Banner
    Girls With ADD - Why It Is So Often Missed
    By Kimberly Crandell | January 24th 2009 08:56 AM | 57 comments | Print | E-mail | Track Comments
    About Kimberly

    I'm a mother of three, with an aeronautical engineering degree.  Although it's been a while since I've done any aircraft

    ...

    View Kimberly's Profile

    When thinking of a child with ADD, most people will picture an easily-distracted hyperactive child... long on energy, and short on attention span.  And although that is sometimes the case, that description accurately describes only a portion of children diagnosed with ADD - and very rarely describes the behavior of girls with the condition.

    In fact, many people think Attention Deficit Disorder (ADD) is a boy's disease. It is commonly believed that it occurs at least twice as often in boys as in girls.  Although it is true that boys are more often diagnosed,  the rates are actually about the same in both genders. Boys more often have the variety called Attention Deficit/Hyperactivity Disorder (ADHD) - and that's what tends to get their problem noticed.

    Parents, teachers, and even health professionals tend to picture the classic case of ADD as a boy with a lot of hyperactivity. The average girl with ADD acts differently. In girls, the disorganization and distraction results in lack of activity--they are just too confused to get things started, and instead are often described as daydreamers.

    This is in stark contrast to the boys. Boys' distractibility is expressed as impulsivity--a flurry of activity. While both genders have trouble learning the nuances of social interactions, the results for each are different. Girls end up shy and withdrawn - they don't like the negative reactions they get when they don't clue in to the nuances. Boys on the other hand are more likely to proceed with social behavior that is considered inappropriate. While they are bewildered when they get negative reactions, they continue.

    A girl's environment is more likely to be disorganized -- their desk, their bedroom, their backpack.  Although both genders have problems in this area, as girls with ADD hit the teen years the increased organizational demands of junior high and high school become too much. Grades suffer, and they may become tired and disheartened by poor school performance. The girls with hyperactivity may throw themselves into social relationships to compensate. They may be described as boy-crazy or party girls. ADD and ADHD girls alike begin to show more risky sexual and other behaviors. They may use drugs or alcohol both due to increasing impulsivity and to self-medicate. Shoplifting, teen pregnancy, and eating disorders are also found more often in females with ADD.

    Why the Symptoms Are Different

    The differences in actual environmental disorganization are clearly due to social factors. But, no one knows for certain why there is such a large difference in hyperactive behavior between the two genders. It could be that girls have more pressure to conform. Wild, loud social behavior in a boy may be tolerated. But, a girl may be more pressured to be quiet and behave. Likewise for girls, the impulsive actions may get a more negative reaction from adults and peers alike. In fact, it has been found that girls with ADHD (those who do express the hyperactive qualities) have more negative social consequences than boys. This is true even though the boys have more hyperactivity.

    From a physiology perspective, researchers have found girls' brains differ from those of boys in several ways - including weight, size, and the relative proportion of certain structures in the brain. This difference may explain why males and females generally display different strengths and weaknesses. It may also account for the different types of ADHD symptoms they display. Research in this area is ongoing.

    In general, girls are much more likely to have ADD without the hyperactive component. This is in contrast to ADHD (Attention Deficit Hyperactivity Disorder) that boys tend to have. Because a girl isn't disruptive in the classroom, her problem does not create the same need for an immediate solution. As a result, her inability to focus and complete work is likely to be overlooked as a symptom of a more complex issue - and instead is blamed more on lack of discipline or motivation on her part.

    A girl with ADD has fewer learning problems in early grades than her male counterparts. Boys often get diagnosed through evaluation of learning problems. Girls with ADD, especially those with high intelligence, may actually be good students and/or well-behaved - and as a result raise absolutely no alarms that anything may be amiss.

    When girls with ADD do not conform to social roles, it is often described in gender-specific terms, rather than as a medical problem.  They are labeled tomboys or flighty as girls, and boy-crazy or party girls as teens.  Again, girls are more likely to meet social pressure to conform, rather than recognition and treatment of a disease.

    Often girls with ADD are misdiagnosed with depression.  The symptoms of ADD and depression overlap: low energy levels, disorganization, social withdrawal, and trouble concentrating.  Even more confusing, the unrecognized ADD can lead to major coping problems, which in turn lead to actual depression on top of the ADD.

    Typical signs of ADD in girls include:

    • Difficulty maintaining focus
    • Easily distracted
    • Disorganized and “messy”
    • Forgetful
    • Difficulty completing tasks
    • Daydreaming
    • Slow to process information and directions (It may even appear that they aren’t hearing you)
    • Careless
    • Often late (poor time management)

    It's easy for a girl to read this and see many of these characteristics in herself.  Being unprepared, shy, or daydreamy is a part of every girl's life to some degree.  However, if several of these behavioral descriptions apply, it may be worthwhile to have a formal evaluation.  Even if it is determined that the behaviors are not due to ADD, reassurance will be gained just from knowing.  And if ADD is suspected, she can receive treatment or change her environment to maximize her potential.   Often times, simply understanding ADD’s impact in one’s life relieves girls of a huge burden and frees them from the damaging labels of “spacey,” “careless,” “unmotivated,” “stupid” or “lazy.” They simply have ADD and their future feels much brighter.


    Comments

    ADD can be very well described as a cultural affliction in which the growth stages of certain individuals fail to line up with the demands imposed by school curricula which are based on economic ,and social control considerations ,and are not informed by biological or epistemological understandings.

    The Anonymous commentator uses a turgid writing style typical of a particular scholarly camp. The classic fall back position here is to deny that ADHD exists and thus invalidate the insightful discussions of adults who retain ADHD characteristics. If the writer were to enter into meaningful discourse, they may be pleasantly (or unpleasantly, depending on the path travelled) surprised to find a great deal of useful data.
    It is true that the DSM IV R is a load of cobblers !!! It describes a neurological condition involving developmental delays and abnormalities in purely behavioural terms. At the time DSM IV R was put together, neuro-imaging was in its infancy , the ADHD research field was dominated by "soft sciences",and psychiatry had many more "unreconstructed Freudians". Since then, a significant number of researchers have fleshed out a model which is less dependent on subjective categorical criteria and recognises various domains of difficulty which are dimensional and clearly anchored to a biological underpinning.
    As far back as 2000, Barkley was firmly of the opinion that the sex ratio would be close to 1:1 if the bias towards recognising hyperactivity in boys was balanced by the recognition of the deleterious outcomes for girls with the less obvious handicaps of processing and organisational deficits. Current studies within adult cohorts clearly show a sex ratio close to 1:1
    If one uses a DSM IV R categorical process to evaluate a multi-factorial , dimensional problem, the answers are clearly dependent on cut-off points, arbitrarily set by different researchers, at different points. The room for disagreement is factorial !!!
    Arguing about ADD or AD/HD or ADHD (with or without hyperactivity), is reminiscent of the discourse on the number of angels able to stand on the head of a pin. The harsh reality is, that politics (and pseudo-religion) have over-ridden science. The evidence for a neurological disorder (or disorders), presently encapsulated inadequately by DSM IV R as ADHD is overwhelming. When DSM V finally sees the light of day we may hope for a greater understanding (though I'm not holding my breath).

    Very well written argument

    Very amusing that Calochilus wants to dismiss my comments based on my writing style or association with some unidentified faction . Certianly not true in the latter case.
    Why indulge in what amount to ad hominem attacks? I don't doubt there are a great deal od data collected. Still unexamined assumpions can distort the interpretation of data. I'll try to state my position more clearly. These "behavior problems" reflect the apparently untested assumption that sitting still, moving the eyes in linear sequence,processing abstractions all day is the only way for children to learn what they need to know to function as adult citizens. . But some chidren have the need to move around and learn how to coordinate in the local gravitational field. The education system is still acting out the idea of mind body seperation.As far as I know no one has thus far demonstrated this notion scientifically. Children who need to move around,who are kinaesthetic learners,or day dreamers are not flawed,or learning disabled,and would likely do much better if they were educated with techniques that made use of their individual learning styles,rather than one based on statistical averages ,designed to train obediant workers to complete tasks on schedule. Educate from the Latin Educare means literally to bring out what is within.
    Another untested assumption is that adults know what children need to learn ,while chldren have no idea. But how many people who are really accomplished at something were deeply drawn to from a young age,or had a life-changing first encounter with what really interested them? SOme of these ADD daydreamers might be wondrously creative,given the chance to follow their muse,instead of being drugged into normalcy.

    jtwitten
    Not to blow up everyone's false dichotomy party, but the third option is that ADHD represents a real challenge to attention (etc. symptoms) and there are some number of non-traditional learning children that are misdiagnosed.  I think this point of view is a bit more in line Calochilus' point about the multi-factorial approach to diagnosis used by the DSM.   From a prediction stand-point, anything that makes a diagnosis based on fitting any 3 of 5 symptoms is an indication that we are not even close to a complete understanding of the condition.

    Anonymous (from the Greek for "without a name"), the etymological history of a modern English word is not necessarily a good guideline for how we should teach our children.  The Roman method of education is not a feasible method around here, as Missouri has a paucity of Greek slaves.
    OK s where's the control group study of children who aren't raised standard N. American/European behavioral norms, and education systems which emphasize the mastery of abstract symbol systems ,and specialization? Nuerological and psuchological research in general greatly suffers from the failure to account for culturaly based assumptions .Where are the MRIs of hunter gatherers?
    I don;t think anyone has made the case that this complex of behaviors is a disorder. If you can make the case ,then please do so. I think it;s a failure to conform. Are there studies of anyone doing other approaches such as whole body learning , or Montessori approach etc with ADD/ADDHD diagnosed kids?
    Seems to me it's a leap in logic to equate my pointing out the etymology of a word,for epistemologic reasons with advocating any particular system of education.
    I think the point that were not close to a complete undersanding is very well taken.

    jtwitten
    Your use of the etymology implied a goal for education, not necessarily a system.  The historical choice of a word to describe the philosophy this process does imply that its orginial meaning should have any relevance to "education" today.  My argument is that we should be completely unconstrained by such historical baggage in trying to address the goal of improving outcomes for our children.  For instance, given the human predilection for conflating correlation with causation, I might argue that education should be about "overcoming what is withing", as opposed to "drawing it out".

    It is extremely difficult to eliminate covariates from cross-cultural studies.   It is difficult for me to conceive of an ethical experiment that would do so.

    Define "disorder."  Do the extreme ends of a continuous distribution count as a "disorder"?  Must people with "disorder" be part of a completely separate distribution?  I am not sure that I have a good definition, but the question implies that you do.
    So by delineatig the etymology of a term, you think I'm implying support for returning to Roman education? I imagine you know it's likely that most scientists up till the mid 20th century studied Latin and Greek. It seems to me you've taken part of my comments out of context,and applied associational thinking . If you look at my comments in context ,perhaps you could address my larger point instead of attempting to trivialize my position,which I don;t think you've actually understood,perhaps I'm wrong.At any rate I would say a perceived implication is subjective.
    I would have been more accurate to say 'so called disorder'. The way the term is used in the present discussion seems to mean that indivduals under consideration are fundamentally flawed. I say the flaws are in the current education system,with curricula developed by committees,often not well informed almost always subject to political pressures and social trends.The epistemological aspects of the approach assume that a certain style of learning,out of many possible is the correct one;that children are a blank slate ,that all start with more or less the same capacities ,talents needs etc. and that an assembly line approach of teaching the same material in more less the same sequence to everyone od the same age will maximixe results. The cogent problem as I see it for attention problems, is having pupils sit still at desks and read the abstract symbols of text or maths ,eyes moving left to right,etc. There is certainly data suggesting that this is not the optimal approach .The organism has evolved to move and develop coordination in the physical world,and education which forces too much concentration on abstractions too early distorts the process. Attention does ,after all mean to narrow,attenuate the focus of awareness. Give early primary school kids 3d geometric puzzles and you'll eventually get more of them doing advanced math more easily. KIds who learn music,which has an instant feedback loop that includes kinaesthetic functioning develop their learning skills more effectively than kids who don;t learn music. If the music education includes improvisation as well as rote,the student develops better creative problem solving capacites in general. Here's a link to a Montessori approach to attention problemshttp://www.familyeducation.com/whatworks/item/front/1,2551,1-9126-12092,00.html
    As for leaving behind historical baggage,~Could be good but extremely difficult to do.

    jtwitten
    I think we agree that the etymology is irrelevant.

    I also agree that the blank slate paradigm has been demonstrated to be incorrect and to base our educational system off it is foolish.  I would also agree that a set of some "non-traditional" learners are misdiagnosed.  The simple and inescapable fact of misdiagnoses does not mean that there is not an underlying disorder.  One problem is that different groups define disorder differently.  Frequently, they agree on the observations of a child's actions, but disagree on how to define those actions and the root cause.

    Since we are all humans, there must be some commonality.  Eventually, there must be a limit to the variation from ths commonality that can be considered a non-disorder.  You may be correct it your critique of "traditional" teaching methods in that they do not optimally encompass as much of the diversity.  Since we are stuck with historical baggage, it is also important to consider whether new teaching methods will equip students to function in our society.  I do, however, think it would be great if we could restructure our societies to accommodate a greater diversity of thought and approaches.
    I'm not sure what you mean by most of this. What is a "local gravitational field"? Gravity varies very little on the surface of the planet so I'm not sure why you would phrase something like this.

    Mind body separation has nothing to do with my son's ADD. His difficulty in keeping his attention on the task at hand has nothing to do with a harmless tendency to "daydream." I find it offensive when you to belittle his challenges in such a manner. He is not untested - he was administered a WISC test by a doctor of psychology which showed a characteristic gap between his verbal comprehension and spacial reasoning (high) and his working memory and processing (low). These scores usually vary by only a few points in the general population yet my son's high and low scores were separated by 50 points on a scale similar to an IQ score, with the normalized average at 100 points. Is that scientific enough for you? Once medicated, his standardized test scores rocketed 30 percentile points in math and a staggering 60 percentile points in reading. Is that enough of a demonstration for you?

    I don't live by standardized test scores and I don't need my son to conform - he wore his tricorn hat to the first day of school. But he tried so hard at school and struggled to learn what came so much more easily to others. His evaluation and subsequent treatment under the care of an experienced psychiatrist has removed the shackles for him. I am thankful that we were able to remove some barriers before he became too discouraged and gave up on school. Medication will never completely rid him of the negative parts of his ADD and it doesn't mask the gifts that so often come with this condition - creativity, empathy, a sensitive nature. If being able to thrive in the real world is being "drugged into normalcy" then I think we'll go ahead and take it.

    I hope your ignorant attitude and tendacy to pontificate on matters of which you know nothing doesn't deter people from getting the professional medical evaluation and advice their children deserve. You need to keep your "unexamined assumptions" to yourself.

    Of course there are always better ways to teach than what the current standard is. People are individuals and some will learn better in one way, while others learn better in another way. Hands on learning seems to benefit most people and obviously having a teacher who can spend one on one time with each student is ideal. However, that does not mean that ADD/ADHD does not exist or should not be treated. While it is true that it may be overdiagnosed, it is not just a cop - out or a way to sedate children into behaving the way adults want them to. I am an adult who has recently been diagnosed with ADD and can attest to the fact that it is real. I have struggled with it all of my life, not knowing or understanding why ordinary everyday things came so easily to others and seemed impossible to me. I did not have the hyperactivity (I am a female) and always tried to remain invisible and never draw attention to myself. Imagine trying to learn something, either by reading or by listening to someone speak, or by having a conversation with someone and being interrupted constantly. How much would you retain or even take in of what you are trying to learn? The only thing is that with ADD/ADHD you are being interupted by your own brain. It is like someone else has a remote control and is constantly changing the channel. Even one on one, I can be involved in a conversation and I just cannot focus completely. I will hear every couple of words and then my brain will be jumping to something else, I will realize this after a few seconds and tune back into the conversation, only to have my brain jump away again, constantly spinning. Trying to complete 10 tasks at once and so completing none. I am very grateful that I now have some treatment options and yes, the medication so far works. Obviously, if they find other more organic treatments that are as effective, I would be very supportive. Medical science is constantly growing and changing and it is true that in 50 years we may look back and be appalled that we treated ADD with stimulants because maybe, there are better ways of going about it. However, for me, it is nice to be able to complete a spreadsheet in a timely manner without constantly zoning out or making mistakes. It is nice to be able to organize my thoughts and focus on what it is that I need to do. It is nice to have a conversation where I am completely engaged and I don't have to pretend that I actually heard what was said.

    The topic of this article is gender differences, however I agree that it is most likely that the majority of the so-called diagnosis is merely an expression of forcing to conformity. In this context perhaps the girls are lucky, then?

    It is no way that so many of us have behavioral disorders. Even the name for this so-called illness is suspicious. It is more a happy marriage between politicians (social control) and the pharmaceutical industry (economic) than anything else.

    I just wanted to point out one small point of contention with this article. Attention Deficit Disorder (ADD) is an older classification (DSM III, I believe), and does not form a single diagnosis on its own. As of the DSM IV, ADD was combined with Hyperactivity Disorder, to form Attention Deficit/Hyperactivity Disorder (ADHD), along with 3 subtypes: Predominantly Hyperactive, Predominantly inattentive, or combined type. The article incorrectly stipulates that ADHD is a subtype/variant of ADD.

    Kimberly Crandell
    Chris, you are right.  Thank you for the correction.  What was once referred to as simply "ADD" had been more recently referred to as the "Predominantly Inattentive" subtype of ADHD. 
    I have ADD as a boy and when I was young i was pretty much daydreaming all the time, i was withdrawn and very quiet.
    However now that i am in my teens (16) i find the increasingly difficult to speak with people, especially of the opposite gender... I do pretty good in school however
    I have several of the symptoms, including feeling very sad all the fucking time :(
    Maybe i should just go back to Ritalin and pump my veins full of drugs to make people like me more

    Becky Jungbauer
    Thanks for the interesting article! As a girl myself, I appreciate when traditionally male-diagnosed conditions and diseases are brought to the forefront so women don't have to surmount the barrier of docs not believing us. Heart disease is another example. (And it goes both ways, of course; men get breast cancer and other "female" diseases.) Did you run across any research about inheritance patterns? For example, the dad has ADHD of one variation, the daughter and son inherit ADHD variations of their own?
    Kimberly Crandell
    Becky, I was actually wondering the same thing.  I don't know what studies have been done on that, but I'd be curious to see what genetic tie, if any, there was.  This is a subject of interest for me, so hopefully I can find some info and maybe write a followup.
    Hi Kimberly! What a wonderful article! I like how you've pointed out that ADHD & ADD symptoms are different for girls than they are for boys. I run a parenting site, ParentingPink.com, and would love to re-publish this article there if possible. Our readers are parents of daughters and this information is so important. If not, that's ok. Just thought I would ask and commend your article :-)

    Kimberly Crandell
    I'm glad you like the article.  Interesting information, isn't it?  As I understand it however, because of this site's copyright agreements we cannot allow "republishing" of our articles.  However, you can take an excerpt of the first paragraph and then provide a link here to the rest of the article.  I hope that will work for you?

    Thanks so much for your comments!
    Kimberly
    Hi Kimberly
    My daughters teachers are constantly telling me that she daydreams and is off with the fairies, her daycare teachers thought she might have bi polar because she just wasn't like the other kids, my Doctor said the teachers are not Doctors and should not diagnose a child with such a thing.

    I can relate to so many points in your article so it's made me think.

    HOWEVER not one person has yet been able to advise me on where or how do I get my daughter checked to see if she is just a shy little girl or if there is actually something else going on with her - as a mother I want to give her all the help I can (without the use of medication if possible) but I have no idea where to go. Can you suggest a good place to start?

    Thanks

    I had my daughter tested and have a friend who had his son tested. They were both assessed by psychiatrists who specialized in children. Generally, they will give the parents and the teachers rating scale questionaires to see how the child rates in regards to the behaviors that are indicators. They also should look at family history as well as assess for bi-polar (some of the bi-polar behaviors are similar to ADD/ADHD) as well as depression and other factors. I am positive that my dad has ADHD although, he has not been diagnosed. I have it and so does my daughter. It can be genetic, however, isn't always directly inherited. I assume there must be a gene passing it down, however, I am not sure if they know much about that yet.

    Becky Jungbauer
    I did a quick search on pubmed and found that ADHD linkage findings "have not all been consistently replicated, suggesting that other approaches to linkage analysis in ADHD might be necessary, such as the use of (quantitative) endophenotypes (heritable traits associated with an increased risk for ADHD)." One abstract also suggested that there was "an excess of regions harbouring serotonin receptors" in their linkage scan - certainly not a surprise given the manifestation of the condition.
    Kimberly Crandell
    Well hell, there goes my follow-up article.
    Becky Jungbauer
    No, that was to give you a prompt, not take away your thunder!!
    While ever the diagnostic criteria for ADHD are firmly rooted in behavioural term, this will continue to be so. If , however one looks at markers which have a physiological basis there is hope that some sense might be made. The concept of assortative mating (like with like) has been explored but in all the studies I have seen, the researchers have been looking at two unrelated aspects and using these to show assortative mating does not occur (Duh!!)
    See http://www.informaworld.com/smpp/content~content=a904705967~db=all for one of the better studies. It is not clear from the abstract but it should be deducible from the data, that assortative mating has some influence.
    One might hope to see some study that examines this problem at a more basic level. Anecdotally, the links are strong.

    Thanks for this excellent article Kimberley. I have some comments:

    * More work is definitely needed on identifying gender differences in ADHD presentation. Hyperactivity is often expressed differently in girls, for example in fidgeting and verbal impulsivity. However, it's important to recognise that some boys fit your criteria and also miss out on diagnosis for the same reasons. Whether we're talking about ADHD, heart disease or even sexual performance, for example, gender differences are never black and white.

    * The theory, repeated here by Anonymous, that ADHD is just a category devised for people that schools fail and redesigning schools will solve their problems is a fallacy. I was a bright girl with ADHD and schools were great for me. No amount of tinkering with the school or later, universities, would have solved my problems completing assignments and consistently performing at a level that demonstrated my capacity and drive. Methylphenidate and dexamphetamine, however, are effective remedies that allow me to harness my creativity, intellect and passions effectively so that I can attain qualifications and satisfying employment and parent my own ADHD children well. Frankly I'd rather have the life I want, rather than merely daydream about it. That's not to say that education systems and institutions cannot be improved to better serve those who do poorly. We do need to invest adequately in all citizens if we want to see good results. And universities need to do a lot of work in redressing systemic discrimination against students whose past failure or poor progress is a result of not knowing they had ADHD.

    Kimberly Crandell
    Thank you for sharing your insight, Contempa.  It's very interesting to hear from individuals that have struggled with ADHD, and your particular perspective on diagnosis and treatment. 
    I'm not repeating anyone's theories,I'm stating my own observatios. I'm glad you found a way to make things work for you . You do reference qualifications for emplyment.MY pint was the education system is set up to train people to complete tasks on schedule,not assist them in recognizing and optimizing their own strengthst and weaknesses,developig their talentspursuimg their interests. The kind of fundamental change I think is called for will not result from any amount of tinkering with the schools,but requires an entirely different model of the nature and mechanisms of learning.
    Have you ever looked at how Montessori education actually works?
    Here's link on a Montessori approach to attention defecit issues. I'm not advocating Montessori per se ,its just an example of a more effctive approach,in which the school finds what works for the student,rather than forcing the student to conform to an assembly line.

    Hi anonymous,

    I know about the Montessori approach and I'm not arguing against them per se. The conventional schools and universities that I attended did encourage me to pursue my interests and develop my talents. They could have done better at this but that was not the key problem. No-one, including myself, doubted that I was talented and very intelligent. But they certainly did not understand why I wasn't able to perform consistently enough to succeed on my own terms (and theirs). Knowing about ADHD is fantastic in itself because it validates what you already know about yourself but were not allowed to assert due to the blinkers of conventional attributions. And dexamphetamine and methylphenidate are the most successful therapies. Not surprisingly, they worked for me.

    I was going to finish my initial contribution with the following line: Don't worry, anonymous, no-one's going to normalize me! Perhaps I should have.

    An observation on gender-differences in childhood disorders is that boys tend to have more neurological/executive function-based symptoms, while girls have more emotional symptoms. One thought on applying this to ADHD, is that it might manifested differently in boys vs. girls. At the same time, ADHD has been thought to be more of a male disorder for a long time, & this might reflect the actual nature of the construct. It's interesting that the symptoms that you pick out for girls are the inattentive symptoms; in Rusell Barkley's fascinating work, he made the case that predominately inattentive ADHD shouldn't be considered ADHD. Inattentive symptoms are of course terrible in their own right, but he seems quite convinced that it's not quite the same as ADHD.

    Hi kerrjac,

    I haven't seen anything by Russell Barkley that predominantly inattentive ADHD is not part of ADHD. I understand that he nominates impulsivity as a core trait. Recently I believe he has written that research shows the hyperactivity dimensions of the diagnostic criteria are not necessary to establish a diagnosis. So called inattention and impulsivity continue to be critical problem areas for people with ADHD.

    See if you can find a full text of

    Barkley, R. A. (1997). Inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94.

    (Or the book, ADHD & The Nature of Self-Control)

    The distinction between inattentive & hyperactive symptoms is a core part of his theory that ADHD is developmental disorder of executive function impairment.

    Hi kerrjac,

    Thanks for these references. I can't comment on Barkley's opinions at the time without reading the documents in question. Certainly a vast amount of research has been conducted in the ensuing 11-12 years. Only last night I read an abstract of research reporting that there was no difference in results of executive functioning tests between a group with ADHD combined type and a group with ADHD inattentive. I will try and find the reference for you later.

    Hi Contempa, yeah the empirical research using highly standardized tests of executive function has *not* supported Barkley's distinction between subtypes of ADHD. There might be various reasons for this. Barkley thinks that it's due to the limitations of those tests, particularly their lack of validity across different aspects of one's life (ei, 'ecological validity'), and for the most part I buy his claim.

    Across his clinical career, Barkley's observed qualitative differences between those with ADHD-inattentive and the rest of kids with ADHD, convincing him that they're separate entities. These differences have borne a number of significant empirical findings, particularly regarding age of onset and I think gender.

    The theory is that ADHD is a developmental disorder of executive function. This is responsible for the hyperactive symptoms, which almost always come at an earlier age of onset. In fact, you rarely see ADHD-inattentive in younger children (~<6). Later in life, the lag in certain executive functions leads to qualitatively different symptoms, which are manifested as inattentive symptoms. However, inattentive symptoms are rather vague, & they're not specific to ADHD. Similar or identical symptoms appear in other disorders, such as depression or retardation. So essentially ADHD earlier in life can cause inattention, but so can many other things. The implications are that (1) we should treat ADHD like other developmental disorders; (2) we shouldn't treat predominately inattentive ADHD (particularly when it's later onset) as ADHD.

    Hi kerrjac,

    I think if you wish to invoke Russell Barkley's name in support of your thesis that ADHD predominantly inattentive should be treated differently than "ADHD", then you should supply specific quotes.

    Right now i am interested in knowing exactly what treatments you propose should be offered to individuals with different subtypes of ADHD and why. When it comes to why, I'm interested in evidence from research published in peer reviewed journals rather than the account you've given of Barkley's views.

    Here's a quote from a speech Barkley gave. You can find the whole speech here http://www.greatschools.net/pdfs/2200_7-barktran.pdf?date=4-12-05. I hesitate to post such a long quote but Barkley tends to be pretty enlivening, even if you disagree.

    Is Inattentive AD/HD Really Another Type of Disorder?

    Now, if you will take the DSM, and use it with those modifications, you’ll be doing a damn good job of diagnosis. Now I want to come back to this group that we call Inattentive AD/HD. We used to call them ADD without Hyperactivity. These days some people are just using the term ADD for them. I don’t like that. Part of the problem with using that term is that that was the old term for AD/HD over 10 years ago, so it creates a lot of labeling confusion. ADD and AD/HD are the same thing. ADD is the earlier, 1987 term—goes all the way back to 1980, in fact, whereas AD/HD is the more recent label.

    So let’s talk about this Inattentive type: the kids who come to see us who don’t show problems with hyperactivity, who aren’t impulsive. What do we know about that subtype? We know enough that several of us in the research community have taken to arguing that this is a different disorder. This does not belong in AD/HD. This is not AD/HD. This is a real attention disorder with real information processing deficits, and it has little in common with the other two kinds of AD/HD. The Hyperactive type of AD/HD and the Combined type of AD/HD are the same disorder. You’re just catching it at different developmental stages. Kids start out with Hyperactivity; the attention deficits come within a few years after that, and then they move into being the Combined type. But these children, on the other hand, are a different story all together.

    Why do I think this is a different disorder? Why do some of my colleagues agree with it? Why do the rest of my scientific colleagues certainly agree that this is a qualitatively different group of children? Whether you view them as a different subtype or as an entirely different disorder is less of concern to me than that you understand these are not the same kids. They do not have the same risk, the same co-morbidities, the same causes and the same outcome, and it is likely that they do not respond to the same treatments the same way. But we will not know any more about treatment if we don’t view them differently, because everyone will assume as you may do, quite naively, that the treatments for one apply to all the subtypes, and they don’t. We have discovered a new disorder and it does not belong here. It needs its own name and its own criteria and it needs to get out of this category known as the disruptive behavior disorders, because it has no affinity for them. So let me show you why many of
    my colleagues are now slowly coming around to an idea that 10 years ago I argued for. This is a different disorder.
    Why do I think it’s a different disorder? Because these children come in with the opposite symptoms. Instead of being hyperactive, intrusive, distractable, they’re lethargic, slow-moving, hypoactive, spacey, daydreamy, quiet, passive, withdrawn, confused, in a fog. They are the polar opposite of the AD/HD child in their clinical presentation. This is not an impulsive, disruptive, intrusive, aggressive, emotional, naive child. This is a kid who is staring, daydreaming, confused, and not processing information accurately. This is a real attention deficit, if attention means information processing. These kids have a processing deficit. AD/HD children do not. Do not confuse these two groups. They do not have the same problems with paying attention.

    Other things we see in these children: when we bring them into the clinic, and we run them
    through a battery of neuropsychological tests, they have deficits in an area we call selective attention. Selective attention is how quickly you can deduce what’s important from unimportant in a spatial array of information, how fast you accurately process information coming at you. AD/HD children have no trouble with selective attention. And by the way, let’s put an end then, to this metaphor for AD/HD that it’s a filtering problem. Because it isn’t. Real AD/HD has no trouble with filtering, selecting information. AD/HD children perceive the world exactly as everybody else does. These children don’t. These kids have a selective attention problem, which by the way explains something that we have found in about six different studies. These kids make more mistakes in academic work than AD/HD children do, many more mistakes. The problem that AD/HD children have is with productivity; number of problems attempted. The problem with these kids is accuracy: the number of errors made. These kids have a real problem with input coming into the brain, how quickly they can handle it, how accurately they can select it out, and deal with it. These children have memory problems. AD/HD children do not. These children have trouble with getting information out of short-term and long-term memory and doing it correctly. It’s especially so for long-term memory, so that they show a very erratic recall of information. AD/HD children, if they have a memory problem, it’s going to be in a very unusual form of memory we’re going to talk about later today. But this is traditional long-term storage, and these children have some trouble with that, probably for the same reason. They’re not getting information out of memory any more accurately than they’re processing information coming into the brain. There are problems with selection, with filtering, with focusing their attention. These children have a very different social profile. The traditional AD/HD child is often a rejected child, because they’re immature and emotional and hotheaded and demanding and controlling and impulsive and often aggressive, so that when we compute a social profile of the AD/HD children they often wind up as being the least liked, the least popular and most likely to fight.

    That is their peer group profile. That is what Ken Dodge and his profile of peer acceptance views as the rejected child. And 50 percent or more of AD/HD children are utterly rejected by their peer group; these [inattentive] children, very different picture. These children are overlooked. In Ken Dodge’s taxonomy of social problems, they’re neglected. Why? Because they’re passive, uninvolved. They’re staring, daydreaming, hypoactive, absent-minded, passive. Unengaged is a better term for them. They’re not disliked by the other kids. They’re not rejected by them. The other kids just don’t know them. They’re not engaging. They’re not out there participating. They’re just kind of passive kids. They have more friends than AD/HD children have, actually. These kids tend to be neglected, not rejected. It’s a very different social profile.

    Other differences: there is no affinity of this disorder for Oppositional (Defiant) or Conduct Disorder that we can tell. They basically have the same base rates as the normal population. But many AD/HD children are likely to go on to develop Oppositional Disorder and Conduct Disorder. Forty-five to 55 percent of AD/HD children develop Oppositional Disorder by age 7, and another 25-45 percent move up to Conduct Disorder by ages 8 to 12. AD/HD goes with Oppositional and Conduct Disorder. The inattentive group does not. You see another reason why they don’t belong in this group? Those three disorders—AD/HD, ODD, and CD—are all part of a larger category we call the disruptive disorders. The inattentive group isn’t and it shouldn’t be there.

    Other differences that we see: by definition, of course, these kids are not impulsive. They don’t have any difficulties with inhibition. These children do not respond to stimulants anywhere near as well as AD/HD hyperactive, impulsive children do. Only about one in five of these children will show a sufficiently therapeutic response to maintain them on medication after an initial period of titration. Oh, you’ll find that about two-thirds of them show mild improvement, but those improvements are not enough to justify calling them clinical responders, therapeutic responders. Ninety-two percent of AD/HD children respond to stimulants. Twenty percent of these children respond to stimulants. And the dosing is different. AD/HD children tend to be better on moderate to high doses. Inattentive children, if they’re going to respond at all, it’s at very light doses, small doses.

    So the drug response is different. And that’s all we know. [At this time] there are no other studies of treatment of this group—none. The only studies are five involving medication and mine was the only one that tested multiple doses with a placebo control.

    There are only two pages in my parents’ book, Taking Charge of ADHD, on this group, and it tells you what I just told you. This is what we know. These are different kids. This is a different disorder. Stay tuned. We don’t know what to do with them. It’s up to you. You’re just going to have to cobble together some help any way you can and hope that it works, because there is no science beyond what I just told you.

    They may have different causes. They certainly have different family histories. Those children tend to come from families where there are more anxiety disorders and learning disabilities. AD/HD children come from families where there’s more AD/HD, Conduct Disorder, antisocial behavior, and substance abuse. The family histories of these two groups are not the same.

    Now, we have to be careful here, because the Inattentive group, it turns out, is rather a wastebasket group of kids. First of all, in that group are the true Inattentive kids. But also in that group are AD/HD children who came in one symptom short of being in the Combined group, right? They’ve got six inattention and five hyperactive symptoms, and according to the DSM, if they don’t have six, they’re not in the Combined type. Well, yes they are, and you should think of them as being Combined type children, even if they come up one symptom short. Don’t put those kids into the Inattentive group. The Inattentive group in our clinic is for kids with three symptoms or fewer off of that Hyperactive-Impulsive list. Any more than three and you’re better off thinking of them as what we call sub-threshold Combined type children.

    There’s another group, the group that starts out being in the Combined type and by adolescence or adulthood are no longer so hyperactive, but they meet the criteria on the Hyperactive list. Now you would flip them over into the Inattentive type. Don’t do it. You always think of them as Combined type. So, bottom line is this: If any point in your history there was a whiff of problems with inhibition and impulse control, you’re a traditional AD/HD Combined type kid, and it shouldn’t matter what the DSM is telling you about cut-off scores. Clinically that’s how you would approach that child. That’s a Combined type kid. And you reserve this Inattentive group for kids who have never in their lives had trouble with inhibition. Those are the spacey, daydreamy, confused, in a fog, sluggish, hypoactive, slow-moving group. And as long as you conceptualize them that way, you won’t make any clinical mistakes. But if you follow the DSM as it’s written—perhaps you have OCD and you just have to follow all those criteria, just as they’re written—then you’re going to get yourself into some trouble. Because remember, the DSM was not chiseled in stone in Israel. It’s a set of guidelines developed to help make clinical decisions, but it’s to be used with clinical judgment and understanding of the criteria.

    Okay, that’s just to resolve some confusion. And by the way, I said the Inattentive group was a wastebasket. Why did I say that? Inattention is nonspecific. Inattention is unhelpful in defining what disorder you have, because most mental disorders produce inattention. So if somebody walks into your clinic and says, you know, I’m having a lot of trouble concentrating, can’t pay attention, can’t finish work, you have no idea what they have. You don’t automatically say, oh, that’s AD/HD, I’ve heard about that. This could be a psychotic. This person could be a substance abuser. This person could have a generalized anxiety disorder or panic attacks or major depression or bipolar illness. How the hell do you know what they have?

    For now, just know that the Inattentive type of AD/HD is a real wastebasket category of really inattentive children, along with children who have other disorders that are producing their inattention. There really is an Inattentive group out there, but they have a different disorder, and it’s not AD/HD.

    Hi kerrjac,

    Thanks for this. It is interesting because I have always seen myself as combined type yet others would tend to think of me as inattentive subtype. This seems to confirm my own instincts.

    I have always seen impulsivity as being pretty much essential to ADHD including the inattentive subtype. However, impulsivity can be masked by shyness and anxiety. impulsivity is typically expressed verbally in girls. Interrupting, talking over the top of others, coming out with bloopers, going off at tangents, excitedly blurting out something off topic, etc. ADHDers tend to be either switched on or off. A girl who's learnt that the group will punish her for breaking social rules, may well not participate in a conversation at all because she will know that there's no halfway so it's safer to hold herself back. She is very likely to be misdiagnosed with depression.

    It's often the case that ADHDers who are not visibly hyperactive are very mentally hyperactivity. But gotta go, I impulsively replied to this and now I'm late. Should have taken those meds. I'll post later with a reference to one of my favourite characterisations of ADHD.

    Here's a delightful and informative story of a young woman with predominantly inattentive ADHD whose life was turned around by medication. It's particularly pertinent to the materials Kerrjac posted.

    http://www.additudemag.com/adhd/article/5193.html

    Larry Arnold
    This is interesting because the study of autism is also dogged by the same assertion that it is more common in boys, the ratio of 1:4 being most often quoted.

    This used to be the case with dyslexia too until research by Finucci&Childs, 1981, and Shaywiyz et al, 1990  showed that the apparent bias was an artefact of referral generated by cultural expectations of how the sexes behave that led to under diagnosis in girls. There has also been the suggestion that the ratio is an artefact of the testing and the criteria themselves as is suggested in this paper "Gender ratio in dyslexia"

    In autism, Tony Atwood strongly contends that the gender ratio is an artefact of the more subtle manifestation of autism in girls and cites his clinical experience to support a more equal gender ratio. This has been increasingly in the news lately

    I personally challenged Michael Rutter on this some time ago, and he insisted that it was a scientific fact that the ratio was 4:1 because this was shown in "all the studies" I told him I though that was very unscientific thinking, in that how could he be sure that the gender ratio in the studies was not a result of persistent selection bias in the recruitment of subjects, in that if Atwood is right, there will be fewer girls actually diagnosed, and if the popular scientific meme is that there are more boys than girls, this will show up in the recruitment of research subjects and be self perpetuating. In other words the historical corpus of research proved nothing, because none of it was based on a general population survey taking into account recent criticisms of diagnostic bias.  "Girls with mild autism are less likely to be identified and diagnosed than boys, a study suggests".

    As for arguing anything by DSMIV as some commentators do, to establish the "truth" of their position, it is bit like the language pedant who will argue by such and such an edition of Websters or the Oxford English Dictionary, dictionaries being only a reflection of language usage which is constantly in flux, the language being defined by it's actual usage and not the dictionary which only follows when the usage has been relatively stable over time. As anyone who is current ought to know, DSM is subject to revision at this moment, and the definitions there are rather like a Camel, which has been described as a Horse designed by committee. They reflect current clinical practice rather than the cutting edge of research.
    You're right that selection bias might be wrecking havoc here, but just b/c that's a possibility doesn't make it so. Society may be more on the lookout for ADHD in boys, & that maybe b/c we define ADHD by behavior that we see more often in boys; but at the same time we may define ADHD by behaviors that we see more often in boys b/c ADHD tends to be more of a problem in boys.

    Given all the mental, physical, physiological differences btwn males & females, one would expect that they have different rates of various mental or medical conditions. To take an extreme example, postpartum depression has not been documented in men; & I don't think it's due to selection bias.

    Of course we want to be sure that we're not missing conditions like ADHD in females; but that's no reason to assume that rates of ADHD are equal across both genders. If we 1st assume that the rates are equal, & then go about refining the definition of ADHD in the general population, then we're looking for trouble, b/c we're increasing the chances of making up fictitious mental disorders/criteria.

    Furthermore, there is sound theoretical evidence for why ADHD is more common among men, as it correlates with risk-taking behavior, oppositional defiance disorder, places kids at risk for antisocial personality disorder, & criminal behavior...all of which are much more common in males. Now, you could argue that society exhibits a selection bias for each of the latter factors in addition to ADHD, but by then you'd be proposing more of a conspiracy theory.

    Dear John
    I was going to twit you about male post-natal depression until I read this article
    http://www.guardian.co.uk/society/2008/apr/16/mentalhealth2
    I think I'll have to go back and actually read the underlying research before I make too much comment. I suspect the confusion of causality with correlation may play part of the role. The other part may well be the presence of ADHD in the males suffering depression.
    (So much for a "Dear John" letter)

    Larry Arnold
    I am neither an expert on ADHD nor Dyslexia, but I do know that there have been papers on dyslexia that have demonstrated a bias in how that is identified. The famous ones are:
    Shaywitz, S., Shaywitz, B., et al. (1990).
    "Prevalence of reading disability in boys and girls:  Results of the Connecticut Longitudinal Study." Journal of the American Medical Association, 264(8),  998-1002.

    and

    Finucci, J. M.,&Childs, B. (1981). Are there really more dyslexic boys than girls ? In A. Ansara, N Geschwind, A. Galaburda, M. Albert,&N. Gartrell (Eds,), Sex differences in dyslexia. Townson, MD : The Orton Dyslexia Society.

    (I just borrowed the citations out of an old essay of mine)

    So it is not unreasonable to suppose that the same might apply to the identification of other disorders, because this is certainly being suggested in Autism.

    Of course that does not mean that there will a 50/50 split anymore than the population is evenly split between boys and girls. However I do think it is somewhat arrogant to totally discount the possibility of selection bias, after all you cannot rule it out until you have considered it.

    It is often forgotten the degree to which there is a social overlay with every medical condition, how one is socialised to deal with pain, and disability. I am a perfect example myself, when I was examined sometime ago by a rheumatologist, I remained silent throughout the whole performance,  I did not realise that I was supposed to cry out, whenever he pulled my joints into a position that caused me pain, boys (at least where I come from) are brought up not to. It might have served my interests better if I had have cried out, because then I would have had attention to my problems sooner.

    Hey Laurence,

    Just from browsing around a bit on pubmed, it looks like the issue with reading disorders isn't fully decided (see http://www.ncbi.nlm.nih.gov/pubmed/11682360?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed, & the similar articles it links up w/), & some of the latest reviews are just returning to the belief that reading disorders are more prevalent in boys.

    An overall difficulty in these studies is that boys & girls are on slightly different time-lines. In fact, these different timelines account most of the gender differences in intelligence; from what I understand, gender differences in intelligence disappear almost completely if you discount age. Of course, in these studies, the researchers often have to match the participants by age. Barkley in fact viewed ADHD as a developmental disorder that was almost temporal in nature, placing children w/ADHD a few years behind their same-aged peers. This is why, he thought, it's manifested differently (as more inattentive symptoms) at older ages; & it's also probably why it's diagnosed early particularly in boys. By adulthood, he argued, the disorder can still be prevalent, but it becomes less noticeable over the years; b/c age-differences in cognitive development are less striking when you're an adult than when you're a child.

    Getting back to the issue at hand, I think that there are lots of clues that you can take from gender differences, even if they might be 'societal biases'; & sometimes those biases may represent nature itself.

    Take risky behaviors, which are characteristic of ADHD - men are much more likely to preform them; they're also more likely to be suspected of performing them; cycling back around, they also maybe - just maybe - more likely to perform them b/c society expects that of them. Consequently, if get rid of the societal bias, you might help get rid of those risky behaviors that men do just b/c they think it's expected of them. But I doubt you'd still get rid of most or even a sizable portion of mens' propensity towards risk. Some 95% of incarcerated people are male; it's hard to imagine how all of that is attributable to society bias. It's possible, particularly since not all societal biases represent underlying biology (racial relations comes to mind), but it's a stretch.

    I agree w/you that we need to be on the watch-out for societal bias when it comes to comparing rates of diagnosis of boys & girls. But at the same time, I don't think that every gender difference should raise a red flag, as if to indicate that we may have to rethink things. Instead, science should heed these gender differences as theoretical milestones. Some gender differences are quite obvious - like physical ones - & others are less so - like differences in hormones, or different rates of mental disorders. When we find the less obvious ones, that's really interesting; we're making connections. Somewhere underneath these findings lies a lesson - not about gender relations - but about the true nature of certain phenomena, included in this case I suspect ADHD.

    Larry Arnold
    An overall difficulty in these studies is that boys&girls are on slightly different time-lines. In fact, these different timelines account most of the gender differences in intelligence; from what I understand, gender differences in intelligence disappear almost completely if you discount age. Of course, in these studies, the researchers often have to match the participants by age. Barkley in fact viewed ADHD as a developmental disorder that was almost temporal in nature, placing children w/ADHD a few years behind their same-aged peers. This is why, he thought, it's manifested differently (as more inattentive symptoms) at older ages; & it's also probably why it's diagnosed early particularly in boys. By adulthood, he argued, the disorder can still be prevalent, but it becomes less noticeable over the years; b/c age-differences in cognitive development are less striking when you're an adult than when you're a child.

    Indeed that is one of the fundemental problems of research in that are we ever comparing like with like? and being able to look at a paper "sideways" to see if there is not some extraneous factor accounting for the differences or similarities one sees beyond those ones study allows for is a skill the honest researcher needs to employ. Which of course is why peer review and debate is so important.

    I can't help thinking though that there are a lot of contrarians for the sake of it rushing to press,  - maybe we all have a touch of ODD :)  and yes it does seem that certain theories are cyclical, so we might be undergoing a swing back. Joking apart, the best way to test a hypothesis is to set out to disprove it, and then if one cannot, one has to acknowlege there is some substance to  it, but we do have a real problem in replicating some work when it can be realised that when you examine the data sets carefully it turns out the research cohorts are not really comparable at all.
    It remains to be seen whether ADHD is more prevalent amongst girls than is currently thought. However, Kerrjac says it can't be more prevalent in girls b/c it's associated with "male" behaviours such as risktaking and "male" disorders such as ODD and antisocial personality disorder.

    Firstly risktaking is a subset of behaviours linked to the stimulus driven nature of ADHD. Preferences for activities that are novel, intensely interesting or urgent also comes within this stimulus driven aspect of ADHD. Hence, obvious risktaking is not necessary for a diagnosis of ADHD.

    Secondly, not everyone with ADHD will exhibit ODD (or Conduct Disorder) and while ADHD and CD can progress to Antisocial Personality Disorder, this is not inevitable. However. some girls with ADHD do have ODD or CD, but these girls are more likely to be noticed and diagnosed.

    Mind you, based on prison data, a significant number of individuals with ADHD are not diagnosed or treated.

    The groups most at risk of lack of diagnosis, however, are those whose behaviour is not offensive. These individuals may have combined type ADHD or predominantly inattentive ADHD, however they are not disruptive in a classroom.

    It's important that choice of therapy remain with the individual or parent. What worries me about Kerrjac's line of argument is the possibility that individuals with ADHD might be put into an "inattentive" category from the outset and face multiple barriers to stimulant therapy. If someone's goal in seeking a diagnosis is to try out stimulant meds to determine whether they make a difference, then that is perfectly reasonable and must not be thwarted by health provider created red tape in the form of rigid treatment protocols. Here in Australia, informed consent is the law. Protocols do not override informed consent.

    Kerrjac also asserts that Barkley claimed inattentiveness becomes less of an issue as one gets older. I disagree. Firstly, individuals who don't know they have ADHD will often follow a downhill trajectory as life becomes harder and harder. I also think it's likely that as one's energy dissipates in old age, it is harder to make up for ADHD deficits - but I'm not old enough to speak from personal experience. However, as women live longer it's critical that ADHD is recognized among older women as well as older men to avoid misdiagnosis with mood disorders and cognitive problems of aging.

    btw. Kerrjac also made reference to postnatal depression - this is another condition that is probably often misdiagnosed when the real problem is actually ADHD. This is yet another reason why it is critical to recognise ADHD in girls and women, whatever the actual male:femaie ratio is. The main problem right now is lack of diagnosis.

    It's not that ADHD "can't" be more prevalent in girls than boys. Rather, the fact that research seems to show that it's more prevalent in boys than girls fits in w/other research on gender differences regarding risk factors for risky/deviant behavior, & other mental disorders, & maybe for developmental disorders as well. The latter provide convergent evidence, which can help us learn more about the theory of ADHD. The purpose of all this isn't to treat everyone the same & come out w/rigid guidelines. It's to learn about ADHD, & get at the theory behind it. Gender differences are valuable. They exist. More importantly, we can use them to learn more.

    Larry Arnold
    To say that I consider there are flaws in the nosology of DSM would be an understatement. In some cases the categories are too broad, and in others too specific.  Being that it is a clinical manual of observable effects rather than encyclopedia of known or probable neurological causation is the problem for researchers. Does one use the accepted categories in ones research because it allows consistency or should one apply the notions of Glaser and Strauss' grounded research and revise as one goes along, with the danger that one comes up with different definitions of what one is studying from what one started out with?

    To look at it another way I could take a set of physical symptoms, and name a disease entity after them. Let us call it for example "distal parasthesia" to make it sound proper. It may well be an accurate description of something that a lot of people suffer from. (tingling and loss of feeling in the extremities) but it would actually contain a lot of different disease processes, for instance diabetes, nerve degeneration, even hypothermia which are very different in nature and demand different solutions.

    "Conduct disorder", seems to me like a less than useful descriptor to have within DSM. The scope for societal definition of what is good and bad behaviour is too vast, and the category does not hold up as something that has a definate organic (after Kraepelin's notions ) or neurological difference behind it unless one is a belated follower of Lombroso that is.  I can recall a paper presentation (though not the presenter I will have to look that up) who seemed to confirm my doubts about conduct disorder in that her research into people with the disorder turned up two rather different subtypes, different enough I would say not to call them sub types at all any more than a person with diabetes and a person with MS could be described as subtypes of my notional disorder "distal parasthesia". One of those "subtypes" was very far from the classical notion of the scheming psychopath, devoid of empathy.

    As to how one ends up with a diagnosis of ODD or CD I do not know, that would be worthy of research in itself, but I can't help thinking that this is an excuse for societies failure to come to grips with the consequences of a variety of differences that are swept under the diagnostic carpet.

    ODD and CD open up a whole new bag of worms regarding the gender ratio that is found within the prison system which is more the realm of the sociological researcher than the psychological, since there are many reasons why Men and Women are dealt with differently within the criminal justice systems of our Western nations.
    http://eprints.qut.edu.au/14882/1/14882.pdf

    Above is a relevant link on girls and ADHD.

    Incidentally, I have 2 daughters with ADHD who were both noticeably hyperactive from a young age, yet one of them was incredibly motivated also and an excellent student until things started going wrong in yr 6 in the form of work not being submitted. By yr 8, I had a child who was confused and depressed by her deteriorating performance in school. Luckily she had a mother who knew exactly what this meant and diagnosis and treatment led to a fast turnaround. I hate to think what might have happened had I still not known about ADHD by then.

    I think psychologists and others researching ADHD should pay attention to the popular literature put out by the ADHD community rather than merely focussing on academic papers.

    My own view of ADHD is that it's predominantly a reward system problem that manifests itself in a variety of ways. I particularly like the account of Carla Berg Nelson in “Rhythms of the Racing Brain” (in Thom Hartmann & Janie Bowman with Susan Burgess eds, Think Fast! The ADD Experience, California, Underwood Books, 1996, 41.).

    As Nelson puts it:

    "Whatever the differences across the ADD spectrum, a “pull to the stimulus” propels us all. Without this stimulus fuel, our brains sputter and stall."

    Dr William Dodson, a Denver psychiatrist, expresses this stimulus driven characteristic eloquently:

    "People who do not have ADHD have importance-based nervous systems. That is, the importance of a task helps them engage with it immediately, get access to their abilities, and persist with the task all the way to completion. They see the tasks that require completion, arrange them in order of priority, engage in them, and gain access to the skills they need to complete the tasks. Even when a task is more important to an employer, spouse, teacher, or parent than to the person himself or herself, a person without ADHD still manages to accomplish it.

    "Adults with ADHD report that they cannot remember a single instance in which the importance of a task all by itself ever helped them accomplish it. To a person with ADHD, importance is nothing but a nag. … .

    "Every aspect of performance, mood, and energy in a person with ADHD is determined by his or her momentary sense of 4 things: interest, challenge or competitiveness, novelty, and sometimes a sense of urgency brought on by a deadline or impending disaster. In these circumstances, persons with ADHD can engage and produce huge amounts of high-quality work on deadline – as with the student who completes weeks of work the night before an examination or the night before a paper is due. Every person with ADHD can recall a lifetime of experiences in which they are "in the zone" and perform at a high level, only to have it slip away when they lose their sense of interest, challenge, novelty, or urgency. The clinical challenge is to find multiple ways by which people with ADHD can accomplish the tasks of their lives on demand." (“Real-World Office Management of ADHD in Adults (attention deficit hyperactivity disorder)” (Nov 1, 2006) 23.13 Psychiatric Times 67. Health Reference Center Academic).

    It won't happen in DSM V, but eventually this aspect of ADHD should be included in the diagnostic criteria even if it's simply described as inconsistent performance. The failure to acknowledge this variability in performance led me to argue my way through my own diagnostic interview. And finally, when I asked tentatively, "So do you think I have ADHD?", he replied, looking like he'd gone a few rounds, "DEFINITELY!".

    Hi Arnold and Kerrjac,

    I thoroughly recommend that you read Dr Thomas E Brown's "Attention Deficit Disorder: The Unfocused Mind in Children and Adults", Yale Uni Press, 2005. I think his definition of ADHD is excellent as is his discussion of consequences for individuals.

    There is an excellent book on Girls with ADHD by Kate Nadeau et al, but I loaned it to someone so can't give the reference - you can look it up if you're interested. There are more books on ADHD in women but I haven't read them apart from Sari Solden's classic, "Women wth ADD" which does focus on inattentive ADHD but has relevance to women with combined type as well I believe.

    I am doing my dissertation on changing the diagnosis of girls for AD/HD with the new DSM-V. I have been looking everywhere to see if the DSM-V is going to do that. Will you be able to help me? I would like to stress, if the DSM-V will not include that change, why it is so important that this change be made in the future. I would love to have Dr. Russell's permission to use his research and to quote him. Even better yet, to try and have a conference with him in person. I hold him as the greatest and most reliable source on the subject of AD/HD.

    Hi Carole,
    Very interesting to hear from you. Where are you doing your dissertation and what changes do you propose?

    thank you so much i am 14 years of age and i didnt fully get why my mom was telling me i have add , so i looked it up and im glad to find this site

    Hi, just thought I'd start weighing in, as a woman with ADD (Inattentive type) and having been diagnosed since the age of ten.

    Above someone wrote:
    Did you run across any research about inheritance patterns? For example, the dad has ADHD of one variation, the daughter and son inherit ADHD variations of their own?

    My dad has ADD (inattentive type) as well, although I have seen kids through different programs throughout the years who have ADD (hyperactive type) and their parents are just ADDi and vice versa. The type does change and a person can move between the extremes at any time. In fact in Ratey's book "Driven to Distraction" they do mention that some adults lose the hyperactive label over time, and some don't.

    I resemble the remark about people thinking I was lazy, flighty, a daydreamer, I lived inside my head a lot. Being socially awkward led to being made fun of which only created a vicious cycle. As an adult, I'm still considered flighty and a daydreamer and just generally out of step with everyone else. I've learned to play that to my advantage though. I'm smart enough that even though I'm not being treated I have coping mechanisms, not all of us turn out bad! I've got a job, an apartment, two cats, tons of friends and aquaintances, and a definite life goals. I may say things I don't mean, interrupt people, get impatient, lose my train of thought and find whole new different shiny trains to follow, but that's OK.

    I'm also tired of people saying that if we change the way we teach kids, or blaming it all on something else, or saying it doesn't exist. Yes. it does. It exists as a condition as long as it impedes on someone's ability to function at a normal level. That is the basis of a disorder and I think close to the DSM definition. Sure there are flaws within that, and not everyone's going to comfortably fit between all of those guidelines. When I read the criteria for ADDi I don't fit all the requirements either, but that's why they say it has to be a certain ammount and a significant change over time.

    And as an aside, it would probably take a normal person about oh, 10 minutes to write this, but because I started running off, it took me about 25 minutes. LOL

    I have just found out that I have ADD, which came as quite a shock. I'm 14 years old and have coped fine all my life until last summer when I started my exams and pressure got kicked up.
    I was first diagnosed with depression but just found out last week that I had ADD.
    I had no idea what is was until I started reading about it and found it hard to believe that I had this disorder my whole life but only now was it causing me problems.
    I keep myself to myself and right now I am really struggling with coming to terms with the fact I have ADD so if anyone has any help for me I would be most grateful.

    Hey, Anonymous!

    It's not the end of the world! Believe me when I tell you it isn't.

    Being ADD isn't like being stupid, or slow, or being labelled a learning disorder. You just think differently than anyone else. I definitely reccomend you talk some of this over with your doctor. Check out Ratey's "Driven to Distraction' it's got plenty of insights into what makes an ADDer think, especially since Ratey himself was diagnosed long before he switched to helping those of us. Since you're a teenager there are plenty of support groups out there for teenagers who have ADD just ask!

    Sure it's not going to be a picnic, then again, life isn't either. But remember that you're going to have days like that, and laugh. I've come out of the ADD closet so to speak to everyone around me so when I do zone out and they snap me back to attention I go, "Sorry, ADD moment." and we laugh it off. Especially when I laugh it off with a "Hey I don't have ADD! I have ADOS: AD--oooh, shiny!" or "I used to have ADHD until I realized I wasn't a high enough resolution!"

    So if you ever need a chat, I've got my blog linked to my name. I'm not a creeper, a 28 year old chick who's been there, done that.

    hi i think this info is very good.My son has add and i also think my daughter has it many or should i say all remind me of my daughter who 10 and struggles in school and has an IEP .We are also not sure wether shes dyslexic as she writes alot of numbers backwards and sometimes letters she getting better with that and also struggles with reading.I may get her tested but i have thought teachers and docs to get my son and its very tireing being disabled myself.By the way haveing add is def not being stupid you just think diff . i liked the last message.

    For maybe a year or two now, ive kind of felt like i might have ADD. The signs of ADD in teen girls all described me perfectly (except for the last one that said girls with ADD are often late for stuff- im often unintentionally early). I tried telling my Mum i think i have ADD, but she said that getting tested for ADD is really expensive, and she doesnt belive me so she wont pay for it. I also told one of my teachers (one that i actually TRUSTED- notice the past tense there), but he said that i was just being lazy and i need to try harder. But i do try- as hard as i can! But apperantly thats not good enough, because my marks are dropping. I used to always get at least 85% on all my subjects on my report cards. But now theyre starting to go down to the 70s. Im afraid that they will continue to go down. And i only have one year left of jr high. If my marks are low, i wont be able to go to a good high school, no matter how hard i try. Im out of ideas for what to do about it thought, since no one believes theres actauly somethin wrong.