Introducing ADHD 

Attention deficit hyperactivity disorder (ADHD) is a brain-based condition, which usually develops as a result of genetic or environmental factors, or both. ADHD is commonly associated with the key features of inattention, hyperactivity and impulsivity but awareness is growing of the impact of ADHD on the parts of the brain that help you plan, prioritise and perform complex tasks, called ‘executive functioning’. ADHD presents differently in people depending on their age, gender and the ‘sub-type’ of ADHD. This has led to a gender gap in the diagnosis and treatment of ADHD, with boys three times more likely to access a diagnosis and early treatment for ADHD than girls in the UK. 

What is ADHD? 

Attention deficit hyperactivity disorder (ADHD) is defined in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as having three sub-types within the broader ADHD category: 

1. Primarily hyperactive-impulsive type: individuals who appear ‘driven by a motor’ and are constantly on the go.  Impatient, interrupting, blurting, lacking inhibition or impulse control… 
2. Primarily inattentive type: previously known as Attention Deficit Disorder (ADD) and the sub-type most commonly diagnosed in girls and women, it is often the most challenging to identify in a classroom environment.  Daydreamers, timeblind, poor organisational skills, poor planning skills, forgetful. 
3. Primarily combined type: for those who display a combination of inattention, hyperactivity and impulsivity 

Diagnostic and Statistical Manual of Mental Disorders, (DSM-5, American Psychiatric Association 2013) 

Don’t We All Have a Bit of ADHD? 

Many of the behaviours associated with a diagnosis of ADHD will be familiar to all of us. We can likely all remember a time when we’ve forgotten our keys, or felt so overwhelmed with jobs or tasks that we don’t know where to start. If you’re a parent or teacher, you may recall observing children bursting with so much excitement at sharing a story that they’ve interrupted you, or they’ve come in from playing outside on a windy day and they struggle to calm down no matter how many times you’ve asked. Children and adults, with or without a diagnosis of ADHD, may show some or all of the behaviours associated with ADHD when tired, anxious or unwell. Similarly, not all children with ADHD will share all of the same experiences. For a diagnosis of ADHD to be considered, these behaviours will have been observed for a long time, usually since childhood, and will have a significant impact on their ability to function throughout the day.   

ADHD on the rise? 

While media reports may suggest that ADHD is ‘on the rise’ in the UK, the condition remains largely under-identified, especially in girls and adults.  In the UK, 3.62% of boys and 0.85% of girls are estimated to have a diagnosis of ADHD.  Girls remain less likely than boys to be referred for assessment for ADHD, are more likely to have undiagnosed ADHD and more likely to receive an incorrect diagnosis of a mental health condition or other neurodevelopmental condition (NICE 2018).     

Understanding ADHD in girls 

Girls are more likely to present with the behaviours associated with inattentive ADHD, which are harder to identify than the hyperactivity or impulsivity normally associated with ADHD.  Hyperactivity in girls can be overlooked with over-thinking, rumination, constant worrying, interrupting conversations, blurting out comments, poor self-image, constant talking and fidgeting not always seen as potential signs in girls who are experts at masking their hyperactive traits. Inattention in girls may be missed with many of these traits mistaken for being a daydreamer: forgetfulness, time-blindness, procrastination, not listening to instructions, unable to start tasks, sustain effort on tasks or complete activities. Girls are more likely to conform to societal expectations of how they are expected to behave, which leads to ‘masking’ of their behaviours and later diagnosis and treatment.  Hyperactive girls may find themselves given the monikers: chatterbox, foghorn, nosey-parker, bossy-boots, whereas their inattentive female peers may be labelled: head in the clouds, lazy, ditzy, daydreamer, unfocused, clumsy clogs. Navigating friendships for girls with ADHD poses many challenges and scaffolded support from adults at an early stage is key to positive self-image and emotional wellbeing. Whilst it does not yet form part of the diagnostic criteria, recent research shows the link between ADHD and challenges with emotional regulation. Rejection sensitive dysphoria (RSD) impacts profoundly on the emotional regulation of many individuals with ADHD, tending to affect girls more acutely than boys. It describes an extreme emotional sensitivity and emotional pain triggered by the perception that a person has been rejected or criticised by important people in their life.  Failing to live up to your own high expectations can cause the same painful reactions.  Other people may see those with RSD as being perfectionists, as overly sensitive, over-reactive, or being unable to handle any kind of criticism. RSD can compound feelings of shame and negative self-image, which is common for girls with ADHD.  Symptoms of anxiety or depression are more commonly displayed in girls than in boys and healthcare providers may prefer to treat these symptoms before assessing for ADHD, which can lead to a delay in diagnosis and effective treatment.   

Why does ADHD present differently in girls? 

While ADHD is generally considered to be a condition that remains stable over time, for girls and women this is not the case. ADHD symptoms for girls can change over time and can fluctuate over the course of the month due to changing oestrogen levels. Oestrogen protects the brain by enhancing neurotransmitter activity, which then impacts the executive functioning skills of focus, attention, motivation, verbal memory, sleep and concentration. During a woman’s lifespan, oestrogen increases during puberty, around age 9 when ADHD symptoms become more apparent in girls. Girls and women experience a decrease in oestrogen during their menstrual cycle, after childbirth, during peri-menopause and the menopause.  ADHD symptoms increase as oestrogen decreases. These behaviours can either be missed or present as anxiety or mood dysregulation leading to misdiagnosis and years of incorrect treatment.  

Treating Girls with ADHD 

Research, including that of the key study from the National Institute of Mental Health Multimodal Treatment Study of Children with ADHD (1997), confirms that the most effective course of treatment for children and adults with ADHD is a holistic package of support, including both ADHD medication and additional support, which may include Cognitive Behaviour Therapy or ADHD Coaching. For advice on the diagnostic process, the first port of call should be your GP. 

ADHD coaching focuses on strengthening executive functioning skills and goal-directed behaviours. Children and adults with ADHD also benefit from therapeutic intervention that includes play therapy, art therapy and equine therapy. Supplementary remedies including nutritional advice – a protein-rich diet is great for ADHD – and ensuring that you have enough exercise in your week is key to keeping your brain healthy. Mindful meditation also forms a key part of many therapeutic plans, encouraging time to slow down and focus on the present. 

Top Tips for Raising Girls with ADHD
 

1. Create a time and space for self-regulation after school: For some girls this is the trampoline and cartwheels in the garden and for others it’s a blanket fort or cuddled up under the duvet with headphones on. With snacks. They will need snacks; the crunchier the better.
2. Scaffold clear expectations both of what is happening and what is expected of her: Wherever possible provide written backup to set her up for success. A whiteboard on the fridge where you write daily reminders can be helpful. As she gets older, encourage her to set reminders on her phone or tablet.
3. Give specific praise:  be clear when she’s done something well about what she’s done well and why. She then knows what to do more of.
4. Be patient.  Girls with ADHD tend to ask lots of questions.  The same questions. Often because they can’t remember the answers or weren’t fully listening to your answer the first time.  Be patient and try to remain calm as you repeat it – for the 57th time. Written back up helps. Mini whiteboards and post-it notes are great for reminders around the house!
5. Teach self-compassion.  Many women who are diagnosed as adults with ADHD talk of feeling shame growing up undiagnosed. The best lesson you can teach is to be kind to herself and be kind to yourself. We are all doing the best we can.