The ADHD Phenotype in Black and White Girls From Childhood to Adolescence: Results From the Community-Based Pittsburgh Girls Study

Abstract

Objective:

The goal of the present study is to describe the ADHD phenotype from childhood to adolescence in Black and White girls in a community sample.

Method:

Primary caregivers enrolled in the population-based, longitudinal Pittsburgh Girls Study reported on girls’ ADHD symptoms and impairment from ages 7 to 17; diagnostic subtypes were estimated based on meeting symptom criteria.

Results:

The prevalence of any subtype of ADHD ranged from 6.4 to 9.2% and from 2.3 to 6.4% for Black and White girls respectively; the inattentive subtype was most endorsed. A relatively equal number of new diagnoses at each age was observed. Persistence of ADHD diagnoses was typically 1 to 2 years.

Conclusions:

ADHD in the community is relatively common, with the inattentive subtype as the most common phenotype for Black and White girls. Research on developmentally sensitive periods for symptom exacerbation or new onset of ADHD in girls is needed.

Keywords

ADHD girls black girls white girls phenotype community-based

Tribute to Joseph Biederman

Joe Biederman was Dr. Keenan’s first research mentor, and as such he has a profound presence in her work. In addition to the enormous depth and breadth of his scientific work, Joe’s legacy is preserved in how he shaped the behavior of the many emerging clinical scientists that he mentored. Joe showed empathy and respect for the participants in his research studies, he was egalitarian in his interactions with all his colleagues—faculty, trainees, research staff and administrators, and his rigor in conducting research was unsurpassed. Perhaps most important was the passion he displayed for improving the mental health of children. He believed that scientific inquiry could be harnessed to reduce stigma and disparities, and improve treatment and prevention. He and his colleagues conducted one the largest studies of clinically referred girls with ADHD, an understudied and under-treated population. We are pleased to expand on this body of research by describing the ADHD phenotype from childhood to adolescence in Black and White girls in a community sample.

Introduction

Data on diagnostic phenotypes are important for treatment, prevention, and generation of causal models of child psychopathology. Characteristics such as prevalence, age of onset, course, and impairment are critical to determining the timing of preventive interventions, engaging in surveillance regarding critical periods of exacerbation or increasing impairment, and revealing developmental periods within which potential causes should be studied (Merikangas & Salum, 2023). The population within which diagnostic phenotyping is conducted also is relevant. Clinically referred samples can help guide treatment research for individuals with more severe presentations, persistent courses, and co-occurring conditions. Equally important are non-clinical community-based samples, which likely represent a broader range of severity from mild to severe. In addition, studying diagnostic phenotypes in community samples may increase the diversity of the population studied, as biases resulting from sex stereotyping impact the assessment of impairment as well as attributions of causal factors for behavioral and emotional functioning. Further, a history of and continuing experiences with racism in healthcare delivery and the continued structural and systemic barriers to assessment and treatment have resulted in reduced representation of Black youth in mental health research (Metzger et al., 2023).

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by deficits in controlling attention, activity, and impulses that negatively impact functioning across two or more settings (American Psychiatric Association [APA], 2022). ADHD is a commonly diagnosed psychiatric condition in children, with prevalence estimates generally ranging from 7 to 10% in the United States (Centers for Disease Control and Prevention [CDC], 2022; Merikangas et al., 2010; Thomas et al., 2015). There are three subtypes of ADHD: predominantly inattentive, predominantly hyperactive/impulsive, and a combined inattention and hyperactivity/impulsivity subtype. ADHD typically has an onset in childhood, is persistent (Van Meter et al., 2023), and is associated with an increased risk for depression (Garcia-Argibay et al., 2023), suicidality (Austgulen et al., 2023), and substance use (Mustonen et al., 2023). Thus, accurate diagnostic phenotyping of ADHD may reduce the risk of persistent behavioral and emotional problems across the lifespan via early identification, deployment of preventive interventions, and surveillance regarding symptom exacerbation.

Across several large-scale population studies, the prevalence rate of ADHD is approximately twice as high for boys than for girls (CDC, 2022; Merikangas et al., 2010). This sex difference in prevalence is likely a leading reason for the sex disparity in ADHD research, with much more published research on ADHD in boys than in girls (Hinshaw et al., 2022). What we do know about ADHD in girls has been expertly summarized by Hinshaw et al. (2022). Most studies of clinical samples have included relatively small numbers of girls. One exception to this is the Massachusetts General Hospital Studies of Girls and Boys (see Uchida et al., 2018 for a review), which included one of the largest studies of clinically referred girls with ADHD (n = 140; Faraone et al., 2000). In this study, girls with ADHD were more likely to present with the inattentive subtype than the hyperactivity and impulsivity or combined subtype (Biederman et al., 2002). Girls with ADHD were also significantly more likely to develop additional psychiatric disorders and engage in high-risk and/or self-harm behaviors as they entered late adolescence and early adulthood than girls without ADHD (Biederman et al., 2010). In addition, the majority of clinically referred girls with ADHD continued to meet criteria into adolescence (Mick et al., 2011). Similar results were reported by Hinshaw and colleagues who conducted a study of girls with ADHD recruited from schools and health-care providers called the Berkeley Girls with ADHD Longitudinal Study (Hinshaw, 2002). Symptoms of inattention and executive dysfunction tended to persist into adolescence for girls diagnosed with ADHD in elementary school, although reductions in hyperactive and impulsive symptoms were observed overall (Owens et al., 2017). Importantly, even with the reduction of hyperactive symptoms, significant impairment remained across academic, social, and neurocognitive domains for girls with ADHD (Hinshaw et al., 2006; Hinshaw et al., 2007). Babinski et al. (2011) assessed the functioning of young adult women who had been diagnosed in childhood with ADHD and found impairments in academic, occupational, and social relationships compared to demographically matched women without ADHD.

The prevalence of ADHD in the community using clinically informed methods has been challenging to estimate given the lack of epidemiological studies in the U.S. focusing on children’s mental health (Merikangas & Salum, 2023). Results from the recently fielded Adolescent Brain Cognitive Development (ABCD) study of 11,874 boys and girls aged 9 and 10 years who were recruited from schools at 21 sites across the U.S. yielded a prevalence of 2.3% in 9- to 10-year-old girls, 14% of whom identified as Black, and 24% of whom identified as Latina (Olfson et al., 2023).

In addition to the dearth of research on ADHD in females from community studies, very few data are available on ADHD in Black girls (Hinshaw et al., 2022). Cénat et al. (2021) sought to identify studies that had empirical data on the prevalence of ADHD in samples of Black people and were conducted in countries where Black people are considered a minority population group (e.g., United States and Canada) for a meta-analysis; 21 studies were identified from 1979 to 2019, which corresponds to a single study reporting on the prevalence of ADHD in Black individuals being conducted every other year. The lack of data on ADHD in girls impacts our capacity to address racial disparities in mental health. We recognize that such disparities reflect racial differences in exposure to stressors, including interpersonal discrimination and systemic and structural racism. The different experiences of being Black and White in the United States may yield different patterns of prevalence, symptoms, course, impairment, and referral (Moody, 2017). As such, diagnostic phenotyping needs to be described separately for racial groups (Buchanan et al., 2020). In this way, we can ensure that prevention efforts and causal models will be relevant for girls from different racial groups.

The aim of this study is to contribute to the current knowledge base on ADHD in girls by describing the prevalence of ADHD subtypes and symptoms, persistence, age of onset, and impairment in Black and White girls participating in the Pittsburgh Girls Study (PGS), a community-based, longitudinal study of girls. We present data separately for Black and White girls from ages 7 to 17 years based on caregiver reports of symptoms and impairment.

Methods

Participants

Details of the PGS were previously published (Keenan et al., 2010). Briefly, the PGS was initiated in 1999-2000 to study the development of behavioral and emotional problems among girls. All homes in neighborhoods in the City of Pittsburgh in which at least 25% of the families were living at or below the poverty level were contacted to determine if the household contained an age-eligible girl (ages 5 and 8 years at study enrollment), and a random selection of 50% of households in all other city neighborhoods were contacted. A total of 103,238 households were enumerated. Among 2,992 eligible families, 85% agreed to participate, resulting in a total sample size of 2,450. Data were collected from the primary caregiver via face-to-face annual in-home assessments beginning in 2000. All study procedures were approved by the University of Pittsburgh Institutional Review Board. Prior to any data collection, we obtained written informed consent from the primary caregiver for their own participation, and verbal assent from the child.

Retention of the sample has been very high, ranging from 97.5% for age 7 to 86.8% for age 17. Some of the yearly retention variability is due to difficulties tracking participants; a minority of families refused to participate over the years (<3% at age 17). Comparisons of those assessed and those not assessed at each age were conducted using chi-square tests. Caregivers of girls who were not assessed were less likely to have received public assistance and more likely to identify as White compared to caregivers of girls who were assessed. There was no difference in the number of ADHD symptoms or diagnoses at age 7 between girls who were and were not retained over the next 10 years.

Measures

Symptoms of ADHD were assessed using caregiver reports on the Child Symptom Inventory (CSI-4; Gadow & Sprafkin, 1994/1997) for ages 7 to 12 years, transitioning to the Adolescent Symptom Inventory (ASI-4; Gadow & Sprafkin, 1994/1997) from age 13 to 17 years. DSM-IV symptoms of ADHD were scored on 4-point scales ranging from 0 (never) to 3 (very often). The ADHD subscale of the CSI/ASI has shown good concurrent validity and good sensitivity and specificity in distinguishing youth with clinical diagnoses from healthy controls (Gadow & Sprafkin, 1994/1997). We used symptom counts to estimate DSM-IV diagnoses of ADHD-combined, primarily inattentive, and primarily hyperactive-impulsive subtypes based on DSM-IV criteria for symptom thresholds. DSM-5-TR (APA, 2022) specifies that “several” symptoms must be present prior to age 12 years for a diagnosis of ADHD. Given the structure of the present study, which included annual prospective assessments of ADHD symptoms, age of onset was defined as the first year that three or more symptoms of ADHD were endorsed.

Parent-rated impairment was assessed via the Child Global Assessment Scale (C-GAS; Setterberg et al., 1992), which is a measure of impairment developed for children 4 to 18 years of age that has been validated for use by parents (Bird et al., 1996). Scores on the C-GAS range from 1 to 100, with each decile containing a description of the degree of impairment in school and family and peer relations. C-GAS scores of 60 or below indicate clinically significant levels of impairment (Bird et al., 1996).

Race was assessed by asking the primary caregiver to indicate all racial and ethnic groups that described the girl’s racial identity.

Data Analysis

The PGS uses an accelerated longitudinal design, with relatively equal numbers of girls at ages 5, 6, 7, and 8 years being enrolled in the study at wave 1. For the present study, data were aligned by age, resulting in a developmental span from ages 7 to 17 years. All analyses were conducted with weighted data to correct for the wave 1 over-sampling of the low-income neighborhoods and to generate prevalence rates that are representative of the population in the City of Pittsburgh.

The distribution of caregiver-reported race for the 2,450 girls was 53% Black, 41% White, 5% multi-racial, and 1%, Asian. Thus, the sample provides good representation for Black and White girls. Given our goal of generating race-specific data on prevalence and course, we include the girls who identified as Black or White in this study.

Results

Prevalence of Meeting Symptom Criteria

The prevalence of meeting symptom criteria for any type of ADHD DSM-IV diagnosis ranged from 6.4% at age 9 years to 9.2% at age 13 years for Black girls (Figure 1) and from 2.3% at age 9 years to 6.4% at age 13 for White girls (Figure 2). The combined subtype was the least common, and the inattentive subtype was the most common diagnostic phenotype for both Black and White girls. Among those girls meeting symptom criteria from ages 13 to 17 years, the age of onset criteria of several symptoms present by 12 years of age was met in 80 to 90% of cases.

Symptom Endorsement

The rate of endorsement for each symptom of ADHD at each age is presented in Table 1 for Black girls and Table 2 for White girls; symptom endorsement is presented for girls meeting criteria for any ADHD subtype. Generally, hyperactivity/impulsivity symptoms were more often reported for younger age groups regardless of ADHD subtype or race. For example, one of the most endorsed symptoms for the 7-year-old group was “interrupts people or butts into other children’s activities,” which was endorsed for 90.0% of Black girls and 74.6% of White girls. The same item was only endorsed for 40.8% of Black girls and 23.2% of White girls in the 17-year-old group. There was also a rise in inattentive symptoms endorsed with increased age for both Black and White girls. The symptom “fails to attend to details” was endorsed for approximately 55% of 7-year-old girls but for >80% of 17-year-old girls. The most consistently endorsed inattentive symptom was “easily distracted,” which was evident across all age groups (68.4–92.6% Black girls, 78.9–95.1% White girls).

Table 1.

Percent of Black Girls Endorsing Specific Symptoms Among Those Meeting Criteria for Any ADHD Subtype at Each Age.

Age in years	7	8	9	10	11	12	13	14	15	16	17
Number meeting criteria	n = 51	n = 68	n = 60	n = 61	n = 64	n = 82	n = 84	n = 84	n = 73	n = 64	n = 61
Fails to attend to details	56.6	55.6	57.6	55.8	64.3	71.2	85.0	80.5	78.6	83.5	82.6
Difficulty paying attention	52.9	60.3	61.1	54.5	67.4	76.6	88.7	76.6	79.5	83.8	83.7
Seems not to listen	50.0	59.4	70.7	66.7	67.9	78.8	79.8	84.5	82.6	77.7	82.8
Difficulty following through	45.2	53.8	73.9	68.1	73.6	77.5	84.4	81.9	85.4	83.0	88.3
Difficulty organizing tasks	26.8	42.5	48.3	53.6	56.9	67.3	73.6	69.4	76.8	76.3	81.0
Avoids mental effort	45.2	48.2	55.9	55.5	62.3	76.0	71.6	63.7	79.9	76.5	71.9
Loses necessary things	31.0	34.9	47.2	38.4	54.7	55.1	52.3	46.7	51.5	55.7	49.2
Easily distracted	68.4	77.6	85.9	82.3	88.7	92.6	89.2	88.9	86.0	75.7	86.5
Forgetful	29.4	45.0	57.3	54.4	66.0	63.3	67.4	68.0	67.4	59.1	70.4
Fidgets with hands or feet	65.5	65.1	61.5	62.1	53.9	46.5	37.9	47.1	44.3	29.2	33.1
Difficulty staying in seat	70.8	58.7	54.1	58.8	43.0	45.0	36.5	46.7	33.2	39.2	25.6
Restless or jittery	56.4	53.4	38.0	41.7	33.2	27.8	28.1	41.9	38.9	29.7	23.4
Difficulty doing things quietly	53.7	48.8	42.3	40.5	36.8	40.6	38.0	43.8	38.2	36.2	42.4
Driven by a motor	65.7	58.2	60.2	60.8	49.8	46.2	47.3	41.9	47.4	44.1	44.4
Talks excessively	74.5	86.7	77.0	85.2	66.4	69.8	62.6	61.7	61.4	60.6	54.5
Blurts out answers	65.7	63.9	57.0	66.1	57.1	56.2	48.6	42.5	46.3	43.4	38.8
Difficulty waiting turn	62.6	45.8	54.4	59.9	49.6	39.2	38.5	32.9	31.9	29.7	24.5
Interrupts or butts in	90.0	64.3	62.2	63.0	58.8	44.7	58.3	52.3	45.5	46.4	40.8

Table 2.

Percent of White Girls Endorsing Specific Symptoms Among Those Meeting Criteria for Any ADHD Subtype at Each Age.

Age in years	7	8	9	10	11	12	13	14	15	16	17
Number meeting criteria	n = 34	n = 51	n = 51	n = 41	n = 57	n = 57	n = 76	n = 59	n = 63	n = 61	n = 59
Fails to attend to details	54.6	67.5	81.8	69.8	84.8	74.2	83.7	77.1	87.3	81.7	89.4
Difficulty paying attention	45.4	58.9	73.5	72.8	84.8	67.8	70.7	77.0	83.5	76.8	81.9
Seems not to listen	71.1	66.4	71.2	72.8	84.8	74.3	80.4	77.2	77.7	86.9	71.6
Difficulty following through	51.0	69.9	77.0	81.9	84.8	75.3	73.9	81.3	87.3	88.0	85.1
Difficulty organizing tasks	38.2	62.7	62.6	75.8	78.3	78.4	80.4	71.9	73.9	82.8	75.6
Avoids mental effort	51.0	68.8	71.2	69.8	84.9	59.2	70.7	70.7	82.4	78.8	85.1
Loses necessary things	32.9	21.8	46.9	63.8	64.1	55.7	43.7	51.0	57.1	63.6	60.7
Easily distracted	83.6	85.6	90.4	78.9	84.8	89.2	83.6	88.5	95.1	89.9	93.7
Forgetful	32.5	44.5	60.3	56.1	73.9	80.5	64.9	62.5	57.1	60.6	67.3
Fidgets with hands or feet	76.3	77.0	65.1	48.3	44.6	47.4	42.4	53.2	36.9	38.6	52.6
Difficulty staying in seat	67.4	56.8	47.2	28.9	22.9	19.5	27.7	25.1	26.4	19.2	21.2
Restless or jittery	61.9	46.9	26.6	34.9	20.7	21.7	24.5	30.4	28.1	24.4	27.4
Difficulty doing things quietly	45.4	22.9	24.2	28.9	25.0	28.1	26.3	23.0	22.3	19.2	19.0
Driven by a motor	78.3	65.0	52.0	59.0	44.6	35.5	36.5	35.5	15.6	23.3	17.9
Talks excessively	85.5	66.4	55.4	53.0	57.6	53.8	46.4	45.0	30.3	25.2	33.7
Blurts out answers	49.0	45.6	32.5	50.0	31.6	37.6	39.0	31.3	22.3	21.2	27.4
Difficulty waiting turn	54.6	44.5	26.6	31.8	27.2	19.3	23.5	15.6	10.7	11.2	12.6
Interrupts or butts in	74.6	56.8	31.4	59.0	42.4	38.8	32.7	38.7	23.4	19.4	23.2

Persistence

For girls meeting criteria for any ADHD subtype in any year, we calculated the number of years that they met the diagnostic symptom threshold for ADHD. As shown in Figures 3 and 4, about two-thirds of the cases of ADHD persisted for 1 to 2 years for both Black and White girls. In addition, we examined the average number of symptoms endorsed at each age for girls meeting criteria for ADHD (at some point) compared to those who never met criteria for ADHD. As shown in Figure 5, Black girls who eventually met criteria for ADHD had on average 4 to 5 symptoms in each year of assessment compared to an average of 1 symptom for Black girls never meeting criteria for ADHD, a difference that was significantly different (F [1,695] = 745.76, p < .001). Similar patterns of symptom persistence were observed for White girls (F [1,526] = 762.35, p < .001; see Figure 6). Thus, girls with ADHD generally evidenced a persistent level of subthreshold symptoms from ages 7 to 17.

Age of Onset

The cumulative age of onset for Black and White girls meeting criteria for ADHD at any age are presented in Figures 7 and 8. For both groups of girls, the age of onset was linear with a relatively equal number of participants at each age.

Associations With Impairment

Black girls with an ADHD diagnosis were rated significantly more impaired than girls without a diagnosis (Table 3). For most age groups, impairment levels did not differ significantly between diagnostic subtypes. At some ages, girls with the combined subtype were rated as significantly more impaired than girls with the inattentive or hyperactivity subtype. For some ages, girls with the hyperactive subtype did not differ from those without diagnoses but showed significantly higher functioning or less impairment than those with the inattentive subtype. For White girls, parents rated girls with any subtype of ADHD as being significantly more impaired than girls without a diagnosis, with larger effect sizes in adolescence than in childhood (Table 4). Comparisons on parent-rated impairment were not conducted for groups with less than 10 diagnosed individuals.

Table 3.

Parent-Rated Impairment Scores for Black Girls With and Without ADHD Diagnoses.

Age	No diagnosis		Inattentive type		Hyperactive type		Combined type		F	p Level	η	Comparisons
Age	Mean	SD	Mean	SD	Mean	SD	Mean	SD	F	p Level	η	Comparisons
7	85.26	10.74	70.56	16.74	75.39	15.1	67.4	19.4	25.26	<.001	0.28	N > H,I,C
8	84.13	11.38	72.18	17.14	76.71	13.36	76.07	13.51	16.12	<.001	0.20	N > H,I
9	83.83	10.89	70.45	15.58	73.14	13.69	66.2	16.47	33.71	<.001	0.28	N > H,I,C
10	81.79	11.06	70.18	13.34	75.32	14.17	61.08	17.31	27.67	<.001	0.26	N > H, I, C; H > C
11	81.87	11.74	67.74	14.60	77.74	11.21	55.75	21.00	43.75	<.001	0.32	N > I, C; I > H, C; H > C>
12	80.96	13.10	68.78	16.11	71.84	12.86	69.58	15.20	23.22	<.001	0.24	N > H, C, I
13	81.08	12.64	63.21	16.86	69.94	12.51	57.58	15.14	63.01	<.001	0.38	N > H, I, C; H > C
14	79.50	13.12	60.82	15.19	67.10	15.76	58.64	15.74	58.23	<.001	0.37	N > H, I, C
15	79.42	13.57	60.72	18.01	65.50	13.42	53.57	17.34	58.94	<.001	0.37	N > H, I, C
16	80.24	13.29	63.32	17.99	70.09	19.79	59.07	18.57	39.57	<.001	0.32	N > I, C
17	80.94	13.12	64.02	16.63	64.00	23.46	50.55	11.11	50.01	<.001	0.35	N > I, H, C; I > C

Note. Comparisons were not tested between cells with an n of less than 10. N = No diagnosis; H = Hyperactive Type; I = Inattentive Type; C = Combined type.

Table 4.

Parent-Rated Impairment Scores for White Girls With and Without ADHD Diagnoses.

Age	No diagnosis		Inattentive type		Hyperactive type		Combined type		F	p Level	η	Comparisons
Age	Mean	SD	Mean	SD	Mean	SD	Mean	SD	F	p Level	η	Comparisons
7	85.16	10.86	76.10	11.47	71.29	14.53			12.04	<.001	0.22	N > H
8	84.83	9.98	70.56	13.17	72.71	15.98			22.63	<.001	0.26	N > H,I
9	84.56	9.65	70.76	12.74					44.96	<.001	0.36	N > I
10	82.97	10.3	68.63	11.72					23.95	<.001	0.27	N > I
11	83.81	10.81	68.94	14.04			56.7	20.95	38.42	<.001	0.34	N > I > C
12	83.17	11.82	70.06	16.59					23.65	<.001	0.27	N > I
13	82.81	11.55	66.28	16.91	72.92	13.00			34.89	<.001	0.33	N > H, I
14	81.15	13.10	61.73	16.13	74.42	13.98			25.50	<.001	0.29	N, H > I
15	82.13	12.53	62.89	13.94					37.01	<.001	0.34	N > I
16	82.53	12.77	63.34	18.77					34.77	<.001	0.34	N > I
17	81.94	13.18	64.59	18.98					26.89	<.001	0.31	N > I

Note. Comparisons were not tested between cells with an n of less than 10. N = No diagnosis; H = Hyperactive Type; I = Inattentive Type; C = Combined type.

Discussion

The purpose of this study was to describe the presentation of ADHD in Black and White girls in a community-based sample. Our results indicate that the prevalence of ADHD ranges from 6 to 9% for Black girls and from 2 to 6% for White girls across ages 7 to 17 years. The most common subtype for both groups of girls is the inattentive subtype, consistent with findings from clinical samples (Biederman et al., 2002). We also observed that the peak prevalence for the inattentive subtype occurred at age 13 years for both Black and White girls. These results raise the question of whether the severity of symptom manifestation (i.e., intensity, persistence, pervasiveness) changes over time or whether the severity is relatively constant, but the impairment (i.e., the impact of the symptom manifestation on daily functioning) increases as environmental demands change. If the former, then it is possible that other maturational processes (e.g., pubertal, neural) are involved in symptom exacerbation, which would be important for causal modeling. If the latter, then better methods for assessing symptom impact at earlier developmental periods are needed to deploy preventive interventions prior to adolescence when the consequences of deficits in attention are arguably more significant. Some researchers have suggested that symptoms of inattention and disorganization, particularly when subtle, may not become clinically significant until early adolescence when there are greater expectations within the educational environment, leading to a delay in diagnosing ADHD in girls (Bruchmüller et al., 2012), whereas others have suggested that ADHD represents a delay in the development of executive functioning skills during adolescence (Gordon & Hinshaw, 2020).

Our results on persistence differed from the results reported for clinical samples (e.g., Mick et al., 2011). In the present study, over 40% of girls who met symptom criteria for any ADHD subtype at any age met criteria for a single year, and an additional 20% met criteria for 2 years. This relatively low level of persistence in diagnosis was in contrast with the persistence of symptoms over time; on average girls who met criteria for ADHD in at least 1 year were reported to have four to five symptoms at each age of assessment, as compared to one symptom for girls who never met criteria. Data from both clinical (Biederman et al., 2018) and community (Hong et al., 2014) samples have shown that subthreshold ADHD, typically defined as four to five symptoms, is associated with significant levels of impairment and risk for co-occurring psychopathology. Therefore, if we reconsider our findings on persistence to include subthreshold and full symptom criteria, we reveal a high level of persistence across the 10-year period of study.

Results from the PGS suggest that for girls in the community, new cases of ADHD occur across childhood and adolescence with similar numbers of new cases reported at each age. According to the DSM-5 (APA, 2022), ADHD is a neurodevelopmental disorder, which typically manifests early in development, often before school age. Most youth with ADHD present for treatment in the elementary school years (Hinshaw, 2018). When considering the emergence of symptoms, that appears to be the case for the girls in the present study. When considering the threshold of meeting diagnostic criteria, however, the results from the present study indicate that the disorder would be better characterized as one of childhood and adolescence. The reframing of the disorder as a life course disorder is relatively recent (Young et al., 2020); our results support the contention that symptoms and impairment are persistent across childhood and adolescence. For girls and young women, such a reframe may be especially important in facilitating the recognition of symptoms and access to treatment.

We note several limitations to this study. First, we used a single informant for the assessment of ADHD and impairment. Although caregivers often serve as the primary informant for the assessment of ADHD in childhood, the addition of self and teacher reports during childhood and adolescence is advised both because the diagnostic criteria require symptoms to be manifest in more than one setting and because some symptoms, such as feelings of restlessness and inattention, may be less obvious to an observer. Second, although our participants were representative of girls living in the City of Pittsburgh at the start of the study, they are not representative of the U.S. Relatedly, the demographic composition of Pittsburgh at the time of enrollment meant that some racial and ethnic groups were not represented. Third, we did not have information on the rate of referral for assessment or treatment uptake. In other research conducted in non-clinical settings (e.g., Zgodic et al., 2023), parents are often asked the question, “Has a doctor or professional told you that your child has ADHD?” Our approach of assessing symptoms in the community allows us to measure the prevalence of symptoms and disorders regardless of identification by a professional, which is useful for generating epidemiological data, but it does not allow us to comment on the rate at which Black and White girls meeting criteria for ADHD are being identified by parent, teachers, or pediatricians as having a diagnosis. Moreover, we were unable to test whether the observed low levels of persistence in meeting diagnostic criteria may have been accounted for in part by treatment engagement. Finally, as stated at the outset, a first step towards addressing racial disparities in health is to describe the diagnostic phenotype separately for Black and White girls, with the longer-term goal of developing models for prevention that are equally relevant. We did not test differences in ADHD characteristics by race given that any differences would be best captured by measures of racism. Such tests are possible in the Pittsburgh Girls Study and will be a goal of our future research.

Footnotes

Acknowledgements

The authors thank the families participating in the Pittsburgh Girls Study for their past and continued participation, and the amazing team of field interviewers and supervisors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research included R01 MH56630.

ORCID iDs

Yangfeifei Gao

Kate Keenan

Author Biographies

Israel Moses Gross, PhD, is an Assistant Professor of Psychiatry and Behavioral Neuroscience at the University of Chicago; his research and clinical interests focus on fostering positive developmental trajectories among children with neurodevelopmental and medical disorders.

Yangfeifei Gao, PhD, is an Assistant Professor of Psychiatry and Behavioral Neuroscience at the University of Chicago; her research focuses on phenotyping heterogeneous neurodevelopmental conditions including autism and ADHD.

Mary J. Lee, PsyD, is a Post-doctoral Fellow in the Department of Psychiatry and Behavioral Neuroscience at the University of Chicago; her research and clinical interests focus on neurocognitive functioning in complex medical conditions and autism spectrum disorder across the lifespan.

Alison E. Hipwell, PhD, ClinPsyD, is Professor of Psychiatry at the University of Pittsburgh; she conducts intergenerational studies of mental health.

Kate Keenan, PhD, is Professor of Psychiatry and Behavioral Neuroscience at the University of Chicago; her research focuses on stress exposure and health and health disparities.

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