Why are boys three to four times more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than girls, when studies have repeatedly shown that girls are just as likely to have it? According to psychiatrist Dr. Doron Almagor, this may be due to how it manifests differently in girls than it does in boys.
Almagor treats ADHD throughout the lifespan. He is also the president of the Canadian ADHD Resource Alliance (CADDRA), which is a Canadian body of physicians that sets the standards for treatment of ADHD in the country.
Originally from Israel, Almagor moved to Canada with his parents when he was 10 years old. During his training in child and adolescent psychiatry, Almagor became exposed to kids with ADHD.
“I found out, as I did my practice, that there was a really wide need for it,” he said. “It’s a very underserviced, under-recognized, underappreciated area within the Canadian health-care system and worldwide as well. I could see changes happening very quickly for people who may have been suffering for years and were then able to turn their lives around. So, that is something I became more involved in.
“I then became more involved with education over the years and really tried to promote the message that it’s something that’s under-recognized and easily addressed. Compared to other treatments in psychiatry, it tends to be much more effective, but underappreciated for being so.”
According to Almagor, one of the myths is that ADHD kids are hyperactive. The reality is that there are different types of ADHD, some of which have no hyperactivity associated with them at all. These used to be referred to as ADD (attention deficit disorder).
“When people hear ADHD, they may not identify themselves as having it or their children or family as having it, because they think hyperactivity has to be there,” said Almagor. “But, there are types of ADHD with no hyperactivity – that’s a more silent type and even more underappreciated.
“The problem with ADHD and all types of ADHD is that they’re defined by symptoms with attention, focus, and with the hyperactive-type problems, with hyperactivity and impulsivity. But these aren’t the real issues ADHD causes. The real issues are things like school failure, low self-esteem, social problems – things that evolve into other issues like depression and anxiety. It’s really the secondary effects of ADHD that are the real problems, rather than the pure attention or hyperactivity issues.
“If a child has ADHD and that causes self-esteem issues, they can’t focus, keep up with their peers, [they] have teachers who are negative about them, and people may say that they’re just being lazy and making careless mistakes. That’s going to be internalized into the child’s character. That will be part of their image of themselves. That’s going to affect how they relate to the rest of the world…. That’s going to be harder to fix as they get older. The earlier it can be addressed, the better.”
Learning disabilities often go together with ADHD. According to Almagor, when someone has been diagnosed with a learning disability, they should also be screened for ADHD, as 50% of those with a learning disability also have ADHD and vice versa.
If a parent is concerned about their child, his or her teachers are in a very good position to be able to gauge where the child is at, as they see them in a context of 30 other kids their age, he said.
“Often, parents may have a 7-year-old who can’t focus, but they may not know if that is the same as or similar to other 7-year-olds. Teachers are always consulted before making a diagnosis.
“Another good first step,” he continued, “is the child’s pediatrician, as many pediatricians are trained in the diagnosis and recognition of ADHD. Pediatricians may be able to diagnose it themselves or may have consultants they rely on, whether that is a child psychiatrist or specialist pediatricians (developmental pediatricians).”
Further testing may be needed to confirm an initial diagnosis, but this testing is covered by the public health-care system when prescribed by the child’s doctor. Psychiatric treatments may not be covered.
Another common misconception concerning ADHD is that medication is the only option, yet, that is only one of the potential treatments.
“Parents need to make sure the pediatrician is open and knowledgeable about ADHD,” said Almagor. “There are still some who don’t believe there is such a thing as ADHD or they’ll do a very quick assessment ruling ADHD out too soon without a full assessment.”
One of CADDRA’s missions is to educate physicians in making proper diagnoses, and providing proper treatment or referring people to the appropriate resources and experts.
CADDRA’s website provides a list of symptoms that people can access that might be helpful in trying to determine if you have a child with ADHD, but Almagor cautioned that these are all just initial screening tools that can only give an indication that further trained assessment may be needed.
“We can’t expect a 10-year-old to focus as well as a 19-year-old,” said Almagor. “Besides initial symptoms, like trouble focusing, secondary symptoms can include being very hesitant about being in school, being withdrawn about school and having low self-esteem about their abilities. These types of things are softer. They’d be good alerts that the child needs further assessment. Being behind in school is another one. But, it might not be ADHD. It might be a learning disability or something else, like depression.
“Girls tend to have the more silent type of ADHD – the inattentive type – so, not as visible. Inattention is internal – hesitancy, being withdrawn and being unsure of their abilities. These are often missed and that’s why girls are only diagnosed later in life.
“Often, when mothers bring in their daughters for assessment, they read about the diagnoses and they self-identify. I see a parent who will say, ‘Now that I’ve learned more about ADHD, my child has it and I realize I have it, too.’ It’s common as well because ADHD is about 80% genetic. So, often when there’s a child that has ADHD, one of the parents has it, too.
“I always ask and try to determine who else in the family might have ADHD and maybe encourage that they also seek out treatment, too. It’s important, as, if a parent is having ADHD symptoms themselves, it may make it harder for them to parent effectively and may make the child’s ADHD worse.
“Even when girls are hyperactive,” he continued, “they’re still often under-treated. They tend to be chatty girls in class and can’t sit still. Recent research from Denmark is showing that girls with ADHD have higher rates of effects of it than boys. So, they have higher rates of drug use and higher death rates, which may be because they’re not being treated.”
In early childhood, boys diagnosed with ADHD outnumber girls four to one, but the number of adult men and women are about equal. Overall, the number of people with ADHD has been steady for the past 30 years, according to Almagor, at around five percent. And, although Almagor said he sees many Jewish patients, he does not attribute this to there being higher percentages of Jews with ADHD as compared to the general population. Rather, he feels Jewish parents’ attentiveness to what is going on may be the cause of them bringing their kids in more often for treatment.
The way in which the condition and its treatment are perceived by the public, said Almagor, is one of the main problems, and it is a problem that may be causing harm to kids.
“I think people avoid treatment or avoid addressing it because of stigma, or they think the only option is medication,” he said. “They need to be aware that treatment for ADHD is what we call ‘integrated.’ We look at psychotherapy as well as medication choices. It can also be addressed without medication, which is often very helpful for the long-term well being of the child.”
Psychotherapy treatments may include a focus around self-regulation in cases with hyperactivity and impulsivity, or being able to learn to think before acting via exercises that include mindfulness and other ways to help children control their impulses. Other treatments for ADHD can include helping with executive functioning to improve organization, focus and the sequencing of tasks. For more information, visit caddra.ca.
Rebeca Kuropatwa is a Winnipeg freelance writer.
