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ADHD in
girls comes in focus
by Dorsey Griffith, Sacramento Bee, October 27, 2002
For more articles on disabilities and special ed visit
www.bridges4kids.org
When people think of attention deficit hyperactivity disorder,
they imagine wound-up boys bouncing off walls causing non-stop
frustration for parents and teachers.
New research, self-help books and a pink-packaged publicity
campaign by the makers of the stimulant drug Ritalin have
given rise to a different picture of ADHD: daydreaming girls
who rarely finish school assignments, but whose troubles go
mostly undetected.
Questions remain about whether that picture is accurate.
Critics find the awareness campaigns troubling. They say not
all inattentive girls have psychiatric disorders, and that
stimulant treatment -- while often helpful in reducing
symptoms -- has not been adequately researched and does not
address underlying learning problems.
For parents whose daughters have struggled in school and at
home, however, the recognition that girls can have ADHD and be
treated has brought immediate relief and hope for the future.
The debate means little to 10-year-old Ashley of Sacramento.
Before being diagnosed with ADHD and taking the stimulant
Ritalin, the talkative blonde with lively green eyes could not
tolerate the sound of a tapping pencil, sit still to read a
short story or complete homework without hours of hair-pulling
trauma.
"I didn't do very good in school," said Ashley, whose name has
been changed for this story at the request of her parents. "I
sorta kinda dozed off whenever the teacher was talking. I was
staring into space thinking about something else."
Now, she said, "I am really good at math. I pay attention and
listen really carefully. And I am really good now at reading."
When it comes to ADHD, boys are referred for psychological
assessment and medical treatment about five times as often as
girls. Boys have been the focus of most of the thousands of
studies on ADHD and its treatment ever since the disorder
first was described 50 years ago.
That's partly because boys more often exhibit symptoms of
hyperactivity, which until the 1970s formed the basis of the
diagnosis.
"Girls are not as troublesome as boys," said Kathleen Nadeau,
a Maryland psychologist and co-director of the National Center
for Gender Issues and AD/HD. "The problem with girls is they
don't bother enough adults. It's the squeaky wheel factor.
That's driving referrals."
Experts who focus on gender differences and ADHD say that if
ignored, the disorder can be devastating for girls, leading to
unwanted pregnancies, substance abuse, sexually transmitted
diseases and automobile accidents.
The most conclusive evidence so far of how ADHD affects girls
comes from a study by Steven Hinshaw, a University of
California, Berkeley, psychologist.
Hinshaw observed the pre-adolescent girls, none taking
stimulant medication, during six-week summer camps. He found
that unlike the girls in a control group, the girls with ADHD
"were disliked by their peers, were underachieving in school,
were more disruptive and aggressive and more withdrawn
socially."
It is the kind of future that Marcia Ingram of Folsom has long
worried could afflict her daughter Alana, an intelligent but
stubborn 7-year-old diagnosed last year with ADHD.
Before being treated, Ingram said, Alana did dangerous and
even destructive things. She said Alana's summer school
teacher described her as "the most disruptive child she'd ever
seen."
"You come to the point and say, 'I can't do this on my own
anymore,' " Ingram said. "I need some help here, or things
will deteriorate."
A pediatrician prescribed Ritalin. Although the medicine calms
Alana, Ingram said it also changes her personality. Alana
hates taking it and sometimes hides the pills under a couch or
potted plant.
"She's a lot easier to handle," Ingram said, "but it takes
away part of her sparkle."
The American Psychiatric Association has established various
subtypes of the disorder: ADHD, combined type; ADHD,
predominantly inattentive type; and ADHD, predominantly
hyperactive-impulsive type.
While boys with ADHD often have the combined type, experts
generally agree that girls with ADHD tend toward the
inattentive type -- they are not generally hyperactive or
impulsive.
Some say subtypes make the disorder too all-inclusive; others
say they're not inclusive enough.
Dr. Lawrence Diller, a developmental pediatrician in Walnut
Creek who wrote the books "Running on Ritalin" and "Should I
Medicate My Child?" argues that broader descriptions of ADHD
have swept more children under the umbrella of a psychiatric
diagnosis. Instead, he said, they may just be children with
different learning styles or disabilities.
"It has become the all-encompassing diagnosis for
under-performance," he said. "The medicine works in the sense
that it will keep the girls focused in the classroom longer.
But it won't overcome their learning ... problem."
Nadeau argues that the broader diagnostic criteria are
inadequate for girls. She says that if the criteria were
updated, the number of children diagnosed would be more evenly
split between girls and boys.
Under current guidelines, a child has to have symptoms before
age 7 to be diagnosed with ADHD, for instance. "With a quiet,
inattentive girl, there is not going to be any record of
problems prior to age 7," Nadeau said.
Why boys and girls with the same disorder may behave so
differently is not known. Hinshaw, of Berkeley, suggests that
both nature and nurture play a role.
Boys may be more genetically predisposed to behavioral and
other developmental abnormalities than girls, he theorizes.
And socialization may lead boys to act more aggressively and
girls to control their emotions.
As a result, many experts believe that girls with ADHD often
are misdiagnosed. Ashley, for example, received years of
therapy for a speech delay that her parents believed was the
cause of her tuning out.
"We went into denial," said Ashley's mother. It was Ashley's
third-grade teacher, whose son has ADHD, who recommended an
evaluation by a psychologist.
But just how well children with the type of ADHD most common
in girls respond to medication is unclear.
"At this point there are no empirical data," said Linda
Pfiffner, a psychologist and professor who runs an ADHD clinic
at the University of California, San Francisco.
Pfiffner said that the only relevant study, published in the
journal Pediatrics in 1991, found that fewer kids with the
non-hyperactive type of ADHD benefited from stimulants than
did kids with the hyperactive type. Additional studies are
under way.
No one has evaluated non-drug approaches in non-hyperactive
children with ADHD either, Pfiffner added. She recently won a
grant from the federal Centers for Disease Control and
Prevention to evaluate the impact of teaching them
organizational and homework study skills.
For Ashley, the medication was a godsend -- like glasses for a
child with poor vision, her mother said.
"The day she started taking it, she was like a different
person," her teacher said. "She was able to focus. She was
able to do her work independently."
When the Ritalin she takes in the morning wears off about 3
p.m., as it did on a recent October afternoon, Ashley hums
with energy, darting from room to room and speaking in run-on
sentences that don't always make sense. Thirty minutes after a
second dose, Ashley sat quietly at a desk working out
beginning algebra problems on her own.
Novartis, the maker of Ritalin, believes many more girls like
Ashley could benefit from medical treatment, if only the
adults in their lives recognized the problem. The company
cites one estimate that 75 percent of girls with ADHD may go
undiagnosed.
In August, the company put out a media packet titled "Boys
with ADHD get treated. Girls retreat into silence." The goal,
a Novartis spokeswoman said, was to educate reporters.
Encased in a pink plastic binder, the packet includes results
of a survey of parents, girls and teachers on gender
differences in the diagnosis and treatment of ADHD.
Girls with ADHD face greater impairment in areas such as
self-esteem and social and family relationships than boys with
the disorder, according to the survey.
It was designed by Dr. Patricia Quinn, a developmental
pediatrician who with Nadeau co-directs the National Center
for Gender Issues and AD/HD and has written several books
about ADHD.
Quinn is a paid consultant to Novartis and to McNeil Consumer
and Specialty Pharmaceuticals, maker of another ADHD drug,
Concerta. But she said the survey design and findings were not
tainted by her financial ties to the drug industry.
The Novartis press packet describes how Ritalin LA -- the
company's new, timed-release formulation of Ritalin -- is
superior to a sugar pill for both combined and inattentive
type ADHD.
Even without such marketing campaigns, ADHD in girls will be
getting more attention in the days to come.
Nadeau said she spends two to three hours a week talking to
reporters about the disorder in girls and is spreading the
word in countries such as Norway and Japan. Next spring, her
center will host a major workshop in Washington on the topic,
and she is testing a new ADHD questionnaire geared toward
girls.
"As soon as we get our questionnaire ... out there being used
by professionals," she said, "a great number of girls will be
diagnosed."
About the Writer
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The Bee's Dorsey Griffith can be reached at (916) 321-1089 or
dgriffith@sacbee.com.
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