We investigated here family and developmental history in matched pairs of female adolescents with ADHD compared to male adolescents with ADHD. Remarkably, there is a large overlap in family and developmental history among female and male adolescents with ADHD. There were only few gender differences between both groups with ADHD, most of them appearing not to be related to the disorder, but to neurotypical development.
Overlap between genders in family and developmental history
Family history is important for the diagnostic process of ADHD as it reveals information about the burden of mental disorders and other diseases in the family, conflicts and relationships in the family and socioeconomic background. Developmental history reveals information about the development of psychopathological markers and finally symptoms of ADHD. In our previous study of family and developmental history, female adolescents with ADHD were compared to male adolescents without psychiatric diagnosis (Waltereit et al., 2019). In our previous study we found for female adolescents with ADHD a profile of family and developmental history significantly differing from male adolescents without psychiatric diagnosis. As we found here only few differences between female and male adolescents, the first main conclusion of this study is that family and developmental history in adolescents with ADHD, as remembered by their parents, is only little influenced by gender. In turn, the picture of female adolescents with ADHD is very typical for the disorder.
The disorder-specific overlap between genders is on first glance surprising, because the current scientific view emphasizes the importance to study and to take gender issues into account, in particular here in mental healthcare of children and adolescents (Blakemore et al., 2009; Endendijk et al., 2018; Young, Adamo, Ásgeirsdóttir, Branney, Beckett, Colley, Cubbin, Deeley, Farrag, Gudjonsson, & Hill, 2020). However, it is also an important finding if gender does not cause relevant differences, here in family and developmental history of adolescents with ADHD.
Gender differences in our sample
There were, however, a couple of gender differences in our findings. For mothers of females with ADHD, more dysfunctional interaction in the mother’s family was reported (Fig. 1B). This has not been described in the literature so far. It may be speculated that dysfunctional family relationships could be better remembered or recognized in the context of females. Gender effects could be recognized in our sample for females as having less adult caregivers than males (Fig. 2B). For female adolescents with ADHD it is described to form damaging peer relationships, for example joining an antisocial peer group or engaging in risky sexual practices and partners instead of forming potentially protective relationships to caregivers like teachers (Young et al., 2020). In medical history, we found females receiving specific medication for ADHD less often than males (Fig. 2C), in line with the literature (Dalsgaard et al., 2014). Pharmacological treatment is associated with improved psychosocial long-term outcomes (Biederman et al., 2009; Halmøy et al., 2009; Kim et al., 2011). Less stimulant treatment in females could be the result of better masking behavior and better social compliance in females (Young et al., 2020) as well as a different symptom perception in parents and teachers when viewing females with ADHD in comparison to males with ADHD (Du Rietz et al., 2016; Quinn & Madhoo, 2014). Better social compliance may result in an underdiagnosis in females with ADHD. In addition, in clinical settings medication was less often considered as a treatment strategy for females even with a diagnosis of ADHD (Quinn & Madhoo, 2014; van Lieshout et al., 2016).
Lower Apgar scores were reported in our sample for males with ADHD (Table 2C). Between Apgar scores and the diagnosis of ADHD no correlation was described in the literature (Silva et al., 2014). By contrast, lower Apgar scores were described for male full-term neonates (Nagy et al., 2009). For mothers of females with ADHD, less social support during pregnancy was remembered compared to mothers of males with ADHD (Fig. 3A). Less social support is part of long-term stressful life events during pregnancy. The literature on this specific issue is scarce. Prenatal stress of the mother seems however to be more harmful for males than for females (Thibaut, 2016). Mothers of females with ADHD in our sample reported less frequent and less prolonged crying behavior during the first year of their child’s life than mothers of males with ADHD (Fig. 3D). ADHD symptoms in children younger than three years have only been sparsely investigated. Increased irritability and increased crying behavior in males or mixed samples with ADHD were reported by mothers in the first year of life of their babies (Bilgin et al., 2020; Hemmi et al., 2011). Gender differences are, to our knowledge, not investigated.
For middle childhood, parents reported more impaired fine motor skills for males with ADHD during preschool and primary school ages (Fig. 4A, Fig. 4C). Female gender is in typically developing children associated with earlier accomplishment of fine motor items (Comuk-Balci et al., 2016). Thus, the finding appears more likely associated with gender and not with ADHD. In comparison to males with ADHD, females with ADHD were reported to have substantially less difficulties with teachers after a school change (Fig. 4B). In contrast, difficulties with concentration of females with ADHD stayed at a consistently high level after changing school (Fig. 4C). However, these data must be interpreted with caution because the number of patients changing school was low (for both females and males 28,3.%, see Table 2E). Nevertheless, interesting tendencies can be seen: while these findings may fit into the social stereotypes of the “externalizing and disruptive boy” and “the dreamy girl who doesn't take medications for ADHD” (Young et al., 2020). Parents reported poorer calculation skills for females with ADHD (Fig. 4E). Males usually are outperforming females in most mathematic competencies. (Winkelmann et al., 2008). Thus, this finding appears related to gender and not to ADHD.
As we have discussed above, we found in our sample a great overlap between females and males with ADHD and only a couple of differences. As we did not correct here for multiple comparisons – in order not to mask remaining differences, besides the main finding of great overlap in the data set – most of these few differences could disappear when applying alpha correction. Irrespective of these considerations, the differences appear more likely to be related to gender and not to reflect a mechanism of ADHD itself.
Gender-sensitive implications for clinical practice
For family and developmental history, we found in our sample an overlap between females and males in the disorder-specific clinical presentation of parentally reported concerns, observations and experiences with their children with ADHD. Our findings support the recommendation that the disorder-specific therapeutical approach should be for females with ADHD similar to males with ADHD (Rucklidge, 2008, 2010), notably therapeutic decisions related to medication in females.
Despite the overall impression of great overlap, we still found a couple of gender differences in our sample, especially gender differences in mathematical competencies and fine motor skills are well-known (Comuk-Balci et al., 2016; Dalsgaard et al., 2014; Winkelmann et al., 2008) and should be considered by the clinician. Therapeutic strategies to improve the individual achievement profile of children and adolescents with ADHD should be developed in a gender-sensitive manner. Other gender differences like less support of female adolescents by adult caregivers, possible transgenerational female stereotypes and gender differences after school changes may be considered by the clinician as well and could be novel questions to be addressed by future research. Taken together, a gender-sensitive view in clinical practice is needed to improve the long-term outcome and the psychosocial wellbeing of both females and males with ADHD.
Limitations of our study are non-blinded student interviewers, localized samples and a limited number of participants. Our study was an exploratory study and equipped with limited resources. However, our study is to our knowledge the first one to investigate gender differences in family and developmental history in ADHD. In addition, the differences found in our exploratory study could establish novel questions for future research.