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 is 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. 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 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.
Psychiatrists estimate that one in three children with ADHD is female. Yet, of every ten children referred for ADHD diagnosis and treatment, only one is a girl. 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 works with children who have 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."
The few studies that have included girls may explain why girls like Barbara are so often undiagnosed. Unlike their hyperactive brothers, girls with ADHD tend to 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.
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 ADHD girls are only half as likely as the boys to exhibit aggression, yet diagnostic codes still define this behavior as an integral part of the disorder. Disruptive behavior is often what drives parents to seek a diagnosis. Girls are less likely to present these problems, which may be one reason why they are less likely to be diagnosed.
Girls may have fewer behavior disorders, but that doesn't make them immune from other conditions that may accompany their ADHD. In fact, according to research conducted at Harvard University, 45 percent of ADHD girls have another serious condition, such as clinical depression and crippling anxiety. Compared to other girls their age, those with ADHD score lower on IQ and academic tests and are at greater risk of teen pregnancy. And they're more likely than even ADHD boys to have trouble with drugs and alcohol.
Finally, the age of onset criteria for ADHD, which requires that symptoms must be present before age seven, is based on research in males. But symptoms of ADHD in females often don't emerge until puberty, a time when most kids have emotional ups and downs. Even experienced clinicians may have difficulty distinguishing ADHD characteristics from normal developmental woes.