Hello and welcome to the podcast series “Moving Forward with ADHD” for the 2023 ADHD Awareness Month. We are Karen Sampson Hoffman of CHADD and Roxanne Fouché of the ADHD Coaches Organization. We are thrilled to invite you on a journey of understanding, insight, and empowerment during ADHD Awareness Month in October and all through the year.
Throughout this series, we’ll be delving deep into the world of ADHD – a condition that affects countless lives around the globe. From its challenges to its strengths, we’re here to explore every facet of ADHD.
Through these episodes produced by the ADHD Awareness Coalition of CHADD, ACO, and ADDA, our goal is to raise awareness, provide support, and foster a sense of community for individuals living with ADHD, their loved ones, and anyone interested in learning more.
We encourage you, our wonderful listeners, to actively engage with us. Reach out to us through our website, ADHDAwarenessMonth.org, or on any of our social media to share your questions, experiences, and thoughts.
So, tune in and get ready to embark on this journey of awareness and compassion. Our podcast series is here to remind us that moving forward as a community and individuals who have ADHD is more than just receiving a diagnosis—it’s a unique lens through which the world can be seen in vibrant, extraordinary ways.
Thank you for joining us.
Understanding Girls and Women with ADHD
Our podcast today features Ellen B. Littman, a clinical psychologist who has specialized in working with those with neurodiverse brains for over 30 years. Described by the American Psychological Association as “a pioneer in the identification of gender differences in ADHD,” Dr. Littman has extensive experience with issues affecting neurodiverse women and girls. You may know of Dr. Littman from her book Understanding Girls with ADHD, first published in 1999, with a second edition published in 2015.
Our podcast today originally aired as an “Ask the Expert” webinar hosted by CHADD’s National Resource Center on ADHD and is shared by permission from CHADD.
Thank you, Dr. Littman, for being here with us to discuss ADHD in woman and girls. Let’s begin with the fact that girls tend to be underdiagnosed with ADHD. Why is that?
Clinics report that women are being diagnosed more often than girls. In fact, in clinics it’s one to one, men to women—and women self-refer. But the ratio of boys to girls being diagnosed in clinics is still about four to one. So that means that we’re still missing a lot of girls, and that’s obviously a problem.
And here are some of the reasons why
ADHD is a product of its history. In the beginning of the last century, parents were struggling to manage hyperactive, impulsive children. Unmanageable girls in the Victorian age were a source of shame, and they were not taken to clinic. And predominantly young white boys were referred to clinic. Studies analyzed this clinic data, and the diagnostic criteria based on this research is what’s in the Diagnostic and Statistical Manual that we use to diagnose ADHD.
But, it described really hyperactive young boys, so our knowledge of girls with ADHD was based on the girls who looked most like hyperactive boys since they were the only ones who could be diagnosed. Even today’s research includes only those diagnosed by the recent criteria, which is still based on symptoms that are easily observed and categorized, and many rating scales are still skewed towards activity level and observable symptoms. We really need self-report scales to get a good sense of one’s internalized symptoms. And research suggests that there is still a bias, meaning that the more inattentive girls are less disruptive and so are less likely to be referred.
And as a result, girls are still significantly underrepresented in the literature. They are about two percent of the focus of ADHD research, even though they’re fifty percent of the population. It’s a pretty scary statistic. And today for many people, ADHD still means hyperactivity or learning problems. They aren’t thinking about what an inattentive girl might look like.
It seems that girls have a different experience with ADHD than boys tend to have. Can you share with us why that may be?
There are some unique factors that makes most girls’ experiences with ADHD completely different from most boys. And the first one is really not well known at all—
The Importance of Estrogen
Estrogen is a hormone that affects cognition, and mood, and sleep. And the brain is one of the target organs for it. And the symptoms that girls experience—they really blossom—when estrogen starts coming into their systems. They appear less symptomatic in elementary school, and as they approach puberty, you see more and more ADHD symptoms.
But up until about a year and a half ago, the diagnosis had an age seven cut off criteria. If you didn’t show symptoms by age seven, you wouldn’t be diagnosed. Most girls did not show symptoms that early, and hence could not be diagnosed. Whereas boys’ symptoms tend to decrease towards puberty and they become sort of less hyperactive—not that all boys are hyperactive—girls’ symptoms just start really blossoming around puberty and by ages fifteen, sixteen you really start seeing the symptoms.
It’s still very hard to receive a diagnosis for women. Even with the recent age changes, the cut off has been changed to age twelve, they still eliminate a lot of girls. This especially includes the ones who compensate the best, which is not to say that they suffer the least.
There’s greater emotional reactivity when estrogen is low. When you have fluctuating levels, as all females do throughout the month and during the PMS week when it’s very low, it wreaks havoc with their ability to self-regulate. They look highly symptomatic and very moody. This is something that most people are not aware of and it’s a huge piece of the picture of ADHD symptoms for girls, but obviously not for boys.
In addition, there is the general likelihood that girls are more likely to have the inattentive presentation of ADHD, which was not even considered as a possibility until 1980. They don’t look overtly symptomatic in ways that are distressing to others. It just doesn’t attract the same kind of attention.
Then there’s the piece about societal expectations which are so different for our girls (from our boys). At a very early age, girls begin to internalize the demands of society—which still supports feminine expectations to accommodate others, need to be passively compliant, and to be cooperative, and to be neat and organized.
Most girls feel compelled to strive for these ideals, even though they call upon the executive functions that perform so unreliably in the ADHD brain. Though they’re really poorly wired to do these things, they feel terrible about themselves if they can’t conform to those expectations.
For girls, far more than for boys, peer interactions are really powerful determinants of self-worth. ADHD makes it difficult for them to comply with the unique demands of girls’ relationships. Missing a subtle social cue or losing track of a fast-paced conversation can result in harsh, negative feedback. While boys often externalize their frustrations, girls—craving social acceptance—try to hide their differences and appear to conform. This becomes almost an obsession in terms of hiding. They internalize their feelings because it’s part of hiding. “No one will know about this,” and it’s the defense mechanism of choice to keep their confusion and their shame a secret.
For most girls, there is constant anxiety about being judged as inadequate and they are fearful of rejection. There’s a lot of depressive feelings when they perceive themselves as underachievers. And it is demoralizing to work so much harder for so much longer to have less success than their peers.
The research says that problems with peers and chronic peer rejection increases the risk for future problems, and especially low self-esteem. What we’re finding is that negative outcomes for girls are much more serious than they are for boys. We’re finding the degree to which they engage in self-harm and suicide attempts is far greater than for boys, or for girls without ADHD. When it comes to self-harm, it’s five times as high as it is for control girls who don’t have ADHD, and for suicide attempts, four times higher than for other girls.
Those are numbers that can’t be ignored and we’re trying to understand why that is. Some of the newest research, just a couple of months old, says that girls who have been exposed to early chronic trauma—meaning neglect over a period of time or any kind of abuse—are at a greater risk for self-injury, eating disorders, and suicidality than those who were not mistreated.
By adolescence, one quarter of those girls with ADHD will report having some further kind of trauma, versus only eleven percent of the girls in control groups. We’re finding out that environmental factors like social and adverse conditions can have an influence on neurobiology. This is yet another piece that we have never factored in, but we’re going to factor in now.
When we are considering ADHD impairments in girls, what should we be looking for? Are there any health or emotional concerns we should have about our girls when it comes to this?
Greater Psychological Risks
Girls also have patterns of impairments that are really quite different from what we see in boys. Many people associate school problems with what they think ADHD is and they worry about school achievement, but the reality is that it affects every possible aspect of life.
There are much greater psychological risks that come with ADHD. There are a lot of physiological things happening inside girls’ bodies that are impossible for them to ignore, and they have to contend with those before they can even begin to process information from the external environment.
It’s only now that emotional reactivity is being considered a core symptom of ADHD. Before, the impairments due to ADHD were considered cognitive impairments. If there were issues with mood and emotionality, that was considered part of some other kinds of problems, and girls were often identified as having those other kinds of problems.
Now we’re finding that that is not just a symptom, it’s one of the core symptoms. For girls—but not boys—there is the added volatility from fluctuating hormone levels that I discussed. Girls can be both hypersensitive—which is not the same as saying too sensitive, it’s just that that’s how their systems are wired—and they are hyper-reactive to whatever is stimulating in the environment. They are also prone to sensory overload.
There’s a narrow window where they’re comfortable emotionally, and then there’s a lot of volatility. The sense of self just gets poorer over time. Conforming to expectations does not come naturally to these girls and they can feel like impostors as they struggle to look like everyone else. They are often ashamed and avoidant, and they judge themselves harshly relative to their peers.
In fact, research even said that their peers tolerate higher levels of ADHD symptoms from boys than from girls. So again, there is a gender appropriateness piece is part of this. And it is true that girls are hard on other girls who do violate those societal roles.
Body Complaints in Girls with ADHD
Another thing that occurs very much with girls, and even more than boys, is somatic complaints—all sorts of body complaints. One of them being tactile defensiveness, which is not wanting to be touched, feeling a little too sensitive, often feeling like people touch them too much or not in the way they want to be touched.
I often speak to mothers who feel terrible and rejected because their daughters don’t want to be hugged or kissed. Or, they push parents away or they get sort of rigid when someone tries to hug them. It feels very personal, obviously, and very upsetting, but that is actually just a physiological sensitivity—and something again in the self-regulation realm that they just can’t quite get comfortable with.
In fact, they’re sensitive to all sorts of environmental things. They have more allergies, more asthma, more rashes, and very often more headaches, stomachaches, and feeling nauseous in the morning. They have a lot of trouble sleeping and are just sensitive to sounds and to intense tastes and odors, and changes in temperatures. These are all things that make them feel like they’re being assaulted by their environment.
But that’s sort of invisible to people who have no trouble processing the environment. So then you might just say something to them while they’ve been struggling with some discomfort in their environment and they may snap at you. You won’t necessarily know that their systems were dealing with an accumulation of different kinds of assaults.
The idea of external locus of control, which is the idea that things happen to them—whether it’s fate or luck—rather than them feeling an internal locus of control, which is, “I decide what happens to me and I can affect change in my life.” They feel like they don’t have that ability to affect change in their lives, especially after puberty. We find that sense of internal locus of control sort of segues into an external locus of control as they move towards puberty. That’s a really upsetting thing, as well.
The ADHD brain struggles to regulate its responses to the environment and some impulsive brains overreact more often and some inattentive brains tend to underreact. But regardless of which end of the continuum it veers towards, it really ends up with a response that’s in the middle of the bell curve. Though this really explains how very impulsive girls and very inattentive girls can look so very different from one another, and yet both have ADHD.
We have heard experts say one of the reasons girls tend to be underdiagnosed is because they more often demonstrate the inattentive form of ADHD. Can you help us understand this?
Inattentive girls can appear passive and not necessarily engaged, and they process information slowly. They may have expressive or receptive language problems—but not necessarily—that’s often suspected, or central auditory processing problems, which certainly can be there. But there’s just a lot of internal and external distraction that makes processing go very slowly.
These girls are very fearful of humiliation and don’t want to volunteer in class. When they start to feel frustrated, they tend to shut down. They don’t want to be the center of attention. A problem in a classroom is they don’t want to volunteer an answer because they might be wrong. They’re very rejection sensitive, whether or not there is rejection, and after a period of time they start to be really fearful of it and come to expect rejection.
These are the girls where the teacher will say, “good student, good grades, but doesn’t participate in class, and, as a result, doesn’t work up to her potential.” They may be sort of doing okay academically, but it may be assumed that they’re just an average student, rather than the fact that there are all these other things that are making them not able to really engage in the classroom and show who they.
Girls with Combined-Type ADHD
On the other hand, we have the combined type girls. These are the girls who are what they call “the chatty ones.” Their desks are always being moved in class because they are giggling and gossiping and interrupting others. These are the things they are identified as by teachers. They can be very precocious and sometimes come up with ideas for a group in a very charismatic way. But they are even more emotionally reactive and there’s a lot of mercurial feelings of being really silly, and then they’re really angry, and then crying, and a lot of drama and slamming of doors and, you know, “I hate you,” and “I’m sorry.” Some of these girls can seem like a bottomless pit of demands to adults, and may feel like they are manipulative, but it’s not. I mean, it’s really their brains just saying, “We don’t have the kind of stimulation we need.” But that isn’t necessarily how it’s going to feel to you or come across to other people.
Taking everything you’ve shared with us so far, what then is it like for a girl who has ADHD? What are some of the experiences girls with ADHD might share?
What Girls with ADHD Need vs Resentment to Rules
Some of the common experiences for girls are that they really need limits, but they resent your supervision. They really need structure, but they resent the rules. They need reminders, but they resent the nagging. They need help self-monitoring, but they resent feeling dependent. And they’re drawn to risky behaviors, but they resent the warnings. And they’re drawn to addictive behaviors, but believe they’re in control. And they need objective input, but they resist treatments if it’s at their parents’ behest.
There are a lot of areas where essentially it looks like they’re arguing with you, but really, as I’m saying, they need some of those things. Part of them knows they need those things. There’s the other, more impulsive part of them, that fights against it. While it may look like the argument is between you and them, it’s often between them and their brain. And, unfortunately, as they start feeling worse about themselves, they start second guessing themselves, and then censoring what they say, and start feeling bad about themselves. And, very often, get into a distorted body image no matter what they look like. They compare themselves to others and are not happy with how they look. And then they sometimes become willing to accept invalidation from others, to get into unhealthy relationships, in their desire to just be in connection with somebody and accepted, even if they are not being treated as respectfully as one would like. At least they’re being included, they think, and that becomes a problem, as well.
A big part of ADHD, regards of presentations, is impulsivity. We can all guess at some of the risks of impulsivity but when it comes to our girls, what should we be concerned about or what should we be looking for?
Risks of Impuslivity
What we’re finding is the risks of impulsivity create more of a problem. Now in their defense, research clearly shows that we’ve discovered that the area of the brain that is involved in impulse control in the prefrontal cortex is not fully myelinated, or completely ready for action, until the very late twenties. Our expectations that a sixteen-year-old is going to show good judgment is just an oxymoron to that idea, since it’s the last portion of their brain to fully develop. Questionable judgment is sort of developmentally appropriate. But, on the other hand, there was a very famous experiment in 1970, the marshmallow experiments, where three- to five-year-olds were given one marshmallow. And they said, “If you don’t touch it for five minutes, you’ll get a second marshmallow” and they just watched kids to see what they would do. They then followed those kids and they have discovered that the kids who were able to inhibit their impulses and not eat the first marshmallow have ended up having more successful lives.
So, it’s important. We’re just finding that out about those kids from the 1970s. We really want to understand the role that impulsivity has in interfering with one’s goals because those people had better life outcomes in all areas.
This is about problems with inhibiting behavior, stopping a behavior, or a plan. They can’t shift their attention quickly enough to change course, so they tend to choose immediate gratification over long term, but larger, rewards.
Another thing that we’ve learned is about the dopamine reward center of the brain. That’s literally an area of the brain that is seeking more dopamine—and accessible dopamine, we believe, has a relationship to ADHD symptoms. We’re finding that especially things that give an intense, quick shot of dopamine to the brain are particularly reinforcing. What we’re finding is that all of the things that can supply dopamine are not necessarily things that you want to reinforce, whether it’s substances, alcohol or drugs or cigarettes or sex.
There are some good things—competition and sports—will raise dopamine, but a lot of the things—driving really fast, gambling, and video games—are incredibly reinforcing to that area of the brain. And if it does sort of ring the bell of the reward center, it’s going to be reinforced and more likely to happen again. Those who really have that more impulsive piece are the ones who are even more sensitive to that happening. And so those are also the girls that require more supervision (whether they like it or not), because these girls are trying to seek acceptance in some way.
Very often it’s some kind of hyper-social behavior; if they can’t conform to the regular rules, they can find the other kids who are all smoking outside of the school or getting high somewhere. These are some of the things that we really have to watch out for.
They often get into early sexual behaviors and STDs and early pregnancy. It’s also much more likely for the girls in the impulsive group to develop addictive behaviors and eating disorders.
Quickly, about eating disorders: the ADHD brain does not give the right messages about how it metabolizes glucose. It always tells you that it needs more glucose for energy, even though it has enough glucose. So, what it’s telling girls with ADHD is that it wants something to convert into glucose, either sugar or some sort of carbs. Literally, the brain is saying, “Please don’t eat a salad. We’re not the least bit interested in salad. You really have to have pasta or bread or a bagel.” Girls can be drawn to these kinds of carbs and then can be having terrible conversations with themselves, “you don’t want to gain weight” or “you don’t want to eat that.” But there is actually a physiological reason that they are drawn to higher carbohydrate foods and not the carrots that you have already peeled for them.
The most important thing we’re finding is these are the girls who are most likely to act on those feelings of desperation that I was discussing earlier. The risk for self-harm and suicidality for the girls with impulsivity are much, much higher than for inattentive girls and, of course, girls who don’t have ADHD.
Let’s talk a little bit about inattention in girls and high IQ. How can this higher IQ help our girls but also get in their way?
Inattentive and High IQ
One area of special interest for me is the high IQ inattentive girls, because these are the girls that are least likely to ever be identified as having ADHD. I’m worried about really missing them. There’s such a huge disparity between intellectual functioning, which can be three years ahead their peers, and social/emotional functioning in the world of ADHD developmental lags, which we usually think of as about three years behind their peers. If you think about someone being intellectually three years ahead and socially/emotionally three years behind, we’re talking about a six year discrepancy between levels of functioning in a young child. That’s just immense. There are tremendous social stressors involved with that and it’s hard for anyone to make sense of it.
You know, they may be more intellectually drawn to converse with adults, but they might prefer to play with younger children. They’re going to look emotionally immature and they’re not going to feel like they really fit anywhere. They get the message their success is tied to a high IQ, and being successful in school becomes part of their identity. Their shame about not succeeding is even more intense than other girls because they’re thinking, “But I’m really smart and I can’t understand why I can’t do this and people who are not as smart are having no trouble doing this.” They struggle with these kinds of conundrums and really don’t know how to label themselves. It’s so shameful, to them, that they don’t really ask for help and this becomes their horrible secret. What they do is they learn to compensate really well, but compensating masks the symptoms of ADHD.
They could often become perfectionistic and become hyper vigilant about not making a mistake. That requires them to be really rigid. They tend to spend extra hours on their homework late at night but they have to make sure their façade is intact and they look good in school. But it’s exhausting. And it’s exhausting to hide and fear that they’ll be discovered as an impostor because they’re working so hard at it and often paralyzed by fears of humiliation so they tend to avoid social situations and they think that no one will really understand them.
Since they’re not asking for help, it’s a catch-22 because they look really successful. They feel like they’re succeeding, but it’s at such a high cost and no one knows the struggle that they’re dealing with. So, their lives continue that way and they’re living with a secret. It’s just another level of struggle.
How Can Parents Help?
How can parents help? Some of these things you’ve heard and read in magazines and books, and I’ll go quickly over that, and maybe some of the things you haven’t heard yet. With most of the families that I see, I never have to say, “You’re not doing enough for your daughter.” But I often have to say, “You might be doing too much.”
Loving, involved parents who educate themselves about ADHD—and I imagine lots of you who are listening to this right now—are sensitive to their daughters’ struggles and attuned to their frustrations and they want to help them. Naturally, you want to insulate them from potential frustration and pain.
The issue is that it’s a really challenging tightrope walk to figure out how you can protect them from overwhelming difficulties, but still allow them to build up their frustration tolerance and learn to creatively problem solve for themselves.
If you intervene too often, intervention becomes part of their definition of love—not the worst thing to have as part of your definition of love—but it creates dependency at the same time.
There is an unspoken message that “I do this for you because you can’t really do it for yourself,” and that becomes an unintended piece of their identity. Figuring out that balance is difficult. It’s really difficult because developmentally, as they change, where the tightrope is strung changes as well. It’s not an easy road for you to walk, but the goal is to breed confidence and independence, and help them solve problems with the way their brains are wired, and teach them the activities of daily living, and let them enjoy the mastery of feeling competent.
I just work with many young girls who go off to college and have never done their own laundry, and have never written a check, and have never had to wake up by themselves in the morning. There are all sorts of things that it become a steep learning curve. Teaching them these things gradually is the only way that they’ll be ready to launch when the time comes.
Teach them everything that they can know about ADHD and anything else that interferes with their learning so they can advocate for themselves instead of you doing it. That’s another thing that gradually needs to be transferred to them. They should learn how their brains work and what situations are uncomfortable for them. Then I’m sure you know about predictable routines and teaching them how to structure things for themselves.
But my strongest suggestion is to consider the struggles that I’m sure you experienced daily with your daughter and the power struggles, which feel very personal and upsetting, are not so much between you and your daughter as between her and her ADHD brain. In other words, her intellectual understanding tells her one thing, like “Mom said I should start my homework now” and she may indeed think that mom is probably right. But then her brain says, “No way. That is too boring. I couldn’t care less about your homework. And math is really hard. I don’t even want to do it. Let’s look around and find something more stimulating.” Then you find her on Instagram or in the snack cabinet. It seems that she defied you. But the reality is some part of her knows she has to do her homework but the brain is pretty powerful. If it says, “I can’t focus, I will not focus on this,” then it will not focus on that.
Acknowledging to her that you appreciate the struggle within her every moment of every day is incredibly validating and it puts you and she on the same team. And together, you’re going to figure out ways to psych out her brain to get it to comply. And that can definitely be done.
When I spoke with a kindergarten girl who had been chastised for standing up during circle time, she told me, “I know. I told my tushy to stay on the rug, but it didn’t listen to me.”
And I think that really captures that struggle between the person and their brain. Your sensitivity to that struggle, regardless of how intentional her behavior may appear, is something that can be really, really helpful and really, really healing for the relationship between you, which in my opinion is probably the most important thing there is.
This has been an insightful half hour with you, Dr. Littman. Thank you for your time, originally with CHADD’s National Resource Center on ADHD, and with us today for ADHD Awareness Month.
If you, our listeners, would like additional information on ADHD in girls and women, please visit us at ADHDAwarenessMonth.org or our partner, CHADD.org/women.
About the Speaker
Dr. Ellen B. Littman (she/her/hers) is a clinical psychologist who has specialized in understanding those with neurodiverse brains for over 30 years. Educated at Brown and Yale Universities, Long Island University, and the Albert Einstein College of Medicine, she is licensed in New York, Connecticut, and Vermont.
Dr. Littman’s practice focuses on the high IQ adolescent and adult neurodiverse population. Described by the American Psychological Association as “a pioneer in the identification of gender differences in ADHD”, she has extensive experience working with women and girls with ADHD.