Special Considerations for Girls with ADHD

Myth: ADHD is a disorder only seen in boys.

Jimmy never stops moving. His loud, rambunctious behaviour often results in visits to the principal’s office. His bedroom appears as though a bomb went off, and his desk is home to a half-eaten sandwich and a variety of “missing” assignments. Jimmy’s teacher often begs him to stop interrupting, and to “just sit down!”  

When people think about ADHD, they often picture a child similar to Jimmy. While this stereotypical description may be fitting to many children with ADHD (particularly boys), this same underlying disorder may present very differently in girls.  

Truth: ADHD is a neurodevelopmental disorder that affects both boys and girls. Symptoms can, however, present differently between genders.  Furthermore, many physicians and other professionals are not trained in the unique presentation of ADHD in females. This can result in a much higher number of boys being referred for and diagnosed with ADHD.

Consider Sally: She’s got her head in the clouds. Total space cadet. “Earth to Sally!” Social butterfly. Lazy. Unmotivated. Far too sensitive. Immature. Drama queen. Hot mess. 

These are a few of the labels and phrases commonly directed toward girls displaying symptoms of ADHD. 

ADHD, or Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder. It is characterized by symptoms of inattention and/or hyperactivity and impulsivity. The diagnostic criteria for ADHD (in accordance with the DSM-5-TR) is essentially the same for boys, girls, children, and adults. 

Dr. Stephen Hinshaw states that although ADHD is an “equal opportunity condition,” it is not equally identified and addressed across genders. Recent statistics show: 

• Boys are 2 to 3 times more likely than girls to be diagnosed with ADHD
• Up to 75% of girls with attention disorders go undiagnosed

Interestingly, the number of males to females diagnosed with ADHD in adulthood is much more comparable (both are diagnosed at roughly the same rate). Girls are less likely to be flagged for ADHD than are boys. The reason for this is not because girls are less likely to have the disorder. ADHD can, however, look different in girls than in boys.  

How might ADHD appear in girls? 

According to the diagnostic criteria outlined in the DSM-5-TR, individuals with ADHD often:

• Make careless mistakes
• Struggle to focus/concentrate for long
• Show poor listening skills
• Leave tasks incomplete
• Avoid effortful/unwanted activities
• Appear disorganized or “messy”
• Are easily distracted
• Often forget to do things

Individuals with ADHD may also display the following symptoms of hyperactivity/impulsivity:

• Constant fidgeting/movement (e.g., doodling, shifting positions in chairs, etc.)
• Inability to stay seated
• Restlessness (e.g., always “on the go”)
• Excessive talking
• Frequent interrupting and/or blurting things out
• Difficulties waiting for their turn

Many of these core symptoms are required in order for a diagnosis of ADHD to be supported. There are, however, some additional challenges that individuals with ADHD (particularly girls) experience.

First, girls with ADHD may appear to others as being overly sensitive. They may cry at the drop of a hat, or they may express other big emotions (e.g., temper tantrums). It is common for girls with ADHD to experience extreme emotional sensitivity/pain after being rejected or teased. This is called, “Rejection Sensitive Dysphoria.”

Second, girls with ADHD often experience challenges with friendships. “Girl world” is complex on the best of days. There is constant pressure on girls to say/do the right thing at the right time in the right way. There are several unspoken “rules” that girls are expected to follow. Such rules often dictate whether or not a girl is “accepted” in her peer group. Children with ADHD are typically two years behind their same-age peers with respect to the development of their social-emotional skills. Therefore, it can be extremely challenging for girls with ADHD to navigate complex social dynamics. This is particularly true as they enter the pre-teen years. Additionally, some symptoms of ADHD (e.g., blurting something out at an inappropriate time) may come across as “socially awkward” or hurtful. This may cause damage to relationships. 

Third, girls with ADHD often display low self-esteem. They are more likely than their typically developing peers to experience failure and setbacks in school. Feelings of inadequacy, brokenness, and shame are often reported by girls with ADHD. They often feel misunderstood, and they blame themselves for their failures. 

Why might ADHD be overlooked in girls?

There are many factors that may help to explain why girls are less likely than their male peers to be referred for and diagnosed with ADHD. 

First, when parents and teachers think about ADHD, they often picture loud, rambunctious behaviours (e.g., “bouncing off the walls”). Such behaviours are characteristic of the hyperactive/impulsive presentation of ADHD, which is more common in boys. Girls more often show the predominantly inattentive presentation, which is characterized by more internalizing symptoms. Such symptoms are less disruptive in the classroom, and are therefore less likely to lead to a referral. While some girls show symptoms of hyperactivity and impulsivity, such symptoms are sometimes assumed to be personality traits and character flaws (e.g., she is a chatterbox, a social butterfly, immature, etc.) rather than ADHD. 

Second, girls with ADHD often go to great lengths to mask their symptoms. This is driven by a strong desire to “fit in” and to conform to traditional expectations placed on females (e.g., to be nice, polite, well behaved, and to do well in school). Girls with ADHD may expend a great deal of effort “holding it together” throughout the school day. Consequently, they may fall apart when they get home at the end of the day. Furthermore, girls with ADHD may very well complete their work and achieve good grades (particularly during elementary school). However, their teachers may not realize that this success comes at a cost. Girls with ADHD may be spending hours upon hours (more than most of their classmates) studying, completing assignments, and organizing their belongings to meet expectations. Although girls may be able to mask their symptoms well during elementary school, many of them begin to struggle more in the higher grades. The reason for this is that, eventually, the demands placed upon them outweigh their coping strategies. This can lead to other conditions, such as depression and anxiety.

Third, comorbid conditions, such as anxiety and depression, are common for individuals with ADHD. Symptoms of such disorders can be more noticeable and concerning than symptoms of ADHD. Therefore, their presence can decrease the likelihood of an ADHD diagnosis. Anxiety may also come with perfectionistic behaviors. These behaviors may cause symptoms of ADHD to be overlooked. For example, careless errors are not seen because of the double-checking required from perfectionism. Overall, symptoms of comorbid conditions are often concerning and therefore become the primary focus for treatment. Unfortunately, in such cases, the underlying ADHD continues to go undetected and therefore untreated. 

Finally, it is important to acknowledge that hormonal fluctuations associated with the female menstrual cycle (PMS) may also affect functioning. Many women report that they struggle most with focus, productivity, and emotion regulation (including frustration tolerance) during the few days before they begin their period. While as young girls they may be able to manage their ADHD symptoms, as they reach adolescence, their symptoms become worse and can cause chaos in their lives as they can no longer cope. Bigger mood swings and reactions to others can cause relationship challenges. And the feelings that most females experience during this time, such as self-doubt, can also become even bigger. This puts them at greater risk for the comorbid conditions of anxiety and depression.

When to seek an assessment:

• If you know a female who is displaying the following patterns, it may be beneficial to seek an assessment. 
• The core symptoms (listed above) seem to be impeding her success in and outside of school
• There is a family history of ADHD (this disorder has a strong genetic component)
• She is failing to achieve grade-level expectations in school
• She is performing well in school, but her success comes at great costs (e.g., late nights, lots of extra parental support, etc.)
• She is often “melting down” after a day of school
• She seems overly sensitive and struggles with friendships
• She is displaying symptoms of depression, anxiety, and/or perfectionism
• Teachers express concerns

How to support:

It is important that girls (and all individuals!) with ADHD receive proper support and accommodations. The gold standard approach to treatment of ADHD is a combination of medication and behavioural strategies. Additionally, it is important to provide education regarding ADHD. This will help girls with this disorder to better understand their challenges and feel less alienated. It may also be beneficial for girls with ADHD to connect with others who are experiencing similar challenges. This will help them to feel validated and better understood. Counselling for co-existing conditions and related challenges (e.g., depression, anxiety, perfectionism, self-esteem, and friendship challenges) may also be necessary in order to promote positive mental health. 

In closing:

Girls with ADHD are not broken, inadequate, or flawed in any way. Rather, they experience a unique pattern of challenges associated with their disorder. It is important to identify and address such challenges so that girls with ADHD can experience success and fulfillment. 

Additional Resources

CADDAC Policy Paper on ADHD and Females: Girls and Women with ADHD- Our missed forgotten and most vulnerable https://caddac.ca/wp-content/uploads/Girls-and-Women-with-ADHD-FINAL-1.pdf 

https://childmind.org/article/how-to-help-girls-with-adhd/ 

https://www.additudemag.com/adhd-in-girls-shame/

https://chesapeakeadd.com/home/education-and-training/articles/high-school-girls-with-adhd/ 

Attention Girls! A Guide to Learn All About Your ADHD by Patricia Quinn

Understanding Girls with ADHD, Updated & Revised: How They Feel and Why They Do What They Do by Kathleen Nadeau, Ellen Littman, and Patricia Quinn

Straight Talk About ADHD in Girls: How to Help Your Daughter Thrive by Dr. Stephen Hinshaw