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Girls with ADHD: Overlooked, Underdiagnosed, and Underserved

by Anita Gurian, PhD

school girlsat computers

Alice, a bright 4th grader, is quiet and well behaved in class. Her academic work is just about on grade level. She chooses to sit in the back of the classroom and much of the time she's doodling in her notebook. Asked to complete a written assignment, Alice works diligently at first, but then she becomes distracted by noise outside the window and loses track of her assignment. The unfinished work then gets stuffed into her messy backpack and is rediscovered several weeks later.

Tom, also a bright 4th grader, has trouble remaining seated. He's always fidgeting with his pencils and anything else on his desk. He shouts out answers and constantly interrupts his teacher with comments and requests to go to the bathroom. Tom's academic work is less than expected for his age and capability.

Which of these two children is the teacher more apt to refer for evaluation? Probably Tom. Boys are three times more likely to be diagnosed with ADHD than girls. What happens to the girls?

Introduction

Boys with ADHD are usually easy to spot because of their behavior. Boys are more likely to have the combined type of ADHD: hyperactive impulsive behaviors, inattentive behaviors, and a combination, so they're more apt to be noticed. Girls are more likely to have the attentional type of ADHD, which can lead to difficulty in attending and focusing rather than in disruptive behavior.

What happens to the girls? Because they don't disrupt the rest of the class, it may take longer for girls to get a diagnosis of ADHD and to get the help they need. Most of the research has been done with boys, and as many as 50 to 75 percent of girls with ADHD are missed. Those girls who do get identified are diagnosed on average five years later than boys (boys are generally diagnosed at age 7 and girls at age 12). Thus, they lose five critical years during which they could have been getting help.

Here's the good news: Educators, mental health researchers, and parents are now becoming aware of the unique needs of girls with ADHD.

Psychological Hurdles for ADHD Girls

Many girls with ADHD can slip by without notice in the early school years, but they're likely to run into trouble in the middle and high school years. When they have to deal with increased demands socially as well as in organizational, planning, memory, and independent study, their psychological problems may become more apparent. According to Kathleen Nadeau, who has studied and written about girls and women with ADHD, young girls experience social deficits early, but these deficits become more intense during the adolescent years when peer relationships become important. Older adolescent girls with ADHD have been found to have more depression and anxiety than girls without ADHD. Adolescence brings challenges for all girls, and even well-adjusted non-ADHD teenage girls report more stressors in life than boys. So teenage girls with ADHD have a double risk for psychological problems since they have to deal with both social and academic pressures.

Several studies have found that teen girls with ADHD are at risk for a variety of psychological problems.

  • A study that tracked 140 teenage girls with ADHD from ages 12 through 17, found that by age 17 the ADHD girls were far more likely than girls without ADHD to be clinically depressed, to have anxiety disorders and to have conduct disorder. (Biederman, 2005).
  • A five-year follow-up study of the largest number of girls with ADHD ever examined found that not only did difficulties persist during their teens, but that new problems emerged. The girls with ADHD were significantly more likely to have problems in academic performance, eating disorders, relationships with peers and teachers, and organizational skills. The girls with ADHD were also found to have mild depression and risky behaviors, such as substance abuse. (Hinshaw, 2006).

How Teachers Can Help—Spotting the Signs in Class

Teachers should be alert to the specific symptoms of ADHD in girls, such as poor concentration, easy distractibility, difficulty focusing, disorganization (messy backpack, loss of schedules and homework), and forgetfulness (forgetting to hand in papers, take assignments home). Other possible clues include nonstop talking, bossiness, interrupting others, slow to pick up social cues, and difficulty paying attention to multi-step directions.

The sensitive teacher can use strategies such as:

  • seat girl in front of room to make sure her attention is not drifting
  • give her a task to help her refocus
  • have her buddy share
  • teach social conventions explicitly (how to join a group, give a compliment)

To help her organize:

  • give her organizing folders and notebooks
  • break down work into simpler component tasks
  • assign classroom responsibilities to make her feel important
  • teach calming techniques, such as deep breathing and visualization when she's overstimulated

How Parents Can Help

  • Make sure your daughter is correctly and promptly diagnosed and that she gets the most effective treatment. According to experts, treatment should combine stimulant medications with behavioral therapy that provides structure, teaches organizational skills, and rewards desired actions. Be particularly sensitive to your daughter's psychological health during adolescence when depression, anxiety, and other disorders may occur. Treatment for girls should be designed to target their particular vulnerabilities and may also include individual, group and/or family therapy, and school support.
  • Help girls identify and develop their areas of talent and competence, such as abilities in the areas of academics, art, music, or sports, or volunteer work to build confidence.
  • During adolescence parents should try to strike a balance between supporting their daughters in carrying out their treatment plan while recognizing their need for independence.

As identification and treatment strategies specifically tailored to the needs of girls with ADHD are developed, more girls with ADHD can look forward to healthy and productive lives.

Sources

Biederman, J. et al, (2005). Journal of the American Academy of Child and Adolescent Psychiatry, 38, 966-975.

Hinshaw, S. et al, (2006). Journal of Consulting and Clinical Psychology, 34, 825-839.

Nadeau, K. (1999). Understanding girls with ADHD