Gender%20Issues%20in%20ADHD

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Gender Issues in ADHD

• Michelle Harwood
• November 12, 2003

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Rates of ADHD Gender Differences

• Clinical samples 101 ratio boys vs. girls
• Community adult samples 2 or 31 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

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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)

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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 impairment?girls less often referred
• Biederman et al., 2002

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Environmental Influences on ADHD

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

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Environmental Influences on ADHD

• Global Assessment of Functioning
• Higher risk factors?greater negative impact for
  boys than girls
• Learning Disability
• Higher risk factors?greater rate of learning
  disabilities for boys than girls
• Girls with ADHD less impaired
• Biederman, Farone, Monuteaux, 2002

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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

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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

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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

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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

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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

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Underdiagnosis in Girls

• Teachers for 8th grade high school
• More observed promiscuous behavior in girls with
  (44) than boys (28) with ADHD
• Receiving ADHD diagnosis?53 girls feel better
  about themselves vs. 36 boys

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Misdiagnosis in Females

• Lazy and irresponsible
• Undisciplined
• Not academically inclined

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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

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Alternative Explanation

• Boys are overdiagnosed with ADHD
• ADHD just typical boy behaviors
• Boys learn to read more slowly than girls high
  expectations?inattentive disruptive
• Gender differences in neurological functioning
• Boys less mature in developing social skills
• Edelman, 1999

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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

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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

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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

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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

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Observed Behavior Gender Differences

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

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Observed Behaviors Comorbidity

• Anxiety?no differences in behavior
• No behavior suppression
• ODD/CD?more breaking rules, impulsivity, and
  aggression
• Abikoff et al., 2002

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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

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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)

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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

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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

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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

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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

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Diagnosis of Girls With ADHD

• 75 girls age 4-19 (37 gt 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 gt 105
• No differences on severity of ADHD symptoms on
  parent or teacher report, neuropsych testing

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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 disorder?use
  in treatment planning
• Average or higher IQ?buffer impairment from
  earlier ADHD symptoms
• Kato et al., 2001

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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)

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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

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Inattentive Girls Daydreamers

• Appear shy avoid drawing attention to
  themselves in school
• Anxious about school forgetful
  disorganized?worry about assignments
• Difficulty staying on task during homework
• Appear easily overwhelmed or slow
• Sometimes anxious or depressed
• Nadeau, 2001

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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

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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-through?impairment with
  greater demands
• Nadeau, 2001

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Reason for Differences in Girls Presentation of
ADHD

• Hormonal influences on behavior
• Socialization differences between genders
• Greater risk of depression and anxiety influences
  behavior

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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

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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

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When Women Are Diagnosed

• Diagnosed in late 30s or early 40s
• Child receives ADHD diagnosis?mother increased
  education about ADHD?recognizes own
  symptoms?self-referral

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ADHD in Women

• 102 mothers ADHD child (mean age 41)
• Half with ADHD
• Characteristics of ADHD women
• Learned helplessness, self-blaming
• External locus of control?less effort
• History of depression anxiety
• Rucklidge Kaplan

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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

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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

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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

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Advocacy for ADHD in Women

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

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QUESTIONS?
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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 teachers 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

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Checklist for ADHD in Girls

• I get upset more easily than my friends
• Sometimes it feels like Im not good at anything
• I am frequently late
• Its hard for me to concentrate when there are
  people around me
• My parents teachers tell me I dont 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