ADHD with childish behavior. I am not in the same camp as the pediatric neurologist Fred Baughman, who has gone on record with his rather brazen perspective: “ADHD is total, 100 percent fraud.” Therefore, off we go.

Let’s return to Frank, introduced earlier. Frank thinks he’s a good planner. According to his mother, that’s plain hogwash. Frank also sees himself as focused and organized when it comes to his homework. Is he, as his mother suspects, a pathological liar? Could he be suffering from amnesia? Dr. Betsy Hoza of Purdue University would say that Frank is neither a pathological liar nor an amnesiac but given to engaging in “positive illusory bias.” For years, Dr. Hoza and her colleagues have examined the peculiar habit ADHD children often have of trumping up their beliefs about themselves relative to their true abilities. Across a variety of research projects, she has discovered that ADHD children tend to believe that they are more socially and academically competent than they indeed are. They also believe their capacity for self-control is higher than what parents and teachers confirm. Dr. Hoza holds fast to the theory that ADHD kids inflate their self-images for protective reasons, because their ADHD confronts them with daily experiences of failure.

But what if, in many cases, it is a child’s inflated self-image that sets him or her up for failure, not ADHD per se? What if, rather than having ADHD, a child has unrealistic performance expectations that make him or her reluctant to persevere in the face of challenge or likely to abort a task at the first sign of failure? What if, instead of treating a child for ADHD, caregivers worked with the child to address his or her overconfidence? Curiously, Dr. Hoza hints at the need for “humility training” with ADHD kids to address their overly positive self-images. This same approach would be applied to problematic childhood narcissism.

In 2006, Dr. Mikaru Lasher and colleagues from Wayne State University in Michigan did what several ADHD investigators have done before and others have done since. They demonstrated to the scientific community that ADHD children tend to score very poorly on measures of empathy (showing concern for others and being aware of how one might make others feel). They even took a page from the work of Dr. Hoza. It was substantiated that ADHD children’s self-perceptions of empathy were inflated compared with what their parents were seeing. As cognitive psychologists, they chalked this up to the lack of cognitive flexibility shown by ADHD children. No doubt, if pushed, they would wax eloquently on ADHD children’s brain deficiencies. Nonetheless, it is tempting to wonder if what they were really measuring were subtle narcissistic tendencies in children labeled ADHD. Lacking empathy and exaggerating one’s skill set are, as we have seen, quintessential narcissistic traits.

ADHD kids are seldom perceived to be perfectionists. Don’t perfectionists persevere until they get it right? Don’t they relish looking for the devil in the details? Don’t they scan their work for errors and revise, revise, revise? Such behaviors are hardly associated with ADHD. Therefore, I had to reflect thoughtfully when I uncovered a bit of scientific knowledge on ADHD kids put out by University of New Orleans psychologist Michelle Martel and her team: “We also found evidence of an unexpected rare group of youngsters with ADHD and obsessive or perfectionistic traits.” What are we to make of this? Actually, there is another way to think of perfectionistic traits. A kid who refuses help and persists in using an ineffective method over and over to no avail is a perfectionist. So too is a kid who avoids or fails to finish tasks that he or she cannot master easily and impeccably. Then again, there is the kid who is only motivated to perform in areas where he or she has a track record of excellence. It must be these forms of perfectionism that Dr. Martel and her colleagues found to be true of a subset of ADHD kids. But wouldn't that suggest that these particular “ADHD” kids fall on the outer edges of the continuum of normal childhood narcissism?

Let’s return to the examples given in the previous section. Take Maria. She’s the drama queen. Parents who think their kid has ADHD often describe scenarios at home where the kid reacts to minor setbacks with bloodcurdling screams or to modest successes with over-the-top exuberance. I can’t tell you the number of times I've had parents in my office describe to me a homework scenario where their otherwise bright, thought-to-be-ADHD kid complains bitterly, writhes around on the floor, and tears up homework in a rage—all to make the homework torture stop. Of course, some of these kids truly have ADHD, and homework truly can represent a form of mental torture. But for others, dramatic displays of emotion are attempts to get out of tasks that warrant commitment, application, and effort. If their caregivers repeatedly succumb to the pressure, these kids often do not acquire the emotional self-control necessary to buckle down and do academic work independently. These emotionally dramatic kids appear on the surface as if they had ADHD. Dr. Linda Thede of the University of Colorado at Colorado Springs would probably concur. At an annual American Psychological Convention, her presentation on the thirty “ADHD” children she had rigorously studied revealed that they were more likely to have histrionic and narcissistic personality traits than non-ADHD children. (“Histrionic” is a fancy clinical word referring to overly dramatic behavior intended to call attention to oneself.)

This brings us full circle. Is it possible that what appear to be ADHD symptoms are really normal narcissistic personality traits that, in high doses, can become problematic for kids? I would say this is certainly true in many, but not all, cases. Hard-to-manage narcissistic traits oftentimes overshadow and better explain what on the surface looks like can certainly lead to a diagnosis of ADHD, when it is the narcissistic traits with which educators and mental health professionals should concern themselves.

This post is adapted from Enrico Gnaulati's Back to Normal: Why Ordinary Childhood Behavior Is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.