Multimodal Treatment for Females with ADHD Background Attention deficit hyperactivity disorder, or ADHD, is a neurobiological disorder that

is often described as a disease of hyperactive boys (Sassi, 2010). Because of the lack of recognition with ADHD in females, it is often referred to as being a hidden disorder in this population (Quinn, 2005). As symptoms are less overt in females, it is much harder to diagnose than in males (Quinn, 2005). The sex-specific prevalence of ADHD is around 1%, which would mean that at least 1 million females in the United States are affected with the disorder (Biederman, Faraone, Mick, Williamson, Wilens, Spencer, Weber, Jetton, Kraus, Pert, & Zalen, 1999). ADHD in females is more likely to be the inattentive subtype. Other symptoms, including forgetfulness, disorganization, low selfesteem, and anxiety, are not as overt as the disruptive behaviors that are demonstrated by males (Quinn, 2005). This often results in only females with substantial impairments getting referred for treatment (Hinshaw, 2002). Coexisting disorders in females are often different than in males (Quinn, 2005). Females with ADHD have higher rates of learning disabilities, anxiety disorders, mood disorders, and substance use disorders (Quinn, 2005). They are also more likely than males to have an external locus of control. These secondary conditions, rather than the underlying ADHD, are more likely to be diagnosed, perhaps resulting in such low referral rates for women with ADHD (Quinn, 2005). Women are more likely to internalize their symptoms and become anxious, depressed, and withdrawn from a social life (Quinn, 2005). Most women with ADHD report levels of very low self-esteem and damaged social relationships. On the CBCL Social Competence Scale, girls were rated by their parents as being significantly less socially competent than males (Quinn, 2005). Common coexisting disorders prevalent in

Multimodal Treatment for Females with ADHD males such as conduct disorder and oppositional defiant disorder are only half as common in females (Quinn, 2005). Moreover, females with ADHD engage in many risky behaviors including sexual promiscuity and substance abuse at a rate that is greater than their male counterparts. Furthermore, they are also more likely to have difficulties with attention and with organization skills. (Quinn, 2005). Thus, as delineated by this research, ADHD looks very different in both genders. Previous related research Because these females are often underreported, far too little research has been dedicated towards looking at gender differences prevalent in this disorder as well as look at treatment specifically geared towards females (Quinn, 2005). Treatment is a critical issue, as nearly half of children with ADHD will go on to develop more serious comorbid disorders (Staller & Farone, 2006). With regards to medicinal treatment, a 2009 study looked at whether male and female adolescents differed in their responses to extended-release methylphenidate stimulant medication. Efficacy was evaluated using an adolescent and parent self-report measure along with measures of inattention and hyperactivity during psychological assessments. As the males and females were equal in impairment, the medication was similarity effective in reducing the ADHD symptoms. There were no gender differences with regards to side effects or effectiveness. This study suggests that the effectiveness and tolerability of stimulant medicine is equivalent for male and female adolescents with ADHD (Mikami, Cox, Davis, Wilson, Merkel, & Burket, 2009). The Multimodal Treatment Study of Children with Attention Deficit/Hyperactivity Disorder Cooperative Group found benefits in combined treatment

Multimodal Treatment for Females with ADHD for children with ADHD (Staller & Faraone, 2006). The children were given medication and behavioral treatment which consisted of parent training, teacher consultations, a summer treatment program, a behavioral specialist in the childs classroom, and case management (Staller & Farone, 2006). While this treatment was effective, sex effects were difficult to assess (Staller & Farone, 2006). Many findings suggest that there is a greater tendency for parents to use authoritarian parenting and discipline styles with females with ADHD, which would suggest that perhaps parent training would be helpful in the treatment of this disorder (Hinshaw, 2002). In neuropsychological measures, females displayed better cognitive strategies than males did (Quinn, 2005). One study showed that behavioral treatment had an unexpectedly strong benefit for children who had both ADHD and anxiety as opposed to those who only had ADHD. These findings suggest that cognitive behavioral therapy would be an effective treatment for this population. Lastly, findings indicate that lacking friends may play a large role in the development of internalizing problems such as loneliness and depression. Evidence suggests that females with ADHD suffer more peer rejection than males with ADHD. Females with ADHD have strained relationships with other peers because they tend to show defensive behavior and act more aggressively (Kelley, English, Schwallie-Giddis & Jones, 2007). Greater loneliness and isolation often leads to their sense of low selfesteem. Social skills interventions, thus far, have shown that acceptance can occur, but most of these interventions do not concentrate on the skills necessary to develop and maintain these friendships. Specific interventions that focus directly on the skills necessary to make friends may be a better treatment. Thus, programs that focus on the

Multimodal Treatment for Females with ADHD development of friendship may be the most beneficial for females with ADHD (Blachman & Hinshaw, 2002). Method Overview This research study will examine a multimodal treatment geared towards females with ADHD. It will be compared to a currently existing family treatment that has been shown to be efficacious, with a mostly male sample, for children with ADHD. As gender considerations have not been examined in depth, this study will look at 2 groups of females and see if the multimodal treatment geared towards females yields more improvement than the family based treatment. This is an important consideration, as we need to understand if the same treatments that work for males work for females or if a more comprehensive, but also more costly and time consuming, treatment yields more significant improvements. Participants will include 220 girls between the ages of 8-13 and will be one of the largest female ADHD samples ever investigated. They will be randomized into 2 groups, one receiving family therapy and the other receiving a multimodal therapy geared towards females. The family therapy group will be given the Problem Solving Communication Training (PSCT), which is a program developed by Robin and Foster (Hibbs & Jensen, 2005). This training model, which uses the adolescent as an active participant in the treatment, includes training in family-based problem solving, communication skills, and behavior-contract principles. The subjects assigned to this group will still take any medication that is administered to them prior to this research study.

Multimodal Treatment for Females with ADHD The components of the multimodal treatment will include pharmacology, individual counseling, social skills training, activities of daily living training, parent training, time, organization and attention training, and academic skills training. This original and unique combination of treatments was selected because it seems to target many of the areas that females with ADHD have trouble in. I hypothesize that both groups will show improvements, but that the females in the multimodal treatment will show more of an improvement than females in the family therapy group overall and in terms of social ability and academics. I also hypothesize that the anxiety levels in the multimodal treatment group will be significantly reduced. Participants Female children between the ages of 8 and 13 will be recruited by sending flyers to various mental health centers, school systems, and pediatric practices throughout Boston and within 40 miles of the city. The range of places to which we are sending the flyers and the diverse makeup of Boston and the surrounding area will make this a heterogeneous sample in terms of diversity. Subjects will be excluded if they have any major sensory handicaps (deaf, blind), psychosis, developmental disorder, an IQ of less than 75, or if they are not proficient in the English language. To promote the generalizability of this study, children with comorbid diagnoses will be included. The subjects must meet DSM-IV criteria for ADHD as diagnosed by a licensed psychologist. Participants will be assigned to two groups using randomization. Measures All of the following measures, besides the initial questionnaire, will be given both before the treatment and after the treatment. The first measure is an initial questionnaire.

Multimodal Treatment for Females with ADHD This questionnaire will be used to ascertain the demographics of the child as well as other background information. The next measure that will be used is the Child Behavior Checklist, or the CBCL. This checklist assesses the childs externalizing behavior. The next measure used will be the SNAP Parent Inattention and Teacher Inattention scales which has a checklist of ADHD items (Hinshaw, 2002). Both the childs teachers and parents will fill out the Daily Behavior Rating System. The Child Depression Inventory and The Multi-dimensional Anxiety Scale for Children, two self-report measures, will be used to assess depression and anxiety (Hinshaw, 2002). The Alabama Parenting Questionnaire will be used to assess parental involvement, positive activities between parent and child, parental use of praise and rewards, and punishment (Hinshaw, 2002). The childs math and reading skills will be assessed using the Wide Range Achievement Test-Revised, or the WRAT-R. Lastly, the child will be administered the Friendship Qualities Measure which is a 43-item scale used to assess the quality of a childs friendships (Blachman & Hinshaw, 2002). Procedure For both treatments All participants who have shown previous positive effects of methylphenidate prior to this treatment will continue to take their medication. They will take the most effective clinical dosage, at a maximum of 50 mg/day (Hibbs & Jensen, 2005). They must continue to be monitored by their primary care physician or by their psychiatrist. Family treatment Each PSCT treatment session will last an hour and be held twice weekly (Hibbs & Jensen, 2005). There will be 18 treatment sessions. At least one parent and the

Multimodal Treatment for Females with ADHD adolescent will be required to attend every session. There are 3 major components to this treatment. The first component is problem solving training. During this component, parents and their children will learn to problem solve using a 5-step approach in which they learn to define the problem, generate solutions, negotiate, decide on a solution, and implement the solution. The next component is communication training. During this component, the therapist will help parents and children to engage in more effective communication skills, especially while discussing family conflicts. These skills include speaking in an even tone, reiterating others concerns before speaking about ones own concerns, and avoiding hurtful language such as insults and putdowns. The last component will be cognitive restructuring. During this component, the therapist will help the parents and adolescent with detecting, confronting, and restructuring negative or extreme belief systems held by both the parents and the children about the others behaviors. The therapist will use direct instruction, feedback, role-play, modeling, and homework assignments during these three components (Hibbs & Jensen, 2005). Multimodal treatment Because this is a multimodal treatment, there are many different components to the 12 month treatment plan. Therapeutic Individual Counseling The subjects will meet with a counselor bi-weekly for an hour. Initially, the counselor will talk to the child about the disorder and inform them about the course and the nature of the disorder. This counselor will help the children identify and label feelings as well as discuss self-esteem issues which seem to be a salient issue with females with ADHD. The counselor will attempt to change the childs perception of

Multimodal Treatment for Females with ADHD rejection and increase self-effectiveness (Hibbs & Jensen, 2005). As females are more likely to have internalizing symptoms, the counselors will also use psychosocial interventions to specifically address anxious and depressed symptoms. They will also teach the child self-control strategies which will help curb impulsive behaviors. Most importantly, perhaps, the counselor will teach the child and the parent cognitivebehavioral techniques. These techniques may be very beneficial for females, especially because females do better than males in cognitive tasks and because behavioral therapy seems to be so effective (Quinn, 2005). Social Skills Training This yearlong component of the treatment may be the most beneficial for females. Girls with ADHD have trouble making friends, and the inattentive type may be unable to maintain friendships at all. This component will take place bi-weekly for an hour in a group setting and it will provide an opportunity for peer interaction. These sessions will focus directly on skills used to develop and maintain friendships. The counselors will help to guide role play in order to solve issues that may be specific to children with ADHD. They will also use direct instruction, modeling, rehearsal, and social reinforcement to practice these skills. The counselors will also focus on curbing the defensive mechanisms that females with ADHD often use which is a contributing factor to their lack of friendships (Kelley, English, Schwallie-Giddis & Jones, 2007). Activities of Daily Living Once monthly for an hour, a therapist will work with the child and parents to develop skills that will be used at home. These skills will be used to encourage independent self-care, chores, homework routines, and systems of rewards for positive

Multimodal Treatment for Females with ADHD behavior and achievements (Kelley, English, Schwallie-Giddis & Jones, 2007). Parent Training Group parent training will be held bi-weekly for 1.5 hours for 4 months. The parent training will be heavily based on Barkleys (1987) behavioral management training. Foremost, the parents will be taught more about the nature of the disorder. Then, the parents will learn how to effectively use praise, attention, and time out while setting up a token economy system. This system uses points whereby privileges and rewards are contingent on points that the child earns with the therapist, at school, during social skills training, and at home (Kelley, English, Schwallie-Giddis & Jones, 2007). Time, Organization & Attention Training This treatment may be more beneficial for females than males because females have more trouble with organization. During this bi-weekly, half hour treatment with the child for 4 months, a counselor will use positive feedback and behavioral modification techniques to enhance the organization skills of the child. They will do this by helping to break tasks into manageable pieces. The counselor will also strive to find strengths in the childs already existing organization system and build upon it (Kelley, English, Schwallie-Giddis & Jones, 2007). Moreover, as females have more of a difficulty in the maintaining attention domain of the disorder, the counselor will suggest and model several tricks that may be used to maintain attention, especially in the classroom and when completing homework. These may range from physical tricks such as squeezing a stress ball while listening to their teacher talk, to cognitive tricks which help the child learn how to pay attention. Academic Skills Training

Multimodal Treatment for Females with ADHD During the first 12 weeks of this treatment, every week for a half hour, the child will meet with a school counselor or school psychologist to work on solutions to solve academic problems. The counselor or psychologist will focus on teaching the child how to listen to and comprehend written and oral instructions, to get ready to work, to effectively use their time, and to review their work after completion. For the next 9 weeks, the children will receive one-on-one tutoring every week which will hone in on their specific deficits in reading, math, and English. These tutoring sessions will be specifically targeted for each individual (Kelley, English, Schwallie-Giddis & Jones, 2007). Analysis/Statistics The hypothesis addresses the question of whether there are group differences between the two treatment groups. Differences will be looked at using the CBCL, the SNAP, the Daily Behavior Rating System, the Child Depression Inventory, the Multidimensional Anxiety Scale for Children, the Alabama Parenting Questionnaire, the WRAT-R, and the Friendship Qualities Measure. All analyses will be performed using SPSS. For these analyses, we will use a multivariate approach, as we have several outcome variables. We will use MANOVA to compare the outcome of both groups as a whole at both pretreatment and posttreatment. MANOVA identifies whether changes in the independent variable have significant effects on the dependent variables. MANOVA will also provide us with additional tests to assess the differences between specific measures. We may find a difference between groups, but it will be important to assess if these differences are accounted for by a few of the measures. Limitations

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Multimodal Treatment for Females with ADHD There are a few limitations to this study. One limitation is that we are investigating females with ADHD in general and are not taking into consideration what subtype of ADHD they may have, such as the inattentive subtype or the combined subtype. Because this is one of the first studies on females with ADHD, we decided not to look at the particular subtypes. Future research should look at treatment outcomes for females with different subtypes. Another limitation is that we are not using any observational measures to assess these children. It may be useful for researchers to observe these females in their natural school and home settings. Finally, another limitation is that both of our treatment groups will remain on medication throughout the treatment. It is important for researchers to continue to study the effects of gender with stimulant medicine and to see if these medications effect females differently throughout their menstrual cycle and through their ever changing hormone cycles. Summary Once ADHD is diagnosed, it is a very treatable condition. Females have the potential to benefit from treatment as much as males, but their gender differences need to be taken into consideration. This treatment model will investigate whether a femalefocused multimodal treatment is more efficacious for females than a family based treatment. This is important to investigate, as it could either show that the family based treatment works just as well which would suggest similarities in treating both genders, or that the more comprehensive and less economical multimodal treatment is necessary.

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