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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
