Work Text:
Introduction
ADHD is an abbreviation for attention-deficit/hyperactivity disorder which is, according to the American Psychological Association, a behavioural syndrome characterised by the persistent presence of six or more symptoms of inattention or impulsivity/hyperactivity. DSM-5 states these criteria as either inattentive symptoms such as careless mistakes, not listening well, not following instructions, being easily distracted, forgetful in daily activities, or hyperactive symptoms such as fidgeting, running about inappropriately (in adults, restlessness) acting as if “driven by a motor”, interrupting or intruding, incessant talking.
ADHD is stereotypically considered a “childhood” disorder as it typically develops in the preschool years (Nigg, 2006). However, some longitudinal studies, such as Faraone & Biederman, 2005, show that up to 60 percent of adults, who were previously diagnosed with ADHD met DSM criteria even in partial remission. Declining of symptoms with age yet doesn’t demonstrate the absence of any difficulties. According to the results of Barkley, 1990, in adulthood ADHD behaviours manifest from 37.4% to 83.7% of cases, depending on the behaviour. Adults with ADHD may also have problems with employment and change jobs frequently (Mannuzza, Klein, Bonagura, et al., 1991).
The rate of heritability of ADHD is around 74% (Faraone, Larsson, 2019). Also, it is known, that there are some genes can affect the development of the disorder such as ADGRL3, ANKK1, BAIAP2, DAT1, DRD4, LRP5, LRP6, and SNAP25 (Demontis, et al, 2019). Nevertheless, the mechanism of their action remains unclear.
Manifestations of ADHD in every person can differ, however, many researchers pinpoint the high differences between manifestations of ADHD in boys and girls. Girls with ADHD are less likely to exhibit disruptive behaviour in the classroom than boys with ADHD (Abikoff et al., 2002), and overall tend to appear less hyperactive to their teachers (Ohan & Johnston, 2005). Also, girls with ADHD have a 62% rate of peer rejection or neglect compared to 9% for girls without a diagnosis (Gaub & Carlson, 1997). In adulthood, 70.6% of women with ADHD report a history of depression (Biederman et al., 1994).
The cause of the difference in manifestation between the two sexes is undefined, thus, nature vs nurture debates are still intense. The research question of this essay is “Why are girls not recognised with ADHD to the same extent as boys?”. As the aetiology of ADHD still isn’t fully clear to understand the nature of the difference in the manifestation of ADHD both in girls and boys it was decided to explore the factors that may either cause or affect the development of ADHD. Knowledge about the roots of this difference can provide more sufficient guidelines for psychologists and psychiatrists who are helping people with ADHD. Also, the uncovering of the nature of ADHD helps break down the social stigma around the disorder. This essay will argue that the difference in the manifestation of ADHD in both sexes is mainly relying on social factors.
Biological factors:
Morphological differences:
The brains of people having ADHD and those who do not have significant morphological differences. One such difference is the amount of grey matter in the basal ganglia. This can be a reason for behavioural differences between people with and without ADHD.
The study by Nakao et al, 2011, showed the reduction of the grey matter in basal ganglia is linked with age in patients with ADHD. This study was a meta-analysis which analysed 14 studies that investigated the volume of grey matter that was measured by a method of voxel-based morphometry. The sample contained 378 patients with ADHD and 344 healthy subjects. The results showed the correlation between the age of the participants and the percentage of the reduction of grey matter in their basal ganglia. This leads to the conclusion that the volume of the grey matter in this area of the brain affects the development of ADHD. The study also showed the use of stimulant medicine by participants increased the volume of the grey matter in the right caudate. This part of the basal ganglia contains dopamine and noradrenaline channels that in the brain of a person with ADHD are not functioning properly. This leads us to the conclusion that the amount of grey matter in the basal ganglia is responsible not only for the development of ADHD but also for its manifestations. The study doesn’t show a significant difference between the reduction of grey matter in male and female patients which leads to the conclusion that the difference in the manifestation of ADHD in boys and girls isn’t coded morphologically.
The study has multiple strengths. One of them is the size of the sample which is around 700 participants. As the meta-analysis included 14 studies, the sample also included people of different ages and people that use different treatments which makes the sample representative. The study also has high internal validity as it was performed following the meta-analysis guidelines. The study also has high ecological validity as the chosen method wasn’t artificial.
However, this study also has limitations. One of them is a publication bias because the study was analysing other studies and the researchers were free to pick the studies, thus, they could unconsciously look for the demanding characteristics. Also, the sample mainly contained males, thus, the results can be generalised mainly to the male part of the population. Due to this, the fact that the results of this study could explain the difference in cross-sex manifestations is highly questionable.
Genetic differences:
ADHD is considered a neurodevelopmental condition. This means that ADHD is a psychological disorder that influences brain functioning and alters neurological development. Neurodevelopmental conditions often cause difficulties in social, cognitive, and emotional functioning. The researchers study the reasons for such conditions and pay much attention to genetic factors. One type of empirical data that outlines genetic factors is polygenic scores (PGS). PGS represents the total number of genetic variants that an individual has to assess their heritable risk of developing a particular disease.
The study by Riglin et al, 2022 that investigated early manifestations of genetic liability for ADHD, autism, and schizophrenia showed that ADHD PGS are associated with specific temperament scales as well as better gross motor scores. The study used data from the AVON Longitudinal Study of Parents and Children (ALSPAC). As the study concentrated on the genetic factors, women, who gave birth, were analysed as well. The data included motor development scores at age 18 months, and language development and temperament scores at age 24 months. In total 7498 children participated in the study. As a reference for generating and analysing PGS was used Polygenic Risk Score software was, as suggested in Euesden et al., 2015. Motor skills were analysed based on the parental report, which was made in the form of a questionnaire that was adapted from the Denver Developmental Screening Test.
The results showed the association of ADHD PGS with higher gross motor, higher activity and lower withdrawal scores which fits ADHD symptoms, according to APA definition. The results also showed that statistically higher gross motor and lower withdrawal associations were more common in males than females. This may lead to the conclusion that males are more likely to inherit alleles of genes which are linked with the manifestation of ADHD symptoms.
This study for sure has many strengths. One of them is a large sample which allows the study’s findings to be generalised to the population. As the sample contained only European individuals, we can argue that all children were raised in similar cultures, thus, there were no cultural features that could affect the final result. Also, the findings clearly show the correlation between PGS and manifestations of neurodevelopmental conditions. Another strength is the researchers took into account different scales that measure the expression of the studied conditions. The way how the empirical data is obtained and converted also gives this study higher internal validity. As children were raised in a fully natural environment we can also argue that this study has high ecological validity.
Yet, it also has limitations. All information about children’s behaviour was provided by parents, we cannot say that it is completely unbiased. As all families came from different environments, we cannot say that all that parents said met the reality. Here a huge role could play the participant bias as well as sampling bias - the sample wasn’t random, thus, the researcher could deliberately look for certain demanding characteristics. The natural environment also means that there could be other factors that affect children's behaviour, and so the behaviour could not only be the consequence of genetic liability.
Social conditions:
Gender socialisation and ADHD:
APA dictionary defines gender-role socialisation as the conditioning of individuals to the roles, expectations, and behaviours that society prescribes for males and females. The product of gender role-socialisation is gender stereotypes about both sexes. One such stereotype is the stereotype that girls should be well-behaved whereas boys are expected to act out.
According to Martin and Halverson, 1981, children around the age of 3, can label themselves as males or females. This is the same age when ADHD usually manifests itself. Based on these facts we can assume that the behaviour that girls with ADHD usually express is the product of their gender socialisation.
The study that was conducted by J.A. Grskovic and S.S. Zentall in 2010 had the purpose to identify the hyperactive, impulsive, social, and emotional characteristics of girls with ADHD. The researchers identified the problem of recognition of ADHD in girls as a setting- They assumed that girls’ ADHD is rarely recognised by teachers as girls tend to behave less actively than boys overall.
The focus group was adult women with ADHD (age range from 27 to 57, mean = 36 years). The participants also were 262 girls that were recruited from five school districts, who were diagnosed with ADHD, had learning disabilities or had no diagnoses at all, and their parents and teachers. The researchers created a questionnaire based on the list of descriptors of the hyperactive and impulsive behaviours of girls with ADHD that was based on Arnold, 1996, adding the items to make it sensitive to females. This list included 44 behaviours and was also divided into 5 categories – activity style, talking style, social style, attentional style, and emotional style. All the participants were given this list where they had to mark each of the behaviours either as almost never, sometimes, often, most of the times, or almost always based on how applicable are these statements to them or their daughters/pupils. The women, parents, teachers, and girls had also completed another questionnaire from 24 items – ADD-H Comprehensive Teacher’s Rating Scale (ACTeRS) (Ullmann, Sleator & Sprague, 1991) which were closely reflecting the concepts provided in DSM-IV-TR (APA, 2000). For the follow-up comparison was used data about the girls’ IQ and their grades in maths and reading.
The results have shown that parents were able to assign 79% of girls to the ADHD group right. The results also illustrated that based on the social factor, parents were able to identify 35% of girls as ones that are having ADHD compared to the teachers, who were able to identify only 23%. There weren’t any differences in age, grade, number of siblings, parents’ marital status, occupation, or income, which allows us to say that they can be generalised to the whole population. The study also has shown the differences in ethnicity, as the Comparison group mainly contained white non-Hispanic girls. That could be caused by the level of individualism in each of the cultures.
The study has multiple strengths. One of them is that the researchers modified the supply material (questionnaire) to adapt it to girls which raise the study’s internal validity. The study was made in a fully natural environment which makes it highly ecologically valid. Also, this study has high cross-cultural validity as participants came from different cultures and had different ethnicities.
However, it’s not perfect, as all studies are. One of the major limitations is the method chosen – as researchers very much relied on the results of self-report questionnaires, the result may not fully illustrate the reality. Also, the level of awareness about ADHD and its stigma among teachers is unknown, therefore, the results cannot be generalised to the whole population. This moreover questions the study’s replicability in slightly different circumstances (for example, in the neighbouring town).
To sum up we can, nevertheless, conclude that gender socialisation as a social factor for sure plays a vital role in the way girls with ADHD are perceived in society and why are they less recognisable.
Cultural norms and ADHD:
APA defines culture as “the characteristic attitudes and behaviours of a particular group within society, such as a profession, social class, or age group.” Each of the cultures can be characterised by Hofstede scales which include individualism, masculinity, power distance, indulgence, long-term orientation and uncertainty avoidance. The perception of people having ADHD, especially girls and women, as any notion or phenomenon will differ depending on the culture of every country, as individualistic and collectivistic cultures adopt different guidelines in their upbringing (Keller, 2010). In collectivistic cultures, unity with a community is highly appreciated, and the level of conformity is usually higher (Asch, 1955), which can also affect the average behaviour of women in this culture.
The study by Klint Carlander, et al, 2022 was investigating the way how young women with ADHD are treated in Swedish Clinics. In the very introduction, the researchers highlighted the fact that they consider women with ADHD to be more vulnerable to sexual exploitation and victimization as they perform risky sexual behavior, and also state that “Due to gender differences in ADHD presentation and symptoms, women are less often referred for diagnostic assessment and treatment than males. “ (p.1). The participants were patients from all of the clinics in Stockholm and Uppsala who were able to speak Swedish. The method of investigation was a semi-structured interview. The interview was built around six themes: background information; prevalence, treatment and care of young women with ADHD; knowledge of sexual risk behavior, mental illness, alcohol and drug use among girls and young women with ADHD; effects of hormonal contraception among
young women with ADHD; current routines/efforts for young women
with ADHD; individual and organisational readiness for change and
development of the current standard of care. During the interview, the participants were asked to reflect and elaborate on their attitudes and thoughts around central topics. All interviews were conducted online via Zoom © and Microsoft Teams ©.
In the results of the study all of the participants reported that regardless of their character, shyness or talkative, they had difficulties in communication with midwives. Midwives, in their turn, reported that for them it was hard to determine if the information given was perceived as adequate. Even though the medical staff was generally aware of the link between ADHD and risky sexual behaviour, they were to some extent viewed as loud and edgy.
The study has many strengths, for example, its sample size which allows it to generalise results to at least one generation of girls with ADHD. Another strength is the high ecological validity as, disregarding the fact that all of the participants were from hospitals, they provided information concerning their life and behaviour which couldn’t be affected by the fact that they took part in the study. Also, due to the structure of the interview participants, as the representatives of a specific social group, were able to bring up theses that researchers, as people from outside, could never think of.
This study also had limitations, such as the method chosen. As it was a semi-structured interview the results lack empirical evidence which makes it difficult to compare the results in case of further replication. Another limitation is the fact that interview was conducted only with girls who knew Swedish as this takes into account most immigrants and non-white girls who could be treated worse due to their ethnicity. Also, due to this circumstance, we cannot trace if there are any ethnical and cross-cultural differences in the manifestation of ADHD as it was shown in Grskovic and Zentall, 2010.
Based on the research above, we can see that even in an individualistic culture, such as Swedish, the manifestations of ADHD are characterised as negative traits, which keeps the stigma around the disorder and therefore raises the level of women's conformity.
Discussion:
Both biological and social-oriented studies provide the basis that allows us to consider that there is surely a difference between the manifestation of symptoms of ADHD in boys and girls. This, however, doesn’t state the reason why it appears in that way. Are the symptoms themselves different due to the biological features of both sexes or the symptoms are less expressed due to different social norms?
As ADHD is a neurodevelopmental condition we can argue that biological factors play a huge role in the formation of the disorder. It was found out that one of the parts of the brain which indicates the development and manifestations of the disorder is basal ganglia; the patients with ADHD have reduced volume of grey matter in that part of the brain. However, the morphological difference between males and females isn’t that huge to become a reason for different manifestations of one disorder among different sexes. Nevertheless, there is a correlation between different expressions of ADHD in boys and girls and alleles of genes coding ADHD behaviours that males are more likely to inherit.
All studies that supported the biological factors as the forming ones were meta-analyses of multiple studies which gives them a larger sample size as well lower external validity due to the publication bias. Nevertheless, as the studies themselves weren’t artificial, the results can be considered ecologically valid to a very huge extent. In addition, these meta-analyses were investigating the studies that used quantitative methods, such as brain scans in the case of Nakao, et al, 2011, and a twin study in the case of Riglin, et al, 2022. This provides evidence with empirical data since the values that the studies are investigating can be measured. Therefore we can argue that the evidence that is provided by the results has high reliability and is also easy to replicate. Nevertheless, these studies also didn’t concentrate only on girls which on the other hand minimises the fact that during the choosing of the sample the researchers looked for demanded characteristics, particularly in girls, however, this also makes the results less generalisable for girls than it is for boys. Thus, we can argue that the basis of biological factors is not investigated enough to conclude that in this case nature plays the major role.
The studies illustrating the impact of social factors clearly showed the role gender socialisation is playing in the manifestation of ADHD in general disregarding the fact of how socially acceptable these expressions appear. Grskovic and Zentall, 2010, clearly illustrate the fact that girls usually tend to mask their ADHD manifestations in public more than they do at home. Klint Carlander, et al, 2022, also highlights the fact that girls with highly expressed ADHD are considered as loud and edgy, which for sure can affect the general women’s intention to be confirmative and therefore hide their “cumbersome” symptoms.
Studies that were used as an argument for social origins in different cross-sexual manifestations of ADHD adapted qualitative methods such as questionnaires (Grskovic and Zentall, 2010) and semi-structured interviews (Klint Carlander, et al, 2022). These methods usually lack empirical evidence, however, in Grskovic and Zentall, 2010 this problem was solved by giving the participants' experiences a rank according to the scale (almost never, sometimes, often, most of the times, almost always). Since such a type of study requires direct interaction between the researcher and the participant, the participant's bias here could affect the result to a very large extent. However, in Grskovic and Zentall, 2010 the publication bias that appears in both studies, supporting the biological factor argument is nearly zero. Both biological and social factor studies had great internal validity as the studies were performed very consistently. Both biological and social factor studies had nearly the same high ecological validity, yet half of them (Riglin, 2022, & Klint Carlander, et al, 2022) lacked cross-cultural validity.
Compared to the studies that supported the biological factor argument and were studying both sexes, studies supporting the social factor argument were more concentrated on studying women in particular. On the one hand, due to this, the correlation between the variables can be seen and the difference between the girls' and the boys' performance cannot be rejected as statistically insignificant. On the other hand, this cannot spot the difference in performance between both sexes as there’s no variable to compare with (if we’re not taking into account the outer sources, such as other studies). Yet this allows us to generalise the results to the whole girls’ population which provides at least some information about the way how every factor affects not only the people with ADHD in general but females with ADHD in particular.
Conclusion:
In conclusion, the evidence that supports the impact of social factors as forming ones seems to be more consistent than the evidence that supports biological factors. All the results of the studies state that girls with ADHD usually appear as less active independent of their age, ethnicity, the environment they are coming from and other factors. This statement is proved by the girls themselves, their parents, and their teachers. The huge amount of diagnostic guidelines relies on the repeated facts of the manifestation of hyperactivity which contradicts the behaviour that society demands from girls. Thus, it can be stated that girls often stay undiagnosed as their symptoms are often less noticeable. Thus, it can be argued that girls suppress their symptoms to appear more gentle and polite. This happens to disregard the culture, as this confirms by both studies that investigate only one culture and studies that didn’t divide samples based on this criteria.
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