Gender Issues in ADHD

1. Gender Issues in ADHD Michelle Harwood November 12, 2003

2. 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

3. 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)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. “Misdiagnosis” in Females • Lazy and irresponsible • Undisciplined • Not “academically inclined”

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Observed Behavior: Gender Differences • ADHD boys vs. ADHD girls • Higher interference, aggression, & gross motor • No gender differences on off-task & fidgeting

21. Observed Behaviors & Comorbidity • Anxietyno differences in behavior • No behavior suppression • ODD/CDmore breaking rules, impulsivity, and aggression • Abikoff et al., 2002

22. 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

23. 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%)

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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)

31. 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

32. 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

33. 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

34. 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

35. Reason for Differences in Girls Presentation of ADHD • Hormonal influences on behavior • Socialization differences between genders • Greater risk of depression and anxiety influences behavior

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. QUESTIONS?

46. 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

47. 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