ADHD in girls

Quick facts about ADHD in girls

  • The diagnosis ratio for boys vs. girls is 4 to 1, for adults 1:1.
  • Girls present with ADHD in a different way than boys, normally they have the inattentive type ADHD. 
  • Girls may be quiet in the classroom and that’s why teachers don’t notice.
  • Girls often internalize their symptoms.
  • ADHD presents at a later age in Girls – the screening tools were designed for hyperactive boys and the age of onset was before 7 years of age. The onset is much later for girls, closer to puberty, and, girls often do not get diagnosed or treated!
  • For a long time, girls and women were not studied in ADHD research and literature.

How Does ADHD Present in Girls

Girls with ADHD usually have the primarily inattentive type of this condition, which may make them appear quiet and dreamy, and can often go unnoticed. Even parents who have had a lot of experience with managing ADHD in their sons can miss the subtle symptoms that indicate their daughter is likely to have ADHD also. Since ADHD symptoms often do not become noticeable as early in girls as they do in boys, this adds to the misunderstandings and misdiagnoses in girls. As a result, it is thought that ADHD is underdiagnosed in girls today and is much more common than previously thought. Do not be deceived into thinking that its effects will be much less harmful for girls as they progress into adulthood. Inattentive ADHD is thought to be more debilitating, especially if left undiagnosed and untreated.  

There are some warning signs to look out for, however, which – if acted upon – could make life easier for girls in this situation.

Indicators of AD/HD in girls

  • Tend to be quiet and dreamy, even anxious.
  • May doodle a lot in class when teacher is talking, etc.
  • Are unable to pay attention fully and listen to what is being said (school, home, friends) and they find it hard to follow instructions.
  • Inattentive ADHD is less likely to cause a classroom disturbance that gets the teachers’ attention.
  • Girls usually lack self-confidence/self-belief.
  • Are usually poor timekeepers, or they over-compensate by being really early for everything.
  • Tend to procrastinate, but they make sure to get their homework completed on time by doing it at the last minute.
  • Tend to be perfectionists, so they appear very organised.
  • May need a lot more time to finish homework because of procrastination and perfectionism.
  • Tend to have dramatic/intense relationships.
  • Are liable to be overly emotional and prone to tantrums, especially at home.
  • Tend to become moody and irritable during the teen years.
  • Struggle with relationships (friends, groups, teachers, etc.).

These girls may be very orderly in the way they record their homework assignments and organize their class files. This can be deceptive to parents who have experienced the disorganized schoolbags and files of their ADHD sons, which constantly need to be monitored to make sure that things did not get lost, etc. Girls are generally much better at being tidy and organized at this stage in their lives, but this is not evidence that they do not have AD/HD. The ADHD symptoms in girls are of a different nature than those of boys, but nonetheless just as debilitating in the long run.

Girls with ADHD experience stress in a more intense way than their non-ADHD peers, but this is usually internal, and not obvious at school. At first, they can cope with school work, but as it gets harder they usually become anxious, overwhelmed, and depressed. This may not happen until University…

Some girls may have the combined Hyperactive-Inattentive type ADHD and these girls differ from their inattentive peers in that they will: 

  • Have a higher activity level.
  • Be excitable and emotional. 
  • Interrupt others frequently, and jump from topic to topic during a conversation. 
  • Be more likely to be aggressive towards teachers they don’t like.
  • Possibly adopt a “silly” personality to mask their deficits. 

They get themselves noticed, but even so, they are not always identified as having ADHD.

During adolescence, girls with ADHD may lack the necessary coping strategies and as a result, they have more impairment on measures of social, school, and family functioning than girls without ADHD. Maintaining friendships in adolescence is impaired/hindered by their forgetfulness, missing dates with friends, apparent lack of interest in what their friends have to say, and the appearance of self-centeredness, all of which makes maintaining friendships difficult for them.

It is very important to have ADHD treated as early as possible so that girls understand the condition and make life and career choices that complement their talents and dispositions. If a girl with ADHD is left undiagnosed or untreated as she enters adolescence and young adulthood, she will almost inevitably encounter a range of adjustment problems that can lead to additional disorders, such as an eating disorder (bulimia, anorexia), a personality disorder, and/or depression. Other behaviours may include early sexual activity driven by a need to feel good, and a misguided sense of wanting to be liked and to be popular. This sometimes impulsive behaviour leads to unprotected sex, a higher ratio of teenage pregnancies, and sexually transmitted infections. They are also at risk of developing chronic low self-esteem, underachievement, and an early smoking habit during their school years.  

What all females with ADHD share are the following symptoms

  • Being forgetful, easily distracted, and often late.
  • Having sleep problems (getting to sleep, staying asleep, quality of sleep).
  • Finding it difficult to concentrate during conversations, affects friendships, school, and work.
  • Experiencing a worsening of symptoms in their teens.
  • Always seeming to be on the outside looking in.
  • Comfort eating.
  • Overexercising or not exercising at all.
  • Typically experience more stress, more acutely than their non-ADHD peers.
  • Viewing their difficulties with organizing and prioritizing as character flaws.

ADHD in females of all ages also has links to emotional dysregulation and mental health problems. This may have a biological basis because research has shown that changes of estrogen levels in the brain can greatly affect girls and women with ADHD symptoms, making them more susceptible to severe premenstrual mood swings, depression and/or anxiety.

Co-existing conditions

Other conditions can also be present along with ADHD:

  • Anxiety Disorders, such as social anxiety disorder or obsessive-compulsive disorder (OCD).
  • Some girls with untreated ADHD suffer also from anxiety and/or depression as adolescents, which is easier to detect and to treat. However, if the underlying ADHD is not recognized and treated, the other treatment for the co-existing conditions is unlikely to relieve the symptoms and the girl continues to suffer because of the untreated ADHD symptoms, which usually get more severe with the onset of puberty. 
  • Emotional dysregulation.
  • Autism Spectrum Conditions – (like ADHD) are also harder to diagnose in girls.
  • If girls have an accompanying learning disability, such as Dyslexia, Dysgraphia, and Dyscalculia, these conditions will generally be identified and appropriate accommodations are given.
  • These girls are in real danger of turning their backs on school as soon as this is allowed, even those who are highly intelligent and creative. This is the reason that we see many intelligent women go back to study later in life when they have learned to deal with stress – and the hormone imbalances of their teenage years have settled down.
  • ADHD is highly comorbid with circadian-based disorders:  Sleep disorders – insomnia, sleep apnea, circadian rhythm sleep-wake disorders.
  • Eating disorders, such as binge eating, obesity, anorexia, bulimia. Comfort eating is common in females with ADHD, especially if untreated; this is a stress reliever for them.

In addition to these, the following comorbidities are prevalent due to how hormones affect teenage girls:

  • Premenstrual Syndrome (PMS) / Premenstrual dysphoric disorder (PMDD).
  • Polycystic Ovary Syndrome (PCOS).

The hormonal changes during puberty often intensify ADHD symptoms, which makes it even more difficult for those who are undiagnosed and untreated. Conforming to society’s expectations is much more difficult for these girls and their sense of inadequacy increases. This can lead to anxiety and depression. 

We know that at the beginning, at puberty, monthly hormonal fluctuations bring high levels of estrogen and progesterone, enhancing neurotransmitters and improving cognitive functioning following menstruation. 
However, when premenstrual hormone levels drop, girls can experience an exacerbation of ADHD symptoms along with typical premenstrual changes.

Low estrogen triggers greater irritability and disruptions of mood, sleep, and concentration. These observable symptoms can easily lead to a diagnosis of PMDD, without consideration of underlying ADHD. If hormones cause a big effect on ADHD in your girls, it would be useful to watch Women, ADHD, and Hormones https://www.youtube.com/watch?v=tPerPxb-RNs 

Diagnosis

Diagnosis should be done by a psychiatrist who is specialized in ADHD in girls and the female presentation of ADHD. Recommendations from one’s local ADHD organization or Support Group would be the ideal way to get this information.
At the outset, the patient will be required to undergo a physical health check to rule out any other causes for her symptoms.
The actual ADHD diagnosis includes completing questionnaires to determine if one’s symptoms indicate possible ADHD. Further questionnaires are also used to analyse mood, sleep patterns, and emotional dysregulation.

The psychiatrist typically will try to get information about one’s development as a child and adolescent and if school reports are available, s/he would be interested in seeing them. It is generally useful to ask the psychiatrist to assess the girl for any possible co-morbidities (eg dyslexia, dyscalculia, dysgraphia, dyspraxia, autism, Tourette’s syndrome).

Other treatment options

Many doctors will recommend medicine. In Belgium medication is usually generic (non-brand). 
Some members report increased medication side-effects for minors using generics, others report positive effects. In addition, ‘out of stock’ situations jeopardise personal outcomes, especially for youths during examination times.

Medication alone is not the best way to treat ADHD; it is usually best to combine medication with another treatment option such as Coaching for ADHD and/or academic success – coaching for girls should ideally combine knowledge of ADHD, with how to perform at your best in school. There may also be a co-occurring condition such as dyslexia, dyscalulia (maths problems) or dysgraphia (writing problems) that needs work.

Cognitive Behavioural Therapy (CBT)
Mindfulness
Neurofeedback

Girls become women…

Slowly but surely the message about girls having ADHD is being read and understood by society. We know that:

  • Since ADHD was first studied in the late 1700’s, it has predominantly been studied in boys: white, hyperactive, school-aged boys, to be specific. While research on girls and women is growing at exponential rates, the myth that ADHD is a condition of boyhood has gotten in the way of adequate diagnostic and treatment services for millions of girls and women with ADHD over the centuries (yes, centuries).
  • According to a prominent study by the National Institute for Mental Health in 2011, about 4.2% of females have received a diagnosis of ADHD at some point in their life. However, we are still learning whether these numbers actually reflect incidence or whether rates of diagnosis for girls and women continued to be underreported.
  • Overall, however, women and girls are less likely to be properly diagnosed with ADHD, with boys and men being more likely than girls and women to be referred for services even when their symptom profiles are exactly the same.

The myth that all people with ADHD are hyperactive likely accounts for another reason that girls and women with the condition are often overlooked. Many girls and women are initially referred for treatment due to symptoms of anxiety and depression, while symptoms of ADHD are missed. A number of complex and nuanced factors further influence the female experience of ADHD, including fluctuating estrogen levels impacting symptoms and gendered expectations of behavior that might complicate how symptoms are perceived.

Source credit ADHD Awareness Month and ADHD Europe https://www.adhdawarenessmonth.org/myth-only-boys-have-adhd/ 

Many girls with ADHD are not spotted in school, and may only be diagnosed at University or even later in life. The hormonal changes during puberty often intensify ADHD symptoms, which makes it even more difficult for those who are undiagnosed and untreated.

Understanding Girls with ADHD
Credit CHADD via Help for ADHD Youtube Channel
In this youtube video, Dr. Ellen Littman talks about understanding Girls with ADHD. She is a pioneer in the identification of gender differences in ADHD, with particular expertise in issues affecting women and girls. Dr. Littman, joined our Annual Conference in Belgium in 2017 to share all her insights, and help us understand more about the situation with undiagnosed ADHD in Girls, and how women struggle later in life.

Did you know that girls with ADHD are more likely to:

  • Experience a worsening of symptoms in their teens?
  • View their difficulties with organizing and prioritizing as character flaws?

ADHD can contribute to unique challenges that only girls with the disorder confront. Learn what you can do, anchored in the latest research, to guide girls through the challenges of ADHD.

Dr. Littman is co-author of the book Understanding Girls with ADHD and contributing author of Understanding Women with ADHD. In her private practice Dr. Littman focuses on high IQ adult and adolescent ADHD populations. She specializes in identifying and treating complex presentations of ADHD that may be misinterpreted or overlooked.

First written in 1999, the new edition of Understanding Girls with ADHD is better than ever. In this expanded and updated book, Kathleen Nadeau, Ellen Littman, and Patricia Quinn deliver a comprehensive, up-to-date, and readable book that illuminates the complexity of ADHD in girls and women, both across the lifespan and across multiple domains of life (e.g. home, school, the workplace, close relationships). Even more, the authors emphasize that ADHD rarely exists in a vacuum and that understanding and treating comorbid disorders is essential.

Understanding Girls with ADHD does not shy away from key areas of controversy. Written with compassion and sensitivity, and full of the clinical wisdom that accompanies years of experience on the front lines, Understanding Girls with ADHD is the go-to book for those needing guidance, support, and knowledge about female manifestations of ADHD – Credit Amazon, Understanding Girls with ADHD.

Recommended articles about girls with ADHD

Decades of failing to recognize ADHD in girls have created a “lost generation” of women… Between 2003 and 2011, parents reported an increase of ADHD diagnoses of 55% for girls, compared to 40% for boys, according to a 2015 study in the Journal of Clinical Psychiatry. Read full article here.

Under-diagnosed and under-treated, girls with ADHD face distinct risks! It took a long time to figure out how attention-deficit/hyperactivity disorder presents in girls and women and the problems it can create. A pioneering study helped change that, but the condition is still often missed. Read full article here.

20 Signs and Symptoms of ADHD in Girls. How the condition tends to present in females may surprise you. Living with undiagnosed ADHD can result in disadvantages, such as a lack of accommodations in the classroom, low self-esteem, and self-blame. Being aware…. Read full article here.

Written by Chantel Fouche, adapted from the experiences of girls/women living with un/diagnosed ADHD and the website www.adhd-women which was authored by Joanne Norris.

Experts

Professor Sandra Kooij
ADHD in Adult Women Psychiatry and Research
Website
LinkedIn

Dr. Werner Van den Bergh
Neuropsychiatrist
Website
E-mail

Contact us

ADHD in Women

Many women have struggled for years living with ADHD, causing implications prior to their delayed diagnosis later in their lives.

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Dyslexia

Dyslexia can be best described as a range of difficulties that make the acquisition of reading, spelling, writing and sometimes mathematics difficult for those afflicted.

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Dyscalculia

Dyscalculia is described as a developmental learning disorder that is characterized by a lack of “skills related to mathematics or arithmetic.

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Why did we start the ADHD Women Project?

In collaboration with ADHS Deutschland e.V, our main goal was to change women’s lives, to provide information, support and a network to be #bettertogether #strongertogether
Women don’t know they have ADHD, or suspect they have ADHD. Our campaign across Belgium and Germany is allowing women to discover more about symptoms and more…. Read more here.

Where can we follow the ADHD Women Project?