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The Dilemma of ADHD in Bright Young Girls

by Dr. Shirley Liu

Listen to the audio here!

Early on in my career, when I was still training to become a psychiatrist, I had the fortune to work with the first adult female I diagnosed with ADHD. She had every indication of an individual with inattentive ADHD: difficulty completing tasks, disorganization, easy distractibility, losing job after job not because she wasn't talented at her work but for careless mistakes and missing deadlines—she even had a brother who was diagnosed with ADHD when they were children, but somehow her diagnosis was missed until she was almost 40. By then, she had endured nearly two decades of disappointment, frustration, and feelings of failure for not being able to "just keep it together" and hold the same job for more than 6 months.1

As I reflect on all the occupational as well as psychosocial consequences she experienced as a result of her unidentified and untreated ADHD, I realize that even within my practice alone, her story is not uncommon. While the majority of the children I see with ADHD are male, the most severe cases of ADHD I have treated have all been in females. Why is that? I believe it is because society tends to overlook the more mild cases of ADHD in girls and not bring them to medical attention unless or until their symptoms are severe, while symptoms in boys are noticed earlier and at lower severity levels.

In fact, it is well-known that girls are underdiagnosed. The rate of diagnosed ADHD in boys has outnumbered that in girls 3:1 for years (although this number is shifting down, and according to the most recent epidemiologic study in the US is now closer to 2:1). Yet, by adulthood, the rates of ADHD have been found to be equal between men and women. What I see happen in the interim is that girls who have unidentified and untreated ADHD encounter more and more social and academic demands as they progress through middle school, high school, college, and work environments, until they themselves are 1) fortunate enough to stumble upon learning more about ADHD in females and 2) experience enough internal distress to self-refer for an evaluation. The consequences of this delayed diagnosis is an entire population of female adolescents, young adults, and adults who struggle with years of underachievement, poor self-esteem, depression, anxiety, and sometimes eating disorders, teen pregnancy, and/or drug use—all associated with untreated ADHD—that could have been prevented.

An ironic twist to this pattern is that it seems it is the girls who naturally find ways to adaptively respond to their ADHD symptoms who are at greatest risk of experiencing such distressing and chronic emotional consequence from this trend of delayed diagnosis. The girls who have severe symptoms in elementary school are, in a way, fortunate enough to be identified early. Similarly, the girls who have moderate symptoms may be challenged enough in middle or high school to exhibit significant enough social consequences to bring them to the attention of mental health experts and then hopefully be appropriately diagnosed. However, it is the young girls who somehow make it through primary school “under the radar” and, later on, whose drive to achieve compels them to compensate for their difficulties with attention and executive dysfunction via pure effort (i.e. spending more hours completing school work, studying longer, employing organizational and time management strategies early on in life), who end up struggling for years or decades with a dark cloud hanging over them. They are the ones who, though able to graduate from college with honors or have a professional career, constantly struggle with the internal questions of, “Why does it take me so much longer to study and earn the “A” than my peers? Why do I always feel so overwhelmed? I know that balancing work and family life is challenging for everyone, but why does it seem so much harder for me? What is wrong with me?” And additionally, they are the ones who are told by those around them, “You are fine; you’re great! You can’t have ADHD,” and are asked to continue to toil quietly on their own and perhaps even keep their feelings of resultant anxiety or depression a secret.

So, the following are a few tips we can keep in mind as we interact with the precious young girls we encounter in our daily lives, in hopes of identifying ADHD in this population earlier and avoiding the above:

1) Don’t automatically assume girls don’t get ADHD. Let’s dispel this myth. Just because they are diagnosed less often does not mean that the condition does not exist in girls—ADHD absolutely can and does occur in girls and women; we need to just look more carefully. And only if we think of and consider it will we be able to overcome the problem of underdiagnosis.

2) Make sure to talk to you children about how they feel about schoolwork and friends, rather than rely solely on the annual parent-teacher conference. Because girls more often present with inattentive rather than hyperactive and impulsive symptoms, they often cause less disruption at school (and perhaps at home too). That means, while the teacher is (understandably) preoccupied with trying to keep Johnny in his seat rather than inappropriately 2walking up and down the aisles during a lesson, the teacher may not notice that Mary is staring out the window daydreaming and also missing the lesson. Similarly, girls have a greater tendency to internalize stressful feelings and experience them as emotional states, while boys have a greater tendency to externalize them into easily observable behaviors. For example, if both Johnny and Mary are struggling to complete an in-class worksheet (because both of them were unfocused and missed the lesson earlier), Johnny may express his frustration by being defiant and audibly refusing to do the worksheet, while Mary might become withdrawn and simply try to hide her difficulty with the worksheet by rushing through it and guessing. Both of these are perfect examples of how “The squeaky wheel gets the oil.” The teacher will likely mention to Johnny’s parents his disruptive behavior and ask his parents to consider an evaluation for ADHD, but because Mary is calm, quiet and not interfering with the rest of the class, the teacher may tell her parents that she “does fine” in class. Of course, teacher input is incredibly useful and valuable. However, it is not the only important source of information. In this case, rather than relying on the old adage of “No news [from teachers] is good news,” you want to take into account a full picture of the child. Does she seem to be “in her own world” a lot at home? Does she forget, lose, or misplace her belongings frequently? Do you have to repeat instructions to her frequently, more than to her siblings or other children? And intentionally ask her about what her experience of class and working in class is like, or better yet, spend time doing homework with her and observe for yourself her behavior. Even though she does well enough to pass, is doing so a challenge or stressful for her? Even though she completes her work, does it take longer than it should? (Asking teachers how long they expect students to require to complete their homework can help give you an idea of what is normal.) These observations and inquiries will go a long way towards helping to uncover hidden cases of ADHD.

3) Don’t always assume, “It is just her personality” or “That’s just how she is.” Indeed, we all have personality styles and idiosyncracies that are unique and make us who we are. However, if there is a pattern of behavior or tendencies that both match the profile of ADHD (e.g. forgetfulness, frequent daydreaming, inattentiveness, etc.) and cause either dysfunction (at school or in the home) or distress (e.g. feelings of self-consciousness, low self-esteem due to difficulty making friends, etc.), then it is worth considering that it may be more than just personality style. When in doubt, there is no harm in having a professional evaluate. As research in neuroscience continues to advance, doctors have more and more objective assessment tools at their disposal to better diagnosis ADHD (including computerized continuous performance tests, neuropsychological testing, and most recently approved by the FDA, brain wave assessment—ask your doctor for more information).

4) Pay attention to family history. ADHD is a highly heritable condition, meaning that it runs in families, and one’s risk of having ADHD increases if one’s relative has ADHD. Thus, if a girl has a sibling, parent, or multiple other relatives who have ADHD, then it makes sense to have a higher suspicion of ADHD in her. This seems to be particularly difficult to keep in mind when a girl has a brother with hyperactive-impulsive ADHD. Parents often are so overwhelmed by their son’s disruptive behavior that their daughter’s quiet, unobtrusive behavior is welcomed with open arms and her lack of performing to her potential in school or internalized depressive and anxious feelings can be easily overlooked. But biologically, she actually has a higher chance of having ADHD than average.

I believe that if the doctors, teachers, parents, and relatives of my first female adult patient with ADHD were made aware of just the few tips above, then she may have been diagnosed and treated earlier and spared the many years of emotional defeat that she suffered. But, looking forward, I am filled with optimism. The message about ADHD in girls and women is without a doubt spreading. And treatment appears just as effective and helpful in females as males. For example, when I graduated from my psychiatry program, my patient was on stimulant treatment and celebrating staying at the same job for the longest duration of her life. We had finally successfully unwrapped her gifts and given her tools she needed to soar.

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