CHAPTER 46

Fostering Self-esteem

Richard Goldstein, MD, FAAP

A mother worries about her spouse’s sarcasm with their son. A father worries that indiscriminate praise at school inflates his child’s sense of her abilities while setting her up for “a rude awakening.” As the pediatrician walks into an examination room, a parent whispers that he wants to discuss their child’s obesity away from the child. An urgent care visit is scheduled to discuss the persistent bullying of a child in school. Embedded in these scenarios and countless others is a concern that a child’s self-esteem is malleable and fragile and that its preservation is crucial to a child’s success. What should a primary care pediatrician know about how a child’s self-concept affects the child’s thoughts, feelings, and behavior?

Basic Concepts

Parents often use the term “self-esteem” to describe their child’s confidence, implying a sense of agency and feelings of self-worth. In fact, self-esteem is a social psychological construct; it is the product of how an individual understands the effects of that individual’s actions (ie, agency) and how the individual believes those actions are seen by others (ie, self-worth). Agency, or self-efficacy, is a child’s confidence in his, her, or their capacity to successfully complete tasks or accomplish goals. Self-worth is the assessment that what a child thinks, wants, and does is important. High self-esteem often is accompanied by a sense of self-respect, purpose, and self-awareness, whereas low self-esteem typically is associated with self-questioning, defensiveness, and disproportionate self-criticism, even when receiving positive feedback. Although it may be most apparent in moments of achievement, self-esteem is also demonstrated by confidence that difficulties, failures, and disappointments are tolerable and can be accommodated. Self-esteem is essential to a child’s well-being and influences the development of relationships and identity during childhood and adulthood. It is grounded in the fact that success with other people is fundamental to a sense of who we are.

Whether a child’s self-estimate is inflated, overly negative, or accurate is not of importance to the concept of self-esteem; no “objective yardstick” exists. In this regard, it is important to understand that a difference exists between high self-esteem and nar-cissism. A child can have a healthy self-regard without a sense of entitlement, grandiosity, or feelings of superior worth. This distinction is important when critically reading research finding correlations between bullies and high self-esteem, for example; studies also find high self-esteem in those who intervene on observing bullying behavior. Alternatively, a child’s disfigurement or disability should not preclude that child from possessing feelings of positive self-esteem. Self-esteem is a phenomenologic construct, and its importance lies in how a child’s self-concept shapes that child’s actions.

Self-esteem requires the development of certain cognitive abilities, but it is also based on experiences with parents, peers, and other caregivers. Preschool-age children become much more independent and spend more time away from primary caregivers compared with younger children. This newly acquired independence, however, does not remove the need for attention, interest, and approval from their parents. Agency must be nurtured, and not simply controlled, to support self-esteem. Opportunities to demonstrate the competence of children can be recognized in the autonomy that appropriate parenting supports and heard as a source of pride in parents taking note of it. Educating parents about what is developmentally correct can be important. Competent play among preschoolers, for example, may involve playing alongside other children and may not necessarily consist of cooperative play (eg, helping each other in addition to playing together). The emergence of self-esteem can be framed in terms of Erik Erikson’s conceptualization of a child’s social development. In the “industry versus inferiority” stage, the task of a child is to demonstrate the child’s efficacy and for those efforts to be acknowledged and appreciated. The joy of autonomy and initiative are suffused with a need to live up to expectations; for example, for a young daughter part of feeling that she is a big girl is feeling that she is a good girl. The first stirrings of conscience and confidence to manage measured responsibility occur in this stage. The complex interaction of temperament, developmental stage, family security, parental style of discipline, sibling and peer interactions, and school experiences coalesce in the experience of a uniquely competent child. For her caregivers, the desire to encourage a kind of fearlessness is balanced by the very real need to keep the child safe and appropriate. All these aspects of her life contribute to the development of her competence, autonomy, and relatedness and animate her self-esteem. The development of self-esteem can be seen when children at the age of 5 years begin to experiment with identity roles, when they demonstrate an awareness of social comparison at age 7 or 8 years in their peer play and activities, and most clearly when they develop a sense of global self-esteem at approximately 8 years of age. Research also concludes that a general decline in self-esteem occurs from childhood through adolescence. It has been suggested that social comparisons and increased awareness of the perspectives of others cause adjustments to a growing child’s self-efficacy and self-worth. This is intensified during adolescence, when physical changes and increased academic and social complexity test children’s sense of who they are. Much of a child’s self-concept is established and reinforced by those around them, especially primary caregivers. Although important activities occur when the child is alone and engaged in individual pursuits, much of a child’s self-concept develops in a context of relatedness. This extends beyond the family during school years, when peers and teachers assume a more influential role in the continued development and reinforcement of self-esteem. The development of self-esteem is transactional, built by the responses children receive to their increasing initiative and abilities, resting on a foundation of security. A secure interpersonal environment is essential to exploration and correction. This transactional nature is at the core of self-esteem interventions and their enthusiasm for effects on individuals as well as society. All parents hope that their children will develop a positive self-concept that will aid them throughout their lives. Unfortunately, discussions related to self-esteem usually are held as a result of a crisis or an observation by worried parents or teachers. Primary care physicians should bring the parent’s or parents’ focus to this important aspect of their child as a normal part of anticipatory guidance. Pediatricians and health professionals are uniquely positioned to offer specific recommendations for fostering self-esteem that may affect the lives of their patients. During health maintenance visits with the child, these health professionals should model respect for the child’s self-concept and highlight the growing capabilities found in the child’s interactions.

Research

Research on self-esteem examines global self-esteem, that is, a measure of the overall assessment of the self, and domain-specific self-esteem, that is, measures of self-assessment related to performance and attributes (eg, academic competence, physical appearance). The most widely used measure for self-esteem, the Rosenberg Self-Esteem Scale, assesses global self-esteem. One difficulty in the self-esteem literature is that interventions meant to address specific performance areas are sometimes assessed with global self-esteem measures and vice versa. It is no surprise that a child’s general sense of self is insufficient to improve the child’s performance on a spelling quiz.

Some proportion of self-esteem is biologically rooted. Twin studies indicate that approximately 40% of variability in self-esteem can be explained by genetic factors. However, self-esteem also is known to have cultural underpinnings that seem to especially resonate in contemporary American culture. Whether the prominence of self-esteem is somehow rooted in the US national identity is unknown, but it is clear that the importance of self-esteem is not universally shared in all populations. For example, it is hard to detect self-esteem as a motivating factor in more collectivist cultures, such as Japan. This stands in broad contrast to its importance in US classroom reform or claims by psychologists first introduced in the 1990s that “self-esteem has profound consequences for every aspect of our existence.” The proper conceptualization and importance of self-esteem remains a matter of debate.

At first glance, it would appear that an association exists between level of self-esteem and important health outcomes. Credible research concludes that high self-esteem predicts decreased rates of depression and increased happiness. Adolescents with high self-esteem have better mental and physical health as well as higher graduation rates and are less likely to have a criminal record. Higher self-esteem predicts improved persistence when confronting failure. Lower levels of self-esteem are associated with increased rates of obesity, drug abuse, and tobacco use. It is uncertain, however, whether the demonstrated outcomes associated with levels of self-esteem are caused by those levels of self-esteem. For example, researchers are still trying to determine whether self-esteem results in higher performance or better performance results in higher self-esteem. Causation can also be considered in the context of known correlations between self-esteem and academic performance and motivation, task performance, aggression, sex and/or gender differences, ethnic differences, and health outcomes.

Whether interventions promoting enhanced self-esteem result in improved outcomes is debatable. Research seems to have tipped the scales toward benefit from such programs when the programs include 3 specific elements: attributional feedback (ie, helping children attribute outcomes to effort), goal feedback (ie, promoting realistic, attainable goals), and contingent praise (ie, praise based on effort and improvements in performance). This seems to underscore the central importance of examining domain-specific interventions and self-estimation.

Parental Guidance

Illness and Difficult Family and Social Challenges

Physical and psychiatric illnesses threaten children’s sense of who they are, undermining their self-efficacy and self-worth. Children can be left uncertain of their standing, expecting failure or feeling that they are inferior. Opportunities may exist for trusted physicians to help affected children and their families find realistic, achievable goals that affirm the children’s sense of agency. It is often beneficial to help a child and family shift the narrative away from preexisting ideals and toward what is possible and of value.

A child’s self-esteem can be particularly vulnerable in certain social and familial situations. A child may respond to negative experiences in school or at home with feelings of shame and worthlessness. Marital conflict, divorce, or the abuse of a parent may negatively influence the self-esteem of children who may feel complicit in or responsible for the problem. In such circumstances, parents are often concerned about the effect on the child, which provides an opportunity to work together to minimize negative effects. Honest, open communication between the physician and the parent or parents reinforces the need for sensitive support of the child and helps the parent or parents set priorities or rehearse how they will talk with the child about a given social or familial situation. (For in-depth discussion of divorce in particular, see Chapter 149.)

The issue of self-esteem is important in the context of managing “new morbidities.” The diagnoses of obesity, attention- deficit/hyperactivity disorder, and learning disabilities can have in common the taint of personal judgment and the threat of undermining self-worth. Frank language that is sensitive to a child’s self-esteem has a role in the disclosure of diagnosis, in addressing the reactions of both parent and child, in determining a realistic treatment plan, in acknowledging the frustrations and shame that come with slow progress, and in the framing of ultimate outcomes. Parents and patients will benefit from careful modeling by the pediatrician of how to represent and talk about the problem.

In the clinical setting, it can be challenging to provide practical advice that reflects research in this area. One helpful model for understanding self-esteem is the self-determination theory, in which a child’s general self-concept is understood as an organization of complex, hierarchically interrelated components. Self-esteem is the evaluative aspect of self-concept and is linked to intrinsic motivation. Research has demonstrated that optimal challenges, effectance-promoting feedback, and freedom from demeaning critique; parenting that promotes autonomy rather than control; and a secure interpersonal environment of relatedness are all essential contributors to intrinsic motivation and, by extension, self-esteem.

Optimal Challenges

Successful parenting creates opportunities for children to safely extend their boundaries while ensuring their feeling of personal control. An overly critical or controlling style of parenting constrains the emergence of a child’s young sense of competence and, by extension, affects the child’s self-esteem. Being handed a scribble drawing by a preschooler and told what it represents is emblematic. An appreciative, interested, positive response to the disordered marks is sustaining, whereas disinterest and immediate correction or criticism is undermining. Inconsistent or harsh parenting and authoritarian as opposed to authoritative parenting styles detrimentally affect levels of self-esteem.

It may be important to discuss the difference between encouragement and pressure with parents, and many parents may benefit from an introduction to the concept of “positive communication.” To support positive self-esteem, children need encouragement at all levels of their development (Box 46.1). This is communicated verbally and nonverbally and should be distinguished from overt pressure. For example, a first grader learning to spell should be praised for early, if flawed, application of phonemes, such as spelling “winter” as “wntur,” and may not need correction at that point. Generally, children should be given room to experiment and develop at their own rate and should not be coaxed into activities before they are ready or judged too harshly for earnest, early attempts.

When pressure occurs, it may be the result of parents having unrealistic expectations of how a child learns and develops or an improper sense that lack of success is caused by laziness or a character flaw. Inadvertent pressure can be detrimental and can cause tremendous frustration when, for example, a parent tries to lead a toddler into toilet training when the child has shown few signs of readiness. Pressuring young children to give up pacifiers or another security object without giving thought to the child’s readiness may also be quite anxiety provoking to them.

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