Perceptions of Girls and ADHD: Results From a National Survey
May 4, 2004
Patricia Quinn, MD; Sharon Wigal, PhD

Online Harris Interactive interviews were conducted with 1797 adults (general public), 541 parents of children with ADHD, 550 teachers, and 346 children aged 12 to 17 years with ADHD. Responses were examined to determine perceptions of ADHD:
o Most of the general public (58%) and teachers (82%) think ADHD is more prevalent in boys.
o The general public and teachers think boys with ADHD are more likely than girls to have behavioral problems (public: 52% vs 26%; teachers: 36% vs 18%, respectively), while girls with ADHD are thought to have less noticeable problems than boys, such as being inattentive (public: 19% vs 11%; teachers: 29% vs 10%, respectively) or feeling depressed (public: 16% vs 1%; teachers: 12% vs 0.0%, respectively).
o Four out of 10 teachers report more difficulty in recognizing ADHD symptoms in girls. An overwhelming majority of teachers (85%) and more than half of the public (57%) and parents (54%) think girls with ADHD are more likely to remain undiagnosed.
o ADHD was reported to have a negative effect on self-esteem, more so in girls.
o Girls who were taking medication for their ADHD were nearly 3 times more likely to report antidepressant treatment prior to their ADHD diagnosis.
o Girls were more likely to feel it was "very difficult" to focus on schoolwork and get along with parents.

ADHD is a well-recognized, chronic behavioral disorder that is characterized by persistent symptoms of impulsivity, hyperactivity, and/or inattention and is frequently diagnosed during childhood. According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, ADHD is defined as the presence of at least 6 symptoms of inattention or hyperactivity/impulsivity that persist for at least 6 months in a way that is maladaptive or developmentally inappropriate. Symptoms of inattention include poor attention to details, limited attention span during tasks or play, forgetfulness, distractibility, and failure to finish assigned activities. Symptoms of hyperactivity/impulsivity include fidgeting, extreme restlessness, excessive motor activity, difficulty taking turns, and a tendency to blurt out answers or interrupt others. In order to meet diagnostic criteria, the symptoms of ADHD must cause clinically significant impairment in school and at home. With an estimated prevalence of 4% to 12% in school-age children, ADHD is believed to be more common in males. Male-female ratios range from 9:1 to 6:1 in clinical samples but are about 3:1 in community-based population studies.

There may be several reasons for the disparity between male-female ratios in clinical and community-based studies. Clinical samples only capture patients who have been referred for treatment, whereas population samples are more representative of the true prevalence and characteristics of ADHD. Clinical samples are therefore more likely to be biased toward more severe, easily recognized cases, whereas community samples are more likely to include a range of severities and clinical presentations. Because girls tend to be inattentive rather than hyperactive/impulsive, they may not be captured by diagnostic criteria that focus primarily on the excess kinetic activity and disruptiveness typical of boys with ADHD, and therefore may not be recognized in the community setting. Also, girls with ADHD are less likely than boys with ADHD to exhibit conduct disorder, aggression, or delinquency, so they are less likely to be referred for disruptive behavior. Moreover, their symptoms do little to raise community awareness of the disease. Thus, ADHD may be missed or its severity may be underestimated in girls, leading to fewer specialist referrals and underrepresentation in clinic-based studies.

The atypical presentation of ADHD in girls may be a barrier to treatment, either because the condition is not recognized or because it is not seen as serious enough to warrant intervention. Paradoxically, when problematic behavior is identified in girls, the degree of deviation from the norm (compared with other girls) is thought to be much greater than it is for boys because girls are inherently less prone to inattention and hyperactivity than are boys. Girls who are referred for psychiatric evaluation often show unusually disruptive behaviors, but they are probably not typical of most girls with ADHD.

There is also evidence that ADHD takes a different type of toll on girls vs on boys. Although they do not differ from boys in measures of impulsivity, school performance, or social interactions, they have greater cognitive and attentional impairment and may be rejected more often by their peers (particularly if they have the inattentive subtype). Needing to repeat a grade in school is also more common among girls than among boys, which supports the observation that they experience more cognitive and academic problems. In a study of adults, females with ADHD showed a higher prevalence of depression, anxiety, and conduct disorder when compared with a control population, as well as cognitive impairments and academic problems. The heavy social and personal impact of ADHD on females points to the importance of early identification and treatment...

Gender Differences in ADHD Recognition
The findings of this survey suggest that gender has important implications for the diagnosis and treatment of ADHD. Among the most striking results is the belief that ADHD often goes unrecognized in girls, a viewpoint broadly held by the general public as well as those who are most familiar with the daily realities of the condition: the parents and teachers of affected children. It was also widely perceived that ADHD presents differently in girls from in boys, and that this is a likely reason for missed or delayed diagnoses in girls. Symptoms such as inattentiveness, poor school performance, and depressive affect are seen as the hallmark signs of ADHD in girls, yet they elicit less attention from teachers and parents than characteristic ADHD symptoms seen in boys, such as disruptive behavior and "acting out." This is partly because girls' symptoms are not recognized as typical indications of ADHD and partly because these symptoms are less noticeable and less troublesome to adults than are boys' symptoms. The tendency of girls to "suffer silently" often means that they bear the burden of untreated ADHD for a much longer time than do boys.

Almost half of the teachers surveyed say that it is harder for them to recognize ADHD symptoms in girls than in boys, and most say they do not have adequate training about the disorder in general. They report that most schools provide little or no training on ADHD for teachers -- in fact, only 10% of schools are reported to provide significant training for teachers to learn about ADHD. Even when teachers suspect a child may have ADHD, only half say they inform a child's parent or guardian. For girls with ADHD, this may be because the teachers are unsure of their opinion or because they are concerned that the girls will feel embarrassed or stigmatized by the diagnosis.

These survey responses are generally consistent with published reports. In the National Institutes of Health Consensus Statement on the diagnosis and treatment of ADHD, gender is acknowledged as a barrier to appropriate diagnosis. While the boy-girl ratio of ADHD in population samples was 3:1, an equal gender distribution was found in a study of adult ADHD. In another study of gender differences in a clinic-referred sample of ADHD in children, girls were generally older than boys at the time of their diagnoses. These data suggest that ADHD in girls may be recognized at a later age than it is in boys. Lack of recognition of symptoms in girls has been attributed to the lack of gender-specific criteria for the diagnosis of ADHD and to the tendency of girls to be inattentive rather than impulsive or disruptive; thus, they can be overlooked by teachers and healthcare providers. Members of the NIH Consensus Development Panel recommend additional studies of the inattentive subtype, particularly because it appears to be more common in girls.

Gender Differences in ADHD Treatment
The failure to recognize ADHD symptoms in girls probably results in significant undertreatment. Although the subjective experience of ADHD is evidently different for girls and boys, it is not a trivial disorder for them, and they are equally in need of professional care. According to the teachers and the children with ADHD responding to this survey, girls are perceived to have at least as much difficulty with schoolwork, friends, and family as do boys. In this survey, there was a trend for girls to report more problems than did boys in these areas, but this may be partly because girls tend to be better at communicating their feelings; boys may well have similar problems but not be able to express them as well. Girls were also described as being likely to engage in promiscuous behavior, which would put them at risk of serious consequences such as unplanned pregnancies or sexually transmitted diseases.

Undertreatment may even be a problem for girls who are correctly diagnosed if their parents are hesitant about letting them use an ADHD medication. In this survey, parents whose children were currently using ADHD medication recalled that at first, they felt pressured not to agree to it, partly due to concerns about side effects and partly due to worries about the stigma associated with ADHD or its treatment. However, the survey suggests that children may feel less stigmatized by ADHD than their parents fear: only 9% of boys and 15% of girls report that they felt worse after being diagnosed with the condition; the remainder felt "about the same" or "better." Similarly, most parents and teachers believe that negative media coverage of ADHD hurts affected children, yet the vast majority of children with ADHD report no negative emotions when seeing the condition portrayed in the media.

Girls may be at a slight advantage over boys in one sense: once they are suspected of having ADHD, their parents tend to be more willing to seek medical advice and less likely to feel pressure not to use drug therapy. Of the parents whose children were currently taking an ADHD medication, 59% of the parents of boys say they were hesitant to put their child on that drug, compared with only 39% of parents of girls. Although the reasons for this disparity are unknown, one possible reason is that ADHD is most often diagnosed in girls when it is severe, so parents are more willing to seek professional help. Another possible reason is that the restlessness and impulsivity of boys with ADHD is seen as being within the spectrum of normal or near-normal behavior for boys, so their parents do not accept it as a medical problem that could require drug treatment. In general, boys and girls respond equally well to medical therapy for ADHD.

The limitations of this study lie in possible selection biases in the sample of respondents. Because the survey was Web-based, respondents had to own a computer and have good literacy and computer skills. Thus, the study sample could be biased toward participants with better education or a higher socioeconomic status than those of the general population. Also, children who are young or have severe impairments in attention or conduct are unlikely to complete a lengthy online questionnaire; therefore, the children answering the survey are likely to be older and have less severe symptoms than children with ADHD in general.

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