Female Adolescents With ADHD

An important limitation of prior research on ADHD is that the vast majority of studies have been conducted primarily on boys.  This may be because ADHD occurs less often in girls than it does in boys. ADHD is also 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) (Rucklidge, J.J., & Tannock, R., 2001), entitled Psychiatric, psychosocial, and cognitive functioning of female adolescents with ADHD. JAACAP, 40, 530-539.), represents an important step in reducing this gap in our knowledge. In this study, the psychiatric, psychological, and cognitive functioning of 13-16 year old adolescent males (n=3D38) and females (n=3D24) was examined.  Each of the subjects had a confirmed diagnosis of ADHD.  Groups of non-ADHD adolescents, male (n=3D20) and female (n=3D28), were also 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 of 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 psycho stimulant such as Ritalin or Dexedrine - but all participants were off medication at the time that 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 for 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 was also conducted.  Attributional style refers to the way individuals tend to explain the occurrence of positive and negative events in their lives.  Extensive 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 other areas as well").  In the cognitive domain, a comprehensive psycho educational assessment was conducted on all participants.  This included an administered IQ test and a 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 ADHD females 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 that 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.  Even ADHD females themselves 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 past and present 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. This difference, on the other hand, 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 ADHD 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, the results for these groups were quite similar, which suggests that the differences reported between males and females with ADHD cannot be 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 and25% reported prior episodes of self-harm indicates the struggles of individuals in this group.  Somewhat surprisingly, and perhaps contrary to the beliefs of many, adolescent girls with ADHD appear 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 illustrate the need to be attentive to such issues. They also 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 stresses 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 more information about ADHD in females for teachers, as they represent the primary group of professionals who come in contact with this underserved group of individuals.

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