ADHD Underdiagnosed in Girls

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Ellen B. Littman, Ph.D

[Clinical Psychiatry News 27(12):15, 1999. 1999 International Medical News Group.]

Source:  Medscape


Despite the media frenzy focused on attention-deficit hyperactivity disorder, it's clear that we've done a lousy job educating teachers, parents, and other front-line professionals about this diagnosis among girls.

Girls with the condition are dramatically underdiagnosed and untreated. In fact, we are missing as many as 75% of girls with attention-deficit hyperactivity disorder (ADHD). For every 10 boys diagnosed with ADHD, only one girl is diagnosed with the condition.

Much of the problem is that ADHD among girls is predominantly the inattentive type, which is all too easily overlooked because it's hidden from view.

Instead of rowdily disrupting classrooms, the typical girl with inattentive-type ADHD is quietly daydreaming. She's not doing poorly enough in school to be raising red flags by failing, but because of her passivity in the academic arena she is not reaching her full potential either.

In fact, inattentive-type girls with superior IQs and no learning disabilities are the last ones to be diagnosed with ADHD, if at all.

Often, the girl with ADHD struggles to compensate at the cost of her self-esteem. She feels anxious and depressed, but doesn't meet criteria for any diagnosable disorder. In the end, whether because of spoken or unspoken messages from teachers or parents, she attributes these chronic struggles to her own laziness and incompetence.

While ADHD symptoms were first described in 1902, it was not until 1980 that the disorder reflected the possibility of inattention without hyperactivity.

Yet despite formal recognition of this concept in recent editions of the DSM, diagnostic checklists used by teachers, pediatricians, and many psychologists and psychiatrists continue to emphasize hyperactive/impulsive behaviors, which are more typical of boys with ADHD.

Studies have shown that even psychologists and psychiatrists diagnose nonhyperactive ADHD correctly only about half the time.

Among the minority of girls with combined-type ADHD -- both hyperactive and inattentive components -- hyperactivity can manifest itself externally in the form of hypertalkativeness or hyperreactivity. These girls typically appear to be silly, show-offs, or boy crazy.

Among other girls with combined-type ADHD, hyperactivity may take the form of an internalized restlessness, manifested as fine motor fidgeting such as hair twirling or cuticle picking.

My colleagues and I are in the process of validating a self-report scale designed to detect these internalized symptoms in girls.

Not surprisingly, among girls and boys actually diagnosed with ADHD, there are few gender differences; ADHD research has historically focused exclusively on boys. The few girls who were included in these studies were hyperactive and, therefore, represented only a small subset of girls with ADHD.

But even among some girls with ADHD who are hyperactive, their behavioral problems really only start to surface after puberty. So even these girls go undiagnosed because their behavior is dismissed as a symptom of adolescence.

Interestingly, clinics that work with adult ADHD patients report male to female ratios that are closer to 1:1, a much more equal distribution than would be expected from childhood data.

Since diagnosis requires the presence of symptoms before age 7, this discrepancy suggests that girls are significantly underdiagnosed.

In my work with adult women with ADHD, I find that many of my patients are self referred after their sons are diagnosed with the condition. Not until they read up on their child's disorder do they recognize their inattentiveness as a sign of ADHD and seek help for it.

In other cases, women spend years being misdiagnosed with depression while every attempt to pharmacologically treat their depression fails.

For these reasons, it is critical that the professional community become aware of the possibility that an ADHD diagnosis underlies the presentation of depressive symptoms.


Ellen B. Littman, Ph.D., is a clinical psychologist in private practice in Mount Kisco, N.Y


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17 March 2002