‘Basically No One Believed Her’: How We’re Failing Girls With ADHD
Looking back, it’s tricky for Ohio mom Nina Weierman to pinpoint which of her own childhood behaviors were signs of ADHD, and which were simply symptoms of being a kid.
“I remember getting in trouble for talking or struggling to stop laughing” at school, Weierman told HuffPost.
But other, more significant issues arose as Weierman grew.
“By the third grade I noticed that I was struggling with things that didn’t seem to be too difficult for other kids,” she said. “I remember being in the library and just breaking down because I couldn’t figure out how to do the research assignment that was in front of me.”
By the time she was in fifth grade, reading had become a challenge.
“I just could not focus and would end up reading the same line over and over again. I remember laying on the floor in the classroom during quiet reading time just pretending to read,” Weierman said.
She continued to struggle throughout high school and into college, where she finally reached out for help. Medication, she says, was “life-changing.”
“I could suddenly think that I needed to do something and actually do it. I could comprehend reading and take good notes in class.”
In addition to helping her complete her coursework and graduate, Weierman says that the diagnosis brought her great relief.
“I was just so happy to have an answer,” she said. “It was eye-opening to realize that I wasn’t just stupid.”
Now, as a parent, “I would never want my kids to struggle through school the way that I did,” Weierman said.
She also wonders what direction her life might have taken and what careers she might have pursued if her ADHD had been diagnosed and treated earlier.
Weierman’s story is typical of girls whose ADHD is diagnosed relatively late in life. When she faced difficulty, she quietly pretended to stay on task rather than disrupt the class. By internalizing her struggles and meeting behavioral expectations, she effectively masked her symptoms for years — unintentionally preventing herself from getting the help that she needed.
In this way, girls with undiagnosed ADHD can end up being punished for their good behavior, struggling silently and alone.
Heidi Borst of North Carolina only realized that she had ADHD after her son received a diagnosis, writing in a New York Times essay, “I attributed my difficulties to character flaws: I was spacey and forgetful, a master procrastinator lacking drive and ambition.”
When Borst struggled in college, “I never imagined an underlying neurological disorder was at play,” she wrote.
While our understanding of ADHD has evolved in the years since Weierman and Borst were in elementary school, it’s still common for girls to face delays in diagnosis.
“It was eye-opening to realize that I wasn’t just stupid.”
– Nina Weierman, who was diagnosed with ADHD in adulthood
Jamie D., a mom in the Washington, D.C., area, told HuffPost that when her daughter, now 11, said she was having trouble paying attention in class, “basically no one believed her.”
“No one seemed to care because she was not disruptive and getting by in school,” said Jamie, who pushed for testing. The diagnosis led to therapy, medication and accommodations at school, all of which have brought about a “huge change.”
Jamie says her daughter is now “thriving” and “so much happier.”
Meg S., a mother of four in Pennsylvania, has been uniquely positioned to see the gender differences in ADHD diagnoses in her 8-year-old boy-girl twins.
While her son’s inattentiveness and other symptoms were noticeable in preschool and he was screened by his pediatrician and referred to a psychiatrist for evaluation, his twin sister is only now awaiting her own evaluation.
“They’ve acted the same in a doctor’s office, but my son has been pegged as inattentive or hyperactive — which he is,” Meg told HuffPost.
“I think I have even downplayed her symptoms over the years because my son’s symptoms seem to so clearly fit the picture society has in their head of ADHD,” she continued.
That picture — of the boy who can’t stay in his seat and keeps interrupting the class — predominates to such an extent that it can render invisible the girls who are similarly, yet often more quietly, struggling.
What is ADHD and how is it diagnosed?
Attention-deficit/hyperactivity disorder is “one of the most common neurodevelopmental disorders of childhood,” according to the Centers for Disease Control and Prevention. As the name suggests, children with ADHD may struggle with inattentiveness, impulsivity and/or hyperactivity.
The organization Children and Adults with Attention-Deficit/Hyperactivity Disorder estimates that 11% of school-aged children have ADHD and that in over 75% of cases, symptoms continue into adulthood.
Children with symptoms of ADHD may be screened by their pediatricians and then referred for a neuropsychological evaluation. Parents can also request an evaluation from their child’s school or district.
A neuropsychologist will meet with your child, talk with them, and have them perform a series of tasks that could be described as games or puzzles. The evaluator will also have you and your child’s teacher fill out questionnaires about your child’s behavior and may conduct a classroom visit to observe your child at school.
How do symptoms tend to differ between boys and girls?
There are three types of ADHD: 1) predominantly inattentive, 2) predominantly hyperactive-impulsive, and 3) combined presentation (a mix of 1 and 2).
It is more common for girls to be diagnosed with inattentive type ADHD, while boys are more often diagnosed with hyperactive-impulsive type or a combined presentation.
This difference often correlates with a delay in diagnosis for girls, whose symptoms tend to be less disruptive in a classroom setting.
“It’s very demoralizing to have ADHD and not know it. People are thinking you’re not making enough of an effort.”
– Dr. Helen Egger, child psychiatrist and chief medical officer of Little Otter
Dr. Helen Egger, a child psychiatrist and chief medical officer of Little Otter, a company that provides online mental health care to kids, told HuffPost, “the average is a nine-year-old boy who is a class clown, who’s not doing well academically, who is getting yelled at all the time at home.”
“And you talk to the parents, and they’re like, yeah, when he was 3, he was standing on top of the dresser and jumping into the crib.”
These are classic examples of hyperactive behavior, more often seen in boys, who are diagnosed with ADHD at twice the rate of girls, and at earlier ages.
Children with inattentive type ADHD — many of them girls, but boys, also — are often described as “daydreamers,” said Helen Egger, who has seen this as both a practitioner and a parent. Her daughter, Rebecca Egger, was diagnosed with ADHD around the eighth grade.
Children with hyperactive presentation are sometimes described as being driven by a motor that just won’t stop. But Rebecca Egger, who is now CEO and co-founder of Little Otter, says she wasn’t like that at all, describing her younger self as “quiet and sleepy.”
“I was always tired all the time. So how can I have a hyperactive disorder?” she said.
Looking back, however, that exhaustion made sense. “You’re constantly trying to make sure you don’t lose something, make sure that you’re on top of something . . . you’re constantly struggling. Everything is that much harder,” she said.
In children, explained Helen Egger, “the rate is boys to girls, two to one. In adulthood, it’s one to one. So why is that? Is that always ‘growing out of it’? Is it women getting diagnosed and recognized?”
Because parents and teachers are usually the ones making referrals, their own biases about who ‘seems’ to have ADHD behavior impact which children get screened. Then, because boys are more often screened and diagnosed, the diagnostic criteria were shaped to conform to a mostly male set of patients.
One study, which compared children who had been diagnosed to children who had a high level of symptoms but did not meet diagnostic criteria, found that the children’s parents underrated hyperactivity and impulsivity in girls and overrated it in boys.
This same study also found that while boys were more likely to exhibit disruptive behavior, girls were more likely to have internalizing symptoms such as anxiety and depression.
“Their minds are wandering, but they’ve sort of been conditioned to say, ‘I’m doing fine, and everything’s OK. I’m holding my stuff together.’”
– Dr. Janine Zee-Cheng
Dr. Janine Zee-Cheng, a pediatrician practicing in Indiana, says she finds herself often digging a little deeper with her questions before suspecting ADHD in a female patient.
She says she’ll see girls around 9 to 13 years old who “come in and they’ll be very anxious and they’ll have some feelings of school avoidance, and then after having some conversations with them, they’re like, ‘Oh, you know, I get distracted partway through a test.’”
“It’s not like they’re jumping out of their chairs, or they’re cutting off the teacher in the middle of a sentence, right? Because their minds are wandering, but they’ve sort of been conditioned to say, ‘I’m doing fine, and everything’s OK. I’m holding my stuff together.’”
Without further probing, such patients might be given a diagnosis of anxiety or depression — which they may also have — but then, the underlying ADHD goes untreated.
“We know that anxiety and depression very often co-occur with ADHD,” explained Helen Egger.
“Of course, we don’t know directionality. But it’s very demoralizing to have ADHD and not know it. People are thinking you’re not making enough of an effort. Or, ‘just try harder, you’re not applying yourself.’ That feeling of failing over and over again, when you’re trying your best, has a huge impact on self-esteem and self-efficacy,” said Helen Egger.
It’s possible that girls who are able to mask their ADHD symptoms with “good” behavior develop anxiety or depression from the strain of compensating for their ADHD.
What does an ADHD diagnosis mean?
Rebecca Egger had dealt with, and gotten therapy for, anxiety since earlier in her childhood, but it wasn’t until the end of middle school that she began to struggle academically and was given the ADHD diagnosis.
Helen Egger says that a gap between a child’s ability and performance is common in kids with ADHD. You know your child is smart, but you’re not seeing it in grades or test scores. These kids are sometimes called unmotivated or said to not live up to their potential.
“Try to understand what your child is experiencing before you interpret the child’s behaviors as lack of commitment,” she said.
“The thing about ADHD is it’s a neurodevelopmental disorder, which means it’s something that is the way your brain was wired,” she continued.
Medication, therapy and learning coping strategies can all help a person live successfully with ADHD, but there is nothing that can be done to “re-wire” their brains.
Some people with ADHD follow the example of others with autism who identify as “neurodivergent” and choose to see ADHD not as a disorder but as a difference that has its own benefits, such as the ability to hyper-focus on something they feel passionate about, or to think outside of the box.
Rebecca Egger recalls an organizational coach she worked with in high school telling her, “I love my job, because people with ADHD are so fun. That’s why I do this job, because you all are really fun and I like how your brains work.”
What’s the value of an ADHD diagnosis?
Practically speaking, you’ll use your child’s diagnosis to access therapy and medication using your health insurance. It will also give your child the right to have a 504 plan that will provide them with accommodations at school. Students diagnosed with ADHD often receive preferential seating (near the teacher) and testing accommodations such as extended time, separate location, and having the questions read aloud.
Of her son’s diagnosis, Meg S. said, “It’s opened all the doors to services he may need. A diagnosis is a means to an end, a description of an observed set of behaviors and needs.”
“Those words on paper allow all the adults in his life to help him the best way they know how to,” she continued.
The validation of having a diagnosis can also bring relief after a lifetime of struggle.
“I remember getting the report back after my testing and it was like, ‘Oh, my God, finally,’” said Rebecca Egger. “When you finally are able to put a name to it, it felt really liberating,” she said.