(PS3-97) Associations Between Sex-gender Alignment, Internalizing Symptoms, and Self-harm in Adolescents with and Without ADHD

Background: Although sex-related differences in clinical presentation of ADHD, internalizing symptoms, and deleterious outcomes are often reported, there is still ambiguity about whether assigned sex at birth or gender account for these differences. This study explores how sex-gender alignment (SGA) impacts internalizing symptoms and self-harm in adolescents with and without ADHD.

Method: 148 participants, ages 12-17, with ADHD (n=74, 29 assigned female at birth [females]) or without ADHD (TD; n=74, 43 females) completed surveys assessing gender identity (YGISH), gender expression (TMF), internalizing symptoms (BASC depression and anxiety subscales), and self-harm (ISAS). Parents rated ADHD symptoms of inattention (IA) and hyperactivity/impulsivity (HI). ANCOVAs evaluated assigned sex at birth*diagnosis subgroup differences in SGA and internalizing symptoms; chi-squared analysis evaluated subgroup differences in self-harm. Moderation and logistic regression analyses evaluated SGA, in context of IA and HI, as a predictor of clinical outcomes across and within sex.

Results: Significant main effects of sex and diagnosis on SGA (females< males, ADHD< TD) and internalizing symptoms (females >males, ADHD >TD), but not self-harm, were observed. Across the sample, less SGA was significantly correlated with higher levels of depression and anxiety (ps< .001). Across the sample, the negative effect of SGA (p< .001) on depression was moderated by IA (p=.038) and HI (p=.034), such that the negative effect of SGA (low scores) on depression (high scores) is strongest at low levels of ADHD symptoms. IA (p=.072) and HI (p=.246) did not moderate the negative effect of SGA (ps=.006-.032) on anxiety. Within females, the negative effect of SGA on depression (ps< .001) and anxiety (ps=.012-.020) was not moderated by IA or HI. Within males, SGA did not have a significant effect on depression (ps=.293-.637) or anxiety (ps=.095-.989). Within sex, logistic regressions found less SGA significantly predicted self-harm in males (p=.022), but not in females (ps=.470-.539).

Conclusion: These findings suggest sex-gender misalignment may be a contributing factor to depression in females and to self-harming behaviors in males. Additionally, ADHD-related symptoms may be a protective factor against the effect of sex-gender misalignment on depression in adolescents. Taken together, findings reflect a nuanced and complex picture that require more research to clarify the impact on clinical outcomes.