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SPECIAL REPORT
ADHD: Not for Boys Only'Girls and women are affected, too, but require more diagnostic acumen
by Patricia O. Quinn, MD
A ttention deficit hyperactivily disorderZA(ADHD} is a ncurobiologic disorder
-*- *. affecting millions of individuals,limiting their potential, affecting theirfamilies, and interfering with many aspectsof their daily lives. For girls and women,however, ADHD is often a hidden disorder,ignored or misdiagnosed by the educationaland medical communities, causing many ofthese girls and women to suffer in silence.
ADHD is an important cause of psychiat-ric disability in girls. The DSM-IV estimatesthe male:female ratio of ADHD as 9: ] (basedon the proportion of girls referred to psychi-atric clinics).'but community-based studieshave reported the ratio to be as low as 2.5:1.'This disparity suggests that the prevalence ofADHD in girls is seriously underestimatedandthat many school-aged girls with ADHDwill not be diagnosed properly and treated.As is the case with boys, without adequatetreatment, girls with ADHD are likely tosuffer underachievement, low self-esteem,impaired social relationships, and significantpsychiatricdisturbance. In addition, researchsuggests that adolescent females with undi-agnosed ADHD engage in "at risk"behaviors,such as promiscuity and substance abuse,at a greater rate than adolescent males withADHD.'
The lack of recognition of ADH D in girlspartly can be explained by the fact that thesymptoms exhibited by females are less overtthan symptoms in boys with ADHD. Girlsmore often present with the inattentivesubtype of ADHD and less often with thecombined or hyperactive/impulsive subtype.Their hyperactivity, when it exists, is morelikely to manifest as "hypertalkativeness" or
This article and the one on p. 34 are part ofBehavioral Health Management s(wo-(ssuespecial report on ADHD; see the May/Juneissue for the introduction (p. 37) and articleson the inattentive subtype of ADHD (p. 38)and adult ADHD (p. 42}.
emotional overreactivity rather than motorhyperactivity. Coexisting disorders in giriswith ADHD are alsooftendifferent from thoseseen in males. Behavior related to conductdisorder and oppositional defiant disorder,commonly associated with ADHD in males,is often the cause for a boy's being sent foran evaluation. Girls with ADHD, however,are considerably less likely to exhibit thesedisruptive behaviors and are more hkely tointernalize symptoms and become anxious,depressed, and/or socially withdrawn. As aconsequenceofundiagnosed ADHD, femalesmay refuse to attend school or develop psy-chosomatic complaints, such as headaches orstomachaches.
ADHD, once properly diagnosed in ei-ther sex, is very treatable. Outcomes can beimproved with medications, lifestyle adapta-tions, andaccommodations at school or work(e.g., Lintimed tests, written instructions, ormentoring), thus allowing individuals withADHD to lead productive lives and to reachrealistic, achievable goals (e.g., graduation,professional degrees, or job advancement).But first, clinicians must become aware ofthe various presentations of this disorder thatvary by gender.
The primary focus of this differentiationmight be on the primary inattentive symp-tomatology in females versus hyperactivityor impulsivity in males. Often it is not untilthe onset of puberty and the demands ofmiddle school that girls with the inattentivesubtypeofADHD demonstrate impairment,and Huessy has pointed out that ADHDsymptoms appear to worsen with the onsetof puberty in girls.' Clinicians need to beaware that inattentive symptoms are diffi-cult to identify, especially in the very young,and that even children with the combinedsubtype of ADHD might not manifest earlysymptoms if sufficient protective infiuencesare in place. High IQ or a structured environ-ment has been shown to mitigate symptomsof ADHD, thus delaying diagnosis. Femalesalso might work harderto compensate for or
hide their symptoms in their efforts to meetparental and/or teacher expectations^ andtherefore might not demonstrate academicdifficuhies or impairments in the classroomduring their early years.
However, as time progresses, it becomesincreasingly difficult for females with ADHDto cope, as environmental demands on themincrease in secondary and postsecondaryacademic settings. The take-home messagefrom al! of this is quite clear: Good gradesand satisfactory teacher reports, especially inelementary school, cannot rule out ADHDin girls.
Diagnosis and treatment also might becomplicated because ADHD is frequentlyaccompanied by significant comorbidity.Biederman and his colleagues have presentedevidence indicating that most people withADHD have at least oneand sometimesmore than oneadditional psychiatricdisorder,""" including:
DepressionTicsTourette syndromeBehavior disordersSubstance abuseObsessive-compulsive disorderAnxiety disordersLearning disabilities
All too often, and especially in females, achnician is too quick to diagnose a coexist-ing condition as primary, thus missing thediagnosis of ADHD altogether. This leads tofurther complications, as the individual doesnot improve or relapses because the ADHDitself has gone untreated.
Research, as well as clinical experience,suggests that girls and women with ADHDcontinue to suffer from high rates of anxietyand depression, and that it is these sea)nd-ary conditions, rather than the underlyingADHD, that are most likely to be diagnosedand treated. It bears repeating that factorscontributing to misdiagnosis include:
30 JULY/AUGUST 2004 www.behavioral.net
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SPECIAl REPORT
GirlswithADHDtendtointernalizesymp-toms" and become socially withdrawn.''Family members, teachers, and peersmisinterpret symptoms of inattention.
Coexisting symptom.s of anxiety anddepressive disorders might obfuscateunderlying ADHD.
Results of a study by Rucklidge and Tan-nock suggest that adolescent femaies withADHD have greater psychological distressthan males with ADHD.'" When compared tomale counterparts, girls with ADHD reportedmore anxiety, more distress, more depressivesymptoms, and an external locus ot control.They were also at risk for more psychologicalimpairments. Becauseof these symptoms,girlsmight bediagnosed,correctly or incorrectly,asdepressed, and ADHD as the primary or co-existing diagnosis might be missed, Althoughsymptoms sped fie to these coexistingdisordersmight respond to appropriate pharmacologicinterventions,thesegirlscontiiiue to struggle iftheir ADHD symptoms also are not treated,
Girls with ADHD commonly are treatedfor depression prior to their A[")HD diag-
nosis. In a nationwide survey conductedin April 2002 by Harris Interactive, 14% ofgirls with ADHD were found to have beentreated with antidepressants prior to theirADHD diagnosis, compared with only 5%of males with ADHD."
To reach a diagnosis of ADHD in females,cliniciansshould continue to follow diagnos-tic criteria outlined in the DSM-IV. The as-sessment ot the primary symptoms ot ADHDtypically includes ratings of symptoms on abehavior checklist or self-report scales. Whendiagnosingfemaleswith ADHD, however, theclinician should be aware that females maypresent ditferently based on gender, andclinicians should use only those scales thathavegender-referenced norms. Professionalswho are accustomed to diagnosing ADHD inmales may be prone to minimize, overlook,or misdiagnose females with ADHD. Diag-nostic issues to keep in mind when makingthe diagnosis in females include:
There is often no report of early child-hood issues.The inattentive subtype often is over-
looked by professionals, parents, andteachers.Girls are more teacher-compliant.These girls often have good academicrecords in early years.Hyperactivity/impulsivity is less com-mon.
Symptoms often present around pubertyrather than during early elementaryyears.High-IQ females may function well butat a great emotional cost.
There is often a history of treatment foranxiety and/or depression.These females often are misdiagnosed asbipolar if the hyperactive component ispresent.
Presenting complaints for women caninclude:
Feeling overwhelmed by everyday activi-tiesChronic disorganizationChronically late and poor time manage-ment
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Senseofshameandinadequacynotliv-ing up to typical societal expectationsFeelings that household managementand meal planning are impossible
In conclusion, treatment outcomes forADHD remain dependent on a clear andprecise diagnosis that addresses symptom-atology and other important variables thatwill dictate intervention strategies. In addi-tion to thecontinuingand pervasive attentiondeficitsseen at each developmental stage,girlswith ADHD present with different needs anddifficulties. Girls with ADHD stand to benefitfrom therapeutic management of ADHD asmuch as boys, but certain differences needto be taken into consideration.
Because girls with ADHD have fewer be-havioral problems, they need less "behaviormanagement." Low self-esteem, shame, anddemoralization secondary to undiagnosedADHD might need to be addressed, how-ever, and coexisting anxiety and depressiontreated. Effective treatment for ADHD in
females will involve a multimodal approachthat includes education, medication, andpsychosocial support that takes into accounttheir unique needs. BHM
Patricia O. Quinn, MD, is Director ofthe National Centerf or Gender Issuesand ADHD. For more information,e-mail [email protected] or visitwww.ncgiadd.org.
For reprints in quantities of 100 ormore, phone (866) 377-6454.
References1. AmcrJLan Psythiatric Association. Diagnostic and
Statistical Manual of Mental Disorders (Text Revi-sion). 4lh ed. Arlington, Va.: American PsychiatricPtiblishinj;, !nc.;20nO.
2. Biederman (, Faraone SV. Mick E, et a!. Clini-cal correlates of ADHD in females: Findings from alarge group of girls ascertained from pediatric andpsychiatric referralsources. I Am AcadChiidAdole.stPsychiatry 1999;.18:966-75.
3. Arnold LE. Sex differences in ADHD: Conferencesiiinmary. J Abnorm Child Psychol 1996;24:555-69.
4. Hucssy HR. The pharmacotherapy of personalitydisorders in women. Paper presented at: 143rd An-nual Meetingof the American Psychiatric Association(symposia); New York; t990.
5. Booth ). Carlson Cl.. Shin M. Canu W. Parent,teacher, and self-rated motivational styles in iheAt)HI>siibtypes. The ADHD Report 2001:9:8-11.
6. Hicrferman |, Newcorn |, Sprich S. Comorbid-ity of attention deficit hyperactivity disorder withconduct, depressive, anxiety, and ulher disorders.Am I Ksycbiatry 199 U148:564-77.
7. Biederman |, Faraone SV, Sjiencer T, et al.Patterns of psychiatric comort>idity. ctignitiitn, andpsychosocial functioning in adults with attentiondeficit hyperactivity disorder. Am | Psychiatry1993:150:1742-8.
8. Brown RT, Ahramowitz A|, Madan-Swain A,et al. ADHD gender differences in a clinic-referredsample. Paper presented at: 36th Annual Meetingof the American Academy of Child and AdoteicentPsychiatry: New Vork:]989.
9. Gaub M, Carlson CL. Gender differences inADHD: A meta-analysis and clinical review. | AmAcad Child Adolesc Psychiatry 1997;36:1036-45.
10. RucklidgeII,TannockR.P.sychi)som/viewarticle/472415.
Expanded coverage of ttiis topic made possible by an unrestricted educational grant from Eli Lilly and Company.
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