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ADD AND GIRLS
ADHASA 2006
WITS
DR SHABEER JEEVA
SPECIALIST PSYCHIATRIST
Melrose arch 011 684 1621
www.adhdclinicjeeva.com
ADHD: Timeline of Definitions
Minimal
Brain
Damage
First
Description of
ADHD by Still
1902
Hyperkinetic Reaction Adult ADHD Studied
of Childhood (DSM-II)
Efficacy of
Amphetamine
Attention Deficit/Hyperactivity
Disorder (DSM-III-R)
1930 1937 1950 1968 1970 1980 1987 1994
Minimal Brain
Dysfunction
Hyperactive Child
Syndrome
Attention Deficit Disorder ±
Hyperactivity (DSM-III)
Attention Deficit/Hyperactivity Disorder (DSM-IV)
Age-Dependent Decline of ADHD
Symptoms
6
Inattention
5
Impulsivity
4
3
}
Syndromatic
Criteria
}
Hyperactivity
Functional
Impairments
2
1
b = –0.25 (–0.35, –0.15)
0
<6
6-8
9-11
12-14 15-17 18-20
Age (y)
Biederman J et al. Am J Psychiatry. 2000;157: 816-818.
ADHD In Girls
Is ADHD a disorder in Girls?
• An estimated 1 million girls and women in the United States are
affected by ADHD (Arnold et al. J Abnorm Child Psychol 1996)
• The Diagnostic and Statistical Manual of Mental Disorders, Fourth
Ed. (DSM-IV) estimates that boys with ADHD outnumber girls with
ADHD by as much as 9:1 (American Psychiatric Association 2000)
However, community-based studies in which the ratio of boys to girls
with ADHD is as low as 2:5:1 indicate that prevalence in girls is
understated (Szatmari, Child Adolesc Psychiatry Clin N Am 1992)
• This suggests that school-aged girls with ADHD are less likely to be
diagnosed properly, and consequently receive inadequate treatment.
(Biederman et al. JAACAP 1999)
Diagnostic issues for girls with
ADHD
Core Symptoms:
• Both boys and girls with ADHD display the same
core symptoms
– Inattention, impulsivity, and hyperactivity.
• Boys tend to have more symptoms of
hyperactivity (Arnold J Abnorm Child Psychol
1996)
• In girls, symptoms of inattention are predominant
(Biederman et al JAACAP 1999)
Symptoms in Girls
• Hyperactivity in girls may manifest as
hyper verbalisation and emotional
excitability, rather than the motoric
hyperactivity seen in boys (Arnold et al. J
Abnorm Child Psych 1996)
Behaviours that may be seen in
girls with ADHD
General
• School phobia or avoidance
• Dishevelled appearance
• Grooming problems
In School
•Withdrawal in the classroom
•Low academic performance
•Low self esteem
•Poor social skills
(Adapted from: Nadeau, Littman and Quinn, Understanding Girls with
AD/HD, Advantage Books 1999)
Comorbidities in girls with ADHD
• Conduct Disorder and oppositional defiant
disorder – prevalence in girls with ADHD is
about half that found in boys with ADHD
(Biederman et al. JAACAP 1999)
• These disorders are associated with the
behavioural deviance and aggression that often
drives clinical referral. Therefore, the low rates
of these disorders in girls and their natural
tendency to be less active, more compliant, and
less aggressive, may account for the under
recognition of ADHD in girls compared with
boys.
Symptom profile of girls with ADHD
•
•
•
•
•
•
•
Acts before thinking
Difficulty waiting turn
Blunt answers
Interrupts
Talks excessively
Difficulty playing quietly
Fidgety
Symptom profile of girls with ADHD
continued
•
•
•
•
•
•
•
Difficulty remaining seated
Does not listen
Loses things
Easily distracted
Difficulty following instructions
Difficulty sustaining attention
Shifts activities
Pharmacotherapy for ADHD in girls
• Pharmacotherapy combined with behavioural is
a highly effective treatment for girls with ADHD
(MTA. Arch Gen Psychiatry 1999)
• Stimulants (e.g. MPH or amphetamine) are the
first-line pharmacotherapy for treating core
symptoms of ADHD (Greenhill et al. JAACAP
2002; AAP, Paediatrics 2001)
• Several studies show that immediate-release
(IR) MPH has equivalent beneficial effects in
boys and girls (Pelham et al. JAACAP 1989;
Sharp et al. JAACAP 1999)
• Of particular relevance to girls is the
recent finding that stimulant
pharmacotherapy in childhood may be
associated with a reduced risk of
subsequent drug and alcohol abuse
(Wilens et al. Paediatrics 2003)
Psychiatric
Comorbidities in
Girls with ADHD
Anxiety
(34%)
MD
(20%)
23%
7%
7% 4% CD
(8%)
2%
Noncomorbid
(55%)
2%
Biederman et al. J Am Acad Child Adolesc Psychiatry. 1999;38:966.
Patients with “ADHD” may suffer
Because…..
•
•
•
•
Their parents don’t understand them;
Their teachers can’t stand them;
Their peers reject them;
Their spouses and bosses can’t stand
their disorganization and intensity;
• They themselves begin to think: “no
matter what I do I can’t win…”
Famous People with Attention Deficit
and Learning Disorders
• Albert Einstein
•Nelson Rockefeller
•Galileo
•Thomas Edison
•Sylvester Stallone
•Mozart
•Gen. George Patton
•Cher
•Leonardo da Vinci
•John F. Kennedy
•Gen. Westmoreland
•Whoppi Goldberg
•Bruce Jenner
•Charles Schwab
•Tom Cruise
•Eddie Rickenbacker
•Danny Glover
•Henry Winkler
•Harry Belafonte
•John Lennon
•F. Scott Fitzgerald
•Walt Disney
•Greg Louganis
•Robin Williams
•Steve McQueen
•Winston Churchill
•Louis Pasteur
•George C. Scott
•Henry Ford
•Werner von Braun
•Tom Smothers
•Robert Kennedy
•Dwight D. Eisenhower
•Suzanne Somers
•George Bernard Shaw
•Lindsay Wagner
•Jules Verne
•Beethoven
•Alexander Graham Bell
•“Magic Johnson”
•Hans Christian Anderson
•Woodrow Wilson
•Carl Lewis
ATTENTION DEFICIT DISORDER
INATTENTION
(Distractible)
IMPULSIVITY
(Act before thinking)
A.D.D.
Girls > Boys
ATTENTION DEFICIT HYPERACTIVITY
DISORDER
INATTENTION
(Distractible)
IMPULSIVITY
(Act before thinking)
A.D.H.D.
HYPERACTIVITY-IMPULSIVITY
CLUSTER
boys>girls
+ Hyperactivity-
Concurrent conditions in dx
ADHD
O.D.D.
S.L.D
C.D.
Prevalence and Genetics of ADHD






6-8% of children; 3-5% of adults
Male-Female: 6:1, 3:1, 1:1
All levels of IQ
All levels of socioeconomic status
Family genetic transmission: 0.91
Inheritance not specific to subtype
Symptoms of Hyperactivity Often
Manifest Differently in Adults
Hyperactivity often changes to inner restlessness
DSM-IV Symptom Domain
 Squirms and fidgets
 Can’t stay seated
 Runs/climbs excessively
 Can’t play/work quietly
 “On the go”/driven by
motor
 Talks excessively
Common Adult Manifestation
 Workaholic
 Overscheduled/
overwhelmed
 Self-selects a very active
job
 Constant activity leading to
family tension
 Talks excessively
Symptoms of Impulsivity Often
Manifest Differently in Adults
Impulsivity in adulthood often carries more
serious consequences
DSM-IV Symptom Domain
 Blurts out answers
 Can’t wait turn
 Intrudes/interrupts others
Common Adult Manifestation
 Low frustration tolerance
− Losing temper
− Quitting jobs
− Ending relationships
− Driving too fast
− Addictive personality
Symptoms of Inattention Often
Manifest Differently in Adults
DSM-IV Symptom Domain
 Difficulty sustaining
attention
 Doesn’t listen
 No follow-through
 Can’t organize
 Loses important things
 Easily distractible,
forgetful
Common Adult Manifestation
 Difficulty sustaining attention
− Meetings, reading, paperwork




Paralyzing procrastination
Slow, inefficient
Poor time management
Disorganized
Comorbid Psychiatric Disturbances Are
Common in Adults With ADHD
Antisocial Disorder (10%)
Major Depressive Disorder (35%)
Bipolar Disorder (15%)
Anxiety Disorders (40%)
Substance Abuse Disorders (50%)
Shekim WO et al. Compr Psychiatry. 1990;31:416-425.
Biederman J et al. Am J Psychiatry. 1993;150:1792-1798.
ADHD and Comorbid
Conditions
Inattention
Impulsivity/
Hyperactivity
Comorbidity
Sound of Music
Is It ADHD?
DSM-IV Inattention Symptoms
in Adults with ADHD
M
•
•
•
•
•
•
•
•
•
Easy distractibility
Difficulty sustaining attention
Difficulty organizing tasks
Difficulty listening
Difficulty following instructions
Lack of sustained mental effort
Inattention to details
Forgetfulness
Losing things
85
88
76
76
71
68
73
71
61
% present
F
T
98
85
85
74
78
74
67
70
63
87.0
86.5
80.5
75.0
74.5
71.0
70.0
70.5
62.0
DSM-IV Hyperactivity-Impulsivity
Symptoms
in Adults with ADHD
M
Hyperactivity
• Running about
• Being on the go
• Talking too much
• Fidgeting
• Difficulty engaging in leisure
• Leaving seat
% present
F
Average
67.1
64.5
55.3
48.7
46.1
34.2
63.0
63.0
70.0
67.0
44.0
22.0
65.05
63.75
62.65
57.85
45.05
28.10
57.9
50.0
56.6
70.0
74.0
59.0
63.95
62.00
57.80
Impulsivity
•
•
•
Difficulty awaiting turn
Interrupting or intruding
Blurting out answers
Associated Symptoms
in Adults with ADHD
% present
Male Female Total
• A sense of underachievement
• An intolerance of boredom
• Many projects going
simultaneously
• Inability to reach potential
• Problems with time management
• Impatience
• Chronic procrastination
• Frequent search for high stimulation
• Sense of insecurity
• Feeling disappointed and discouraged
• Forgetfulness
• Poor self-esteem
92.1 92.6
77.6 100.0
88.5 88.9
92.3
88.8
87.2
85.5
77.6
85.5
84.2
76.3
75.0
73.7
76.3
75.0
83.5
83.3
83.3
81.0
80.8
78.2
73.9
73.3
72.7
81.5
88.9
77.8
77.8
85.2
81.5
74.1
70.4
70.4
Most Frequently Associated
Symptoms in Adult ADHD
(cont’d)
% present
•
•
•
•
•
•
•
•
•
Tendency to say what comes to mind
Trouble in following “proper” procedure
Nervousness
Stress intolerance
Difficulty enjoying work
Frequent mood swings
Long standing unhappiness
Impulsivity
Frequent finger drumming
M
F
T
73.7 70.4 72.0
65.8 77.8 71.8
72.4 62.9 67.7
71.1 62.9 67.0
63.2 62.9 63.1
64.5 59.3 61.9
65.8 55.6 60.7
52.6 66.7 59.6
65.8 48.2 57.0
Most Frequently Associated
Symptoms in Adult ADHD
(cont’d)
•
•
•
•
•
•
•
•
•
Hot temper
Depression
Frequent job changes
Verbal aggression
Self-destructive behavior
Alcohol abuse
Physical aggression
Drug abuse
Difficulty with the law
M
63.2
53.9
44.7
53.4
34.2
19.7
18.4
19.7
10.5
% present
F
T
48.2 55.7
48.2 51.0
55.6 50.1
33.3 43.6
33.3 33.8
11.1 15.4 *
11.1 14.8
3.7 11.7 *
3.7
7.1*
ADHD Comorbidities:
A Developmental Perspective
ODD, CD,
Language Disorders
Learning problems,
Developmental problems
Pre-school
ODD, CD, LD,
Anxiety and/or
Mood Disorders
Anxiety Disorders
Mood Disorders
Substance abuse
Personality Disorders
Adolescent
School-age
ODD, CD, Learning
Disabilities, Anxiety Disorders
Adult
College-age
ODD, CD, LD,
Anxiety Disorders
Mood Disorders
Substance abuse
Comorbidity in Adult ADHD
Disorder
Males
Females
Maj. Dep.
35,71%
54,02%
41,08%
Anxiety Dis
14,76%
27,59%
18,52%
Dysthymic Dis
12,86%
16,09%
13,80%
ODD
5,24%
3,45%
4,71%
CD
0,48%
3,45%
1,35%
36,19%
22,99%
32,32%
210
87
297
ADHD only
19+
Total
ADHD Life Cycle Changes
Prevalence
Child
Adolescent
Adult
7-13%
6-8%
4-5%
Subtype
ADHD>ADD
Comorbidity
ODD,CD + ANX-DEP
LD, LAN D
Rx response
ADHD=ADD
ADD>ADHD
ANX-DEP
SUB USE, PD
very good
very good
very good
(high remission/normalization)
Gender and Comorbidity
• More common in males: Aggressive
Behavior, Substance Abuse, Conduct and
Antisocial Personality Disorder
• More common in females: Anxiety
Disorders and Mood Disorders
Conclusions
• ADHD has a high rate of comorbidity in
adults
• The determination of associated comorbid
disorders in adult ADHD is essential to
establish the “goodness of fit” between
patient symptom/comorbidity profile and
treatment options