We’ve long heard about the negative impact of attention deficit disorder (ADHD) on children and teens. We know ADHD can lead to academic problems, problems with friends and socializing, significant sleep problems, and serious concerns in other areas of a child’s or teen’s life, such as increased criminality for those with ADHD.
But what does the future hold for them? Do these children grow up to be well-adjusted adults?
We know from previous research (e.g., Biederman et al., 2006; Faraone et al., 2006) that by young adulthood, most people who were diagnosed with ADHD as a child or teen continue to suffer from attention deficit disorder symptoms. Previous studies have also shown that boys with ADHD have a significantly greater lifetime risk for antisocial, mood and anxiety disorders compared to those who were not diagnosed with ADHD.
But what about girls? Little has been known about their lifetime risks if diagnosed with attention deficit disorder. Are they the same, better or worse than boys’?
In a recently published study (Biederman et al., 2010), researchers set out to answer that question. They assessed 262 child and teenage girls — both those with an ADHD diagnosis and those without — initially, and then 11 years later on a range of mental health issues. Assessment was done with a standardized structured diagnostic interview (called the SCID), commonly used in this type of research. It allows researchers to get a pretty clear diagnostic picture of an individual. Although the researchers weren’t able to re-interview every research subject at the 11-year followup, they had a good 69-75% follow-up rate.
After controlling for the baseline mental health problems the researchers detected in individuals at the initial assessment, girls diagnosed with ADHD were significantly more likely to suffer 11 years later from antisocial, mood, anxiety, developmental and eating disorders than girls without ADHD. Girls with attention deficit disorder were far more likely than those without to have future problems with depression, anxiety and antisocial behavior.
A girl diagnosed with ADHD as a child or teen suffers from major or clinical depression and anxiety disorders at much higher rates — 20-25 percent — than a boy with ADHD (3-8 percent). Professionals call this “co-morbidity” — when two disorders occur together. A girl with ADHD is far more likely to develop depression or anxiety than a girl without ADHD, or any boy in general.
Now here’s the depressing part of the researchers’ findings — 93 percent of the girls with ADHD had received some form of treatment. Most — 71 percent — received a combination of medication and psychotherapy, 21 percent received medication alone and 1 percent received psychotherapy alone.
There are three ways to interpret this data. One is that despite our best knowledge and efforts, we’re still not doing a very good job in helping treat people with ADHD, especially when it comes to addressing related problems. Two, that we’re so focused on treating the presenting problem — attention deficit disorder — that we miss seeing the developing signs of other mental health concerns. Or three, that people with ADHD are simply predisposed — due to genetics, family background and upbringing, or some other reason — to getting more mental health problems.
The researchers also found that at the 11 year follow-up, a full 62 percent of the girls could still likely be diagnosed with ADHD.
These findings are consistent with prior research findings that found ADHD is a significant risk factor for major depression (which is the most common mood disorder diagnosed), anxiety disorders, and other mental health concerns. I think this data adds to the existing research showing that we’re missing something important here, as well as the ineffectiveness of many current treatment strategies for attention deficit disorder.
Want to see if you’re at risk for ADHD? Take our attention deficit disorder test to get immediate results.
References:
Biederman et al. (2010). Adult Psychiatric Outcomes of Girls With Attention Deficit Hyperactivity Disorder: 11-Year Follow-Up in a Longitudinal Case-Control Study. Am J Psychiatry. DOI: 10.1176/appi.ajp.2009.09050736
Biederman J., Monuteaux M.., Mick E., Spencer T., Wilens T., Silva J., Snyder L., & Faraone S.V. (2006). Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study. Psychol Med, 36, 167 — 179.
Faraone S., Biederman J., & Mick E. (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med, 36, 159 — 165.
26 comments
I was a little girl with ADHD – who grew up into a woman with ADHD. What do we look like as adults? Pretty much like everyone else I guess 🙂
Doc John,
What if a girl was never *diagnosed* as a child, but, discovers she has ADHD as an adult, as I did. Are the findings likely to be the same as far as the co-morbidity goes?
Peace!
I’m sorry, I wasn’t very clear with my question. What I mean by the same findings with co-morbidity is this. Is it likely that the anxiety and depression are the results of having had a pre-existing condition, already? And having had that condition, already having been exposed to psychiatrists, therapists, etc., who may have questioned the child about other thoughts, feelings, thus, exposing them to these other conditions that may never have been present.
Don’t get me wrong. I’m not minimizing. But, having been a teacher for over twenty years, I can assure you that most teen girls go through a “typical” teen angst, over boyfriends, not fitting in, being too fat, too thin, having too many zits before the big party, not having the right clothes, etc. And, for *them* it’s the end of the world!
Now, if they are already seeing a therapist, who makes a big deal out of it, it can be turned into a major issue. If they are dealing with mom, or their girlfriends, it becomes just another teen angst moment that they will laugh about in twenty years.
Context matter, is my point.
So, would the findings be the same, or would they *likely* be the same, for co-morbidity, if the girl was never diagnosed. Because, of course, she would have never been exposed to the psychiatric and theraputic world. And her angst could/would have remained just that, instead of another diagnoses.
Thanks for any thoughts on the matter.
Peace!
With 25 years under my belt since I was diagnosed with ADHD I have written about about ADHD girls and women here:
http://www.adhdaction.com/adhd-girls.html.
I think that this statement from the article here is so true: “A girl diagnosed with ADHD as a child or teen suffers from major or clinical depression and anxiety disorders at much higher rates — 20-25 percent — than a boy with ADHD (3-8 percent).”
It confirms my conclusions too. Thats great.
I look forward to reading the study!
Nathaniel @ ADHDaction.com
Looks like the quiz link is not working.
Thanks, Nathaniel.
But, that doesn’t answer the question I asked, though, it’s great confirmation to the study, with a solid record to stand behind it.
DocJohn, since this was your review, do you happen to know?
Or anyone else?
Peace!
Sunflower,
That’s a very complex question you ask. So many factors, I think that so far, it’s impossible to tease out.
One problem is that “depression” (a mostly useless descriptive term) can manifest very differently in boys and girls (or men and women): Males tend to manifest more irritability or anger than females, who tend to manifest “depression” as more lethargy, weepiness, sadness, etc.
Another problem: Females’ monthly menstrual cycles create a bit of a roller coaster with neurotransmitters. Many women with ADHD find they must increase the stimulant dosage at certain times of the month. But, for the most part, most women with ADHD taking stimulants don’t know this.
Finally, ADHD might be harder on females, as it’s often females who are expected to be the “prefrontal cortex” of a couple or family — that is, organizing the household, shopping, caring for children, and working outside the home, etc. In short, coming up short in the areas traditionally seen as “female” can be “depressing.”
As for this point in the article: “One is that despite our best knowledge and efforts, we’re still not doing a very good job in helping treat people with ADHD, especially when it comes to addressing related problems.”
We do have good evidence-based protocols. Do clinicians follow them? Not enough. To put it simply, the MTA study showed that when children with ADHD received “community care” (meaning, from physicians in their communities), symptoms normalized to 30%. That’s compared to 90% when in the care of physicians associated with the study. A huge gap.
Overall, clinicians are doing a damn lousy job. And for that reason, we risk the baby being thrown out with the bathwater — that is, clinicians deciding that solutions “aren’t working” and moving on to something else. Without ever trying what they should have been doing all along.
Gina Pera, author
Is It You. Me, or Adult A.D.D.?
Re: female vs. male ADHD and adult depression/anxiety: Might there also be some diagnostic bias going on, similar to female borderline or histrionic and male antisocial prevalence?
“A girl diagnosed with ADHD as a child or teen suffers from major or clinical depression and anxiety disorders at much higher rates — 20-25 percent — than a boy with ADHD (3-8 percent).â€
Thanks to all who contributed to this discussion!
my youngest daughter now aged 22 was diagnosed with ADHD when she was 2 yrs old. She now suffers from Bipolar as does anothjer friend of hers who was diagnosed with ADHD when she was young. I definitlely think there is a connection between ADHD and mental health disorders.
Thank you, Gina!
Your post points to many unknowns and why it’s so difficult to make generalizations.
Question,
You make a good point too. The bias involved, even when one tries to overcome and be free from it, has been shown in many studies.
I think you make a very important point. I know a female who was depressed, but, manifest it in irritability and anger. She was told she was bipolar – even though there were no other symptoms of bipolar disorder. It was later determined that she was simply depressed, but, only after she had been drugged with potent bipolar drugs!
Had she been male, simple depression would have been the diagnoses. Because, as Gina pointed out, that’s what is *perceived* to be the *typical* symptoms of depression for each gender. And that’s a symptom of care-giver bias.
Good discussion!
Peace!
QUESTION: Re: female vs. male ADHD and adult depression/anxiety: Might there also be some diagnostic bias going on, similar to female borderline or histrionic and male antisocial prevalence?
I can see how this is possible, too. Sometimes ADHD symptoms in men/boys is attributed to men/boys being men/boys. A sad commentary both on the clinician’s acumen and the perception of male behavior.. ;-[)
g
Sunflower,
ADHD is often misdiagnosed as bi-polar disorder when clinicians fail to understand that irritability and anger are common hallmarks of ADHD. Part impulsivity and part the long-simmering frustration that comes from living with unrecognized ADHD symptoms (always forgetting, being chewed out for forgetting, making careless mistakes, being chewed out for making careless mistakes, etc.)
I attended the APA conference in SF last year and was appalled at the TOTAL lack of programs devoted to ADHD. (There was only one “industry sponsored” lecture, and it was excellent. But the intellectual lightweights who are afraid to be tainted by Big Pharma — or at least for anyone to think they are tainted by Big Pharma – diid not attend.)
This was all the more appalling as the program was chockablock with lectures on Borderline Personality Disorder. This is diagnosed more often in women, of course, and the prognosis is typically considered poor. But oh, can the psychiatrists “self-medicate” session after session dealing with these dramatic and interesting clients! No doubt it makes them feel very important and challenged. Does the patient get better, though?
No, not when the clinician refuses to see how much crossover there is in symptoms between ADHD and Borderline Personality Disorder. There is also some evidence that BPD is highly comorbid with ADHD, and that it’s the added trauma in early life (the combo of having untreated ADHD and living with one or two parents who have ADHD+ as well can be traumatic, especially if symptoms are especially severe.)
Of course, APA conference attendees do not represent the whole of psychiatry. Fortunately, many psychiatrists know better and do recognize ADHD and its evidence-based treatments.
I agree sunflower, there are more “things” going on with girls with ADHD that exacerbate their symptoms than with the boys. I hear that same from friends who work with these girls all the time. I tried to capture it in on my website.
Gina makes a great point of which I am discovering more and more. There does not seem large amount of independent study and reporting on ADHD.
To me this all points in the direction that there needs to be more studies on the differences in ADHD between boys, girls, women and men.
The characteristics of each are quite different, while the core of impulsivity, inattention and hyperactivity symptoms remain pretty much the same.
I follow the difference between boys and girls closely because the up coming DSM V needs to account for this factor. Changing or updating the criteria for the different categories.
I am not an expert in doing studies but I hope that more in this area are completed.
Nathaniel @ ADHDaction.com
sunflower55 wrote: “most teen girls go through a “typical†teen angst, over boyfriends, not fitting in, being too fat, too thin, having too many zits before the big party, not having the right clothes, etc. And, for *them* it’s the end of the world!
Now, if they are already seeing a therapist, who makes a big deal out of it, it can be turned into a major issue. If they are dealing with mom, or their girlfriends, it becomes just another teen angst moment that they will laugh about in twenty years. ”
My daughter has been in therapy for 2 years and her therapist does not make a big deal out of normal life events and pathologize them. Why would a therapist want to do that? She also saw someone else briefly for family therapy, and he was also not like that. I haven’t heard of the therapy approach you describe, sunflower. Doesn’t sound very helpful–I’m glad we have not encountered it.
In my experience as an adult with ADHD, the problem is not the approved treatment strategies for ADHD; it’s that no therapists seem to use approved treatment strategies.
I have found an appalling lack of knowledge about ADHD in the therapists I have seen. One therapist only knew approximately 2 facts about ADHD and tried to tailor her treatment to the few facts she knew, even though they didn’t really fit my situation at all. Then the last therapist I saw basically worked under the assumption that ADHD was really nothing but anxiety (even though research has shown, time and time again, that they are in fact separate conditions). She spent all her time trying to find the anxiety at the roots of my ADD, and didn’t succeed simply because my ADD wasn’t caused by anxiety – I’m not all that anxious a person overall, and when I do experience anxiety, it is a direct result of the stressful situations that have been caused by my lack of organization, lack of planning, and other ADD symptoms.
In summary, I still haven’t found a therapist who was anywhere near as knowledgeable about adult ADD as I was. It’s really kind of disheartening. I think this really stems from a larger problem in the professional community – as Gina mentioned in her experience at the APA conference, it really seems that the mental health community is ignoring this disorder. This can be seen in the paucity of research on adult ADHD, in comparison to the wealth of research that has been done on conditions like depression, bipolar disorder, borderline, anxiety disorders, addiction, etc, which is really a shame because as Gina comments about BPD, a significant number of the people with all these conditions have comorbid ADHD, which may not be recognized by their mental health providers, but is definitely affecting the efficacy of the treatment for their other disorder.
From what I gather, it also seems to be a problem in the training of mental health professionals – I read somewhere that a large number proportion of counselor training programs do not even address ADD in any detail, or simply gloss over it, dismissing it as a result of society’s urge to over-prescribe medications. This attitude toward medications is pretty ironic, seeing as in my experience, medication is the only thing that worked – therapists were pretty useless.
Kate, maybe your situation also pertains to the fact that some effective drugs for ADD treatment are DEA controlled substances? Some doctors simply don’t want to prescribe them. Instead, some only want to prescribe SSRIs, which can be ineffective and actually make people worse off.
Not receiving the appropriate drugs for ADD can seriously diminish life quality, productivity, and a patient’s well being. Unfortunately, its easy to accuse some as “drug seeking” whether or not the individual has a history of substance abuse.
Male,
Immigrant,
I was never diagnose,
Had to work so hard academically, but drop out i my final year at University
Later fingered out something is wrong, ADHD
Rule by my body, hard to fight it.
Feel sorry for the girls, and boys.
Try to find a way to live with it if you can
I never had support, they need all the friend they can keep.
Zinger,
I had no problem getting stimulant medication that is effective for my ADD. My problem was that therapists especially, perhaps more so than psychiatrists, seem completely ignorant of this disorder and therefore have no clue how to give effective counseling for ADD.
Gina,
Thanks for your remarks concerning the mistaking of bipolar for ADHD. I knew there were overlapping symptoms, but, did not understand the issues involved in why there would be other reasons for misdiagnoses.
It’s also very interesting that clinicians would diagnose borderline personality disorder instead of ADHD. I would think they prefer to seek the most easily treated diagnoses first, and then, should that not work, build up to other diagnoses that share the same symptoms.
But, your point about how important that makes *them* is something to be considered too. *Their* ego comes into play here! What a shame when people’s lives are at stake! And being denied a simple medication for ADHD, while being over medicated for borderline personality disorder – with its concomitant poor prognoses – is tantamount to giving a person a life sentence. It’s dangerously close to malpractice.
In their practice, shouldn’t they seek the simplist diagnoses first? Just a question, here. And I do understand that there are many issues involved, because there are no physical tests that one can give to make a clear diagnoses. But, that seems to me to be all the more reason to go slow, and take caution in treatment. After all, the Hippocratic oath does still say, “First, do no harm.”
Thanks again for all the comments here. This is really a great conversation!
Nathaniel,
Yes, I agree that the issue of the differences between girls and boys with ADHD has been under-studied. And, adult ADHD too.
I would tend to disagree with one thing you stated, though. Girls with ADHD tend not to be so “hyper” as boys. They manifest it differently, at least as far as my 24 years in the classroom shows.
Whereas boys tend to get up and walk around the classroom, throw things, hit, kick, or otherwise be unable to keep their hands to themselves, girls behave differently.
Girls twirl their hair. Girls wiggle their leg. They rub their hands or wiggle their thumbs. There’s much less overall disturbance.
This *may* be a result of socialization. Personally, I think it is. But, whatever it is, the symptoms are nonetheless manifest differently.
Peace!
Teri,
I’m glad you haven’t had the experience with your children that I’ve described. And I’m not trying to say that it happens all the time, either. But, I’ve had students who are in school counseling where this type of over-dramatization goes on. And it is *not* helpful to the kids at all.
Do I think that the counselor *wants* to do this purposely? No, I don’t. I think it’s more a manifestation of being young and enthusiastic, and truly wanting to help a kid whose in distress. Perhaps they may even be having some type of counter-transference type of thing going on? (If that’s the right term here?)
But, in any case, the student is becoming *more* emotional, less able to attend to school work, and more apt to spend more time out of class and in the counselor’s office. School work suffers and a whole other batch of problems begins to pile up on the kid. So, what began as a simple teen angst ends up as an emotional roller coaster, and another diagnoses. And that’s not helpful at all, in my opinion.
Peace!
from sunflower: “Do I think that the counselor *wants* to do this purposely? No, I don’t. I think it’s more a manifestation of being young and enthusiastic, and truly wanting to help a kid whose in distress.”
sunflower, I hope the counselors don’t want to do it purposefully, but it sounded like the counselors you described were–it didn’t sound like an unconscious act. I don’t have personal experience with school counselors with the behaviors you describe, so I just don’t know. The 2 therapists my daughter saw were experienced therapists, not affiliated with schools, and also not young. Maybe, as you have suggested, it is indeed the youth and inexperience that results in the “sensationalizing” you have seen. Do you know what mental health/therapy training school counselors have? Maybe they are trying to diagnose mental health disorders and shouldn’t be? Maybe a referral is in order if they suspect something out of their scope of training? Maybe that’s incorrect, and they do have the training for diagnosis and treatment–not trying to knock school counselors–I just don’t know. We found school counselors and similar positions not useful for my daughter’s concerns, and also willing to minimize real trouble and not refer. I had the sense they wanted nothing difficult and preferred to sweep things under the rug–kind of the opposite of the behavior you report. The counselors were, however, good at things like advising students what classes to take, mediating between teachers, students, and parents when students were having trouble in class, etc.
Kate wrote: “I read somewhere that a large number proportion of counselor training programs do not even address ADD in any detail, or simply gloss over it, dismissing it as a result of society’s urge to over-prescribe medications.”
Kate, even in undergraduate psychology courses on mental health disorders, they can skip the chapter on ADHD (that is true at my university). The focus is on mood, anxiety, and personality disorders, and psychosis. So this “skimming over” of ADHD can start early in training.
I am lucky that my therapist has ADHD himself, so is more knowledgable than most. He gave me the names of a therapist who specializes in ADHD behavioral and social therapy, and also a doctor who is an expert in ADHD diagnosis and treatment. I didn’t go to the therapist, but the doc has been very helpful. He told me that anxiety, depression, and ADHD are often co-morbid and it can take a while to tease out what is what. He was willing to do this. It was not a 10 minute assessment and then he had all the answers. I have found ADHD medication extremely helpful and I continue to work on behavioral coping strategies with my therapist.
Terri,
I’m not talking about guidance counselors at school. I’m talking about the mental health counselors. Some are social workers; some with masters level degrees, some without. Others are clinicians with substance abuse training. And I’ve even worked with psychologists. (One was the best I’ve ever worked with, and not at all like I described above.) I’ve worked with a number of different type of counselors over the years. And yes, some are very good; others are like I described above. I wasn’t trying to make a blanket statement, and I’m sorry if I gave that impression. But, I *have* seen that type of behavior all too often, too. It’s not an abnormality, unfortunately.
Peace!
hey im 11 and i figit in class and it started by me takin my earring out and then puttin them back in. then my teacher gave me a sqiushy apple that i never played with. ever since she gave me the squishy apple ive been going two leeged in my chair.(P.S. teachers hate that)people say i have ADHD but i dont know =]
Hey, I was also misdiagnosed with bi-polar disorder after I had my son, was going through an abusive relationship, and was being sexually harassed at work, and believe me, it has turned my world upside down! Prior to the false diagnosis, I had been diagnosed with ADHD three different times in my life, by three different therapists, in three different states. Since they never met eachother, I’m putting a lot of stock into the validity of that diagnosis. I’m just hyperactive and my moods stem from EXTERNAL sources not from the INTERNAL. For instance, if I get down, it is because something crappy happened to me–NOT because I feel that way for no reason! When I feel down because of an external factor, I always evaluate the situation and decide that moping isn’t the answer and brainstorm ways of fixing my situation, then I’m fine. But nooooo, ever since my false diagnosis, my family thinks that it’s just me “cycling” and not me trying to be mature and trying to cope or solve a problem! Ever since my false diagnosis, people treat me like I’m a small child. Other people slllowww their speech to the point of condescension (which would make ANYONE angry–I don’t care who you are–no one like to be treated in such a fashion!) and if I express any emotion, ANY, then some jackass has to ask me if I “took my medication”. I’m hyper get over it! In addition, I have never felt superior or have had “grandiose” thoughts about myself as with someone who is experiencing hypomania would have–in fact, the three diagnoses of ADHD and the false diagnosis of bi-polar has given me an inferiority complex and has made me very wary of others since I have been treated like garbage all of my life since I have a little more energy than the average person! Again, an external factor based on how others treat me. The plus side is that throughout my career, my bosses have always loved me. They accept me for who I am, think my hyperactivity is funny like Jim Carey, and I am more productive than my peers–the hyperfocus symptom that comes with ADHD has worked in my favor since I do something I love. All in all, I’m hoping to find a therapist to straighten things out and maybe help me find a way to cope with people treating me like crap all of the time. Maybe I can take the attitude of “letting my haters be my motivators”. Thank you for listening. I just needed to get that off my chest. It has been bothering me for years.
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