Stop the Cycle of Shame for Girls with ADHD
The stigma of unrecognized ADHD can lead to years of low self-confidence and psychological damage. Here’s why ADHD is so frequently missed or misdiagnosed in girls and women, and how we can help the next generation.
At the age of 21, I proudly realized my dream of reporting for a big daily newspaper. I was getting lots of front-page stories, until I started making stupid mistakes. Most were minor — misspelled names and the like — but then came a doozy: I involuntarily misquoted a prosecutor, making it seem that he’d charged someone with a murder when he hadn’t.
Fearful, with good reason, that I was sabotaging my career, I sought professional help. Given the era — the early 1980s — that meant that I lay on a psychiatrist’s couch for several months and complained about my childhood. I’d never even heard of ADHD in girls. Meanwhile, I took the more pragmatic step of training myself to read every word I wrote for publication at least three times before I filed it.
One or both of these strategies worked, and my career moved forward, unblemished by blunders. But in 2007, I returned to my old psychiatrist, needing help once again. I’d moved from foreign reporting to raising two kids in the suburbs, writing books and magazine stories in whatever time I had. But I was having far too many arguments with my husband and kids, and I could never find my keys — or sunglasses, or pens, or lots of other things.
How the world had changed! This time, instead of the couch and the complaints, there was just one appointment. After spending several hours at the doctor’s office, he concluded that there was a good chance I had ADHD. He prescribed a stimulant to treat it.
Looking at my life through my new ADHD lens cleared up decades of mysteries about my behaviors. At last I knew why my parents used to call me Chatty Kathy, and why I’ve lost so much great jewelry over the years, not to mention other essentials. It also gave me membership into a surprisingly large community of formerly baffled, midlife women who’ve made similar breakthroughs.
ADHD Diagnosis Rates in Women and Girls
Barely 35 years after “Attention Deficit Disorder” first appeared in the bible of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM), front-line clinical therapists say that increasing awareness of the condition has led to many more girls being diagnosed while they’re young. Even so, while girls and boys currently are diagnosed at a ratio of about 1 to 3 — up from about 1 to 8 in the 1990s — the rate for diagnoses of adult women and men is about 1 to 1.
“It’s only a matter of time before we find this is an equal-opportunity disorder, although a less glaringly obvious one for girls,” says psychologist and author Kathleen Nadeau, Ph.D., a pioneering expert on women with ADHD.
That’s not a unique opinion, nor is it unanimous. Experts including psychologist Stephen Hinshaw, Ph.D., head of a major longitudinal study of girls with ADHD, and psychologist and author Russell A. Barkley, Ph.D., believe the 1 to 3 ratio of girls to boys diagnosed with the condition is accurate. “Boys seem to be more vulnerable to psychopathology,” Hinshaw says, citing rates of childhood autism that are also dramatically higher for boys — on the order of 5 to 1.
Hinshaw, author of The Triple Bind: Saving Our Teenage Girls from Today’s Pressures, speculates that higher rates of ADHD in adult women might be explained by women having a variation of the disorder that lasts longer than it does in males.
It’s well known by now, he explains, that boys with ADHD are more likely than girls to demonstrate hyperactivity and impulsivity. More girls than boys are diagnosed with the “inattentive,” day-dreamy type of the disorder. Yet several longitudinal studies show that symptoms of activity fade during adolescence, whereas underlying problems with attention and organizational skills usually persist through adulthood.
Still, other factors might also explain why the male-female rates change in adulthood, Hinshaw says. Perhaps women are more honest than men about attention problems in adulthood. Moreover, he suspects that Nadeau and other experts may be right in suggesting that many young girls with ADHD are under the radar, to be identified only as adults.
Indeed, hyperactivity, and often aggression, goes along with many cases of ADHD. It usually gets more boys with ADHD noticed, and helped, while girls turn their frustration inside. The cost for women is years of low self-confidence and psychological damage.
How Undiagnosed ADHD Puts Girls at Risk
“Girls with ADHD are in deep trouble in a lot of ways,” says Hinshaw. He and his team analyzed results from 10-year, follow-up interviews of 140 girls who were ages 7 to 12 when first surveyed. His data, along with other reports collected over five years, show that girls with ADHD are at 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 mood disorders 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, or than boys with the disorder, for clinical mood disorders and suicide attempts. Another report, published in the American Journal of Psychiatry, revealed that girls with ADHD were more likely than others to engage in antisocial behavior, and to suffer from substance use disorders or 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 mood disorders, 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, my parents may have worried that I had a mood disorder, 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 type of 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 positive for boys but a loss for girls, who fare better with rules and routines, according to Hinshaw.
When women with ADHD marry and have kids, many of them hit what psychotherapist and author Sari Solden calls “a terrible wall of shame.” Society expects tremendous feats of memory and organization from moms, from keeping track of critical facts about teachers and pediatricians to organizing meals and multiple schedules. And without treatment, or a “wife” of their own, many women can’t cut it.
Is ADHD in Girls and Women Hereditary?
ADHD is strongly hereditary, and many women seek help as adults because a light bulb goes off when they have a child who is diagnosed. This was the case with Joy Carr. Watching her preteen son fill out his diagnostic questionnaire brought a flood of memories — of her own messy lockers, lost textbooks, and teachers who called her bright but lazy. Following a familiar pattern for young adults with ADHD, Carr, who lives near Buffalo, New York, dropped out of college as a junior, got married at 22, and had her first child one year later.
For many years, her domestic duties overwhelmed her. She’d start out on a chore, from a list her husband prepared, then get sidetracked, ending up with tasks half-done. “I’d throw a load of laundry in and forget about it for days,” says Carr. “By then, it would smell musty, so I’d wash it again. And then I’d forget about it again.”
In 2007, however, Carr’s life took a turn for the better after she got her ADHD diagnosis and started taking ADHD medication. “The roaring, racing thoughts in my head quieted down,” she says. That same year, she went back to college to complete her undergraduate degree. After coping with her son, she apologized to her mother for the grief she gave her as a child.
Women tell sad stories of showing up for diagnoses. Kathleen Nadeau, who diagnosed herself in her 30s, had been an undergraduate at four different colleges. Sari Solden, who was 42 when she figured out she had ADHD, says her diaries testify to decades of wondering what was wrong. Was she immature? Did she have a brain tumor? Narcolepsy? Trying stimulants after years without them was like “greasing my brain,” Solden says. “I remember going to a dinner that night. I was asked a question, and I actually told a story.”
ADHD in Women: Different Gender, Different Treatment
ADHD not only presents different symptoms in boys and girls, but it often requires a different treatment strategy, says Nadeau. Both genders benefit from stimulant medications, she says, but girls may need treatment for anxiety. They frequently cannot tolerate stimulants without extra pharmaceutical support.
Hinshaw says he’s not convinced that girls need extra meds to tolerate stimulants, compared to boys. He notes that, to the extent that girls are likely to develop mood disorders and anxiety, evidence-based cognitive behavioral therapies may be helpful. Nadeau also recommends group therapy, as a gender-specific strategy, to encourage girls and women to use their verbal skills to give one another support, develop coping strategies, and not feel isolated.
Nadeau and her colleague, pediatrician Patricia Quinn, M.D., have been trying to persuade their peers to adopt a diagnostic tool with symptoms that would help more girls understand that they might have ADHD. Nadeau says she’s not optimistic that such change will come in time for the next edition of the DSM.
Hinshaw’s study, as well as other research that follows girls into adulthood, offers hope for more interventions over time, but, for now, parents and teachers have to work to help girls who are struggling with distraction — spotting them at home and in classrooms, and supporting them in getting diagnoses, even if they may not precisely fit the symptom profile.
Women with ADHD should spread the word. While a little adversity makes you stronger, imagine what women with ADHD could accomplish if we could turn the energy we use to beat ourselves up to going out and changing the world.
ADHD Symptoms Checklist for Girls
Psychologist Kathleen Nadeau has devised a symptoms checklist for girls suspected of having ADHD. It should be filled out by girls themselves, not parents and teachers, because girls experience ADHD more internally than boys, who get attention with unruly behavior.
Many of Nadeau’s questions apply to boys, since they pertain to problems with productivity, general distractibility, impulsivity, hyperactivity, and sleep problems. The excerpts that follow, however, are particularly oriented toward girls:
Anxiety and mood disorders
- I often feel like I want to cry.
- I get a lot of stomachaches or headaches.
- I worry a lot.
- I feel sad, and sometimes I don’t even know why.
- I dread being called on by the teacher because, often, I haven’t been listening carefully.
- I feel embarrassed in class when I don’t know what the teacher told us to do.
- Even when I have something to say, I don’t raise my hand and volunteer in class.
- Sometimes, other girls don’t like me, but I don’t know why.
- I have arguments with my friends.
- When I want to join a group of girls, I don’t know how to approach them, or what to say.
- I often feel left out.
- I get my feelings hurt more than most girls.
- My feelings change a lot.
- I get upset and angry more than other girls.
Parents & Teachers: Does This Sound Like a Girl You Know?
Five telltale signs that your daughter or student may have ADHD — according to Kathleen Nadeau:
- Does she often lose personal items, her keys, or her backpack?
- Is her room always messy — even 15 minutes after you clean it up?
- Does she often feel anxious about getting school assignments in on time?
- Does she talk excessively?
- Does she behave well at school, and come home and explode at the end of the day? Can she be pushed over the edge by trivial provocation?