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Giving Girls the Attention They Need
What Parents Need to Know About Girls and ADD/ADHD

Girls with ADHDDespite reports that boys are three times more likely to have ADD/ADHD than girls, attention deficit is not just a boy's issue. In recent years, research has made clear that girls with attention problems are being under-diagnosed and untreated. While as many as 7 million children and teenagers in the United States have been diagnosed at some time in their lives with ADD/ADHD, alarming reports estimate that as many as 50 percent to 75 percent of girls with the disorder are undiagnosed. Worse, girls with ADD/ADHD are diagnosed on average five years later than boys - boys at age 7, girls at age 12. It's time to look at attention deficit in girls through a new lens.

Boys vs. Girls

Why have girls with attention deficit been ignored?

There are a number of reasons. First, boys with ADD/ADHD stand out in the crowd. In addition to having problems paying attention and getting distracted, they often are hyperactive, impulsive, and disruptive. They are more likely to act out in school, becoming a teacher's worst discipline nightmare or the class clown. ?

Girls with ADD/ADHD, on the other hand, tend to act out less but have more attention problems, leading to academic problems and emotional issues. Girls become more withdrawn and "spacey." Because they are not disrupting the rest of the class, it may take longer for them to get a diagnosis of ADD/ADHD and the help that they need.

In the book Understanding Girls With AD/HD, Kathleen Nadeau, Ph.D., states that "there are many girls left undiagnosed because their symptoms look different," because "girls are less rebellious, less defiant, generally less 'difficult' than boys." Socialized to please their teachers and parents, girls try hard to compensate for the disorder, making it much harder to spot. When teachers or parents do take note, says Nadeau, "[girls'] behavior is often misunderstood as immaturity or lack of academic ability rather than as ADD/ADHD."

With social norms saying "boys will be boys" and expecting girls to become polite, self-controlled "young ladies," who considerately listen to others without interruption, it makes it even more difficult for girls to feel good about themselves when they don't fit in with other girls or are criticized by parents and teachers.

Symptoms of ADD/ADHD in Girls

According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, ADD/ADHD is defined as the presence of at least 6 symptoms of inattention or hyperactivity/impulsivity that persist for at least 6 months in a way that is maladaptive or developmentally inappropriate. Symptoms of inattention include poor attention to details, limited attention span during tasks or play, forgetfulness, distractibility, and failure to finish assigned activities. Symptoms of hyperactivity/impulsivity include fidgeting, extreme restlessness, excessive motor activity, difficulty taking turns, and a tendency to blurt out answers or interrupt others. In order to meet diagnostic criteria, the symptoms of ADD/ADHD must cause clinically significant impairment in school and at home. Clinicians may diagnose a child with ADD/ADHD, combined type, or with attention deficit/hyperactivity disorder, predominantly either inattentive type or hyperactive-impulsive type.

Since girls present different symptoms of attention deficit than boys, it is critical for parents, teachers, and therapists to become familiar with the ways in which girls act out. Signs to look for include: non-stop talking and frequent interruptions, problems making and keeping friends, difficulty paying attention or "ditziness," messiness or disorganization, difficulty finishing tests or assignments on time, and being highly emotional or sensitive.

Dr. Nadeau has identified a number of common "categories" of girls with ADD/ADHD. For example, hyperactive girls are often "tomboys." They are physically active and want to explore their world in sometimes adventurous ways, by climbing trees, playing sports, or rough-housing with brothers or other boys. These girls may struggle with staying organized with homework and cleaning their room, but they often are cooperative at home.

Highly intelligent girls may also have ADD/ADHD. Though hard to identify because they perform adequately in school, as they grow older their problems with concentration and organization become clearer.

Other ADD/ADHD girls may exhibit inattentive "daydreamer" tendencies, quietly listening to their teachers but often thinking about everything but school. They may be forgetful in completing homework assignments and may operate at a slower pace than other girls.

The opposite of the quiet dreamer is the "chatty Kathy" who is animated, excitable, talkative and overly emotional. They interrupt others frequently and can't focus on one topic at a time. In order to compensate for their disorganization and forgetfulness, these girls become "hyper-social" and take risks like smoking, drinking, and becoming sexually active at a young age.

Why ADD/ADHD Is Especially Hard on Girls

Teenage girls with ADD/ADHD face a number of challenges above and beyond the issues facing most teenagers. Girls face unique social pressures to fit in with their peers, and girls with ADD/ADHD, in particular, struggle with feeling "different" from the others. The need for peer acceptance during high school years may lead to dangerous or self-destructive behavior in an effort to "belong."

Girls with ADD/ADHD deal more acutely with low self-esteem and depression. Social pressure to imitate and conform to other girls may be exhausting to a girl with ADD/ADHD. While teenage years are full of self-doubt for most girls, the distinct challenges of ADD/ADHD greatly magnify those feelings. For girls, who are typically encouraged to be orderly, self-controlled, well-groomed, sensitive and compassionate, and obedient, their ADD/ADHD tendencies put them in direct opposition of social norms. Although she may think obsessively about being properly groomed and fashionably dressed, she is unable to stay organized enough to make sure clean, matching clothes are laid out for school. Since depression is easier to recognize than ADD/ADHD in girls, many find themselves misdiagnosed.

The combination of ADD/ADHD hyper-reactivity and typical teenage hormone swings can make girls with the disorder highly reactive and emotional. The uncertainty and competitiveness so common among teenage girls are often more intense for girls with ADD/ADHD. Hurt feelings can quickly escalate into impulsive remarks, outbursts, or overreactions that friends and family may not be able to forgive or tolerate.

Another characteristic of adolescence is the pressure to become mature and responsible. Sometimes parental expectations directly conflict with the neurocognitive patterns associated with ADD/ADHD. Girls may struggle to make normal advances academically, as the school day starts too early and lasts too long to maintain focus and the subjects taught are of little interest.

Teenage girls with ADD/ADHD are at greater risk for pregnancy, substance abuse, and traffic accidents than are other teenage girls. Girls who struggle with low self-esteem often seek affirmation through the sexual attention of boys, and difficulties with impulse control and planning increase the likelihood of unprotected sex, inconsistent use of birth control, and multiple partners. Many girls compensate for their differences by using alcohol or drugs to fit in.

Research Draws Attention

ADD/ADHD affects girls as much as boys. A 1999 study funded by the National Institute of Mental Health and published in the Journal of the American Academy of Child and Adolescent Psychiatry compared 140 ADD/ADHD girls between the ages of 6 and 18 with 122 control girls and found that:

  • Girls with ADD/ADHD exhibited more inattentive symptoms while boys exhibited more hyperactive-impulsive symptoms and disruptive behaviors.
  • Compared to girls without the disorder, girls with ADD/ADHD had significantly higher rates of co-morbid behavior disorders (conditions that occur at the same time) such as oppositional defiant disorder and conduct disorders. (Note these rates are still lower than those seen in boys with ADD/ADHD.)
  • Girls with ADD/ADHD have more mood and anxiety disorders (consistent with the rate seen in boys with ADD/ADHD) than children without ADD/ADHD.
  • Girls with ADD/ADHD, as compared to girls without ADD/ADHD, have a higher risk of smoking and increased alcohol and drug usage.
  • Contrary to previous studies which found that girls with ADD/ADHD demonstrated greater cognitive impairment than boys, this study found that the degree of cognitive impairment was consistent with boys with ADD/ADHD.
  • Girls with ADD/ADHD were about 2.5 times more likely to be diagnosed with a learning disability, more than 16 times more likely to have repeated a grade in school, and almost 10 times as likely to have been placed in a special class at school, as compared to non-ADD/ADHD girls.
In a follow-up study conducted five years later and reported in the June 2006 issue of the Journal of Consulting and Clinical Psychology, researchers evaluated 209 of the girls, who had entered middle and high school. In nearly a dozen areas examined by researchers, including academic performance, eating disorders, relationships with peers and teachers, and organizational skills, the girls with ADD/ADHD were significantly more likely to have problems than the non-ADD/ADHD control group.

Five years later, the gap in reading and math ability had widened and about 30 percent of the girls with ADD/ADHD were at least mildly depressed, compared with 10 percent of the control group. Similar patterns were seen in substance abuse. Researchers concluded that the impairments affecting girls with ADD/ADHD persist through adolescence and must be addressed through early intervention in order to achieve success in adulthood.

What Parents Can Do

The good news is that ADD/ADHD is a highly treatable condition. Talk with your daughter as early as possible and get her the help and support she needs to live up to her potential at home, at school, and in life. There are a number of approaches parents can take to make daily life more comfortable and positive for a teen with ADD/ADHD:

Establish a "quiet zone." Both the withdrawn and hyper categories of girls with ADD/ADHD quickly feel emotionally overwhelmed. Teach your daughter stress management techniques and allow her an emotional "time out" after an upset.

Minimize corrections and criticism. Remember, girls with ADD/ADHD often suffer from low self-esteem. While parents should address negative behaviors, be especially conscious of balancing negative feedback with affection, encouragement, and quality bonding time with the family.

Make home a safe haven. Your teen faces a rough world out there. Home should be a place to regroup, refuel, and rebuild confidence. Be a soft place to fall if she wants to relax, unwind, and discuss the challenges in her day.

Nurture talents and skills. Many girls with ADD/ADHD feel they are failures when it comes to academics and social life. Counteract the negativity by helping your daughter identify a skill or ability. Areas to explore may include part-time work, volunteer work, participation in community projects, or trying new activities like horseback riding, sports, or arts. Finding a talent or activity to feel good about can be a positive turning point for a teenage girl with ADD/ADHD.

Be patient. Teens with ADD/ADHD can undoubtedly be difficult. Remember that ADD/ADHD has a neurological basis, and your teen will be vulnerable to extreme reactions during times of stress, fatigue, hunger, or PMS. Identifying the potential triggers and stressors will help the whole family manage tough situations. Be alert to signs that the "normal" emotional roller coaster has teetered into full-blown anxiety or depression.

Teach advocacy skills. The more your daughter knows about her attention disorder, the more she will be able to understand and convey her needs as an adult. In college or the workforce, she will need to express her needs confidently and convincingly to people who are ill-informed about ADD/ADHD. She needs validation of her right to express her opinion and advocate on her own behalf, and help in learning to express herself in a constructive, effective manner.

Introduce structure. As with girls of all ages with ADD/ADHD, teenage girls need structure and boundaries. Since teenagers crave independence, join forces with a therapist, coach, or school guidance counselor who also can provide structure and teach essential life skills like being on time, staying organized, and setting priorities.

Talk to teachers. Educate your daughter's teachers about ADD/ADHD and her special needs. If your teen is a "chatty Kathy," ask the teacher to seat her near the front of the class and away from other talkative students. Once aware of your daughter's needs, the teacher can encourage her class to be patient and generous with other children's differences, and to be encouraging and supportive to one another.

Get help. When it comes to treating ADD/ADHD, early intervention is the key. A study in the October 1997 issue of the Journal of Attention Disorders found that women with ADD/ADHD who were not diagnosed as children have more symptoms of depression, are more anxious and stressed, have lower self-esteem, and have fewer coping strategies.

If you suspect that your daughter may have ADD/ADHD, seek out professionals who have experience in diagnosing and treating the disorder. One way is to contact C.H.A.D.D. (Children and Adults with Attention Deficit Disorder) to find a chapter near you, where monthly meetings allow you to network with other parents to find the best professionals in your area.

In addition, there are dozens of wilderness camps and therapeutic boarding schools that specialize in treating teens with attention disorders. In addition to providing structure and consistency, these schools employ a professional staff of psychologists, therapists, and teachers with advanced degrees who will specifically tailor a program to address your child's needs. Therapeutic boarding schools and wilderness camps have an excellent track record in helping troubled adolescents by offering support groups to help them feel more accepted and less alone, as well as constructive activities that build self-esteem. Recent studies confirm that adolescents who are kept busy in extracurricular activities, sports, church groups, and so on are less likely to get in trouble during high school. With the appropriate tools and support systems in place, your daughter can flourish and grow into a productive, happy member of society.

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