Childhood ADHD in Girls Tied To Poorer Adult Outcomes

Attention-deficit/hyperactivity disorder (ADHD) continues to be misunderstood as mainly a male childhood condition, yet increasing evidence reveals it persists more often into adulthood than previously thought and manifests distinctly in girls and women.

Compared to males, females with ADHD tend to display less outward hyperactivity and more inward symptoms of inattention and disorganization.

Girls with ADHD may have a high risk for internalizing problems like anxiety or depression and exhibit self-injury more frequently.

Impacted developmentally by ADHD in key areas like relationships and self-efficacy, females also face particular barriers regarding diagnosis and treatment.

Yet the long-term outcomes for women who exhibited ADHD symptoms in girlhood have rarely been investigated.

Owens, E. B., Zalecki, C., Gillette, P., & Hinshaw, S. P. (2017). Girls with childhood ADHD as adults: Cross-domain outcomes by diagnostic persistence. Journal of Consulting and Clinical Psychology, 85(7), 723–736. https://doi.org/10.1037/ccp0000217 

Key Points

• Girls with childhood ADHD, whether it persisted into adulthood or not, showed lower educational attainment, higher BMI, and a much greater likelihood of at least one unplanned pregnancy in adulthood compared to girls without childhood ADHD.
• Girls with childhood ADHD that persisted into adulthood demonstrated additional detrimental outcomes in many domains, including higher rates of internalizing and externalizing disorders, self-injury, occupational impairment, social problems, and overall complications.
• Over two-thirds (74%) of girls with childhood ADHD continued to meet diagnostic criteria in adulthood, underscoring childhood ADHD as a serious, long-term disorder when it persists.
• Childhood-limited ADHD in girls did not predict poor adult outcomes in most domains, except for educational underachievement, elevated BMI, and increased risk of unplanned pregnancy.
• In this all-female sample, ADHD was not associated with objective employment measures, substance use, or driving outcomes in adulthood.

Rationale

Attention-deficit/hyperactivity disorder (ADHD) is increasingly recognized as a lifelong neurodevelopmental condition rather than just a childhood disorder.

Yet the majority of long-term follow-up studies have focused almost exclusively on males (Biederman et al., 2010).

Compared to boys, girls show a different developmental course of ADHD (Owens, Cardoos, & Hinshaw, 2015) and gender-specific outcomes in other domains like internalizing disorders or self-injury (Hinshaw & Kranz, 2009).

Understanding adult outcomes, specifically among females with childhood ADHD, is imperative.

Method

This study followed 140 girls rigorously diagnosed with ADHD in childhood and 88 matched comparisons over 16 years.

ADHD diagnosis and symptom counts were determined through structured interviews and validated rating scales. At the final follow-up around age 25, the researchers obtained self-, parent-, and/or clinician-reports assessing functioning in 10 outcome domains.

Sample

The sample of girls with (n = 140) and without (n = 88) childhood ADHD did not differ significantly on age or other demographics except for slightly higher IQ scores among comparisons. Retention through the final wave was over 92%.

Statistical Analysis

Analyses examined group differences in adult outcomes based on childhood diagnostic status (ADHD vs. non-ADHD) and symptom trajectory (desisters, persisters, partial persisters).

The significance level was set to .001 for omnibus tests, and false discovery rate correction was applied within domains for post-hoc tests to minimize Type I error inflation. Effect sizes were computed for all contrasts.

Results

Girls with persistent childhood ADHD showed the worst functioning across almost all domains except substance use and driving outcomes.

These differences were statistically significant and typically large, with effect sizes ranging from about .6 to 1.5 standard deviations worse than comparisons.

Girls with partial symptom persistence showed moderately impaired functioning in some domains relative to comparisons.

Girls with childhood ADHD that fully remitted (“desisters”) did not differ significantly from comparisons on most adult outcomes but did show medium-sized deficits in educational achievement (ds = -.59 to -1.18) and health domains (ds = .49 to .59).

Insight

This study indicates childhood ADHD in females poses a long-term risk for impairments in multiple domains of functioning if it persists but shows specificity regarding poor adult outcomes when it remits after childhood.

It also reveals ongoing ADHD symptoms are responsible for additional adult problems beyond the residual effects of childhood ADHD alone.

Strengths

• The 16-year prospective follow-up from childhood to adulthood allows strong causal inferences regarding the developmental impact of childhood ADHD over time.
• Using rigorous diagnostic criteria during childhood, including structured clinical interviews, ensures an accurate ADHD sample and strengthens the baseline data.
• Gathering data from multiple informants (self, parent, clinician) provides a comprehensive, multi-perspective view of functioning across domains in adulthood.
• The statistical analysis applied very strict significant thresholds (p < .001) and false discovery rate correction within domains to minimize Type I errors from multiple tests. This enhances confidence in the reported group differences.
• Reporting effect sizes for all group contrasts, regardless of statistical significance, provides a standardized metric of the magnitude of group differences in outcomes. This allows stronger interpretations.

Limitations

• The sample, while diverse, was drawn from a specific geographic region and included community referrals. It may not generalize fully to nationwide or purely clinic-based populations.
• As a prospective correlational study, it cannot determine causality or clarify mechanisms linking childhood ADHD to adult outcomes. Experimental or time-series designs could better evaluate causal hypotheses in the future.
• Factors predicting remittance versus persistence of ADHD over time were not assessed. Incorporating predictors would allow stronger explanatory models of outcomes.
• There could be biases from self-selection effects despite the very high retention rate through adulthood (over 92% retained). Comparison of retained versus lost participants on baseline measures provides some information about biases.

Implications

• Females with persistent ADHD symptoms in adulthood, stemming from childhood ADHD, represent an at-risk group in need of continued monitoring and evidence-based treatment across the lifespan to address difficulties. Remitted ADHD is associated with more circumscribed risks.
• The education system (primary through postsecondary) requires better support for girls with ADHD, given their continued underachievement into adulthood. Accommodations and access to care must also improve.
• Outreach regarding family planning and healthy weight maintenance is vital for females even when childhood ADHD remits due to increased risk of unplanned pregnancy and obesity persisting in adulthood.
• Researchers and clinicians should forge interdisciplinary collaborations and pursue a developmental life course approach focusing specifically on females to elucidate predictive factors and mechanisms that explain poor outcomes associated with childhood ADHD persisting into the adult years. Policy and practice recommendations could then follow.

Conclusions

Persistent ADHD symptoms in girls pose a significant risk for wide-ranging difficulties by early adulthood.

Remitted childhood ADHD predicts more circumscribed adverse outcomes.

Further research should identify predictors of remittance versus persistence of ADHD in girls and clarify mechanisms linking childhood ADHD to long-term difficulties.

Overall, this study highlights that ADHD in girls, especially when it continues past childhood, has profound effects across multiple domains and developmental stages.

References

Biederman, J., Petty, C. R., Monuteaux, M. C., Fried, R., Byrne, D., Mirto, T., . . . Faraone, S. V. (2010). Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. The American Journal of Psychiatry, 167, 409–417. http://dx.doi.org/10.1176/appi.ajp.2009.09050736

Hinshaw, S. P., & Kranz, R. (2009). The triple bind: Saving our teenage girls from today’s pressures. New York, NY: Ballantine Books.

Owens, E., B., Cardoos, S. L., & Hinsahw, S. P. (2015). Developmental progression and gender differences among individuals with ADHD. In R. A. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th Edition (pp. 223- 255). New York: The Guilford Press.

Learning check

1. How might cultural assumptions about gender influence the diagnosis and treatment of ADHD in girls versus boys? What biases might this introduce?
2. What role might ADHD symptoms play in the higher rates of anxiety, depression, and self-injury seen in adolescent and adult women? How might treatment approaches address this?
3. If ADHD is conceptualized as a developmental disorder, what changes across the lifespan should we expect in symptom presentation and needed supports? How might treatment plans incorporate this developmental lens?
4. What barriers exist in our education, health care, and social support systems that make it difficult for girls and women with ADHD to thrive? How might systems be altered to better serve their needs developmentally?
5. In what ways might girls with persistent ADHD symptoms “fall through the cracks” developmentally compared to boys? What unique risks do you think girls with ongoing ADHD may face across stages like puberty, high school and college, early career, relationships and family formation, midlife, and aging?