How We Are Failing Girls with ADHD
Attention deficit hyperactivity disorder (ADHD) is a mental disorder characterized by hyperactivity and impulsive behavior, and it is the most common neurodevelopmental disorder in children. An estimated 6.1 million (9.4%) of children (ages 2–17) have ADHD in the United States alone. There is not a single definitive cause of ADHD, but genetics, brain function and anatomy, and the environment all come into play. In terms of genetics, ADHD commonly runs in families, so children with the condition have a ¼ chance that a biological parent has ADHD. Impaired function of the prefrontal cortex in the ADHD brain causes difficulties paying attention, a dopamine deficiency in the ADHD limbic system causes restlessness and emotional volatility, the basal ganglia regulates communication between different parts of the brain and is smaller in the ADHD brain, leading to inattention and impulsivity, and a dopamine deficiency in the reticular activating system causes the impulsivity and hyperactivity characteristic of ADHD. Finally, significant head injury or exposure to toxins in the environment has been implicated in the manifestation of ADHD.
This neurodevelopmental disorder also has a profound impact on the brain. There is impaired function of the prefrontal cortex, which controls attention, behavioral, and emotional responses. Thus, people with ADHD’s attention can switch quickly and easily. A deficiency of dopamine in the limbic system leads to restlessness, inattention, or emotional volatility. Similarly, a “short-circuit” in the basal ganglia in the ADHD brain causes inattention and impulsivity. Lastly, a dopamine deficiency in the reticular activating system, a primary relay system between different pathways in the brain, leads to impulsivity and hyperactivity. In that vein, a significant head injury or toxins and chemicals in the environment can contribute to the manifestation of ADHD.
Common signs and symptoms of ADHD are interrupting, trouble waiting for one’s turn, fidgeting, difficulty focusing, making careless errors, trouble staying organized, daydreaming, forgetfulness, and difficulty keeping emotions in check.
Treatment for ADHD centers around helping people stay concentrated and keep their emotions in check. The most common medication prescribed is stimulants, which help patients focus and ignore distractions. Additionally, behavioral therapy can help continue positive behaviors and eliminate unwanted ones while improving social skills and interpersonal relationships. Finally, people with ADHD are encouraged to create routines and schedules, minimize distractions, list goals, plan, and maintain a healthy lifestyle.
However, ADHD manifests in drastically different ways for young men versus young women, and the number of patients that are diagnosed with the disorder varies across gender. Girls’ symptoms are more ‘internal’ and subtle: being withdrawn, low self-esteem, anxiety, inattentiveness, daydreaming, verbal aggression like taunting and teasing others, intellectual impairment, and difficulty in school. On the other hand, boys’ symptoms are more ‘external’ and apparent: impulsivity, “acting out,” hyperactivity, difficulty focusing, inattentiveness, and physical aggression. Due to these differences in visibility of symptoms, boys are almost twice as likely to be diagnosed with ADHD than girls are with 12.9% of boys versus 5.6% of girls.
Thus, young women are often labeled as ‘problem children’ and blamed for their tendency to switch their attention and daydream. This can manifest in other mental conditions, such as anxiety and depression and in low self-esteem as a result of feeling ostracized and having difficulty with academic performance.
Diving into the underlying neural processes behind gender differences in ADHD, magnetic resonance imaging (MRI) studies show reductions in premotor cortex (controls basic motor functions) surface area in boys with ADHD and reductions in prefrontal cortex (controls decision making, behavior, social skills, and cognition) surface area in girls with the disorder.
However, as shown in Figure 1, the diagnostic criteria for ADHD are standardized across different demographics. DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) classification is divided into inattentive, hyperactive and impulsive, or combined. For a child to be diagnosed with ADHD, they must meet 6 or more symptom criteria that are not better accounted for by other psychiatric disorders, and their symptoms must persist for 6 or more months and affect 2 or more settings (e.g. school or home). Symptoms of the hyperactive and impulsive form of ADHD match well with those of boys who have the condition, but symptoms of the inattentive kind do not fully encompass what girls with ADHD experience. Dividing ADHD into three different types is a vital first step in accounting for differences in symptoms for men and women and bridging the gender gap in ADHD diagnosis, but diagnostic tests need to be developed to specifically target the ‘internal’ symptoms of ADHD young women have as they can be confused with another psychiatric disorder like anxiety or depression. Treatment of girls for ADHD should include psychotherapy to cope with anxiety, low self-esteem, and interpersonal relationships, outside of just medication to account for inattentiveness.
As someone who was only recently diagnosed with inattentive ADHD at age 17, I know firsthand how confusing and alienating navigating life with ADHD can be, and I understand how privileged I am to even receive a diagnosis.
Steps should be taken to raise awareness about the differences in the signs and symptoms of ADHD in boys versus girls and to destigmatize ADHD in young women, provide diagnostic testing that identifies the internal, less apparent symptoms of ADHD in young women, and increase support and treatment options for girls coping with difficulties with self-image, academic performance, and anxiety due to ADHD.
