Female Adolescents with ADHD
I was part of a group for my graduate research methods class at the University of Rochester. The professor asked us to propose a new research proposal on the topic of our choice. Our group chose to propose mixed-methods research into the experience of adolescent girls with ADHD. While I contributed to the entire proposal, I recall that I contributed in a major way to the Literature Review component. I have included my Literature Review below.
Female Adolescents with ADHD
Literature Review
We have provided a background to the field and identified four key themes from the literature that have informed our research position.
Background
Early researchers, such as Sir George Still in 1902, described ADHD’s symptoms as "defective moral control" (p. 1), which today we recognize as hallmark features of inattention, disorganization, and hyperactivity-impulsivity, inconsistent with age or developmental level (American Psychiatric Association, 2013). Still noted that male children were more frequently diagnosed in his sample than female children, with 15 males and only five females among the 20 child cases he studied (Still, 1902/2006). This gender disparity continues to be a focal point in modern ADHD research and diagnosis, with the Centers for Disease Control and Prevention (CDC) stating that male children are more likely to be diagnosed with ADHD, with a population prevalence of 15%, compared to 8% in female children (CDC, n.d.). Since 1937, when Charles Bradley discovered treatment via stimulant medication, treatment has consisted of stimulants, but more so, modern treatment uses a comprehensive approach inclusive of behavioral techniques (Bradley, 1937).
ADHD received more interest in the 1950s, being studied by researchers under the heading of hyperactivity, which Laufer, Denhoff, and Solomons (1957) called hyperkinetic impulse disorder (Laufer et al., 1957, p. 1). The American Psychiatric Association's Diagnostic Manual (DSM-I) recognized this condition as a kind of hysteria (American Psychiatric Association, 1952, p. 117). In their study, Laufer et al. (1957) reinforced the observation that this condition affects male children more than female children, with 12 boys and only one female studied.
Further changes in understanding regarding ADHD occurred in the 1970s, with landmark research by Wender, who took a more neurological position and initially coined the term "Minimal Brain Dysfunction" (MBD) (Wender, 1971). In his work Minimal Brain Dysfunction in Children, he describes that MBD is more prevalent in male children than in female children, with ratios ranging from 3:1 to 9:1. He also notes that manifestations of the condition may differ between males and females, with hyperactivity being less prominent in females and instead replaced by a lack of direction and resistance to socializing (Wender & Eisenberg, 1974, p. 24). Later, Wender expanded his work to emphasize not just hyperactivity but also the critical role of attention deficits, leading him to refer to the disorder as Attention Deficit Disorder (ADD) (Wender, 1987).
The 1980s saw ADD officially introduced into the DSM-III, and due to work by Wender, two types of ADD were identified: "ADD-H" with hyperactivity and "ADD" without hyperactivity (American Psychiatric Association [APA], 1980, p. 15). Thanks to the work of several researchers, including Virginia Douglas and Russell Barkley, revisions were added to the DSM-III-R to rename ADD to ADHD, recognizing it as a single disorder that could manifest with or without hyperactivity. Douglas (1983) and Barkley (1981, 1990) conducted significant research that highlighted the importance of attentional and cognitive problems in understanding hyperactivity, which played a crucial role in these diagnostic changes (American Psychiatric Association, 1987). These revisions aimed to capture the full spectrum of the disorder under one title, acknowledging that hyperactivity was more commonly observed in male children, while female children often experienced inattentiveness without hyperactivity (Barkley, 1990; Douglas, 1983).
The historical overview of ADHD demonstrates a longstanding gender bias in diagnosis and treatment, with early research predominantly focusing on males. The evolution from "defective moral control" to ADHD reflects changing societal and medical perspectives, yet issues persist regarding the underdiagnosis and misdiagnosis of females.
Theme 1: Underdiagnosis and Misdiagnosis of Females
According to Rucklidge and Tannock (2001), most research on ADHD has been conducted on males, primarily because the majority of clinical referrals are boys. They argue that this focus on predominantly male samples has resulted in females being overlooked and neglected in ADHD research. Babinski et al. (2011) concur, stating that almost the entire field of ADHD research has been developed predominantly from samples of boys with ADHD. Bauermeister et al. (2007) also agree, noting that males are significantly more likely to be diagnosed with ADHD than females, more than twice as likely. They claim this may be due to boys more readily displaying commonly known features of ADHD, such as hyperactivity.
Fedele et al. (2012) also state that researchers primarily study ADHD in male children, and males are also diagnosed with ADHD at a higher ratio than females. The Centers for Disease Control and Prevention (CDC) stated that boys are more likely to be diagnosed with ADHD, with a population prevalence of 15%, compared to 8% in females (CDC, n.d.). Quinn and Madhoo (2014) agree with the disparity and bias in ADHD diagnosis in females, claiming this also leads to lower levels of treatment.
The literature consistently shows that females are underdiagnosed compared to males. This theme is crucial for understanding the proposed study's focus on educational interventions for females with ADHD, as it highlights the systemic neglect in recognizing their needs.
Theme 2: Greater Severity and Comorbidities for Females
According to Gaub and Carlson (1997), while ADHD may be more prevalent among males, it appears to be more severe in females. Bauermeister et al. (2007) also comment that different types of ADHD—impulsive, inattentive, or combined—seem to present differently in males and females and contribute to different comorbidities by gender. Quinn and Madhoo (2014) note that females may more often have the inattentive type of ADHD. Quinn and Madhoo (2017) also note that females with ADHD tend to internalize their symptoms more, developing comorbidities as coping mechanisms; they may resort to covert rather than overt aggression, leading to greater severity of consequences and more significant confusion in diagnosis. Rucklidge and Tannock (2001) agree that females with ADHD are at greater risk of psychological impairment than males. Fedele et al. (2012) also find that females cite higher impairment from having ADHD than males in many domains: home, life, social life, education, money, daily life, and overall impairment.
While researchers have observed gender differences, there is no complete consensus, nor consensus that females experience ADHD more severely; Lahav et al. (2018), for example, found differences in gender in a weekly calendar planning, but the finding was that females performed better in these organizational tasks than males. A qualitative study by Waltereit et al. (2023) also found that ADHD manifested similarly in males and females, regardless of gender, with only minor gender-specific differences. We agree with their conclusion that more research is needed to understand the nuances of gender differences in individuals with ADHD.
The severity of ADHD in females, particularly among comorbid conditions, underscores the necessity of tailored interventions. This knowledge explicitly links these findings to the study's aim of evaluating the effectiveness of such interventions in educational settings.
Theme 3: School as a Key Context
Hosterman et al. (2008) describe the importance of teachers and the school context in diagnosing and treating ADHD; the teacher is in a valuable position to observe, summarize, and rate a child's behavior. Metzger and Hamilton (2021) tell us about the problems with teacher observations and the high stigma associated with ADHD. They explain that not only will teachers be uninformed about ADHD, but if they know a student's diagnosis, they become more antagonistic towards them. Gaub and Carlson (1997) also state the critical importance of referrals in diagnosing and treating ADHD and the vital role of the teacher and school in conducting this referral. Hoben and Hesson (2021) take things further by looking also at the complex qualitative experiences of academic teachers with ADHD, specifically the lack of support for teachers with ADHD and the potential benefits of feminist pedagogical techniques.
Prosser (2008) also emphasizes the teacher's critical role in helping intervene with those with ADHD. Most teachers have limited knowledge of ADHD, and traditional labels and pedagogical interventions were not adequate for children with ADHD, calling for more inclusive practices. Lee et al. (2019) also emphasized the teacher's ability to help those with ADHD but stressed that teachers need a sense of self-efficacy, which they can achieve by gaining more knowledge about ADHD. Dong et al. (2020) support this idea stating that the school can play a crucial role in collaborating with parents and healthcare professionals and can incorporate universal screening and culturally sensitive targeted interventions.
The role of schools and teachers in diagnosing and supporting students with ADHD is well-documented. This theme directly supports the research question about the educational experiences of adolescent females with ADHD, providing a basis for exploring the efficacy of feminist pedagogical approaches.
Theme 4: Moral Judgment
Attention Deficit Hyperactivity Disorder (ADHD) has a long history intertwined with moral judgment, ever since George Still named the condition "defective moral control" in 1902. Even with the name Attention Deficit Disorder (ADD) (Wender, 1987), the prevailing descriptions of individuals still reflect moral judgment, exemplified through the use of harmful and deficit language.
Researchers can still see moral judgment of the condition in Laufer et al.'s pivotal work, where they describe the child as "impulsive" (Laufer et al., 1957, pp. 622-624), "irritable" (Laufer et al., 1957, pp. 620, 623), and "explosive" (Laufer et al., 1957, pp. 620, 623). Commentary is extended to considering blaming mothers of such children for their poor behavior, stating, "An infant behaving the way just described may seem to offer clear proof of their unfitness to be mothers" (Laufer et al., 1957, p. 623).
The historical and ongoing moral judgments associated with ADHD, particularly concerning gender, are crucial for understanding the disorder's social context. This theme highlights the need for a critical examination of existing educational practices and supports the study's feminist theoretical framework, which denounces moral judgment.
References
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