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ADHD in Girls: Interview with Kathleen Nadeau, PhD is pleased to welcome Kathleen Nadeau, PhD, who shares her expertise on the diagnosis and treatment of ADHD, particularly as it relates to the treatment of girls.

Dr. Nadeau, an internationally recognized expert on ADHD, is a member of the CHADD professional advisory board. A clinical psychologist, she has been in practice for more than 30 years.

She is the co-director of Chesapeake Psychological Services of Maryland. Dr. Nadeau is the author, co-author, and/or editor of numerous books on the topic of ADHD, the co-editor of ADDvance, a magazine for women with ADHD, and the co-publisher of Advantage Books, a specialty press that publishes books related to the topic of ADHD. What have been the most important developments in the area of treating Attention Deficit/Hyperactivity Disorder in recent years?

Dr. Nadeau: One of the most critical developments is the recognition of ADHD as a lifespan disorder that significantly affects many adults. The media seem to portray ADHD as a catchall diagnosis for children (especially boys) with conduct issues. In your opinion, is the diagnosis frequently misapplied to boys and not applied enough to girls?

Dr. Nadeau: ADHD may be over-diagnosed among boys in certain circumstances - there are anecdotal stories of classrooms in which nearly half of the boys are diagnosed with ADHD and prescribed Ritalin. It is important to keep this in perspective. A statewide study in Maryland, for example, found that, if anything, ADHD continues to be under-diagnosed - even among boys. Under 3% of children in Maryland are diagnosed with ADHD, while common estimates suggest that at least 5% of the population has ADHD.

Girls are undoubtedly under-diagnosed and misunderstood. Diagnostic criteria that are currently used were developed to identify boys and are largely inappropriate in identifying girls. Also, the diagnosis is now being applied to adults when it was typically considered a disorder of childhood. Can you comment on this?

Dr. Nadeau: In the past five years we have come to recognize that ADHD is NOT a childhood disorder, but a lifelong disorder. Because many women self-refer for assessment for ADHD, we are beginning to gather convincing evidence of its frequency among females. Establishing a therapeutic alliance with a child, adolescent, or adult suffering from Attention Deficit/Hyperactivity Disorder can be clinically challenging. Are there differences in how you approach a child, adolescent, or adult?

Dr. Nadeau: Therapeutic alliances are usually easy to establish with adults. They recognize their difficulties and refer themselves for treatment. At this point they have already accepted that they need help.

Perhaps the most difficult population to work with is the teen with ADHD. Often teenagers resent the nagging and supervision that they need, and they feel infantilized at the same time. It is essential that the teen get to the point of wanting to develop life management skills for his/her own sake and for the sake of the teen's future. Therapy will never work until the young person buys into the process. And, this may not happen until he/she has experienced some pretty distressing failures.

Children with ADHD need help in understanding what their challenges are. Many kids think in simple terms like "I can't pay attention in class." Often they are quite receptive to tips and suggestions, especially when they learn that homework can be completed more quickly and rewards can be earned more frequently once they work to establish better habits and routines. Behavioral programs are often quite helpful with children with ADHD.

For teens, parents and therapists must be very careful to set up incentive programs that don't seem childish or too controlling. Are there differences in how you approach treatment with a girl and a boy?

Dr. Nadeau: One very important area of growing interest is the better identification and treatment of girls with ADHD. Girls are less likely to be referred because they tend to cause fewer problems in the classroom. Their behavior may be misunderstood as immaturity or lack of academic ability rather than as ADHD. Let me give you an example.

Marie (not her real name) had the good fortune of having a mother who was a trained educator and who recognized that ADHD might be a possibility when Marie began to have difficulty in completing class work and homework in the third grade. Her daughter was evaluated by a well-known neuropsychologist who diagnosed her with "mild" ADHD. Her mother was reluctant to try stimulant medication, but worked with her daughter to become more focused on homework in the evenings.

Marie worked hard, but complained of how difficult school remained for her. Even though her mother was aware of the ADHD, they frequently found themselves in arguments if Marie lost her house keys or forgot her jacket at school.

Finally, as Marie's grades took a downturn in her sophomore year in high school, her mother reluctantly decided upon a trial of stimulant medication. Marie's academics took a rapid and marked turnaround. She became a solid, A/B student whereas before she had made Bs and Cs.

Marie's mother regretted that over the years she had denied her daughter access to the full range of treatment. Today, Marie is a successful college student whose creative talents find their expression in her college major of design. There seems to be a growing interest in evidence based clinical practice. Is the field of ADHD research and treatment working to maximize positive clinical outcomes?

Dr. Nadeau: Unfortunately, the majority of funded research is conducted by physicians in medically oriented clinic settings or by educators in classroom settings. To date, there is almost no evidence-based research on treatment outcomes except those focusing on medication. We have yet to truly study the types of psychotherapeutic interventions that are most effective. Does this work account for gender bias in diagnosis and treatment?

Dr. Nadeau: Gender bias is built into research as long as we are reliant upon DSM-IV diagnostic criteria - which have been developed almost exclusively through the study of boys and of those "outlying' girls whose behavior closely resembles boys with ADHD. There is widespread and growing consensus that there is a need for more gender-sensitive norms. Are there gender differences in how ADHD is presented?

Dr. Nadeau: Girls are more likely to be "primarily inattentive" - a category that has been repeatedly shown to be difficult to recognize both by educators and professionals. They are less aggressive, less likely to show conduct disorders, and less likely to show symptoms in early childhood. In fact, at puberty, just as boys' hyperactivity is lessening, many girls show the first marked signs of ADHD. What do you recommend that clinicians do to prevent girls and women from being overlooked diagnostically?

Dr. Nadeau: I have worked with other professionals to develop a self-report questionnaire for girls. The questionnaire is available on our website at ADHD Self-Rating Scale for Girls.

Parents and teachers complete most AD/HD questionnaires. It is important for girls to be allowed to self-report because many of their experiences are difficult to observe externally, but still have a profound impact on them. Any girl who is struggling academically should routinely be given such a self-report form. Overall, do you see any positive trends in the area of treatment outcomes, prevention, and intervention? Is this disorder curable?

Dr. Nadeau: The disorder isn't curable, but it's highly treatable. I see positive developments in many areas. Medications are continuing to be developed that are longer lasting and have fewer side effects. The field of ADD coaching is becoming widely accepted and can be very effective in supporting the individual with ADHD in developing better coping skills. The more the general public is educated regarding this very common disorder, the greater the chance that children can grow up feeling supported rather than criticized and blamed. Are there simple assessment tools you would recommend for use by therapists who are not ADHD specialists?

Dr. Nadeau: There are simple screening instruments that can be used, but if ADHD is suspected, the child or adult should be referred to an expert for a complete assessment. Do you have any tips to offer that might help clinicians for whom ADHD is not an area of clinical specialty?

Dr. Nadeau: Yes, beware of dismissing ADHD symptoms as the result of anxiety and/or depression. Depression often accompanies ADHD, but if there is a lifelong history of disorganization and a family history of disorganization - then ADHD is a strong likelihood along with co-existing conditions. Do you have any resources to recommend?

Dr. Nadeau: There are a range of ADHD websites, but typically I recommend the CHADD site. Parents can be sure to receive accurate information there.

Parents and professionals should be advised that there is a predominance of negative and inaccurate information regarding stimulant medication on the Internet. They should be careful to get their information from qualified sources such as NIMH and CHADD.

I can also recommend the following books.

  • A Comprehensive Guide to ADD in Adults
  • ADD in the Workplace
  • Survival Guide for College Students with ADHD or LD Thank you, Dr. Nadeau, for sharing your expertise with us.

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Page last modified or reviewed on January 27, 2014