By: Barbra Williams Cosentino, RN, CSW
Jack, age nine, constantly gets into trouble in school, squirming in his seat, shouting out answers without being called on, and sometimes standing up for no apparent reason. His homework and classroom assignments are a mess, his backpack is disorganized, and his room at home is in disarray. He has trouble staying focused on schoolwork, but his mom says in frustration, “He can concentrate on Play Station games for hours without losing focus.” Emily, also nine, has been called a daydreamer for as long as she can remember. In class, the teacher frequently observes her doodling in her notebook, curling a strand of her long brown hair around her finger, or staring out of the window. When she sits down to do her homework at night, she often discovers that she forgot to write down the assignment or that she left a book she needs in her desk at school. Although Emily is very bright and never gets into trouble in school, her difficulty with organization and concentration have begun to negatively affect her grades.
Two children, a boy and a girl. Although their behaviors look very different, they have both been diagnosed with having attention deficit/hyperactivity disorder (ADHD), a behavioral disorder characterized by three major symptoms:
- bullet Inattention: the child has difficulty sustaining attention, listening, and attending to details.
- He or she is easily distracted, often loses things, and presents as forgetful and disorganized.
- Impulsivity: the child may have poor frustration tolerance and may have trouble waiting, taking turns, or sharing.
- Hyperactivity: the child seems to be constantly in motion, squirming, fidgeting, running, and climbing more than other children. He or she talks excessively and at inappropriate times.</UL= bullet
Clinicians may diagnose a child with ADHD, combined type, or with attention deficit/hyperactivity disorder, predominantly either inattentive type or hyperactive-impulsive type.
More than one million children in the United States have been diagnosed with this disorder, which until recently was believed to be anywhere from four times to nine times more prevalent in boys than in girls. However, researchers have reported that, partially because girls tend to be inattentive rather than hyperactive and therefore less disruptive in school and at home, many girls go undiagnosed or are mistakenly believed to suffer from anxiety or depression as a primary diagnosis. One oft-quoted study suggests that as many as 75 percent of girls with ADHD may be missed. In 1994, ADHD researchers at a conference sponsored by the National Institutes of Health concluded that there was a need to develop rating scales that are more sensitive to ADHD as it typically manifests itself in girls, since the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) were and are somewhat limited, not necessarily reflecting the signs and symptoms exhibited by a girl with ADHD who is predominantly inattentive and distractible, rather than hyperactive. Pediatrician Williams Sears, MD, author of The ADD (Attention Deficit Disorder) Book, states that boys with ADHD are more likely to act out in school, becoming either the class discipline problem or the class clown, whereas girls tend to be more withdrawn and “spacey.” In some respects, adds Sears, boys enter school with a disadvantage, since the traditional classroom mode of teaching is usually geared more to the female gender. Girls seem to adapt better to the traditional classroom situation, which requires children to sit still for long periods of time. Sears feels that children with ADD often do better with male teachers, who may talk less and who may have a teaching style that helps restless or disorganized children to more consistently pay attention. Not surprisingly, he also finds that fathers tend to be more tolerant of their child’s hyperactive behavior than mothers. Other researchers have found that mothers of girls with ADHD are more critical of their offspring’s behavior than are mothers of sons with ADHD. Harlan R. Gephart, MD, Immediate Past Chair of the American Board of Pediatrics and an ADHD expert, points out that while hyperactive boys tend to be referred for evaluation somewhere between ages five and seven, the referral spike for girls is often in middle school (ages 10-11), when previously well-functioning girls begin to be overwhelmed by the complexity of classroom changes, increased homework assignments, and large class sizes. These girls begin to fall back academically due to their increasingly obvious disorganization, and they also begin to struggle socially.
Research done in the past ten years has also suggested that ADHD affects males and females differently. A 1999 study funded by the National Institute of Mental Health (NIH) compared 140 ADHD girls with 122 control girls and found that:
<UL= bullet Girls with ADHD were more likely to have innattentive symptoms as opposed to hyperactive-impulsive symptoms and disruptive behaviors seen in boys.
Compared to girls without the disorder, girls with ADHD had significantly higher rates of comorbid behavior disorders (conditions that occur at the same time) such as oppositional defiant disorder and conduct disorder. (Although these rates are lower than those seen in boys with ADHD.)
Girls with ADHD displayed higher levels of mood and anxiety disorders (consistent with those seen in boys with ADHD) than in children without ADHD.
As compared to non-affected youngsters, girls with ADHD appear to be at higher risk of increased alcohol and drug usage (including smoking).
Contrary to previous studies which found that girls with ADHD demonstrated greater cognitive impairment than boys, this study found that the magnitude of cognitive impairments was consistent with reports on boys with ADHD. In August 2002, results of the first national survey to explore gender differences in ADHD were released, with findings that have important implications for diagnosis and treatment. The study, carried out by Harris Interactive on behalf of Novartis Pharmaceuticals Corporation (makers of several drugs used to treat ADHD), interviewed more than 3000 people (parents of children with ADHD, adolescents age 12-17 who have ADHD, teachers, and the general public) to document perceptions surrounding the disorder. The survey findings suggest that girls with ADHD face greater impairment in important areas of social development than boys with the disorder, including having more trouble making friends, getting along with parents, or feeling good about themselves. (Fifty-five percent of parents of girls agreed that their daughters’ ADHD affects their self-esteem a great deal, as compared with 46 percent of boys’ parents.) Results of the survey show that girls with ADHD are three times more likely to be treated for depression than boys with ADHD. “Unfortunately, all too often girls with ADHD are missed altogether or misdiagnosed with depression because girls tend to internalize their symptoms. Therefore, the unique difficulties that girls with ADHD encounter are often prolonged,” says Patricia Quinn, MD, Director, National Center for Gender Issues and ADHD and an independent advisor on the survey. The survey results showed that girls’ parents were more willing to seek medical assistance for their child’s symptoms than boys’ parents. Ninety-two percent of parents of girls were “very willing” to seek help, as compared to only 73 percent of boys’ parents. Approximately two-thirds of parents of boys received pressure from family and friends to not put their child on medication, whereas this was the case in only 31 percent of the parents of girls. Most teachers did not realize that girls with ADHD are more likely to have difficulty with social relationships, with three out of ten teachers believing that boys with ADHD were more likely to have difficulty getting along with others. The majority of teachers (85 percent) thought that girls with ADHD are more likely to go undiagnosed, and the majority of them said this is because “girls don’t act out.” Seventy-seven percent of teachers surveyed said they suspect they have children with ADHD in their classes who have not been diagnosed. Approximately 79 percent of the general public surveyed said medications have been helpful for those they know with ADHD, but only 52 percent of the public believes it is “very important” to treat and diagnose this condition. Of the adolescents surveyed, most who were receiving medication for their ADHD felt it was helpful in important aspects of their daily lives, including getting along with parents (82 percent), feeling good about themselves/feeling happy (80 percent) and making friends (67 percent). Almost all the youngsters on medications felt that their treatment has helped them to focus on schoolwork (95 percent) and “to get things done” (94 percent). Although ADHD has long been thought of as “a boy’s problem,” experts agree that the disorder is widely underdiagnosed in girls. As we learn more about gender differences in ADHD, it becomes clear that continuing to educate parents, teachers, healthcare professionals, and the general public about this disorder and how it manifests itself differently in boys and girls is a crucial first step in facilitating early, effective diagnosis and treatment.
