The Dark Side Of ADHD Part 3

The Dark Side of ADHD

Hello, people, welcome back to the blog! This week, we’re continuing our discussion on the dark side of ADHD, with a look at gender differences within the disorder. 

Before we get to that, I want you to imagine this: Little Janie sits quietly at her desk in second grade. She isn’t talking and she isn’t acting out. That’s great, but she also isn’t learning… anything. Her inattention and inability to focus are obvious every time her teacher asks her a question, which isn’t very often. Teachers like Miss Jones like interaction; they tend to shy away from vacant stares like the one that usually occupies Janie’s face. So Miss Jones’ gaze moves to Barbara, who’s listening attentively- she’s not a “space cadet”- she’s clearly keeping up with what’s going on. So once again, Janie is overlooked, passed over…

Janie’s fraternal twin brother, Johnny, on the other hand, gets lots of attention… though not always for the best reasons. Diagnosed with ADHD last year, he has a reputation for being a bright kid, even if he’s usually hyperactive. Treatment for his ADHD has helped him; he’s a better student than he was, and he gets along better with the other kids. He has some behavior problems, but his natural charm keeps him from getting into too much trouble. But Miss Jones can tell immediately if he’s missed his medication, because it makes all the difference in the world for Johnny. It’s been a total lifesaver. Good for Johnny. But meanwhile, Janie is in her own little world, drowning in inattention. And no one is any the wiser… especially Janie.

Unfortunately, scenarios like this play out day in, day out, all across the globe. Why? Because the vast majority of people diagnosed with ADHD are male. In fact, according to the CDC, boys are three times more likely to receive an ADHD diagnosis than girls, but I’ve seen that number quoted as double that. Statistics say that during their lifetimes, an average of 13 percent of men will be diagnosed with ADHD, while just 5 percent of women will be diagnosed. Girls aren’t any less less susceptible to the disorder than boys, so why are boys three times more likely to receive a diagnosis? That’s what we’ll talk about today.

In a nutshell, it’s because ADHD symptoms present differently in girls and boys. Boys tend to show more obvious externalized symptoms, such as hyperactivity and impulsivity, while girls’ often display the inattentive aspects of the disorder, with symptoms that are more internalized and much more subtle. In general, boys’ symptoms are typically simply more pronounced and extreme as compared to girls. Captain Obvious says that hyperactive characteristics are obviously much easier to spot than more subtle symptoms like inattention. Some ADHD signs in girls can be very difficult to identify. When girls have primarily inattentive type ADHD, without hyperactivity, research indicates that up to 75 percent are undiagnosed. Ultimately, it takes a higher burden of risk factors for symptoms to be recognized in girls- the threshold for referral and diagnosis seems to be much higher than for boys- so girls are less often referred to behavior specialists for evaluation, and this leads to fewer girls being diagnosed. 

There are other theories as to why it’s more commonly diagnosed in boys. One is that there may be actual neurobiological differences. Some researchers think that girls may have a protective effect at the genetic level, that they are in some way “protected” from developing ADHD, though the jury’s still out on that. 

Another reason why boys are much more commonly diagnosed with ADHD than girls is because boys with ADHD have been found to have more obvious co-existing disorders, like conduct disorder and oppositional defiant disorder, whereas girls do not. The girls’ internalized symptoms are less disruptive in the classroom than the aggression and rule breaking typically exhibited by boys, so this results in fewer referrals, diagnoses, and treatment in girls. The ole “squeaky wheel gets the grease” kind of thing. 

Why else? Well, yes, girls are less likely to exhibit hyperactivity, but even when they do, they’re more likely to “just” be over-talkative, or maybe a little rebellious, more of a “wild child,” so the symptoms aren’t recognized for what they are, as being caused by ADHD. Also, girls with ADHD might get noticed in school for being overly chatty, but we expect girls to be more sociable than boys, so teachers might chalk this up to the girls being immature, rather than possibly having ADHD. And girls with primarily inattentive type ADHD, who don’t have hyperactivity, might just be described as distracted or “daydreamy” or overly emotional or “sensitive.” For some reason, we just seem to attribute these behaviors in girls to other things first, whereas with boys, if they’re running around, the first thought is usually ADHD. It’s nearly automatic, and that’s a problem for both the boys and the girls. 

Another contributing factor to why so many more boys get diagnosed is that girls are better at compensating for their ADHD symptoms than boys are. Girls develop better coping strategies to make up for their ADHD-related difficulties than boys, such as working harder to maintain classroom performance. As a result, they can better mitigate or mask the impact of their diagnosis. This is similar to how girls with autism “mask” their symptoms. At one time, it was theorized that autism was strictly a “boy disorder,” but of course that’s not the case. It’s a similar situation. Girls simply tend to adapt better. Even if they are hyperactive, girls are less likely to blurt things out in class or shove the kid next to them. This is where the social or societal aspect comes in. A girl that runs around and acts aggressively would be criticized more harshly by her peers. It’s much harder for girls to behave that way, to get away with it, so they tend not to. 

All of these behaviors I’ve mentioned are signs of ADHD, but people react to them in different ways, for lots of reasons. Ultimately, not only are teachers and families less likely to notice signs of ADHD in girls, but they may even be more accepting of the signs girls often show. Parents and teachers either don’t notice girls’ inattentive behaviors and/ or seem to down play girls’ hyperactive and impulsive symptoms, while playing up those same types of behaviors in boys. Seems to be a much bigger issue when it’s a boy. 

Since girls with ADHD often display fewer behavioral problems and have less noticeable symptoms, their difficulties are often overlooked and/ or mislabeled. Many times, the behaviors are wrongly attributed to anxiety or depression. Even when girls are properly diagnosed, it happens an average of five years later than boys. This can lead to serious problems in the future, as girls with undiagnosed and late diagnosed ADHD are more likely to have problems in school, social settings, and personal relationships than other girls. Research indicates that this can have a very negative impact on girls’ self-esteem, and can even affect their long term mental health. Boys with ADHD typically externalize their frustrations, but girls with ADHD usually turn their pain and anger inward- they tend to blame themselves- and this puts them at an increased risk for depression, anxiety, panic disorders, eating disorders, chronic sleep deprivation, and substance abuse. This doesn’t just impact them long term, as adults, these things can affect them even as they enter their teenage years. 

Many late diagnosed adult women with ADHD show symptoms similar to those found in post-traumatic stress disorder, PTSD, where the coexisting panic and anxiety are the result of the classroom trauma they experienced during childhood from the undiagnosed ADHD. For example, if the woman dealt with low self-esteem from attention problems back in grade school, returning to school later in life may trigger those same emotions. Some women aren’t diagnosed until much later in life, around their 30s and 40s, when one of their children is diagnosed with ADHD. This happens more than you’d imagine… when undergoing the process with their children, they recognize the symptoms in themselves. Being diagnosed much later in life can lead to problems, such as the woman blaming herself for things going wrong, or believing that she cannot achieve higher goals, especially if her symptoms interfered in her school or work performance. Studies have indicated that these women are prone to financial problems, underemployment, divorce, and/ or lack of education. It’s a sad situation, and they blame themselves, as though at age seven they should’ve known they had ADHD. That’s why it’s important that everyone recognize the signs in girls and boys.

Recognizing ADHD in Girls

As I mentioned above, girls with ADHD often display the inattentive aspects of the disorder, whereas boys usually show the hyperactive characteristics. These hyperactive behaviors are easy to identify at home and in the classroom, as the child usually can’t sit still and behaves in an impulsive or dangerous manner. The inattentive behaviors are generally more subtle and can be difficult to spot. That child is unlikely to be disruptive in class, but they will miss assignments, will be forgetful, or just seem “spacey,” and this can be mistaken for laziness or even a learning disability. It’s important to know about the different ways kids can act out, and which behaviors tend to get overlooked. That awareness can help girls with ADHD get the help they need sooner, and that definitely makes for a better long term outcome.

Girls’ symptoms typically include:

-Inattentiveness or a tendency to “daydream”

-Trouble focusing

-Appearing not to listen

-Verbal aggression, such as teasing, taunting, or name calling

-Being withdrawn

-Low self-esteem

-Anxiety

-Intellectual impairment

-Difficulty with academic achievement

Recognizing ADHD in Boys

Though ADHD is often underdiagnosed in girls, it can be missed in boys as well. Traditionally, boys are seen as energetic, so if they run around and act out, it may be dismissed as simply “boys being boys.” But it’s a mistake to assume that all boys with ADHD are hyperactive or impulsive; some boys display the inattentive aspects of the disorder, and they may not be diagnosed because they aren’t physically disruptive.

Boys with ADHD tend to display the symptoms that most people think of when they imagine ADHD behavior. These include:

-Impulsivity or “acting out”

-Hyperactivity, such as running and hitting

-Lack of focus, including inattentiveness

-Inability to sit still

-Physical aggression

-Talking excessively

-Frequently interrupting other peoples’ conversations and activities

While the symptoms of ADHD may present differently in boys and girls, it’s critical for them to be treated. While the symptoms of ADHD usually lessen with age, they still tend to have adverse effects. People with ADHD often struggle with school, work, and relationships- even as adults- and they’re also more likely to develop other conditions, including anxiety, depression, and learning disabilities. If you suspect your child has ADHD, take them to a doctor for an evaluation as soon as possible. Getting a prompt diagnosis and treatment will not only improve symptoms, but it can also help prevent other disorders from developing in the future.

I hope you enjoyed this blog and found it to be interesting and educational. Please feel free to share it with family and friends. Be sure to check out my YouTube channel with all of my videos, and I’d appreciate it if you would like, subscribe, leave comments, and share those vids! As always, my book Tales from the Couch has more educational topics and patient stories, and is available in office and on Amazon. 

Thank you and be well people!

MGA