ADHD in girls – don’t let them fall through the cracks

Girls with Attention Deficit hyperactivity Disorder (ADHD) may be labelled many things before they receive an accurate diagnosis, as there is strong public perception that ADHD is a behavioural disorder that primarily affects boys. When left undiagnosed, ADHD in girls can affect their emotional health and general well-being.

Over 30 years ago, Berry, Shaywitz and Shaywitz (2020) warned that girls constitute a ‘silent minority’ in ADHD, with more internalised behaviour making them less likely to be referred for assessment. To date, this still appears to be the case. Girls with ADHD remain more likely to be unrecognised or mis-identified, leading to lower-than-expected rates of referral, assessment, and treatment for ADHD. This is generally attributed to the higher rate of internalised and inattentive behaviours present in girls, together with their compensatory functions, which mask or overshadow the effects of ADHD symptoms. The challenge is to raise awareness and provide training on the presence and presentation of ADHD in girls.

The fact is that ADHD is equally common in girls and boys, but girls may go undiagnosed. This is because girls are less likely to be hyperactive, they also tend to have less trouble with self-control and are less disruptive at home and in class – so their symptoms may fly under the radar.

Girls may also be perceived as overly sensitive or emotional, and often try to compensate for their symptoms by putting all their energy into things they do well, which is not as common as in boys. Girls are more likely to be ‘people pleasers’, doing all they can to fit in, even when they feel they are ‘different’. However, their outward success in one area can make it harder to notice their struggles in other areas, adding to the masking of symptoms.   

Many children with ADHD also struggle with making and keeping friends, and it can be even trickier for girls. Their social world can be more complicated than that of boys, and they may feel rejected and socially isolated – responding with bravado to buffer them from social isolation. However, this ‘brave face’ is unlikely to prevent them from feeling distressed and developing low mood and anxiety. Girls can also struggle with low self-esteem and feelings of shame, and are more likely than boys to blame themselves for problems caused by ADHD.

Treatment

Prompt identification and treatment of ADHD is recommended, as there is evidence of long-term functional benefits associated with treatment. ADHD is typically treated with medication, psychoeducation, diet and therapeutic interventions at all ages. A multi-modal treatment approach is reported to be most beneficial.

Understanding what ADHD looks like in girls is the first step towards improving detection, assessment, and treatment, and ultimately enhancing long-term outcomes for girls and women with ADHD.  Therefore, to facilitate identification, it is important to move away from the previously predominating ‘disruptive boy’ stereotype of ADHD, and understand the more subtle and internalised presentation that predominates in girls.

Summary

• A person with ADHD has differences in brain development and brain activity that affect certain executive functions such as attention, the ability to sit still, and self-regulation.
• ADHD often expresses itself differently in girls through excessive talking, poor self-esteem, worrying, perfectionism and risk-taking. Inattention in girls with ADHD may present as being easily distracted, impulsive, disorganised, overwhelmed, emotional dysregulation and lacking in effort or motivation.

What can you do?

If you think your daughter has ADHD, speak to your child’s educational team first, to best understand how her symptoms present in the school environment, and for them to get a better understanding of how it plays out in the home environment. Together you can decide if seeking medical advice is needed in order to better support her through a diagnosis and further treatment.

For more information, visit www.bellavista.org.za

References:

BMC Psychiatry.2020. Berry CA, Shaywitz JE, Shaywitz B. Girls with attention deficit disorder: a silent minority? A report on behavioral and cognitive characterisitics. Pediatrics. 

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