By Dr. Julie Caplan
It took me 43.5 years to be diagnosed with ADHD. When it happened, I took a deep breath and sighed because my entire life finally made sense. All of the parts of me that had always felt broken or wrong weren’t actually either of those things. As it turns out, my brain is neurodivergent, and how I take in and process information is different than neurotypical brains. But why, you might ask, did it take so long for me to be diagnosed, particularly given that diagnosing ADHD is part of what I do professionally? I’m happy to tell you. As much as I don’t like to be binary when it comes to gender, research shows that ADHD looks much different in girls than in boys. So much so, that 50-75% of girls miss out on being diagnosed. And, on average, girls are diagnosed about five years later than boys.
Gender Bias in Diagnosing Girls with ADHD
It’s not that girls have different symptoms than boys, it’s more that the symptoms are interpreted differently based on societal expectations. Girls are often socialized to be people pleasers, and they may pay higher penalties for not living up to others’ expectations. Often, we mask our symptoms by overcompensating in different areas or intently studying our peers and how they do things, which is exhausting. Typically, undiagnosed ADHDer girls are bright and have been able to compensate for their struggles by implementing intrinsic strategies without knowing that’s what they’re doing. This means using context clues to pick up on any information they might have missed, such as visual cues (e.g., looking at the board to see what page you’re supposed to be on), peer referencing (e.g., looking at your seatmate’s book to see what page you’re supposed to be on), or simply having the confidence to confirm the information just taught or what the expectation is (e.g., asking the teacher what page you’re supposed to be on).
I have to think a lot harder about small, everyday things that come much easier and intuitively to a neurotypical brain. For example, I set multiple alarms to make sure I’m on time everywhere (or, ten minutes early, preferably), I doodle when taking in auditory information because I know that the kinesthetic movement helps me remain engaged, I outsource areas of weakness (shout out to my laundry service), and I lean heavily into my known strengths. The extra steps necessary for an ADHD brain to function successfully in a neurotypical world means that most of us are in a state of chronic overwhelm. For those who don’t already have healthy coping skills or distress tolerance tools in place, this chronic overwhelm can take a heavy toll, and it can lead to potential mood issues and increased anxiety, as well as to higher risk behaviors, such as substance use.
As with ADHDer boys, ADHDer girls struggle to pay attention to boring things, have trouble sustaining their effort, can be “spacy” or “daydreamy,” tend to hyperfocus on passions and preferred interests, and have difficulty with executive functioning. For me, the executive functioning issues showed up via chronic disorganization of my physical space, as well as via procrastination, trouble prioritizing, and time-management. My backpack and desk were always messy and full of crumpled papers, as was my room at home. I started longer projects at the last minute, and I never studied until the night before a test. I couldn’t write a five-paragraph essay to save my life because I couldn’t figure out how to organize it. I was able to achieve decent grades, but my report cards all had one comment in common: “Julie is smart, but she is not working up to her potential.” This is what we call a clue, my friends. If your student is getting good grades, but still receiving comments like this, it’s a sign that it might be helpful to look into whether something else is going on.
Ants in Your Pants or Social Butterfly?
ADHD has three subtypes: predominantly inattentive, predominantly hyperactive/impulsive, or combined presentation (symptoms of both). Younger boys are much more likely to be impacted by the hyperactive and impulsive symptoms, the “ants in your pants” phenomenon. These behaviors tend to be more overt, and as such, much more noticeable by others. Because of this, boys often are identified much earlier than girls. Ultimately, because girls tend to cause fewer problems in the classroom, they are more likely to be missed. I can tell you that I read books underneath my desk all throughout elementary school, and no one noticed. Inattention can also show up as a student who seems to be shy and studious, but who fails to finish her work even though she knows the material, or who appears to need more time to process the things she sees and hears.
Also, this is not to say that the hyperactive and impulsive symptoms don’t show up in girls. They do, but they may be interpreted by others as something else, such as the social butterfly who can’t stop chatting with her friends. Or an immature girl who seems socially behind her peers. Or in a perceived lack of academic ability, which is in actuality due to inattention rather than skill deficit. Or a girl who appears to be defiant or not listening. It’s important to know what to look for so that ADHDer girls can be identified as young as possible and provided the right strategies to nurture their strengths and support their stretches.
She’s So Moody!
A big part of being an ADHDer is grappling with emotional dysregulation. That’s just a fancy term for having really big feelings without the ability to temper them with logic and reasoning. An ADHDer’s frontal lobe is three years behind in development, so the brain is, in essence, developing asynchronously. This is super confusing for all involved because a girl who seems to be on par with her peers or advanced in some areas falters in other areas. When I was in elementary school, I constantly was being called “moody” or “too sensitive.” And, in hindsight, yes, I was! I truly was feeling all of the feelings and to a great intensity, but I didn’t have sufficient coping resources at hand to help me through them because everyone around me thought I was doing these things on purpose. Not the case!
When you are labeled as difficult, it can lead to decreased self-esteem and low confidence. Additionally, if someone is inattentive around peers, they can miss nuanced social cues. Moreover, hyperactivity and impulsivity can look to others as if you are being bossy, interrupting others, monopolizing conversations, having a lack of reciprocity, or appearing selfish or self-centered. This disconnect can lead to increased peer conflict both in and out of school, including ostracization, ignoring, rumors, and cyberbullying, as well as more overt criticism, name calling, and exclusion from play dates and birthday parties.
My hope is that by writing this blog I can help all of the undiagnosed or late-diagnosed female-identified ADHDers out there to be seen, heard, and understood (and diagnosed!). It’s hard to live in a world that wasn’t designed for us, but there are certainly many strategies we can put in place to make things feel easier. Fortunately, awareness into ADHD has increased, and stigma has decreased. Ultimately, never be afraid to be who you are, even when others don’t seem to be able to understand or appreciate your sparkle. The more you get to know yourself, the more you’ll shine.
One thought on “Girls and ADHD: We Do it Backwards and in High Heels”
Julie, you write so well. And I am so so sorry that you had to struggle for so long until you finally figured out why. I am really looking forward to more. Much, much love, Jackie Freedman