ADHD: Girls are 50% less likely of being diagnosed due to discrimination

Deliberately having excluded the more internalised symptoms of ADHD (Mind Wandering and Emotional Dysregulation) in modern diagnosis of ADHD, we’ve caused a very skewed and sex discriminating clinical practice, which not only causes that less than 50% of girls who clearly present with ADHD (internalizing) symptoms, get a diagnosis, and those who are lucky enough to do so, are around age 12 before the are recognised and can begin treatment. This is way too late, as girls aged between 12-15 years, are 2x more like to become pregnant, and 3.6x more likely to become parents, than same aged girls, without ADHD!

Around the age of 10-12 years, most girls begin mensturating and their hormonal changes excerberate the internalised comorbidities (anxiety, depression), as well as increased risk of substance abuse, and on top of that, earlier sexual debut age, causing a significant overpresentation in involvement in early pregnancy (twice as many as girls at the same age). Likewise, parenthood between 12-15 years are 3,6x and 16-19 years are 1,94x more likely for girls with ADHD, that those without!.

In short, we are neglecting to protect these girls from early parenthood, social stigma, lack of education, less income potential, and more serious degree of comorbidities, solely based on sex discrimination.

Teenage Pregnancy and Parenthood

Early Pregnancy: Individuals with ADHD are at increased risk for a host of negative outcomes including risky sexual behavior, early age of first sexual intercourse, infrequent use of condoms or other forms of birth control, high rates of sexually transmitted diseases, and a high number of sexual partners. This study extends prior literature by examining mediators during adolescence, through which ADHD may lead to early involvement in a pregnancy. Consistent with prior literature, we found that the ADHD group was at more than two times increased risk of reporting a pregnancy by age 18 (9.3% vs. 4.6%). According to data published by the Centers for Disease Control, the rate of early pregnancy (i.e., pregnancies occurring before 18 years old) was 4.09%, demonstrating equivalent rates of early pregnancy in the LNGG [control] and rates twice as high as this national report in the ADHD group. [Meinzer et al., (2017)]

Early Parenthood: Compared to individuals without ADHD, those with ADHD were significantly more likely to become parents at age 12-15 (IRR for females: 3.62 [95%CI 2.14-6.13] and for males: 2.30 [95%CI 1.27-4.17]) and at age 16-19 (IRR for females: 1.94 [95%CI 1.62-2.33] and for males: 2.27 [95%CI 1.90-2.70]). Individuals with ADHD are significantly more likely to become teenage parents compared to individuals without ADHD. Therefore, it may be appropriate to target this group with an intervention program including sexual education and contraceptive counseling. In conclusion, the results of this nationwide cohort study show that, compared to individuals without ADHD, those with ADHD I) are more likely to become parents while being teenagers, II) are less likely to become parents in general, III) are more likely to have many children if they do become parents, and IV) have less children on average (only males). From a clinical perspective, the most important finding of our study is that individuals with ADHD are significantly more likely to become parents during their teenage years compared to individuals without ADHD. Since teenage parenthood is associated with a number of adverse outcomes for both parents and children, it may be of relevance to target this group with an intervention program (including sexual education and contraceptive counseling) to reduce the number of teenage pregnancies. [Østergaard et al. (2017)]

Adult ADHD and Pregnancy

Later Pregnancy: Compared to the reference sample, women in the abortion sample [18-46 years] were three times more likely to report a history of any mental disorder (OR ¼ 3.06, 95% CI ¼ 2.36e3.98). The highest odds were found for conduct disorder (OR ¼ 6.97, 95% CI ¼ 4.41e11.01) and drug dependence (OR ¼ 4.96, 95% CI ¼ 2.55e9.66). Similar results were found for lifetime-minus-last-year prevalence estimates and for women who had first-time abortions only. The results support the notion that psychiatric history may explain associations that have been found between abortion and mental health. Psychiatric history should therefore be taken into account when investigating the mental health consequences of abortion. [Ditzhuijzen et al. (2013)]

Odds Ratio is akin to the risk of an event happening, here it is abortion

Diagnosis and sex discrimination

The rest of the article is an excerpt of the latest scientific evidence on this discrimination, from [Mowlem et al. (2019)]

Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms

Key points from [Mowlem et al. (2019)]

Abstract

We investigate if different factors influence whether girls versus boys meet diagnostic criteria for attention-deficit/hyperactivity disorder(ADHD) among children with high ADHD symptoms. Participants were 283 children aged 7–12 from a population-based study. Girls and boys meeting diagnostic criteria for ADHD, based on an objective investigator-based interview, were compared to children who did not meet criteria despite high symptoms on a rating-scale measure of ADHD. We assessed factors that could differentially relate to diagnosis across girls and boys including ADHD symptoms, co-occurring behavioural/emotional problems and impairment, and sex-effects in rater perceptions of ADHD symptoms. While overall similar factors distinguished girls and boys who met diagnostic criteria from high-symptom peers, effect sizes were larger in girls. Emotional problems were particularly salient to distinguishing diagnosed versus high-symptom girls but not boys. Parents rated boys meeting diagnostic criteria as more impaired than high-symptom boys but did not do so for girls, and under-rated diagnosed girls’ hyperactive/impulsive symptoms compared to more objective interview assessment, with the opposite observed in boys. Results suggest girls’ ADHD may need to be made more prominent by additional behavioural/emotional problems for them to meet full diagnostic criteria and that sex differences in parental perceptions of ADHD behaviours and impairment exist. [Mowlem et al. (2019)]

The Sex Discriminating Diagnosis

A well-established feature of attention-deficit/hyperactivity disorder (ADHD) is the large sex difference in referral and diagnostic rates. The ratio of boys to girls diagnosed with ADHD in childhood falls in the range of 2:1 to 10:1 (Arnett et al., 2015; Biederman et al., 2002; Novik et al., 2006; Ramtekkar et al., 2010; Willcutt, 2012), with higher ratios seen in clinical compared to population samples. This difference highlights the possibility that ADHD may be underdiagnosed in girls in clinical practice (Ramtekkar et al., 2010). Further, it suggests that investigating sex differences in population-based samples could extend and enrich our understanding of the ADHD construct beyond that of clinical samples. [Mowlem et al. (2019)]

Boys’ symptoms are more visible

It has also been shown that proportionally more boys than girls with ADHD annoy or upset their teachers, and that parents see the ‘feminine’ ADHD diagnostic items as less problematic than the ‘masculine’ ones (Graetz et al., 2005; Ohan and Johnston, 2005). It is highly likely that these explanations, along with the greater rate of diagnosis in boys, has led to an ADHD stereotype of a ‘disruptive boy’, which may influence how behaviour in boys and girls is perceived by individuals key to the referral and diagnostic process (e.g., parents and teachers). Consistent with this view, it has been shown that parents perceived the DSM-IV ADHD criteria as being descriptive of boys (Ohan and Johnston, 2005). [Mowlem et al. (2019)]

Girls’ symptoms are more emotional

In this study, we compared girls and boys who met full ADHD diagnostic criteria using an objective interview assessment to those who, did not despite elevated levels of ADHD symptoms. When examining the factors that distinguished girls and boys who met full diagnostic criteria from their high-symptom peers, we found diagnosed girls had more additional problems than high-symptom girls, while this effect was less strong for boys. This could suggest girls with ADHD require a higher burden of other behavioural/emotional problems before they meet criteria for the disorder. We also found sex-dependent parental perceptions of ADHD behaviours and impairment. Overall there were no significant sex by diagnosis interactions, suggesting that many of the same factors distinguished high-symptom children from those who met diagnostic criteria in both boys and girls. We found that girls meeting diagnostic criteria had higher rated emotional, conduct, and peer problems, total problem scores, and complaints about hyperactivity at school compared to the girls with high symptoms that did not pass the diagnostic threshold. [Mowlem et al. (2019)]

Emotional symptoms overlooked

The prominence of emotional symptoms in girls meeting diagnostic criteria suggests that this characteristic may be more important to the female phenotype and that girls may express their difficulties differently to boys. It is possible that emotional problems are not perceived to be as problematic compared to disruptive behaviours by individuals key in the diagnostic process, such as parents and teachers, reducing the likelihood of referral compared to children displaying disruptive behaviours. Further, perhaps emotional problems experienced by girls with ADHD are how they express or manifest their impairment, which could overshadow their ADHD symptoms in clinical assessment and lead to receiving alternative diagnoses more closely associated with the internal manifestation of symptoms (e.g., anxiety or depression), or delay time to diagnosis. Indeed, there is evidence to suggest that girls are diagnosed later (Agnew-Blais et al., 2016). This is problematic given the long-term outcomes associated with ADHD (Barkley, 2002; Shaw et al., 2012) and may be a particular issue if these symptoms result from the strain of compensating for their symptoms. It is important that the presence of emotional problems does not rule out
an ADHD diagnoses (Quinn, 2008). [Mowlem et al. (2019)]

Social adaptiveness hides Girls’ symptoms

One characteristic that may influence the perception of impairment is prosocial behaviour. Not only is it clear that social functioning is likely to be linked with perceptions of impairment and coping, socially adaptive behaviour may mask symptoms and impairment to informants (Livingston and Happé, 2017). It appears that prosocial behaviour may have an influence on diagnostic status in girls but not boys. One interpretation of these findings it that in the presence of positive social behaviour, girls’ symptoms may be ‘masked’ making them appear less impaired, which could reduce the likelihood of girls with ADHD symptoms being referred and subsequently fewer girls compared to boys being diagnosed with ADHD. This hypothesis requires more research, along with the question of whether prosocial behaviour acts as a form of compensatory mechanism in girls with ADHD. It may also be that girls are more resilient to the impairments imposed by their ADHD symptoms and additional behavioural and emotional problems are therefore needed for impairment to be experienced. [Mowlem et al. (2019)]

Conclusion

In summary, these data suggest that factors which distinguish girls who meet full ADHD diagnostic criteria from high-symptom peers who do not may be somewhat sex specific, with additional behavioural and emotional problems playing a larger role in distinguishing diagnosed from high-symptom girls than the equivalent male comparison. Additionally, we found different parental perceptions of ADHD behaviours as shown by our comparison of parent report to a more objective measure of ADHD symptoms. Such differences may explain why girls are less likely to be referred for their ADHD behaviours. This may also contribute to the relatively low recognition rate of ADHD in girls in clinical practice if girls with ADHD are perceived to display less stereotypical disruptive ADHD behaviours and perceived as less impaired by symptoms than boys, especially in the presence of socially adaptive behaviour and more internalising emotional symptoms. From a clinical perspective, our findings highlight the importance of detailed interview assessments in the diagnostic process, especially for girls who may not be identified with rating-scale measures which are more subject to sex biased perceptions of behaviour, and that emotional problems should not be used to rule out an ADHD diagnoses. [Mowlem et al. (2019)]

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