ADHD in Girls

5 Things Every Doctor (and Parent) Should Know about Girls and ADHD

New research suggests that to effectively diagnose ADHD symptoms in women and girls, doctors should consider hormonal fluctuations, trauma, family dynamics, self-esteem, and eating habits. Encouraging feedback about ADD treatment is also essential when treating young women for attention deficit disorder.

To diagnose ADD in women and girls, doctors should consider hormonal fluctuations, trauma, family dynamics, self-esteem and eating habits
An illustration of a woman in front of a "female symbol." If her doctors considered hormonal fluctuations, trauma, family dynamics, self esteem, and eating habits, they could better treat her attention deficit disorder.

Today there is greater awareness of the challenges of diagnosing girls with attention deficit hyperactivity disorder (ADHD or ADD). Their tendencies to mask their inattentive traits and internalize their feelings make their symptoms harder to recognize. As a result, they are often diagnosed later in life, after comorbidities have begun to interfere with healthy behaviors, when unhealthy coping skills start to undermine their sense of self.

Studies show that fewer girls than boys with ADHD are referred for treatment, and fewer girls than boys receive treatment. In a Dutch study, 47 percent of boys were prescribed medication compared to 6 percent of girls, and 38 percent of boys received counseling compared to 8 percent of girls. This pattern of under-treatment reflects entrenched gender bias. However unintentional, later ADHD diagnoses increase the complexity of treatment.

Girls tend to censor themselves in situations in which they feel insecure. For girls with ADHD, meeting with a doctor qualifies as stressful and intimidating. Most girls with ADHD gauge their self-worth by their executive functioning difficulties, and they begin treatment in a position of shame. In many cases, they feel awkward being the center of attention, and can’t admit needing a stranger’s help. They hesitate to articulate their feelings without encouragement. They may respond to questions by saying “fine,” when what they mean is “there’s no way I’m telling you these pills aren’t working.”

ADHD Treatment Means More Than Medication

The definition of “treatment” often leads to misunderstanding between clinicians and families. Many people believe that treatment means taking ADHD medication. They see a binary choice: If they’re not ready for or interested in medication, they’re not ready to pursue treatment. Parents who are understandably ambivalent about medication communicate their discomfort to their daughters. Families should be provided with full explanations of the multimodal approach at the onset of treatment.

An interactive network of support, spearheaded by the clinician, and that includes teachers, coaches, and other adults, is a welcoming concept to most families. ADHD management approaches could include:

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  •  Education about ADHD in girls for all family members
  • Individual and/or family psychotherapy
  • Streamlining home routines and creating predictable systems
  • Learning management skills designed for those with ADHD and not for neurotypicals
  •  Coaching
  •  Sports and exercise
  • Girls’ support group
  • Dialectical behavior therapy skills training
  • Neurofeedback
  • Medication

For many reasons, girls with ADHD offer what they think is expected of them in a clinical interview; they hide their truths and guard their secrets. The following are five ideas for circumventing the fear, stigma, and resistance to get more honest feedback from girls with ADHD. They will help doctors develop the best treatment plan.

Factor In Hormonal Fluctuations and ADHD Symptoms

It is generally accepted that, before their periods, many females experience demoralizing symptoms related to plummeting estrogen levels. They may feel insecure, tearful, irritable, confused (with tinges of paranoia), and, sometimes, hopeless. This is not the way these girls seem during most of the month, but the week before their period, they may appear troubled.

It is thought that the Premenstrual Syndrome (PMS) exacerbates ADHD symptoms, and ADHD amplifies the difficulties. During this time, many girls self-medicate with drugs, alcohol, food, and/or sex, which complicates the picture. After their period, they will likely have more hopefulness, better emotional regulation, and be more positive about interactions. They are less stressed and able to assess their world more accurately.

[Click to Read: ADHD is Different in Women]

When a girl enters your office, how do you know which girl you’re seeing? Clinicians should always ask about menstruation cycles, what they are like, and where in their monthly cycle they are at the moment. Most girls have no idea that estrogen plays a large role in cognition, behavior, and ADHD symptoms, and won’t know why it’s relevant to discuss. This is not information that girls will volunteer without support, and exploring sexual activity and relationships is more intimidating if the clinician is male. This is not elective information, however; the impact of hormonal fluctuations is a core aspect in the lives of females.

Encourage Feedback About ADHD Treatment

Many girls believe that saying their medication is not working, or that they are struggling with side effects, is like telling the clinician that he was wrong — about the drug and maybe about the diagnosis itself. Girls may take a medication that is not particularly effective for them for a long time without speaking up.

They believe that, whatever the medication, you’re supposed to take the amount as prescribed. A recent study suggests that, in a majority of young teens, the main reasons that they stop taking their medication are that they feel it doesn’t help, or because of side effects. The more openly these issues are discussed, the less likely that they will stop taking the medication. Lack of communication is always detrimental to the therapeutic alliance; it’s essential that girls know that honesty about the medicine is encouraged.

Girls resist the idea that their opinion on something as important as medicine really matters. They need to know explicitly that they are believed; they do not easily accept that proposition because the world has already betrayed their trust. Self-doubt surrounds their perceived lack of credibility. It’s important to let them know how vital their feedback is, and that sharing the details of their experience is important.

Acknowledge Trauma Associated with ADHD

Research suggests that, for girls with ADHD, the experience of trauma is common. While the symptoms of ADHD and trauma can overlap, it is not unusual for both to be simultaneous challenges. There may have been an incident that has been difficult to get past, such as observing a violent crime or a rape. There is also chronic lower-level trauma that might include daily anxieties about home or school. One girl was both ashamed and protective when she described her daily experience of waiting to find out whether or not her father would be coming home drunk. She said, “I sit real quietly so I can hear his footsteps in the hall before he opens the door. It makes it so I can’t focus on anything else.” For girls who have had traumatic experiences, scanning their environment for danger trumps all else and skews their view of their world.

The trauma-informed interview happens more often today, but too few clinicians ask about trauma directly. It is painful and intrusive unless handled with delicacy. Again, it is unlikely that girls will volunteer to discuss one of their most painful experiences with a stranger, especially a male. In many cases, even parents are reluctant to open that can of worms. Some girls have never told their parents, and some parents would shut them down if they tried. Protecting others, out of loyalty or fear, creates hypervigilance, and they may be more likely to confide their fears and feelings to a woman. Until their secret is revealed, their responses may seem incomprehensible and their needs obscured.

Understand Family Dynamics Around ADHD

Some new studies suggest that gender differences affect parenting responses to daughters with ADHD. The findings implicate the insidious impact of gender role expectations: Mothers expect more conflict with their daughters if their teacher reports aggression or rule-breaking. Fathers expect more conflict when teachers report ADHD symptoms.

Clinicians’ assessments will become clearer by considering the implications of these findings. In other words, it is possible that fathers are less triggered than mothers by externalizing behaviors, and perhaps may under-report them during a visit with the doctor. Or that mothers may focus clinician visits on the difficulty of managing challenging behaviors.

Is it possible that shame is a factor for mothers of daughters with negative behaviors? It has been suggested that girls are discouraged from discussing their difficulties by their mothers. Many parents are ashamed if their daughters behave in challenging ways, and interpret that as disobedience. Another recent study suggests that the parenting effectiveness of mothers may depend on their daughters’ ADHD subtype. Tailoring treatment to a specific subtype is most effective for mother and child. Parents and doctors need to know that each kind of ADHD wiring requires its own specialized approach.

Know How ADD Affects Eating and Self-Esteem

Society puts a lot of emphasis on girls’ weight, body shape, and size. Most girls with ADHD have been shamed and criticized for their looks as well as their behavior. Many girls have come to loathe themselves for “out-of-control” food choices and avoid discussing the topic, closely guarding their food-related secrets. Many are unaware that ADHD’s self-regulation challenges affect eating behaviors, and that hormones complicate the experience.

I get the most enthusiastic engagement with a girl with ADHD when I explain why ADHD brains crave carbs. Embracing the science behind it, they are relieved to hear that it isn’t their lack of control that explains why they choose carbs over salads. When they can dismiss the idea of poor food choices as a character flaw, they feel better about themselves.

There is a difference between girls and boys when it comes to ADHD evaluation and treatment. Girls share, perhaps too much, when they trust the intimacy of friends, but they silence themselves when they fear judgment, especially from adults. They have greater social disabilities. They have lower self-efficacy and poorer coping strategies, and they have more comorbidities than boys. As a result, their treatment requires a different approach—one that may be more time-consuming than that for boys, but more rewarding for girls and clinicians.

Ellen B. Littman, Ph.D., has been involved in the field of attention disorders for more than 27 years. She is a pioneer in the identification of gender differences in ADHD. Internationally recognized and published, she is co-author of the book Understanding Girls with ADHD.

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The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude