Gender Issues in ADHD

Michelle Harwood

November 12, 2003

Rates of ADHD: Gender Differences

• Clinical samples 10:1 ratio boys vs. girls• Community & adult samples 2 or 3:1 ratio

• Gender differences for children with ADHD– Girls have lower rates of ODD & CD

– Girls have lower IQ (especially VIQ)

– Girls = boys for rates of mood, anxiety, & LD

» Wilens, Biederman, & Spencer, 2002; Kato et al., 2001

Gender Differences in ADHD

• 140 boys, 140 girls with ADHD-psychiatric referral sample– 120 boys, 120 girls as comparison group

• Girls more often inattentive type• Girls less likely to receive medication or

therapy focused on ADHD• ADHD greater risk factor for substance

disorders in girls (20 x more than boys)

Gender Differences in Comorbidity

• Differences based on varied base rates for genders – independent of ADHD status– Girls had fewer learning disabilities, ODD, CD,

major depressive disorder– Girls had more panic disorder– Girls had less school problems & engaged in

more activities

• Less impairmentgirls less often referred» Biederman et al., 2002

Environmental Influences on ADHD

• 280 ADHD, 242 healthy controls, ages 6-17

• Rutter’s indicators of adversity– Family conflict, SES, family size, maternal

psychopathology, paternal criminalility

• Risk for ADHD higher with increased number of adversity factors– No gender difference

Environmental Influences on ADHD

• Global Assessment of Functioning– Higher risk factorsgreater negative impact

for boys than girls

• Learning Disability– Higher risk factorsgreater rate of learning

disabilities for boys than girls

• Girls with ADHD less impaired» Biederman, Farone, & Monuteaux, 2002

Additional Gender Differences

• Girls with ADHD have higher rates of speech & language disorders than boys with ADHD

• Girls with ADHD have lower intellectual abilities than boys with ADHD

» Gaub & Carlson, 1997; James & Taylor, 1990

Diagnosis Trends: US National Ambulatory Medical Care

Survey• Overall cases of ADHD tripled from 1990

(947,208) to 1998 (3,234,180)

• Gender changes from 1991/92 – 1997/98– ADHD tripled for girls, doubled for boys

– Medication tripled for girls, doubled for boys

» Robinson, Skaer, Sclar, & Galin, 2002

Meta-analysis of Gender Differences

• ADHD in girls – ratings compared to boys– Lower hyperactivity, inattention, impulsivity– Lower externalizing problems– Higher intellectual impairments– Higher internalizing problems

» Gershon, 2002

Gender Difference in Diagnosis

• More girls than boys diagnosed with Inattentive Type ADHD– Academic difficulties

• Boys with more disruptive behavior– Diagnosed and treated at younger age

Underdiagnosis in Girls

• Estimated that 75% of girls with ADHD do not receive diagnosis

• National survey results– 85% teachers assume girls more likely to be

undiagnosed• 92% attribute this ADHD girls not “acting out”

– Girls with ADHD 3x more likely than boys with ADHD to be treated for depression

• Girls may be misdiagnosed with depression

Underdiagnosis in Girls

• Teachers for 8th grade & high school– More observed promiscuous behavior in girls

with (44%) than boys (28%) with ADHD

• Receiving ADHD diagnosis53% girls feel better about themselves vs. 36% boys

“Misdiagnosis” in Females

• Lazy and irresponsible

• Undisciplined

• Not “academically inclined”

Reasons for Underdiagnosis of ADHD in Girls

• DSM-IV criteria more appropriate for boys

• Girls ADHD behavior is less obvious and problematic for teachers and parents– Inattentive type more common– Less comorbid ODD, CD, LD

• Girls better able to hide, disguise, & compensate for their symptoms

Alternative Explanation

• Boys are overdiagnosed with ADHD

• ADHD just “typical” boy behaviors– Boys learn to read more slowly than girls –

high expectationsinattentive & disruptive– Gender differences in neurological functioning– Boys less mature in developing social skills

» Edelman, 1999

Gender and Race Interaction

• Teacher rated severity of ADHD symptom– African-American boys rated most severe– Caucasian girls rated least severe– African American girls = Caucasian boys

» Riccio, 2003

Observed Classroom Behavior• MTA study participants

– 403 boys, 99 girls, ages 7-10– Paired comparison classmates

• Higher externalizing behaviors in boys– Ratings of gender biases & expectations vs. observable

gender differences

• Classroom Observation Code– Gross motor, ADHD (interference), off task, aggression

Observed Behavior: Main Effects

• Main effects ADHD vs. controls– ADHD higher scores than controls on all

behavior measures

• Main effects for sex– Boys higher interference, gross motor, ADHD– Girls higher absence of negative behaviors

Observed Behavior: Gender Differences

• ADHD boys vs. control boys– Higher rates on all observed behaviors

• ADHD girls vs. control girls– Higher verbal aggression with peers, solicit

teacher attention, noncompliance etc.– No difference in physical aggression, verbal

aggression to teacher, or out-of-chair

Observed Behavior: Gender Differences

• ADHD boys vs. ADHD girls– Higher interference, aggression, & gross motor– No gender differences on off-task & fidgeting

Observed Behaviors & Comorbidity

• Anxietyno differences in behavior– No behavior suppression

• ODD/CDmore breaking rules, impulsivity, and aggression

» Abikoff et al., 2002

ADHD in Girls

• Studies focused only on ADHD in girls vs. comparison of boys to girls– Comparison uses boys symptoms as norm for

comparison

» WebMD

Comparing ADHD Girls and Control Girls

• Girls age 6-12 at summer day camp– 93 Combined Type ADHD, 47 Inattentive Type

ADHD, 88 age/gender matched controls

– All girls unmedicated during camp

• ADHD girls– Higher rates of ESE placement

– Higher rates of repeated grade

– Higher rates of adoption (20-25%)

– Higher abuse rates for Combined Type (18%)

Comparing ADHD Girls and Control Girls

• Comorbidity– Speech & language delays/problems

• ¼ ADHD (both subtypes)

– ODD/CD Highest for Combined (71%/26%)• Inattentive higher rates than controls

– Anxiety & Depression highest for Combined• Inattentive higher rates than controls

Comparing ADHD Girls and Control Girls

• Cognitive differences– ADHD groups lower on WISC-III & WIAT

• Scores within normal range

• Behavior differences– Combined type

• Higher relational aggression• Higher negative peer nominations (peer rejection)

– Inattentive type • Higher observed social isolation

» Hinshaw, 2002

Neuropsychological Difficulties• Summer camp sample

– 10 neuropsychological tests

• Rank order (lowest to highest scores)– Combined type, inattentive type, controls– Differences not based on demographic or comorbidity

• ADHD deficits in executive functioning– Self-regulation, planning, response organization, short

& long term memory, vigilance, & inhibitory control– Somewhat greater deficits in combined type

• ADHD deficits in motor speed & language

Neuropsychological Difficulties: Diagnostic Classification

• 70% correct overall– 78% with ADHD classified correctly– 58% without ADHD classified correctly

• High rate of false positives

• Poor classification of Combined vs. Inattentive type ADHD

» Hinshaw et al., 2002

Diagnosis of Girls With ADHD

• 75 girls age 4-19 (37% > age 8)– ADHD or subthreshold symptom diagnosis

• More likely to be diagnosed after age 8– Comorbid depressive disorder– Internalizing TRF score above clinical cutoff– Verbal IQ > 105

• No differences on severity of ADHD symptoms on parent or teacher report, neuropsych testing

Clinical Implications for Assessment With Older Girls

• ADHD evaluations - assess for mood disorders & other internalizing symptoms

• Mood disorder evaluation – assess for attention difficulties

• If ADHD comorbid with internalizing disorderuse in treatment planning

• Average or higher IQbuffer impairment from earlier ADHD symptoms

» Kato et al., 2001

Girls Expression of ADHD Symptoms

• Inattentive symptoms – appear “lazy” or “spacey”

• Hyperactivity – extremely talkative• High rates of relational aggression• Less rebellious, defiant, & “difficult”

behavior than boys• Symptoms increase with hormonal changes

at puberty (opposite of boys)

Hyperactive/impulsive Girls: “Tomboys”

• Physically active, risk-taking behavior– Time spent playing with boys– Interest in stereotypically male activities

• At school – disorganized, messy handwriting, switching activities

• Unlike ADHD boys – cooperative at home, attempt to please teacher at school

» Nadeau, 2001

Inattentive Girls: “Daydreamers”

• Appear shy – avoid drawing attention to themselves in school

• Anxious about school – forgetful & disorganizedworry about assignments

• Difficulty staying on task during homework• Appear easily overwhelmed or slow• Sometimes anxious or depressed

» Nadeau, 2001

Combined Type: “Chatty Kathy”

• Hyper-talkative• “Silly,” excitable, & overemotional• At school – interrupt, constant talking• In conversation – interrupt others &

themselves, switch topic, poor organization• Hyper-social – active, talkative, exciting

– Dramatic friendships – overreact & argue» Nadeau, 2001

ADHD in Girls With High IQs

• Compensate for symptoms during elementary school

• School and social difficulties not apparent until middle or high school– Problems with concentration, planning,

organization, and follow-throughimpairment with greater demands

» Nadeau, 2001

Reason for Differences in Girls Presentation of ADHD

• Hormonal influences on behavior

• Socialization differences between genders

• Greater risk of depression and anxiety influences behavior

Outcome of Untreated ADHD in Girls: Childhood/adolescence

• Depression & low self-esteem– View self as “quitter,” or untalented

• Anxiety

• Academic problems & underachievement

• Smoking in middle & high school

• Substance use

• Earlier sexual activity & teen pregnancy

Presentation of Women With ADHD

• Time management difficulties

• Disorganization

• Chronic stress/feeling overwhelmed

• Poor money management

• Sibling or child with ADHD

• History of anxiety or depression

When Women Are Diagnosed

• Diagnosed in late 30s or early 40s– Child receives ADHD diagnosismother

increased education about ADHDrecognizes own symptomsself-referral

ADHD in Women

• 102 mothers ADHD child (mean age 41)– Half with ADHD

• Characteristics of ADHD women– Learned helplessness, self-blaming– External locus of controlless effort– History of depression & anxiety

» Rucklidge & Kaplan

Comorbid PTSD

• PTSD symptoms resulting from classroom trauma during childhood

• Correlation between ADHD and PTSD symptoms – direction remains unclear

• Potential negative implications for adult women returning to school

» Adelizzi

Outcome of Untreated ADHD for Women

• Poor organization & time management chronic stress

• Divorce• Single parent (50% for ADHD child)

– Inconsistent parenting

• Financial Difficulties• Underemployment• Substance abuse• Eating disorders

Treatment for Women With ADHD

• Stimulant medication + therapy

• Therapy focused on ADHD – structured, goal-oriented coaching– Address low self-esteem

• Support groups for women returning to college

Advocacy for ADHD in Women

• National Center for Gender Issues in ADHD– www.addvance.com/ADDvance/NCGI.htim– ADDvance Online News – monthly newsletter

QUESTIONS?

Checklist for ADHD in Girls: Addvance.com

• I have trouble finishing my assignments in class

• I daydream in class

• Even when I try to listen my mind wanders

• I forget to bring papers & permission slips from home

• I have trouble following the teacher’s directions

• My mind wanders when I read

• Projects & papers are hard for me to finish

• I often do my work at the last minute & turn things in late

• I forget to bring the right books home from school

Checklist for ADHD in Girls• I get upset more easily than my friends• Sometimes it feels like I’m not good at anything• I am frequently late• It’s hard for me to concentrate when there are people

around me• My parents & teachers tell me I don’t try hard enough• Other kids tease me about being spacey• I feel different from other girls• I loose track of time• I have a messy book bag• My room at home is a disaster

» Nadeau