ADHD in girls and women

Symptoms, Diagnosis and Treatment

There are still a lack of studies focusing specifically on girls and women with Attention-Deficit / Hyperactivity Disorder (ADHD), especially in Europe. Yet, it is generally accepted today that girls and women are as likely to have ADHD together with one or more coexisting condition as boys and men. 

 In spite of this, data from the U.S Center for Disease Control and Prevention (CDC) in 2012 estimates that boys are at least twice more likely to be diagnosed with ADHD than girls as the symptoms in girls are less obvious and may not fit the common stereotypes associated with ADHD. It doesn’t help that the current diagnostic criteria is still more appropriate for males than females, and that parents and teachers are more prone to asking that boys be diagnosed because of their more problematic ADHD behaviours.  ADHD in girls and women is therefore still very much a hidden disability, the true cost of which can only be measured through the different psychiatric disorders women present with in adulthood. 

 Since the DSM V came into effect in January 2016 in which the age of onset of symptoms is listed as being before the age of 12, one would expect this to have changed; however, until the use of gender specific symptom check lists is recommended in this manual, many girls and women will still remain undiagnosed.

 Mahone (2016) posits that girls with ADHD can present with different cognitive and behavioural patterns than boys with ADHD because of the types of comorbid conditions typical for each, earlier maturation and failure to identify the more subtle patterns of symptoms in girls.  Skogli et. al. (2013) found that girls with ADHD could be more accurately distinguished from the control sample by the presence of co-existing symptoms, particularly with the presence of anxiety whereas in boys, parental reports of executive function were a much better measure for distinguishing them.  Both Skogli and Mahone caution that despite this difference, girls are at a significant psychosocial risk into adulthood. Assessment for and diagnosis of ADHD in girls is more complicated than in boys because of later onset, more subtle clinical manifestations and wording in many popular rating scales that emphasize externalizing behaviours seen more commonly in boys; as a result, many remain undiagnosed into adulthood. 

 This is highlighted in a 2005 study looking at gender differences in ADHD found higher rates of “oppositional defiant disorder” and “conduct disorder” in males, and higher rates of “separation anxiety disorder” in females, suggesting that internalizing disorders are more common in females and externalizing disorders are more common in males. While most boys with ADHD tend to express their frustration physically and verbally, girls are more likely to internalize their anger and pain; Dr. Stephen Hinshaw (2002, 2006, 2008, 2012) has dedicated many studies to girls with ADHD and concludes that girls with combined-type ADHD are significantly more likely to self-harm or attempt suicide. 

 When girls are indentified and referred for psychiatric evaluation, they tend to have unusually disruptive behaviours, indicating that the symptoms need to be severe for girls to be diagnosed and treated for ADHD. (Nadeau (2005). 

Dr. Joseph Biederman (2002) from Harvard Medical School found that girls with ADHD were more likely to have conduct, mood, and anxiety disorders, lower IQ and achievement scores, and more impairment on measures of social, school, and family functioning than girls without ADHD. 

 A research study has found that the brains of boys with ADHD show significant shape and volume differences compared to boys without ADHD. The size and shape variations suggest that ADHD in boys affects brain circuits that control basic motor responses, such as “hitting the brakes” or suppressing impulsive actions. These variations were not evident in the brains of girls with ADHD, which may account for the way ADHD plays out in boys versus girls. 

 Also, a study by the Kennedy Krieger Institute and Johns Hopkins University suggests that girls with ADHD have greater control over their physical movements than do boys of the same age with ADHD, possibly because girls’ brains mature earlier. They tend also to have better coping strategies than males, which can hide their symptoms.

 According to the 5th edition of the DSM, ADHD symptoms may fall into three categories: predominantly hyperactive, predominantly inattentive, and combined type. Inattentive ADHD is thought to be more common in girls and women than it is in boys and men, but inattentive ADHD symptoms are still largely misunderstood by medical professionals who mistake them for mood disorders, anxiety, or another related condition (Quinn 2014). 

 Julia J. Rucklidge, PhD, assistant psychology professor at the University of Christchurch, New Zealand, says females have different hormonal influences to start with, as it is known that estrogen influence in the brain can greatly affect their behaviour during and beyond puberty. They socialize differently and therefore tend to express themselves in a different manner and are more susceptible to such problems as depression or anxiety. 

 Possible Complications if Left Untreated

 Many studies confirm that untreated ADHD in girls can lead to underachievement in various aspects of their lives as well as the risk of developing additional psychiatric disorders in adulthood.  

 Dr. Ellen Littman (2012) points out that if a girl with ADHD is left undiagnosed or untreated as she enters adolescence and young adulthood, she will almost inevitably encounter a range of adjustment problems that can lead to one or more additional disorders, such as depression, anxiety, or an eating disorder such as bulimia. Women with ADHD are more likely to engage in high-risk sexual behavior and to develop substance addiction. In addition, women with ADHD may experience chronic stress, and this can increase their risk of stress-related diseases such as fibromyalgia.

 According to Dr. Kathleen Nadeau (2012), girls with untreated ADHD are at risk of developing chronic low self-esteem, underachievement, anxiety, depression, teen pregnancy, and an early smoking habit during middle school and high school and in adulthood, they are more likely to face divorce, financial crises, single-parenting a child with ADHD, never completing university, underemployment, substance abuse, eating disorders, and constant stress due to difficulty in managing the demands of daily life.

Dr. Jane Adelizzi  (1997) studied women diagnosed with ADHD and learning difficulties who, as a result of experiencing classroom trauma over a span of years, developed a set of symptoms that are recognizable as post-traumatic stress disorder. 

 Anxiety and depression, common comorbidities in female patients with ADHD, can lead to missed or misleading (2014).

 Thus, the heavy social and personal impact of ADHD on females points to the importance of early identification and treatment. In order to achieve this goal, the indicators (symptoms) need to be better understood by parents, teachers, healthcare professionals and society at large.

 

Symptoms of ADHD in Girls 

 The following symptoms are particularly associated with girls:

  1. Inattention: Girls with ADHD may find it hard to concentrate. They may be unable to focus for long enough to complete a task at home or at school. However, if they find something interesting, they may be completely absorbed by it to the detriment of what is going on around them. They may frequently be late with assignments despite efforts to stay on schedule and be prone to forgetting what they have just read needing to be reminded by others in their environment. 
  2. Distractibility: Girls with ADHD may be easily distracted by what is happening outside, or by their own thoughts.
  3. Hyperactivity: Although some girls are excessively active and fidgety, like boys, others are quieter in their movements. They may fidget, shuffle in their chairs, or doodle.
  4. Impulsivity: Girls may be overemotional, and this may leave them unable to slow down or to think about what they say, often interrupting people when they are talking, jumping from one topic of conversation to another without warning
  5. It can be hard for them to know what is and is not socially appropriate, and this can lead to difficulties in making and keeping friends.
  6. Executive malfunctions: Organizational skills may pose a challenge. Girls with ADHD may have poor time management skills, and they may find it hard to follow multi-step directions or complete a task. They may often lose items such as a phone or important papers. They may have difficulty keeping track of school assignments and deadlines, even if they are making a great effort to stay organized. They almost certainly have trouble getting to sleep at night and getting up in the morning. Their sleep pattern may seem disrupted and they often wake up feeling as if they have not slept at all – and this despite being the required number of hours asleep.
  7. Difficulty handling stress: those who are not diagnosed or treated run the risk of using drugs, alcohol, food, etc. to relieve their ADHD symptoms, leading to addictions, bulimia, etc. as well as the risk of developing fibromyalgia as adults.

 Girls with ADHD seem to be cope better with ADHD than boys of the same age until they enter puberty when the estrogen levels play havoc with their moods and emotions (Littman, 2012).

Teenage girls with ADHD tend to be at more risk of developing eating disorders than their non-ADHD peers, those with the combined type being more at risk than the inattentive type – especially of developing bulimia (University of Virginia, March 15, 2008)

 When to See a Specialist

If caregivers think that a girl has ADHD, they should consult a professional team; some pediatricians have specialist training in behaviour and development, but it is advisable to have girls assessed by a child psychiatrist or psychologist knowledgeable about ADHD and related conditions in girls. This information can be given to them by their local or national ADHD support organizations.

 Accurate ADHD diagnosis in women and girls requires establishing a symptom history and an understanding of its gender-specific presentation. Coexisting anxiety and depression are prominent in female patients with ADHD; satisfactory academic achievement should not rule out an ADHD diagnosis.

 Treatments

 A doctor may prescribe medication, psychotherapy or both, but the girl/woman may look also for:

  • Understanding and accepting her challenges instead of judging and blaming herself 
  • Exploring professional treatment options, reading relevant books or articles on the subject, finding suitable group behavioral therapy
  • Establishing simple routines for meals, homework, play, rest and going to bed at a regular hour
  • Supporting time management by setting an alarm clock to time activities and deadlines
  • Acknowledging and rewarding small achievements
  • Identifying the sources of stress in daily life and making changes to lower stress levels
  • Simplifying the schedule as much as possible and scheduling daily “time out” for herself
  • Learning to ask clearly for structure and support from family and friends
  • Encouraging her to exercise or play a team sport
  • Focusing on the things she loves and prioritizing those
  • Following a healthy eating plan under supervision if needed
  • Addressing addictions (drugs, alcohol, food, etc.)
  • Taking steps to reduce anxiety and stress (mindfulness practice, yoga, pilates, etc.)
  • Taking part in a Sleep assessment to analyse sleep pattern and quality of sleep

 As the girl enters adolescence and becomes more independent, she will probably need support to help her regulate her own behaviour. Women with ADHD typically present with serious time management challenges, chronic disorganization, long-standing feelings of stress and being overwhelmed, difficulties with money management, parenting children with ADHD, and a history of anxiety and depression. 

 The disorder is typically treated with a combination of stimulant medication and ADHD-focused psychotherapy that is very structured, goal-oriented and incorporates many ‘coaching’ techniques, as well as standard psychotherapy as women with ADHD struggle with low self-esteem, which needs to be addressed too. Mindfulness training has been shown to help girls and women manage their emotions, anxieties and life stresses and can be started as early as 8-10 years if age. There may also be a need for SSRI medication to balance their moods.

 

References

  • Adelizzi, J.U. (1998). Shades of trauma. Plymouth, MA: Jones River Press.
  • Bauermeister et al. “ADHD and gender: are risk and sequela of ADHD the same for boys and girls” 2007 J.Child Psychol and Psychiatry 48:8 831-839
  • Biederman, J., Farone, S., Mick, E., et al. (1999). Clinical correlates of ADHD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 996-975.
  • Costello, E Jane, Ph D, S. Musillo, A. Erkanli, Ph D, G Keeler, MS, A Angold, MRCPsich, “Prevalence and development of Psychiatric Disorders in Childhood and adolescence”, Arch. Gen. Psych. 2003, 60:837-844.
  • Cross CP, Copping LT, Campbell A. “Sex differences in Impulsivity: a Meta-Analysis. “Psychol Bull.2011;137:97-130.
  • Elkind et al. “The impact of ADHD on preadolescent adjustment may be greater for girls than for boys” .J.Clin.Child.Adolesc.Psychol. 40(4). 532-545.
  • Gaub M, Carlson CL. Gender differences in ADHD: a meta-analysis and critical review [published correction appears in J Am Acad Child Adolesc Psychiatry.1997;36:1783]. J Am Acad Child Adolesc Psychiatry.1997;36:1036-1045.
  • Greene et al. “Social Impairment in Girls with ADHD: Patterns, Gender comparison and Correlates”. 2001. J.Am.Acad.Child.Adolesc.Psychiatry. 40(6) 70.
  • Hinshaw, S.P. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices, Journal of Consulting and Clinical Psychology, 70(5), 1086-1098.
  • Hinshaw, S.P., Carte, E.T., Sami, T., et al. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: II. Neuropsychological performance in relation to subtypes and individual classification. Journal of Consulting and Clinical Psychology, 70(5), 1099-1111.
  • Hinshaw SP, Owens EB, Sami N, Fargeon S. Prospective follow-up of girls with attention-deficit/hyperactivity disorder into adolescence: evidence for continuing cross-domain impairment. J Consult Clin Psychol.2006;74:489-499.
  • Lahey, B. et al.: Are there sex differences in the predictive validity of DSMIV ADHD among Younger children? 2007. J.Clinical Child and Adolesc Psychology 36(2) 113-126
  • Littman, E (2012). The Secret Lives of Girls with ADHD.  Attention, 19(6), 18-20.
  • Littman, E (2013).  Girls with ADHD Face Unique Challenges.  SmartKids with LD, 12, 2-3.
  • Littman, E (2014). Women with ADHD. In The Hidden Side of Adult ADHD: Professional and Personal Perspectives (El lado oculto del TDAH en la edad adulta – Una propuesta inclusiva desde lo profesional y la experiencia).   Ediciones Aljibe, Malaga, Spain.
  • Mahone ME, PhD: Neuropsychiatric Differences between Boys and Girls with ADHD: November 21, 2016 in Psychiatric Times
  • Mikami AY, Hinshaw SP, Patterson KA, Lee JC. Eating pathology among adolescent girls with attention-deficit/hyperactivity disorder. J Abnorm Psychol.2008;117:225-235.
  • Miller M, Ho J, Hinshaw SP. Executive functions in girls with ADHD followed prospectively into young adulthood. Neuropsychology.2012;26:278-287.
  • Monuteaux et al. 2010. “The influencia of sex on the course and psychiatric correlates of ADHD from childhood to adolescence: a longitudinal study”.  J.Child Psychol and Psychiatry 51:3 (233-241)
  • Nadeau, K.G., & Quinn, P.O. (Eds.) (2002). Gender issues and AD/HD: Research, diagnosis, and treatment. Silver Spring, MD: Advantage Books.
  • Nadeau, K.G., & Quinn, P.O. (Eds.) (2002). Understanding women with AD/HD. Silver Spring, MD: Advantage Books.
  • Nadeau, K, Littman, E, & Quinn, P (2015). Understanding Girls with ADHD, 2nd edition.  Advantage Books, Silver Springs, MD.
  • O’Brien JW, Dowell LR, Mostofsky SH, et al. Neuropsychological profile of executive function in girls with attention-deficit/hyperactivity disorder. Arch Clin Neuropsychol.2010;25:656-670.
  • Quinn, Patricia O. MD & Madhoo, Manisha MD. “A Review of ADHD in Women and Girls: Uncovering this Hidden Diagnosis” in Prim.Care Companion CNS Disord. 2014:16(3): PCC. 13r01596.
  • Ramtekkar et al. Sex and age differences in TDAH symptoms and Diagnoses: implication for DSMV and ICD-11. 2010 J.Am Acad.Child & Adolesc. Psychiatry. 49:3.
  • Rucklidge, J.J., & Kaplan, B.J. (2000). Attributions and perceptions of childhood in women with AD/HD symptomatology. Journal of Clinical Psychology, 56(6), 711-722.
  • Rucklidge, J.J., & Kaplan, B.J. (1997). Psychological functioning in women identified in adulthood with attention-deficit/hyperactivity disorder. Journal of Attention Disorders, 2(3), 167-176.
  • Stene Novik, T et al. Influence of gender on ADHD in Europe. ADORE Study.