Why Is It Challenging to Diagnose ADHD in Girls?
In my last article, ADHD: It’s Not Just a Guy Thing, I pointed out that conditions such as anxiety and depression can often mask or hide undiagnosed ADHD, especially in girls. What are some other reasons that girls with ADHD remain under the radar? In his article, Neuropsychiatric Differences Between Boys and Girls With ADHD, E. Mark Mahone, Ph. D suggests two additional factors that may be at play: gender bias in the wording of DSM IV criteria and maturational differences between boys and girls.
When a parent or teacher voices a concern about troublesome behaviors or lack of progress in school, clinicians turn to the Diagnostic and Statistical Manual of Mental Disorders for guidance in matching symptoms to a list of known identifiers for various mental health disorders. Dr. Mahone raises a concern about this practice when he states “One concern has been that the wording of DSM-IV diagnostic criteria for ADHD and the majority of rating scales are geared toward the manifestation of ADHD in boys”, For instance, he cites research that has shown that therapists, parents and teachers rate behaviors consistent with ADHD as more problematic in boys than in girls.
One hallmark of ADHD is a child’s propensity to being easily distracted. As a teacher, I was often tasked with tracking behavior and analyzing the data to see if a student was indeed able to attend to a task or lesson. I had to ask, what does distraction look like? How will I know if a child is paying attention? In some children, it’s obvious. They stop engaging in one task and pick up another. For example a child may stop solving the math problem and start talking to the kid next to him or take out a favorite toy and play with it. But what about those kids who are sitting still, looking at the teacher while she’s explaining a concept but they’ve mentally checked out of the lesson and into more pleasant thoughts? That’s pretty tough to observe and quantify. The proof will come later when they don’t know the content or understand what to do in the followup assignment. They’re labeled as low achievers or daydreamers. In my experience, the boys were more visibly distracted. I could spot it quickly, while the girls were the quiet dreamy type of distracted.
Noncompliance with instructions is another behavior to look for when diagnosing ADHD. As I said in my previous article, girls are more socially conditioned to please adults. This makes ADHD harder to spot. A young girl with ADHD may find ways to cope or cover up those lapses of attention and have to work harder to keep up with expectations. All the while, she’s internalizing those thoughts of inadequacy, guilt and shame.
A second diagnostic concern revolves around the maturational process. Dr. Mahone points out that boys take longer to develop self control skills than girls and are thus more likely to be diagnosed with ADHD when they’re young. When it comes to motor development, girls also mature earlier than boys so they’re not necessarily the ones who are bouncing off the walls in those early school years. It sounds like girls are sidestepping that window of opportunity for diagnosis, because they have already mastered some of those developmental milestones that the boys are still working on during those years from birth to 7.
Given our humble human condition that leads to often unintentional biases, coupled with gender differences, it’s important to take as much information as possible into consideration when identifying ADHD. This is a field that is always evolving as researchers are able to shed more light on the disorder. Our clinicians are tasked with sifting through the information to find the appropriate diagnosis. This is no simple task, given the complexities of the human mind and body. I think the medical and mental health community agrees that our girls deserve a closer look and more considered approach to diagnosis and treatment.
Suzanne Leon is a Certified Professional Coach who works with people affected by ADHD/ADD. Visit her website to learn more about the services she provides.
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