Why ADHD in Girls Is Often Overlooked

“Clearly some of our daughters are falling through the cracks.”

Barbara sits quietly at her desk in second grade. She isn’t talking and she isn’t acting out. She also isn’t learning anything. Her inattention and inability to focus are apparent every time her teacher asks her a question, which isn’t very often. Teachers like interaction; they tend to shy away from vacuous stares. And so kids like Barbara are often overlooked in the classroom, passed over in favor of the kids who are able to “keep up” with what’s going on.

Barbara’s brother, on the other hand, gets lots of attention. Diagnosed with ADHD when he was in second grade, he has a reputation for being a bright kid, even if he is hyperactive. Treatment for his ADHD has helped him be a better student and has improved his ability to play with other kids. He has some behavior problems, but his natural charm keeps him from getting into too much trouble. Still, his teachers say that they can immediately tell if Kaleb has missed his medication. “It makes all the difference in the world,” says his third grade teacher. “For Kaleb, medication has been a lifesaver.”

Meanwhile, Barbara is drowning in inattention.

[Self-Test: The ADHD Test for Girls]

Missed Diagnosis

Psychiatrists estimate that nearly half of all children with ADHD are female. Indeed, Stephen Hinshaw, professor of psychology at University of California at Berkeley, says ADHD is an “equal-opportunity condition.”  Yet 50% fewer girls are referred for ADHD evaluations and treatment than boys. Clearly some of our daughters are falling through the cracks.

Part of the problem is a lack of research. According to Dr. David Rabiner, a psychologist and researcher who specializes in ADHD, “One of the important shortcomings of most of the research-based information on ADHD is that the vast majority of studies have been conducted solely on boys, or, have included very few girls in the sample. As a result, the scientific literature on ADHD is almost exclusively based on male subjects.”

Hinshaw, an expert in child clinical psychology and developmental psychopathology, has dedicated much of his work to studying and understanding ADHD in girls. He is the lead author on the most comprehensive studies on the topic to date.

These studies, published in the Journal of Consulting and Clinical Psychology, contradict earlier findings about girls with ADHD. But Hinshaw’s explanation is simple: Unlike the 6- to 12-year-old girls in his studies, the female subjects participating in previous studies were taking ADHD medication. Hinshaw’s work also included a much larger sample than nearly all earlier studies and was conducted over a longer period of time — in fact, it’s still ongoing, with periodic follow-up assessments.

[Not Ditzy. Not Lazy. And Definitely Not Dumb.]

“These girls, compared to a matched comparison group, are very impaired, academically and socially,” Hinshaw said. “Social problems with peers are quite predictive of long-term adjustment problems, so it will be essential to observe outcomes as the sample matures.”

Hinshaw’s study involved one of the largest samples in the world of preadolescent girls with ADHD. A total of 228 girls — 140 diagnosed with ADHD and 88 not diagnosed with ADHD — were studied intensively at six-week summer camps held three years in a row. There were approximately 80 girls at each year’s camp, which ran in 1997, 1998 and 1999. The families of the girls with ADHD had to agree to take their children off of ADHD medication during the six weeks so their natural behavior patterns could be observed.

The girls spent six weeks enjoying typical summer camp activities, including a structured series of classroom, art, drama, and outdoor activities. They were very closely monitored by professionals with training in micro-observation. Their “counselors” took copious notes relating to each girl’s activities; they did not know which girls had ADHD diagnoses. In addition, all the girls received individual neuropsychological assessments.

Hinshaw said that, during outdoor sports and play at camp, “the girls with ADHD were less likely to follow the directions of the teacher than were the comparison girls. They were also more likely to tease their peers and show aggressive behavior, though not at the same rate as boys with ADHD, as observed in previous summer camps. They were also more likely to display social isolation — wandering and failing to become engaged in activities.

“As a group, these girls show as much executive function deficit on neuropsychological tests as boys who have been diagnosed with ADHD. These functions are crucial for long-term academic, social, and occupational success,” Hinshaw said. “Deficits in executive functions are seen in other disorders, such as autism, but they may well be the core underlying problems for youth and adults with ADHD.”

Although boys diagnosed with ADHD outnumber girls approximately three to one, Hinshaw suggests some girls have been underdiagnosed, particularly those with the inattentive ADHD, which seems more prevalent in girls.

“The inattentive type of ADHD is marked less by disruptive, impulsive behavior and more by disorganized, unfocused performance,” Hinshaw said. “The latter isn’t as likely to be recognized or cause as much concern to teachers.”

[Easy-to-Miss ADHD Symptoms in Girls]

Less-Visible Symptoms

These studies, and the others that have included girls, may explain why girls like Barbara are so often undiagnosed — they have ADHD without hyperactivity. They don’t fidget or squirm or get up to sharpen their pencil every two minutes. Instead, they just sit at their desk and zone out. These girls have the same ADHD problems of inattention, distractibility, and poor impulse control, but few parents, teachers, or clinicians ever suspect these girls have ADHD because they aren’t hyperactive.

Patricia Quinn, M.D., director of the National Center for Gender Issues and ADHD, and Sharon Wigal, Ph.D., associate clinical professor of pediatrics at the University of California at Irvine, conducted an interactive poll on girls and ADHD, and found the same: ADHD often expresses itself in girls through excessive talking, poor self-esteem, worrying, perfectionism, risk-taking, and nosiness — not the typical hyperactivity and lack of focus that is often seen in boys.

Quinn and Wigal’s poll also found that 4 out of 10 teachers reported more difficulty in recognizing ADHD symptoms in girls than in boys, who they believe are more likely to exhibit behavioral problems. As such, girls are more likely than boys to be asked to repeat a grade due to poor school performance rather than undergo an evaluation for ADHD or LD (and then seek diagnosis and treatment). “A year later, the girl is no better off because she still hasn’t figured out the source of her problems,” Dr. Quinn says.

For a long time, the ADHD diagnosis requirements stated that symptoms must be present before age seven, based on research in males. The new criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), allows for symptoms to emerge up until age 12, giving more time for ADHD to surface in girls.

That’s important because symptoms of ADHD in females often don’t emerge until puberty, a time when most kids experience emotional ups and downs. Even experienced clinicians may have difficulty distinguishing ADHD characteristics from normal developmental woes. Due to social pressures and cultural expectations, girls seem more compelled than boys to get their schoolwork done. Generally speaking, they want to please more than boys do, and they’re expected to do well in school. Therefore, ADHD symptoms may not become overly apparent until middle or high school, when a student’s work requirements increase dramatically.

Girls with ADHD are also less likely to exhibit disruptive behavior or conduct disorders. Research led by child and adolescent psychiatrist Joseph Biederman, M.D., of Massachusetts General Hospital found that girls with ADHD are only half as likely to exhibit aggression as are boys with the condition. Disruptive behavior is often what drives parents to seek a diagnosis. Girls are less likely to present these problems, which is another reason why they are not diagnosed.

Co-Existing Disorders Complicate a Girl’s ADHD Experience

According to research conducted at Harvard University, 45 percent of girls with ADHD have another serious condition, such as clinical depression or crippling anxiety. Quinn and Wigal’s poll results support this — girls with ADHD tend to have more mood disorders, anxiety, and self-esteem problems than do girls without ADHD. And girls were three times more likely than boys to report taking antidepressants prior to being diagnosed with ADHD.

Compared to other girls their age, those with ADHD score lower on IQ and academic tests and are at greater risk for teen pregnancy. And they’re more likely than even ADHD boys to have trouble with drugs and alcohol.

“Girls with ADHD are in deep trouble in a lot of ways,” says Hinshaw. In 2009 and 2010, his team analyzed results from follow-up interviews of 140 girls who were aged seven to 12 when first surveyed, 10 years earlier. His data, along with other reports over the last five years, show that girls with ADHD are at a significantly increased risk for problems ranging from low academic achievement to drug and alcohol abuse, and even suicide attempts. Females, in general, suffer greater rates of anxiety and depression than males, and it appears that the rate is even more pronounced when ADHD is a factor.

A study published in the Archives of General Psychiatry found that girls with ADHD were at far higher risk than other girls, and boys with the disorder, for mood disorders. Another report, published in the American Journal of Psychiatry, revealed that girls with ADHD were more likely than others to engage in antisocial and addictive behavior, and to have anxiety.

What’s clear from his follow-up, Hinshaw says, is that girls with ADHD share with boys the strong risks of school failure, rejection by peers, and substance abuse. Unlike boys, they also have a particularly high risk for developing a mood disorder, self-injuring behavior, and eating disorders. “In other words, girls with ADHD appear to show a wider range of difficult outcomes than do boys,” he says.

Hinshaw says girls are harmed by earlier, and more effective, socialization. They are trained from an early age not to make trouble, and to disguise mistakes and miscues. They turn their frustration on themselves, rather than others.

“When I was a teen,” says Katherine Ellison, a Pulitzer-winning investigative journalist, speaker, and author, “my parents may have worried that I was depressed, but they never suspected that I might have an attention disorder.” And so it goes in many families today. Girls with inattentive ADHD will probably be diagnosed later than boys, and for something entirely different.

Meanwhile, girls with the hyperactive/impulsive or combined-type ADHD are stigmatized more than boys with the same diagnosis. Kids on the playground regard impulsivity and distraction as boyish. Boys are more likely to get a pass from other kids and teachers, especially if their symptoms aren’t severe. Girls get ostracized.

For many young women, the anxiety, stress, and low self-esteem that comes with ADHD feels intolerable by early adulthood. The structure of school is gone, a significant loss for girls, who fare better with rules and routines, according to Hinshaw.

Boys diagnosed with ADHD still outnumber girls, suggesting a serious problem with under-diagnosis and under-appreciation of the condition in females, according to Hinshaw’s studies, and others. Hinshaw says he hopes continued research will bring attention to a population of young girls whose problems may have been ignored.

“Our hope,” he said, “is that these efforts will spur the field towards theoretically rigorous attempts to understand the underlying processes and mechanisms responsible for ADHD in both boys and girls and to provide a sound scientific basis towards better classification, prediction and intervention.”

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