Why ADHD Is Recognized Late in Girls

In a classroom, one child keeps getting up, making noise, rummaging through their friends' notebooks. Within a few weeks the teacher calls in the parent.

In the same classroom another child looks out of the window, chews her pencil, makes you ask the question twice. The notebook says "very absent-minded." Nobody calls in the parent.

In ADHD, the chance that the second child goes unnoticed is markedly higher than for the first. This article explains why that is so, particularly for girls.

Is the difference in diagnosis real

In clinical referrals, the number of boys diagnosed with ADHD is higher than the number of girls. But the number of referrals may not reflect the true distribution of the condition. The review by Quinn and Madhoo describes the ADHD of girls and women as remaining a "hidden diagnosis," because the symptoms look different and the criteria and expectations derive from samples of boys.

The view today is that ADHD is not so much rarer in girls as recognized later and less often in girls. In saying this I am not giving an exact ratio; there are differences between studies.

How it looks in girls

The symptoms are the same, but the presentation can be different.

• The predominantly inattentive picture is more common. Instead of restlessness and impulsivity: dreaminess, forgetfulness, a messy bag and notebooks, missing verbal instructions.
• Hyperactivity turns inward. Instead of getting out of the seat, talking constantly, fiddling with hair or nails, inner restlessness.
• Compensation. Trying to cover the difficulty with attention by working extra, by perfectionism and by checklists. Grades can be good, and nobody sees the price.
• Emotional reactions. Oversensitivity to criticism, crying easily, anxiety. In a girl these are read as "emotional" and are not linked to ADHD.
• The social area. Missing details and interrupting, being misunderstood in friendships. The article on ADHD and friendship covers this topic more broadly.

These symptoms on their own are not a diagnosis. Anxiety, depression, sleep problems and learning difficulties can look similar; the physician separates them.

Why it is missed

Three reasons reinforce one another.

They do not disturb anyone. The child that teachers and families turn to for help is the child who strains the people around them. The quiet girl is less caught by this threshold.

The expectations are different. In society girls are more expected to be orderly, attentive and neat. Messiness is interpreted as a "lack of character," and no medical look follows.

The criteria and scales came from samples of boys. The classic scales focus on behavior that disturbs the classroom. They can be weak at catching inner restlessness and a scattered mind.

The cost of a late diagnosis

The long-term follow-up study by Hinshaw and colleagues reported that girls diagnosed with ADHD in childhood were at greater risk than the control group in young adulthood in terms of functioning, self-harm and suicide attempts. This is not a fate; it is a warning: if a child interprets her own difficulty as inadequacy for years, self-esteem is damaged.

So the real goal, as much as getting a diagnosis, is to break the child's narrative of "I'm lazy, I'm inadequate" early.

What parents and teachers can look at

• Are the grades good but the child worn out when she comes home, and does homework take hours?
• Has the sentence "very smart but messy" been repeated for years?
• Is the child being excessively hard on herself in order to keep up?
• Are forgetting and lost belongings frequent and more than expected for her age?
• When she makes a mistake, is there disproportionate guilt and crying?

A "yes" to several of these questions is a sufficient reason for a specialist interview. For the process you can look at the article on how ADHD is diagnosed in children.

Girls can become even more invisible in adolescence

In adolescence, hormonal change, social pressure and the growing school load sometimes intensify the symptoms. The reasons for this are in the article on ADHD in teenagers. A girl who went unnoticed in childhood may turn up in this period with a diagnosis of anxiety or depression, and the underlying ADHD may not be thought of as a separate heading for a long time.

Conclusion

A quiet child does not mean there is no problem. A successful child does not mean a comfortable one. Girl or boy, what needs to be measured is not how much the child disturbs those around her, but how much her functioning is strained.

This article is for information; the decision on a diagnosis for your child belongs to the physician.