April 12, 2009

ADHD: Girls

When Chloe's mother brought her into my office, she didn't know what was wrong. She told me that her 10-year-old was doing very poorly in school. She seemed to get along with everyone very well, but didn't have many friends. When her mother sat with her while doing homework, it didn't seem to be too hard for her, and she appeared to know and understand everything required. But reports from her teacher were that she wasn't doing a lot of the classwork and she almost never turned in her homework. Chloe always liked talking to me and her mother asked if I could try to figure out what was going on.

I asked a lot of questions about social changes in Chloe's life, but there hadn't been any. She continued to be well medically, and was growing fine. Chloe herself said that she wanted to do better in school but didn't know how. She denied having difficulty with reading, or writing, or math, or social studies. She didn't know why she didn't hand in her homework, but was aware of many days when her teacher asked for homework but she either didn't know there was homework or didn't know what the assignment was. She has also sometimes been surprised by tests in class she didn't know or forgot were coming. She never got in trouble in class. Her teacher said she would often be caught daydreaming. I asked how long this had been going on. Her mother said all year. I asked about last year and the year before that. After some thought, her mother said that these were all comments she had heard before, even in kindergarten.

Only a few years ago medical authorities taught that about 4 or 5 boys had ADHD for every girl. This was undisputed, and confirmed by the general experience of elementary school teachers everywhere. Almost always, it was the boys who got in trouble both in and out of the classroom. These days, most books will say that it's twice as many boys than girls.

Is ADHD truly more common in boys? Or do boys force us to give them the diagnosis twice as often because of their behavior? Perhaps because boys with ADHD are more often singled out for their disruptive actions in the classroom, they are more likely to get sent to the principal's office, more likely to have their parents called by the teacher, more likely to get taken to the doctor, and thus more likely to get diagnosed with ADHD. So maybe ADHD isn't twice as likely in boys, it's twice as likely to get diagnosed in boys. (I have mixed feelings about this. Is the overdiagnosis of ADHD in boys because it's more likely or are boys unfairly singled out by our elementary school methods and institutions?)

Luckily, there are really smart scientists like Stephen Hinshaw at the University of California, Berkeley. He and his colleagues have been following and researching girls with ADHD for more than a decade. What they have found suggests that it's probably close to equally likely in girls as boys, but that many more girls never get diagnosed. Those that do, get recognized much later, sometimes in late elementary school or even when they are teenagers. Those that never get diagnosed, never get treated. Since there's good evidence of the effectiveness of treatment, some girls really have a tough time. For all girls with ADHD, they often have continuing difficulty both socially and academically, and have a much more difficult adolescence.

When I received the reports from Chloe's current and prior-year teachers (I have them fill out questionnaires), it was clear that Chloe had ADHD, Inattentive type without hyperactivity. I urged mom to consider medication, which has been shown to be very effective and safe, but she didn't. We'll try some behavioral therapy, I guess. While it avoids medication, it is significantly less likely to be effective by itself.

Many boys are brought to me for evaluation of ADHD. Usually they are 4-8 years old or so, just starting their school years. Where are the girls? How many have been missed? The words used to describe the behavior of boys who are referred are almost always negative: disruptive or out-of-control, for example. For girls, the words are not so scary: daydreaming, forgetful. I wonder if this is influenced by our different expectations for girls. Maybe because the words we get from teachers describing the girls aren't so alarming, we don't rush to take action.

Studies show that early patterns of school failure are a real warning sign. Early intervention for problems like ADHD or learning disabilities are often very effective and help the child all through school. Girls with ADHD have continuing social and academic problems, are more likely to drop out, have more substance use problems, eating disorders, and depression. Isn't that worth preventing if we can?

The photograph is by Jim Steinhardt, and is from the 1940's.

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Please let me know what you think. Do you know a child or situation like this?