Why we overlook so many of our girls: Thoughts on the ‘H’ in ADHD

Jessica Narowlansky, Psychotherapist and Specialist Education Consultant at the Child and Adolescent Development Centre London, shares her insights on ADHD in girls

Although there is no doubt that awareness around ADHD has improved significantly over the last 10 years, it is clear that our girls are still disproportionately falling through the diagnostic net.

Although to some extent changes made in diagnostic criteria for ADHD have helped rectify this, sadly the issue persists and our girls are suffering. In my view, unfortunately, this has as much to do with social and outdated stereotypes around ADHD as it does with fine-tuning diagnostic criteria to encompass experiences more representative of ADHD in women and girls.

As a mental health practitioner in 2022, it is still an all to frequent occurrence that a young girl will be referred to me with acute mental health concerns such as anxiety, depression, disordered eating or seemingly inexplicable physical symptoms where no medical cause can be found (e.g. persistent headaches, stomach aches, heart palpitations, etc) only to discover in a surprisingly high number of these cases over time what emerges is these behaviours and symptoms are actually a mental health response to an undiagnosed neurological difference such as Dyslexia, ADHD or Autism.

With regard to ADHD specifically in my experience two of the greatest stumbling blocks to identifying the correct diagnostic pathway for girls are:

1) Referral bias from a behavioural perspective: girls often do not demonstrate the stereotypical behaviours associated with ‘hyperactivity’ (a much misunderstood word – I will come back to this later) which is generally the primary flag for referral

2) Referral bias from a social expectation perspective: girls with ADHD are statistically less likely to underperform in school to the same extent as boys. In other words, many girls are doing ‘too well’ in school academically and seeming to manage ‘too well’ socially to call attention to their difficulty

Before elaborating on referral bias further, it is important to understand that ADHD can fall into one of three subtypes:

• Primarily Hyperactive and Impulsive
• Primarily Inattentive (previously called ADD)
• Combined Type

As studies show time and time again, for a number of social and possibly neurobiological reasons,  girls are more likely to present with the primarily inattentive subtype.

I believe this differentiation goes right to the heart of what can make girls invisible as our associations and images of ADHD continue to be aligned with the hyperactive and impulsivity subtype (children who are unable to sit still and/or are underachieving).

What this means, therefore, is a ‘… low index of clinical suspicion exists for girls [as] their presentation is considered “subthreshold” because inattentiveness is more prominent than hyperactivity/impulsivity.’

Furthermore, increasingly studies show ‘that many children with the inattentive subtype of ADHD may go undiagnosed because they do not tend to disrupt the learning environment’, meaning, as ever, it is the squeaky wheel that gets the grease and our girls are statistically less likely to squeak!

What is critical to understand with ADHD is that ‘hyperactivity’ does not mean a child has an inherent and inexplicable excess of energy, quite the contrary.

In truth, heightened behaviours are due to a natural under stimulation of the nervous system leaving the ADHD brain forever seeking sensory stimuli, ‘… in mundane, low-stimulation situations…’ such as sitting in a classroom ‘…, these restless brains may compel their owners to increase the intensity level with fidgeting, noise, laughter, or conflict if there is no other route to high stimulation available.’

However, this seeking of sensory input can mean more than one thing. This can also mean the attentional drift away from one stimulus in favour of another. The child who is seen as the perpetual day dreamer, those lost in thought or the child who seems to be focusing on the wrong bit of the classroom task may well also have a brain that is, in a sense, stimuli seeking by stealth.

These quiet drifters, statistically most likely to be girls, are therefore overlooked as they silently discover that they have been sitting in class for an hour and unbeknownst to anyone, including themselves, have missed the lesson whilst appearing present.

Many of my bright and diligent female ADHD clients tell painful stories of arriving home from school and disappearing into their bedrooms where they work for hours to teach themselves what they missed in lessons. They then engage in homework tasks generally meant to take an hour or two but as here again they struggle to focus and with their lack of temporal awareness (issues with time keeping is a classic struggle with ADHD) time slips away and hours later they are still hard at work. Others still can find themselves sitting for hours feeling unable to get started (task initiation is also a classic struggle with ADHD).

In either case they are then left with a never ending cycle of anxiety and worry believing they will never catch up, that they will never have enough time, they will never get it right. As they are unaware that this is not a difficulty all their friends face, they blame themselves for their perceived shortcomings and the vicious cycle of pummelling their self-esteem goes round.

Much as there is a misconception that ADHD will inevitably resolve in adulthood (another unfortunate myth that leaves many ADHD adults struggling with real world consequences such as managing household bills, deadlines at work or the demands of personal relationships) this concept of pigeonholing ADHD via perceptions of what hyperactivity is expected to look like needs to change.

As a growing body of evidence suggests that concept of inattention in itself needs to be thought about far more deeply and for us to ‘shift away from recognizing the disorder as one of “attention” problem to one of executive dysfunction [as] ADHD is now known to present with a wide range of cognitive deficits, including motivational dysfunction, delay aversion inefficient motor speed and coordination slowed processing speed and variability of responding’.

Whilst it certainly is true that some of our children make the classic hyperactivity marker easy to spot, this should not be confused with the ‘H’ in ADHD telling the whole (or even a large part) of the story. We are needing to truly open our eyes to the reality that the ‘diversity’ aspect of neurodiversity runs far deeper and is far more complex than we realise even now.

Why do I bang this particular drum so loudly? Through my work I have found that what my clients seek most, neurodiverse or otherwise, is what we all seek regardless of age; to forge a better understanding of who we are as people and why we do the things we do.

As I say to most every family I meet, I do not see a diagnosis as an end point, rather I see it as helping us find the right road map to help the individual in front of us better understand their journey through school and through life.

The danger in not providing this neuro-cartology is in the absence of constructive information to contextualise their experience, a young person will fill that void with their own underdeveloped rationale of why they are as they are. All too often the landscape our girls design instead is one riddled with self-doubt, self-criticism, a belief that they are somehow flawed as people and that nothing can ever change.

It is therefore critical that we become more aware of what ‘difference’ can really mean and understand that the ‘H’ in ADHD, like so many things in life, is far more subtle and nuanced than it appears.

Sources

Kaylen, W. (2022). What Is ADHD? Attention Deficit Hyperactivity Disorder in Children and Adults, ADDitude Magazine: Inside the ADHD mind, https://www.additudemag.com/what-is-adhd-symptoms-causes-treatments/

Littman, E. (2022). Never Enough? Why ADHD Brains Crave Stimulation. ADDitude Magazine: Inside the ADHD mind, https://www.additudemag.com/brain-stimulation-and-adhd-cravings-dependency-and-regulation/

Mahone, E. M., & Wodka, E. L. (2008). The neurobiological profile of girls with ADHD. Developmental Disabilities Research Reviews, 14(4), 276-284.

Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. Prim Care Companion CNS Disord, 16(3).

Rucklidge, J. J. (2010). Gender Differences  in Attention-Deficit/Hyperactivity Disorder. Psychiatric Clinics of North America, 33(2), 357-373.