Time to get beyond the myths about attention deficit hyperactivity disorder

Children with ADHD need a lot of support but girls with symptoms can fly under the radar, writes Andrea Mara

THERE are many myths about attention deficit hyperactivity disorder (ADHD) — that it’s always synonymous with “hyper”, that it’s a new-fangled label for “bold” and that it only affects boys.

In fact, girls may be just as likely to have ADHD — it just doesn’t look the same as it does in boys. That’s according to Dr Ellen Littman, a New York-based clinical psychologist who recently travelled to Dublin to deliver a keynote address at HADD ADHD-Ireland’s “ADHD, Girls, and Women” event.

ADHD affects around one in 20 children, and it’s genetic, so while treatable, it doesn’t just go away.

“Children with ADHD are born with it,” explains Stephanie Mahony, co-founder of HADD-ADHD Ireland. “Kids can present as restless, uncomfortable, and in some case poor sleepers — particularly as babies.”

Unfortunately, it can cause problems for them at school, says Mahony.

“People may not want to mix with them because they can be disruptive. They’re in their own heads and they don’t know what’s going on. Their concentration levels can be very varied and they don’t like sitting still for too long.”

So is ADHD a new phenomenon?

“No,” says Mahony, “It’s been around since time began, but in the past, children were termed ‘naughty’ or ‘bold’.” And indeed, the child with ADHD is always the one in trouble she says.

“They might be the one to hit another child or take their pencil. They’ve no filter, they can’t see that what they’re doing is not appropriate. They’re a lot of work and need an
awful lot of support from everyone in their lives.”

In this country, according to statistics from HADD ADHD-Ireland, there’s a 4:1 boy: girl ratio for ADHD diagnosis in childhood. So is it a predominantly male disorder?

Dr Littman, co-author of Understanding Girls with ADHD, doesn’t believe it is. She points out that in adult clinics, where men and women can self-refer, the ratio is closer to 1:1. So why don’t we know about girls with ADHD?

It’s because ADHD symptoms present differently in girls, says Dr Littman.

“For boys, it’s more behaviour-based and externalised — how their behaviours impact others — and that’s how it’s always been looked at. For girls, it’s about an inner sense of impairment — but no-one is really measuring that, because girls internalise their experience.”

She points out that hyperactive and impulsive behaviours are more easily observable, but don’t always present with girls.

“Relatively new research shows that for girls there’s a tremendous hormonal involvement in how their symptoms are expressed. The way ADHD has been measured until recently, children had to have observable symptoms by age seven to be diagnosed.

“Girls may have symptoms but they’re under the radar until oestrogen starts coursing through their bodies and that doesn’t happen until puberty. Doing a history with parents who say ‘She didn’t have any symptoms until age 15’, [the clinician] will say ‘Oh well, that can’t be ADHD’.”

Socio-cultural factors also have an impact. “For girls, gender role expectations are a huge piece of how they define themselves whereas that’s a relatively small issue for males,” says Dr Littman.

“Socio-culturally, the demands for the feminine ideal require perfect choreography of the executive functions, so that you can be a good listener, empathetic, a good caretaker, cooperative, and have good social skills.

These are all things that the ADHD brain is not well-wired for, so they end up having a lot of gender atypical behaviours like being messy or interrupting or competitive or forgetful or not remembering things that are going on in other girls’ lives — and these things alienate other girls.”

Peer relationships are very important and there are social consequences for not being gender-typical, explains Dr Littman.

“There’s a tremendous amount of rejection and girls feel confused and inadequate, and if they don’t know they have ADHD they tend to attribute this to character flaws, so there’s a lot of shame. Shame isn’t an official symptom of ADD but for girls it’s probably the number one symptom.”

So what should parents do if they suspect their daughter has ADHD?

“Find a clinician who is experienced in treating girls with ADHD,” Dr Littman’s advises.

“Because if they only know what a hyperactive boy looks like, they’re going to think it’s not ADHD. Everyone in the family needs psycho-education to give them the big picture of this
disorder, instead of the narrow picture of distractibility and concentration.

“Parents need to learn the best way to support the girl’s self-esteem, and to make her life more predictable We need to train girls to advocate for themselves, for example, to ask for more time on tests or to say, ‘I didn’t understand, can you tell me again?’ They feel so much shame, and they don’t ask for help.”

* SeeHADD.ie for more information on ADHD Month and on services provided by HADD ADHD-Ireland

Commons signs of ADHD 

According to Dr Littman, girls with ADHD may experience the following:

* Emotional dis-regulation — hyper-reactive, likely to burst into tears or scream at someone, to be enraged and nobody sees it coming.

* Hyper sensitivity issues — complaints about headaches, stomach aches, nausea. A lot of girls start every day this way, not even aware they’re dreading going to school and being called on in class.

* There’s a huge correlation with eating disorders especially bulimia and binge eating, so there are struggles with weight which affects self-esteem.

* A lot of these girls are rejection sensitive, they tend to isolate themselves — they won’t want to go to situations where will feel left out.

* Girls may turn to perfectionism as a way of trying to control things.


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