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Sex Differences in Externalizing and Internalizing Symptoms in ADHD, Autism, and General Population Samples

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Abstract

Oppositional behavior, irritability, and aggression are common in autism and ADHD-Combined presentation (but less frequent in ADHD-Inattentive), and children with autism are at high risk for anxiety. No study has compared sex differences in externalizing and internalizing symptoms between ADHD-Combined, ADHD-Inattentive, autism, and general population samples. The samples comprised 1436 children with autism (with or without ADHD), 1056 with ADHD without autism, and 665 from the general population, 2–17 years. Nine externalizing, four internalizing, and nine somatic symptoms rated by mothers on the Pediatric Behavior Scale did not differ significantly between girls and boys in the autism, ADHD-Combined, and ADHD-Inattentive samples. In the general population, boys had more externalizing problems than girls (particularly hyperactivity, inattention, and aggression), whereas anxiety, depression, and somatic complaints did not differ, with the exception of more stomachaches in girls. The finding that boys have more externalizing problems than girls in the general population has implications for interpreting rating scales. Raw score to standard score conversions for most scales are based on general population sex- and age-specific norms. Therefore, standard scores mask sex differences, and the same standard score for a girl and a boy is not equivalent. A boy must have more severe externalizing problems to earn the same elevated standard score as a girl. When making diagnostic and treatment decisions, clinicians should take into consideration both symptom raw scores (e.g., “often a problem” reflecting symptom severity and the DSM threshold for clinical significance) and standard scores (symptom severity adjusted for sex and age effects).

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Authors and Affiliations

  1. Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Office: C5635, Hershey, PA, 17033, USA

    Susan D. Mayes, Peter J. Castagna & Daniel A. Waschbusch

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  1. Susan D. Mayes
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Correspondence to Peter J. Castagna.

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Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Susan D. Mayes, Peter J. Castagna and Daniel A. Waschbusch declare no conflict of interest.

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The study was approved by the Institutional Review Board (IRB). Informed consent was obtained from the parents and assent from the children in the general population sample. Informed parent consent and child assent were waived by the IRB for the ADHD and autism samples because analyses were conducted retrospectively on existing clinical data for these children.

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Mayes, S.D., Castagna, P.J. & Waschbusch, D.A. Sex Differences in Externalizing and Internalizing Symptoms in ADHD, Autism, and General Population Samples. J Psychopathol Behav Assess 42, 519–526 (2020). https://doi.org/10.1007/s10862-020-09798-4

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