ADHD and girls: Hidden in plain sight

Olivia Riddle investigates why girls with ADHD are often missed.

What is attention-deficit/hyperactivity disorder (ADHD)?

Individuals diagnosed with attention-deficit/hyperactivity disorder(ADHD) typically present with persistent patterns of inattention and/or hyperactivity-impulsivity. This will interfere with their functioning or development (American Psychiatric Association, 2013). ADHD is believed to occur in approximately 5-10% of children (Olsson, 2023). A child with ADHD may struggle to sustain their attention during tasks or play, be resistant to completing tasks requiring mental effort, or lose things they need to carry out these activities. Children with ADHD may also struggle to sit still, wait their turn or interrupt others who are speaking.
ADHD is split into ‘three presentations’. These include:
• Predominantly ‘Inattentive’
• Predominantly ‘Hyperactive-Impulsive’
• A combination of the two

Gender differences in identification and assessment

Why are girls underdiagnosed with ADHD compared to boys? Until fairly recently, tools used to identify ADHD were based on studies conducted only with young boys (Chronis-Tuscano, 2022). This has had far reaching consequences, with educators, carers and clinicians only aware of the male presentation. This, along with the pervasive myth that girls “cannot have ADHD”, has contributed to many girls not being referred for assessment. Accordingly, in many females, ADHD has remained “hidden”.

Females with ADHD are believed to often present differently to their male counterparts (Steer et al., 2021). For example, girls may display fewer symptoms of hyperactivity and impulsivity, and more symptoms of inattention. This inattention may look like daydreaming, disorganisation, forgetfulness or a lack of motivation.  Whilst a girl with ADHD may not present as physically “restless” as a boy, this does not mean that her mind is not racing with a multitude of thoughts. Instead of “hyperactive”, girls may be considered “hyper-talkative” or “hyper-emotional” instead.  Females are also likely to “mask” their difficulties from the outside world through the use of compensatory strategies (Young et al., 2020) . This use of masking is often applied as a way to avoid social judgement for “violating feminine norms” (Attoe et al., 2023). Research suggests that gender-based biases in teachers and parents also contribute to a girl being less likely to be referred for an assessment (Sciutto et al., 2004; Young et al., 2020; Olsson, 2023;) Overall, research suggests that girls need to present with more “extreme” symptoms to be acknowledged and recognised as having ADHD. 

While the research into girls and women who experience ADHD continues to grow, it still remains small.  Without the necessary support in place, girls are at risk of experiencing greater difficulties at school, both academically and socially, along with an increased threat to their self-esteem (Young et al., 2020). Indeed, women  without a diagnosis have reported that they spent “their lives feeling different, stupid or lazy” and “and blaming themselves for their underachievement” (Attoe et al., 2023).   

Accordingly, the gender gap in diagnosing ADHD in girls and women must be closed. ADHD is a manageable condition, and with early intervention, there should be no reason that individuals cannot thrive, both academically and professionally.

What can we do as parents and as educators?

• We should all aim to be curious and question our own personal perceptions of ADHD and neurodiversity in general.  Educate yourself with  up-to-date and reputable sources. I’ve listed some sources below for further information.
• Share what you learn with friends, family and colleagues to help to change the public perception of ADHD as a ‘male only’ difference.
• If you suspect your daughter presents with ADHD, get clued up about what ADHD does and does not look like in girls. See this article for more information: https://childmind.org/article/how-to-tell-if-your-daughter-has-adhd/.
• Schools should support staff through providing training on the presence and presentation of ADHD in girls (and, of course, in boys too). Training should draw attention to the stereotypes commonly understood and question their validity.
• Strategies and interventions to support pupils with ADHD at school should be individually tailored. Currently, the evidence suggests that this is not the case and a “one size fits all” approach is often adopted.
• And it goes without saying… let’s advocate for girls with ADHD, and always acknowledge, praise and reward their efforts.

Further resources:

https://childmind.org/

https://adhdgirls.co.uk

htt[s://www.adhdfoundation.org.uk/about-us

https://chadd.org/for-adults/women-and-girls

References

Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders, 27(7), 645–657.

Olsson, A (2023) Teachers’ gendered perceptions of attention deficit hyperactivity disorder – a literature review, European Journal of Special Needs Education, 38:3, 303-316.

Steer, J.,  Bilbow, A., Berry, C., Brunet, J., Hill, P., Doig, A., Akins, E., Ivens, V., Cubbin, S., & Parry, A. (2021). Understanding ADHD in Girls and Women. Jessica Kingsley Publishers.

Sciutto, M. J., Nolfi, C. J., & Bluhm, C. (2004). Effects of Child Gender and Symptom Type on Referrals for ADHD by Elementary School Teachers. Journal of Emotional and Behavioral Disorders, 12(4), 247–253.

Young, S., Adamo, N., Ásgeirsdóttir, B.B. et al. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. (2020) BMC Psychiatry 20, 404.