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ARE GIRLS WITH ADHD SLIPPING THROUGH THE CRACKS?GIRLS MAY FACE GREATER SOCIAL IMPAIRMENT THAN BOYS, ADHD SURVEY SHOWS

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by Barbra Williams Cosentino, R.N., C.S.W.

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Jack, age 9, constantly gets into trouble in school, squirming in his seat, shouting out answers without being called on, and sometimes standing up for no apparent reason. His homework and classroom assignments are a mess, his backpack is disorganized, and his room at home is in disarray. He has trouble staying focused on schoolwork, but his mom says in frustration, "He can concentrate on Play Station games for hours without losing focus." Emily, also 9, has been called a daydreamer for as long as she can remember. In class, the teacher frequently observes her doodling in her notebook, curling a strand of her long brown hair around her finger, or staring out of the window. When she sits down to do her homework at night, she often discovers that she forgot to write down the assignment or that she left a book she needs in her desk at school. Although Emily is very bright and never gets into trouble in school, her difficulty with organization and concentration have begun to negatively affect her grades. Two children, a boy and a girl. Although their behavior looks very different, they have both been diagnosed with attention deficit/hyperactivity disorder (ADHD), a behavioral disorder characterized by three major symptoms: – Inattention: difficulty sustaining attention, listening and attending to details. The child is easily distracted, often loses things, and presents as forgetful and disorganized. – Impulsivity: the child has poor frustration tolerance and may have trouble waiting, taking turns or sharing. – Hyperactivity: child seems to be constantly in motion, squirming and fidgeting, running and climbing more than other children. Talks excessively and at inappropriate times. Clinicians may diagnose a child with ADHD, combined type, or with attention deficit/hyperactivity disorder, predominantly either inattentive type or hyperactive-impulsive type. More than 1 million children in the U.S. have the disorder, which until recently was believed to be anywhere from four to nine times more prevalent in boys than in girls. (Most researchers now believe the correct ratio is one girl to three boys). However, researchers have reported that, partially because they tend to be inattentive rather than hyperactive, many girls go undiagnosed or are mistakenly believed to suffer from anxiety or depression as a primary diagnosis. One often-quoted study suggests that as many as 75 percent of girls with ADHD may be missed. According to Debra Seltzer, M.D., acting director of developmental and behavioral pediatrics at Columbia University College of Physicians and Surgeons, girls are much more likely than boys to slip through the cracks because they exhibit fewer behavioral problems in school. Boys with ADHD are jumping out of their seats, knocking over books or loudly making jokes, she says, while the girls are just sitting there daydreaming, not being disruptive at all.

Special considerations for girls In 1994, ADHD researchers at a conference sponsored by the National Institutes of Health concluded that there was a need to develop rating scales that are more sensitive to ADHD as it typically manifests itself in girls — since the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) were and are somewhat limited; not necessarily reflecting the signs and symptoms exhibited by a girl with ADHD who is predominantly inattentive and distractible, rather than hyperactive. Pediatrician William Sears, M.D., author of The ADD Book, says boys with ADHD are more likely to act out in school, becoming either the class discipline problem or the class clown, whereas girls tend to be more withdrawn and "spacey”. In some respects, boys enter school with a disadvantage, since the traditional classroom mode of teaching is usually geared more to the female gender, Dr. Sears says. Girls seem to adapt better to the traditional classroom situation, which requires children to sit still for long periods of time. Dr. Sears feels that children with ADD often do better with male teachers, who may talk less and who may have a teaching style that helps restless or disorganized children to more consistently pay attention. Not surprisingly, he also finds that fathers tend to be more tolerant of their child's hyperactive behavior than mothers. Other researchers have found that mothers of girls with ADHD are more critical of their offspring's behavior than are mothers of sons with ADHD. Harlan R. Gephart, M.D., immediate past chair of the American Board of Pediatrics and an ADHD expert, points out that while hyperactive boys tend to be referred for evaluation somewhere between ages 5 and 7, the referral spike for girls is often in middle school (ages 10-11) — when previously well-functioning girls begin to be overwhelmed by the complexity of classroom changes, increased homework assignments, and large class sizes. These girls begin to fall back academically due to their increasingly obvious disorganization, and they also begin to struggle socially. As ADHD girls enter adolescence, hormonal changes can contribute to increased attentional deficits and mood swings, Dr. Gephart points out.

The effects, by gender Research conducted in the past 10 years has suggested that ADHD affects males and females differently. A 1999 study funded by the National Institute of Mental Health (NIMH), compared 140 ADHD girls with 122 control girls, and found that: – Girls with ADHD were more likely to have innattentive symptoms ,as opposed to hyperactive-impulsive symptoms and disruptive behaviors seen in boys. – Compared to girls without the disorder, girls with ADHD had significantly higher rates of comorbid behavior disorders such as oppositional defiant disorder and conduct disorder. (Although these rates are lower than those seen in boys with ADHD.) – Girls with ADHD displayed higher levels of mood and anxiety disorders, including major depression (consistent with those seen in boys with ADHD) than in children without ADHD. – As compared to non-affected youngsters, girls with ADHD appear to be at significantly higher risk of increased alcohol and drug usage (including smoking). – Contrary to previous studies which found that girls with ADHD demonstrated greater cognitive impairment than boys, this study found that the magnitude of cognitive impairment was consistent with reports on boys with ADHD.

The social difficulties for girls Results of the first national survey to explore gender differences in ADHD were recently released, with findings that have important implications for diagnosis and treatment. The study, conducted by Harris Interactive on behalf of Novartis Pharmaceuticals Corporation (makers of several drugs used to treat ADHD), involved interviews with more than 3,000 people (parents of children with ADHD, adolescents aged 12-17 who have ADHD, teachers, and the general public) to document perceptions surrounding the disorder. The survey findings suggest that girls with ADHD face greater impairment in important areas of social development than boys with the disorder, including having more trouble making friends, getting along with parents, or feeling good about themselves. (Fifty-five percent of parents of girls agreed that their daughters' ADHD affected the girls’ self-esteem a great deal, as compared with 46 percent of boys' parents). Results of the survey show that girls with ADHD are three times more likely to be treated for depression than boys with ADHD. "Unfortunately, all too often, girls with ADHD are missed altogether or misdiagnosed with depression because girls tend to internalize their symptoms. Therefore, the unique difficulties that girls with ADHD encounter are often prolonged," says Patricia Quinn, M.D., director of the National Center for Gender Issues and ADHD, and an independent advisor on the survey. The survey results show that girls' parents were more willing to seek medical assistance for their child's symptoms than boys' parents. Ninety-two percent of parents of girls were "very willing" to seek help, as compared to only 73 percent of boys’ parents. Approximately two-thirds of parents of boys received pressure from family and friends to not put their child on medication, whereas this was the case in only 31 percent of the parents of girls. Most teachers surveyed did not realize that girls with ADHD are more likely to have difficulty with social relationships, with three out of 10 teachers believing that boys with ADHD were more likely to have difficulty getting along with others. The majority of teachers (85 percent) thought that girls with ADHD are more likely to go undiagnosed, and the majority of them said this is because "girls don't act out." Seventy-seven percent of teachers surveyed said they suspect they have children with ADHD in their classes who have not been diagnosed. Approximately 79 percent of the general public surveyed said medications have been helpful for those they know with ADHD, but only 52 percent of the public believes it is "very important" to treat and diagnose this condition. Of the adolescents surveyed, most who were receiving medication for their ADHD felt it was helpful in important aspects of their daily lives, including getting along with parents (82 percent), feeling good about themselves/feeling happy (80 percent), and making friends (67 percent). Almost all the youngsters on medication felt that their treatment has helped them to focus on schoolwork (95 percent), and "to get things done" (94 percent). Although ADHD has long been thought of as "a boys’ problem", experts agree that the disorder is widely underdiagnosed in girls. As we learn more about gender differences in ADHD, it becomes clear that continuing to educate parents, teachers, health care professionals and the general public about this disorder and how it manifests itself differently in boys and girls is a crucial first step in facilitating early, effective diagnosis and treatment.

ADHD + Bipolar newly documented While bipolar disorder usually waits to manifest itself until adulthood, it does occasionally root itself in childhood. In fact, researchers now believe that children can have both bipolar disorder and ADHD simultaneously, a wholly distinct disorder. According to a study conducted by researchers at Massachusetts General Hospital, because ADHD is more common than bipolar disorder, the latter may be overlooked. Conventional ADHD therapies like Ritalin or Adderall can worsen an undiagnosed bipolar disorder. A bipolar child may exhibit either manic or depressive symptoms such as severe changes in mood, repeated high risk taking, irritability, loss of enjoyment in favorite activities, low energy levels, or major changes in eating or sleeping patterns; a diagnosis can only be made with careful observation over an extended period of time. In contrast, a child with ADHD shows frequent signs of inattention, distractibility, hyperactivity or impulsiveness. Teachers, parents, and friends often know that the child is “misbehaving” or “different”, but they may not be able to tell exactly what is wrong. Study investigators hoped to find a familial association of ADHD and bipolar disorder among parents and siblings of young people with bipolar disorder. In interviews with 189 parents and siblings of 69 children who had bipolar disorder, they found that of the children who had bipolar disorder, 14 percent of the relatives had bipolar disorder and 20 percent had ADHD. They then compared the data on these children and their relatives with similar information on the relatives of children with ADHD but without bipolar disorder, and with information on children who did not have either disorder. Among the children with only ADHD, 4 percent of the relatives had bipolar disorder and 19 percent had ADHD. Among a group of children free of either disorder, only 3 percent of the relatives had bipolar disorder and only 5 percent had ADHD. The data confirms the suspicions of many physicians and pediatricians: children with bipolar disorder, a relatively new diagnosis, are likely to be members of families where others have the illness, too.

—————————————— How Are Tomboys Born?

The levels of testosterone a girl is exposed to in her mother’s womb could mean the difference between whether she eventually chooses tree climbing and mud pie-making over playing with dolls or acting out a tea party. According to the results of a long-term study of pregnancy and health published in the November-December issue of Child Development, there may be a definite connection between testosterone levels during pregnancy and gender-role behavior in pre-school girls. Previous studies in laboratory animals support the maternal hormone-behavior relationship, researchers say. The study followed 679 children born during an 18-month period in the early ‘90s; blood was drawn from their pregnant mothers and analyzed for the levels of the male sex hormone. The data from the Avon Longitudinal Study involved parents and/or caregivers supplying information on a questionnaire about their children’s involvement, at age 3 1/2, in specific gender-role behaviors, such as sex-typical toys, games and activities. The link between high testosterone levels among mothers during pregnancy and their daughters’ higher “masculine” scores showed a relationship that was not found between these hormone levels in boys and their gender-related behavior. However, researchers did note that the relationship between child behavior and testosterone is minor, accounting for a mere 2 percent of the variance in the gender-role behavior found in girls in the study, leaving open the possibility of other factors playing a role. These could include, but are not limited to, maternal education, older siblings in the house, a male adult in the house, or parental adherence to traditional sex roles. Researchers also surmised that girls could be especially susceptible to testosterone effects since boys are ordinarily exposed to higher portions of the prenatal male hormone. Social factors may also have an impact on the development of tomboy-like behavior, the study found. — Kirsten Matthew

 


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