Antisocial Behavior in Females With Comorbid Diagnoses of ADHD and Conduct Disorder

Antisocial Behavior in Females with Comorbid Diagnoses of ADHD

Detention centers and residential treatment facilities are replete with male and female youth that have been in and out of the juvenile justice system for many years. Although the majority of the populations in these facilities are male, the number of female juvenile offenders is continually increasing. Many of the children in these facilities have a history of behavioral difficulties that may or may not have been diagnosed during much of their childhood.

Antisocial behaviors are acts that violate social rules and the basic rights of others. They include conduct intended to injure people or damage property, illegal behavior, and defiance of generally accepted rules and authority, such as truancy from school. "These antisocial behaviors exist along a severity continuum (Clark, et al., 2002). When childhood antisocial behaviors exceed certain defined thresholds -- the diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994) -- the child is considered to have CD and possibly a comorbid condition. Together with attention deficit hyperactivity disorder (ADHD), these two disorders are classified as "disruptive behavior disorders" in the DSM-IV (Clark)."

Antisocial behaviors represented in the DSM-IV diagnostic criteria for conduct disorder (CD) include aggression toward people and animals, destruction of property, deceitfulness, theft, and other serious social rule violations (Clark, et al., 2002). A diagnosis of CD also requires a persistent behavior pattern in which 3 or more of a total of 15 behaviors occur over a 12-month period. The DSM-IV specifies childhood-onset and adolescent-onset types of CD and different degrees of severity of the disorder.

Female antisocial behavior and conduct disorder has often times gone overlooked due to the abundance of research available for males. This paper will examine existing research to discuss antisocial behavior in females with comorbid diagnoses of ADHD and conduct disorder, explaining the fundamentals of both conditions and the factors that led to the association of males with the disorders.

Introduction

Behaviors associated with attention deficit hyperactivity disorder (ADHD) and conduct disorder (CD) are often blamed for incidences of juvenile offense. In many cases, these disorders occur simultaneously, making it extremely difficult for researchers to determine exactly how much each disorder contributes to delinquent behavior. Thirty to fifty percent of adolescents diagnosed with ADHD are also diagnosed with CD, though the two disorders are very different.

CD usually means that the juvenile violates the social norms and rights of others. According to statistics, this condition is generally a male disorder, occurring in 9% of boys and 2% of girls under the age of 18. Conduct Disorder usually appears before puberty in males, and after puberty in females. Many of these children have normal IQ's, but have two or three years behind academically, and have lower verbal skills and abstract reasoning abilities.

Children and adolescents with this disorder seem to constantly be in trouble, with parents, teachers, other children or even the law. They display signs of low self-esteem, anger, frustration, irritability, hot tempers and recklessness. CD often leads to adult antisocial personality disorder.

According to DSM-IV documents, typical patterns of behavior in people with conduct disorder fall into four main categories: aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules. In most cases, aggression is necessary for a diagnosis of conduct disorder (Lexcen and Redding, 2000). Rates are 6% to 16% for males less than age 18 years, and 2% to 9% for females. Boys outnumber girls in aggressive acts, but it is questionable whether DSM-IV criteria adequately assess the diagnosis of conduct disorder in girls or their level of aggression.

Recent studies reveal that approximately 90% of incarcerated juveniles were diagnosed with CD, which is characterized by persistent violation of age-appropriate societal norms or rules or a disregard for the rights of other individuals. Many of these juvenile were also diagnosed with ADHD.

ADHD is characterized by symptoms of inattention, hyperactivity, or impulsivity. Children and adolescents with ADHD usually show signs of poor school performance, reduced participation in extracurricular activities, and negative social relationships. People with ADHD have limited problem-solving skills and difficulty paying attention. ADHD in adults causes mental illness, incarceration, job failures, and marital problems.

Today, ADHD is the most common psychiatric disorder affecting children and adolescents. ADHD is often accompanied by at least one comorbidity: most commonly, CD (Weller, et al., 1999, p. 60). Aggressive behaviors are often observed in juveniles with ADHD and CD. While many theories explain the fundamentals of aggression in these disorders, no single theory has accurately accounted for all the different types of aggressive behaviors associated with them.

However, a great deal of research has revealed that young people who have aggressive behavior with ADHD differ from those who have ADHD without aggression (Weller, et al., 1999, p. 60). Aggressive behavior in children with ADHD is associated with greater psychological disturbance, antisocial familial factors, and subsequent development of antisocial personality and substance abuse. In children, ADHD without aggression is associated with greater cognitive deficits, cognitive problems at follow-up, and learning difficulties in siblings.

Statement of the Problem

Earlier research suggested that these two syndromes stemmed from the same underlying condition, despite the fact that they had different symptoms, particularly since both diagnoses seemed to predict juvenile criminal offending. However, recent studies reveal that the two diagnoses represent two distinct disorders, with ADHD relating more closely to cognitive and academic problems and CD relating more closely to delinquency in childhood and adolescence.

According to Weller, et. al (1999): "The reliability of measurable epidemiologic samples of aggression in children and adolescents is inadequate because aggressive behaviors of all types have extremely low base rates. Subcategories of aggression such as physical, nonphysical, and verbal aggression occur even less frequently, which results in even more problems in reliability of measurements." Traditionally, males outnumber females in physically aggressive acts. However, girls are more likely to exhibit relational aggression, such as threats of ending friendships, exclusion of others from cliques, and non-confrontational verbal devaluations, all of which are harder to assess than physical aggression.

Comorbidity issues are also important in assessing aggression because, in many cases, ADHD children have comorbid oppositional defiant disorder or conduct disorder. Rating scales used to evaluate aggression in children and adolescents are the Iowa Conners Teacher Questionnaire, the Children's Aggression Scale, and the parent and teacher versions of the Child Behavior Checklist. However, these scales are often inaccurate in diagnosing females. Therefore, there is a gender bias in terms of referring children for assessment or treatment, and girls are less likely to be referred because the scales are based on male-dominated research.

Due to the lack of available research on female adolescents and comorbid ADHD, it is difficult to accurately diagnose these disorders and, in many cases, they are undiagnosed and untreated (Weller, et al., 1999, p. 60). Early detection of ADHD and associated comorbidities in a young girl's development would allow for appropriate treatment and counseling. However, many girls never receive the necessary care because they are never diagnosed.

Review of Existing Literature

Multisystemic Treatment (MST), which includes traditional treatment and interventions with offenders in school and community settings, has been shown to be a highly effective intervention for the delinquent behaviors associated with CD and comorbid disorders (Lexcen and Redding, 2000). Juvenile offending, regardless of diagnostic status, is best treated as a potentially chronic disorder requiring multiple, persistent interventions across numerous settings, rather than an acute condition that resolves after a brief intervention. One of the most important aspects of helping female juveniles is coming up with a method to diagnose their condition. To do so, it is important to fully understand antisocial behavior in females.

According to studies, as a whole, CD appears more often in males than in females, with a rate of 6% to 10% for males, and 2% to 9% for females (APA, 1994). These rates vary depending on the age range and type of disorder. Some studies estimate the male-female ratio between about 3:1 and 5:1. However, while more males are affected at all ages, the gap between males and females closes at adolescence. Therefore, by mid-adolescence, females surpass males in the onset of CDs (Offord, 1987).

Despite the obvious need for female-based research on CD and comorbid ADHD, there is little research focusing on females. Gender differences in the expression of CD become more obvious at adolescence, as boys are more likely to exhibit aggressive behavior than girls. Still, girls at this age often engage in other types of antisocial behavior as a result of these disorders, including covert juvenile offenses and prostitution. There are also likely to display non-violent aggression.

While these differences can be seen in the majority of adolescents, they seem to disappear in adolescents who are severely disturbed. Over the past several years, the number of very aggressive girls has increased. Many of these girls have been victims of sever abuse and neglect. These factors paint a very complex clinical picture and present enormous risks to society.

Girls and Antisocial Behavior

For year, society has placed most of its attention on aggression in children on boys. Most people assume that boys are more aggressive because their forms of aggression are more visible. Teacher see them fighting in school and displaying other signs of aggression. For this reason, much of the research on aggressive children, particularly regarding CD and ADHD, has focused on the more overt, physical types of aggression characteristics of boys.

According to Crick and Grotpeter (1995, p. 710), much of this research has overlooked aggressive behavior in girls because the patterns of aggression in girls are different than in boys. This is why there is so much more research on boys. While most definitions of aggression include behaviors that aim to hurt or harm others, this study suggested that aggression also includes behaviors that "best thwart or damage goals that are valued by their respective gender peer groups" (p. 710).

In this light, boys tend to harm others with physical or verbal aggression because this behavior is consistent with the physical dominance goals of boys. Girls, however, are more likely to focus their aggression on relational issues because this behavior is consistent with the social and intimacy goals of girls. This kind of aggression, which is called "relational aggression" is more characteristic of girls, though not exclusive to girls, and is done with the intention of damaging another child's friendship or feelings of inclusion within a social group (p. 711).

Still, despite the fact that the aggression shown by girls is less obvious than aggression shown by boys, it still shows a need for intervention. Girls' relational aggression can include excluding another child from a clique as a form of retaliation, intentionally hurting or controlling a child, and spreading rumors about a child (p. 711). These patterns are indicative of CD and comorbid ADHD.

In most cases, this type of behavior is cause for concern. Most aggressive girls have more social and emotional problems and experience more loneliness, depression, negative self-perceptions, and peer rejection than others. They are also more likely to engage in antisocial behavior and have problems with authority and the law.

Breakthrough in Research

Recently, psychologist Stephen P. Hinshaw, PhD, published two studies the focused on ADHD in girls last October, and females with ADHD finally began receiving long overdue attention from researchers (Crawford, 2003). Hinshaw was one of the first psychologists to study the disorder as it related to girls. The majority of prior studies focused on comparing girls to boys -- using the ADHD symptoms for boys as the marker against which girls should be measured.

However, Hinshaw's research revealed "that girls experience significant struggles that are often overlooked because their ADHD symptoms bear little resemblance to those of boys (Crawford, 2003)."

Historically, research on ADHD has focused almost exclusively on hyperactive little boys, and only in the past six or seven years has any research focused on adult ADHD," according to psychologist Kathleen Nadeau, an expert on the disorder in women and director of Chesapeake Psychological Services of Maryland in Silver Spring (Crawford, 2003). "And the recognition of females [with the disorder] has lagged even further behind."