Mrs. Dawson’s fourth grade students assemble in small groups to work on a project. She asks Steven and Julie to join three other students. A mother helping in the classroom notices Steven is better regulated than during her last visit. While he still wriggles in his seat and occasionally interrupts a classmate, he doesn’t pound his desk and talk non-stop like he used to. He also seems happier and more cooperative. Julie is her usual chatty, polite self. She smiles and waves her hands as she talks to the group. Today, though, the other girls in the group seem annoyed with Julie. When the group session is over, Steven sits attentively at his desk in the front of the classroom. Julie’s smile has faded and she stares out the window.

What’s going on with Steven and Julie? Steven was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) four months ago. His teacher has made classroom accommodations, such as allowing him to sit up front where he’ll be less distracted. His parents and his treatment team decided that taking medication could support him in learning skills as he鈥檚 being coached on his ability to self-regulate. His self-esteem is growing as he succeeds in his school work and relationships.

What no one knows is that Julie also has ADHD. She struggles to please others, but they don’t seem to understand her friendly overtures. Determined to be a good student, she spends hours on homework because daydreams get in the way. Her self-esteem is sinking as she questions her academic and social abilities. Julie’s struggles are overlooked.

Squeaky wheels get the grease

Many people think of ADHD as a condition that only affects boys. In fact, some studies estimate at least six times as many boys as girls are referred to clinics for diagnosis. But field studies suggest that, in the general population, the actual ratio of boys to girls with ADHD is 3:1. To understand why this disparity exists, we must understand how professionals have traditionally defined and diagnosed ADHD —聽and how that view is changing. For many years, hyperactive and impulsive behavior was considered the primary trait of children with ADHD. It鈥檚 a trait that tends to be more visible and disruptive in classroom and home settings. Although symptoms of ADHD vary from child to child, impulsivity and overactivity is more common in boys than in girls. This has made it easier to diagnose and treat boys, and also explains why so many ADHD studies have focused on boys. Once researchers discovered a population of boys who were inattentive but not hyperactive or impulsive, the definition of ADHD was updated and now includes three聽different types:

  • Inattentive
  • Hyperactive/impulsive
  • Combined type (a combination of the first two types)

Inattentive type ADHD is harder to diagnose in both boys and girls since their behavior doesn’t “give them away.” Bright, inattentive girls often compensate for inattention by becoming super-organized or hyper-focused on school work. Such girls often succeed in school, but their private struggles remains unseen.

The experience of having ADHD can differ between girls and boys. It鈥檚 less likely for girls to be hyperactive, but even when they are, the symptoms may simply manifest differently. For instance, girls may be seen as overly sensitive or emotional. They might interrupt conversations and be more talkative, often more so than boys with ADHD. Those girls are often seen as 鈥渟ocial butterflies.鈥�

But other girls who have hyperactive/impulsive or combined type ADHD are seen as “tomboys” because they鈥檙e more overactive physically. Those girls have a better chance of being diagnosed earlier.

Set up by social expectations

Having ADHD seems to impair girls’ social relationships far more than it does for boys. As Janet Giler, Ph.D., points out, “Males and females, in general, operate by different social rules. … Female social rules place a greater value on cooperation, listening, care-taking, and relationship maintaining activities. … It would make sense that the traits of ADHD might make females seem less cooperative.” As a result, girls with ADHD suffer more peer rejection, and therefore, as one found, are more likely to try very hard to mask their symptoms to avoid this rejection.

Remember Julie? In accordance with social norms, she鈥檚 friendly and well-meaning but often gets distracted while a classmate is talking to her. She misses the other person’s social cues, and doesn’t respond in an expected or socially preferred manner. Boys tend to be more direct with each other and resolve their conflicts more openly, so a boy with ADHD isn’t expected to have the same set of social skills as a girl. A girl who is both impulsive and inattentive is likely to experience more social blunders than a boy with the same diagnosis.

Society often expects girls to conform to the standards of being especially thoughtful, polite, and compliant. If a girl has ADHD, this can be a difficult goal to attain.

Brain differences in boys and girls

At least one research study found the brains of boys with ADHD showed significant shape and volume differences compared to boys without ADHD. The size and shape variations suggest that ADHD in boys affects brain circuits that control basic motor responses, such as “hitting the brakes” or suppressing impulsive actions. These same variations were not evident in the brains of girls with ADHD, which may account for the way ADHD plays out in boys versus girls. Also, a study by the Kennedy Krieger Institute and Johns Hopkins University School of Medicine suggests that girls with ADHD have greater control over their physical movements than do boys of the same age with ADHD, possibly because girls’ brains mature earlier.

That鈥檚 not to say that the brains of girls who have ADHD don鈥檛 vary from those of girls who don鈥檛 have ADHD. In fact, in , MRI scans showed that girls ages 8 to 12 with ADHD had differences in the size of certain parts of their cerebellum compared to girls without ADHD.

When hormones wreak havoc

ADHD is often hard to detect in girls until they reach puberty and hormone changes can cause dramatic mood swings and disruptive behavior. A girl who has kept her ADHD hidden until puberty may appear to “erupt” suddenly when female hormones flood her body. Because the current criteria for ADHD state symptoms must be present before age 7, many doctors dismiss the possibility of ADHD in girls whose symptoms don’t appear until puberty. (By contrast, boys who’ve been treated for ADHD since their early years often show a change in symptoms when they reach puberty. For them, hyperactivity may start to look more like restlessness.)

Teenage girls with ADHD appear to be at greater risk for eating disorders than their non-affected peers. Girls with combined type ADHD (both inattention and hyperactivity/impulsivity) seem more likely to develop bulimia than girls who have the inattentive type of ADHD. But, studies show, both groups of girls are more likely to be overweight and to suffer from rejection and low self-esteem. There is also a concern that girls taking stimulant medication for ADHD might abuse the drugs to suppress their appetite and lose weight.

The emotional cost of under-diagnosing ADHD in girls

Girls whose ADHD isn’t diagnosed and treated by the time they reach puberty are at risk for developing other psychological disorders, such as anxiety and depression. This is understandable, when you consider the amount of time undiagnosed girls spend struggling, not understanding why things are harder for them that others, and blaming themselves for poor academic performance and peer rejection. As girls mature, they tend to internalize their feelings, making their struggle less noticeable to adults who might help them. Adolescent girls who don’t receive help for ADHD and co-existing psychological problems are at high risk for risky behaviors, such as over-eating, smoking, and alcohol misuse.

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Help and hope for girls with ADHD

Clearly, better methods for diagnosing and managing ADHD in girls are needed. Fortunately, many professionals are working toward this goal. They have found, for example, that because a girl’s outward behavior can mask her ADHD, having her answer certain questions (self-reporting) can help make a proper diagnosis. Professionals have also found some methods that are especially effective for managing ADHD in girls, including:

  • Group counseling with other girls who have ADHD. This allows girls to support and learn from each other while improving social skills within a peer group.
  • Coaching for ADHD by a trained adult outside the family. Having a mentor provides support beyond what the girl gets at home and can relieve pressure on her family relationships.
  • Understanding and support from mothers. Parents who understand the impact ADHD has on their daughters may be more effective in steering them, not forcing them, toward success.

As professionals pay more attention to the traits and needs of girls with ADHD, we can hope for earlier diagnosis and more effective treatment. Parents can help by staying abreast of the research in this area — and by staying open to the idea that girls may also have ADHD.

ADHD by other names and acronyms

While Attention-Deficit Hyperactivity Disorder (ADHD) is the official term and acronym used by today’s mental health care professionals, it is sometimes referred to by other names and abbreviations. For example, it is sometimes called:

  • AD/HD (with a聽slash)
  • Attention Deficit Disorder (ADD)
  • Attention Disorder

References

  • Is ADHD More Likely To Affect Movement In Boys Or Girls?, American Academy of Neurology, November 5, 2008.
  • Brain Abnormalities That May Play Key Role in ADHD, Kennedy Krieger Institute, November 18, 2008.
  • Adolescent Girls with ADHD Are at Increased Risk For Eating Disorders, Study Shows, University of Virginia, March 15, 2008.