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Misdiagnosis of Females with ADD (ADHD)

Patricia O. Quinn, MD

ADD (ADHD) is probably the most common psychiatric diagnosis in children with between 6-12% of the population affected by symptoms of the disorder that impair functioning. DSM-IV (APA, 1994) did much to help focus the world on the fact that ADD (ADHD) is a disorder of both attention and hyperactivity, and that one or the other pattern may predominate in individuals. However, it did little to clarify the diagnostic picture for females with ADD (ADHD). When the DSM was revised in 1994, experts were still primarily engaged in research and had developed their clinical experience treating children (specifically elementary school-aged boys). Those symptoms proposed as diagnostic criteria for the disorder reflected this focus, often referring to behaviors that are developmentally inappropriate for an adult (e.g., schoolwork, climbing activities, leaving seat, etc.) or a female. Results of a recent study confirm that these diagnostic criteria may be more descriptive of males than females (Ohan & Johnston, 1999), suggesting that if more gender-sensitive, gender-appropriate diagnostic criteria were adopted, we may find that yet another long-held belief about ADD (ADHD)-that it is a disorder primarily affecting males-is inaccurate.

In addition, Criterion E of DSM-IV is meant to prevent the misdiagnosis of ADD (ADHD) when another disorder is responsible for the symptomatology. However, the diagnosis of ADD (ADHD) is frequently accompanied by coexisting conditions. Biederman and his colleagues (Biederman, Newcomb, & Sprich, 1991; Biederman, Faraone, & Lapey, 1992; Biederman, Faraone, Spencer, & Wilens, 1993) have presented evidence indicating that the majority of persons with ADD (ADHD) have a least one and sometimes more than one additional psychiatric disorder including depression.

In the United States, nearly twice as many women (12 percent) as men (6 percent) are affected by depressive illness (NIMH). The explanation for the gender gap in susceptibility to depression may lie in a combination of biological, genetic, psychological, and social factors. Thus, women with low-esteem, pessimistic views, and tendencies towards stress are often prone to clinical depression. Women and girls with ADD (ADHD) clearly fit this picture.

Girls with ADD (ADHD) are often misdiagnosed with depression. In a recent nationwide survey conducted in April, 2002 by Harris International, girls with ADD (ADHD) were found to have been commonly diagnosed as depressed prior to their ADD (ADHD) diagnosis with 14% of these girls treated with antidepressants compared to only 5% of males with ADD (ADHD). These results underscore the importance of looking at ADD (ADHD) as a diagnosis and the importance of ascertaining why girls with ADD (ADHD) are often overlooked or have symptoms that are misinterpreted resulting in a missed or misdiagnosis. Research, as well as clinical experience, suggests that girls and women with ADD (ADHD) continue to suffer from high rates of anxiety and depression, and that it is these secondary conditions, rather than the underlying ADD (ADHD), which are most likely to be diagnosed and treated. Factors contributing to misdiagnosis include the following:

• Girls with ADD (ADHD) tend to internalize symptoms (Brown et al, 1989; Gaub & Carlson, 1997) and become socially withdrawn.

• Family members, teachers and peers misinterpret symptoms of inattention; anxiety and depressive disorders may also obfuscate underlying ADD (ADHD) in women.

The following brief case report illustrates this diagnostic dilemma. "Lacy" is 23 and a recent college graduate. She was referred for evaluation because of psychological stress associated with her first year of law school. During the initial psychiatric interview, rating scales were completed, for mood and/or ADD (ADHD) symptomatology. Lacy's scores showed elevations of distractibility, procrastination, and daydreaming. Vegetative symptoms of depression, such as sleep and appetite disturbances, were within normal limits. Psychiatric history revealed that her ADD (ADHD) symptoms rather than her depressive symptoms were historically her problem. Lacy's father had been treated for ADD (ADHD) for several years and this also made the diagnosis more clear. Treatment with stimulants was instituted and her mood and academic performance improved dramatically

This case demonstrates that emotional distress is not synonymous with depression. It was ADD (ADHD) symptoms, not depressive symptoms that caused self-doubt, generalized anxiety and confusion in this woman. Treatment for ADD (ADHD) promoted productivity and afforded self-awareness. Had ADD (ADHD) screening not been obtained on initial presentation, it is likely that her treatment would have focused on depression alone, underscoring the importance of routine screening for ADD (ADHD) in women who present with anxiety and/or depression.

In conclusion, the recognition of ADD (ADHD) symptoms as they present in females is crucial. Appropriate and timely diagnosis and treatment would help prevent delayed diagnosis in females when depression, as a result of ADD (ADHD) symptoms, becomes more profound. In addition, incorrect or missed diagnosis leads to delayed treatment with stimulants and may result in the substitute or inappropriate use of antidepressants as seen in the Harris survey population. Stimulant medications should be considered the first line therapy for ADD (ADHD) in girls and women with antidepressants reserved for those with true coexisting depression.

Resources on women and ADHD:

Women’s AD/HD Self-Assessment Symptom Inventory (SASI) written by Kathleen Nadeau, Ph.D. and Patricia Quinn, M.D.

Gender Issues and ADHD edited by Patricia Quinn, M.D. and Kathleen Nadeau, Ph.D.

Understanding Women with ADHD edited by Kathleen Nadeau, Ph.D. and Patricia Quinn, M.D.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual for mental disorders (4th ed.). Washington, DC: Author.

Biederman, J., Newcomb, J., & Sprich, S. (1991). Comorbidity of ADHD with conduct, depressive, anxiety and other disorders. American Journal of Psychiatry, 148, 564-577.

Biederman, J., Faraone, S., Spencer, T., & Wilens, T. (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with ADHD. American Journal of Psychiatry, 150, 1792-1798.

Biederman, J., Faraone, S.V., & Lapey, K. (1992). Comorbidity of diagnosis in attention-deficit hyperactivity disorder. In G. Weiss (Ed.), Attention-deficit hyperactivity disorder, Child & adolescent psychiatric clinics of North America. Philadelphia: Sanders.

Brown, R.T., Madan-Swain, A., & Baldwin, K. (1991). Gender differences in a clinic referred sample of attention deficit disorder children. Child Psychiatry and Human Development, 22, 111-128.

Gaub, M., & Carlson, C. (1997). Gender differences in ADHD: A meta-analysis and critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1036-1045.

Ohan, J.L., & Johnston, C. (1999). Gender appropriateness of diagnostic criteria for the externalizing disorders. In M. Moretti (Chair), Aggression in girls: Diagnostic issues and interpersonal factors. Symposium conducted at the biennial meeting of the Society for Research in Child Development, Albuquerque, NM.