Attention Deficit Hyperactivity Disorder (ADHD) is one of the world’s most common childhood disorders, with an estimated prevalence of 5.29%. It is also a highly misunderstood neurodevelopmental condition.
Whilst many associate it with hyperactivity and overmedication, particularly in young boys, ADHD encompasses a wide range of symptoms. ADHD is also being increasingly diagnosed in adults and girls.
ADHD is diagnosed three times more frequently in boys than girls. Not long ago, however, this figure was closer to 10 to 1. Although the margins are narrowing, by adulthood the level of diagnoses across the sexes is roughly the same - so to what can we attribute the lower rates identified in childhood?
One potential explanation is that the symptoms observed in girls and boys can be quite different. Boys tend to exhibit the more “obvious” signs of ADHD such as hyperactivity and conduct disorder, whereas the difficulties experienced by girls tend to be attentional such as daydreaming in class.
For this reason, ADHD in girls may not be as obvious in an educational setting and therefore fall under the radar.
The hyperactive symptoms more commonly displayed by boys are more likely to be problematic in the home or classroom, and may therefore more quickly draw the attention of teachers, special needs officers etc.
Girls on the other hand, tend to experience the difficulties of ADHD in a more internal manner. It has also been argued that as girls are socialised by society to behave in a more reserved manner that they are better than boys at covering up symptoms.
There is also limited public knowledge in terms of the different ways ADHD may express itself among the sexes.
So in what ways may ADHD look different in girls than boys?
An interesting paper by Rucklidge (2010) explored gender differences in ADHD. In a review of previous studies, she found a number of differences in a variety of areas.
This is potentially the most widely recognised symptom of ADHD and is the main symptom that boys tend to exhibit more than their female counterparts. Children with ADHD may find it difficult to sit still and may also exhibit impulsivity for example non- stop talking, making inappropriate comments and being impatient.
Although many children may be high-energy, in order to meet the clinical criteria for these facet of ADHD the hyperactivity and impulsivity demonstrated must be impacting the child’s life and have been doing so for six months or more.
Inattentive ADHD is that which leads to trouble focusing and being easily distracted. Children with ADHD are daydreamers who get bored easily. Whilst this could easily be said of many children, in the case of those with inattentive ADHD this leads to trouble completing schoolwork and avoiding tasks requiring focus. Children with ADHD may also be highly disorganised with messy rooms.
Again, whilst many of these are common childhood traits, those with ADHD will suffer both at home and at school due to the severity of these symptoms.
Girls display attentional ADHD more so than boys.
Tactile Defensiveness (TD) refers to both behaviours and emotional responses which are out of proportion to tactile (relating to sense of touch) stimuli. Children with TD may be overwhelmed by sensory overload and in extreme cases may find everyday activities such as having hair brushed or eating cold food intolerable.
TD is commonly associated with ADHD and is exhibited more frequently by females.
Social and Psychological Functioning:
Studies have also found some marked differences in these areas between girls and boys. Boys have been found to be more aggressive, particularly with peers. Interestingly, it has been found that girls suffer from lower self-esteem and demonstrate poorer coping strategies than boys.
This could be due to the more internalised nature of female ADHD but could also be the result of later diagnosis.
Effects of late diagnosis
Early identification and intervention are obviously important in terms of determining future outcomes. Children who receive support at home and at school are much more likely to manage their condition into the future.
Unfortunately, at present ADHD tends to be diagnosed later in girls than in boys. Until recently, the American Psychiatric Association diagnosis manual specified 7 as the cut- off age for symptoms to be evident. Although this has recently been increased to 12, it is quite possible that the narrow age- range previously provided prevented some diagnoses from being made.
Some studies estimate that as many as 50- 75 percent of girls with ADHD are not diagnosed.
Studies have found that both men and women diagnosed as adults struggle in a wide array of domains and have lower self- esteem, poorer coping strategies and higher levels of depression. In addition adults identified with ADHD later in life tend to have negative attributions about themselves.
The lack of a diagnosis may lead individuals to having their difficulties attributed to laziness or lack of ability both by themselves and others.
As of yet however, no study has compared those diagnosed during adulthood with those diagnosed during childhood.
So what should you look out for in order to spot the signs of ADHD in girls?
The following signs may indicate that ADHD is going unnoticed:
If this sounds familiar it may be worth speaking to a GP or therapist in order to further investigate the basis of these problems. Given the lack of awareness regarding girls with ADHD, and the detrimental impact of later diagnosis, it is important not to let girls with ADHD continue to fall under the radar.
By Dr. Syras Derksen
Hamed, A. M., Kauer, A. J., & Stevens, H. E. (2015). Why the diagnosis of attention deficit hyperactivity disorder matters. Frontiers in psychiatry , 6 .
Rucklidge, J. J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America , 33 (2), 357-373.
It is old news that dysfunctional or insecure relationships in childhood may lead to difficulties down the line. Whilst this has long been known, a recent study has shed further light on the reasons for this, and the specific effects poor attachments may have.
Attachments are the relationships we have with caregivers from an early age. In general, attachment styles may be divided into four categories: secure, anxious-preoccupied, dismissive-avoidant and fearful-avoidant. The type of attachment style we develop is directly linked to the quality of care we receive. For example, a neglectful parent may contribute to their child’s dismissive- avoidant attachment style (Cassidy, 1999).
Insecure attachment styles have been linked to range of adult mental health issues. These range from anxiety and depression to relationship issues and even health problems. Obviously attachment styles are an important research area, but why does the human brain react so negatively to poor parenting?
The study, published in Frontiers in Human Neuroscience, found that insecure childhood attachments can negatively influence our ability to deal with stress as adults (Leyh, 2016). We are all aware that there is huge variability in how individuals deal with stress. This is evident in any office in the world! Some people remain calm and proactive in the face of adversity, whilst some crumble and become extremely negative.
One of the reasons for this, according to Dr. Rainer Leyh and his team, is that our negative childhood experiences and attachment styles stay with us throughout adulthood, and rear their heads when we are faced with a stressful or anxiety provoking scenario.
In this report on the study, Dr Christine Heinsich gives the example of a car approaching a traffic light. For the driver, when they are in a neutral state, following the signal is easy and may even come automatically. For an emotional driver however, following the signal is much more difficult. They may stop late or fail to stop altogether, driving straight through the light.
What moderates our ability to stay calm under emotional strain? For those of us that had emotionally attentive parents or caregivers it can be a lot easier. The key term is “emotional regulation”. Emotional Regulation is our ability to control our emotions, and our reactions and subsequent behaviours in response to them. Attachment styles have been directly linked to emotional regulation.
In the aforementioned study, adults were recruited who had a wide range of childhood parental/ caregiver experiences. Participants were asked to perform a task which involved identifying a target letter from a series of flashing letters. The task was conducted in different conditions, some which evoked a positive emotional response, some which evoked a negative response and others which evoked neutral. The participants’ brain activity was recorded using a type of brain scanning called “EEG”.
Subjects with insecure childhood attachments had significantly more trouble performing under the negative conditions than those with secure childhood attachments. Another interesting finding was that those with insecure attachments also exhibited lower brain activity under negative conditions when attempting to identify the target letter.
The poorer the task performance, the poorer the strategies for emotional regulation. One theory put forth by the researchers, is that the more effort you have to exert on inhibiting your emotion, the less resources you have to perform on the task. Therefore, negative childhood experiences may make all those day- to- day struggles we encounter just that little bit more difficult.
Were there any potential limitations to this study? It could be argued that as the target letters were unrelated to the emotional cures, it is difficult to generalise them to everyday life. Future studies will have to find a way to make the testing environment more realistic.
Despite this, it does see clear that poor relationships with our caregivers can have long- lasting consequences.
How do I know if I have difficulties with attachment and/ or emotional regulation?
It can be difficult to know whether any of this applies to you. You may have difficulties with emotional regulation if:
Implications for relationships
Those who are negatively attached may bring these issues and insecurities into relationships. Attachment style can have massive connotations, particularly for romantic relationships, and it is important to be aware of how it can affect you.
It is easy to see the connection between a turbulent relationship, and the findings of the study we have just discussed. Being resilient and calm when faced with stressful situations, arguments and all that comes with a relationship, is often central to its success. For those with poor emotional regulation, this can be difficult.
What can you do about insecure attachment?
New research is increasingly shedding light on how our past experiences can shape our present and future. It is fascinating what we area learning, but also important to stress that your past does not necessarily dictate your future, and we all have the ability to change long- learned behaviours.
By Dr. Syras Derksen,
Cassidy, J. (1999). Handbook of attachment: Theory, research, and clinical applications. Rough Guides.
Leyh, R., Heinisch, C., Kungl, M. T., & Spangler, G. (2016). Attachment representation moderates the influence of emotional context on information processing. Frontiers in Human Neuroscience, 10, 278.
We all know individuals who are of a more melancholy disposition than others. In A. A. Milne’s popular set of children’s stories, the friends of Winnie-the-Pooh include both Tigger – the bouncing, happy tiger; and Eeyore – the somber, plodding donkey. Even from a young age, we all understand that it is completely acceptable for individuals to have their own unique dispositions and levels of emotional valence.
However, when a friend or loved one’s general tendency towards being blue seems to worsen, and perhaps begins to impair day-to-day functioning, it is exceptionally difficult to assess the seriousness and potential danger of the situation. In particular, it can be hard to know when a period of melancholy crosses the line into untreated major depression.
Depression Can Be Misdiagnosed
A recent study published in the JAMA Internal Medicine journal by the American Medical Association indicated that in the United States, a large proportion of individuals seeking attention for depression-related symptoms are misdiagnosed. The study surveyed over 46,000 US adults aged 18 or older in 2012-2013.
Using an established scale to measure depressive symptoms, the study established that around 8.4% of the participants in the sample had depression. However, only 28.7% of those individuals had received treatment. Meanwhile, of those who were undergoing treatment for depression (either psychotherapy or antidepressant medication), only 29.9% screened positive for symptoms of major depression.
This means that there are some serious challenges associated with the correct identification of depression, and diagnosis and treatment is not necessarily always straightforward.
In an effort to widen the scope of research into the prevalence of depression misdiagnosis, another study conducted a meta-analysis of 118 different studies assessing the accuracy of depression diagnoses. The final analysis contained data from more than 50,000 patients across 41 different studies, in countries including the United States, Canada, and various European countries, among others.
In the end, the study suggested that for every 100 cases of potential depression seen by a primary care physician, 15 cases are false positives (treatment was prescribed when there was no real depression), 10 cases are missed (treatment is not prescribed when there is real depression), and 10 cases are correctly identified (treatment is provided for real, identified depression).
One reason for this pattern of diagnosis is the difficulty in ascertaining the difference between depression and psychological distress. The AMA study described in the previous section measured the difference between depression and serious psychological distress, and found that among adults who were undergoing treatment for major depression, 29.9% had depression and 21.8% had serious psychological distress.
In addition, factors such as age, culture, and available medical resources can impact diagnoses. In general, the studies concluded that developing a relationship with a mental health care professional and undergoing multiple diagnostic visits over a longer period of time can substantially increase diagnostic accuracy.
Signs to Look For
To address the complexity of depression diagnosis, there are several mnemonics that have been developed in an effort to make the symptoms of depression more memorable. The mnemonic below, published by Blenkiron, 2006, lists 10 symptoms of depression aligning with the 10 letters of the word. Here we present the list and supplement each item with a brief description.
As was apparent from the list above, each symptom presented must recur in an individual for a period of multiple days before it should be considered a possible indicator for major depression. Generally speaking, until multiple of the symptoms above are present much of the time for a sustained period lasting around two weeks, there should not be major cause for concern.
However, anyone with any concern over the mental health or safety of a friend or loved one should consult with a mental health professional. Individuals who fear for anyone’s immediate safety should contact emergency services.
By Dr. Syras Derksen,
Blenkiron, P. (2006). A mnemonic for depression. BMJ: British Medical Journal, 332(7540), 551.
Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: a meta-analysis. The Lancet, 374(9690), 609-619.
Olfson, M., Blanco, C., & Marcus, S. C. (2016). Treatment of Adult Depression in the United States. JAMA Internal Medicine, 176(10), 1482.
In our increasingly digital age, addiction to internet use is growing in prevalence, and has recently received more and more attention from medical and scientific researchers. Nowhere is the problem more alarming than with adolescents, who have the greatest access to internet-based technologies, and also have the most at stake developmentally.
Some rather sensationalized news sources have even referred to the rise of internet addiction as a new “electric heroin,” citing the research demonstrating how internet use and serious substance abuse demonstrate similarities in their symptomologies and in the way that they stimulate the reward pathways of the brain.
While the danger and addictive potential of heroin use makes the comparison a little strained, excessive internet use is nonetheless a condition that merits serious attention.
The History Of Internet Addiction
The possibility for addictive behavior related to internet use was first proposed in 1995. The term was initially used in jest, because at the time the rarity of personal computers and the unlikelihood of any individual developing an addiction to internet use made the idea ridiculous.
In the ensuing years, however, the explosion of internet technologies rapidly made internet addiction a reality. By 1998 a diagnostic tool known as the Internet Addiction Tool (IAT) was developed by Dr. Kimberly Young in order to assess whether an individual’s internet use was pathological.
The assessment was based on the criteria for pathological gambling listed in the DSM-IV (the American Psychological Association’s diagnostic manual for mental disorders). This was based on the logic that despite the fact that internet addiction had not yet been recognized by the psychological establishment as a real disorder, the symptoms it presented were similar enough to gambling addiction that the two could be diagnosed in a comparable fashion. When the DSM-V was released in 2013, pathological gambling was updated to a condition now called “gambling disorder,” but problem internet use was once again left out.
Notwithstanding, psychological and medical researchers across the world have begun devoting major resources towards studying the effects of internet use, especially on school age populations ranging from ages 5-22. This field of research has been especially active in Asian countries such as China, Japan, Korea, and Taiwan; countries in which the vast majority of the population have access to the internet and incidence of internet addiction is especially high. Recent studies have found that an estimated 19.8% of adolescents in Taiwan and 20% of adolescents in Korea screened positive for either internet addiction or excessive internet use.
The Diverse Manifestations of Excessive Internet Use
Internet Addiction has been grossly understudied, and additional research is required to establish prevalence rates in European and North American countries. The various diagnostic tools currently available are often times outdated, and assess patterns of internet use that are no longer relevant. Future research is needed to validate measuring tools that more accurately reflect the actual patterns of internet use in today’s adolescents.
In the 1990s, the internet functions available to the average user were so limited that one of the only possible types of pathological use was compulsively checking websites, in a pattern that closely mirrored compulsive gambling. However, today’s adolescents use the internet for so many different things that, depending on their pattern of use, the internet can either enable or catalyze a host of different disordered patterns of thinking.
For example, online gaming can be associated with the impulsivity often marked in cases of Attention Deficit Hyperactivity Disorder (ADHD). Adolescents with a bent towards narcissistic personality disorder might gravitate towards excessive self-promotion on networking outlets like Twitter, Facebook, or Instagram. The constant stream of world news and cultural information present on social media websites can enable a crippling fear of missing out (or “FOMO”) that might co-occur with an anxiety disorder. And the internet also provides opportunities for the destructive cyber-bullying perpetuated by over-aggressive adolescents.
Of course it is impossible to determine if the disordered or problematic patterns of thinking listed above are caused by internet use or if the internet use simply enables preexisting pathological tendencies to manifest. It is also possible that there is a reciprocal relationship, with excessive internet use both fostering and enabling the expression of negative behavior patterns.
Diagnosis and Understanding
While this diversity of the symptomology of internet addiction makes it difficult to issue blanket statements, the important thing is to have the discernment to distinguish between frequent internet use and the excessive patterns of use that can lead to addiction.
Internet use should not be judged to be excessive until several of the following criteria are met (among others): impaired psychological well-being; worsened academic performance; physical abnormalities including back pain, eye strain or carpal tunnel syndrome; severely decreased family and peer interactions; and finally the traditional markers of addiction, including increased tolerance, signs of withdrawal after lack of use, disregard for consequences, and difficulty controlling behavior.
While discussions of internet addiction can often alarm parents who may believe that their child spends too much time online, it’s important not to jump to conclusions nor to inhibit overall internet use wholesale. Internet use is not per se harmful or inhibiting; in fact, there is a mountain of evidence that adolescents with regular internet access generally have higher test scores, a greater motivation to learn, greater access to health information, and a general feeling of empowerment compared to adolescents without internet access.
As was noted above, there are many diverse uses for internet technologies, and each has the potential to enable various different disordered patterns of thinking. What is required in such a complex situation is a sensitivity to the overall developmental context of an adolescent’s physical, emotional, and social situation.
While internet addiction has recently been given increasing attention by mental health professionals and should be taken seriously, parents of adolescents should not jump to conclusions. Using the criteria listed above, in addition to outside research and, if necessary, consultation with a certified health professional, parents of adolescents can be more secure in their ability to discern between the excessive internet use that marks internet addiction and the frequent internet use that marks 21st century adolescence.
By Dr. Syras Derksen,
Guan, S. S. A., & Subrahmanyam, K. (2009). Youth Internet Use: Risks and opportunities. Current Opinion in Psychiatry, 22(4), 351-356.
Ong, S. H., & Tan, Y. R. (2014). Internet Addiction in Young People. Annals of Academy of Medicine, Singapore, 43(7), 378-382.
Tao, R., Huang, X., Wang, J., Zhang, H., Zhang, Y., & Li, M. (2010). Proposed Diagnostic Criteria for Internet Addiction. Addiction, 105(3), 556-564.
Wallace, P. (2014). Internet Addiction Disorder and Youth. EMBO Reports, 15(1), 12-16.
A personality disorder is defined as an “inner experience” (that is, our personal interpretation and understanding of things that happen, as well as our own thoughts and feelings) that deviates significantly from expectations of our culture (DSM-5). There are a number of types of personality disorders, showing different patterns of that inner experience. One such type is Borderline Personality Disorder (BPD). BPD may be diagnosed when a person shows instability in four key areas:
Receiving a diagnosis of BPD can be a source of anxiety in itself as there is not as much awareness of the condition as other psychological diagnoses such as anxiety or depression. On one hand, there may be some relief in knowing that the intense symptoms someone is feeling has a name, but it also elicits questions about treatment and whether they will ever feel “normal”.
Medication VS. Therapy
While there is no medication to specifically address BPD, prescriptions may be made for specific symptoms such as mood reactivity or anxiety. Therapy is considered particularly important for individuals with BPD. One specific type of therapy that has garnered significant attention for its effective treatment of BPD is known as Dialectical Behavior Therapy (DBT). Generally, BPD symptom severity and risk of suicide are greatest in young adulthood, and then often diminish with age, particularly with therapeutic intervention.
Dialectical Behavior Therapy (DBT)
The word “dialectic” means looking at opposing ideas in order to find the truth. In the case of DBT, this type of therapy aims at broadening our perspectives and developing skills to both accept and regulate our emotions. DBT also places value on developing skills for having healthy relationships.
DBT is practiced in both individual therapy and in group sessions. Group sessions follow a particular structure of training skills from four different modules:
If DBT is started in a structured setting, clients often then continue with individual therapy afterward to continue the skill development and receive effective support.
By Kristi MacDonald
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Linehan, M. M., & Wilks, C. R. (2015). The Course and Evolution of Dialectical Behavior Therapy. American Journal of Psychotherapy, 69(2), 97-110.
Palmer, R. L. (2002). Dialectical behaviour therapy for borderline personality disorder. Advances in Psychiatric Treatment, 8(1), 10-16. doi:10.1192/apt.8.1.10
We can now see narcissism in the brain. Brain scans of people with Narcissistic Personality Disorder (NPD) showed they have less brain matter in areas associated with emotional empathy. This is the first time anyone has seen the evidence of narcissism in brain structures.
The inability to feel empathy is one of the hallmarks of NPD. Researchers have found that people with this disorder can take the perspective of another person in a purely intellectual way. However, when it comes to actually feeling what another person is going through, narcissists have difficulty.
A group of German researchers recently studied the source of this lack of emotional empathy in people with NPD. In their research, they collected MRI brain scans of 17 people with NPD along with 17 people from the community for comparison. The researchers first looked at brain volume overall and found that the people with NPD were similar to the healthy individuals. That is, both groups’ brains’ were similar overall.
The researchers then examined the areas of the brain that are now considered areas associated with empathy (i.e., bilateral anterior insula, anterior and median parts of the cingulate cortex, and the supplementary motor area). They found that the patients with NPD had less brain matter in areas that overlapped with the areas associated with empathy (i.e., left anterior insula, rostral and median cingulate cortex as well as dorsolateral and medial parts of the prefrontal cortex).
Put simply, the empathic areas of the brain were less developed in people with Narcissistic Personality Disorder (NPD).
Narcissistic Personality Disorder affects about 1% of the general population and it has been shown to impair interpersonal functioning. This groundbreaking research will likely help legitimize the disorder and, ironically, help people to empathize with people who are suffering with this illness.
By Dr. Syras Derksen
Schulze, L., Dziobek, I., Vater, A., Heekeren, H. R., Bajbouj, M., Renneberg, B., Heuser, I., & Roepke, S. (2013). Gray matter abnormalities in patients with Narcissistic Personality Disorder. Journal of Psychiatric Research, 47, 1363-1369. (http://www.journalofpsychiatricresearch.com/article/S0022-3956%2813%2900157-X/abstract)
Tickling someone is fun, and it can be fun to tickled (sometimes). So this means that ticklish people are more fun, right?
Darwin thought so. He thought comedy and tickling both "tickled the mind." Humorous people laugh because of funny jokes and because someone tickles them. Sounds like a fun person to me.
This year some Swiss researchers actually showed Darwin was wrong. The Swiss discovered, after a few brain scans, that humour and ticklish giggles are actually quite different.
Tickling does cause some of the same regions of the brain to light up as a good joke, but tickling also lights up the hypothalamus. This region regulates a lot of instinctive functions (body temp., hunger etc.). It also activates the anticipation of pain areas of the brain.
These extra areas of activation explain why people act like they are under attack when they are being tickled, and why you might have been kicked or punched when tickling someone. It also begins to explain how being tickled can be painful and make you laugh at the same time.
Tickling, even with all its mixed feelings, does put us in a fun mood. Two researchers from California tickled people before and after a comedy. These tickled individuals were more likely to laugh than people not tickled before the comedy. Not only that, they also laughed more after the comedy when they were tickled. Looks like tickling gets you in the mood for more tickling.
A ticklish person may not be more fun, but tickling does seem to put us in the mood for fun.
By Dr. Syras Derksen