ADHD in Girls

Picture it: somewhere in a second-grade classroom in Birmingham, Alabama, a teacher is in the middle of leading her class through their math lesson. An 8-year-old boy with chewed-down fingernails, Jack, takes a pause from tapping his pencil on his desk to blurt out an answer, interrupting his teacher before she even finishes her question. She sighs and reminds him that if he speaks without being called on again, she will have to have a conference with his parents. Other children in the classroom roll their eyes in frustration with Jack. His teacher asks another question. Jack knows the answer but keeps his mouth shut tightly this time, squirming in his seat with the effort. Next to him, 8-year-old Jane quietly reads a book in her lap. She is so focused on the book’s plot that she has missed the entire exchange between Jack and his teacher. Which child do you think may have ADHD? The answer may surprise you.

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental conditions, affecting approximately 1 in 9 (11.4%) children in the United States. Based on prevalence estimates, boys are disproportionately diagnosed with ADHD compared to girls, with male-to-female ratios ranging from 2:1 to 10:1. Does this mean that fewer girls have ADHD compared to boys? Not quite. Research suggests that girls may be underdiagnosed or misdiagnosed due to differences in how ADHD presents between boys and girls.

ADHD Presentation in Girls and Boys

While girls with ADHD certainly can and do exhibit symptoms of hyperactivity and impulsivity, they tend to show fewer of these symptoms relative to boys with ADHD. In contrast to boys, girls more commonly have a predominantly inattentive presentation of ADHD. Additionally, boys with ADHD often display more externalizing behaviors, meaning they direct their behavior outward toward other people (e.g., disruptive behavior, aggression, rule-breaking, defiance). Girls, on the other hand, typically experience more internalizing behaviors, meaning their emotional and behavioral responses are directed inward (e.g., anxiety, depression). Sometimes, girls with ADHD may be described as “daydreamers” or “spacey.” Even when they display symptoms of hyperactivity and impulsivity (e.g., excessive talking, blurting out answers), they may be described as “chatty” or have these behaviors chalked up to being a social butterfly.

Because symptoms of ADHD are often first recognized in the classroom setting, and externalizing behaviors are more easily identifiable compared to internalizing behaviors, boys are referred for ADHD evaluations (and subsequently diagnosed) at higher rates than girls. Think about it this way – Inattention generally doesn’t get in the way of anything for other people. Children who primarily struggle with paying attention aren’t disrupting the class, intruding on other children’s activities, or getting into trouble. This makes it very easy for parents and teachers to unintentionally overlook symptoms of inattention. On top of this, girls may be socialized differently than boys, where parents and teachers have different expectations for behavior. As girls get older, they may develop coping strategies to compensate for challenges related to ADHD, which can mask how impairing their symptoms truly are.

ADHD has been referred to as the “hidden disorder” in girls due to these reasons. Because a diagnosis helps us understand a child’s unique strengths and challenges, girls who go undiagnosed can come up with their own explanations for why there are struggling (e.g., “I’m so stupid. Why do I even try? I can’t do anything right!”). They may even experience criticism from parents, teachers, and other children… especially when they are bright and others believe they “should” be performing better than they are. Moreover, they may not receive adequate supports and accommodations that would help them succeed. This can ultimately impact children’s self-esteem and result in difficulties with perfectionism and fear of making mistakes.

Obstacles to Care

Whether in Alabama or elsewhere, children with ADHD face numerous obstacles to useful assistance. Two of the most common are 1) stigma/denial about the reality of this syndrome, and 2) access to evaluation and treatment.

Especially when you consider the scenario shared above describing a young girl focused on her book, it is easy to see how some adults can dismiss the reality of this child’s possible attentional deficits. However, hyperfocus is just one symptom of ADHD that can be easy to overlook, especially in girls. Collectively, we are doing a better job of moving toward an attitude of acceptance regarding the reality of ADHD; however, the condition is still under-evaluated and therefore under-diagnosed in Alabama, meaning that many children who could benefit from treatment never have access to the care that could make their lives better.

Another considerable obstacle is access to care. Whether in Birmingham, Huntsville, Mobile, Montgomery, or any other corner of the state of Alabama, parents seeking an ADHD evaluation for their child tend to encounter the same frustration: every child psychologist who is trained to provide such an evaluation is booked up for many months. There are also many areas in smaller Alabama towns without a child psychologist in their midst. In these areas of Alabama, parents will have to travel to bigger cities such as Birmingham, Huntsville, or Montgomery to seek evaluation services for their children, and will likely have to make this trip several times in order to complete the series of meetings required for a comprehensive evaluation. Without an evaluation, children cannot access the care they need.

A Better Way

At Upward Behavioral Health, we are proud to offer virtual ADHD evaluations for children ages 6-17 in the state of Alabama. We recognize that symptoms of ADHD can look a little different in girls compared to boys, and we strive to help families understand and support their children’s differences, even when they don’t fit the stereotypical mold of ADHD. Our current wait times are reasonable and we are able to offer pediatric ADHD and autism evaluations to children anywhere in the state of Alabama. If your child needs an ADHD evaluation, please reach out to us for a free consultation call with Dr. Ramsey.  

Concern about virtual evaluation? Please see here to learn more about this process! Virtual evaluations have been demonstrated to be equally as valid and effective as in-person evaluations, and virtual testing offers unique benefits.