ADHD in Girls: Too Often Undetected and Undiagnosed

ADHD in girls may look like daydreaming

ADHD in girls often goes undetected and undiagnosed. In fact, boys are almost twice as likely to be diagnosed with ADHD than girls. That doesn’t mean that more boys are affected by attention deficit/hyperactivity disorder. Rather, ADHD in girls may go undetected, as girls tend to have fewer and less noticeable ADHD symptoms and behaviors than boys. Undiagnosed ADHD, meanwhile, can put girls—and women—at risk for developing depression, anxiety, and eating disorders. Testing is crucial for girls who struggle in school, as treatment can lead to a much brighter future for girls with ADHD.

We think of boys with ADHD as being loud and climbing the walls, but girls with ADHD may go quiet and spacy. This is because boys are more likely to have symptoms of hyperactivity and impulsivity. Girls, meanwhile, tend toward symptoms of inattention. Even when girls do have the hyperactivity/impulsivity behaviors of ADHD, it’s different. Girls with ADHD may just be more inclined to be energetic and talkative, rather than exhibiting the out-of-control, bouncing off the walls behavior of boys.

With boys, it’s all out there, easy to see. ADHD in girls, on the other hand, can escape detection. Parents may not think of their popular, social butterfly daughter as having a learning difficulty. This can lead to a delay in diagnosis or worse yet, no diagnosis at all—and no treatment.

ADHD is a bit of a wastebasket term. There’s the attention deficit side of the condition, which makes it difficult to focus and pay attention. And there’s the hyperactivity side of ADHD, which leads to impulsive behavior. Some kids one component, while others have a mixture of both sides of the ADHD coin: impulsivity and inattention.

ADHD in Girls can be Subtle

In girls, however, the symptoms can be subtle, explains Sam Goldstein, a school psychologist and pediatric neuropsychologist, and the founder and former editor in chief of the Journal of Attention Disorders, “Girls are less likely than boys to be diagnosed with ADHD because their symptoms often differ from the typical hyperactive and disruptive behaviors seen in boys. Girls are more likely to exhibit inattentive symptoms, which are less noticeable and usually go unrecognized in educational settings, leading to underdiagnosis or delayed diagnosis.”[1]

IEP and Special Education Consultant Shelley Kenow, says that in her opinion, girls are less likely to be diagnosed with ADHD because they tend to have the less obvious signs. “Girls will remain quiet, stay in their seat, and not act out so they don’t get noticed as much by the teachers or parents.”

Allison Paugh, a psychiatric mental health nurse practitioner (MSN, BSN) with ADHD Advisor, treats both children and adults with ADHD, makes the point that the symptoms of ADHD in girls are the opposite of ADHD symptoms in boys. “Boys often present as excessively hyperactive, loud, impulsivity, blurting out in class, fidgeting, restless, versus the girl’s presentation that is often more internalized (inattentive, quiet). Girls are often able to mask their symptoms, whereas hyperactivity, impulsivity is observable by teachers, parents and other peers.”

Do Fewer Girls Have ADHD?

Considering that underdiagnosis of ADHD in girls is now a known phenomenon, why does it remain a problem? More to the point—isn’t it just possible that fewer girls have ADHD? How can we know?

For one thing, says Dr. Goldstein, there’s a bias. Even experts are more likely to associate ADHD with boys. Also, a significant number of women are being diagnosed with the condition, which tells us they had it all along. “The statistics on the percentage of girls with ADHD are often underestimated due to diagnostic biases and the subtler presentation of symptoms in girls. Studies suggest that many girls remain undiagnosed or are diagnosed later in life, which challenges the accuracy of current prevalence data.”[2]

The place where ADHD is most likely to be noticed is in the classroom. But parents should not assume that if their daughter has ADHD, the teacher would know it. The teacher may not connect the subtle nature of ADHD symptoms, as they present in girls. It may be up to the parent to spot possible signs of ADHD to ensure their daughter receives testing.

What should parents be watching for? “Parents should suspect their daughters might have ADHD if they notice persistent issues with attention, organization, and memory, particularly if these problems impact academic performance or social relationships,” says Dr. Goldstein.
“Unlike boys, girls with ADHD may appear shy or withdrawn rather than disruptive, which can make the symptoms less obvious.”[3]

Toddlers can also be Impulsive

Some of the symptoms of ADHD, for instance impulsivity, may seem like normal behavior in a toddler. In ADHD, however, kids don’t grow out of these behaviors. Getting help is critical, even before the child ever reaches the classroom, especially when that child is a girl whose ADHD may go undetected, hence untreated.

Kenow says a child of 4 years who exhibits the following symptoms should be evaluated by a professional:

• Struggles to complete tasks
• Has trouble getting started on tasks
• Finds it difficult to focus
• Has difficulty weeding out unimportant information
• Fails to pay attention when spoken to
• Seems withdrawn
• Is impulsive
• Cries easily

“Many of these characteristics could be typical childhood behavior, but I believe it is never too early to be aware and seek assistance from professionals. I think it is better to be curious and wrong than not to be curious,” says Kenow. “I have heard parents say more times than I can count, ‘I wish I would have trusted my gut sooner.’”

ADHD in Girls: Internal Emotional Process

Goldstein adds that some of the signs of ADHD in girls are more about their internal emotional process, compared to the overt behaviors so typical of ADHD in boys. In addition to inattentiveness, difficulty organizing tasks, forgetfulness, and being easily distracted, “Girls may also experience internalized symptoms such as anxiety and low self-esteem, making ADHD harder to detect compared to boys, who often display more overt hyperactive behavior,”[4] says Goldstein.

Paugh suggests that while the core symptoms of ADHD are the same in girls as in boys (inattention, hyperactivity, and impulsivity); however, the way these symptoms present can look very different. “Very often, girls may be internally hyperactive: feeling ‘on the go’ in their mind; thinking about several things at once; and feeling impatient with a tedious task or conversation.”

ADHD in Girls—Common Symptoms

According to Paugh, here are how some of the most common symptoms of ADHD to watch for in girls:

• Reads ahead in class on an assigned novel, but then forgets to complete the questions (inattention)
• May become lost in thought (daydreaming)
• Able to sit quietly in class, but doodles instead of taking notes (fidgeting-hyperactive symptom)
• Acts like “Chatty Cathy,” always chatting with others in school and at home (hyperactive symptom)
• Extreme focus on things that interests them (hyperfocus)
• Extreme emotional dysregulation
• Blurting out a thought (impulsivity)

So let’s say you suspect your daughter has ADHD. What should you do? The experts agree: get a comprehensive evaluation from a pediatrician or mental health professional specializing in ADHD. “Early intervention is crucial,” says Goldstein, “and the review may include behavioral assessments, interviews, and possibly teacher input.”[5]

Teacher input is important, agrees Kenow, but not always reliable. “Reaching out to the child’s teacher can help parents get an understanding of their daughter in a different environment. Be wary of relying solely on the teacher, however, because ADHD in girls is often overlooked since girls tend not to be overly active and get into trouble.”

Kenow reminds us that the evaluation process is not cut and dried, especially because of the built-in bias that sometimes blinds even ADHD experts when it comes to girls.  “If the parent has visited the child’s pediatrician/primary care provider but the child was not diagnosed and the parent still feels in their gut something is amiss, seek out a neurologist or a neuropsychologist.”

Managing the Symptoms

Let’s say your daughter has already been diagnosed with ADHD. How can you, as her parent, help her to manage her symptoms? Goldstein offers a three-pronged approach. “Parents can help their daughters manage ADHD symptoms by establishing structured routines, breaking tasks into smaller steps, and providing consistent positive reinforcement,” says Goldstein.

“Additionally, working with schools to develop individualized education plans (IEPs) and seeking therapy, such as cognitive-behavioral therapy, can be beneficial.”[6]

Kenow says that knowing how to help children with ADHD is dependent on identifying exactly where the struggles lie. “For example, if the child has ADHD and it presents with being unable to follow multiple directions, the parent can break tasks into smaller steps and give a visual checklist for the child to complete. Many parents and teachers have told me they give one direction and the child can’t follow it. However, when I inquire further about the one direction it actually has many steps.

Break it Down

“When a parent says, ‘Clean your room,’ that sounds like one direction but in reality it is probably ten or more directions. There could be making the bed; folding clothes; hanging clothes; picking up toys; putting the toys in a proper place; putting the clothes in a proper place; deciding if clothes are clean or dirty and knowing where to place each; vacuuming; dusting, and on and on.

“Another example is if the child doesn’t appear to listen when spoken to. Parents can speak with fewer words and then ask the daughter to explain in her own words what she was just told,” says Kenow. “The parent should get to eye level with the child and tell her to look at the parent’s face or in the eyes. Oftentimes our children are distracted by what else is in the environment, so it’s important to clear out as many of those distractions as possible (i.e., pausing a game or TV; muting music; going into a quieter room; or going into a room with fewer things on the counter or wall).”

Paugh says parents should not underestimate the power of just letting their daughter know they’re ready to listen and help. “Parents should let them know that they are available to assist and listen to any challenges they’re experiencing. Talk openly, without criticism of symptoms that the parent is noticing that seem concerning, and then strategize with them to assist in accommodations (simpler instructions; repeating requests; making a white board with assigned task so they can self-reflect; and so forth),” says Paugh.

“Above all, empower girls to know that ADHD is a beautiful thing and never means that they are stupid or lazy. Help connect daughters with other girls that have ADHD to avoid alienation. ADHD should never be presented as a negative,” insists Paugh. “ADHD has many beautiful components (problem-solving, ability to hyperfocus, creativity), it’s just the areas that are causing issues that need some further assistance.”

Teachers Should Be Watchful

Because ADHD in girls so often goes unnoticed, teachers, every bit as much as parents, should be conscious of this fact, and let the parents know of any concerns they may have. “Teachers who suspect a female student has ADHD should document their observations and communicate their concerns to the student’s parents and school counselor,” says Goldstein. “Early collaboration is essential to ensure the student receives a proper assessment and any necessary accommodations in the classroom.”[7]

What services should be provided to girls with ADHD? And are our public schools doing enough for them? “Girls with ADHD benefit from services such as individualized education plans (IEPs), counseling, and classroom accommodations like extended test time or breaks,” says Goldstein, “However, public schools often fall short in recognizing and addressing the unique needs of girls with ADHD, as their symptoms can be less disruptive and more easily overlooked.”[8]

Do They Grow Out of it?

So, assuming you—and the experts—figure out that your daughter has ADHD, and you’re making sure she gets all the supports and help she needs, what does the future hold? Do girls “age out” of ADHD? The answer, as you might have suspected, is no.

“A person does not ever ‘age out’ of ADHD,” says Paugh. “However, symptoms may become more manageable as girls mature, especially if they have been given strategies and coping techniques to assist in earlier years.”

No, agrees Kenow. Learning how to manage symptoms early can make all the difference. Then too, there is medication. But children don’t grow out of ADHD, whether they are boys or girls.    “They may learn ways to manage their symptoms through strategies and/or medicine,” says Kenow, “but once a person is diagnosed with ADHD, it never goes away.”

Lifelong Condition

Goldstein concurs, but adds that supports and strategies to manage the condition continue to be important into adulthood. “ADHD is a lifelong condition, and while some girls may experience a reduction in symptoms as they age, many continue to struggle with attention and executive function issues into adulthood. It’s crucial for ongoing support and strategies to be in place to help manage symptoms throughout life.”[9]

It’s critical to diagnose and treat ADHD in girls while they are still young. Early diagnosis and treatment of ADHD in girls is essential for fostering positive outcomes in their personal and professional lives as they age. Untreated ADHD can make it difficult to maintain long-term relationships and achieve career success. This often results in self-blame and diminished self-esteem for those women unfortunate enough to go through life with undetected ADHD. By recognizing and addressing ADHD early on, we can help empower girls to thrive, ensuring they have the tools and support necessary to navigate life’s complexities with confidence.

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[1] Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Psychiatry Research. Retrieved from https://www.sciencedirect.com/science/article/pii/S0165178118317347.

[2] Martin, J. (2024). Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry. Retrieved from https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00010-5/fulltext.

[3] Derks, E. M., Hudziak, J. J., & Boomsma, D. I. (2007). Why more boys than girls with ADHD receive treatment: A study of Dutch twins. Twin Research and Human Genetics. Retrieved from https://www.cambridge.org/core/journals/twin-research-and-human-genetics/article/why-more-boys-than-girls-with-adhd-receive-treatment-a-study-of-dutch-twins/E9145B8BE604F2D746898799B4AC61A6

[4] Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Psychiatry Research. Retrieved from https://www.sciencedirect.com/science/article/pii/S0165178118317347.

[5] Martin, J. (2024). Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry. Retrieved from https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00010-5/fulltext.

[6] Derks, E. M., Hudziak, J. J., & Boomsma, D. I. (2007). Why more boys than girls with ADHD receive treatment: A study of Dutch twins. Twin Research and Human Genetics. Retrieved from https://www.cambridge.org/core/journals/twin-research-and-human-genetics/article/why-more-boys-than-girls-with-adhd-receive-treatment-a-study-of-dutch-twins/E9145B8BE604F2D746898799B4AC61A6.

[7] Martin, J. (2024). Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry. Retrieved from https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(24)00010-5/fulltext.

[8] Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Psychiatry Research. Retrieved from https://www.sciencedirect.com/science/article/pii/S0165178118317347.

[9] Derks, E. M., Hudziak, J. J., & Boomsma, D. I. (2007). Why more boys than girls with ADHD receive treatment: A study of Dutch twins. Twin Research and Human Genetics. Retrieved from https://www.cambridge.org/core/journals/twin-research-and-human-genetics/article/why-more-boys-than-girls-with-adhd-receive-treatment-a-study-of-dutch-twins/E9145B8BE604F2D746898799B4AC61A6.