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No BS, Just Science?

Correct. Since the Internet is filled up with garbage about ADHD, I’ve spent 8 years now on reading the scientific evidence on PubMed to ensure that what you find on my blog is – NO BS, Just Science …

#SeeMeToo – ADHD In Women Is Overlooked And Misunderstood

Scientific consensus agrees, that ADHD is a genetic, neurobiological, mental disorder, and that ADHD is something that you are born…

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Scientific consensus agrees, that ADHD is a genetic, neurobiological, mental disorder, and that ADHD is something that you are born with, and that the symptomatology changes across the lifespan, and finally that it is a condition that you will die with. So I wonder why the current ‘truth’ about the sex ratio in ADHD is 4:1 (men vs. women) since the global distribution of the sexes are 2:1 (or almost 50/50%), and I cannot conceive WHAT the basis for this difference is – other than bias and year and years of confirmation bias in the diagnostic manuals. I think it’s time to ‘get real’ and make some fundamental changes, to accommodate a fair and correct treatment of girls and women – world-wide …#SeeMeToo

The Problem is, that …

… modern scientific consensus is, that ADHD contains 5 major core behavioral symptoms:

  • Hyperactivity
  • Impulsivity
  • Distractability
  • Emotional Dysregulation
  • Mind Wandering

Hyperactivity/Impulsivity are PUBLIC behaviors, were as Distractability, Emotional Dysregulation, and Mind Wandering are PRIVATE behaviors (even though they eventually will be displayed through the public, external behavior).

Since ADHD is a diagnosis where there are no biological tests, like bloodwork etc., that can confirm or deny, whether a person was born with ADHD or not, all diagnostic work is done, based on the person diagnosing and their individual perception of whether the female exhibits the symptoms, as they are defined in the diagnosing manual, and it is humanly impossible to NOT be subjective when doing so, which in turn leads to – false beliefs, fuzzy logic, and confirmation bias.

This graphic is from an analysis I did a year ago, which clearly shows the lifespan discrepancies in the medicinal treatment of ADHD, grouped by age and sex, over a 5 year period in Denmark. Since this analysis, I have done some follow-up analysis, which shows that the age group with the most increase in new patients prescribed ADHD mediciation, are women between 25 and 55 years of age, being mothers and grandmothers of children being diagnosed with ADHD, further lending credence to both the views of Young et al., 2020 and what I personally states as facts.

Therefore the current DSM-5 uses criteria or clusters of criterias, to determine whether or not, the person’s behavior is within what is expected , as it is seen across the species Homo Sapiens Sapiens, on average. This is referred to as Neurotypical (NT) with the ADHD/Autistic community.

The challenges though, is that our species is the only one which is mentally able to ‘predict the future’, you may know this a planning, imagining, dreaming, wishing etc., and we are the only known species in the universe, that have this ability.

BUT, this comes with a very big caveat, our brain filters, distracts, and distorts the stimuli that our body and senses registers. What this means, is that reality do not exist – at all … and if you have a problem with understanding and accepting this scientific fact, then go make a cup of tea instead of reading on, because I’m convinced that you’d be wasting your time continuing, and if you are comfortable in your current, ordered perception of the world in which you exist as it is now, please do not allow me to broaden your insight into the latest science on this topic …

That said, this leads me to conclude that there are 3 major problems behind this blatant and obvious discrimination of women vs. men in relation to diagnosis of ADHD:

  1. You are a woman, not a man, therefore we hold you to a much higher standard, that we do, if you were a man.
  2. You are not running around causing trouble everywhere, stealing, lying, kicking, screaming or being at the root cause of anti-social activities in your community.
  3. You are sitting, quietly, in the back of the class, reading Harry Potter and dreaming of your after-school activity with your horse …
This graphic shows the distribution of the 3 core presentations of ADHD, grouped in age groups and presentation variant, for both sexes (ADDspeaker, 2020)

So in conclusion, what I believe is, that it is the culture in the people who work with children, have a ‘learned bias’ through outdated educational teachings, combined with the social consensus of ‘what ADHD looks like’, and lastly with the confirmation bias of trained professionals tasked with diagnosing females with ADHD. These are my personally beliefs, I agree, but they are based on scientific evidence and 8 years of working with females with ADHD (diagnosed and undiagnosed) And the overwhelming experience I have, is that females are being GROSSLY overlooked, and therefore I have coined 2020 as the year were we finally get this corrected – together – are you ready to help me, help you, realize that vision?

What does the science say?

Susan Young, PhD, Imperial College London is one of my absolute idols within the ADHD research community… Not only is she a badass woman (she’s spent years in the british correctional service, including Broadmore, studying ADHD and ciminality amongst the most feared convicts in the UK, she is likewise a gifted scientist, and finally, she is also a very nice person to interact with and open-minded.

Therefore I have decided to base this article on information and evidence from her latest publication: ADHD in Females, which is an expert consensus statement on the current state of affairs on this topic..

ADHD in Females – What the Consensus says!

There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females (Young et al., 2020).

Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males (Young et al., 2020).

This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral (Young et al., 2020).

Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD (Young et al., 2020).

This disparity in prevalence between boys and girls may stem from a variety of potential factors. The contribution of greater genetic vulnerability, endocrine factors, psychosocial contributors, or a propensity to respond negatively to certain early life stressors in boys have been proposed or investigated as potential contributors to sexual dimorphism in prevalence and presentation (Young et al., 2020).

Whilst in childhood there is a clear male preponderance of ADHD, in adult samples sex differences in prevalence are more modest or absent (Young et al., 2020).

This may be due to a variety of factors, with potential contributions from the greater reliance on self-report in older samples, greater persistence in females alongside increased levels of remission in males, and potentially more common late onset cases in females (Young et al., 2020).

Comprehensive views of the aetiology of ADHD incorporate biological, environmental and cultural perspectives and influences (Young et al., 2020).

Substantial genetic influences have been identified in ADHD (Young et al., 2020).

Individuals who have ADHD are more likely to have children, parents and/or siblings with ADHD (Young et al., 2020).

The ‘female protective effect’ theory suggests that girls and women may need to reach a higher threshold of genetic and environmental exposures for ADHD to be expressed, thereby accounting for the lower prevalence in females and the higher familial transmission rates seen in families where females are affected (Young et al., 2020).

Research suggests that siblings of affected girls have more ADHD symptoms compared with siblings of affected boys (Young et al., 2020).

There is increasing recognition that females with ADHD show a somewhat modified set of behaviours, symptoms and comorbidities when compared with males with ADHD; they are less likely to be identified and referred for assessment and thus their needs are less likely to be met (Young et al., 2020).

It is unknown how often a diagnosis of ADHD is being missed or misdiagnosed in females, but it has become clear that a better understanding of ADHD in girls and women is needed if we are to improve their longer-term wellbeing and functional and clinical outcomes (Young et al., 2020).

ADHD symptoms

Research in population-based samples indicates that for both sexes the hyperactive-impulsive type predominates in pre-schoolers, whereas the inattentive-type is the most common presentation from mid-to-late childhood and into adulthood (Young et al., 2020).

By contrast, clinical studies typically report a greater prevalence of combined-type ADHD (Young et al., 2020).

Early meta-analyses of gender effects have found lower severity of hyperactivity-impulsivity, or all ADHD symptoms (inattention, hyperactivity, impulsivity) in girls than boys, although individual studies show more mixed results (Young et al., 2020).

Inconsistent findings may reflect that clinic referral and diagnosis tends to favour combined subtypes equally across genders, whilst community sampling points to greater prevalence of inattentive type ADHD in girls than in boys (Young et al., 2020).

Hyperactive-impulsive symptoms have been linked to higher clinic ascertainment rates, and may be more commonly seen in boys, with inattention symptoms being less obvious and therefore less likely to be detected (Young et al., 2020).

These differences may lead to the perception that females with ADHD are less impaired (Young et al., 2020).

People may experience and respond to the same behaviour of males and females in different ways due to gender-related behavioural expectations (Young et al., 2020).

For example in two studies where teachers were presented with ADHD-like vignettes, when simply varying the child’s name and pronouns used from male to female, boys names were more likely to be referred for additional support and considered more suitable for treatment (Young et al., 2020).

Parents may also underestimate impairment and severity of hyperactive/impulsive symptoms in girls whilst over-rating these same symptoms in boys (Young et al., 2020).

Compensatory behaviours in girls, such as socially adaptive behaviour, compliance, increased resilience or coping strategies to mask behaviour may also contribute to differing perceptions that may in turn prevent referral (Young et al., 2020).

Less is known about the presentation of ADHD in older adults but evidence suggests whilst symptoms tend to decline, ADHD may persist into middle and old age, with a more even male-to-female community prevalence and referral rate with increasing age (Young et al., 2020).

Associated features, functional problems and impairments In both children and adults ADHD is commonly accompanied by emotional lability and emotion dysregulation problems (irritability, low frustration tolerance, mood changes) (Young et al., 2020).

Difficulties of this nature may be more common or severe in girls and women and emotion dysregulation problems are associated with a broad range of impairments in adulthood, including educational, occupational, social, familial, criminal, driving and financial problems (Young et al., 2020).

In an Icelandic study of ADHD symptoms in university students, poor social functioning best predicted dissatisfaction with life in males, whereas among females the best predictor of life dissatisfaction was poor emotional control (Young et al., 2020).

Cognitive problems are well established in ADHD, spanning difficulties with executive dysfunction (such as inhibition, planning, working memory and set shifting) and non-executive cognitive domains (e.g. word reading, reaction times, colour or letter naming, response consistency) (Young et al., 2020).

However, ADHD may also be associated with general impairments in intellectual functioning, which tends to be more prominent in females (Young et al., 2020).

Subtle social cognition deficits, including facial and vocal emotion recognition, have also been reported in both males and females with ADHD, with no clear sex-related differences (Young et al., 2020).

A similar level of social impairment has been identified for ADHD males and females (Young et al., 2020).

Autistic-like symptoms, including social and communication impairments, are common in both girls and boys with ADHD, and although these present at a higher rate in boys, likely influenced by the higher base incidence of ASD in boys, alongside greater difficulties in detecting ASD in girls (Young et al., 2020).

Children with ADHD are more likely to experience rejection and unpopularity and have fewer friendships than their peers and social problems can persist into adulthood (Young et al., 2020).

Disruption to relationships with parents, siblings and peers has been reported for females with ADHD (Young et al., 2020).

Girls with ADHD may apply a range of ineffective strategies to resolve their peer relationship problems, and experience more bullying than their peers, including physical, social-relational, and cyberbullying victimisation, whilst in boys physical victimisation appears to be more common (Young et al., 2020).

Peer victimisation has been associated with reduced selfesteem and self-efficacy, and increased anxiety and depression symptoms in young people with ADHD (Young et al., 2020).

Adverse outcomes have been associated with interpersonal difficulties in females with ADHD including lower satisfaction with romantic relationships and lower self esteem (Young et al., 2020).

There is some evidence to suggest that elevated symptoms of ADHD are associated with excessive internet use in children and adolescents, as well as adults, but the causal direction of this association is unclear (i.e. elevated ADHD symptoms could trigger excessive internet use, or excessive internet use could lead to elevated symptoms of ADHD) (Young et al., 2020).

Excessive gaming has also been reported. It is not clear whether this association is stronger in males or females or if it is equivalent across the sexes (Young et al., 2020).

A large webbased survey of adult internet behaviours and psychopathology in Norway found that elevated ADHD symptoms were associated with increased addictive technological behaviours, including social media use and gaming (Young et al., 2020).

Overall however, addictive social media use was more common in women (Young et al., 2020).

Throughout adolescence and the transition into adulthood, there is an increase in risk taking behaviour which may be associated with symptoms of hyperactivity and/ or impulsivity (Young et al., 2020).

For example, young people with ADHD become sexually active earlier, have more sexual partners and are more frequently treated for sexually transmitted infections (Young et al., 2020).

Rates of teenage, early or unplanned pregnancies are elevated in girls and women with ADHD (Young et al., 2020).

Pregnant women with ADHD are more likely to smoke up to the third trimester, or be obese or underweight (Young et al., 2020).

A review of ADHD and driving reported that adults with a history of ADHD may be more likely to be unsafe or reckless drivers and have more frequent or severe crashes, albeit with no specific examination of sex differences (Young et al., 2020).

One study with data from the US National Epidemiologic Survey on Alcohol and Related Conditions, showed that reckless driving was significantly more frequent in men compared with women with ADHD, reflecting the same pattern as seen the general population (Young et al., 2020).

This suggests that reckless driving is likely to be similarly proportionally enhanced in women as in men with ADHD. Studies specifically reporting driving problems in women with ADHD have shown no significant association between ADHD and driving outcomes (Young et al., 2020).

However, results from a prospective follow-up study of a nationwide birth cohort in Danish registers, reported increased mortality rate among individuals with ADHD; when compared with males with ADHD, females with ADHD had an increased mortality rate after controlling for comorbid CD, ODD and SUD. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents (Young et al., 2020).

The authors speculate that the gender difference may be driven by females being less likely to be diagnosed and receive treatment than males with the disorder, leading to greater risk of accidental death. Delinquency and criminality in females with ADHD is more common compared with their non-ADHD peers but less severe or prevalent than reported in males with ADHD (Young et al., 2020).

A study examining adult criminal outcomes in children with ADHD, showed males were twice more likely to be convicted than females, but convictions in females occurred at eighteen times the rate seen in the general population (Young et al., 2020).

Prevalence of ADHD in prison populations is estimated at 25%, with no significant differences seen in relation to gender or age (Young et al., 2020).

Triggers for referral

There are multiple potential triggers that may prompt the referral of females for assessment (Young et al., 2020).

Some of these triggers are indicative of other associated conditions and it is the clustering of multiple trait-like symptoms that are pervasive and impairing that is informative, rather than state-like symptoms showing situational change (Young et al., 2020).

The decision to refer would also be strongly supported if there is a first-degree relative with ADHD. The stereotype of the ADHD ‘disruptive boy’ is likely to influence the likelihood of referral and access to diagnosis and treatment (Young et al., 2020).

The key message is not to disregard females because they do not present with the externalising behavioural problems, or the disruptive, hard-to-manage presentation (e.g. engaging in boisterous, loud behaviours) commonly associated with males with ADHD (Young et al., 2020).

Females with ADHD may be overlooked and/or their symptoms misinterpreted, particularly for those in highly structured environments, receiving a high level of support, and for those who have developed strategies to mask or compensate for their difficulties.

Young et al., 2020

Females with ADHD may be overlooked and/or their symptoms misinterpreted, particularly for those in highly structured environments, receiving a high level of support, and for those who have developed strategies to mask or compensate for their difficulties (Young et al., 2020).

It is important to be mindful that environmental demands (including educational, occupational, financial, familial and social functions and responsibilities) increase in number, scope and complexity with age and level of independence, whilst support resources decline (Young et al., 2020).

Many young peoples’ struggles and impairments become apparent as they lose the family and educational scaffolding that was previously in place (Young et al., 2020).

Therefore, young people (both males and females) may be particularly vulnerable at times of transition, when symptoms become exposed. Increased functional demands on transition to secondary school (planning ahead, organising work and juggling assignments) may lead them to feel overwhelmed. This may impact on self-esteem and result in learner anxiety and perfectionism in an attempt to compensate (Young et al., 2020).

Periods of transition may therefore unmask unidentified ADHD by exposing or exacerbating symptoms, together with the development of internalising problems leading to increased vulnerability …

Young et al., 2020

Periods of transition may therefore unmask unidentified ADHD by exposing or exacerbating symptoms, together with the development of internalising problems leading to increased vulnerability (Young et al., 2020).

These environmental changes often occur at a time when girls undergo changes in their physiological and sexual maturation (Young et al., 2020).

There is growing recognition that puberty is a phase of high risk for mental health problems (Young et al., 2020).

The developmental changes that occur during puberty and later in adolescence may lead females with ADHD to be particularly psychologically vulnerable if they are not able to access support. Difficulty coping with more complex social interactions and resolving interpersonal conflict may also trigger cause for concern (Young et al., 2020).

As girls with ADHD move into their teenage years, difficulty maintaining friendships often becomes more marked and they may feel rejected and socially isolated. Some respond with bravado to buffer them from social isolation but a ‘brave face’ is unlikely to prevent them from feeling distressed and developing low mood and anxiety …

Young et al., 2020

As girls with ADHD move into their teenage years, difficulty maintaining friendships often becomes more marked and they may feel rejected and socially isolated. Some respond with bravado to buffer them from social isolation but a ‘brave face’ is unlikely to prevent them from feeling distressed and developing low mood and anxiety (Young et al., 2020).

Dysfunctional coping strategies and the lack of a support network may lead them to express these feelings by self-harming behaviours (e.g. cutting) or changes in eating patterns. The identification of specific educational or learning problems may also be an important trigger for referral (Young et al., 2020).

Children may be diagnosed with specific learning difficulties, such as dyslexia, when a diagnosis of ADHD may be more appropriate. Parents/carers and teachers may note the disparity between educational performance (day-to-day classroom contribution) and achievement (end grades) (Young et al., 2020).

Many young people with ADHD do not exceed the mandatory minimum level of schooling, and the problems described above may become even more marked when they enter further education and/or leave home (Young et al., 2020).

Research suggests that adolescent school girls with elevated ADHD symptoms make significantly fewer plans for their future than their peers, suggesting that they leave this to chance and opportunistic encounters …

Young et al., 2020

Research suggests that adolescent school girls with elevated ADHD symptoms make significantly fewer plans for their future than their peers, suggesting that they leave this to chance and opportunistic encounters (Young et al., 2020).

Those who enter the world of work may find that their difficulties evolve into employment impairments and limitations. However, as they mature young people may begin to develop greater awareness of their difficulties, leading to an increase in self-referrals …

Young et al., 2020

Those who enter the world of work may find that their difficulties evolve into employment impairments and limitations. However, as they mature young people may begin to develop greater awareness of their difficulties, leading to an increase in self-referrals (Young et al., 2020).

Conclusions

This consensus will inform effective identification, treatment and support of girls and women with ADHD. To facilitate identification, it is important to move away from the previously predominating ‘disruptive boy’ stereotype of ADHD and understand the more subtle and internalised presentation that predominates in girls and women. In treatment, it is important to consider a lifespan model of care for females with ADHD, which supports the complex and developmentally changing presentation of ADHD in females. Appropriate intervention is expected to have a positive impact on affected girls and women with ADHD, their families, and more broadly on society leading to increased productivity, decreased resource utilization and, most importantly, better outcomes for girls and women (Young et al., 2020).

References

Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9

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