ADHD is a neurodevelopmental disorder with onset during childhood that often persists into adulthood. In the most recent National Survey of Children’s Health (Visser et al., 2014), it was reported that 11% of U.S. children and adolescents ages 4 to 17 have been diagnosed with ADHD in their lifetime. Of those who had ever been diagnosed with ADHD, 8.8% were reported to currently have symptoms of ADHD. When examining those currently diagnosed with ADHD, 12.1% of males met criteria for ADHD and 5.5% of females met criteria for ADHD. This reflects that males are twice as likely to be diagnosed with ADHD. These findings are consistent with previous research (Froehlich et al., 2007). In that study, the prevalence of ADHD in children in the U.S. ages 8 to 15 was found to be 8.7%. The incidence of ADHD in males was found to be 11.8% and in females it was 5.4%. Thus, it appears that males are at least twice as likely to be diagnosed with ADHD as opposed to females. And females often go undiagnosed.
Based on data collected from the National Comorbidity Survey Replication (Kessler et al., 2006), the estimated prevalence of adult ADHD was 4.4% of the population. “ADHD is not a benign disorder. For those it afflicts it can cause devastating problems” (Barkley et al., 2002, p. 90). Those with ADHD have been found to have impairments in virtually every aspect of their life – education, occupation, social, community, legal, dating and marital relationships, driving, leisure, financial and daily responsibilities (Barkley et al., 2002; Young et al., 2013).
Although ADHD is perhaps the most researched condition of childhood, and there is evidence that it has long-term implications in adulthood, there has been little focus on ADHD in females until recently. Two major studies in this area emerged in the past decade. Biederman et al. (2010) reported the results of an 11-year longitudinal follow-up study of females ages 6 to 18. At the time of follow-up, only 42% were receiving some form of treatment (17% were receiving medication alone and 25% were receiving medication and counseling). The mean age at follow-up was 22. The demographics revealed that the group was largely Caucasian and came from intact families. At the time of follow-up, 62% still had impairing symptoms of ADHD. There were several major findings from the study. The females with ADHD had significantly higher risks of antisocial, mood, and anxiety disorders than those who did not have ADHD. The females with ADHD demonstrated higher rates of depressive and anxiety disorders when compared to males with ADHD. However, there was a lower risk of antisocial personality disorders when compared to males with ADHD. Females in the ADHD group showed higher rates of agoraphobia (25%) and social phobia (20%) than did those without ADHD. Those with ADHD showed significantly higher rates of substance abuse (nicotine, alcohol and drugs) and bulimia than other females.
A second follow-up study (Hinshaw et al., 2012) of females with ADHD focused on a more ethnically diverse population over 10 years. Participants’ ages at the time of the follow-up study ranged from 17 to 24. The ADHD group included females with ADHD-Combined Type and ADHD-Predominantly Inattentive Type. The outcomes revealed that those with both types of ADHD showed greater symptoms of depression and dysthymia, anxiety, Oppositional Defiant Disorder, substance use and overall impairment in functioning. In addition, academic achievement in math was almost one standard deviation below those without ADHD. In most of the domains studied, there was little difference between females with the Inattentive Type of ADHD and the Combined Type of ADHD. The exception to this was noted in the area of injurious behaviors. Those with ADHD-Combined Type reported high rates of suicide attempts (22.4%) and self-injury (50.6%) when compared to those with ADHD-Inattentive Type.
So, what does all of this mean to parents and educators? First, be aware that we are likely under-diagnosing, under-treating and misunderstanding females with ADHD. Females often demonstrate compliant behavior at school but demonstrate separation anxiety, temper outbursts, social difficulties, and difficulty with organization and completion of tasks at home. When elementary school and young teenage females present with anxiety that does not improve with therapy, suspect ADHD. When adolescent females are demonstrating non-compliant behaviors at home; sneaking out of the house at night; experimenting with nicotine, alcohol and drugs; engaging in self-harm; and have declining grades, they need to be evaluated for ADHD as a possible underlying factor.
To date, there are no evidenced-based treatments designed specifically for females with ADHD. However, The American Academy of Child and Adolescent Psychiatry published Practice Parameter for the Assessment and Treatment of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (2007). Based on those treatment guidelines and my clinical experience, the following components of treatment are recommended. Treatment of ADHD starts with a thorough assessment – diagnosis (if relevant) of ADHD and co-morbid conditions. The second part of treatment is parent and patient education about ADHD. While education alone does not treat ADHD, it provides a framework for understanding the executive functioning deficits and behaviors that cause impairments in functioning at a level expected of the female’s age. Parent education about ADHD also leads to the development of parenting strategies and behavioral interventions for the individual. The third part of treatment is consideration of medication. The fourth part of treatment is building in supports and accommodations at home, in the community and at school. The final part of treatment is ongoing follow-up and therapy for co-morbid conditions and specific behavioral difficulties in the home, school or community.
Russell Barkley, Ph.D., a psychologist who has dedicated his career to the research and treatment of ADHD across the lifespan, has published extensively on ADHD and executive functioning. In working with children and adolescents, and the adults in their lives, I rely greatly on Dr. Barkley’s research which is summarized in his most recent books (www.russellbarkley.com) and excellent lectures available online (www.adhdlectures.com and https://www.youtube.com/watch?v=SCAGc-rkIfo). In working with parents and others who desire to help children and adolescents with ADHD, these are my Top 10 considerations:
- Poor impulse control (including excessive talking and emotionally impulsive responses) emerges before concerns regarding attention and concentration.
- ADHD is not just an academic problem. Many individuals with ADHD do well academically until the need for organization and time management outstrip their academic and cognitive abilities. This pattern is often seen as the individual transitions to middle school, high school, or college.
- Those with ADHD typically have about a 30% delay in the acquisition of independent skills and self-regulation.
- For individuals with ADHD, time is the enemy. If they are doing something they enjoy, there is never enough time. If they need to do something that they do not want to do, they will avoid and procrastinate or rush through the task.
- Individuals with ADHD have trouble sustaining concentrated mental effort.
- They have trouble remembering to do what they need to do when they need to do it.
- Those with ADHD tend to live in the moment – they do not reflect on the past to remember what happened last time or look to the future to consider the consequences of their behavior.
- ADHD causes individuals to have trouble stopping a behavior before it is completed to change what they are thinking or doing.
- Most of what we know about ADHD is based on research on males but females with ADHD are just as much at risk for problems in all domains of functioning.
Although I see children and adolescents (both male and female) with a wide range of issues, there is probably no other group that responds as well to treatment as females with ADHD. While there is no cure for ADHD, hope and help starts with a diagnosis. Without an appropriate diagnosis, much time, energy and money is spent without effective treatment. When treatments do not work, frustration and blame increase. The long-term trajectory for females with ADHD is filled with potential pitfalls, and the best way to help the individual and her family navigate the course to adulthood and beyond is to stay ahead of potential problems by addressing them quickly if and when they do arise. Appropriate assessment, treatment and guidance can help these girls and young women thrive.
References
Barkley, R. A. et al. (2002). International consensus statement on ADHD. Clinical Child and Family Psychology Review, 5, 89-111.
Biederman, J., Petty, C. R., Monuteaux, M.C., Fried, R., Byrne, D., Mirto, T., Spencer, T., Wilens, T.E., & Faraone, S. V. (2010). Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-Year follow-up in a longitudinal case-control study. American Journal of Psychiatry, 167, 409-417.
Chronis, A.M., Johnes, H.A., & Raggi, V.L. (2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26, 486-502.
Froehlich, T. E., Lamphear, B. P., Epstein, J. N., Barbaresi, W. J., Katusic, S. K., & Kahn, R. S. (2006). Prevalence, recognition, and treatment of attention-deficit/hyperactivity disorder in a national sample of US children. Archives of Pediatric Adolescent Medicine, 161(9), 857-864.
Hinshaw, S. P., Huggins, S. P., Montnegro-Nevado, A. J., Owens, E.B., Schrodek, E., Swanson, E.N., & Zalecki, C. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continued impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80, 1041-1051. doi: 10.1037/a0029451.
Kessler, R. C., Adler, L. Barkley, R., Biederman, J., Conners, C. K., Demler, O., Faraone, S. V., Greenhill, L. L., & Howes, M. J. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163(4), 716-723.
Pliszka, S. Practice parameter for the assessment and treatment of children and adolescents with Attention-Deficit/Hyperactivity Disorder. (2007). Journal of American Academy of Child and Adolescent Psychiatry, 46(7). 894-921.
Sonuga-Barke, E.J.S. et al. (2013). Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry, 170, 275-289.
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M.D., Ghanour, R. M., Perous, R., & Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 34-46.