March 1, 2022

A new consensus statement updates what is known about ADHD in girls and women, and offers professional advice

Boys are three times as likely as girls to be diagnosed with ADHD, and anywhere from three to sixteen times more likely to be referred for treatment.

An international team of experts recently published a consensus statement addressing this discrepancy and offering guidance to rectify the imbalance and improve diagnosis and care for girls and women with ADHD. Here are some key conclusions.

ADHD symptoms:

-Experts caution that ADHD behaviors typically express themselves differently in boys than in girls.
-That in turn leads to gender-based biases in teachers and parents. In two studies in which teachers were shown vignettes of individuals with typical ADHD behaviors, switching from female to male names and pronouns led to higher rates of referral for support and treatment.

Comorbidity:

-A major reason for this different expression of ADHD in boys is that they have much higher rates of comorbid externalizing disorders, such as the conduct disorder and oppositional defiant disorder, leading them to break rules and get into fights in school. This no doubt contributes to lower rates of referral for girls.
-On the other hand, females are more likely to have comorbid internalizing disorders, such as emotional problems, anxiety, and depression. These may be interpreted as primary conditions, and the link to ADHD is missed altogether.
-Because ADHD has come to be associated with many externalizing disorders, it is then easy to fail to identify it when it is associated with internalizing disorders such as eating disorders.
-Untreated ADHD in girls can increase the risk of substance use disorders.

Associated vulnerabilities:

Children with ADHD are more likely to be unpopular with their peers and to experience rejection. Whereas boys are more likely to experience that rejection in physical ways, girls are more likely to experience it in social ways and through cyberbullying. That, in turn, contributes to lower self-esteem, which could explain some comorbid internalizing disorders.

Symptoms of hyperactivity/impulsivity, one of the two key components of ADHD, are associated with higher rates of risk-taking behavior:

- Like males with ADHD, females with ADHD have higher injury rates.
-Both males and females with ADHD are more likely to underachieve in school or drop out altogether.
-Overall, adolescents with ADHD become sexually active earlier, have more sexual partners, and are more frequently treated for sexually transmitted diseases than their normally developing peers. That also leads to higher rates of teenage and unplanned pregnancies.
-As with males with ADHD, females with ADHD have higher rates of criminal behavior than normally developing peers. While females with ADHD are still half as likely to be convicted of a crime than males with ADHD, one study showed they nevertheless are eighteen times more likely to be convicted of a crime than normally developing females.

Compensatory or coping behaviors:

- Girls may turn to drink alcohol, smoking cannabis, smoking cigarettes, or vaping nicotine to cope with emotional anguish, social isolation, and rejection.
-Some girls may seek to build social support through high-risk activities such as joining a gang, becoming promiscuous, and engaging in criminal behavior.

Triggers for possible referral

Ages 5-11:

-Bedwetting, nail-biting

Ages 5-16:

-Early sexualized behavior

Ages 5-18:

-Suspensions, expulsions, frequent detentions
-Poor attendance/truancy
-Consistent lateness, poor organization
-Academic difficulties, low academic self-esteem
-Conduct problems, conflicts with parents and peers
-Bullying (usually as victims)
-Regular tobacco and alcohol use
- Obesity and other eating disorders
- Repeated injuries
- Sleep difficulties
- Executive function difficulties
- Extreme emotional meltdowns

Ages 12 and above:

- Relationship problems, anxiety about relationships
- Social rejection, isolation
- Substance abuse, including alcohol
- Risky sexual behavior
- Underage or unwanted pregnancy
- Delinquency or criminal behavior (including shoplifting, vandalism)
- Low self-esteem
- Self-harm, suicidality

Ages 16 and above:

- Dropping out of school
- Losing jobs
- Parenting problems
- Criminality
- Financial difficulties
- Traffic crashes
- Internalizing conditions: depression, anxiety

Ages 18 and above:

- Gambling problems, compulsive shopping
- Personality disorder
- Chronic fatigue syndrome
- Fibromyalgia

The key message is not to disregard females because they do not present with the externalizing behavioral problems, or the disruptive, hard-to-manage boisterous, or loud behaviors typically associated with males with ADHD.

Diagnosis

The authors emphasize that "comprehensive assessment should be completed to accurately capture the symptoms of ADHD across multiple settings, their persistence over time, and associated functional impairments. High rates of comorbidity are typically present. The assessment process is typically tripartite, involving the use of rating scales, a clinical interview, and ideally objective information from informants or school reports."

Rating scales: Ideally rely on those that provide female norms, making them more sensitive to female presentation.

Clinical interviews:

-Be mindful of age-appropriate, common-occurring conditions in females with ADHD, including autistic spectrum disorder, tics, mood disorders, anxiety, eating disorders, fibromyalgia, and chronic fatigue syndrome.
- Be alert to signs of self-harming behaviors(especially cutting), which peak in adolescence and early adulthood.
-Given that heritability of ADHD is high, ranging between 70-80% in both children and adults, be mindful that informants who are family members may also have ADHD (possibly undiagnosed) which may affect their judgment of "typical" behavior. The assessor should obtain specific examples of behavior from the informant and use these to make clinically informed judgments, rather than relying upon the informants' perception of what is typical or atypical.

Treatment

Pharmacological:

- Recommendations for medication do not differ by sex, except that pharmacological treatment is generally not advised during pregnancy or breastfeeding.
- A systematic review and network meta-analysis recommended methylphenidate for children and adolescents and amphetamines for adults, taking into account both efficacy and safety. Larger confidence intervals about the tolerability and efficacy of bupropion, clonidine, and guanine were reported, indicating less conclusive results about the efficacy and tolerability of these oral medications. The use of medication should be followed up over time to verify if medications are effective and well-tolerated, and to manage the effects of related conditions(e.g. anxiety, depression) if they emerge.

Non-pharmacological:

- Cognitive behavioral therapy (CBT) together with psychoeducation (which can be provided to both patients and parent/guardians together or independently) are the best forms of psychological treatment.
- Parents and other guardians of teenage girls need to be shown how to identify deliberate self-harming or risky behavior.
- Adolescent girls may require assistance in addressing risky behavior (sexual risk, substance misuse) and improving self-management. Girls with ADHD are more vulnerable to sexual exploitation and have higher rates of early and unwanted pregnancy.
- Adults are more likely to require interventions to address employment problems, child-rearing, and parenting. Women with ADHD are also more vulnerable to sexual exploitation, including physical and sexual violence.
- Interventions should support attendance and engagement with education to avoid early school-leaving, diminished educational attainment, and associated vulnerabilities. While externalizing conditions have a greater impact on classroom behavior, internalizing conditions affect motivation and thus the ability to benefit from education.

Institutional outreach

- Educational, social care, occupational, and criminal justice system professionals should be trained to improve the detection and referral of ADHD in girls and women.
- Flexible learning systems and support with childcare can help women with ADHD return to education after having a baby.
- Depending on the country of residence, women who disclose their disability to their employer may be entitled to reasonable adjustments to the workplace to accommodate their condition.
- Low to no-cost apps are available to assist persons with ADHD with itineraries, lists, and reminders.
- Career planning should take into account that some occupations may provide a better fit for women with ADHD: "some individuals with ADHD show a preference for more stimulating environments, active, hands-on, or busy and fast-paced jobs."
- Persons with ADHD, both male and female, make up roughly a quarter of the prison population: "Evidence indicates that ADHD treatment is associated with reduced rates of criminality, is tolerated and effective in prison inmates, and improves their quality of life and cognitive function. This has led to speculation that effective identification and treatment of ADHD may help to reduce re-offending."

The authors concluded, "To facilitate identification, it is important to move away from the previously predominating disruptive boy stereotype of ADHD and understand the more subtle and internalized presentation that predominates in girls and women."

Susan Young, Nicoletta Adamo, BryndísBjörkÁsgeirsdóttir, Polly Branney, Michelle Beckett, William Colley, Sally Cubbin, Quinton Deeley, Emad Farrag, Gisli Gudjonsson, Peter Hill, JackHollingdale, OzgeKilic, Tony Lloyd, Peter Mason, Eleni Paliokosta, Sri Perecherla, Jane Sedgwick, Caroline Skirrow, Kevin Tierney, Kobus van Rensburg, EmmaWoodhouse, “Females with ADHD: An expert consensus statement taking a lifespan approach guiding the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women,” BMC Psychiatry(2020)20:404,https://doi.org/10.1186/s12888-020-02707-9.

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Where Does ADHD Fit in the Psychopathology Hierarchy? A Symptom-Focused Study

NEWS TUESDAY: Where Does ADHD Fit in the Psychopathology Hierarchy? A Symptom-Focused Study

Background:

Our understanding of Attention-deficit/hyperactivity disorder (ADHD) has grown and evolved considerably since it first appeared in the DSM-II as “Hyperkinetic Reaction of Childhood.”  This study aimed to find the disorder’s placement within the modern psychopathology classification systems like the Hierarchical Taxonomy Of Psychopathology (HiTOP). 

The HiTOP model aims to address limitations of traditional classification systems for mental illness, such as the DSM-5 and ICD-10, by organizing psychopathology according to evidence from research on observable patterns of mental health problems.. Is ADHD best categorized under externalizing conditions, neurodevelopmental disorders, or something else entirely? A recent study by Zheyue Peng, Kasey Stanton, Beatriz Dominguez-Alvarez, and Ashley L. Watts takes a closer look at this question using a symptom-focused approach.

The Study:

Traditionally, ADHD has been associated with externalizing behaviors, such as impulsivity and hyperactivity, or with neurodevelopmental traits, like cognitive delays. However, this study challenges the idea of placing ADHD into a single category. Instead, it maps ADHD symptoms across three major psychopathology spectra: externalizing, neurodevelopmental, and internalizing.

The findings reveal that ADHD symptoms don’t fit neatly into one box. For example, symptoms like impulsivity, poor school performance, and low perseverance were strongly associated with externalizing behaviors. On the other hand, cognitive disengagement (e.g., daydreaming, blank staring) and immaturity were closely linked to neurodevelopmental challenges. Interestingly, cognitive disengagement also showed ties to internalizing symptoms, such as anxiety or depression.

This research underscores the complexity of ADHD. Rather than treating ADHD as a single, unitary construct, the study advocates for a symptom-based approach to better understand and treat individuals. By acknowledging that ADHD symptoms relate to multiple psychopathology spectra, clinicians and researchers can move toward more nuanced classification systems and targeted interventions.

Conclusion: 

Ultimately, this study highlights the need for modern systems to move beyond rigid categories and adopt a more flexible, symptom-focused framework for understanding ADHD’s place in psychopathology.

January 6, 2025

No Link Found Between Maternal Coffee Consumption and Subsequent Neurodevelopmental Difficulties

Norwegian nationwide population study finds no link between maternal coffee consumption during pregnancy and offspring neurodevelopmental difficulties, including ADHD

The Background:

Caffeine and its primary breakdown compounds – paraxanthine, theophylline, and theobromine (also the primary alkaloid in chocolate) – readily cross the placenta and tend to linger due to the underdevelopment of fetal caffeine metabolizing enzymes.

Could accumulating caffeine metabolites harm the developing fetal brain? Studies to date have come to contradictory conclusions, some finding an association, others finding none.

Norway has a national single-payer health insurance system with a national health registry comprehensively tracking virtually all residents.

The Methods:

An international study team used Norways’s registry, and its Mother, Father, and Child Cohort Study (MoBa) to explore the relationship between maternal and paternal coffee consumption and offspring neurodevelopmental difficulties (ND), including symptoms of ADHD as determined from validated rating scales, using 58,964 mother-child pairs and 22,576 father-child pairs, covering the decade 1999-2008.

Unadjusted results indicated a strong association between maternal coffee consumption before and during pregnancy with offspring ADHD, but none with paternal coffee consumption. Superficially, that might seem like compelling evidence.

Yet after adjusting for education, income, smoking, and alcohol, “previously significant effects attenuated towards zero and some associations switched from being positive to negative.”

Then, after further adjusting for genetic confounding, ADHD symptoms at 1.5 years, 3 years, 5 years (on both of two different rating scales), and 8 years (including separate measures of inattention and hyperactivity symptoms) all became indistinguishable between offspring from mothers consuming coffee during pregnancy and offspring of mothers abstaining from coffee during pregnancy. 

Conclusion:

The team concluded, “This study applied several conventional and genetic epidemiological approaches to investigate the potential relationship between maternal coffee consumption during pregnancy and offspring NDs [neurodevelopmental difficulties]. When considering the results of the conventional and genetic epidemiological analyses, as well as the broader literature, we conclude that there is little evidence that maternal coffee consumption during pregnancy is strongly causally related to offspring NDs.”

More specifically, the team found no evidence of any causal relationship with offspring ADHD

January 2, 2025

Swedish Nationwide Population Study Finds Strong Association Between ADHD and Sleep Disorder Diagnoses and Sleep Medication Prescriptions

There has been consistent evidence of an association between ADHD and subjectively reported sleep problems even in patients not medicated for the disorder. There have also been studies using wrist-worn actigraphy (a wrist watch-like device that measures gross motor activity) and sleep lab-based polysomnography that measure objective sleep parameters. 

What has been missing are large population-based cohort studies to explore the prevalence rates of different sleep disorders and medical prescriptions in ADHD. 

Methods Used: 

Sweden has a single-payer health insurance system and a series of national population registers that track virtually its entire population. Using the Swedish Total Population Register, a local research team created a cohort of all 6,470,658 persons born between 1945 and 2008. They linked this to the Swedish National Patient Register, which includes inpatient hospitalizations from 1975 to 2013, and outpatient specialist diagnoses from 2001 to 2013, to identify diagnoses of sleep disorders. They also linked to the Prescribed Drug Register, covering 2005 to 2013, to identify prescriptions for sleep medications. 

Summary of Findings: 

Overall, persons with ADHD were eight times more likely to be diagnosed with any sleep disorder relative to normally developing peers. Broken down by age, adolescents with ADHD were 16 times more likely to receive such diagnoses, young adults (18-30) twelve times more likely, children and mid-age adults (31-45) eight times more likely, and older adults six times more likely. 

Broken down by specific sleep disorder diagnoses, relative to normally developing peers, persons with ADHD were: 

  • Five times more likely to have sleep terrors and seven times more likely to have nightmares. 
  • Six times more likely to sleepwalk. 
  • Seven times more likely to have restless leg syndrome. 
  • Sixteen times more likely to have insomnia. 
  • Nineteen times more likely to have disorders of sleep/wake schedule (circadian rhythms). 
  • Twenty times more likely to have hypersomnia (excessive sleeping). 
  • Over seventy times more likely to exhibit narcolepsy (daytime sleepiness) and cataplexy (sudden loss of muscle tone leading to collapse). 

As for sleep medication, relative to normally developing peers, persons with ADHD were: 

  • Seven times more likely to be prescribed the hypnotic zolpidem (Ambien). 
  • Eight times more likely to be prescribed the hypnotic zopiclone or the antihistamine propriomazine. 
  • Ten times more likely to be prescribed the sedative and hypnotic zaleplon (Sonata). 
  • Fourteen times more likely to be prescribed any sleep medication. 
  • 37 times more likely to be prescribed melatonin, the body’s natural sleep-inducing hormone, which is a prescription medication in Europe. 

Conclusion: 

The team concluded, “Our findings also suggest that greater clinical attention should be directed towards addressing sleep problems in individuals with ADHD. This entails implementing proactive measures through sleep education programmes and providing both pharmacological and non-pharmacological approaches such as cognitive behavioural therapy and parental sleep training.” 

December 12, 2024