Article

Influence of Gender on Attention Deficit Hyperactivity

Disorder in Children Referred to a Psychiatric Clinic

Joseph Biederman, M.D.
Eric Mick, Sc.D.
Stephen V. Faraone, Ph.D.
Ellen Braaten, Ph.D.
Alysa Doyle, Ph.D.
Thomas Spencer, M.D.
Timothy E. Wilens, M.D.
Elizabeth Frazier, B.A.
Mary Ann Johnson, R.N., M.S.,
C.S.
Objective: The substantial discrepancy
in the male-to-female ratio between
clinic-referred (10 to 1) and community (3
to 1) samples of children with attention
deficit hyperactivity disorder (ADHD) sug-
gests that gender differences may be op-
erant in the phenotypic expression of
ADHD. In this study the authors systemat-
ically examined the impact of gender on
the clinical features of ADHD in a group of
children referred to a clinic.
Method: The study included 140 boys and
140 girls with ADHD and 120 boys and 122
girls without ADHD as comparison sub-
jects. All subjects were systematically as-
sessed with structured diagnostic inter-
views and neuropsychological batteries for
subtypes of ADHD as well as emotional,
school, intellectual, interpersonal, and
family functioning.
Results: Girls with ADHD were more likely
than boys to have the predominantly inat-
tentive type of ADHD, less likely to have a
learning disability, and less likely to mani-
fest problems in school or in their spare
time. In addition, girls with ADHD were at
less risk for comorbid major depression,
conduct disorder, and oppositional defiant
disorder than boys with ADHD. A statisti-
cally significant gender-by-ADHD interac-
tion was identified for comorbid substance
use disorders as well.
Conclusions: The lower likelihood for
girls to manifest psychiatric, cognitive,
and functional impairment than boys
could result in gender-based referral bias
unfavorable to girls with ADHD.

(Am J Psychiatry 2002; 159:36–42)

D espite the fact that a large number of girls might be

suffering from attention deficit hyperactivity disorder
(ADHD), the scientific literature on ADHD is almost exclu-
sively based on boys. To address the paucity of informa-
tion on ADHD in girls, in an earlier study (1) we compared
the clinical correlates of ADHD in a large group of girls
with and without ADHD ascertained from pediatric and
psychiatric facilities. This study showed that ADHD in girls
was characterized by prototypical symptoms of the disor-
der, comorbid psychopathology, social dysfunction, cog-
nitive impairments, school failure, and adversity in the
family environment.
Despite this level of dysfunction, a substantial discrep-
ancy exists in the male-to-female ratio between clinic-re-
ferred (10 to 1) and community (3 to 1) samples of children
with ADHD (2, 3). Although the reasons for the apparent
underidentification of girls with ADHD remain unclear,
Gaub and Carlson (3) suggested in their meta-analysis that
gender differences in the phenotypic expression of the
disorder may be driving referral of more boys than girls.
However, Gaub and Carlson also pointed out that the
dearth of research comparing boys and girls with ADHD
limits the conclusions that can be drawn from the extant
literature. In addition to the scarcity of such studies, the
previous studies of gender and ADHD that have been pub-
lished are limited by small sample sizes, a limited scope of
assessment, and the absence of gender-matched compar-
ison subjects (4). These limitations impede an adequate
understanding of gender effects and the ability to separate
gender effects on ADHD from the main effect of gender
within ADHD subjects.
In view of the importance of early and appropriate treat-
ments for ADHD, a comprehensive understanding of gen-
der differences and similarities in the clinical manifesta-
tions of ADHD has major public health and scientific
importance for the advancement of women’s health. To
this end, we systematically compared boys and girls with
and without ADHD in multiple domains of functioning.
We hypothesized that ADHD in girls would be character-
ized by lower rates of comorbid disruptive behavior disor-
der, a preponderance of the inattentive subtype of ADHD,
and less cognitive dysfunction than ADHD in boys.
Method
Subjects
Data from two identically designed family studies of ADHD (1,
5) were combined. Our first study (5) ascertained boys with or
without ADHD who were 6–17 years old at the time of ascertain-
ment; this study included 140 boys with ADHD and 120 boys
without ADHD. Our second study (1) ascertained girls with and
without ADHD who were also 6–17 years old at the time of ascer-
tainment; this study included 140 girls with ADHD and 122 girls
without ADHD.

36 Am J Psychiatry 159:1, January 2002


Ascertainment
Potential subjects were excluded from both studies if they had
been adopted or if their nuclear family was not available for study.
We excluded subjects if they had major sensorimotor handicaps
(paralysis, deafness, blindness), psychosis, autism, inadequate
command of the English language, or a full-scale IQ (6) less than
80. Parents provided written informed consent for their children,
and children and adolescents provided written assent to their
participation.
Two independent sources provided the children with ADHD.
We selected psychiatrically referred children with ADHD from
consecutive referrals to a pediatric psychopharmacology clinic at
the Massachusetts General Hospital (selection criteria are de-
scribed later in this article). Parents, pediatricians, and schools
had referred these children for psychiatric evaluations. The other
source of children with ADHD were pediatric patients from a
health maintenance organization (HMO). Within each setting, we
selected comparison subjects without ADHD from outpatients at
pediatric medical clinics.
A three-stage ascertainment procedure was used to select the
subjects. For children with ADHD, the first stage was the patient’s
referral to a psychiatric or pediatric clinic resulting in a clinical di-
agnosis of ADHD by a child psychiatrist or pediatrician, which
was recorded in the clinic record. A second stage confirmed the
diagnosis of ADHD after all children with a positive diagnosis at
the first stage were screened by administering a telephone ques-
tionnaire asking the child’s mother about the 14 DSM-III-R symp-
toms of ADHD. The third stage confirmed the diagnosis made on
the basis of the telephone questionnaire with face-to-face struc-
tured interviews with the mother. Only patients who received a
diagnosis of ADHD at all three stages were included in the final
analysis. Comparison subjects without ADHD were ascertained
from referrals to medical clinics for routine physical examina-
tions at both the Massachusetts General Hospital and the HMO
sites. The mothers of these children were also interviewed by tele-
phone and face-to-face; children included in the study did not
meet ADHD criteria at any of the three stages.
Measures
Psychiatric assessments of the children were made by using the
Schedule for Affective Disorders and Schizophrenia for School-
Age Children—Epidemiologic Version (K-SADS-E) (7). Diagnoses
were based on independent interviews with the mothers and di-
rect interviews with the children older than 12 years. Diagnostic
assessments of parents were based on the Structured Clinical In-
terview for DSM-III-R (8) conducted with each parent. To assess
childhood diagnoses in the parents, modules from the K-SADS-E
covering childhood diagnoses were administered. All assess-
ments were made by raters who were blind to the child’s diagnosis
(ADHD or no ADHD) and ascertainment site. Different interview-
ers met with mothers and children to maintain blindness to
ADHD status and to prevent information from one informant in-
fluencing the assessment of the other.
A committee of three psychiatrists (J.B., T.S., and T.E.W.), each
board certified in both child and adult psychiatry, resolved all di-
agnostic uncertainties. The committee members were blind to
the subjects’ ascertainment group, ascertainment site, all data
collected from family members, and all nondiagnostic data (e.g.,
neuropsychological tests). Kappa coefficients of agreement were
computed between raters and three board-certified psychiatrists
who listened to audiotaped interviews made by the raters. Based
on 173 interviews, the median kappa was 0.86; for ADHD, kappa=
0.99; for conduct disorder, kappa=0.93; for multiple anxiety disor-
ders, kappa=0.80; for major depression, kappa=0.83; and for bi-
polar disorder, kappa=0.94. These statistics for multiple raters rat-
ing the same interview show excellent agreement of ratings but
Am J Psychiatry 159:1, January 2002
BIEDERMAN, MICK, FARAONE, ET AL.
do not address the degree of agreement that would be attained
between two separate interviews of the same patient.
In addition to psychiatric data, we assessed social functioning
with the Social Adjustment Inventory for Children and Adoles-
cents (9), socioeconomic status with the Hollingshead scale (10),
divorce or separation of parents in family of origin, the family en-
vironment with the Family Environment Scale (11), indicators of
social adversity from Rutter’s Isle of Wight study (12), perinatal
complications with the Diagnostic Interview for Children and Ad-
olescents—Parent Version (13, 14), full-scale IQ based on the vo-
cabulary and block design subtests of the Wechsler intelligence
tests (15), reading and arithmetic achievement with subtests of
the Wide Range Achievement Test, Revised (16), adaptive func-
tioning with the Global Assessment of Functioning Scale (DSM-
III-R), and school difficulties (special class, repeated grades, tu-
toring) with structured diagnostic interview of the mother. The
definition of learning disabilities under Public Law 94-142 re-
quires a substantial discrepancy between a child’s potential and
achievement (17). We operationalized this with the procedure
recommended by Reynolds (18) that we have used elsewhere (19).
Statistical Analysis
Our main hypothesis was that there is no difference between
boys and girls with respect to the impact that ADHD exerts on
functioning in multiple domains. Data from comparison subjects
without ADHD are presented so that interactions could be tested
to determine if ADHD is a similar risk factor in boys and girls with
respect to sex-matched children without ADHD. To determine if
girls with ADHD have different clinic presentations from boys
with the disorder, we also present within-ADHD between-gender
pairwise comparisons. Binary data were analyzed with logistic re-
gression models, and continuous data were analyzed with ordi-
nary least-squares regression. Wald’s chi-square test was used to
determine statistical significance. The effects of gender within the
ADHD groups were tested with pairwise comparisons by using
Pearson’s chi-square or analysis of variance for binary and contin-
uous data, respectively. Statistical significance was determined at
p<0.05.
Results
Demographic characteristics of the subjects are pre-
sented in Table 1. Although subjects from the study of girls
with and without ADHD were slightly older than the sub-
jects from the study of boys, the interaction between gen-
der and ADHD status was not statistically significant. This
indicated that the distance in age between the girls with
and without ADHD was not different from the distance be-
tween the boys with and without ADHD. Likewise, ADHD
was not associated with lower socioeconomic status and
divorce or separation differently in boys and girls. We also
failed to identify any statistically significant differences in
demographic variables in pairwise comparisons of boys
and girls with ADHD (Table 1).
Comparisons of children with and without ADHD for
both studies were ascertained by using DSM-III-R criteria
for ADHD, which did not distinguish the subtypes of the
disorder introduced in DSM-IV. However, additional
symptoms required to make DSM-IV diagnoses were col-
lected in the study of girls, and proxies for the subtypes
were available for the study of boys (20). More girls who
met DSM-III-R criteria for ADHD failed to meet DSM-IV
37
GENDER AND ADHD

TABLE 1. Demographic Characteristics of Girls and Boys in Two Studies of Children With and Without ADHD
Study of Girls Study of Boys Interaction of Gender
Characteristic ADHD (N=140) No ADHD (N=122) ADHD (N=140) No ADHD (N=120) and ADHD Status
Mean SD Mean SD Mean SD Mean SD Beta 95% CI

Age at ascertainment (years) 11.2 3.4 12.2 3.0 10.5 3.0 11.6 3.7 –0.02 –1.1 to 1.1
Socioeconomic status (Hollingshead
Four-Factor Index) 1.9 0.9 1.7 0.8 1.9 1.0 1.5 0.7 0.2 –0.1 to 0.5

N % N % N % N % Odds Ratio 95% CI

Parents divorced or separated 39 28 22 18 40 29 21 18 0.9 0.4 to 2.2

FIGURE 1. DSM-IV Subtypes of ADHD in Boys and Girls in in girls. The odds ratio of 0.05 indicates that ADHD in-
Two Studies of Children With DSM-III-R ADHD creased the risk for substance use disorders one-20th as
much in boys as it increased the risk for substance use dis-
100 Combined
orders in girls. For other disorders the gender-by-diagno-
90 Hyperactive/
Impulsive sis interaction was not significant, indicating that other
80 gender differences between boys and girls with ADHD
Inattentive
70 were the same as the gender difference observed for boys
60 and girls without ADHD.
Percent

50 For example, girls with ADHD were at significantly lower

risk for any other behavior disorder than boys with ADHD.
40
This is a result of a naturally lower base rate of behavior
30
disorders in girls regardless of ADHD status. Similar re-
20
sults were observed for conduct disorder, oppositional de-
10 fiant disorder, major depression, and (in the opposite di-
0 rection) panic disorder.
Girls Boys The children’s scores on the subscales of the WISC-R (6)
With ADHD With ADHD
(N=140) (N=140) are presented in Table 3. Again, gender did not modify the
impact of ADHD on measures of intelligence (no gender-
by-ADHD diagnosis interactions were statistically signifi-
criteria for ADHD (N=11 [8%]) than boys who met DSM-
cant). However, girls with ADHD had statistically signifi-
III-R criteria (N=1 [0.7%]). Although the combined type
cantly, but not clinically meaningful, lower scores than
was the most prevalent type for both boys and girls with
boys with ADHD for estimated full-scale IQ and the block
ADHD, girls with ADHD were 2.2 times (95% confidence
design, and oral arithmetic subscales. Boys with ADHD
interval=1.2–4.0) more likely to be diagnosed as primarily
had significantly lower scores on reading achievement
inattentive than were boys with ADHD (Figure 1).
and significantly greater rates of learning disability than
Girls with ADHD were statistically but not clinically
girls with ADHD, however (Table 3).
meaningfully older at onset of ADHD than boys with
Although there were no gender-by-ADHD interactions
ADHD (mean=3.5 years, SD=2.5, versus mean=2.7, SD=
for any of the psychosocial functioning items studied (Ta-
2.0) (t=–3.0, df=277, p=0.003). Although all of the children
ble 4), girls with ADHD had fewer school problems and
with ADHD were from clinical settings, there were differ-
participated in more spare-time activities than boys with
ences in the rates of medication and psychotherapy tar-
ADHD. Despite the differences in the rate of psychiatric
geted for ADHD between boys and girls. The majority of
comorbidity and slightly lower intellectual functioning,
both boys and girls received treatment, but girls were less
there were no gender-by-ADHD interactions for indexes of
likely to receive pharmacotherapy (70% [N=98] versus 82%
the family environment, nor were there any pairwise dif-
[N=115]) (χ2=5.7, df=1, p=0.02) and psychotherapy (51%
ferences between boys and girls with ADHD.
[N=71] versus 64% [N=89]) (χ2=5.7, df=1, p=0.02). How-
For each statistically significant within-ADHD gender
ever, the mean number of years from the onset of ADHD to
difference we evaluated the impact of the higher rate of
the first encounter with treatment for the disorder was not
the inattentive subtype of ADHD in girls (data not pre-
different in girls and boys with ADHD (mean=4.5, SD=3.5,
sented). In no case was a gender difference found to be ac-
versus mean=3.1, SD=2.0) (t=0.1, df=203, p=0.9).
counted for by subtype differences between boys and girls.
The profile of psychiatric comorbidity of ADHD was
quite similar in boys and girls (Table 2). For substance use
Discussion
disorders there was a significant gender-by-diagnosis in-
teraction, indicating that ADHD was a significantly weaker ADHD in girls was more likely to be predominantly the
risk factor for substance use disorders in boys than it was inattentive subtype, less likely to be associated with a

38 Am J Psychiatry 159:1, January 2002

 BIEDERMAN, MICK, FARAONE, ET AL.

TABLE 2. Psychiatric Comorbidity Among Girls and Boys in Two Studies of Children With and Without ADHD
Study of Girls Study of Boys Interaction of Gender
ADHD (N=140) No ADHD (N=122) ADHD (N=140) No ADHD (N=120) and ADHD Status
Diagnosis N % N % N % N % Odds Ratio 95% CI p
Any behavior disordera 50 36 5 4 93 66 13 11 1.3 0.4 to 4.0
Conduct disorderb 11 8 0 0 30 21 4 3 0.6 —c 0.71
Oppositional defiant disordera 49 35 5 4 92 66 13 11 1.3 0.4 to 4.0
Any mood disorder 38 27 2 2 50 36 3 3 1.0 0.1 to 6.3
Major depression (severe)d 21 15 1 1 40 29 2 2 0.9 0.1 to 11.3
Bipolar disorder 15 11 0 0 15 11 0 0 —e
Dysthymia 13 9 1 1 6 4 1 1 0.4 0.1 to 8.3
Multiple anxiety disorders 46 33 6 5 39 28 5 4 0.9 0.3 to 3.5
Simple phobia 40 29 13 11 26 19 6 5 1.3 0.4 to 4.1
Social phobia 20 14 4 3 18 13 4 3 0.9 0.2 to 4.2
Agoraphobia 22 16 3 2 13 9 2 2 0.8 0.1 to 5.7
Panic disorderf 7 5 1 1 1 1 0 0 —e
Separation anxiety 36 26 12 10 40 29 6 5 2.4 0.8 to 7.5
Overanxious disorder 40 29 2 2 42 30 8 7 0.3 0.05 to 1.3
Substance use disorders 9 6 0 0 3 2 7 6 0.05 —c 0.004
Psychosis 1 1 0 0 0 0 1 1 1.0 —c 0.99
OCD 7 5 1 1 5 4 2 2 0.3 0.02 to 5.1
Tic disorder 21 15 5 4 23 16 5 4 1.1 0.3 to 4.5
Enuresis 35 25 7 6 45 32 17 14 0.5 0.2 to 1.5
Encopresis 6 4 8 7 3 2 9 8 0.5 —c 0.48
Anorexia 2 1 0 0 0 0 0 0 —e
Bulimia 2 1 0 0 0 0 0 0 —e
a Significant difference between boys and girls with ADHD (χ2=26.4, df=1, p<0.001).
b Significant difference between boys and girls with ADHD (χ2=10.3, df=1, p=0.001).
c Exact logistic regression used; meaningful confidence intervals were not estimated.
d Significant difference between boys and girls with ADHD (χ2=5.2, df=1, p=0.002).
e Not defined.
f Significant difference between boys and girls with ADHD (χ2=7.7, df=1, p=0.006).

learning disability in reading or mathematics, and less
likely to be associated with problems in school or fewer
spare-time activities than ADHD in boys. Since these gen-
der differences were apparent in the absence of gender-
by-ADHD interactions, our results suggest that the risk for
ADHD-associated impairments may be similarly elevated
in both boys and girls, but that gender-specific variation in
baseline risks may result in different rates of psychiatric
morbidity and dysfunction that may adversely affect the
identification of the disorder in girls.
The single statistically significantly gender-by-ADHD
interaction identified was the association between ADHD
and substance use disorders (alcohol or drug abuse or de-
pendence). That ADHD in girls was a more serious risk
factor for substance use disorders than it was in boys was
an unanticipated and surprising finding. In the light of on-
going concerns regarding ADHD as a putative risk factor
for substance use disorders (21), this finding may indicate
that girls are particularly at risk in early adolescence.
Given that the ages at onset of ADHD and substance use
disorders are separated by at least a decade (22, 23), this
finding would support the targeting of substance abuse
prevention programs to girls with ADHD.
With the single exception of substance use disorders,
however, no statistically significant gender-by-ADHD inter-
actions were identified in the multiple outcomes evaluated.
These results suggest that with the exception of substance
use disorders, ADHD expresses itself similarly in boys and
girls relative to comparison subjects of the same gender, in-
dicating that ADHD-associated impairments are correlates
of ADHD in both boys and girls. However, between-gender
differences were identified among the children with ADHD,
such as the higher rate among girls of symptoms of inatten-
tion and lower rates of comorbidity with disruptive behav-
ior disorders, major depression, and learning disabilities.
Since these differences were attributable to the main effects
of gender rather than modification of the ADHD effect by
gender, these findings indicate that girls were at the same
relative risk for these adverse outcomes as boys but that
girls had different clinical presentations.
For example, although girls with ADHD were at signifi-
cantly greater risk for disruptive behavior disorders (con-
duct and oppositional defiant disorder) than girls without
ADHD (1), disruptive behavior disorders were clearly less
prevalent in girls, regardless of ADHD status. As suggested
by Gaub and Carlson (3), the lower risk of disruptive be-
havior disorders in girls could have led to the underidenti-
fication and underreferral of girls with ADHD because
clinical referrals are often based on overt problem behav-
ior and aggression. Consistent with this suggestion, girls
with ADHD had fewer school problems and participated
in more spare-time activities than boys with ADHD.
Furthermore, our results show that, although the com-
bined type of ADHD was the predominant type in both
girls and boys, girls with ADHD were twice as likely as boys
with ADHD to manifest the predominantly inattentive
type of the disorder. Since symptoms of inattention are
more covert than those of hyperactivity and impulsivity,

Am J Psychiatry 159:1, January 2002 39

GENDER AND ADHD

TABLE 3. Cognitive Functioning Among Girls and Boys in Two Studies of Children With and Without ADHD
Study of Girls Study of Boys Interaction of Gender
Measure ADHD (N=140) No ADHD (N=122) ADHD (N=140) No ADHD (N=120) and ADHD Status
Mean SD Mean SD Mean SD Mean SD Beta 95% CI

Block designa 11.2 3.1 12.4 3.2 13.3 3.8 15.2 3.3 –0.9 –2.0 to 0.3
Vocabulary 10.4 3.1 11.7 2.5 11.1 3.2 13.0 2.7 –0.7 –1.7 to 0.3
Digit span 8.8 3.1 10.5 2.9 8.9 2.8 10.7 2.8 –0.1 –1.1 to 0.9
Digit symbol codingb 10.7 3.1 12.2 3.1 9.9 3.5 11.8 2.6 –0.4 –1.5 to 0.6
Oral arithmeticc 9.9 2.7 12.0 2.9 10.6 3.1 12.4 2.9 0.3 –0.7 to 1.3
Freedom from distractibility IQ 98.4 13.7 108.9 16.7 98.8 15.8 111.1 13.3 –1.8 –7.0 to 3.4
Estimated full-scale IQd 104.0 12.5 109.9 11.2 109.5 13.5 118.4 10.2 –3.0 –7.2 to 1.1
Mathematical achievement 95.5 13.3 106.2 15.4 96.7 17.2 111.5 16.4 –3.9 –9.4 to 1.5
Reading achievemente 100.1 15.2 109.6 10.9 93.1 16.8 100.6 10.1 1.9 –2.9 to 6.7

N % N % N % N % Odds Ratio 95% CI

Learning disabilityf 16 12 7 6 40 30 12 10 1.7 0.5 to 5.5

Arithmeticg 9 7 5 4 28 21 9 8 1.9 0.5 to 7.7
Readingh 7 5 2 2 24 18 4 3 1.9 0.3 to 13.2
a Significant difference between boys and girls with ADHD (F=22.0, df=1, 275, p<0.001).
b Significant difference between boys and girls with ADHD (F=4.4, df=1, 275, p=0.04).
c Significant difference between boys and girls with ADHD (F=4.8, df=1, 275, p=0.03).
d Significant difference between boys and girls with ADHD (F=12.5, df=1, 275, p<0.001).
e Significant difference between boys and girls with ADHD (F=1.3, df=1, 268, p<0.001).
f Data were available for 509 subjects: 138 girls with ADHD, 122 girls without ADHD, 133 boys with ADHD, and 116 boys without ADHD. Signif-
icant difference between boys and girls with ADHD (χ2=13.9, df=1, p<0.001).
g Significant difference between boys and girls with ADHD (χ2=12.1, df=1, p<0.001).
h Significant difference between boys and girls with ADHD (χ2=11.3, df=1, p=0.001).

the higher rate of these symptoms in girls with ADHD than
in boys with ADHD may also partially explain the mark-
edly higher male-to-female ratios in groups of children
who are clinically referred for ADHD than in children with
the disorder who are not clinically referred.
Although girls with ADHD had statistically significantly
lower IQs than boys, these differences were small and of
limited clinical significance. These results are largely con-
sistent with those of other studies that have failed to iden-
tify meaningful effects of gender on cognitive perfor-
mance (24, 25), but we found that girls with ADHD had
significantly lower rates of psychometrically defined
learning disabilities, reflecting the absence of a significant
discrepancy between IQ and achievement scores in read-
ing and mathematics. Since academic underachievement
represents another leading reason for parents and teach-
ers to seek help for children with ADHD, the markedly
lower rate of learning disability in girls with this disorder
may also decrease identification of ADHD in girls.
Girls with ADHD were at significantly greater risk for co-
morbid major depression than girls without ADHD (1) but
had a significantly lower rate of comorbid major depres-
sion than boys with ADHD. This finding was not antici-
pated, since depression is commonly viewed as a predom-
inantly female disorder (26). Although the reasons for this
result are not entirely clear, it is consistent with findings
documenting that prepubertal-onset major depression is
largely male predominant (27). More consistent with the
adult literature is the finding of a higher rate of panic dis-
order in girls with ADHD than in boys with ADHD. The ex-
tant literature documents a higher rate of panic disorder
in females over males, regardless of age (28).
Modest but statistically significant differences were ob-
served in the treatment variables examined: boys with
ADHD tended to receive more pharmacotherapy and psy-
chotherapy than girls with the disorder. Although this re-
sult suggests that girls are less likely to receive appropriate
treatment for ADHD, the differences observed between
boys and girls were quite small and are not consistent with
the notion of inadequate treatment of girls with ADHD.
Rather, these findings could be interpreted as suggesting
that, once identified, ADHD may be treated similarly in
boys and girls.
Our results must be viewed in the light of some method-
ological limitations. Because only Caucasian subjects
were included, our results do not generalize to children of
other racial or ethnic backgrounds. Since these results are
cross-sectional, we cannot test the longitudinal impact of
gender on ADHD or the relative effect of treatment in girls
and boys. Our assessments relied on indirect parental re-
ports and direct interviews with those children older than
12 years (half of the children studied) but did not include
information collected from teachers or younger children.
This limitation is not likely to affect the findings presented
here because 1) both boys and girls were subjected to the
same methods, 2) we have found parent reports to be very
reliable and stable over time in our studies (29), and
3) others have raised questions regarding the validity of re-
ports taken from very young children (30).
In this study, children who met DSM-III-R criteria for
ADHD but not DSM-IV criteria were included in the analy-
sis. We did not use DSM-IV criteria to define ADHD in the
study groups in this report because both samples were as-
certained on the basis of DSM-III-R. On the basis of previ-

40 Am J Psychiatry 159:1, January 2002

 BIEDERMAN, MICK, FARAONE, ET AL.

TABLE 4. Psychosocial Environment of Girls and Boys in Two Studies of Children With and Without ADHD
Study of Girls Study of Boys Interaction of Gender
ADHD (N=140) No ADHD (N=122) ADHD (N=140) No ADHD (N=120) and ADHD Status
Psychosocial Variable Mean SD Mean SD Mean SD Mean SD Beta 95% CI
Interpersonal relationships
School behavior problemsa 2.6 0.8 1.5 0.6 2.8 0.8 1.7 0.7 –0.04 –0.3 to 0.2
Spare time activitiesb 2.1 0.7 1.9 0.5 1.9 0.6 1.7 0.5 0.06 –0.1 to 0.3
Spare time problems 2.1 0.8 1.4 0.5 2.2 0.9 1.5 0.6 –0.03 –0.3 to 0.2
Activity with peers 2.1 0.7 1.7 0.6 2.1 0.8 1.7 0.6 –0.01 –0.2 to 0.2
Problems with peers 2.1 0.8 1.3 0.5 2.2 0.9 1.5 0.5 –0.03 –0.3 to 0.2
Relationships with opposite sexc 2.5 0.8 2.3 0.7 2.3 0.9 2.3 0.8 –0.20 –0.6 to 0.3
Problems with opposite sexc 1.6 0.8 1.2 0.5 1.4 0.7 1.4 0.5 –0.40 –0.7 to 0.01
Activity with siblings 1.8 0.7 1.7 0.7 1.8 0.9 1.5 0.7 0.10 –0.1 to 0.4
Problems with siblings 1.9 0.7 1.5 0.6 1.9 1.1 1.5 0.8 –0.06 –0.4 to 0.2
Relationship with mother 1.5 0.6 1.5 0.6 1.6 0.7 1.4 0.5 0.09 –0.1 to 0.3
Relationship with father 1.8 0.8 1.7 0.8 1.8 1.0 1.6 0.8 0.05 –0.3 to 0.3
Problems with parents 2.0 0.8 1.3 0.5 2.1 0.8 1.3 0.5 0.10 –0.1 to 0.4
Family environment
Conflict 58.4 11.4 51.2 12.2 57.6 13.2 50.7 13.1 –0.30 –4.7 to 4.0
Cohesion 42.2 19.8 53.9 16.0 43.6 21.7 53.1 18.2 2.30 –4.4 to 8.9
Expressiveness 46.5 12.9 47.5 14.9 47.4 14.8 51.9 14.6 –3.50 –8.5 to 1.5
a Significant difference between girls and boys with ADHD (F=4.5, df=1, 265, p=0.03).
b Significant difference between girls and boys with ADHD (F=6.6, df=1, 265, p=0.01).
c Based on a subgroup of children (N=224) for whom the questions were answered by a parent or by self-report.

ous work showing that DSM-III-R-diagnosed ADHD is
highly convergent with DSM-IV-diagnosed ADHD in both
boys and girls (positive predictive value of 93%) (1, 31), we
believe that these results are informative today. The groups
of boys and girls were also ascertained 5 years apart from
each other, so that cohort effects could be misconstrued as
gender effects. Although the baseline risk of psychopathol-
ogy and other functional characteristics examined here
could be expected to change with time, the odds ratio in
contemporaneous comparison subjects should stay con-
stant. Thus, if we assume that there are no other confound-
ing variables, a statistically significant interaction could
not be due to a cohort effect and may reasonably be attrib-
uted to gender. In addition, we could not specifically test
the hypothesis that girls are underidentified because all of
the children with ADHD were referred for treatment.
Despite these considerations, our results suggest that
although gender is a limited effect modifier of ADHD as a
risk factor for ADHD-associated dysfunction in referred
children and adolescents, gender did have an effect on the
clinical presentation of the disorder. This was largely due
to the finding that girls with ADHD were less likely than
boys with ADHD to have comorbid disruptive behavior
problems, learning disabilities, and social dysfunction
and that the rate of symptoms of inattention was higher in
girls with ADHD. Since these features could result in a gen-
der-based referral bias unfavorable to girls, more work is
needed in both referred and nonreferred samples of chil-
dren with ADHD to assess this issue more fully.
Received Nov. 27, 2000; revision received April 10, 2001; accepted
June 26, 2001. From the Pediatric Psychopharmacology Unit, Child
Psychiatry Service, Massachusetts General Hospital, Harvard Medical
School. Address reprint requests to Dr. Biederman, Pediatric Psycho-
pharmacology Unit (WACC 725), Massachusetts General Hospital, 15
Parkman St., Boston, MA 02114; biederman@helix.mgh.harvard.edu
(e-mail).
Supported in part by National Institute of Child Health and Human
Development grant HD-36317 and NIMH grant MH-50657 (Dr. Bied-
erman).
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