Not Just The Boys: Why is ADHD Missed in Girls?

We don’t often think of girls when thinking of ADHD because of research bias and restrictive gender norms.

Girls have ADHD too, but they exhibit the symptoms differently and so tend to go undiagnosed.

(Photo: iStockphoto)

What are the words that pop in your head when you think attention deficit hyperactivity disorder (ADHD)?

Loud, disruptive, defiant, child…boy?

Ruksheda“That’s the typical image,” says Dr Ruksheda Syeda, a Mumbai-based psychiatrist and psychotherapist.

We don’t often think of girls when thinking of the neuro-developmental disorder. Besides our own internalised sexism, this is largely due to something that has finally come to light – research bias. A lancet report on gender norms highlighted the gender disparity in healthcare when gender biases seep into research and create healthcare inequalities.

Girls have ADHD too, but they exhibit the symptoms differently and so tend to go undiagnosed.

Stories of gender bias and the gender gap are springing out everywhere we look, as if finally unbound.

(This is part of an on-going series on #ResearchBias, click on the links below for the other part:)

Gender Gap: Why Are We Missing The Girls?

Girls with ADHD tend to be disorganised and can’t finish their work, and would often be labelled as “shabby”.(Photo: iStockphoto)

Recently, an article deriding a study that only used male mice to determine diagnoses and symptoms of diseases to be representative of all genders went viral. Why weren’t female rats used, came the justifiable angry question, since it was revealed that women and men exhibit symptoms differently.

Opening the can of worms that is gendered research bias, means exploring the many ways the gendered stereotypes seep into scientific research – from who is researched (men), to who the subjects are (men/male animals) to who the medicines are primarily decided for (still men).

Dr Syeda tells me, “The way disorders are studied, they are looked at from a male perspective. Not just with ADHD, even with heart attacks, women exhibit different symptoms” and so we have missing treating them because were looking for the wrong signs.

A 2013 study in the Indian Journal of Psychiatry revealed that 11.32% of children in India had ADHD, with 66.7% of those being boys and 33.3% being girls.

Boys are socialised to be more overt in their expressions, and so any signs of hyperactivity are noticed more easily. A boy jumping around or a girl lost in her thought may both have attention issues, but the girl would have channeled this inward even resulting in anxiety and depression.

Of course, this may not always be so cut and dry. “The ‘hyperactivity’ portion of ADHD gets seen and diagnosed most often, even in boys, says Dr Syeda.

ADHD has three components,

• Hyperactivity,
• Impulsivity
• Attention deficiency

But, ADHD is still largely seen as a hyperactivity-first issues, and “not every child with ADHD will have all the components, and typically a young girl would not present with a lot of external disruptive behaviour. She would possibly be disruptive in other, self-directed ways, with increased anxiety and inattention.”

“ADHD impairs the executive functioning of the brain, and this essentially controls everything that goes into completing a task – from organising your thought process, to deciding the order in which to do things to actually carrying them out.”

“So, they might pick up a stick to throw it and then half-way forget what they’re doing with a stick in their hand.”

Undiagnosed Girls and Self-Esteem Issues: “They Start Believing They Are Dumb”

With girls, they would be disorganised and can’t finish their work, and would often be labelled as “shabby”.

According to Healthline, the symptoms in girls include:

• Daydreaming
• Difficulties in completing tasks
• Making careless mistakes
• Having a messy bedroom, space
• Excessive talking and interrupting
• Anxiety
• Depression

Her internalised symptoms, coupled with straying from the gender norms of bring an organised girl, would lead to low-self esteem. Often girls mask their symptoms to conform, and berate themselves internally for not “having it together.”

“They start believing they are dumb” especially as it seems they can’t complete simple tasks for no reason. (But there is a reason, an uncontrollable condition and it is treatable!)

The problem of missing girls becomes even more pertinent as a devastating 2016 study reveals that girls with ADHD have severe mental health issues and “were three to four times more likely to attempt suicide and two to three times more likely to report injuring themselves.”

Additionally, Dr Syeda tells me that girls with ADHD often have peer-interaction issues, and “volatile friendships because they have an emotional disregulation. So they typically may not have friends and be seen as aggressive and have different moods” and be labelled as ‘moody’ or ‘weird’.

This would further plunge their self-esteem down the tunnel. “They might think they are forever creating issues,” says Dr Syeda.

“It is a lifetime disorder which presents differently at different ages, so it’s not just a hyperactive child.”

Dr Ruksheda Syeda

It could be a young adult who cannot find their career of choice and they keep moving from profession to profession because of changing interests. “They, whether they are male or female, might have trouble holding onto a job,” says Dr Syeda.

“A Girl Child is a Girl Child”- Societal Gender Biases Further Stigmatise Girls

Societal roles further stigmatise girls with the disorder, and Dr Seyda tells me that especially in a place like India, girls may not be given the attention and treatment they deserve.

So not only are the differing symptoms missed because of a lack of awareness (research gender bias), we aren’t looking hard enough at our girls for any signs of discomfort (societal gender bias).

“The attention and access to any kind of nutritional or health facilities for girls is below par to a boy child.”

“People will ask, ‘Will this affect her chances of getting married?’’ and we have to say that’s not what we are looking at for her as a child now. People feel if they can just make her get through basic studies and get her married off, it’s fine. So, even if there is a diagnosis there is no attention paid to its management.”

Usually, girls are diagnosed for their symptoms not ADHD directly, so they might come in for their depression and we may find an underlying cause of that being ADHD.

“A lot of people with ADHD have co-diagnosis,” and this is where it gets trickier. “Maybe only their depression/anxiety would get treated, often even doctors believe ADHD to be a child’s issue so they ignore those signs,” and thirdly, it is hard to disentangle mental illnesses like depression/anxiety from ADHD in how they present so it is hard to find out.

“I’ve seen cases, like one 22-year-old man who went to the psychiatrist to be told he can’t have ADHD as it is a child’s problem.”

Why Do Boys and Girls Present Differently?

Is it all just socialisation? Yes and no.

“There is a genetic reason, the sexes are born differently and their gene expression is different. Any illness, even a heart attack is presented differently and this isn't because of gender roles or social norms.”

So it may be harmful attributing this primarily to gendered social norms as we may miss out on biological differences and related symptoms.

A lot of ADHD symptoms, like daydreaming and attention issues, seem vague and applicable to almost everyone. “We look at the context to see if the issues clinically corelate, as unfortunately there are no bio-markers. Like how sadness is not depression, and we discover if it is really ADHD by putting the child in therapy and correcting their behaviour through play or yoga before we diagnosis it and perhaps prescribe medication.”

She adds, “It is also a highly individualised disorder, and while it is gendered, everyone presents differently.”

A lot of girls get diagnosed later in life and have a revelation - “They would say, ‘Oh, now I understand why I was like that earlier or why I reacted like that.”

“Thankfully, by the time they are older, they are better at managing life and functionality,” Dr Syeda concludes. Although a diagnosis, even a late one, is a sure relief.