Late Diagnosis, Little Treatment: What ADHD Looks Like in Girls and Women
Many young girls and women with ADHD — most with inattentive symptoms — are being drowned out by loud, hyperactive boys who demonstrate the condition’s stereotypical behavior. Learn how to recognize symptoms and turn around this unfair unbalance for your daughter or yourself.
Twenty-year-old Andrea Burns fits the profile of ADHD in girls perfectly. She wasn’t officially diagnosed with attention deficit disorder (ADHD) until her freshman year at Indiana University in Bloomington, even though she showed obvious signs of ADHD in middle school.
After an academic advisor had her undergo a LASSI (Learning and Studies Strategy Inventory) screening to evaluate learning behaviors and academic achievement, the results indicated what she and her family had long suspected.
Things had to get really bad — Burns was close to failing out — before she was even tested. “In high school, I had a tutor to help me with different subjects, but once I got to college, I was expected to do it all by myself. I was studying all of the time, but doing poorly on tests because I’d freeze up,” says Burns. “And I’d try to listen in class, but I had a hard time concentrating and focusing on what the teacher was saying. I’d take lots of notes, but when I reviewed them, I couldn’t make sense of what I wrote,” says the communications major, now entering her junior year.
After a diagnosis of ADHD – Primarily Inattentive Type, Burns was prescribed medication. She saw almost immediate results: “I was finally able to focus during a lecture and take good notes, which helped improve my grades. For the first time I felt in control in the classroom.”
Burns is relieved to have identified the cause of her poor school performance, and happy she’s able to treat it. But it’s unfair that she, like so many other girls, suffered a decade or more with an untreated condition that can negatively impact life in so many ways. Why are girls being diagnosed so much later than boys, if at all? And what do teachers, pediatricians, and parents need to do to bring about a change?
One of the key reasons girls are so often overlooked is that they exhibit hyperactivity differently than boys, according to Patricia Quinn, M.D., director of the National Center for Gender Issues and ADHD in Washington, D.C. “In a classroom setting, a boy might continually blurt out answers or repeatedly tap his foot, whereas a girl might demonstrate hyperactivity by talking incessantly,” she says. A girl who talks all the time is often viewed by the teacher as chatty, not hyper or problematic — and thus is less likely to be recommended for an evaluation.
Another reason that ADHD is often missed in girls is that they’re more likely than boys to suffer from inattentive ADHD. The symptoms of this sub-type (which include poor attention to detail, limited attention span, forgetfulness, distractibility, and failure to finish assigned activities) tend to be less disruptive and obvious than those of hyperactive ADHD. Put simply, a (hyperactive) boy who repeatedly bangs on his desk will be noticed before the (inattentive) girl who twirls her hair while staring out the window. “I believe I was overlooked for so long because I didn’t show hyperactivity the way my two brothers with ADHD have,” says Burns.
It comes as no surprise that a recent national online Harris Interactive poll reaffirms that, with respect to ADHD, girls have gone largely unnoticed. Dr. Quinn and Sharon Wigal, Ph.D., associate clinical professor of pediatrics at the University of California at Irvine, surveyed 3,234 people, including members of the general public (adults without ADHD whose children don’t have the condition), parents of children with the condition, teachers, and children with ADHD, ages 12 to 17. Among those polled, 85 percent of the teachers and more than half of the parents and the general public believe that girls with ADHD are more likely to go undiagnosed. They said that girls are more likely to “suffer silently” or show fewer symptoms. And four out of 10 teachers report more difficulty in recognizing ADHD symptoms in girls than in boys.
Polled parents and teachers also said that, among children with ADHD, boys are more likely than girls to exhibit behavioral problems, while girls are more often inattentive or depressed. Drs. Quinn and Wigal said these differences cause some girls with ADHD to slip through the cracks. “The failure to recognize ADHD symptoms in girls probably results in significant undertreatment,” they wrote. “…it is not a trivial disorder for them, and they are equally in need of professional care.”
The Price Girls Pay
Another revelation from the Harris poll: Females may suffer more negative effects from their ADHD than their male counterparts. The survey showed that girls are more likely than boys to be asked to repeat a grade due to poor school performance. When a boy struggles, he’s more likely to be evaluated for ADHD or LD (and then diagnosed) than held back. But a teacher who observes a disorganized female student — one who can’t plan ahead, meet project deadlines, and so on — believes that she’ll benefit by being held back a year. “A year later, the girl is no better off because she still hasn’t figured out the source of her problems,” says Dr. Quinn.
The self-esteem of girls with ADHD also appears to be more impaired than that of boys with ADHD (which may explain why the survey found that girls were three times more likely to report taking antidepressants prior to being diagnosed). It’s not surprising, then, that the condition can take a toll on a female’s emotional health and general well-being. According to Dr. Quinn, girls with ADHD tend to have more mood disorders, anxiety, and self-esteem problems than non-ADHD girls. “They might get an A on a report, but because they had to work three times as hard to get it, they see themselves as not being as smart as other people,” she says.
Another reason that girls go undetected for so long has to do with how differently each gender approaches school. Dr. Quinn offers this example: “A male and female student with ADHD are assigned a long-term project. They each put off the work for weeks. Then, the night before the project is due, each remembers the deadline. Rather than attempt to get the work done, the boy decides to watch back-to-back episodes of SpongeBob. Meanwhile, the girl freaks out and tries to make a perfect project overnight. (Perfectionism is another common behavior in ADHD girls.) She demands that her mother help her while she stays up until 1 a.m. to finish her work. When she hands in the assignment the next day, the teacher has no clue that it was done at the last minute.”
Girls seem compelled to get their schoolwork done because our culture encourages them to be more socially conscious. They want to please more than boys, and they’re expected to do well in school.
Because grades K through six aren’t as challenging as higher grades, a girl with undiagnosed ADHD might do fine in elementary school — and then falter. “In middle and high school, the attentional demands are greater for a student, so she can’t get by working at 50 percent efficiency,” says Andrew Adesman, M.D., director of the division of behavioral and developmental disorders at Schneider’s Children’s Hospital in New Hyde Park, New York, and member of the national board of directors for CHADD. “And because the kids in junior high and high school more often change classes, teachers don’t have the time to get to know the kids and spot problems.”
Some girls also compensate by developing strategies that mask their ADHD. As mentioned earlier, it might be perfectionism. For instance, a girl might spend hours taking notes on each chapter she’s being tested on in order to assure a good grade. Or she might become obsessive-compulsive, checking and rechecking her backpack to make sure she has everything.
ADHD gender differences also show up outside the classroom. Research shows that girls with ADHD may be rejected more often by their peers than boys. The main reason is that, compared to boys’, girls’ friendships require greater sophistication and more maintenance. “Two boys can meet on the playground and start digging a hole to China with their shovels, and they’re instant friends. Friendship among girls is more complex, even at young ages. It requires picking up on social cues and bonding,” says Dr. Quinn.
With tendencies toward impulsivity, hyperactivity, and forgetfulness, it can be hard to keep your mouth closed, not to constantly interrupt, or to remember your best friend’s birthday. And when everyone in the group is admiring Jessica’s new earrings and the girl with ADHD blurts out something totally unrelated, the other girls look at her and wonder where she’s coming from. This kind of social awkwardness makes it difficult for a girl to feel good about herself and sustain relationships.
Unfortunately, these signs often aren’t enough to suggest ADHD. In the case of 14-year-old Danielle Cardali of North Babylon, New York, it took two evaluations before her teacher and parents were able to pinpoint why her grades remained low. Being classified with ADHD in fourth grade, she was entitled to 45 minutes a day of one-on-one teacher time in a resource room. But real improvement didn’t come until seventh grade, when she was prescribed Strattera and Concerta. “After that first quarter on the medication, I got high C’s and low B’s,” says Cardali. “I seemed to have a better understanding of what was going on in class.”
In some cases, a parent will stumble upon ADHD after a learning disability is discovered. (They often co-exist, which is why it’s important when testing for one also to screen for the other.) That was the case with 7-year-old Allison Isidore of Montclair, New Jersey. Her mom, Liz Birge, had an opportunity to see her daughter at work in the classroom for 45 minutes once a week, when she volunteered to assist in a writing workshop. Liz discovered that her first-grader was having a great deal of trouble matching sounds to letters and that she showed no interest in trying to write. Testing revealed that Allison has both a learning disability and ADHD.
If parents suspect that their daughter has ADHD (or a learning disability), Drs. Quinn and Wigal urge them not to wait, even if teachers haven’t expressed concern. As mentioned earlier, teachers usually look for hyperactivity, disorganization, or forgetfulness as the signs of ADHD before recommending an evaluation. But the way ADHD often expresses itself in girls — excessive talking, poor self-esteem, worrying, perfectionism, risk-taking, and nosiness — is seldom read as such [see What ADHD Looks Like in Girls].
Your daughter’s pediatrician may be able to do an evaluation (if your daughter is an adolescent, find out first if the doctor is comfortable working with teens), but it’s best to work with an ADHD specialist. Make sure the evaluating clinician takes a thorough medical history (including family history, due to the high heritability of ADHD). The doctor should also work with your child’s school to obtain more information about her behaviors. “And since adolescents are a great source of information about their own experience, encourage a teen to talk directly with her doctor,” advises Dr. Wigal.
Ultimately, for a girl suffering from ADHD, an official diagnosis can be welcome news. “Everyone presumes that a diagnosis of ADHD is a stigma,” says Dr. Quinn. “In fact, 56 percent of the girls in our survey said that they felt better after finally having a name for what they felt. Only 15 percent said they felt worse. For most, it was a relief to find out they weren’t lazy, crazy, or stupid.”
More good news: Parents of girls diagnosed with ADHD are more likely to seek treatment than parents of boys diagnosed with ADHD, because only the more severe cases are diagnosed. “Girls may be at a slight advantage over boys in one sense,” wrote Quinn and Wigal in the Harris survey paper. “Once they are suspected of having ADHD, their parents tend to be more willing to seek medical advice.” And that bodes well for girls.