Clinician Gender Bias and Attention Deficit Hyperactivity Disorder Diagnosis
Young 16-year-old Molly sits in her chemistry class, surrounded by her peers, yet feels utterly alone. Molly’s peers joke with the teacher and each other, shout out answers to organic equations, and receive excellent grades on all assignments. She, meanwhile, sits in silence, embarrassed that she cannot shout out correct answers, and makes an attempt to understand the instructions on the worksheet the instructor handed her almost twenty minutes ago. Molly is constantly distracted by the people walking past the classroom and by the chaos happening within her own room. She dazes off for a few minutes thinking about the conversation she had with her parents before leaving for school this morning about how they are disgusted by the organization of her room. Molly looks over to the boy next to her, Jason, who is constantly jumping out of his seat, obsessively talking, and obnoxiously shouting out correct answers before anyone else has an opportunity to respond. Jason had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) two years prior and has been making significant progress with the aid of medication and therapy. It is possible that both Jason and Molly are suffering from ADHD; however, clinician gender bias may be the reason that Molly has yet to be diagnosed or receive the assistance she needs to reach her full potential.
The current ADHD criterion identified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition revised (DSM-IV-TR) is focused on identifying behaviors of hyperactivity/impulsivity and inattention. The DSM-IV-TR identifies three subtypes of ADHD; these are Attention Deficit Hyperactivity Disorder, predominately hyperactive/impulsive type (ADHD-HI); Attention Deficit Hyperactivity Disorder, predominately inattentive type (ADHD-IA); and Attention Deficit Hyperactivity Disorder, combined type (ADHD-C). Also, the DSM-IV-TR reports that more instances of ADHD occur in males than in females, resulting in a male-to-female ratio of approximately 2:1 to 9:1, varying based on subtype and environment. However, it is important to note that the majority of early ADHD research conducted used only male participants. It is therefore speculated that significant gender differences may exist in the symptomatic expression of ADHD.
To further investigate into these gender differences, Biederman, J., Mick, E., Faraone, S.V., Braaten, E., Doyle, A., Spencer, T., et al. conducted a study examining the significance of gender in the clinical features of ADHD in children and adolescents aged 6–17 years (2002). The study consisted of four different groups of participants. The classification was as follows: 140 boys with ADHD, 140 girls with ADHD, 120 boys without ADHD, and 122 girls without ADHD. The participants were evaluated with diagnostic interviews and assessments of their emotional, school, intellectual, interpersonal, and family functioning. The researchers also conducted a series of neuropsychological tests to screen for the subtypes of ADHD. Aside from this, the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version (K-SADS-E) was also used as a psychiatric assessment tool. A team of three psychiatrists was also employed to clarify any diagnostic uncertainties by listening to the recorded interviews. The interviewers and doctors were both blind to the subjects’ diagnoses and background information.
The results of Biederman’s study did not show statistically significant evidence indicating gender differences in ADHD symptom presentation. However, girls were more frequently diagnosed with the inattentive subtype of ADHD and the age of onset was statistically higher in girls than in boys, with p=.003. Also, there was a notable difference in the treatment prescribed to boys versus girls. Increased rates of psychotherapy and medication were seen in males (p=.02 for both interactions). Furthermore, girls with ADHD were found to have a significantly higher risk of developing comorbid substance abuse disorders than were boys (odds ratio=.05). In conclusion, the findings from this study did not suggest any gender differences in ADHD symptom expression; the data, however, did highlight evidence of gender bias among clinicians in the diagnosis and treatment of children with ADHD.
Biederman, Kwan, Aleardi, Chouinard, Marino and Cole et al also continued their research on ADHD to investigate a theory suggested by Guab and Carlson (2005). These researchers examined whether gender differences in the phenotypic expression of ADHD caused an increase in the boys’ referral rate. Biederman et al consequently conducted a study on the siblings of the subjects referred in the previously mentioned research. The purpose of this study was to assess for gender differences in individuals with and without ADHD, in a population that was not referred for treatment.
The same four populations were arranged in conducting the study with the siblings. Of the 577 subjects, there were 25 ADHD females, 235 non-ADHD females, 73 ADHD males, and 244 non-ADHD males. There were also no statistically significant interactions found among the populations for age, socioeconomic status, substance use disorders, and intactness of family. Most importantly, there were no statistically significant differences found for any variables between ADHD females and ADHD males. The data collected in this study demonstrated that characteristics such as age of onset, impairment level, age at first treatment, comorbidity, academic ability, and family history were evenly dispersed throughout both genders. Biederman et al. therefore proposed that ADHD is similarly expressed in both genders and that any gender differences expressed may be representative of referral bias.
Waschbusch and King conducted a separate study to investigate whether teachers and mothers would demonstrate gender bias if instructed to make same and opposite sex comparisons while determining if a referral was necessary (2006). The results of the study showed that even when mother and teachers were instructed to use gender as a reference when assessing symptoms, boys continued to have a higher ADHD prevalence rate. Waschbusch and King suggested that this difference may be the result of boys having a variance in symptomatology than girls. It was also proposed that a lower threshold is necessary to identify DSM symptoms in girls. In conclusion, Waschbusch and King suggested that females exhibit more covert symptoms as opposed to males who demonstrate overt types of symptoms. Females, for example, had a higher instance of attention, mood, and anxiety tribulations, whereas males may fight and have higher impairment in information processing and moral reasoning.
Based on the researches presented above, it is therefore suggested that there are no significant differences in gender expression of ADHD. Despite these insignificant findings, however, the research indicated that females may have a higher incidence rate of the inattentive type of ADHD as well as comorbid mental illnesses. As a result, it is suggested that females may be under-diagnosed with ADHD because they are more likely to exhibit inattentive symptoms rather than what teachers and clinicians perceive as the stereotyped hyperactive behavior of ADHD. Consequently, if these females are left undiagnosed, this may correlate with their comorbidity of ADHD, depression and or substance abuse.
Sari Solden, MS, LMFT, author of Women with Attention Deficit Disorder, states that young women are often overlooked because they lack the stereotypical hyperactivity of ADHD that males tend to exhibit more; their behavior is appropriate, and they are not disruptive or bothersome to their classmates. In her book, Solden quotes Kathleen Nadeau, Ph.D., when describing such persons as “people pleasers.” These individuals often become symptomatic at home, after an extensive day of holding it together and trying to appease parents and teachers. Solden suggests that females often exhibit impairment in ways other than hyperactivity. One key indicator of this behavior is extreme disorganization. Solden recommends the examination of messy lockers, bedrooms, and handwriting. In addition, she states, individuals may also be emotionally and visually sensitive; this may result in high distractibility by the external environment and their internal cognitions.
Colleen Walton conducted a study in 1996 that examined whether a child’s gender influenced school psychologists’ diagnosis of ADHD. Walton’s sample consisted of 217 male and female school psychologists who have a Master’s degree as a minimum educational level attainment. Subjects were sent a case study and questionnaire and were asked to return it once completed, within a two-week time period. The participants were split into two groups; the first group received a case study about a male child named Chris and results from several neuropsychological tests, and the second group received the same case study and results but described Chris as female. Walton reports that the case study was designed, with the help of two consulting psychologists, to replicate a child that had the less “noisy” symptoms of ADHD, more closely resembling the symptoms of the inattentive type.
Walton’s results provided no significant evidence that suggested gender bias had influenced the school psychologists’ diagnosis of the child. The results thereby implicated that these school psychologists deemed the DSM-IV-TR criterion appropriate for both genders. The findings also indicated that the neuropsychological test results that accompanied the case study had an impact on the decision to diagnose the patient with ADHD.
Previous research suggests that ADHD symptom expression is the same for both genders. In addition, females are commonly under-diagnosed because they are less likely to exhibit the stereotypical hyperactivity of their male counter parts. Therefore, the present research intends to examine whether gender bias plays a role in the referral and diagnoses of teachers and clinicians. A study similar to Walton’s will be conducted with a few alterations. First, two gender-neutral case studies will be presented to the same participant at separate times. Also, instead of utilizing the same case study (demonstrating only one subtype of ADHD), two separate case studies will be presented. In addition, each case study will represent symptoms signifying either the inattentive or hyperactive/impulsive ADHD subtypes. The participants will also not receive neuropsychological test results. Finally, the participants will be expected to participate in person rather than through the mail. If statistically significant evidence is found, then perhaps there will be an increase in the teachers and clinicians’ awareness for the potentiality of bias. This will ultimately lead to improve the lives of individuals such as Molly and allow all persons affected by ADHD to receive appropriate treatment.
Five hundred teachers, of both genders, who currently have valid Illinois Standard Teaching Certifications, will be randomly selected from a list obtained ethically from the Illinois State Board of Education. In order to obtain an Illinois Standard Teaching Certification, individuals are required to have at least four years of experience and must have completed extensive graduate course work in addition to the classes required for their bachelor’s degree. It is therefore assumed that these individuals possess the adequate knowledge and experience to make an accurate ADHD referral. In addition, five hundred psychologists, of both genders, who are at least a Licensed Clinical Professional Counselor (LCPC), will be randomly selected from the data base ethically obtained by the Illinois Division for Professional Regulation (IDPR). These psychologists should have spent at least two years working as a licensed clinician. Furthermore, these individuals should have had at least 2,000 hours of supervision and have taken a national licensing exam. It is therefore assumed that these experts are qualified to make accurate diagnoses. It is expected that the age range will range between 27 and 65 years for both teachers and clinicians.
Teachers and clinicians who were randomly selected will receive a letter inviting them to participate in an important study evaluating DSM-IV-TR diagnostic criteria for Attention Deficit and Disruptive Behavior Disorders. This letter will also include a list of several session dates for participants to choose from and information regarding payment for participation.
Gender Bias. Gender bias will be measured with a questionnaire that asks participants to make a judgment regarding a patient’s gender based on a case study. This will be done in a somewhat deceptive manner as the participant is not directly asked what gender they think the patient is; rather, they are asked to complete a document resembling an insurance company’s consultation form. The form will ask for the patient’s number and require the participant to check a box indicating gender. In addition, the case studies are gender-neutral and make no implications towards the sex of the child. Also, since the participant will not have access to the case study while completing the evaluation form, they will be forced to make their evaluation based on their own assumption. Gender bias will also be investigated with a checklist composed primarily of ADHD symptoms and other variables unrelated to ADHD including socioeconomic status, race and gender. This will assist in determining whether individuals consider gender as a factor in diagnosis. The case studies and check list will be composed after consulting with a male and female psychologist, who both specialize in ADHD. This will be done so that realistic case studies may be presented resembling children that meet the criteria for ADHD Hyperactive/Impulsive type and ADHD Inattentive type.
Finally, based on both the patient evaluation and the ADHD survey, participants are asked to explain their rationale for deciding the Axis I diagnosis and any other pieces of information or instruments they have successfully used to diagnose someone with ADHD. This was included as a final attempt to catch the participant’s gender bias and or assess whether certain diagnostic tools frequently appear along with gender bias.
ADHD’s Effect on Diagnosis. As a means of evaluating the effects of gender influences on diagnosis, the participants are asked to diagnose the two case studies. The participant will be asked to decide if the patient meets the criteria for any of the four disorders defined in the DSM-IV-TR as Attention Deficit and Disruptive Behavior disorders. This will be done using a Likert scale with scores ranging from 0 (definitely does not have this diagnosis) to 5 (definitely does have this disorder). In addition, the participant is given the option of selecting “This patient does not have an attention deficit or disruptive behavior disorder,” and is encouraged to write in an alternative Axis I diagnosis.
The study will be conducted in a large lecture hall at Roosevelt University, so that the subjects are able to be seated one seat apart from each other. The study sessions will be facilitated by one of two researchers of the same gender, who resemble one another in appearance and voice tone. In addition, the two facilitators will be trained to behave and speak exactly the same. The dialogue for the study session can be seen in the Appendix. When the participant first arrives, they will be asked to sign a consent form and given a black pen. Participants will be asked to not talk to one another or use any supplemental materials other than what has already been provided for them. Four large banners that display the DSM-IV-TR criteria for Attention Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder and Disruptive Behavior Disorder Not Otherwise Specified will be hung in the front of the testing room. The participants will be asked to read and evaluate two case studies, at separate times, within a given short period of time. Finally, after evaluating the two case studies, the teachers and clinicians will be asked to complete a short survey on Attention Deficit Hyperactivity Disorder. The time constraint will be used as a means to simulate the circumstances in which a clinician or educator may actually be forced to make diagnostic decisions. Moreover, as implied by Nisbett and Wilson, participants are more likely to exhibit true emotions when given a short amount of time to analyze data and come to a decision (1977). The participants will have five minutes to read the case study, twelve minutes to complete the patient evaluation, and five minutes to complete the ADHD survey.
At the conclusion of the session, as part of the debriefing process, a short discussion regarding gender bias in diagnosis will be conducted. Also, any questions the participants may have will be answered at this time. The participants will then be asked to sign a debriefing and disclosure form. The participants will receive $20 each for their participation.
It is expected that the results of this study will show that Teachers and Clinicians are more likely to refer and diagnose the patient with more hyperactive, impulsive behaviors as ADHD and male. It is also projected that Teachers and Clinicians are more likely to label the patient with inattentive tendencies as female. Furthermore, it is speculated that some participants may actually identify the ADHD-IV patient as female and fail to diagnose it as ADHD. It is proposed that these individuals may instead suggest the child is actually experiencing some other form of mental illness such as depression.
The present research intends to provide significant evidence suggesting the influence of gender bias on teachers’ and clinicians’ diagnosis of Attention Deficit Hyperactivity Disorder. Bias in diagnosis will be measured by the frequency of occurrence that teachers and clinicians report gender in accordance with either the case study representing inattentive or hyperactive/impulsive expression of ADHD. Bias will also be examined based on the rate that teachers and clinicians elect the patient’s mental illness and the gender related indicators important for diagnosis.
If the findings from this study are in line with current ADHD research, then it is expected that no supporting evidence will be found to indicate that the gender the participant selects will influence the diagnosis of illness. Furthermore, if Biederman et al and Sari Solden’s assumptions are valid, then the data produced from this research should demonstrate that participants will more likely identify the case study representing the inattentive type of ADHD as female and the hyperactive/impulsive case as male. There should also be a significant difference in incidence rate amongst the variables teachers and clinicians consider important for diagnosis. One assumption that could be confirmed in this study is that, according to teachers and clinicians, being male may be an important factor in determining ADHD.
There are some important limitations of the present research that need to be addressed. First, there may be some travel restraints for participants to physically get to the testing venue. Since the participants are randomly selected from lists of teachers and clinicians throughout the entire state of Illinois, it may be a significant burden for chosen participants residing in central and southern Illinois to travel all the way to Chicago. Second, the study is focused only on participants from Illinois. This presents the possibility that there may be statistical bias such that the chosen population from Illinois may not be representative of the United States population in general. In order to obtain a more accurate estimate, teachers and clinicians should be recruited from the entire United States. In addition, this study only investigates the bias in diagnosis for children. Further research should be conducted on gender bias when diagnosing adult patients. Finally, this researcher could not find a measuring tool that has been empirically shown to be an accurate indicator of gender bias. It is suggested by this researcher that such a tool does not exist. Since this is the first study measuring ADHD gender bias in this manner, and as written by Lopez, the participants might suspect the intent of the study and may result in dishonest reports (1993). It is suggested that future research be conducted as a means to construct a tool that accurately measures gender bias.
In another light, research regarding clinician gender bias in ADHD diagnosis is pertinent to the advancement of women’s health. This may enable clinicians to become unbiased experts of identifying the clinical presentation of ADHD symptoms. This research could also imply a correlation for comorbid females with ADHD and depression. For instance, as Solden suggested, some females may not be diagnosed as a result of the inattentive symptoms they present. As a consequence, they continue to struggle with these symptoms until a point of severe psychological distress is reached. This may result to their falling into a vicious cycle that reiterates and exaggerates the ADHD symptoms to such a significant level of impairment, that they are referred for treatment of a disorder they don’t have. For example, a female may constantly receive negative feedback for her inattentive behaviors, such as poor grades for penmanship or punishment for a dirty room. As a result, these constant negative reinforcements may act as a catalyst in her development of a low level of self-esteem and ultimately may trigger a false diagnosis of depression.
The present research hopes to investigate whether gender bias exists when teachers refer students and clinicians make diagnoses. If significant evidence is found, then teachers and clinicians may become more aware of their own biases and make more accurate referrals and diagnoses. In conclusion, this investigation, as well as future studies, has the potential to significantly enhance the lives of individuals such as Molly and allow all affected persons with ADHD to receive appropriate treatment.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental Disorders (Revised 4th ed.). Washington, DC: Author.
Biederman, J., Kwon, A., Aleardi, M., Chouinard, V., Marino, T., Cole, H., et al. (2005). Absence of Gender Effects on Attention Deficit Hyperactivity Disorder: Findings in Nonreferred Subjects. American Journal of Psychiatry, 162(6), 1083-1089.
Biederman, J., Mick, E., Faraone, S.V., Braaten, E., Doyle, A., Spencer, T., et al. (2002). Influence of Gender on Attention Deficit Hyperactivity Disorder in Children Referred to A Psychiatric Clinic. American Journal of Psychiatry, 159, 36-42.
Lopez, S.R. (1993, January). Gender Bias in Clinical Judgment: An Assessment of the Analogue Method’s Transparency and Social Desirability. Sex Roles: A Journal of Research. Retrieved April 21, 2008, from://findarticles.com/p/articles/mi_m2294/is_n1-2_v28/ai_13810697
Solden, S. (2005). Women with Attention Deficit Disorder: Embrace Your Differences and Transform Your Life (Revised 2nd ed.). Nevada City: Underwood Books.
Walton, C.D. (1996). Effect of Gender on School Psychologists’ Diagnosis of Attention Deficit/Hyperactivity Disorder. Unpublished doctoral dissertation, University of Toledo, Toledo.