Understanding Girls with ADHD

The first edition came out in 1999 from Advantage Books under the title Understanding Girls with AD/HD. In 2015 an expanded and updated edition was published by the same publisher. The subtitle of this edition speaks of explaining what girls feel and why they behave as they do. The foreword was written by Stephen Hinshaw.

I could not reach a verified Turkish edition; I am leaving the title in English.

Three authors, one gap

Kathleen Nadeau is a clinical psychologist; she is the founder of the Chesapeake Center, one of the big ADHD clinics in the US. Patricia Quinn is a physician working in developmental pediatrics. Ellen Littman is a clinical psychologist. Nadeau and Quinn were placed on CHADD's honor roll in 1999 for their pioneering work on ADHD in girls and women.

The book was born of an observation these authors had voiced for years: ADHD research and diagnostic criteria had largely been built on boys who showed active, disruptive behavior. Girls were not visible in this framework.

In 1999 this was a minority view. Today it is the mainstream knowledge of the field.

In this respect part of the book's value is historical. It is one of the first books to treat ADHD in girls as a separate question. The 2015 edition has been updated by adding the research accumulated in between to this pioneering work.

Why it was hard to read

I started the book as a parent's book and soon realized I was reading my own childhood.

The girls described do not draw attention. Children who are quiet in class, who look out of the window, who do their homework the last night, who do not understand what they are doing wrong in friendships, whom teachers say would succeed if they worked harder. They spend a great deal of energy not showing their problems to anyone.

For a woman diagnosed late, reading these chapters is a kind of mourning. The sentence "I could have been seen" sits somewhere on every page.

But the book does not stay in this feeling, and I appreciated that. The direction of the narrative is always the same: how can we do this differently for the girl who is growing up now?

From 1999 to 2015

When the first edition was written there was very little research on ADHD in girls; the authors' clinical experience therefore carried a bigger load. The first edition also had age-based checklists from preschool to high school.

The 2015 edition includes the research accumulated in between. According to Gina Pera's review of this edition, the update gives much more room to findings on differences in brain structure, developmental course and mental health risks specific to girls.

It is meaningful in this respect that the foreword belongs to Hinshaw. The long-term risks of ADHD in girls turned into data in the years between the two editions largely through his team's long follow-up study.

A structure that moves age by age

I saw the contents of the 2015 edition. The book first explains why ADHD looks different in girls, then handles the developmental stages one by one, then moves on to interventions.

Opening chapters. The first chapter focuses on what it means to be misunderstood as a child. Then it explains what makes ADHD in girls different, the brain and other biological factors, and that ADHD in girls is far more than what is seen.

Developmental stages. Preschool, elementary school, middle school and high school. Each period is a separate chapter.

This structure is the most useful side of the book. A parent can go directly to the chapter for their child's age.

The preschool chapter is especially important, because early signs in girls are often read as personality traits: dreamy, very talkative, a bit messy.

The elementary school chapter tries to tell normal development from ADHD. The middle school chapter focuses on new difficulties, the high school chapter on growing demands and growing risks.

Intervention chapters. Supporting functioning at school, executive function skills, approaches that are effective in managing ADHD, the medication decision and co-occurring psychiatric conditions. Toward the end there is also a chapter devoted to common developmental problems.

Middle school and high school

These two chapters are, I think, the most painful but most necessary part of the book.

In this period two things happen at once. The structure of school loosens: many teachers instead of one, long-term assignments, the expectation of planning on your own. The social world gets more complicated too: subtle rules in friendships, exclusion and indirect forms of conflict come to the front.

For a girl with ADHD these two together are a heavy load. A child who could get by in elementary school on her intelligence or the teacher's close follow-up may begin to fail to hold on in middle school. To an outside observer this looks like a child who has suddenly become lazy or lost interest.

That is why diagnosis at these ages, or even much later, is so common.

The picture the book draws

The book's basic claims about ADHD in girls are roughly these.

An inward-looking appearance. In girls the inattentive-predominant picture is seen more often and does not draw attention. Even when there is restlessness it shows up more as talkativeness or inner restlessness.

Self-blame. Girls direct their difficulties at themselves instead of outward. Shame and low self-esteem start early.

Conflict with social expectations. Girls are expected to be agreeable, helpful and organized. When the impulsivity and messiness of ADHD collide with these expectations, peer rejection and loneliness follow.

Worsening in adolescence. With hormonal changes, difficulties with emotional regulation grow. In the same period academic and social demands also grow.

High risk. Anxiety, depression, eating disorders, self-harm and risky behavior are important dangers that accompany ADHD in girls.

Where research confirmed the book

An important part of these claims has been supported by later research.

The long-term study run by Stephen Hinshaw, who wrote the foreword, is the most striking example. Hinshaw and colleagues (2012) followed girls diagnosed with ADHD in childhood into young adulthood and showed that girls with ADHD continued to have markedly more loss of function than their peers. Rates of suicide attempts and self-harm were also high.

The book's warnings are not exaggerated in this respect. The risks faced by girls with ADHD who go untreated are real.

The expert consensus statement published by Young and colleagues (2020) on ADHD in girls and women also matches the book's basic theses: that ADHD in girls is less recognized, can be hidden by compensation strategies and masking, is often misidentified as anxiety or depression, and that diagnosis is delayed.

On heredity too, the book's biological framework is in line with current data. Faraone and Larsson (2019) give heritability as about 74 percent. This picture requires taking seriously the part that going unnoticed plays in girls being diagnosed less. I wrote about masking separately from this angle.

Hope as an intervention

There is a recurring idea in the book's recommendations to parents: one of the biggest needs of a girl with ADHD is positive reinforcement and hope in place of constant criticism. There are also concrete suggestions such as routines, checklists and taking part in activities outside school; most of these are things that are good for every child.

These suggestions may look ordinary at first glance. But when you think of the child the book describes, a child who directs her difficulties at herself and learns shame early, an ordinary sentence gains weight. Every criticism this child hears confirms something she already believes about herself.

The matter of activities outside school is important too. A field where the child is good, where success is not measured by grades, is a place where self-confidence can take shelter.

Where it gets stuck in its own pattern

The book was written to break a pattern. Reading it today I see that in some places it sets up a new pattern.

The narrative that girls are inward and inattentive, boys outward and active, catches the general tendency. But not every girl fits this description. There are also active, impulsive, angry girls, and since these children fit neither the boy pattern nor the girl pattern, they can become invisible a second time.

The book does not leave these children completely out, but the weight of the narrative is on the quiet, dreamy girl.

The second matter is hormones. The idea that hormonal changes in adolescence affect ADHD symptoms is reasonable and in line with clinical observations. But controlled research on the relationship of the menstrual cycle and hormones to ADHD symptoms is still limited. Some of the book's statements on this stand more firmly than the evidence can give even today. I covered the current state of the subject in the article ADHD, hormones and the menstrual cycle.

The third is culture. The book says very valuable things about how gender expectations shape the look of ADHD. But it hardly takes into account that these expectations change from culture to culture. The social dynamics of an American middle school are not the same as those of a middle school in Türkiye.

Technology is not the only thing that has aged

The 2015 update is important, but the skeleton of the book is still the skeleton of 1999.

As a reader review also pointed out, the effect of social media on girls' adolescence is hardly touched. For an adolescent girl with ADHD, subjects like constant comparison, rejection sensitivity and impulsive posting are among the places most in need of discussion today.

The medication chapter is written with the knowledge of 2015. As its title makes clear, it admits that the decision is not easy. But it should not be used as a current medication guide. The medication decision is made with a child psychiatrist.

A note for mothers

When you think of heredity, one more thing comes to mind: the chance that the mother of a girl with ADHD has ADHD too.

For a mother who recognizes her own childhood while trying to understand her daughter, this book is read on two layers. Nadeau and Quinn also have a separate book for adult women, Understanding Women with AD/HD. The two can be thought of side by side.

For whom

For the parent of a girl with ADHD. Especially when you feel your child is struggling but the school sees no problem, because the child is quiet.

For teachers and school counselors who work with girls. To understand that the child who does not draw attention in class may also need support.

Also for adult women diagnosed late, with a warning. This book was not written for adult women, but for someone who wants to understand her own childhood it is a powerful mirror. You need to be ready to look into that mirror.

For someone who wants to understand ADHD in adult women, this book is not enough on its own. For the whole picture across the lifespan, you can begin with the article ADHD in women across the lifespan.

How to read it

You do not need to read it from beginning to end. The opening chapters are for everyone; then the chapter for the child's age, then the intervention chapters.

If the child is young, I suggest not reading the adolescence and high school chapters early. The description of risk is heavy and can create unnecessary anxiety for the parent of a child who is still in preschool.

An observation in the book, a checklist or a story that feels familiar does not replace a diagnosis. A parent who suspects ADHD in their child should see a child psychiatrist.

It is around three hundred and forty pages. The chapters are short and can be read independently.