Dr Claire Russon, Clinical Psychologist, Emotional Health Service, AfC

ADHD and girls

• Neurodevelopmental disorder - inattention, hyperactivity and impulsive behaviours

• Subtypes – inattentive, hyperactive/impulsive or combined

• Interferes with functioning, two or more settings• High degree of ‘heterogeneity’ – multiple

pathways• Treatments – No ‘cure’ - parent

support/behaviour management programmes, therapy (where co-existing mental health difficulties), medication (Concerta, Ritalin, Equasym)

ADHD overview

• …..are variably brain-based, behavioural, motivational, or cultural and often a combination

• …..each explain some aspects of ADHD but not all – there is no single theory or consensus

Theories of ADHD….

• Behaviour Inhibition Theory (Barkley, 1997) - Central behaviour regulation deficit which causes deficits in working memory, self-regulation, motor control

• Executive dysfunction theories – impairment in ‘higher level’ cognitive processes in the brain (e.g. planning, reasoning, working memory, response inhibition)

• Structural brain differences – e.g. less grey matter in the caudate nucleus (Roman-Urestarazu, 2015)

• Dysfunctional dopamine – baseline levels of dopamine lower, higher release in response to external stimuli (e.g. Sikstrom and Soderland, 2007)

• State regulation – children with ADHD have difficulty maintaining optimal activation states

• Delay Aversion and Dual Pathway – motivational theory (Sonuga-Barke et al). Core symptoms reduce subjective experience of delay. Dual pathway – ADHD develops either from delay aversion or from deficits in capacity to inhibit behaviour (link to executive dysfunction theories)

• Dynamic developmental – behavioural theory (Sagvolden et al). Smaller ‘window of opportunity’ to reinforce socially desirable behaviour. Socially undesirable behaviour not extinguished due to faulty processes (link to dopamine and executive function theories also).

• Cultural construct – ADHD as a culture specific way of understanding and responding to behaviour (Timimi, 2004, 2005)

Sonuga-Barke and Coghill (2015): ADHD as context dependent Overlaps between ADHD symptoms and

neuropsychological deficits Complexity and heterogeneity Overlaps between ADHD and other difficulties Developmental factors (how our

neuropsychology is shaped e.g. maternal depression)

Neuropsych impairments may mediate causes of ADHD and expression of symptoms

Contemporary ideas

• 2.5% overall, 4:1 male to female ratio• 3.62% of boys, 0.85% of girls• 3-9% of school-age children in the UK (NICE

guidelines)

Prevalence

What are young people with ADHD like? Why?Your experiences….

The ADHD ‘phenotype’

Relatively little information on girls – most studies with boysBiederman et al (1999) • Symptoms of ADHD appear in girls as with

boys • Girls also experience clinically significant

impairment in school, family and peer functioning

The role of gender

• Different behaviour manifestations – girls less ‘visible’

• Gendered assumptions about anxiety• Earlier brain maturation – girls ‘age it out’• The role of social skills• Tendency to pathologise boy’s behaviour but

girl’s emotions • Referral bias• Social context

So why haven’t we noticed this before?

• Lots of similarities with boys but there may be… Later stage of onset More subtle clinical manifestations/less overt behaviour (CD, ODD) Increased risk for ‘internalizing’ disorders (depression, anxiety

etc.) More inattentive subtype Role of hormones in earlier maturation Less atypical motor development than boys Speedier but more difficulties with independent planning Higher levels of cognitive impairment More ‘complex, varied and unpredictable lives’

Sources: Mahone & Wodka, 2008; Quinn, 2005; Hinshaw, 1994; McGoldrick, Carter & Garcia-Preto, 2011

Girls are more ‘complicated’?

• Girls show less ‘externalising’ behaviour• Outward expression of behaviours vs behaviour

or difficulty expressed inward and towards the self

Soffer, Mautone & Power (2008) • Boys: more symptoms and externalising • Girls: increased risk for intellectual and academic

impairment and internalising disorders (anxiety, depression etc.)

Behavioural manifestations

• Girls symptoms more likely to be attributed to internalising disorders such

as anxiety

• Quinn (2005) o Females often present with more anxiety, low mood than male

counterpartso Dysphoria key part of self-reported presentation o Co-morbidities rather than underlying disorder more likely to be

diagnosed in women

• Harris International (2002) – 14% adolescent girls diagnosed with ADHD given antidepressants before ADHD diagnosis, compared to 5% of boys

• Long-standing assumption that women are more emotional – ‘weaker’ than men? Origins of ‘hysteria’ – women and madness

The assumption of an emotional cause

• Girls are more socially skilled so can ‘mask’

symptoms • Long-standing argument also in ASD about why

lower diagnostic rates in girls • Quinn (2005) – Girls may work hard to compensate

or hide symptoms

Social skills

• Earlier brain maturation in girls (1-2 years) so symptoms less visible than in boys of the same age

• EF - Planning, organisation, response inhibition, attention, reasoning, working memory associated with frontal lobe, prefrontal cortex etc.

Brain maturation and executive functioning (EF)

• Miller, Loya & Hinshaw (2013): EF development varies over time and plays a role in symptom change in girls with ADHD. Greatest impairment in EF = greatest improvement over time and greater improvement in symptoms

• Rinsky and Hinshaw (2011): Poorer EF scores = poorer social functioning whether ADHD or not. Some EF indicators (e.g. planning) predicted internalising disorders – mediated by social functioning

The role of EF

• Wright (2015) - care access and ADHD recognition influenced by: Views of teacher and impacts on parent decision-making Beliefs about efficacy of treatment and acceptability of

behaviour Gender and ethnicity – e.g. influence of child’s gender

on conceptualisation of the problem Cultural differences in parent thresholds for acceptable

behaviour Impacts of identification (outcomes may be detrimental

if no follow up treatment etc. - stigma) • Visibility of inattentive symptoms in the classroom –

teachers less likely to recognise signs unless behaviour also disruptive (McGee and Feehan, 1991)

Referral bias

Timimi (2005) • Many studies of ADHD have taken place without

attention to context yet ADHD is culturally mediated and social context plays a key role in symptom manifestation, co-morbidity and outcomes

• Increased preoccupation in western culture with rights of children but also children being dangerous. Boys problematised more in late part of 20thC. Lack of male role models, poor schooling, family instability, impact of feminism and masculinity crisis

The role of social context

Roskam et al (2014): Increased ADHD symptoms predicted by duration of exposure to early attachment deprivation

Peris and Hinshaw (2003) - High parental EE (emotional expression) esp criticism associated with ADHD and aggression (stronger for ADHD)

Biederman et al (2011) – 11 year follow up study. ADHD persisted in 33%, partially in 29%. Predictors of persistance included psychiatric co-morbidity, family history of psychopathology, family and school functioning at baseline

?Poverty, socio-economic status, culture/ethnicity

Social factors influencing ADHD

• Girls are raised to internalise, boys to externalise (Quinn, Solden)

• Lives of women and girls may be more complex and unpredictable (McGoldrick, Carter & Garcia-Preto, 2011)

• ‘Tomboys’, ‘daydreamers’ or ‘Chatty Kathy’s’

• Typical profile of ADHD fitting with idea of femininity?

Gender

“-- their finances may be in chaos; their paperwork and record-keeping are often poorly managed; they may struggle unsuccessfully to keep up with the demands of their jobs; and they may feel even less able to keep up with the daily tasks of meals, laundry, and life management5…., struggling valiantly to keep up with increasingly difficult demands by working into the night and spending their free time trying to "get organized." But whether a woman's life is clearly in chaos or whether she is able to hide her struggles, she often describes herself as feeling overwhelmed and exhausted6.” (from National Resource Center on ADHD website)

What does a woman with ADHD ‘look’ like?

• What are the roles women and girls play in society? Are these different from men? What are these roles determined by?

• How are men’s and women’s behaviours and emotions construed by society?

• What might be the implications for ADHD and it’s recognition?

Exercise

• Early identification of ADHD important for access to appropriate support, to minimize future risks - co-morbid mental health issues, substance misuse, poor achievement, social exclusion (e.g. Nigg, 2013) – currently girls being recognised later?

• ?Obscuring socio-cultural complexity of girls lives as with boys

Implications

• Single gender interventions? Girls: more assertiveness, self-management and compliance in single

gender interventions. Boys: more appropriate social behaviour and less aggression in mixed gender interventions (Babinski et al, 2013)

• Need to address EF specifically? Cognitive interventions? No compelling evidence yet (e.g. working memory, Chacko et al 2014)

• Need to address gender specific issues? Quinn (2005): Response to stimulant medication mediated by

hormones? Role of shame and self-blame• Attention to peer relations?

Peer relations may increase risk for internalising symptoms – more in girls than boys. No difference for externalising (Becker et al, 2013)

• Attention to social context and developmental issues? Family factors, stress, culture – the lives of women and girls Age, developmental stage of young person

Treatment implications

• More research?• Attention to context?• Your thoughts…..?

Where to next….?

Heterogeneity – variability in presentation/symptoms (two people with the same diagnosis can present very differently)Co-morbidity – more than one disorderNeuropsychological – psychological processes and behaviours linked to the structure and function of the brain (cognitive aspects such as memory, planning, reasoning, response inhibition etc)Externalising behaviour – outward expression of behaviour (in ADHD – aggression, hyperactivity)Internalising behaviour – expression of behaviour or difficulty inward towards the self (inattention, anxiety, low mood etc) Dysphoria – mood variation or instability

Glossary

• Soffer, S.L., Mautone, J.A., & Power, T.J. (2008). Understanding Girls with Attention-Deficit/Hyperactivity Disorder (ADHD): Applying Research to Clinical Practice. International Journal of Behavioural Consultation and Therapy, Vol. 4(1)

• Babinski, D.E., Sibley, M.H., Ross, J.M., & Pelham, W.E. (2013). The Effects of Single Versus Mixed Gender Treatment for Adolescent Girls with ADHD. Journal of Clinical Child & Adolescent Psychology, Vol. 42(2)

• Becker, S.P., McBurnett, K., Hinshaw, S.P., & Pfiffner, L.J. (2013). Negative Social Preference in Relation to Internalizing Symptoms Among Children with ADHD Predominantly Inattentive Type: Girls Fare Worse Than Boys. Journal of Clinical Child and Adolescent Psychology, 42(6), 784-795

References

• Mahone, E.M., & Wodka, E.L. (2008). The Neurobiological Profile of Girls with ADHD. Developmental Disabilities Research Reviews, 14, 276-284

• Miller, M., Loya, F., & Hinshaw, S.P. (2013). Executive functions in girls with and without childhood ADHD: developmental trajectories and associations with symptom change. Journal of Child Psychology and Psychiatry, 54(9), pp 1005-1015

• Rinsky, J.R. & Hinshaw, S.P. (2011). Linkages between childhood executive functioning and adolescent social functioning and psychopathology in girls with ADHD. Child Neuropsychology, 17(4), 368-390

References

• Quinn, P.O. (2005). Treating Adolescent Girls and Women with ADHD: Gender-Specific Issues. Journal of Clinical Psychology, 61(5), 579-587

• Peris, T.S. and Hinshaw, S.P. (2003). Family dynamics and preadolescent girls with ADHD: the relationship between expressed emotion, ADHD symptomatology, and comorbid disruptive behaviour. Joournal of Child Psychology and Psychiatry, 44(8), 1177-1190

• Biederman, J., Petty, C.C., O’Connor, K.B. et al (2012). Predictors of persistence in girls with attention deficit hyperactivity disorder: results from an 11-year controlled follow-up study. Acta Psychiatrica Scandinavica, 125, 147-156

References

• Roskam, I., Stievenart, M., & Tessier, R. et al (2014). Another way of thinking about ADHD: the predictive role of early attachment deprivation in adolescents’ level of symptoms. Social Psychiatry Psychiatry Epidemiology, 49, 133-144

• Wright, N., Moldavsky, M., & Schneider, J. et al (2015). Practitioner Review: Pathways to care for ADHD – a systematic review of barriers and facilitators. Journal of Child Psychology and Psychiatry, 56(6), 598-617

• Timimi, S. (2005). Naughty Boys anti-social behaviour, ADHD and the role of culture. China: Palgrave Macmillan

References