Perhaps as a result of the stereotype of ADHD being that of a disruptive young boy1, ADHD is thought to be under-recognised in girls and women2. The following recommendations by expert consensus to aid in the identification and treatment of ADHD in girls and women were published by Young et al. in 20201. They are provided as an adjunct resource for site users and are not part of the Saudi ADHD CPG.
Diagnostic Interview
Below are ten additional considerations that are key consensus recommendations when evaluation women or girls for suspected attention-deficit/hyperactivity disorder.
Rating scales
- Norms from predominantly male or mixed-sex samples may disadvantage female patients. Rating scales providing female norms may provide cut-offs more sensitive to female presentation.
- Where female norms are not available, greater emphasis on collateral information is required (e.g. parental and school reports).
- Findings should be interpreted cautiously. Rigid adherence to cut-offs may lead to a high proportion of false positives and negatives.
Clinical interview
- Assessors should bear in mind that family members may also have ADHD which may affect their judgment of ‘typical’ behaviour.
- Small modifications to symptoms may help to capture more female-centric behaviour.
- Assessors should examine factors that may mask or moderate behaviour in different settings, e.g. compensatory strategies or accommodations at home or school (both functional and dysfunctional).
- Age-appropriate, common co-occurring conditions in females with ADHD should be explored, including ASD, tics, mood disorders, anxiety, eating disorders, fibromyalgia and chronic fatigue syndrome.
- A risk assessment and consideration of future challenges (e.g. personal, clinical, educational, social-relational and psychosexual) is required.
Collateral information
- School reports may comment more on attentional problems (daydreaming, distracted, disorganised, lacking in motivation and effort) or interpersonal relationship problems in girls with ADHD.
- Objective neuropsychological test results are not specific markers of ADHD but may provide useful supplementary clinical information. The QB scales have female-specific normative data and may therefore be more sensitive.
Treatment
Below are thirteen additional considerations that are key consensus recommendations during the treatment of women or girls affected by attention-deficit/hyperactivity disorder.
Pharmacological treatment
- Medication recommendations do not differ by sex and differ only modestly by age.
- Treatment monitoring may require deviation from conventional outcomes from rating scales and behaviour management. Individualised targets (e.g. emotional lability, academic attainment) may be more appropriate.
- Prescribing needs to consider interactions between ADHD and other medications for comorbid conditions, where applicable.
- Where mood problems are apparent but not pervasive it is advisable to treat ADHD symptoms and monitor for improvement first, prior to considering or initiating treatment for mood disorders.
- Appetite suppression as a side effect of stimulant medication should be considered if eating disorders are a concern.
- Risks of substance use whilst on ADHD medications should be considered and discussed with patients.
- Treatment with ADHD medications is generally not advised during pregnancy or breastfeeding.
- Review is advised during and after key periods of hormonal change (menopause, pregnancy).
- Psychoeducation on pharmacological treatment options and treatment targets for parents and affected girls may help to improve adherence and engagement.
- Regular review is required throughout development and may be especially important at times of key transitions.
Non-pharmacological treatment
- Whenever possible, provide psychoeducation taking a lifespan approach.
- Parents and carers of teenage girls need psychoeducation to support detection of deliberate self-harming or risky behaviour.
- Follow-up sessions are essential for support at key points of transition.
- Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry, 20, 404. https://dx.doi.org/10.1186/s12888-020-02707-9 ↩︎
- Recommendation 2.3, Evidence-Based Clinical Practice Guideline for Management of Attention Deficit Hyperactivity Disorder (ADHD) in Saudi Arabia. Riyadh: Saudi ADHD Society; 2020. ISBN: 978-603-03-4786-5. https://cpg.adhd.org.sa/en/recommendations/#rec2.3 ↩︎
3. Image credit: Pink paper framed with pills, puzzle pieces, brain and question mark with copy space by AtlasStudio from Noun Project (CC BY-NC-ND 2.0)