ADHD/ADD in Girls

David Rabiner, Ph.D. Research Professor, Duke University

        



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David Rabiner, Ph.D.
Duke University

(Note: If you are looking for information on Attention Deficit  Disorder (ADD) please be aware that much of what is discussed below should also be relevant.  Technically, the term ADD is no longer used.  Instead, children who have the inattentive symptoms of ADHD but who do not show hyperactive/impulsive symptoms are now diagnosed with ADHD, Predominantly Inattentive Type rather than with ADD.  These terms mean pretty much the same thing but the latter is no longer technically correct.)



ADHD/ADD in Girls

One of the important shortcomings of most of the search based information on ADHD/ADD is that the vast majority of studies have been conducted solely on boys, or, have included very few girls in the sample. As a result, the scientific literature on ADHD/ADD is almost exclusively based on male subjects.

Recently, a study funded by the National Institute of Mental Health on a large group of girls both with and without ADHD/ADD was published in the Journal of the American Academy of Child and Adolescent Psychiatry (Biederman, J. et al., (1999). Clinical correlates of ADHD/ADD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 966-975. In this study, the authors examined the clinical correlates of ADHD/ADD in girls so that similarities and differences with what has been found among boys with ADHD/ADD could be ascertained. This study represents the largest and most comprehensive study of girls with ADHD/ADD that has been published to date.

Participants in this study were girls between the ages of 6 and 18. There were 140 girls who had been diagnosed with ADHD/ADD based on structured psychiatric interviews conducted with the child's parent(s). In addition, 122 girls of similar ages and other backgrounds who did not have ADHD/ADD were included as comparison subjects. These two groups of girls were compared on a wide variety of characteristics so that the researchers could learn about the problems associated with ADHD/ADD in females specifically.

Among the girls who were diagnosed with ADHD/ADD, 59% had the combined type (i.e. both inattentive and hyperactive/impulsive symptoms), 27% had the Predominantly Inattentive type, and only 7% had the Predominantly Hyperactive/Impulsive type. Overall, a significantly greater proportion of symptoms of inattention were present according to parents relative to either hyperactive/impulsive symptoms.

The major findings are summarized below.

Girls with ADHD/ADD were significantly more likely to be diagnosed with other disorders as well.

Compared to girls without ADHD/ADD, girls with ADHD/ADD were more likely to be diagnosed with co-morbid conduct disorder, oppositional defiant disorder, mood disorders, anxiety disorders, and substance use disorders. Tic disorders and enuresis (i.e. bed wetting or day-time wetting) were also more common in the girls with ADHD/ADD.

Overall, 45% of the girls with ADHD/ADD were diagnosed with at least one other condition. Only 4% of the girls with ADHD/ADD had more than 2 co-morbid disorders, however.

Although the rate of co-morbid behavior disorders in girls with ADHD/ADD was high, it was still no more than half of the rate that has been previously reported for boys. Because disruptive behavior disorders are one of the main reason that children get identified and referred for treatment, the authors speculate that the lower incidence of these problems in girls with ADHD/ADD may partially explain the marked gender differences that are often found in children with ADHD/ADD who are receiving clinical treatment.

The rate of mood and anxiety disorders in girls with ADHD/ADD was quite similar to what has been previously found in boys. Contrary to what some have suggested, there was thus no evidence in this sample of children that girls with ADHD/ADD are more likely than boys to have problems in these areas. There was, however, an indication that problems with substance use were more common among girls with ADHD/ADD than has been previously found to be true for boys. For example, girls with ADHD/ADD were about 4 times as likely to be smokers.

COGNITIVE, SCHOOL, AND FAMILY FUNCTIONING

Girls with ADHD/ADD had scores on measures of intellectual functioning and academic achievement that were modestly lower than what was found in the non-ADHD/ADD girls. They were also about 2.5 more likely to be diagnosed with a learning disability, more than 16 times more likely to have repeated a grade in school, and almost 10 times as likely to have been placed in a special class at school.

It is perplexing why girls with ADHD/ADD were so much more likely to have repeated a grade given that the difference in the academic achievement test scores were, although lower, not so dramatically different from other girls. I think this may reflect that fact that achievement testing - which is done on an individual basis - tends to reflect the highest level of work that children are capable of. In many instances, this is quite a bit higher than the level that a child with ADHD/ADD actually performs at on a day to day basis. So, these data may reflect the debilitating effect that ADHD/ADD has on a child's typical school performance, which can result in grade retention and special class placement even for children who are quite bright and capable.

Whatever the explanation, these data underscore how important it is for parents to insure that their daughter's educational needs are being carefully and adequately addressed. Children with ADHD/ADD are often legally entitled to special educational services to help address the unique needs that they have. You can learn about the educational rights for children with ADHD/ADD by going here. The parents of girls with ADHD/ADD also described their family life as less cohesive and reported greater amounts of conflict with their daughters.

CLINICAL IMPLICATIONS

The results of this study make clear that ADHD/ADD in girls is as serious a condition and has a comparably large negative impact on children's functioning and adjustment as it does in boys. Overall, the correlates of ADHD/ADD in girls were remarkably similar to what is known to be true for boys. Among the few differences found were that girls were less likely to be diagnosed with a co-morbid behavior disorder than boys (i.e. oppositional defiant disorder or conduct disorder) and perhaps more likely to have problems related to substance use. Rates of mood and anxiety disorders, and impairment in academic functioning appeared to be quite comparable.

The lower rates of disruptive behavior problems, along with the preponderance of inattentive symptoms relative to hyperactive/ impulsive symptoms, may partially explain why ADHD/ADD in girls may often not be recognized. Because rates of mood and anxiety disorders were similar to what has been found in boys, the authors speculate that in conjunction with the lower levels of disruptive behavior and hyperactive/impulsive symptoms, this may lead clinicians to diagnose girls with the former types of disorders rather than ADHD/ADD. In fact, in a study recently published in the journal Pediatrics it was reported that pediatricians were significantly more likely to diagnose boys with ADHD/ADD than girls, even when the problems described by parents were quite comparable.

The authors stress that clinicians need to be aware that, despite their lower rates of disruptive disorders, ADHD/ADD in girls is a serious condition associated with impairment in multiple areas of children's functioning. Thus, there is no reason to assume that the treatment of girls with ADHD/ADD should be any less aggressive or comprehensive than that of boys.

Parents need to be aware that their daughter with ADHD/ADD is at significantly increased risk for a variety of other conditions as discussed above. In fact, in this study, almost 50% of girls with ADHD/ADD had at least one other diagnosable disorder. It is thus essential that evaluations of girls for ADHD/ADD take a broad look at their emotional, behavioral, social, and academic functioning so that a comprehensive treatment plan addressing all areas of important difficulty can be developed and implemented. In particular, given the indication of possible increased risk of substance use in girls with ADHD/ADD, this may be an area that is especially important for parents to monitor.

Too often, in my opinion, even if ADHD/ADD in females is identified, necessary attention to areas of difficulty apart from core ADHD/ADD symptoms may not be targeted in a child's treatment, or may not be addressed in the most helpful way. This is especially likely to be the case when a primary care physician is the sole treatment provider, as physicians are typically less attentive to a child's overall emotional and behavioral functioning in their evaluations, and may tend to rely on medication treatment alone when other interventions may also be needed.

There are several limitations to this study that the authors acknowledge. First, the girls with ADHD/ADD were referred from both psychiatric and pediatric facilities/practitioners, and the degree to which they are representative of girls with ADHD/ADD in the general community can not be determined with any certainty. Thus, it is quite possible that the girls in this study were more impaired than would be girls with ADHD/ADD from the general population.

In addition, it is clear that research on treatment specifically in girls with ADHD/ADD is sorely needed. Currently, most of the data on both medical and non-medical treatment of ADHD/ADD is also based predominantly on boys. To my knowledge, there is currently no clear indication of any known differential effect for various treatments that is specifically related to gender, but this may be partially because the studies that are required to carefully look at this issue have not really been done.


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