An important limitation in prior research on ADHD is that the vast majority has been conducted primarily with boys.  In part, this is because ADHD occurs less often in girls than in boys. And, ADHD is more likely to be overlooked in girls than in boys, even when it is present.  Whatever the reasons for the relative lack of research on ADHD girls, the result is that researchers know less about how ADHD influences girls' development and psychological functioning.  This is especially true in the case of adolescent females with ADHD.

A paper published in a recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) represents an important step in reducing this current gap in our knowledge (Rucklidge, J.J., & Tannock, R. (2001). "Psychiatric, psychosocial, and cognitive functioning of female adolescents with ADHD". JAACAP, 40, 530-539.)  In this study, the psychiatric, psychological, and cognitive functioning of 13-16 year old adolescent males (n=38) and females (n=24) with a confirmed diagnosis of ADHD was examined.  Groups of non-ADHD male (n=20) and female adolescents (n=28) also were included for comparison purposes.

The inclusion of these four groups enabled the authors to examine how the functioning of female adolescents with ADHD compared to both female adolescents without ADHD and male adolescents with ADHD - these are both areas about which relatively little is currently known.  Among the adolescents with ADHD, 33% of the females and 20% of the males were newly diagnosed during the study, while the others had been previously diagnosed. About 50% of all participants (both male and female) were receiving medication treatment - generally with a psychostimulant such as Ritalin or Dexedrine - but all participants were off medication at the time the study assessments were conducted.

Measures

In order to obtain a comprehensive view of the adolescents' functioning, a wide variety of measures were included in this study.  To assess psychiatric functioning (i.e. the presence of psychiatric diagnoses in addition to ADHD), adolescents and their parents underwent structured psychiatric interviews.  Parents, teachers, and the adolescents themselves also completed the appropriate version of the Conners Rating Scale, a standardized behavior-rating instrument that is widely used in the assessment of ADHD and other behavior/emotional problems.

To assess psychological functioning, adolescents completed self-report measures of symptoms of both depression and anxiety using the Child Depression Inventory (CDI) and the Revised Children's Manifest Anxiety Scale (RCMAS).  An assessment of adolescents' attributional style and locus of control also was conducted.  Attributional style refers to the way individuals tend to explain the occurrence of positive and negative events in their lives.  Extensive prior research has indicated that, in general, individuals who are depressed tend to see positive events as the result of external factors rather than their own efforts. They also see positive events as unstable - i.e. unlikely to occur again.  In contrast, negative events (i.e. failing to obtain a desired outcome) are understood as internally caused (i.e. "I'm not good enough."), stable (i.e."Things will never work out the way I want"), and global (i.e. "This will be true in others areas as well").

In the cognitive domain, a comprehensive psychoeducational assessment was conducted on all participants.  This included an individually administered IQ test and test of academic achievement.

Results

Psychiatric symptoms

As one might expect, compared to non-ADHD females, ADHD females had higher scores on all Conners scales specific to the problems associated with ADHD. In addition to the ADHD-specific scales, however, ADHD females also had higher ratings on scales that measure oppositional behavior, cognitive problems, anxiety, perfectionism, social problems, and emotional liability. Thus, adolescent girls with ADHD were struggling in a wide variety of areas according to their parents, their teachers, and themselves.

Not only were adolescent females with ADHD having more difficulties across multiple areas than non-ADHD females, but there was also evidence of greater difficulties in some areas than was reported for the ADHD males.  Parents reported ADHD females had more inattentive symptoms, cognitive problems, social problems, and ADHD symptoms overall.  Teachers reported that ADHD females had more ADHD symptoms than ADHD males.   ADHD females themselves even reported more conduct problems, cognitive problems, and ADHD symptoms. Thus, contrary to what is often believed, adolescent females with ADHD appeared to be having more difficulty in a variety of areas than adolescent males with ADHD.

Psychosocial measures

Compared to non-ADHD females, adolescent females with ADHD reported higher overall levels of anxiety, physiological symptoms of anxiety, social concerns, depressive symptoms, feelings of ineffectiveness, and negative self-esteem.   They were less satisfied with their teachers, had experienced a greater number of negative life events, were more suspicious of others, and more obsessive.  They also demonstrated a less healthy pattern of attributions.  (That is, they were more likely to explain negative events as being caused by stable characteristics of themselves and positive events as resulting from external factors and being unlikely to reoccur.)  Given this combination of findings, it is not surprising that they were also more likely to report both current and past suicidal thoughts.

Even compared to adolescent males with ADHD, females with ADHD reported more interpersonal problems, feelings of ineffectiveness, lack of pleasure, and negative self-esteem.  They also reported more obsessive symptoms and anxiety, as well as a strong tendency to be affected by negative life events.

Both males and females with ADHD were somewhat more likely than non-ADHD adolescents to report that they used some illegal substance during the past 12 months. The difference, however, was not significant.   Among the ADHD adolescents, those who were taking medication to treat their ADHD - about half of each group - were no more likely to report illicit drug use than those not treated with medication.  In fact, those who were not being treated with medication were twice as likely to report prior or current drug use and this difference was statistically significant.

Cognitive functioning

Compared to non-ADHD females, adolescent girls with ADHD had significantly lower IQ scores and achievement scores in reading, spelling, and math. Despite scoring lower than non-ADHD females, however, the mean score for adolescent females still fell within the average range.  Compared to adolescent males with ADHD, there were no IQ or academic achievement differences.

Note: Comparisons between non-ADHD male and female adolescents were also made on all measures collected in the study.  In general, results for these groups were quite similar, which suggests that the differences reported between males and females with ADHD cannot attributed solely to gender.

Summary and Implications

The results of this study underscore the degree to which ADHD among female adolescents is a serious concern.  Clearly, the females in this study were not simply a bit more " dreamy" or impulsive than their peers.  Instead, they were more impaired than non-ADHD peers on virtually every measure of psychiatric, psychological, and cognitive functioning examined.  The fact that 50% of these girls had entertained prior suicidal considerations and 25% reported prior episodes of self-harm underscores the struggles of individuals in this group.

Somewhat surprisingly, and perhaps contrary to the beliefs of many, adolescent girls with ADHD appeared to be having a more difficult time than adolescent boys with ADHD.  Parents and teachers rated girls as having more ADHD symptoms, and noted that girls also displayed more behavioral difficulties, social difficulties, anxiety, and depression.  In regards to adolescents' own reports, when any differences between males and females with ADHD were found, it was always in the direction of females reporting more distress.  While this may possibly reflect the fact that girls are simply more willing to acknowledge emotional difficulties than boys, the fact that parents and teachers reported similar differences seems to make this explanation less likely.  In future work it would be especially important to examine why ADHD may take a greater toll on the psychological functioning of girls than boys.  Perhaps this is related to differences in how boys and girls with ADHD are treated, since girls are less likely to be identified and receive appropriate care.

As always, it is important to remember that the results of this study represent what was found for adolescent girls with ADHD as a group, and would not represent the experience of all such individuals.  Thus, many adolescent girls with ADHD would not experience the same kinds of struggles described here, and parents should not assume that their own child is experiencing such problems.  These findings do underscore the need to be attentive to such issues, however, and alert both parents and professionals to the kinds of experiences that may be more likely among teen-age girls with ADHD.

In summary, this is an important study in that it is the first attempt to take a comprehensive look at the functioning of female adolescents with ADHD - a group that has been widely neglected in prior research.  These females were at high risk for a variety of psychological problems - higher even than males with ADHD. This underscores the need to pay especially close attention to these issues in the treatment of ADHD girls.  As the authors of this study suggest, perhaps treatment may need to address these psychological "side effects" more systematically in females.  The authors also emphasize the importance of providing better education about ADHD in females for teachers, as they represent the primary professionals who come in contact with this underserved group of individuals.

Some of you may recall a controversy that emerged last year around the increasing use of stimulant medication treatment in preschool children. This controversy erupted in response to an article published in the Journal of the American Medical Association that documented 200-300% increases in stimulant prescribing to preschool children between 1991 and 1995.  Although the percentage of preschool children treated with stimulants was still less than 1%, there were understandable concerns about this large rate of increase.

These concerns reflect the fact that the efficacy of stimulant medication treatment for preschoolers is more variable than in older children, and the rate of side effects appears to be higher.  In addition, some professionals have noted that little is known about the possible impact of stimulant medication on the neurological development of children when started at such a young age and continued over many years.

Because of these issues, treatment guidelines published recently by the American Academy of Child and Adolescent Psychiatry indicate that stimulant medication should "only be used in the more severe cases or when parent training and placement in a highly structured, well-staffed preschool program have been unsuccessful or are not possible."   In light of this recommendation, it is unfortunate that good studies on the effectiveness of behavioral treatment for preschoolers manifesting symptoms of ADHD are few and far between.  How well such interventions actually work with preschoolers is thus largely unknown.  Because ADHD symptoms often emerge at such an early age, and can create significant difficulties in a child's early development, it is especially important to develop and document effective treatments for preschoolers with ADHD.

A study published in a recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) examines the impact of two parent-based therapies for preschoolers with ADHD, thus representing an important addition to the ADHD treatment literature (Sonuga-Barke, E.S. et al., 2001. "Parent-based therapies for preschool ADHD: A randomized controlled trial with a community sample". JAACAP, 40, 402-408). Participants in this study were 78 3-year-old children (48 boys and 30 girls) meeting DSM-IV criteria for ADHD, as well as their parents.

These children were initially identified based on a large-scale screening in an entire community, rather than by selecting families who had already been referred for treatment.  This is an important strength of the study, in that the participants are representative of children in the general population who manifest ADHD symptoms, rather than the relatively small percentage whose parents seek treatment for their child at such an early age.

Parents of children scoring above a certain level on the screening were informed about the study and offered a more thorough evaluation for their child.  When parents agreed, and the subsequent evaluation was consistent with an ADHD diagnosis, the families were assigned at random to one of three different groups.  Parents in two of these groups received an active treatment while the third group was a waiting-list control group.  This design enabled the researchers to examine the impact of the 2 different treatments compared (see below for a description of each treatment) and whether parents and children who received treatment were doing better at follow-up than those in the waiting list control group.  Mothers were the recipients of the treatment in all cases.  No explanation is provided for why fathers were not included.

The parent-training group was an eight-week program in which participants were educated about ADHD and introduced to a range of behavioral strategies for increasing attention and reducing defiant behavior.  All meetings occurred during one-hour weekly visits conducted in participants' homes. In most meetings, the therapist worked directly with the mother and child.  The behavioral techniques covered in this program included teaching parents how to effectively praise their child, ignoring minor misbehaviors, giving clear and effective commands, using distraction effectively, avoiding threats, etc.  In addition, parents were instructed to complete a behavior diary for their child so that their efforts to implement new strategies could be reviewed each week.

Parents assigned to the other treatment group received no direct training in behavioral strategies as discussed above.  Instead, they were given the opportunity to discuss issues of concern to them and the impact of their child's behavior problems on family life, in a supportive and non-threatening atmosphere.  Thus, rather than being taught specific skills that could be used to manage their child's behavior, they were simply provided the opportunity to discuss their concerns with an empathic listener.  This also occurred over eight weekly meetings conducted in the parents' homes.

Results

Two types of outcome measures were obtained at the end of the eight-week treatments, and again 15 weeks later.  One set of outcome measures focused on ADHD symptoms and conduct problems in the preschoolers.  This was obtained both through a structured interview with each mother and through observing each child engaging in a solitary play activity.  During the observation of the children at play, the researchers focused on patterns of attention to, and switching from, one activity to another.  Based on this observation, an index of attention/engagement was computed for each child indicating the child's ability to stay focused and engaged during play activities (as opposed to "bouncing" from one incomplete activity to another).

The second type of outcome data collected concerned measures of maternal well-being.  Of primary concern here were maternal reports of depressed moods and their sense of competence/effectiveness and satisfaction as a parent.  Collecting these data enabled the researchers to examine whether either treatment improved mothers' perception of their parenting abilities, in addition to simply noting whether changes occurred in child behavior as a result of treatment.  Because parenting a preschooler with ADHD can be such a difficult experience, mothers' moods and their satisfaction with parenting are important types of data to collect.

Preliminary analysis indicated that, prior to the treatment, there were no differences in the preschoolers' behavior or maternal ratings of well-being, parental efficacy, or parental satisfaction.  At the conclusion of the eight-week treatment period, however, mothers in the parent-training group reported that their children showed significantly fewer ADHD symptoms and conduct problems than did the mothers receiving supportive treatment or the mothers in the waiting-list control group.  These changes were consistent with ratings made by blind observers of the children's behavior during the free-play observation -- preschoolers of mothers receiving parent-training intervention were seen as more attentive and engaged than the other preschoolers.

Even more impressive is the fact that these changes noted immediately following treatment were still evident 15 weeks later.  This was true even though there had been no additional contact with the mothers or children during this time.  Overall, 53% of preschoolers in the parent-training group were rated as having made a clinically significant recovery, compared to only 38% of those in the supportive treatment group and 25% from the no-treatment control group.  These data indicate that, although a certain number of preschoolers meeting the criteria for ADHD will show improved behavior over time even when no intervention is received, the parent-training intervention tested in this study more than doubled the number of children for whom this was the case.  The magnitude of the improvement reported for preschoolers in this group was comparable to what has been reported for stimulant medication treatment in this age group.

Similar results were obtained for maternal ratings of well-being, sense of parental efficacy, and feelings of satisfaction as a parent.  Compared to mothers in the supportive treatment and waiting-list control group, mothers who learned specific parenting skills reported greater feelings of well-being, parental efficacy, and parental satisfaction immediately following treatment.  Although there was some decline in all three areas over the next 15 weeks, they were still doing better than the other mothers at this time.  Mothers who received supportive treatment, although not doing as well as those who learned specific parenting skills, also tended to be feeling somewhat better than mothers in the control group at the end of treatment. However, this did not persist.

Summary and Implications

The results of this study clearly indicate that behavioral interventions in which parents are taught specific strategies/skills for managing the difficult behavior of preschoolers with ADHD can produce significant improvements for a large percentage of these children.  The gains that can be expected include: reductions in core ADHD symptoms, reduced oppositional behavior, and greater feelings of well-being, sense of parental efficacy, and sense of parental satisfaction in the mothers of these children.

These results are important for several reasons.  First, they provide a firm basis for the recommendation that behavioral intervention - rather than stimulant medication - is an appropriate first line treatment for preschoolers with ADHD.  When done well, it appears that many ADHD preschoolers may improve to the point where the use of stimulants is no longer necessary.  Second, it is especially encouraging, I think, that the program used to produce these gains could be realistically available on a widespread basis.  Remember that the gains reported were for a program that consisted of eight weekly one-hour home visits.  This truly is the type of intervention that could be made available in many communities.  In contrast, the behavioral intervention used in the MTA study has been criticized on the basis that it was so comprehensive that it really could not be realistically implemented outside of the research setting.  Perhaps significant gains from behavioral treatment using a relatively brief intervention are more easily obtained when children are younger and more malleable.

As with any study, there are some caveats that are important to note. First, although the parent-training intervention resulted in clinically significant improvement in 53% of the preschoolers, still nearly half did not obtain such benefit.  This represents a large number of preschoolers with ADHD for whom additional interventions would be required.   Perhaps a longer and more intensive behavioral approach would have promoted gains in this group.  Or, this may be a group for whom treatment with stimulant medication turns out to be an appropriate option.

(Note:  There currently is a large-scale study underway of stimulant medication in preschoolers with ADHD.  In this study, a course of behavioral treatment similar to what was used here will first be implemented with all participants, and medication will only be tried for children who do not respond to the behavioral approach.  This study thus promises to shed important light on the efficacy and safety of stimulant medication for ADHD preschoolers who are not helped significantly by behavioral treatment alone. It is likely to be several years, however, before the results of this study are available.)

Second, we cannot be sure from this study what the longer-term impact of the behavioral intervention is likely to be.  It would be very informative to follow the children treated successfully in this study and see how they do over time.  One possibility is that they continue to do well and their symptoms remain manageable.  This would be very exciting indeed, as it would suggest that early intervention could change the developmental course in children showing early signs of ADHD.  Alternatively, as these children get older and enter school, their symptoms may become more prominent and require other treatments to manage them effectively.

Let's hope that more information on this important development question becomes available within the next several years.