Paying attention to girls
Research shows moreof them suffering from attention-deficit disorder than previously believed

By Carol Hyman, Public Affairs

02 October 2002 | Although boys with Attention Deficit Hyperactivity Disorder (ADHD) greatly outnumber girls, girls have been underdiagnosed and their condition is much underappreciated, according to a pair of studies in the October issue of the Journal of Consulting and Clinical Psychology.

The lead author is Stephen Hinshaw, professor of psychology at UC Berkeley. His work focused on a much larger sample of girls than nearly all previous studies, was conducted over a longer period of time, and – unlike at least one key study from the late 1990s — was based on subjects who were not taking ADHD medication during the study period.

“These girls, compared to a matched comparison group, are very impaired, academically and socially,” says Hinshaw, an expert in child clinical psychology and developmental psychopathology, noting that the girls are rejected by their peers and have a harder time making and keeping friends. “Social problems with peers are quite predictive of long-term adjustment problems,” he explains, “so it will be essential to observe outcomes as the sample matures.”

The girls also were more likely to have had contributive early-life experiences (e.g., being adopted), histories of speech and language problems and learning difficulties, or relatives with ADHD.

Closely watched campers
Hinshaw’s study involved one of the largest samples in the world of preadolescent girls with ADHD. A total of 228 girls — 140 diagnosed with ADHD and 88 not so diagnosed — were studied intensively at six-week summer camps held in 1997, 1998, and 1999. There were approximately 80 girls at each year’s camp.

The girls were recruited to participate in the camps in a number of ways. For the ADHD sample, Hinshaw sent mailings to health-maintenance organizations, clinics, hospitals, mental-health centers, pediatric practices, and local school districts. In addition, presentations were made to self-help groups, and advertisements were placed in newspapers.

To recruit girls without ADHD, similar mailings were sent to school districts and community centers in the Bay Area, and advertisements were again placed in papers. The ads were almost identical to those for girls with ADHD, except the wording em-phasized “summer enrichment programs” rather than “summer enrichment programs for girls with attentional problems.”

Girls in both groups who appeared to be good candidates for the program participated in several levels of family screenings and evaluations to make sure they met appropriate criteria for the study. In addition, the families of the girls with ADHD had to agree to take the children off of ADHD medication during the six weeks they’d be spending in camp, so that their natural behavior patterns could be observed.

The sample was ethnically diverse: 53 percent Caucasian, 27 percent African American, 11 percent Latina, and 9 percent Asian American. Incomes of these families ranged from upper class to low enough to qualify for public assistance. Girls with IQs lower than 70, overt neurological damage, psychosis, and medical conditions that precluded participation in camp activities were excluded from the study.

The girls spent six weeks enjoying the same activities that children who go to other summer camps enjoy, but they were very closely monitored by people with training in micro-observation. Their “counselors” took copious notes relating to each girl’s activities; the staff was not aware of which girls had ADHD diagnoses.

The summer programs, located on the campus of a local school, featured a structured series of classroom, art, drama, and outdoor activities. In addition, all the girls received individual neuropsychological assessments.

More aggressive, but less social
Hinshaw says that, during outdoor sports and play at camp, “the girls with ADHD were less likely to follow the directions of the teacher than the comparison girls. They were also more likely to tease their peers and show aggressive behavior, though not at the same rate as boys with ADHD we’d observed in previous summer camps. They were also more likely to display social isolation — wandering and failing to become engaged in activities.

“As a group, these girls show as much executive function deficit on neuropsychological tests as boys who have been diagnosed with ADHD.” The term “executive function” refers to actions such as goal setting, planning, organization, monitoring one’s behavior during an activity, and changing strategies in response to alterations in a situation.

Hinshaw says that selected girls from the study sample are participating in brain-imaging studies at Berkeley to better pinpoint both working memory and executive function through examination of brain-behavior relationships. “These functions are crucial for long-term academic, social, and occupational success,” Hin-shaw says. “Deficits in executive functions are seen in other disorders, such as autism, but they may well be the core underlying problems for youth and adults with ADHD.”
The girls and their families currently are participating in a follow-up study, so some of them have been followed for five years into adolescence.

Although boys diagnosed with ADHD outnumber girls approximately three to one, it may be that some girls have been underdiagnosed, particularly those with the “inattentive type” of the disorder, which seems more prevalent in girls. “The inattentive type of ADHD is marked less by disruptive, impulsive behavior and more by disorganized, unfocused performance,” Hinshaw says. “The latter isn’t as likely to be recognized or cause as much concern to teachers.”

Hinshaw hopes his project will bring attention to a population of young girls whose problems may have been ignored. “Our hope,” he says, “is that these efforts will spur the field toward theoretically rigorous attempts to understand the underlying processes and mechanisms responsible for ADHD in both boys and girls, and to provide a sound scientific basis towards better classification, prediction, and intervention.”