Diagnosing ADHD in Girls and Women

ADHD symptoms are expressed very differently in girls than in boys.  Research indicates that up to 75% of girls with ADHD go undiagnosed.  Girls on average are diagnosed five years later than boys (average age for diagnosis in boys is 7, average age in girls is 12).  These facts are so very important because undiagnosed ADHD can lead to depression, anxiety, eating disorders and other mood disorders.

Girls are consistently under-identified because of the differences in expression of ADHD.  Girls with ADHD are often people pleasers, and they try harder to compensate for and hide their symptoms.  They often have a fear of judgment and resort to masking.  In clinical settings girls often silence themselves, too entrenched in the opinion that their voice doesn’t matter, too worried about upsetting their parents or even the clinician.  There is a referral bias due to less disruptive behaviour.  Because ADHD symptoms in girls are often internal, their behaviors are less problematic for parents and teachers and therefore girls with ADHD can fly under the radar.

Symptoms of ADHD in girls can be:

• low self-esteem
• being withdrawn
• anxiety
• intellectual impairment
• difficulty with academic achievement
• tendency to daydream
• trouble focusing
• appearing not to listen
• verbal aggression such as taunting and name-calling
• executive function problems

When finding an ADHD doctor, credentials matter less than the knowledge the doctor has on ADHD and its different presentations.  The following should be factored in by the clinician:

• Girls will often not speak up in a clinical session, particularly if the doctor is male. Lack of communication is essential for correct diagnosis and treatment, and girls need to know that their voice matters and they are believed.

• Hormonal fluctuations need to be factored in. Premenstrual Syndrome (PMS) can exacerbate ADHD symptoms, including emotional regulation, anxiety, irritability, insecurity and depression.  Clinicians should always ask about menstruation cycles because fluctuating estrogen levels play such a large role in ADHD symptoms.

• Shame on the parents’ behalf can be problematic, as they are often not comfortable discussing the challenging behaviors of their daughters. Sometimes they are worried their parenting will be judged, or that their daughters will be seen as disobedient and uncontrollable.  Parents need to know that the clinician will suspend judgement, so parents can speak freely about the struggles their daughter is having.

• Self-esteem and eating disorders. ADHD brings with it challenges of self-regulation, and this can affect eating behaviors.  Girls often have low self-esteem, body shame and body dysmorphia, and for ADHD girls, these are often exponentially greater.  The ADHD brain also generally craves carbs, which can cause girls to ‘give-in’ to this craving and then berate themselves for their lack of ‘will-power’.  This is something that should be addressed by the clinician.

When ADHDers are diagnosed in adulthood, their problems can be even greater.  They have suffered years of feeling different, lazy, inadequate, and more.  Women are often diagnosed with emotional disorders like depression and anxiety before being diagnosed with ADHD. They spend years experimenting with different medications to try to alleviate their symptoms to no avail.  This is so difficult to swallow because ADHD is such a treatable condition, and if people, doctors included, had more knowledge of how ADHD presents in females, this could be avoided.

It is important to note that not all boys display the more acknowledged symptoms of ADHD, such as impulsiveness, excitability and hyperactivity.  There are often boys who also go through life undiagnosed, boys who display the more internalized symptoms that ADHD girls do.  Too many children and adults are struggling through life unnecessarily.  This is why it is important that the criteria is changed to include all symptoms, both hyperactive and inattentive, as well as emotional, and that more people are educated in all aspects of ADHD.