Understanding Girls with AD/HD: Symptoms and Strategies

Girls with AD/HD often suffer in silence - and remain undiagnosed. When their symptoms finally surface, they can be dangerous. Learn what to watch for in your daughter - and how to help her.

By GreatSchools Staff

Mrs. Dawson's fourth-grade students assemble in small groups to work on a project. She asks Steven and Julie to join three other students. A mother helping in the classroom notices Steven is better behaved than during her last visit. While he still wriggles in his seat and occasionally interrupts a classmate, he doesn't pound his desk and talk non-stop like he used to. He also smiles now and is more cooperative. Julie is her usual chatty, polite self. She smiles and waves her hands as she talks to the group. Today, though, the other girls in the group seem annoyed with Julie. When the group session is over, Steven sits attentively at his desk in the front of the classroom. Julie's smile has faded and she stares out the window.

What's going on with Steven and Julie? Steven was diagnosed with Attention Deficit/Hyperactivity Disorder (AD/HD) four months ago. His teacher has made classroom accommodations, such as allowing him to sit up front where he'll be less distracted. He's taking medication and being coached on his behavior. His self-esteem grows as he succeeds in his school work and relationships.

What no one knows is that Julie also has AD/HD. She struggles to please others, but they don't seem to understand her friendly overtures. Determined to be a good student, she spends hours on homework because daydreams get in the way. Her self-esteem is sinking as she questions her academic and social abilities. Julie suffers in silence.

Squeaky Wheels Get the Grease

Many people think of AD/HD as a boy's disorder. In fact, some studies estimate at least six times as many boys as girls are referred to clinics for diagnosis. But field studies suggest that, in the general population, the actual ratio of boys to girls with AD/HD is 3:1. To understand why this disparity exists, we must understand how professionals have traditionally defined and diagnosed AD/HD - and how that view is changing. For many years, hyperactive and impulsive behavior was considered the primary trait of children with AD/HD. Since many more boys than girls fit that description, they've been much easier to diagnose and treat. This also explains why most AD/HD studies have focused on boys. Then in the 1980's, researchers discovered a population of boys who were inattentive but not hyperactive or impulsive. With this discovery, the definition of AD/HD was updated and now includes 3 different types:

The inattentive type of AD/HD is harder to diagnose in both boys and girls since their behavior doesn't "give them away." Bright, inattentive girls often compensate for inattention by becoming super-organized or hyper-focused on school work. Such girls often succeed in school, but their private struggle remains a secret.

Girls who are hyperactive and impulsive are rare. Some hyperactive girls are seen as tomboys and have a better chance of being diagnosed. Other hyperactive girls aren't overactive in a physical sense; instead, they're super-talkative "social butterflies."

Set Up by Social Expectations

Having AD/HD seems to impair girls' social relationships far more than it does for boys. As Janet Giler, Ph.D., points out, "Males and females, in general, operate by different social rules...Female social rules place a greater value on cooperation, listening, care-taking, and relationship maintaining activities ...It would make sense that the traits of AD/HD might make females seem less cooperative." As a result, girls with AD/HD suffer more peer rejection.

Remember Julie? While friendly and well-meaning, she often gets distracted while a classmate is talking to her. She misses the other person's social cues, and doesn't respond in a desirable manner. Boys tend to be more direct with each other and resolve their conflicts more openly, so a boy with AD/HD doesn't require the same set of social skills. A girl who is both impulsive and inattentive is likely to commit many social blunders.

Mothers often expect their daughters to conform to the standards of society by being especially thoughtful, polite and compliant. If a girl has AD/HD, this can be a difficult goal to attain.

Brain Differences in Boys and Girls

At least one research study found the brains of boys with AD/HD showed significant shape and volume differences compared to boys without AD/HD. The size and shape variations suggest that AD/HD in boys affects brain circuits that control basic motor responses, such as "hitting the brakes" or supressing impulsive actions. These variations were not evident in the brains of girls with AD/HD, which may account for the way AD/HD plays out in boys versus girls. Also, a study by the Kennedy Krieger Institute and Johns Hopkins University School of Medicine suggests that girls with AD/HD have greater control over their physical movements than do boys of the same age with AD/HD, possibly because girls' brains mature earlier.

When Hormones Wreak Havoc

AD/HD is often hard to detect in girls until they reach puberty and hormone changes can cause dramatic mood swings and disruptive behavior. A girl who has kept her AD/HD hidden until puberty may appear to "erupt" suddenly when female hormones flood her body. Because the current criteria for AD/HD state symptoms must be present before age 7, many doctors dismiss the possibility of AD/HD in girls whose symptoms don't appear until puberty. (By contrast, hyperactive/impulsive boys who've been treated for AD/HD since their early years often calm down when they reach puberty. For them, hyperactivity mellows into restlessness.)

Teenage girls with AD/HD appear to be at greater risk for eating disorders than their non-affected peers. Girls with the combined type of AD/HD (both inattention and hyperactivity/impulsivity) seem more likely to develop bulimia than girls who have the inattentive type of AD/HD. But, studies show, both groups of girls are likely to be overweight and to suffer from rejection and low self-esteem. There is also a concern that girls taking stimulant medication for AD/HD might abuse the drugs to suppress their appetite and lose weight.

The Emotional Cost of Under-Diagnosis

Girls whose AD/HD isn't diagnosed and treated by the time they reach puberty are at risk for developing other psychological disorders, such as anxiety and depression. This is understandable, since many girls have spent their lives suffering, struggling, and blaming themselves for poor academic performance and peer rejection. As girls mature, they tend to internalize their feelings, making their struggle less noticeable to adults who might help them. Adolescent girls who don't receive help for AD/HD and co-existing psychological problems are at high risk for addictive behaviors, such as over-eating, smoking, alcohol abuse and sexual promiscuity.

Help and Hope for Girls with AD/HD

Clearly, better methods for diagnosing and managing AD/HD in girls are needed. Fortunately, many professionals are working toward this goal. They have found, for example, that because a girl's outward behavior can mask her AD/HD, having her answer certain questions (self-reporting) can help make a proper diagnosis. Professionals have also found some methods that are especially effective for managing AD/HD in girls, including:

As professionals pay more attention to the traits and needs of girls with AD/HD, we can hope for earlier diagnosis and more effective treatment. Parents can help by staying abreast of the research in this area - and by staying in close touch with their daughters.

AD/HD by Other Names and Acronyms

While Attention-Deficit/Hyperactivity Disorder (AD/HD) is the official term and acronym used by today's mental health care professionals, it is sometimes referred to by other names and abbreviations. For example, it is sometimes called: