Mention ADHD (Attention Deficit Hyperactivity Disorder), and you may quickly be submerged in a conversation that includes the stereotypical imagery of loud tween and teen boys, demonstrating hyperactivity and boisterous behaviours. You may also be invited to an energetic discussion about the pros and cons of medication.
You are not so likely to hear of the remarkable prevalence of ADHD in tween and teen girls or of the very different and often undiagnosed presentation in females across their lifespan.
ADHD is a neurodevelopmental disorder, often diagnosed in childhood and during the transition into adulthood. It is estimated that around 7% of young people meet the criteria for diagnosis.
The average age of ADHD diagnosis is seven years, with signs and symptoms often first noticed or reported between three to six years. Boys are more than three times more likely to be diagnosed with ADHD than their female peers.
In girls, diagnosis can often be missed in the early years, with many not receiving their initial diagnosis until adolescence or adulthood.
Missed and Misunderstood: ADHD in Girls and Women
ADHD is chronically under-diagnosed in girls and women.
‘Inattentive ADHD’ is the type most often seen in girls. Unfortunately, the complex nature of the presentation, together with a lack of specialist knowledge, can lead to prolonged investigations and unsatisfactory treatment.
The signs and symptoms are often missed during the tween and teenage years and beyond. In fact, many girls and women are not diagnosed until much later in life. Whilst women of all ages describe their ADHD diagnosis as the missing piece of their personal puzzle, they also report feeling sad and confused that they were not diagnosed earlier in life.
ADHD symptoms in girls and women may typically be mistaken for stress, anxiety, hormonal imbalance or other medical and psychological issues.
And for Mums Too: Mums with ADHD
Many women are diagnosed with ADHD in later life, sometimes when they are mothers themselves and seeking help for their sons or daughters.
Adult women are, in fact, the fastest-growing population of ADHD diagnosis worldwide. We hear from mothers worldwide who have recently received a diagnosis of ADHD and feel like a light was turned on in their world. Many describe diagnosis in later life as a game-changer and a ‘light bulb’ moment, explaining a lot of their difficulties in earlier life.
Mums, it is never too late to be assessed yourself. It could be the missing piece of your jigsaw too.
Suffering in Silence
Difficulty in recognising ADHD symptoms in girls and young women leads to a significantly lower number of referrals to specialist ADHD mental health practitioners from both their families and the education system. Males are more like to be referred and to receive a diagnosis than their female peers.
Four out of 10 teachers report difficulty in assessing the signs of ADHD in their female students. Parents similarly report seeking help for tween and teen boys and young adult men with perceived behavioural problems more readily than their female siblings.
Young girls often suffer the effects of untreated ADHD in silence. Often labelled (incorrectly and inappropriately) as clumsy, lazy or disorganised, young girls with symptoms of ADHD can find themselves becoming increasingly distressed. Anxiety, depression, lack of confidence, feeling left behind and self-critical are often seen in girls with difficulties arising from undiagnosed ADHD.
ADHD or ADD – What’s in a Name?
Attention Deficit Hyperactivity Disorder or Attention Deficit Disorder are terms used to describe a set of symptoms and behaviours. ADD, a now-outdated name was previously used to describe ‘Inattentive type ADHD’. Whilst both terms may be used interchangeably, ‘Inattentive type ADHD’ is preferred.
The American Psychiatric Association describes three types of ADHD in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5):
- Predominantly Hyperactive ADHD
- Predominately Inattentive ADHD (more often diagnosed in girls/women)
- Combined Type ADHD.
Signs and Symptoms of Predominantly Hyperactive ADHD
This type of ADHD is more recognisable and more often diagnosed in children and men. Signs and symptoms include:
- Finding difficulty sitting still or quietly, especially in calm or serene surroundings
- Fidgeting or moving much of the time
- Difficulty concentrating
- Excessive physical movement
- Talking fast and often, interrupting others
- Difficulty taking turns or waiting for a turn
Signs and symptoms of Predominantly Inattentive ADHD
This type of ADHD is more commonly diagnosed in girls and adults and was previously known as ADD.
Tween and teen girls with this type of ADHD present with a variety of signs and symptoms. Whilst not all of this list will apply to all young people; it is a good starting point for family discussions.
- Daydreaming, quietly gazing or staring into space/‘spacey’
- Frequently changing activity or task, describing activities as ‘boring’
- Shyness and inattentiveness
- Low self-esteem and/or difficulty regulating feelings
- Difficulty starting projects or homework
- Difficulty in revising or preparing for tests
- Appearing disorganised or erratic
- Feeling that life is out of control or that it is impossible to meet demands
- Messy at home and/or at school
- Difficulty organising ideas and actions
- Difficulty balancing financial allowance or money
- Difficulty in finishing complex or monotonous tasks
- Described (incorrectly) as ‘lazy’ by others at home or school
- Overly concerned about looks or body image
- Sometimes described as ‘silly’ or lacking awareness
- Feeling sad or anxious, feeling left out
- Not being able to follow, zoning out or saying ‘I don’t know’ in conversations
- Difficulty making or keeping friendships
- Talking often during class time
- Easily distracted
- Finding it difficult to listen to or follow a ‘list’ of instructions
- Skin picking, hair pulling when sedentary
- Perfectionism to cover perceived inadequacies (perhaps in school settings)
- Overly reliant on social media ‘Likes’ and online activities
- ‘Hyper-focus’ on activities of interest and difficulty moving between tasks.
Signs and symptoms of Combined Type ADHD
Combined Type ADHD is where both the Hyperactive and Inattentive types are present. Signs and symptoms will be similar to those listed above but will typically be a mixture of the two.
* The above lists are intended as a starting point in the exploration of ADHD in young girls. They are not intended to be a diagnostic tool, nor are they intended to replace a licensed medical professional or mental health specialist’s advice. Please consult your family medical practitioner or specialist treatment programs for ADHD for further guidance.
Does ADHD Run in Families?
ADHD is said to have a high degree of heritability. That means that if a close family member has been diagnosed with ADHD, then there is a statistically higher chance that other family members will also be diagnosed.
The National Institute of Health estimates that one-third of fathers diagnosed with ADHD will have children who also meet the threshold for diagnosis.
Researchers have not been able to pinpoint a single or specific cause for ADHD in children or adults. The most recent research indicates that whilst our genes can play a large part in the development of ADHD, there may be other factors, including our environment, with possible links to diet/nutrition.
What Else Can Be a Risk Factor in ADHD?
ADHD is an area that has a great deal of ongoing research. Currently, it is believed that the following groups may have an increased risk factor for the development of ADHD:
- Children born pre-term (before their due date)
- Children who are looked after or cared for outside of the family
- Children diagnosed with OCD or CD
- Children diagnosed with epilepsy
- Children with neurodevelopment disorders (such as Autism Spectrum Disorder, TIC Disorders, Trichotillomania and other skin pulling and picking disorders, and learning disabilities)
- Teenagers and adults diagnosed with substance use disorder
- Children, teenagers or adults known to justice systems.
School, University and ADHD
ADHD can affect young people’s ability to focus, remain engaged and sustain attention during class time. Parents and teachers may feel that the young person is not putting in the required effort or becomes too easily distracted. For girls in the classroom, reports may suggest that they talk excessively in class and cause disruption for themselves and others.
Self-esteem and confidence can be easily impacted in girls who feel that they are in some way different from others. They often report feeling ‘stupid’, ‘silly’ or falling behind. This can be very damaging to the development of their young minds, but they can work through these unpleasant thoughts and beliefs with the proper support and therapy.
Having the support of both mental health professionals and school/university makes a significant difference in the outcome for young girls. Simple changes, along with developing an educational plan that fits their needs, are the first steps to success.
Getting Help for ADHD
An assessment is the first step for girls and their families, where ADHD is suspected. Dr Rasyid, Consultant Psychiatrist and ADHD specialist, explains: ‘Involving both the family and the school or educational setting in the initial assessment process, is essential to good long-term outcomes. A really detailed assessment will help your treatment team to understand any other issues that may also be evident, including learning challenges or co-occurring psychiatric illness. Finding the best solution takes teamwork and the involvement of young people in their treatment plan’.
Parents and carers can join local and online support groups focused on ADHD.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and Attention Deficit Disorder Association are valuable resources.
Finding an ADHD Specialist for Adolescents
Parents of tween and teen girls can help by finding specialists in Adolescent Mental Health, for example, at The Wave Clinic.
ADHD often co-occurs with other mental health concerns or additional learning needs. A mental health team may look at several other commonly co-occurring diagnoses. More than two-thirds of young people diagnosed with ADHD have at least one other mental health diagnosis.
ADHD may coexist with one or more mental health disorders, such as.
- Oppositional defiant disorder
- Conduct disorder
- Mood disorders
- Substance abuse disorder (alcohol/drug addiction)
- Personality disorders (including BDP)
- Eating disorders
Treatment for ADHD
Finding a professional and receiving a diagnosis is the first step on the treatment journey.
Locating a specialist interested in the most current treatment methods and evidence-based care for ADHD is essential. Dr Rasyid advises families to initially discuss the possibility of ADHD with their medical providers. ‘Taking a good medical history and really getting to know the young person is essential in finding answers. Schools and parents are an invaluable resource, although it is often the young person themselves who is most aware’.
For many young people, visiting a paediatric clinic or mental health practitioner will be the first line in treatment. There may be instances or more complex situations when residential treatment or therapeutic boarding schools are preferred.
Medication and treatment planning
Those newly diagnosed with ADHD benefit from consistency and support. Your treatment team will work with you to create a treatment plan.
A mental health practitioner will discuss the benefits and drawbacks of both pharmacological and non-pharmacological treatments. They will assess whether medication may be beneficial in each case. Overall, medication in the treatment of ADHD is highly effective. There are, however, many considerations that need to be taken into account for each young person. Medication may be started with the dose gradually being adjusted over time.
Parenting strategies may be suggested or a recommendation to engage in Family Therapy. Individual therapy will also be advised.
Skills groups can be useful to encourage social skills, problem-solving, impulse management, active listening skills and expressing emotions.
There may be other practical and environmental changes beneficial for girls and young women diagnosed with ADHD. These can include changes to lighting, reducing distractions (using noise-cancelling headphones), changing seating positions and using fidget gadgets to improve short-term focus.
* If you or anybody you care for is in immediate danger, please contact your nearest Emergency Health Provider and ask for the On-Call Psychiatric Team.
Evans, S., Sarno Owens, J., & Bunford, N. (2014). Evidence-based psychosocial treatments for children and adolescents with attention deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology.
Fiona Yassin is the International Clinical Director at The Wave Clinic, Kuala Lumpur.
She is trained in CBT-e (The Oxford Group, CREDO), FREED, EMDR (EMDRIA) and is an Accredited Clinical Supervisor (UNCG). Fiona is a Fellow of ACCPH and a member of IAEDP, FDAP and ANZMH. Fiona is an accredited Child and Family Trauma Professional and an accredited UK Psychotherapist, MICP #361609.