At Last, Attention Shifts to Girls
Tuesday, July 11, 2006
A major long-term study of girls diagnosed with attention-deficit hyperactivity disorder (ADHD) in elementary school has found they are at greater risk for substance abuse, emotional problems and academic difficulties in adolescence than their peers who don't have the common neurobehavioral condition. The results, experts say, should help dispel the myth that the disorder, which affects an estimated 4.4 million American children, poses less of a risk to girls than to boys, on whom most research has focused.
The federally funded study by researchers at the University of California, Berkeley, involves more than 200 girls who have been followed since 1997, when they were 6 to 12. The broadly focused study is designed to measure the ways ADHD, a disorder characterized by pervasive inattention and impulsivity, affects peer relationships, impairs school performance and is linked to substance abuse and psychological problems.
"Can you believe it's 2006" and the first long-term prospective study of girls with ADHD is just being published, asked psychologist William Pelham, an ADHD expert at the State University of New York at Buffalo.
Girls, Pelham said, have been under-diagnosed and overlooked in large part because their behavior tends to be less disruptive -- although their problems may be just as severe.
Psychologist Stephen P. Hinshaw, lead author of the study -- published in the June issue of the Journal of Consulting and Clinical Psychology -- called the results "surprising and discouraging."
"The cumulative picture is that girls with ADHD are at risk for a lot of problems," said Hinshaw, chairman of the psychology department at Berkeley and a prominent ADHD researcher. Hinshaw said he and his colleagues did not expect the "breadth of impairment" they found. The team began the study with 228 girls: 140 had ADHD, while 88 did not.
Five years later, researchers conducted a follow-up study involving 209 of the girls, who had entered middle and high school. In nearly a dozen areas examined by researchers -- including academic performance, prevalence of eating disorders, relationships with peers and teachers, and organizational skills -- the girls with ADHD were significantly more likely to have problems than those in a matched control group who did not have the disorder.
The gap in reading and math ability had widened in five years and new concerns had emerged: About 30 percent of the girls with ADHD were at least mildly depressed, compared with 10 percent of the control group, Hinshaw said. The same percentages were seen in substance abuse.
One area showed marked improvement: The girls in the ADHD group showed fewer signs of hyperactivity as they grew older, the same trend seen among boys in other studies.
Pelham called Hinshaw's results "very important" because so little is known about teenage girls with ADHD. Too often, he said, the problem is either overlooked or misdiagnosed as depression.
A long-term study published in May by researchers at Massachusetts General Hospital in Boston found that teenage girls with ADHD were more likely to have mood or anxiety disorders than those without the disorder.
"Most girls do as well as boys" when their ADHD is treated, Pelham said. The optimal treatment combines the use of stimulant medications, such as Ritalin or Adderall, with behavioral therapy that provides structure, teaches organizational skills and rewards desired actions, experts say.
To Washington area developmental pediatrician Patricia Quinn, who has specialized in the treatment of ADHD for nearly 30 years, the results of Hinshaw's study serve as a warning.
"People think if a girl is ditzy she's not going to have serious problems, but this study confirms that's not true," said Quinn, who has co-authored books about girls and women with ADHD.
Molly Zametkin, 18, a recent graduate of Walter Johnson High School in Bethesda, knows firsthand that girls can be as affected as boys, even if their problems seem less obvious.
First diagnosed in elementary school, Zametkin, who described herself as "a little space cadet who was never hyperactive," vehemently fought her parents' efforts to treat ADHD with medication and therapy. Her father is a research psychiatrist at the National Institute of Mental Health.
Only after years of struggling in school, Zametkin said, did she accept that "it was a problem I couldn't fix by myself"; she began taking medication regularly when she started high school.
The Berkeley findings, she said, mirror aspects of her experience as well as what she sees in other girls who have ADHD, especially their battles with food and their use of drugs, alcohol and cigarettes.
"Any girl with ADHD is going to be more impulsive and more of a risk-taker," Zametkin said. "And impulsivity makes it easier to give in to peer pressure in any situation."
Hinshaw's study was launched at a time when officials at the National Institutes of Health, which is funding it, were seeking to include more women and minorities in medical research.
Berkeley researchers recruited an ethnically and economically diverse group of girls: Slightly more than half were white, 27 percent were African American, 11 percent were Latina and 9 percent were Asian American.
All attended a free five-week summer program where they were closely monitored by the staff, who did not know which girls had been diagnosed with ADHD. Most of those taking medications agreed to stop while the program was in session, though treatment decisions were left to parents. Observations by the staff were augmented by testing, interviews and other assessments.
In the first study of these girls, published in 2002, Hinshaw and his colleagues reported that the ADHD group had more problems making and keeping friends, and functioning outside school; they also lagged behind their peers academically.
How, Hinshaw and his team wondered, would they fare after five years? To answer that question, researchers reassessed 92 percent of the group who agreed to cooperate and had dispersed to eight states as well as South Korea and Australia. Researchers conducted eight-hour assessments of each girl.
Some in the ADHD group had received no treatment during the intervening five years, while others received extensive help. About 50 percent, Hinshaw said, had taken medication at some point and 80 percent were receiving special services, mostly in school. Some had made significant recoveries and no longer had ADHD, but most continued to struggle.
Previous studies have found that about 30 percent of children diagnosed with ADHD in childhood appear to outgrow the problem during adolescence; by adulthood about 50 percent are no longer impaired.
To Hinshaw, devising effective treatments for girls remains paramount.
"Girls have a different way of relating and deserve study in their own right," he said, and should receive treatments that are not mere imitations of those boys receive. "This is not a short-term disorder." ·