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Quiet Riot: Girls with ADHD Sit in Silence

The image of a boy running chaotically around a playground is what most parents expect to see with attention deficit hyperactivity disorder (ADHD). But that quiet girl daydreaming her way through class may also have the same problem, and the subtlety may cause it to go undiagnosed for years longer than her male counterpart.

The difference in how girls and boys with ADHD act causes a lot of confusion for parents trying to help their child achieve their best. So what should moms and dads be looking for if they suspect their little girl has ADHD?

Dr. Martin T. Stein, professor of pediatrics and director of Developmental Behavioral Pediatrics at the University of California, San Diego, describes how girls with ADHD typically act and the best ways teachers and parents can help them succeed.

Is ADHD more common in boys than girls?
By the criteria we use for the diagnosis of ADHD, for every girl with the diagnosis, at least three or four boys are also diagnosed. So, it's about a 3:1 or 4:1 ratio of boys to girls.

However, if you look at the ratio in those who are referred to a doctor by an outside group, like from a school or a church, the ratio is as high as 9:1 boy to girl. This difference is because the only children who are diagnosed in these environments have associated problems, such as conduct disorder, severe depression, anxiety or oppositional behavior. And, as you will see, boys with ADHD tend to have more of these associated problems.

Why do boys with ADHD tend to be noticed more often?
There are three subtypes of ADHD. One type is primarily identified by hyperactive impulsive behaviors. A second type is primarily identified by inattentive behaviors. Finally, the third type combines both groups: hyperactive impulsive and inattentive.

Most boys have a combined type of ADHD, where they have both hyperactive impulsive and inattentive symptoms. Additionally, they tend to have these symptoms for enough time to cause a functional impairment that leads to an easy diagnosis of ADHD. Many girls, on the other hand, are more likely to just have the inattentive form of ADHD.

So, do girls simply have a different set of symptoms than boys?
Boys have what people generally think of as ADHD. They're overactive. They're getting up all the time in class. They're fidgety. They're inattentive. Some of these behaviors, like touching and talking to other kids, create behavioral problems or disorder in the classroom. So, they're more likely to come to the attention of teachers and parents earlier on.

When do people tend to recognize the symptoms of ADHD in girls?
It is said that girls with ADHD who primarily have the inattentive type are likely to have a diagnosis several years later than boys. It could be as early as the third or fourth grade, when academic material increases in its level of difficulty. But in some cases, particularly when the child is a little brighter and has some strategies to get around it, girls are not diagnosed until junior high. Here, the levels of organization and classes that require greater sequencing, memory and organizational skills come into play, so that's when all these inattentive symptoms make learning—at least in traditional classroom settings—very difficult for many of the girls with inattentive ADHD.

Is it more likely that a girl with ADHD will go undiagnosed?
Yes. And if the child is underachieving, and a teacher or parent doesn't recognize the symptoms of inattention or ADHD, they might think it's a learning disability, but more commonly, they get a label of laziness.

How do these labels affect a young girl?
There are many potential outcomes to it. At the worst end, she goes through school and it's not diagnosed or attended to. The interesting thing is that these girls with inattentive ADHD will do well on standardized tests in some cases. So, parents and teachers recognize their ability, but since they're still underachieving in the classroom, they are called lazy, and it can affect self-esteem.

But these inattentive symptoms can also affect social interactions. Think about somebody who can't concentrate on social interchange and is less focused, not organized and barely getting to places on time. This can affect social interaction as well.

What should teachers be looking for if they suspect a girl has ADHD?
There are very specific symptoms for ADHD, which include poor concentration, easy distractibility, difficulty focusing on material, disorganization and forgetfulness. An example of this in school would be a girl who does the homework for class, but forgets to turn it in. At home, difficulty in organizing can be seen as a very disorganized room or it can be seen in school as not keeping a record of when assignments are due. All of these symptoms should be red flags to a teacher.

How would treatment differ in a girl with the inattentive type of ADHD?
There are really three treatment approaches to ADHD: education, behavioral management and medication.

First, a very clear education is important in helping the parent and the child understand what ADHD is. Here, we would talk about the myths of ADHD and remove misconceptions to give the family a clear understanding that this is a biological condition.

The next treatment strategy would be behavior management, where we make some environmental accommodations for the child. For the inattentive form, treatment probably consists of accommodations more than anything else.

What accommodations can be made in school and at home?
In the classroom, we may suggest that the child sit up front, closer to the teacher. Then, the teacher can keep the child on task, tap her shoulder periodically, make more eye contact, remind the child to write assignments down and make sure she hands in the homework. Also, giving assignments in smaller parcels is sometimes helpful. And it helps if parents go over the assignments when they are completed.

At home, these girls shouldn't be doing homework in a room with a lot of distraction: Led Zeppelin should not be on the stereo, the television shouldn't be on and computer games shouldn't be played. It should be quiet, fairly boring and without visual or auditory distractions. They shouldn't be doing homework in the kitchen or dining room when there are other kids around.

How do reward systems fit into behavioral management?
The basic behavioral management with ADHD is no different than with any behavioral condition in children and adults. The principles are rewarding good behavior, giving a lot of strokes and commendations when good behavior is occurring. Good behavior could mean just turning in your homework or getting a better grade than you did last week, completing assignments or getting a star from the teacher for that day or that week. But it is important to give lots of positive feedback when it's deserved.

It is important to not make a lot of negative feedback, especially for minor things. In other words, choose your areas of concern. Don't constantly be putting the child down.

It helps to set up some kind of a token economy, where you give rewards for good behavior or, in some cases, remove privileges for negative behaviors. But these all have to be very carefully organized so the child understands the contract, and so they can be used both in school and at home.

The Academy of Pediatrics recently published a very good book for parents on ADHD: ADHD: A Complete and Authoritative Guide. There are a couple of chapters there on suggestions for parents and teachers on behavior modification techniques.

Is the role of medications different for girls?
So far, there isn't strong evidence to support different practices for medications between boys and girls. Some individual clinicians feel that some medicines work better in girls than boys, but the scientific studies have not yet shown strong differences either in response to the medications or with regard to side effects.

Would you recommend trying behavioral therapies first before resorting to the medications or do you think they work best together?
Ideally, one or both treatment methods are used. I emphasize that both medications and behavior management have a strong evidence base to their effectiveness. Even if a parent chooses medication, I always encourage and teach the behavior modification.

Now, the behavioral management requires a lot of effort and learning on the part of the parents and teachers, so often someone to do this teaching is not available. Pediatricians, who see most of the children with ADHD, often don't have the time or training to really do very specific planning with behavior modification. We try to do some, but a child requires some real guidance and several sessions to set up an effective system. It takes a lot of time and most insurance companies will not pay for that.

What overall message do you have for parents concerned about ADHD?
I think many parents still feel that ADHD is primarily a condition of boys, because they see it as a disorder where there's a lot of hyperactivity and aggressive behavior. And it certainly does occur in girls, so I think the more teachers and parents are attuned to this, the more attention kids will get in treatment.

These kids are not bad people. They have lots of ability and talent, but they have this problem with inattention that's getting in the way of learning and social experiences.