Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders

We evaluated the association between attention deficit hyperactivity disorder (ADHD) and the age of onset of psychoactive substance use disorders (PSUD) in adults with ADHD. We hypothesized that ADHD and psychiatric comorbidity would be risk factors for early onset PSUD. We compared 120 referred adults having a clinical diagnosis of childhood-onset ADHD with 268 non-ADHD adults. All diagnoses were obtained using DSM-III-R based structured psychiatric interviews. We used group comparisons of age at onset and Cox proportional hazard models to examine the development of PSUD over time. ADHD was associated with earlier onset of PSUD independently of psychiatric comorbidity. Conduct and juvenile bipolar disorders conferred a significantly increased risk for early onset PSUD independently of ADHD. Psychiatric disorders commonly emerged before the onset of PSUD in both groups. Persistent ADHD with and without psychiatric comorbidity was associated with adolescent onset PSUD. In addition, comorbidity with conduct and juvenile bipolar disorders predicted very early onset PSUD in both ADHD and non-ADHD individuals. These findings confirm and extend previous findings documenting important associations between PSUD and psychiatric comorbidity including persistent ADHD.

Predicting desipramine levels in children and adolescents: a naturalistic clinical study

OBJECTIVE

To determine the predictability and stability of desipramine (DMI) concentrations in a clinically treated sample of children, estimating the risk of developing potentially toxic DMI levels at a higher dose after a most recent level in a clinically acceptable range.

METHOD

Subjects were 90 consecutive psychiatrically referred children and adolescents treated with DMI with at least two assays of serum DMI concentrations (462 pairs). Assay data were analyzed after log transformation and linear regression.

RESULTS

Despite wide between-patient variability in serum DMI levels at the same dose, future within-subject DMI blood levels were highly predictable from knowledge of current levels, current dose, and the future dose. When the DMI serum level was 200 to 300 ng/ml, there was a 7.0% risk for subsequent levels at the same dose to exceed 300 ng/mL, but potentially toxic levels above 500 ng/mL were very infrequent (1.7%).

CONCLUSIONS

Although the results of this naturalistic clinical study may not generalize to other situations, the results indicate a reasonable stability, predictability, and safety of DMI levels in individual psychiatrically treated children that result from clinically chosen dose changes.

A study of the quantitative and qualitative impact of catheter shaft angulation in a mechanical intravascular ultrasound system

Nonuniform rotation of mechanical intravascular ultrasound transducers may give rise to a geometric distortion of the ultrasound image known as the rotation angle artefact. This investigation studied the influence of different degrees and combinations of catheter shaft angulation on image morphology and the quantitative impact of the artefact using a circular perspex phantom and 3.5 F, 30 MHz Boston Scientific "Sonicath" catheters connected to a Hewlett Packard Sonos intravascular scanner. Major and minor diameters, cross-sectional area and circumference of the phantom lumen were measured and a "distortion index" calculated. Visually apparent geometric distortion was graded from 1 (absent) to 4 (severe). As expected, eccentric transducer location was associated much more frequently with identifiable distortion (70%) than was a concentric location (6%). Greater distortion occurred with increasing degrees of catheter shaft angulation, and was more pronounced in images from older catheters. The lumen area measurements in images in which no artefact was identified were accurate to within +/- 10% in 97% of cases, compared to only 81% of cases when an artefact was noted. The quantitative accuracy of an image in which geometric distortion is identified is thus not reliable. The direction of the quantitative error cannot be confidently predicted in any given case, although the mean lumen area tends to increase as the grade of distortion increases.

Characterisation of atherosclerotic plaque by spectral analysis of intravascular ultrasound: an in vitro methodology

Raw 30-MHz intravascular ultrasound data have been captured from postmortem coronary arteries (n = 4) to develop radio frequency analysis techniques for the characterisation of atherosclerotic plaque. Digitised data acquired from positions (n = 8) within diseased sections of artery were compared with the corresponding histology and radiology. Scan-converted images were used to locate regions of interest (ROI = 33) within areas of tissue composition: loose fibrotic tissue (LFT), dense fibrotic tissue (DFT) and calcium (CA). A range of parameters was extracted from the normalised power spectrum of each ROI within the bandwidth 17-42 MHz. Significant discrimination between LFT/DFT and between LFT/CA was provided by maximum power and spectral slope (dBMHz-1). However, the greatest discriminative power was given by the y-axis (0 Hz) intercept of the spectral slope: LFT/DFT (p = 0.001); LFT/CA (p = 0.0001); and DFT/CA (p = 0.089).

Characterisation of red and white thrombus by intravascular ultrasound using radiofrequency and videodensitometric data-based texture analysis

Visual assessment of intravascular ultrasound (IVUS) video images cannot reliably identify thrombus. We examined if texture analysis of radiofrequency (r.f.) data or videodensitometric data (VD) could distinguish thrombi of different ages and cell compositions. Whole human blood (red clot = RC), platelet-rich plasma (white clot = WC) and plasma (n = 6/group) were imaged at 4 and 24 h with 30 MHz IVUS transducers. At 4 h, VD- and r.f.-based analyses revealed significant differences between RC and WC with variance (VD red 26.4 +/- 2.5, white 33.9 +/- 7.8; r.f. red 1.4 +/- 0.5, white 4.9 +/- 1.3), kurtosis (VD red 0.29 +/- 0.9, white 0.23 +/- 0.3) and skewness (VD red 0.23 +/- 0.13, white 0.35 +/- 0.52; r.f. red 0.06 +/- 0.01, white -0.06 +/- 0.05). Also mean grey-level from both data sets was higher in RC (VD 134.8 +/- 18.0; r.f. -13.3 +/- 1.2) than in WC (VD 105.3 +/- 17.4, r.f. 16.5 +/- 2.2) (p < 0.01). With increasing time, variance increased in WC (5.5 +/- 1.5 at 24 h) and decreased in RC (0.9 +/- 0.3.3 at 24 h). The more heterogeneous structure of WC may be distinguished from that of RC using texture analysis of either VD or r.f.-signals.

Oral manifestations seen in association with a case of trisomy for the short arm of chromosome 9

A case of trisomy for the short arm of chromosome 9 in a 13-year-old boy is described. Particular emphasis is placed upon a number of abnormal dental findings, which include enamel hypoplasia, hypodontia, and severe dental crowding. The difficulties of providing comprehensive dental treatment in cases such as these is discussed.

An image-processing strategy for the segmentation and quantification of microaneurysms in fluorescein angiograms of the ocular fundus

Digital image-processing techniques can provide an objective and highly repeatable way of quantifying retinal pathology. This study describes an image-processing strategy which detects and quantifies microaneurysms present in digitized fluorescein angiograms. After preprocessing stages, a bilinear top-hat transformation and matched filtering are employed to provide an initial segmentation of the images. Thresholding this processed image results in a binary image containing candidate microaneurysms. A novel region-growing algorithm fully delineates each marked object and subsequent analysis of the size, shape, and energy characteristics of each candidate results in the final segmentation of microaneurysms. The technique is assessed by comparing the computer's results with microaneurysm counts carried out by five clinicians, using Receiver Operating Characteristic (ROC) curves. The performance of the automated technique matched that of the clinicians' analyses. This strategy is valuable in providing a way of accurately monitoring the progression of diabetic retinopathy.

Three-year follow-up of participants in a commercial weight loss program. Can you keep it off?

BACKGROUND

One third of Americans are obese, according to the 1988-1991 National Health and Nutrition Endpoint Survey III survey. Obesity increases the risk of death and a variety of chronic diseases. Numerous commercial weight loss programs demonstrate short-term success.

OBJECTIVE

To assess maintenance of weight loss achieved during dieting.

METHODS

We surveyed 192 participants in the Sandoz Nutrition (Sandoz Pharmaceuticals, Minneapolis, Minn) diet program approximately 3 years after participation. Initial date were supplied by the diet clinics and follow-up data, including weight at various points after the program, participation in other weight loss programs, and lifestyle variables, such as exercise, smoking, and television watching, were collected by a mailed questionnaire.

RESULTS

On average, the group lost 22 kg during the diet program. After the follow-up period, the mean weight (mean, 102.6 kg) was only modestly less than the group's original weight at the start of the diet (mean, 105.9 kg). Twelve percent of the subjects maintained 75% of their weight loss after leaving the diet program, 57% maintained at least 5% of the loss, and 40% gained back more than they had lost during the diet. The frequency of exercise after the diet program was the strongest predictor of weight loss maintenance, while television viewing predicted a gain in weight.

CONCLUSION

Given the apparent lack of substantial, long-term success at weight reduction, perhaps greater emphasis should be placed on prevention of obesity.

A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders

BACKGROUND

Previous cross-sectional data showed that children and adolescents with attention-deficit hyperactivity disorder (ADHD) are at increased risk of comorbid conduct, mood, and anxiety disorders as well as impairments in cognitive, social, family, and school functioning. However, longitudinal data were needed to confirm these initial impressions.

METHODS

Using DSM-III-R structured diagnostic interviews and raters blinded as to diagnosis, we reexamined psychiatric diagnoses at 1- and 4-year follow-ups in children with ADHD and controls. In addition, subjects were evaluated for cognitive, achievement, social, school and family functioning.

RESULTS

Analyses of follow-up findings revealed significant differences between children with ADHD and controls in rates of behavioral, mood, and anxiety disorders, with these disorders increasing markedly from baseline to follow-up assessments. In addition, children with ADHD had significantly more impaired cognitive, family, school, and psychosocial functioning than did controls. Baseline diagnosis of conduct disorder predicted major depression and bipolar disorder at follow-up, and anxiety disorders at baseline predicted anxiety disorders at follow-up.

CONCLUSION

These results confirm and extend previous retrospective results indicating that children with ADHD are at high risk of developing a wide range of impairments affecting multiple domains of psychopathology such as cognition, interpersonal, school, and family functioning. These findings provide further support for the value of considering psychiatric comorbidity in both clinical assessment and research protocols involving children with ADHD.

Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle

OBJECTIVE

To evaluate the scope of the available therapeutic armamentarium in attention-deficit hyperactivity disorder (ADHD).

METHOD

The literature of medication trials in ADHD was systematically reviewed, with attention to issues of psychiatric comorbidity, age, gender, and ethnic background.

RESULTS

One hundred fifty-five controlled studies of 5,768 children, adolescents, and adults have documented the efficacy of stimulants in an estimated 70% of subjects. The literature clearly documents that stimulants not only improve abnormal behaviors of ADHD, but also self-esteem, cognition, and social and family function. However, response varied in different age groups and with certain comorbid conditions. In addition, there is an impressive body of literature documenting the efficacy of tricyclic antidepressants on ADHD in more than 1,000 subjects. Studies of alternative antidepressants, antipsychotics, antihypertensives, and other compounds were also reviewed.

CONCLUSIONS

The available literature indicates the important role of psychopharmacological agents in the reduction of the core symptoms of ADHD and associated impairments. More research is needed on alternative pharmacological treatments and to further evaluate established therapeutics beyond school-age Caucasian boys. In addition, more research is needed on the efficacy of treatment for comorbid ADHD, use of combined medications, and the combination of medication and psychosocial treatment.

Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study

OBJECTIVE

To evaluate the predictors of persistence and the timing of remission of attention-deficit hyperactivity disorder (ADHD).

METHOD

Subjects were 6- to 17-year old Caucasian, non-Hispanic boys with and without ADHD. DSM-III-R structured diagnostic interviews and blind raters were used to examine psychiatric diagnoses, cognitive achievement, social, school, and family functioning at a 4-year follow-up assessment.

RESULTS

At the 4-year follow-up assessment, 85% of children with ADHD continued to have the disorder and 15% remitted. Of those who remitted, half did so in childhood and the other half in adolescence. Predictors of persistence were familiality of ADHD, psychosocial adversity, and comorbidity with conduct, mood, and anxiety disorders.

CONCLUSIONS

The findings prospectively confirm that the majority of children with ADHD will continue to express the disorder 4 years later. For a minority of children, ADHD was a transient disorder that remits early in development. In addition, we have shown that persistence of ADHD is predictable. Familiality, adversity, and psychiatric comorbidity may be clinically useful predictors of which children with ADHD are at risk for a persistent disorder.

Enrollment in the Health Alliance Plan HMO is not an independent risk factor for coronary artery bypass graft surgery

BACKGROUND

Henry Ford Hospital is the sole provider of cardiac surgical services for the Health Alliance Plan, a health maintenance organization (HMO) that presently serves 450,000 enrollees.

METHODS AND RESULTS

To determine the effect of managed care referral patterns on the outcome of coronary artery bypass graft (CABG) surgery, we retrospectively reviewed two concurrent groups of patients, 569 HMO patients and 225 patients with free-for-service (FFS) insurance, who had undergone isolated primary CABG surgery between January 1, 1990 and January 31, 1994. The 605 patients with Medicare operated on during the same time frame were excluded to obviate age bias. Age, sex, use of cardiac medications, history of prior percutaneous transluminal coronary angioplasty or thrombolytic therapy, history of recent and remote myocardial infarction, extent of coronary disease, presence of preexisting comorbid conditions, and incidence of unstable clinical syndromes and left ventricular dysfunction (ejection fraction < 40%) were comparable for both groups. In hospital mortality (HMO group, 1.9%; FFS group, 2.2%), mean ICU stay (HMO, 2.6 +/- 0.3 days; FFS, 2.3 +/- 0.3 days), and total hospital length of stay (HMO, 9.8 +/- 0.8 days; FFS, 8.6 +/- 0.6 days) were likewise similar.

CONCLUSIONS

These data refute the notion that the gate-keeper mentality often associated with managed-care health insurance vehicles results in delayed referral of patients with coronary artery disease and results in suboptimal outcome.

The relationship between tic disorders and Tourette's syndrome revisited

OBJECTIVE

The relationship between Tourette's syndrome (TS) and chronic tic disorder is of great clinical and scientific importance because of uncertainties in both prognosis and pharmacotherapeutic strategies. One approach to evaluating the relationship between TS and chronic tics is to examine whether they share similar neuropsychological and psychiatric correlates.

METHOD

Children with TS (n = 32) and children with chronic tics (n = 39) were ascertained from an unselected sample of the children referred for psychopharmacological treatment and examined using standardized diagnostic assessments and testing procedures.

RESULTS

Children with TS and those with chronic tics were similar to each other and different from controls in clinical correlates that included psychiatric comorbidity, as well as school, neuropsychological, and psychosocial impairments. Patients with TS also had higher rates of obsessive-compulsive disorder, oppositional defiant disorder, and simple phobia than did patients with chronic tic disorder.

CONCLUSIONS

These findings indicate that TS and chronic tic disorder are part of the same disease entity, with TS being a more severe form of tic disorder.

ADHD and thyroid abnormalities: a research note

Contradictory findings have been reported on associations between ADHD and thyroid abnormalities including the syndrome of generalized resistance to thyroid hormone. We systematically reviewed thyroid function in a large group of children and adolescents with ADHD (N = 132). We failed to find evidence of generalized resistance to thyroid hormone. Although mild laboratory abnormalities in thyroid function were observed in a minority of ADHD subjects, they were not different than rates reported in the literature for normal children.

A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood-onset attention-deficit hyperactivity disorder

BACKGROUND

There are few controlled studies of methylphenidate hydrochloride in adults with attention-deficit hyperactivity disorder (ADHD), and their results have been equivocal. The discrepancies among these studies may be related to low doses, diagnostic uncertainties, and lack of attention to comorbid disorders.

METHODS

We conducted a randomized, 7-week, placebo-controlled, crossover study of methylphenidate in 23 adult patients with DSM-III-R ADHD using standardized instruments for diagnosis, separate assessments of ADHD and depressive and anxiety symptoms, and a robust daily dose of methylphenidate hydrochloride, 1.0 mg/kg per day.

RESULTS

We found a marked therapeutic response for methylphenidate treatment of ADHD symptoms that exceeded the placebo response (78% vs 4%, P < .0001). Response to methylphenidate was independent of gender, psychiatric comorbidity with anxiety or moderate depression, or family history of psychiatric disorders.

CONCLUSION

Robust doses of methylphenidate are effective in the treatment of adult ADHD.

Nutritional support of the hospitalized patient: a team approach

Nutritional deficits have long been recognized as contributing factors to morbidity and mortality of hospitalized patients. A multi-disciplinary team approach to nutritional support has been shown to be superior to non-team approaches. A formal consultive nutritional support team has been active at St. Dominic Hospital since 1991. The benefits of our nutritional support team at St. Dominic Hospital are described. Acquisition of an Indirect calorimeter has improved measurements of caloric and substrate requirements. Individualized nutritional prescriptions more closely meet assessed patient needs. Utilization of less expensive, more physiologic enteral feeding routes have increased. Also, the number of total parenteral nutrition (TPN) bags admixed and wasted have decreased, despite an increase in the percent of patients with moderate to severe nutritional risk. The nutritional support service at St. Dominic Hospital has improved patient care while reducing cost to both the institutional and patient.

Effects of moderate hyperglycemia on the temporal profile of brain tissue intracellular pH and [Mg2+] after global cerebral ischemia in rats

In an attempt to understand the mechanisms by which preischemic plasma glucose (pg) worsens neurologic and neuropathologic outcomes, we investigated the effect of moderate preischemic hyperglycemia (200 mg/dl < mean plasma glucose < 360 mg/dl) on postischemic energy metabolism, tissue intracellular pH (pHi) and tissue free intracellular pMg (= -log[Mg2+]) over a one week period after transient global cerebral ischemia in the rat. In vivo 31P nuclear magnetic resonance spectroscopy was performed prior to and daily up to 1 week (wk) in rats after 12 min of forebrain ischemia, induced by bicarotid occlusion concurrent with systemic hypotension. Preischemic plasma glucose significantly affected 1 wk postischemic survival (p = 0.05, Fisher's exact test). The temporal profile of the brain tissue pHi was significantly different (p < 0.03) between the moderate hyperglycemic (H-1wk, n = 7, mean pg = 266.0 +/- 47.3 mg/dl) and the normoglycemic (N-1wk, n = 8, mean pg = 91.2 +/- 23.7 mg/dl) ischemic animals over 1 wk. Postischemic tissue alkalosis was measured at 24 (p = < 0.006) and 48h (p = 0.001) postischemia in the N-1wk group. A single marginally significant (p = 0.011) mean pHi upshift was measured at 72h postischemia in the H-1wk group. The mean change in pHi at 24h postischemia from the baseline values in moderate hyperglycemic animals that survived only 48h after ischemia (H-48h, n = 6, mean pg = 298.8 +/- 70.1 mg/dl) was significantly lower (p = 0.02) than that of the N-1wk ischemic animals.(ABSTRACT TRUNCATED AT 250 WORDS)

High risk for attention deficit hyperactivity disorder among children of parents with childhood onset of the disorder: a pilot study

OBJECTIVE

Although well-documented in clinical and epidemiological studies of attention deficit hyperactivity disorder (ADHD) in children, the familial nature of the adult syndrome has not been well investigated. One approach to evaluate the familial nature of adult ADHD is through a high-risk design aimed at estimating the risk for the disorder in children of parents with child-hood-onset ADHD.

METHOD

Children at risk for ADHD were ascertained from the study group of 84 referred adults with clinical diagnoses of childhood onset of the disorder, confirmed by structured interviews. Diagnostic information on the disorder was derived from the ADHD module of the Schedule for Affective Disorders and Schizophrenia for School Age Children--Epidemiologic Version, supplemented with information regarding treatment for ADHD for the affected child and school history including repeated grades, placement in special classes, and tutoring.

RESULTS

Of the 84 children at risk, 48 (57%) met criteria for ADHD. The rate of the disorder in children of adults with the disorder was significantly higher than the previously reported rate of ADHD among siblings of children with the disorder. Of the 48 ADHD children of parents with the disorder, 36 (75%) were treated for it. The rates of school failure were almost identical to those previously reported in a group of referred children and adolescents with ADHD.

CONCLUSIONS

These results support the validity of the adult diagnosis of ADHD and suggest that the adult form of this disorder may have stronger familial etiological risk factors than its pediatric form. If these results are confirmed, families selected through adult probands with ADHD might be especially useful for testing genetic hypotheses about the disorder.

Similarities in response to fluoxetine in the treatment of children and adolescents with obsessive-compulsive disorder

OBJECTIVE

Obsessive-compulsive disorder (OCD) is a relatively common disorder that frequently has its onset in childhood and is associated with substantial morbidity and dysfunction despite availability of new treatments. However, antiobsessional agents have not been systematically evaluated in young children and their effectiveness beyond the short term has not been well studied. The purpose of this study was to evaluate the usefulness of fluoxetine in the long-term treatment of both children and adolescents with OCD.

METHOD

All pediatric patients with a DSM-III-R diagnosis of OCD who were treated with fluoxetine were ascertained from retrospective chart reviews of a pediatric psychopharmacology clinic. Response to treatment was evaluated by experienced clinicians using the Clinical Global Impression Scale.

RESULTS

Of 38 identified patients, 28 (74%) showed moderate to marked improvement of OCD symptoms on doses averaging 50 mg/day (1.0 mg/kg per day) over an average follow-up period of 19 months. Similar effects were observed in children and adolescents.

CONCLUSION

Although limited by their retrospective nature, these findings indicate that fluoxetine may be effective in prepubertal children and that the effect can be sustained over time.

Quantitative image analysis of macular drusen from fundus photographs and scanning laser ophthalmoscope images

Drusen are common features in the ageing macula and are associated with exudative age-related macular degeneration (ARMD). They appear as characteristic structures in indirect mode infrared scanning laser ophthalmoscope (SLO) images. Manual counting of drusen area in SLO images has shown no significant difference from that in standard fundus photographs in 6 eyes of 5 patients (p > 0.5). Computerised image processing techniques have been applied to digitised colour fundus photographs and indirect mode images to quantify the area of the macula affected by drusen in an automated fashion. Application of these methods may permit objective and repeatable assessment of the natural history of macular drusen. For a specificity of 90%, a sensitivity of 60% for colour fundus photographs and 35% for SLO images has been achieved, when compared with manual counting. The colour fundus photograph method also showed superior reproducibility compared with the SLO technique.

Blood conservation in coronary artery surgery

BACKGROUND

Most patients undergoing coronary artery bypass surgery receive homologous blood transfusions despite the availability of multiple pharmacologic and blood salvage conservation strategies.

METHODS

The efficacy of defining strict transfusion criteria as the sole blood conservation strategy was adjudicated prospectively by comparing homologous blood product usage in 314 consecutive patients undergoing isolated primary coronary artery bypass surgery (group 2) with a retrospective group of 947 consecutive patients undergoing the same procedure but transfused without protocol (group 1).

RESULTS

The incidence of red cell transfusion and plasma transfusion decreased from 40.5% to 25.8% and 23.8% to 13.4% in groups 1 and 2, respectively (p < 0.001). The percentage of patients receiving no homologous blood products increased from 47.6% in group 1 to 68.5% in group 2 (p < 0.001). Decreasing body weight and preoperative hematocrit were found to be highly significant predictors of the need for red blood cell transfusion (p < 0.001). Significant postoperative determinants included intensive care unit and hospital length of stay and reoperation for bleeding (p < 0.001 each).

CONCLUSIONS

Because major determinant of homologous blood transfusion during coronary bypass surgery is the predictable and unavoidable dilution of a small red cell mass that occurs when instituting cardiopulmonary bypass, adherence to defined transfusion criteria alone is a simple, safe, and effective strategy for decreasing blood product utilization.

Gender differences in a sample of adults with attention deficit hyperactivity disorder

Although originally conceptualized as a childhood disorder, attention deficit hyperactivity disorder (ADHD) may also be an adult disorder. However, despite increasing media attention to adult ADHD, its validity has only recently been studied in a systematic fashion. The overrepresentation of females in adult samples in comparison to pediatric samples of ADHD raises additional questions about the validity of this disorder in adults. The goal of this article is to explore whether ADHD is a valid clinical entity in female subjects and whether it is expressed differently in male and female adults. To this end, we examined the clinical, cognitive, and functional characteristics of 128 referred adult ADHD cases of both sexes. Each subject had a clinical diagnosis of childhood-onset ADHD confirmed by structured interview. The male and female ADHD adults were similar to one another but more disturbed and impaired than non-ADHD adult control subjects. Compared with normal control females, ADHD women had higher rates of major depression, anxiety disorders, and conduct disorder; and more evidence of school failure and cognitive impairment. The consistency of these findings in both genders further supports the validity of the diagnosis of ADHD in adults. Our results stress the viability and importance of identification of female subjects with ADHD. The underidentification and undertreatment of females with ADHD may have substantial mental health and educational implications, suggesting that research is needed to develop a better understanding of clinical indicators of ADHD in females.