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What is the prevalence of psychopathology in girls with and without attention-deficit hyperactivity disorder (ADHD) followed into young adulthood?
A total of 262 girls aged between 6 and 18 years were recruited from various from various psychiatric and paediatric sources. Out of these, 140 girls had DSM-III-R ADHD, and 122 did not (controls). Exclusion criteria: being adopted, nuclear family not available for participation, major sensorimotor disabilities, psychosis, autism, full-scale IQ<80, or inadequate ability with the English language.
USA; time period not stated.
Diagnosis of ADHD.
Lifetime and previous-year DSM-IV psychopathology, including composite categories of antisocial disorders, mood disorders, anxiety disorders, developmental disorder, and substance-dependence disorders. Diagnoses were assessed in interviews with the participants and their mothers using the Structured Clinical Interview for DSM-IV and modules of the DSM-IV modified Schedule for Affective Disorders and Schizophrenia for School-Age Children – Epidemiologic Version. Assessments were made blinded to original diagnoses.
Longitudinal case–control study.
Follow up period:
Mean 11 years.
Of the 262 girls enrolled, 187 (71.4%; 96 cases and 91 controls; mean age 22 years) completed follow-up and were analysed. At 11-year follow-up, the risk of mood, anxiety and antisocial disorders in the previous year was significantly higher in girls with ADHD at the start of the study than that observed in controls after adjusting for age and baseline psychopathology (p<0.05). There was no significant difference between cases and controls in substance-dependence disorders or eating disorders in fully adjusted analyses. The risk of lifetime diagnoses was increased in girls with ADHD, compared to those in control group for all composite disorder categories (antisocial disorders: HR 7.2, 95% CI 4.0 to 12.7; mood disorders HR 6.8, 95% CI 3.7 to 12.6; anxiety disorders: HR 2.1, 95% CI 1.6 to 2.9; developmental disorders: HR 3.2, 95% CI 2.0 to 5.3; substance dependence disorders: 2.7, 95% CI 1.6 to 4.3; eating disorders: HR 3.5, 95% CI 1.6 to 7.3).
By young adulthood, girls with ADHD are at high risk for antisocial, substance dependence, mood, anxiety, and eating disorders.
While there is agreement among clinicians that gender-related differences exist in the prevalence of coexisting conditions seen with ADHD, these differences have usually been described in clusters – where men have been found to have more ‘externalizing’ disruptive disorders and women tending to have more ‘internalizing’ disorders such as anxiety and depression. While research in women continues to lag behind studies that are looking at adult men with ADHD, many clinicians are reporting unique issues and coexisting conditions in women with ADHD within their practices. Compared to non-ADHD women, women with ADHD were more likely to have experienced more depressive episodes in the past, to have sought professional mental health treatment and to have a greater use of psychotropic medications prior to diagnosis.
For some time, it has been known that women with ADHD are more likely to internalize symptoms and become anxious and depressed than are men with ADHD.1 ,2 The present study confirms these subjective impressions by means of a 11-year prospective follow-up (participants were between 15 and 30 years) of girls diagnosed with ADHD and documents not only continued impaired functioning in 62% but also a significantly higher risk of major depression, anxiety and antisocial behaviors in these young women versus a comparison group. Compared to young women without ADHD, those with ADHD were found to be 6.8, 2.1 and 3.5 times more likely to be diagnosed with major depression, anxiety disorders, and eating disorders, respectively. It has been found that though the rate of presence of behavioural disorders such as antisocial behaviour and anxiety will likely level out by age 25, showing no further scope for increase, mood disorders will likely persist and continue to grow, simultaneously. Thus, for the clinician, this situation often presents a serious diagnostic dilemma. Seeing these depressive symptoms, he may be more likely to treat these symptoms only and leave, in turn, the ADHD untreated with such an omission resulting in continued impairments in functioning. In addition, this study underscores previous reports of eating disorders in women with ADHD. These findings should lead clinicians to not only monitor more closely girls with ADHD, beginning in adolescence for the presence of eating disorders, but also prompt them to take a critical look at the effectiveness of all treatment programs being prescribed.
Sources of funding Eli Lilly and Company Foundation and the Pediatric Psychopharmacology Philanthropy fund.
Competing interests PQ has a consulting relationship with McNeil Pediatrics, a division of Ortho, McNeil, Janssen Pharmaceuticals, Inc. In addition, she was a speaker for Lilly UK at their annual ADHD conference in 2009.
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