1. SPECIALIST PSYCHIATRIST
ADD AND GIRLS
ADHASA 2006
WITS
DR SHABEER JEEVA
SPECIALIST PSYCHIATRIST
Melrose arch

2. ADHD In Girls DR. SHABEER A. JEEVA CHILD & ADOLESCENT PSYCHIATRIST
M.D., D.PSYCH., F.R.C.P. (C)
The Centre for Medical Excellence
2nd Floor
18 High Street
Melrose Arch
2196

3. ADHD: Timeline of Definitions
Minimal
Brain
Damage
Adult ADHD Studied
Hyperkinetic Reaction of Childhood (DSM-II)
First Description of ADHD by Still
Attention Deficit/Hyperactivity
Disorder (DSM-III-R)
Efficacy of Amphetamine
1902
1930
1937
1950
1980
1987
1994
The definition of ADHD has changed over the years, but the core symptoms of this neurobehavioral syndrome have always been defined by behavioral characteristics.
In the early 20th century, these behavioral characteristics were considered the sequelae of an insult to the brain—either a head injury or a central nervous system (CNS) infection. When the characteristics were found in children without a history of such an insult, the CNS damage was considered to be minimal (only manifesting as a behavioral change); hence the term minimal brain damage. Later, the term minimal brain dysfunction was used to describe a cluster of symptoms that included specific learning disabilities, hyperkinesis, impulsivity, and short attention span. Minimal brain dysfunction, however, was vague and overinclusive and lacked predictive validity. In 1937, Bradley et al reported on the effects of amphetamines in reducing disruptive behaviors and improving academic performance of behaviorally disordered children. Amphetamines have been used successfully in the treatment of ADHD for more than 60 years.
Dissatisfaction with the term minimal brain dysfunction led to the coining of hyperactive child syndrome. In 1968, DSM-II described the behavioral manifestations of overactivity, restlessness, distractibility, and short attention span as components of a specific syndrome, hyperkinetic reaction of childhood, emphasizing motoric symptoms.
More modern classifications (DSM-III, DSM-III-R, DSM-IV) have described the signs and symptoms of the disorder without implying specific etiology (as minimal brain damage did). Current criteria emphasize 3 main behavioral areas—inattention, impulsivity, and hyperactivity.
In the 1970s, Wender and colleagues studied adults with ADHD with regard to both characteristics and treatment response.
Minimal Brain Dysfunction
Hyperactive Child Syndrome
Attention Deficit Disorder ± Hyperactivity (DSM-III)
Attention Deficit/Hyperactivity Disorder (DSM-IV)

4. Age-Dependent Decline of ADHD Symptoms6 }
Inattention
Syndromatic
Criteria 5
Impulsivity 4 }
Mean No. Symptoms 3
Functional Impairments
Hyperactivity 2
The inattentive symptom cluster of ADHD does not diminish substantially with age. Individuals continue to be well above the syndromatic criteria and very much above the functional impairment demarcations. Hence, attentional symptoms are often the “hidden demon” of the disorder over time. 1
b = –0.25 (–0.35, –0.15)
<6
6-8
9-11
12-14
15-17
18-20
Age (y)
Biederman J et al. Am J Psychiatry. 2000;157:

5. ADHD In Girls Is ADHD a disorder in Girls?
An estimated 1 million girls and women in the United States are affected by ADHD (Arnold et al. J Abnorm Child Psychol 1996)
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Ed. (DSM-IV) estimates that boys with ADHD outnumber girls with ADHD by as much as 9:1 (American Psychiatric Association 2000) However, community-based studies in which the ratio of boys to girls with ADHD is as low as 2:5:1 indicate that prevalence in girls is understated (Szatmari, Child Adolesc Psychiatry Clin N Am 1992)
This suggests that school-aged girls with ADHD are less likely to be diagnosed properly, and consequently receive inadequate treatment. (Biederman et al. JAACAP 1999)

6. Diagnostic issues for girls with ADHD
Core Symptoms:
Both boys and girls with ADHD display the same core symptoms
Inattention, impulsivity, and hyperactivity.
Boys tend to have more symptoms of hyperactivity (Arnold J Abnorm Child Psychol 1996)
In girls, symptoms of inattention are predominant (Biederman et al JAACAP 1999)

7. Symptoms in Girls
Hyperactivity in girls may manifest as hyper verbalisation and emotional excitability, rather than the motoric hyperactivity seen in boys (Arnold et al. J Abnorm Child Psych 1996)

8. Behaviours that may be seen in girls with ADHD
General
School phobia or avoidance
Dishevelled appearance
Grooming problems

9. In School Withdrawal in the classroom Low academic performance
Low self esteem
Poor social skills
(Adapted from: Nadeau, Littman and Quinn, Understanding Girls with AD/HD, Advantage Books 1999)

10. Comorbidities in girls with ADHD
Conduct Disorder and oppositional defiant disorder – prevalence in girls with ADHD is about half that found in boys with ADHD (Biederman et al. JAACAP 1999)

11. These disorders are associated with the behavioural deviance and aggression that often drives clinical referral. Therefore, the low rates of these disorders in girls and their natural tendency to be less active, more compliant, and less aggressive, may account for the under recognition of ADHD in girls compared with boys.

12. Symptom profile of girls with ADHD
Acts before thinking
Difficulty waiting turn
Blunt answers
Interrupts
Talks excessively
Difficulty playing quietly
Fidgety

13. Symptom profile of girls with ADHD continued
Difficulty remaining seated
Does not listen
Loses things
Easily distracted
Difficulty following instructions
Difficulty sustaining attention
Shifts activities

14. Pharmacotherapy for ADHD in girls
Pharmacotherapy combined with behavioural is a highly effective treatment for girls with ADHD (MTA. Arch Gen Psychiatry 1999)
Stimulants (e.g. MPH or amphetamine) are the first-line pharmacotherapy for treating core symptoms of ADHD (Greenhill et al. JAACAP 2002; AAP, Paediatrics 2001)
Several studies show that immediate-release (IR) MPH has equivalent beneficial effects in boys and girls (Pelham et al. JAACAP 1989; Sharp et al. JAACAP 1999)

15. Of particular relevance to girls is the recent finding that stimulant pharmacotherapy in childhood may be associated with a reduced risk of subsequent drug and alcohol abuse (Wilens et al. Paediatrics 2003)

16. Psychiatric Comorbidities in Girls with ADHD
Anxiety
(34%)
MD (20%) 7% 7%
CD (8%) 4%
A study of girls with ADHD at Massachusetts General Hospital reported rates of psychiatric comorbidities in girls that are similar to the rates previously reported for boys. The results of this study emphasize the severity of the disorder in girls and a high level of comorbid psychopathology that must be considered when diagnosing and treating girls with ADHD.
MD = mood disorder.
23% 2%
Non- comorbid (55%) 2%
Biederman et al. J Am Acad Child Adolesc Psychiatry. 1999;38:966.

18. Patients with “ADHD” may suffer Because…..
Their parents don’t understand them;
Their teachers can’t stand them;
Their peers reject them;
Their spouses and bosses can’t stand their disorganization and intensity;
They themselves begin to think: “no matter what I do I can’t win…”

19. Famous People with Attention Deficit and Learning Disorders
Albert Einstein
Thomas Edison
Gen. George Patton
John F. Kennedy
Bruce Jenner
Eddie Rickenbacker
Harry Belafonte
Walt Disney
Steve McQueen
George C. Scott
Tom Smothers
Suzanne Somers
Jules Verne
“Magic Johnson”
Carl Lewis
Nelson Rockefeller
Sylvester Stallone
Cher
Gen. Westmoreland
Charles Schwab
Danny Glover
John Lennon
Greg Louganis
Winston Churchill
Henry Ford
Robert Kennedy
George Bernard Shaw
Beethoven
Hans Christian Anderson
Galileo
Mozart
Leonardo da Vinci
Whoppi Goldberg
Tom Cruise
Henry Winkler
F. Scott Fitzgerald
Robin Williams
Louis Pasteur
Werner von Braun
Dwight D. Eisenhower
Lindsay Wagner
Alexander Graham Bell
Woodrow Wilson

20. ATTENTION DEFICIT DISORDER
INATTENTION IMPULSIVITY
(Distractible) (Act before thinking)
A.D.D.
Girls > Boys

21. ATTENTION DEFICIT HYPERACTIVITY DISORDER
INATTENTION IMPULSIVITY
(Distractible) (Act before thinking)
A.D.H.D.
HYPERACTIVITY-IMPULSIVITY
CLUSTER + Hyperactivity-boys>girls

22. Concurrent conditions in dx
ADHD
S.L.D
O.D.D.
C.D.

23. Prevalence and Genetics of ADHD
6-8% of children; 3-5% of adults
Male-Female: 6:1, 3:1, 1:1
All levels of IQ
All levels of socioeconomic status
Family genetic transmission: 0.91
Inheritance not specific to subtype

24. Symptoms of Hyperactivity Often Manifest Differently in Adults
Hyperactivity often changes to inner restlessness
DSM-IV Symptom Domain
Squirms and fidgets
Can’t stay seated
Runs/climbs excessively
Can’t play/work quietly
“On the go”/driven by motor
Talks excessively
Common Adult Manifestation
Workaholic
Overscheduled/ overwhelmed
Self-selects a very active job
Constant activity leading to family tension
Talks excessively

25. Symptoms of Impulsivity Often Manifest Differently in Adults
Impulsivity in adulthood often carries more serious consequences
DSM-IV Symptom Domain
Blurts out answers
Can’t wait turn
Intrudes/interrupts others
Common Adult Manifestation
Low frustration tolerance
Losing temper
Quitting jobs
Ending relationships
Driving too fast
Addictive personality

26. Symptoms of Inattention Often Manifest Differently in Adults
DSM-IV Symptom Domain
Difficulty sustaining attention
Doesn’t listen
No follow-through
Can’t organize
Loses important things
Easily distractible, forgetful
Common Adult Manifestation
Difficulty sustaining attention
Meetings, reading, paperwork
Paralyzing procrastination
Slow, inefficient
Poor time management
Disorganized

27. Comorbid Psychiatric Disturbances Are Common in Adults With ADHD
Antisocial Disorder (10%)
Major Depressive Disorder (35%)
Bipolar Disorder (15%)
Anxiety Disorders (40%)
Substance Abuse Disorders (50%)
These rates indicate the presence of particular disorders over the lifetime of adults with ADHD.
Shekim WO et al. Compr Psychiatry. 1990;31:
Biederman J et al. Am J Psychiatry. 1993;150:

28. ADHD and Comorbid Conditions
Impulsivity/
Hyperactivity
Inattention
In the diagnostic assessment of ADHD it is important to address possible co-occurring psychiatric disorders, referred to as comorbidity, as they may influence treatment and outcome.
ADHD is frequently comorbid with other psychiatric disorders. These include disruptive behavior disorders, mood disorders, anxiety, and learning disorders.
Comorbidity

29. Sound of Music

30. Is It ADHD?

31. DSM-IV Inattention Symptoms in Adults with ADHD
% present
M F T
Easy distractibility
Difficulty sustaining attention
Difficulty organizing tasks
Difficulty listening
Difficulty following instructions
Lack of sustained mental effort
Inattention to details
Forgetfulness
Losing things

32. DSM-IV Hyperactivity-Impulsivity Symptoms in Adults with ADHD
% present
M F Average
Hyperactivity
Running about
Being on the go
Talking too much
Fidgeting
Difficulty engaging in leisure
Leaving seat
Impulsivity
Difficulty awaiting turn
Interrupting or intruding
Blurting out answers

33. Associated Symptoms in Adults with ADHD
% present
Male Female Total
A sense of underachievement
An intolerance of boredom
Many projects going
simultaneously
Inability to reach potential
Problems with time management
Impatience
Chronic procrastination
Frequent search for high stimulation
Sense of insecurity
Feeling disappointed and discouraged
Forgetfulness
Poor self-esteem

34. Most Frequently Associated Symptoms in Adult ADHD (cont’d)
% present
M F T
Tendency to say what comes to mind
Trouble in following “proper” procedure
Nervousness
Stress intolerance
Difficulty enjoying work
Frequent mood swings
Long standing unhappiness
Impulsivity
Frequent finger drumming

35. Most Frequently Associated Symptoms in Adult ADHD (cont’d)
% present
M F T
Hot temper
Depression
Frequent job changes
Verbal aggression
Self-destructive behavior
Alcohol abuse *
Physical aggression
Drug abuse *
Difficulty with the law *

36. ADHD Comorbidities: A Developmental Perspective
ODD, CD,
Language Disorders
Learning problems,
Developmental problems
Anxiety Disorders
Mood Disorders
Substance abuse
Personality Disorders
ODD, CD, LD,
Anxiety and/or
Mood Disorders
Pre-school Adolescent Adult
School-age College-age
Over 60% of childhood ADHD continues into adulthood1.
1. Baren M. ADHD in adolescents: Will you know it when you see it? Contemporary Pediatrics 2002; 19:
ODD, CD, LD,
Anxiety Disorders
Mood Disorders
Substance abuse
ODD, CD, Learning Disabilities, Anxiety Disorders

37. Comorbidity in Adult ADHD
Disorder
Males
Females
Total
Maj. Dep.
35,71%
54,02%
41,08%
Anxiety Dis
14,76%
27,59%
18,52%
Dysthymic Dis
12,86%
16,09%
13,80%
ODD
5,24%
3,45%
4,71% CD
0,48%
1,35%
ADHD only
36,19%
22,99%
32,32%
19+
210 87
297

38. ADHD Life Cycle Changes
Child Adolescent Adult Prevalence % % %
Subtype ADHD>ADD ADHD=ADD ADD>ADHD
Comorbidity ODD,CD ANX-DEP ANX-DEP
LD, LAN D SUB USE, PD
Rx response very good very good very good
(high remission/normalization)

39. Gender and Comorbidity
More common in males: Aggressive Behavior, Substance Abuse, Conduct and Antisocial Personality Disorder
More common in females: Anxiety Disorders and Mood Disorders

40. Conclusions ADHD has a high rate of comorbidity in adults
The determination of associated comorbid disorders in adult ADHD is essential to establish the “goodness of fit” between patient symptom/comorbidity profile and treatment options