February 20 - 26, 2022: Issue 527


ADHD Affects Girls Too, And It Can Present Differently To The Way It Does In Boys: Here’s What To Look Out For

Credit: Photographee.eu/Shutterstock
On Friday February 18th ABC News ran a great report, ''Women with ADHD 'falling through the cracks' with diagnosis and treatment''.

The report pointed out there's an assumption that ADHD only affects disruptive young boys, but some experts worry that stereotype means the condition goes undiagnosed in women for decades meaning they go without help or a misdiagnosed and treated for other conditions. For these now adult women it can mean years of feeling misunderstood and struggling to cope.

ADHD as a condition that presents in females has been studied more in recent years, A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis. Patricia O. Quinn, MD and Manisha Madhoo, MD, October 2014 NCBI, and Problematic Peer Functioning in Girls with ADHD: A Systematic Literature Review. Francien M. Kok, Yvonne Groen, Anselm B. M. Fuermaier, and Oliver Tucha, Hanna Christiansen, Editor, November 2016. PLOS One, are among a growing body of studies focussed on the impacts of this condition on girls and women.

Many of these state that those previous studies that did examine girls, often used a male comparison sample, disregarding the inherent gender differences between girls and boys. Previous studies have highlighted this limitation and recommended the need for comparisons between ADHD females and typical females, in order to elucidate the picture of female ADHD with regards to problematic peer functioning. 

This week an insight from mid 2021 by Dr. Rachael Murrihy*, ''ADHD affects girls too, and it can present differently to the way it does in boys. Here’s what to look out for'' first published in The Conversation

While an extract from a 2017 article written by Meadow Schroeder, Assistant Professor of Education, University of Calgary, ''Fourteen signs your daughter may have ADHD'' provides;

Signs that your daughter might have ADHD

There are many symptoms of ADHD shared by both boys and girls. The following are examples of how they can manifest in girls:

  1. Homework takes longer than it should. She forgets about it or is distracted by surfing the internet or texting her friends and ends up staying up late the night before an assignment is due to finish it.
  2. She is an inefficient student. While she appears to study for tests, her performance does not seem to match the time spent studying.
  3. She has weak reading comprehension. She can get facts from a text but does not make links between the ideas she reads. She misses details in instructions on assignments and tests.
  4. She struggles with friendships because she does not read social cues or follow conversations. Peers start to reject and isolate her or make fun of her.
  5. She forgets things she needs (e.g. dance shoes or soccer cleats). This is a classic sign but agreeable girls with ADHD will often have friends or adults who compensate for them (for example sharing a pen because she doesn’t have one).
  6. She misplaces her things regularly (for example her phone, keys or bank card).
  7. She talks, and talks and talks.
  8. She does not run and climb about like boys but is the classroom helper and is social and chatty in class.
  9. She has lots of friends because she is fun to be around but when she tries to organize activities she seems anxious and indecisive. Her friends help her make decisions, find her things and keep her organised.
  10. She has great ideas and wants to start acting on them right away but does not finish projects or follow through.
  11. She is chronically late or is not ready when she needs to be.
  12. She channels hyperactivity by being involved in many extracurricular activities like swimming, school clubs and soccer.
  13. She does not seem to learn from consequences.
  14. She has wide swings in mood. One moment she is on top of the world and the next moment she is crushed because of a casual comment that is taken as harsh criticism.

Lastly, symptoms of ADHD in girls are sometimes masked because they work hard to meet adult expectations. Without meaning to, adults have different expectations of girls than boys. In my clinical experience, adults expect girls to be tidy and organised, achieve good grades and to be easy-going. In turn, girls are more likely to want to obey social norms and not cause trouble. They will work extra hard to achieve success by staying up late to finish homework or tidying their rooms when asked.

Undiagnosed ADHD has long-term consequences including an increased likelihood of engaging in risky behaviours — such as unprotected sex and substance use — as well as academic underachievement and low self-esteem. Perhaps most alarmingly, girls who struggle with ADHD for a long period of time can suffer from mental health problems.

As a psychologist in clinical practice, I used to see many older girls and adult women with ADHD who had already been prescribed medication to treat anxiety and depression. Early diagnosis then is vital. - Meadow Schroeder

While ''Girls have ADHD too – here's why doctors may be missing them'' by Florence Mowlem, The Conversation, August 2018 provides:

One reason that fewer girls are diagnosed with ADHD is that girls may be more likely to have the inattentive-type ADHD symptoms, rather than the hyperactive and impulsive symptoms that are more common in boys. The issue is that while inattention and an inability to focus will cause problems for a child, such symptoms may be less disruptive and noticeable for parents or teachers, which means that these children's ADHD may go unrecognised.

If a male stereotype is seen as the norm, potentially only the girls with the most severe, or most "male-like", symptoms that manifest as disruptive behaviour will be identified. We cannot definitively say that affected girls are not getting referred to clinics, but if they are, and if the symptoms of their ADHD are somewhat different to those seen in boys, they may well receive alternative diagnoses, such as anxiety or depression, instead. 

''Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment''. Florence D. Mowlem, Mina A. Rosenqvist, Joanna Martin, Paul Lichtenstein, Philip Asherson & Henrik Larsson. European Child & Adolescent Psychiatry volume 28, pages481–489 - August 2018

If you think your daughter may have ADHD, you should consult with your GP, a psychologist or paediatrician who is familiar with ADHD and can provide an in-depth assessment.

ADHD Affects Girls Too, And It Can Present Differently To The Way It Does In Boys. Here’s What To Look Out For

by Dr. Rachael Murrihy

Two female Australian comedians recently revealed they’ve been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).

In an interview before her shows at the Melbourne International Comedy Festival, Fiona O’Loughlin alluded to lifelong challenges including disorganisation and inability to sustain attention.

O'Loughlin, 57, described her diagnosis as a “seismic shift” in her life, and said medication has helped her immensely. But her struggle with focus will be a story familiar to many girls with ADHD.

And in an article published this week, Em Rusciano also revealed she’s been diagnosed with ADHD. For Rusciano, too, treatment has been transformative. The 42-year-old wrote on Facebook:

I don’t feel the world coming at me at 100 all the time anymore. The constant sensory overload has stopped. I don’t feel overwhelmed by life quite as much.

While some of us might perceive ADHD as a condition that affects males (particularly boys), it affects girls and women too. And it’s important to understand that the way it presents in girls can be quite different to the way it manifests itself in boys.

What is ADHD?

Best understood as a persistent, and sometimes lifelong, neurodevelopmental disorder, ADHD includes problems with sustaining attention, resisting distraction, and moderating activity levels to suit the environment (for example, sitting in a classroom).

Young people with ADHD vary considerably in their behaviours. A child might exhibit symptoms of hyperactivity-impulsivity (for example, fidgeting and squirming, or frequently leaving their seat in class), or inattention (careless mistakes, trouble focusing in class, difficulty keeping their belongings in order), or more commonly, both. Hyperfocus (an intense fixation on one activity) can also be a symptom.

Of course, these behaviours are common in childhood to varying degrees. Diagnosis is based on whether symptoms are excessive for the child’s age, developmental level, and cultural background (parents across different cultures may differ in whether they see a child’s behaviour as hyperactive or normal).

diagnosis is only made if there’s clear evidence that the symptoms impair functioning across several life domains such as at school, at home and with friends.

Does ADHD look different in girls?

Researchers have only recently started to unravel the expression of ADHD in girls.

The way ADHD presents in girls and boys is in many ways similar, but there are a few noteworthy differences. Most importantly, while symptoms of hyperactivity-impulsivity are present across genders (with some studies showing more hyperactivity in boys), symptoms of inattention, which can be easier to overlook, are seen more frequently in girls.

Further, the onset of ADHD symptoms can differ across gender. Symptoms of hyperactivity tend to present early in school life. Inattentiveness, by contrast, has a slightly later onset. So girls with ADHD can often go undetected until academic and organisational demands increase in late primary and high school.

Girls with ADHD are also at higher risk of developing depression and anxiety than boys. If depression and anxiety occur at the same time as ADHD, it can be more difficult to diagnose ADHD.

A range of possible mechanisms have been implicated in the difference in ADHD expression between genders, from hormonal changes, to cognitive differences, to social factors. But we need more research to truly understand the reasons behind the disparity.

Boys versus girls

ADHD is the most common psychological disorder among Australian youth. The second Australian Child and Adolescent Survey of Mental Health and Wellbeing, published in 2015, reported 7.4% of 4-17-year-olds had ADHD over the previous 12 months.

Interestingly, more than twice as many boys have ADHD than girls. The disparity in prevalence may be a result of ADHD being historically viewed as a male disorder.

This gender difference in prevalence has prompted controversy about diagnostic criteria and brought the female expression of ADHD into sharper focus.

There’s some suggestion the current diagnostic framework, developed on male-dominated samples, is inadequate for girls and sees more boys than girls get a diagnosis. Some researchers have suggested symptom thresholds for diagnosis in girls should be modified.

Are there female expressions of hyperactivity-impulsivity (for example, internal feelings of restlessness) that could be added to the diagnostic criteria? Should there be gender-specific cut-offs for current criteria (for example, a lower threshold for hyperactivity for girls)?

Until further research is conducted, the jury is out on any changes to the current system.

Importantly, many parents and teachers have long-held stereotypes of an ADHD child as a disruptive and hyperactive boy with difficulties staying still and keeping on-task. This perceptual bias influences who they recognise as potentially having ADHD and refer to treatment.

Research shows even when students display equivalent levels of impairment, teachers still refer more boys than girls for ADHD treatment.

Some signs of ADHD in girls

Does your child do the following more than other children of her age?

  • make careless mistakes
  • daydream or appear spaced out
  • fail to pay close attention to details
  • have difficulty remaining focused in class, reading, homework, conversations
  • doesn’t seem to listen (appears distracted)
  • have difficulty organising tasks and materials
  • is reluctant to engage in tasks that require mental effort (schoolwork, homework)
  • often loses everyday things
  • is forgetful in daily activities.

Keep an eye out for an increase in symptoms in late primary or early high school, as workload increases.

A good rule of thumb for when it’s time to seek help is when a child is starting to fail, fall behind or perform significantly below their ability either in schoolwork, friendships or family relationships.

There’s no cure for ADHD, but treatment aims to manage symptoms. Across genders, the first line of treatment for children is stimulant medication (such as Ritalin, Adderall or Concerta) and behaviour management (parent training and classroom management).

As more research on female ADHD emerges, we can consider treatment modifications specific to gender.

For many girls, ADHD is a serious and debilitating illness. Ensuring girls are identified early and accurately and that they receive evidence-based treatment is crucial.

* Dr Rachael Murrihy is the Director of The Kidman Centre, a department within the Faculty of Science at UTS dedicated to the understanding, prevention and reduction of mental health problems in young people aged 5 to 25. Dr Murrihy obtained her Doctorate of Clinical Psychology from the University of Wollongong in 2006 and subsequently received the John Freestone Award for outstanding achievement in a clinical training program.