The 2023 ADHD Awareness Month theme in the United States is “Moving Forward with ADHD” to expand our understanding of attention deficit hyperactivity disorder (ADHD), particularly girls with ADHD. That’s because clinics report that the ratio of men to women diagnosed as adults with ADHD is one to one, according to www.ADHDAwarenessmonth2023.com, but the ratio of boys to girls being diagnosed in clinics is much higher, approximately 4 to 1, according to clinical psychologist, Dr. Ellen B. Littman (*please note the CDC’s statistics of boys compared to girls with ADHD is 13 percent for boys compared to 6 percent for girls). “So that means we’re still missing a lot of girls, and that’s obviously a problem,” says Dr. Littman during an interview with Karen Sampson Hoffman of Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) and Roxanne Fouché of the ADHD Coaches Organization on www.ADHDAwarenessmonth2023.com.
Littman attributes this discrepancy to a few main things including how ADHD has been traditionally diagnosed throughout history, focusing on hyperactive boys, but that criteria of hyperactivity does not always translate for girls. Meaning, often symptoms exhibited by girls with ADHD are not hyperactivity. In fact, many girls with ADHD do not exhibit any signs of it until they reach puberty with the onset of estrogen, which Dr. Littman says causes girls’ ADHD to “blossom.”
“Girls appear less symptomatic in elementary school, and as they approach puberty, you see more and more ADHD symptoms,” says Dr. Littman on www.ADHDAwarenessmonth2023.com.
The problem with this is that until very recently, the cut-off age for getting diagnosed was seven years old (and now it’s 12, which is still problematic). “Most girls did not show symptoms that early and hence could not be diagnosed,” says Dr. Littman on www.ADHDAwarenessmonth2023.com.
Exacerbating the whole problem is that even when girls reach puberty and their ADHD ‘kicks in,’ they still may not exhibit the kind of hyperactivity that is typically associated with ADHD. Instead, they may just appear “inattentive” – but not “disruptive” – according to Dr. Littman. “Even today’s research includes only those diagnosed by the recent criteria, which is still based on symptoms that are easily observed and categorized, and many rating scales are still skewed towards activity level and observable symptoms. We really need self-report scales to get a good sense of one’s internalized symptoms. And research suggests that there is still a bias, meaning that the more inattentive girls are less disruptive and so are less likely to be referred (for ADHD),” says Dr. Littman in www.ADHDAwarenessmonth2023.com.
However, there has been enough awareness surrounding the issue of inattentiveness of girls with ADHD that there are now officially considered three types of ADHD: 1) hyperactive-impulsive 2) inattentive 3) combined (combination of 1 & 2).
But again, it’s not always so easy to diagnose girls with ADHD because in addition to reasons noted above, there is another issue, societal expectations, which Dr. Littman says encourages girls at a very young age to “internalize the demands of society which still supports feminine expectations to accommodate others” during her interview on www.ADHDAwarenessmonth2023.
And Littman is not alone in her opinions. Many experts concur, including Julia Edwards, LMHC, a therapist and ADHD-certified clinical services provider, who attributes the underdiagnosis of girls with ADHD due to “cultural and gender biases and expectations” including that “females don’t typically display the external symptoms associated with ADHD,” according to an interview with her on www.PsychCentral.com. Which begs the question, what do you do if you think your daughter or a loved one has ADHD? Begin by finding a specialist who is aware of gender bias when it comes to diagnosing ADHD; with a correct diagnosis, you can get the correct care for her. And remember, many people don’t get diagnosed until they are adults, especially females, so don’t be shy about advocating for yourself if that’s the case.
Below is a list of common visible ADHD symptoms according to Julia Edwards, LMHC on www.psychcentral.com. These symptoms include:
- excessive fidgeting
- rushing or being late or too early
- body-focused repetitive behaviors (e.g., skin picking, nail picking or biting, hair pulling or twirling, leg bouncing)
- getting easily distracted by external stimuli
- anger outbursts (e.g., road rage or meltdowns)
- overplanning or poor planning
- being overly organized or disorganized
- constantly losing items (e.g., phone, keys, wallet, etc.)
- substance use or addictive behaviors
- binge eating disorder
This information is for educational purposes. Please consult your physician for any medical issues. The Visiting Nurse Association (VNA) is committed to bringing trusted and quality home care to Indian River and Brevard County patients. For more information about VNA services, call 772-567-5551 in Indian River County or 321-752-7550 in Brevard County, or visit www.vnatc.com.