Teenage Girls with ADHD

Suffering in Silence

Nature has not always been a woman’s best friend and during the teenage years the hurdles that have to be negotiated and overcome by young women are invariably challenging, overwhelming, frightening, demoralising and seemingly unsurpassable, even for the most adept and well-functioning  adolescent. When Attention Deficit Hyperactivity Disorder (ADHD) is added to the mix, the result can be a downward spiral and a self-destructive experience.

Diagnosis of ADHD in adolescent girls

An early diagnosis and treatment of ADHD is very important as it will lead to better cognitive, academic, social and psychological functioning in subsequent years (Weiss et al, 1985) it therefore becomes crucial that at least by early adolescence those suffering from this condition will have been correctly identified and receiving treatment. However many adolescent girls with ADHD go undiagnosed or misdiagnosed for a number of reasons.

Girls with ADHD often behave very different to boys, falling into the much harder to diagnose ADHD category of “predominantly inattentive type” (DSM-IV, 1994). The diagnostic approach for ADHD is biased in favour of disruptive behaviour and male gender and girls with inattentive symptoms but no conduct problems are more likely to be thought of as learning disabled rather than ADHD (Hinshaw, 2002).

Many teenage girls with ADHD go undiagnosed or misdiagnosed for a number of reasons.

• Girls may work harder to hide their academic difficulties to conform to teenage expectations

• Girls are misdiagnosed as depressed

• Girls who are intelligent are able to compensate for their ADHD symptoms particularly in Primary School and are more likely for a later diagnosis

The ratio of boys with ADHD to girls with ADHD is 6:1 to 12:1 in clinic samples, 3:1 in community samples and recent studies suggest it may be equal if the inattentive subtype is considered (Gaub & Carlson, 1997). However, when girls suspected of having ADHD are referred for diagnosis and treatment they are often much older and they have deteriorated so much that their presentation is similar to that of very disturbed hyperactive boys.

Girls of with Inattentive type ADHD daydream more, appear passive and academically withdrawn, are shy, timid and easily overwhelmed. They rarely act out, they may have difficulty verbalising their thoughts and feelings, they can be easily discouraged and they may appear as “sluggish” and lethargic.

These girls are often more conscientious and guilt-ridden and they work harder in order to hide their academic difficulties and to conform to their teachers’ and parents’ expectations.

They come to the attention of mental health services later than boys and they are more likely to be diagnosed as anxious and/or depressed (Biederman et al, 1994).

Those girls who are particularly bright, resourceful, better adjusted psychologically and with a nurturing, supportive, encouraging and facilitating family and school environment (“scaffolding”) are able to mask and compensate for their ADHD symptoms for much longer and they are therefore more likely to receive a late diagnosis, if they do.

A girl’s inattentive-subtype ADHD that has not been recognised as such during early years is no less real when it raises its head during adolescence, a time when the demands for planning, organisation, recall, and focus become intense, sometimes accompanied by severe behaviour disturbance.  

It is ironic that factors such as a high IQ, obsessive and perfectionistic symptoms to do well in school, absence of learning difficulties, a good temperament, a stable psychosocial environment and hard working habits can work against them in being not recognised early enough for being dysfunctional and impaired.

Despite numerous discussions for a need to have gender-based diagnostic criteria for ADHD, mental health professionals continue to rely on behaviour criteria that better identify disruptive boys.

The challenges faced by adolescent girls with ADHD

Although many of the issues below also present challenges for girls without ADHD, these seem to be more common, frequent and severe among girls who are confronted with the double challenge of adolescence and ADHD.

Girls with ADHD begin to experience social deficits as early as preschool years (Greene et al, 2001) and these have their greatest impact during adolescence when girls begin the psychologically separation from their family (much harder for girls than boys). This is when social life, status within peer group and forming early intimate relationships acquire a much greater importance. Many women with ADHD often recall feeling “different” from the other girls when growing up and being marginalised by their peer group. The need to overcome this apparent “difference” and to be accepted by the peer group during the teenage years is intense and in an effort to “belong” it may lead to dangerous or self-destructive behaviour.

Understanding, acceptance and support by the family is crucial but it can do little to compensate for the damaging feelings of non-belonging and rejection experienced by the all-important peer group during adolescence. The low self-esteem feelings that girls with ADHD experience as a result are disturbing, unsettling and often haunt them for years to come.

Inability to meet social expectations

Identity confusion, self-doubt, anxiety, uncertainty about the future and insecurity about one’s core values are endemic in adolescence. However, the special challenges girls with ADHD face greatly intensify these feelings. Society in general and families in particular have already drawn a “script” for what they expect of their sons and daughters. For girls, the demands are greater than for boys and they come sooner. For example, girls are encouraged to be neat, “feminine” (controlled and passive), lady-like (emulate older female role models), carefully groomed (in order to be attractive to the opposite sex), sensitive to the feelings of others (preparation for motherhood) and obedient and compliant with adults (submissive). These very expectations are very often the direct opposites of those tendencies natural to many girls with ADHD.

Many adolescent girls with ADHD anxiously comply with these expectations sometimes obsessively, to these expectations in an attempt to gain some acceptance and respect from their family and teachers so as to compensate for the disappointments they experience in their peer group. They may try hard to be fashionable and well dressed. However they often let themselves down by their inability to organise their rooms and life so as to have and be able to find in the chaos of their room clean and colour-coordinated clothes on school mornings and so as to avoid the sneers and caustic remarks coming from their peers. 

In addition their ability to understand social cues and meet the demands of social conventions appears to lack both focus and timing. Janet Giler in her paper in 2000 identifies specific problems in five areas.  They are:  1- appearing uninterested because of poor listening skills; 2- displaying poor management or expression of anger or moods; 3- bragging or being outspoken and appearing self-involved; 4-forgetting appointments or being late; and 5-failing to show interest by NOT remembering or checking with their friends about their feelings, relationships or reactions to events that have occurred in their friend’s life.

Although all of these are important probably the issue of poor listening skills is crucial. Listening requires taking the time to let the other person be the centre of attention by focusing on the topic however girls with ADHD want to interrupt or change the topic and tell how they were affected or reminded of an experience they had. Unfortunately, changing the topic or telling personal associations with the topic, makes the female with ADHD the centre of the conversation.  This can often be perceived this as selfish, self-centered, or just uninterested.  

In addition failure to filter thoughts and being impulsive about someone else’s flaws or being over complimentary about their own abilities looks or interests can also cause a range of socialisation difficulties.

Emotional reactivity and hormonal fluctuations

Most adolescents are “jumpy” but the typical hyper-reactivity of ADHD increases during adolescence as hormonal fluctuations complicate and escalate behaviour. The self-doubts, competitiveness, abruptness and irritability so common among adolescent girls are often more intense for girls with ADHD. They get much more easily hurt and these painful feelings can rapidly escalate into impulsive remarks, verbal or physical over-reactions. However, as soon as the drama is over and the curtain has fallen, they are often ready to forgive and forget. Following the storm, they behave as if nothing has happened and they are surprised and bewildered when those they have stung with their comments remain bruised and intolerant of further temper explosions.

Depression

The pressure to conform to the peer group’s unwritten and constantly shifting rules and expectations can become the driving force and raison d’être for an adolescent girl. An enormous and disproportionate amount of energy that stuns parents is spent on analysing and scrutinising their peers: they watch, they comment, they gossip, they compare, they imitate, they identify, they conform or they criticise. But whereas in normal adolescent girls this is a phase they are able to negotiate, it causes deep despair and despondency in adolescent girls with ADHD.

Anxiety and depression are common in women with ADHD, often beginning during the pressure years of adolescence. Such depression is much easier to identify and many adolescent girls and women with ADHD find themselves treated for depression while their ADHD goes unrecognised (Kessler et al, 2006).

Pressures to “mature”

Adolescents have fallen victim to the widespread and commonly held adult view and belief that adolescence is a transient stage not to be enjoyed in its own right but as a passage that prepares them for adulthood. The pressure to “grow up” and become “responsible” precedes adolescence and increases dramatically during time.  

The incompatibility of secondary school and ADHD

As if social pressures were not enough, the academic pressures reach a climax in secondary school.

The mass education of the secondary school system seems designed to be ADHD-unfriendly. The day starts too early, it lasts too long and it demands that students find their way around a large, often complex maze of corridors and staircases in order to get on time to their various classrooms. The expectations to focus, concentrate, be organised and proactive, and by far exceed the capacity of most students, even those without ADHD.

As if that was not enough, students with ADHD are put in the position of being forced to read and study subjects that hold little or no interest for them and they will probably be strongly advised against doing any of them once they have moved on from secondary school.

Sexual risks

Impulsivity, restricted thinking of consequences and the need to belong may steer adolescent girls with ADHD in the direction of early sexual relationships and a greater risk for an unwanted pregnancies than other adolescent girls (Arnold, 1996). They struggle with chronic low self-esteem and the need to belong to their peer group and so they may seek affirmation through the sexual attentions of boys in an effort to compensate for feelings of inadequacy in other areas of their lives. Because of their difficulties with impulse control, planning ability and inconsistency, many of these girls are prone to have unprotected sex, use birth control inconsistently, have multiple partners and are at an increased risk of sexually transmitted illnesses.  

ADHD and driving

Studies of adolescents with ADHD have shown that they have a greater likelihood of being involved in traffic accidents (Snyder, JM, 2002). Most studies have only examined the driving behaviour of boys with ADHD, but two studies in New Zealand (Nada-Raja et al, 1997) and subsequently (Woodward et al, 2000) looked at both boys and girls and found that girls with attentional difficulties were equally at a high risk for both traffic accidents and driving offences.

Risk for substance abuse and addictive behaviours

Experimentation with alcohol, nicotine and substances begins earlier in young people with ADHD and adolescent girls are no exception. 60% of adolescents with ADHD will have used illicit substances by the age of 14 years compared to 17 years for controls, 15% of adolescent girls with ADHD already have a substance use disorder (SUD) and one in five smokes cigarettes (Biederman et al, 1999). What is more frightening is that it takes 6 years for 50% of teenagers without ADHD  to remit from substance abuse compared to 12 years for ADHD patients (Wilens et al, 1998).

How Parents and Professionals Can Help 

Watch out for the emotional roller coaster

The intensity of feelings and reactions so often seen in adolescent girls with ADHD has a neurobiological basis; their reactions tend to be even more extreme at times of stress, fatigue, hunger, sleeplessness or premenstrual symptoms (PMS). The adolescent girl, her parents and her teachers need to recognise the additional vulnerability that she has and to begin to identify and manage the potential stresses that can worsen her reactions.

Treatment begins with the diagnosis. Medication and psychotherapy used together seem to be the most effective treatment. Stimulants are the treatment of choice and their response rate of girls is similar to that of boys. Appetite suppression may not lead to weight loss and if the girl is pregnant, stimulants should be avoided.

 Medication regimes often need to address a complex set of issues, including anxiety and/or depression, rather than ADHD alone but some medications for mood disorders may interfere with attention.

Relationships with peers and issues of self-image and self-worth are so dominant among most adolescent girls with ADHD that psychotherapy needs to be specifically aimed at addressing these. Group psychotherapy can be very supportive and effective because the group also serves as a platform for sharing experiences and coping strategies with like-minded adolescents. Such a group could take place in school by a school counsellor, or in a community mental health service.

Many mothers can be hypercritical of their daughters with ADHD through lack of knowledge of their condition. These mother-daughter relationship issues need to be thoroughly addressed and clarified either in formal or informal therapy sessions and discussions.

Treat Premenstrual Syndrome (PMS)

Premenstrual Syndrome PMS or PMT or Premenstrual tension particularly affects teenage girls with ADHD.

The tremendous hormonal changes and fluctuations during the menstrual cycle intensify and complicate the confusion and unpredictability that are associated with growing up with ADHD. While PMS may bring annoyance, irritability, fatigue, or cramping for many adolescent girls, those with ADHD may also feel such an increase in the intensity of their emotional reactions, bad temper, and low frustration tolerance that they require immediate and active intervention.

All those involved in managing adolescent girls with ADHD should be aware of this additional vulnerability and keep up-to-date on research on PMS and new treatment approaches for decreasing its impact. Premenstrual symptoms are worse the period and although selective serotonin re-uptake inhibitors are well known to control PMS, more recent research suggests a number of other to ways to reduce PMS symptoms in the more vulnerable ADHD population (Rapkin & Winer, 2008).

Reduce the risk of anxiety and depression

Emotion can quickly and easily fire up and get out of control when everything appears too much and environmental stressors suddenly overwhelm the adolescent girl’s already strained psychological system and self control. The break-up of a relationship, a failed exam, a rejection letter from a university or prospective employment, an accidental pregnancy, any of these may be enough to push her into depths of anxiety or depression that may require both medication and psychotherapy.

 Parents and professionals need to be vigilant during the teenage years in order to assess whether the “normal” emotional roller coaster for their adolescent with ADHD has gone over the edge and developed into a severe level of anxiety or depression that requires treatment in its own right in addition to her treatment for ADHD. Because stimulant medication for ADHD may tend to increase anxiety, a small dose of an antidepressant may effectively counteract anxiety and also treat depressive symptoms.

Reduce sexual risks

Support groups specifically designed for adolescent girls with ADHD can help them feel more accepted and less alone without having to seek male sexual attention.

Helping teenage girls with ADHD become engaged in structured, constructive and rewarding activities will help them channel their energy, increase their confidence and help them improve their sense of self-worth. Recent studies confirm what we have always known, that those adolescents who are kept out of harm’s way, busy with extracurricular activities, sports, etc. are less likely to get in trouble during high school (Guindon, ed. 2009).

Last but not least, an open, genuine, trusting, honest and supportive relationship with their parents gives them somewhere to turn to for advice if they become sexually active, either to help them make a sensible choice of birth control or to help them make the best decision they can should they become accidentally pregnant.

Reduce the risks associated with ADHD and driving

An increasing number of young women take their driving lessons earlier than before. Parents of daughters with ADHD but also their instructors need to impress upon them that they may require more practice in driving so that their driving skills can become better embedded and more automatic, requiring less concentrated effort and attention.

Since attention problems are often strongly involved in traffic accidents, young people with ADHD should take care to drive in less distracting situations during their first years as drivers. They should avoid heavy traffic, social distractions, such as excited, talkative peers, develop a more conscious awareness of their need to “keep their eyes on the road” and certainly they should not drink, smoke cannabis or take other illicit drugs while driving.

Even in adulthood, individuals with ADHD may find themselves distracted by conversation while driving as well as the issue of mobile phones and background music.

Situations that may lead to impulsive reactions, such as driving with peers who have been drinking and who may encourage an adolescent girl with ADHD to take a ride with them “for fun” should be discussed in advance and avoided, if possible.

Recognise and embrace their strengths

Girls who have developed an ability or talent in some area are better protected from the clouds of self-defeating gloom. One of the most constructive approaches in helping adolescent girls with ADHD through their high school years is to actively help them recognise and develop areas of competence and talent. The more they are in touch with their areas of competence the less vulnerable they will be to criticisms and frustrations.

There are many arenas in which they can show their abilities and develop competence: part-time work after school, voluntary work and taking part in community projects that can all be enormously beneficial in helping them build a sense of self-confidence.

Help them learn assertiveness and self-advocacy

It is during the secondary school years when adolescents develop the skills necessary not only to survive the jungle of peer relationships but also those needed for a more independent life beyond school.

They will need to know well and be able to express their needs with confidence and convincingly to academic staff or prospective employers who are likely to be either uninformed or poorly informed about ADHD.

The need for and benefits of structure

Adolescent girls but particularly those with ADHD need structure, support and encouragement in order to maintain some order in their lives. Because of their quest for independence and separation from their parents, it is probably wiser if someone else other than their parents provides this structure. This can be a therapist, a coach, a school guidance counsellor or a trusting relative. Learning to be on time, developing strategies to improve their organisation, setting priorities and being proactive rather than staying in a reactive mode, must be seen for their benefit and not as something imposed by their parents.

Conclusion

The teenage years are especially challenging for adolescent girls with ADHD. To meet these challenges, they need understanding and support from their peers, their parents and schools combined with appropriate medical and psychological treatment, depending on their particular needs and issues. With the right supports and interventions, they can make the crucial transition from the confusion and self-doubt of adolescence to a sense of growing strength, self esteem and competence as they enter their young adult years. 

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