Attention-deficit/hyperactivity disorder (ADHD) is typically diagnosed at higher rates in biological males than females. This may be due to cultural bias and assumptions embedded in current diagnostic criteria, leading to the ADHD signs and symptoms in girls and women being overlooked or misdiagnosed as emotional or anxiety disorders.1 This may cause girls and women to feel ignored and invalidated or even go without appropriate treatment.1
What Is ADHD?
Attention-deficit/hyperactivity disorder (ADHD) is a neurological, mental health disorder in which individuals experience chronic issues with inattention, hyperactivity, and/or impulsivity.2 There are three types of ADHD: hyperactive type, inattentive type, or a combination of the two.1,2,3 It affects executive functioning, which naturally affects cognitive development in areas like attention, response, anticipation, processing, and memory.4
Onset of ADHD starts in childhood with symptoms persisting throughout adulthood. It is said to be caused by genetics, environmental risk factors, or even birth issues.3 There’s no “cure” for ADHD, but symptoms can be more manageable or less severe with treatments.
ADHD Symptoms In Girls
In general, it’s common for any developing child with ADHD to be treated as if they lack motivation vs. immediately investigating whether or not they have a neurological disorder. Girls tend to display more inattentive symptoms vs. hyperactive symptoms.1,3 They often share that they feel confused, especially in the academic setting, which has nothing to do with intellectual capacity.
Girls with hyperactive symptoms of ADHD may be viewed as “talking excessively” when really they’re struggling with impulse control, want to be more engaged, or just want to feel included. Because of high emotional vulnerability, girls with ADHD may also be perceived as more “deviant” because of what female behaviors are expected to look like culturally.4
With high expectations and pressures to perform and act a certain way, girls can experience more perceived impairment in their social relationships.5 Additionally, emotional lability or shifts in mood are common in kids with ADHD.6 For girls with ADHD, they’re often misdiagnosed with depression or an anxiety disorder, or told they’re moody or that it’s “just hormones.”
While anyone of any gender can experience a combination of typical and less-common ADHD symptoms, ADHD symptoms in girls can include:1
- Difficulty staying on task when in a distracting environment (like a busy classroom or noisy environment)
- Difficulty with time blindness and time management
- Difficulty relaxing at home or school or taking a needed break
- Issues with disorganization at home or school; for example, girls may struggle with keeping a tidy room or staying organized with their homework and other important tasks
- Losing things easily, like their house keys or their phone
- Impulsive behaviors, like compulsive shopping or overspending
- Feeling like they are often daydreaming or can’t pay attention
- Struggling with chronic procrastination
- Easily overwhelmed, even when doing fun things; for girls in particular, they may be labeled “emotional” when really their brain is overworked and exhausted
- Struggles with both ADHD and perfectionism, leading to rejection sensitive dysphoria or what looks like poor emotional regulation and crying easily
ADHD In Girls vs. Boys
Biological males and females have historically demonstrated seemingly different behaviors in their presentation of ADHD. For boys, typical ADHD presentations may look like external behavior problems related to hyperactivity. For girls, symptoms may be internalized with symptoms like inattention and emotional dysregulation, or less obvious problems.
Some major differences in male/female presentation of ADHD are linked to the female connection to perfectionism; this extreme performance pressure can produce low self-esteem and self-judgment. Young people are highly focused on social conformity and for girls with ADHD, they may be at higher risk of being bullied or even victimized on a public platform.6
Why Does ADHD In Girls Go Unnoticed?
There are many factors contributing to the high male and low female ADHD diagnosis rates. It’s possible that females with ADHD may have developed better coping strategies to hide symptoms or are quick to accept that what they’re going through is normal when it’s not.7 Certain labels like “intense” or “dramatic” tend to apply to girls, even though everyone experiences emotions unique to them vs. their gender.
Sex and hormones play also play a role in perception of symptoms and behaviors. For example, boys with sexual hyperactivity tend to be accepted as developmentally normal, whereas females with hyperactive sexual behavior are label promiscuous, which can damage reputations and self-esteem.6
For girls, repeated invalidation can cause a frustration response that’s likely appropriate, given the circumstances. A theory called the “female protective effect” suggests girls and women have to reach a higher threshold of genetic and environmental causes of ADHD in order for symptoms to be deemed “legitimate.”6 This kind of bias for girls and women with ADHD is present in the medical community and influences who is referred for testing and treatment.
Treatment for ADHD in Girls
Without treatment, ADHD can have a deep impact in social or academic engagements for children, or even more severe consequences in adulthood when the stakes start to feel higher. Even though there can be different presentations of symptoms, girls with ADHD experience the same negative consequences as boys.7 When their difficulties are overlooked, it tends to cause girls to suffer in silence instead of getting needed treatment, which typically includes medication and therapy to learn appropriate coping skills.
There are several types of medications used to treat ADHD, including stimulants or non-stimulants, and antidepressants. Treating girls for ADHD is complex, with many biological factors weighing in. There’s not a lot of consistent research to determine what medications are best for girls vs. boys with ADHD, but there’s research demonstrating that non-stimulants tend to better address symptoms like emotional dysregulation and impulsivity in girls.8
Some research suggests that hormones play a role in ADHD expression and pharmaceutical treatment response during the different phases of the menstrual cycle.7,8
Many parents are apprehensive to start medications for their child because of potential side effects. It’s important to consider a cost-benefit analysis, or be aware that the severity of ADHD outweighs the risk of potential side effects. If nothing else, try to view medication as a way to explore what works and what doesn’t. Medications can be stopped and other forms of treatment tried, but ADHD symptoms don’t just go away.
Prescribing medication can make a huge difference in overall quality of life, but cognitive and behavioral therapies also play a role. Cognitive behavior therapy or CBT for ADHD is an effective way to become aware of unhelpful thoughts, confront them, and choose better behaviors. CBT for pre-teen/teen girls may help them examine their own self-esteem and embrace their atypical brain vs. focusing on perceived deficits.
For young children with ADHD, peer-to-peer and parent-child skills training includes opportunities to learn and practice more desired behaviors.9 In this type of therapy, an adult (the therapist) and the parent practice and role-play with the child what prosocial behaviors look like, and work through ADHD symptoms like impulsivity, frustration, and emotional dysregulation.9
It’s important to find a therapist who has knowledge of ADHD and best practices of treatment. A neurodiversity affirming therapist will be able to help patients understand the unique way their brain works. Like with any mental health disorder, acceptance and validation play a huge role in the quality of treatment.
Many people come to therapy for other reasons, not knowing they may have ADHD. A skilled therapist will be able to openly discuss ADHD symptoms, make recommendations for testing or medicinal treatment, and work with the patient to develop skills and a better understanding of their personal strengths.
Note that unintentional gender biases exist in mental health diagnosis and treatment because of what our culture deems appropriate or “normal” for a certain sex/gender.10 These limitations and assumptions are problematic when it comes to getting treatment. Find a neurodiversity affirming provider who is skilled at diagnosing mental health disorders and aware of the complexities of ADHD and co-occurring disorders that are overshadowed in girls and women.