Mental Wellness

ADHD is Underdiagnosed in Girls; Here’s Anna’s Story


To say I was taken aback would be an understatement. Sitting in a blue plastic chair with my knees tucked up to my chin, I was convinced my daughter’s first-grade teacher was confusing her with another classmate. My mind couldn’t grasp the teacher’s insinuation that associated my calm and cooperative Anna with attention-deficit hyperactivity disorder, commonly known as ADHD.

ADHD conjures up images of wiggly little boys making mischief in the classroom and falling behind academically. But Anna spoke in full sentences at 18 months and was so articulate that others remarked that she seemed much older. She was well-behaved, mature and an easy kid. She sat through movies at a young age and focused intently while reading. I comforted myself that I did my part to give her the best start possible: breast-feeding her through infancy, reading to her every night since she was a baby, and making organic purees from scratch.  How could anything be wrong?

Anna’s backstory didn’t seem to mesh with the teacher’s observation that she was “unfocused in the classroom,” “having difficulty staying on task” and “not performing at the level she should be.” She told me Anna was cooperative but would ask to use the bathroom often, or to see the nurse about small insignificant things.

“Do you see any of this behavior at home?” the teacher asked.

Well sure, a little bit, I thought, but Anna is 6. Aren’t her actions typical for kids her age?

While her teacher didn’t actually say “attention-deficit hyperactive disorder” out loud, there was no doubt she wanted me to speak to our pediatrician about having Anna tested. I wasn’t convinced.

Driving home from the school, I thought about Anna’s behavior over the years and realized that her attention did seem to drift. In dance class she was in her own world and didn’t always follow the routines; then she quit dance after one year. Soccer was more of the same. Discovering multiple ways to adjust her pinny vest was way more interesting than engaging in the game happening around her.

I made an appointment for Anna to be evaluated by our pediatrician. And, as is typical for girls, my daughter passed the attention-deficit hyperactivity disorder screening, albeit with “a few small red flags.” Still, there was nothing to hang a diagnosis on. Our pediatrician chalked up her behaviors to immaturity. We moved on.

Then her second-grade teacher noticed some of the same issues with focusing and following tasks. After I told her that Anna was tested for ADHD the previous year and had passed, the teacher replied, “I would fall off my chair backwards if you told me Anna has ADHD.” I felt validated and reassured for about five seconds until the teacher mentioned something called an auditory processing disorder, a condition where kids can not process what they hear because their ears and brain don’t fully coordinate.1 There is interference with the way the brain recognizes and interprets sounds, especially speech. So, we had Anna tested for the condition…and she passed.

When Anna moved into fourth grade, I was called to the school to discuss the continuing attention and task issues she was having in the classroom. This time, the meeting included her teacher and the district’s psychologist and case manager. They had tested Anna and were confident she had ADHD.

Why attention-deficit hyperactivity disorder is missed in girls. Infographic: Gender Differences in ADHD Symptoms.

Why was it so hard to diagnose Anna over the years and why were there so many varying opinions? I learned through my research that ADHD in girls is not as easy to spot as it is boys2. According to the Centers for Disease Control and Prevention (CDC), boys are three times more likely to receive an ADHD diagnosis than girls.3 That’s because girls are less likely to struggle with hyperactivity, fidgeting and impulsive behaviors that are typical for boys with the disorder. Girls like Anna are often pleasant members of the classroom, cooperative and not disruptive. Attention-deficit hyperactivity disorder is also underdiagnosed in girls because many experts consider it a predominantly male disorder. Too often they end up falling through the cracks, unnoticed as they struggle.

Kids with ADHD (and others with attention-deficit disorder without hyperactivity) struggle because they lack “executive skills.” Understood.org describes executive skills as the “CEO of the brain.”4 It’s what enables people to set goals, plan steps and get things done, like:

  • Paying attention
  • Following directions or a sequence of steps
  • Organizing materials
  • Planning and prioritizing
  • Starting tasks and staying focused on them to completion
  • Self-monitoring (keeping track of what they’re doing)
  • Regulating emotions

Kids with ADHD typically have few or no executive skills. Because they also tend to lack attention to detail, they are mislabeled as lazy, unintelligent, daydreamy and underachieving.

During the meeting, Anna’s fourth-grade teacher, the school psychologist and the case manager expressed concern about her moving on to fifth grade in “upper elementary,” a new school with higher expectations for students. They suggested that Anna needed a 504 Plan to help her succeed there.  By law, schools in our home state of New Jersey are compelled to develop a 504 Plan, which is a formal, individual education plan for a child identified with a disability. The 504 Plan provides the education support the child needs, prevents discrimination and protects their rights in school.

So, we went back to the pediatrician with the school’s test results and recommendations, and obtained the required medical diagnosis of attention-deficit hyperactivity disorder so that the district could consider Anna for the 504 Plan. Anna’s father and I advocated for her to get the accommodations she needed to be successful in school, and she was approved for the 504 Plan.

You can imagine how happy we were that Anna completed fifth grade with honors, performing her best academically since kindergarten. She grew in confidence as she learned how to develop coping strategies and better relationships with her peers. She entered and completed her second season of Lacrosse, joined clubs and enrolled in her second season theater camp this summer.

Good grades were not my biggest concern, however. As girls head into adolescence they are more likely to face serious mental and emotional struggles, especially if ADHD is present. According to CHADD National Resource Center on ADHD, girls with the condition are more likely to struggle with depression, anxiety, substance abuse and eating disorders. They feel stress more and have lower self-esteem.5

Talk therapy has been an important part of Anna’s life and she enjoys the opportunity to be herself in a safe environment. Therapy has taught her coping skills and encourages her to express her feelings. My hope for my daughter is to keep the communication ball rolling. Between bullying, peer pressure, social media and the opioid crisis, life for adolescents and teenagers is hard enough without being predisposed for depression.

I’ve learned that parents of kids with ADHD need to be especially vigilant. That’s because these children are more impulsive and likely to act “in the moment” when they are feeling down or hopeless. They may not be able to step back and see the bigger picture. One study found that teens who were diagnosed with attention-deficit hyperactivity disorder at a young age were twice as likely to make a suicide attempt than peers who did not have the disorder.6

Anna is 11 now. She has struggled with anxiety since early elementary school. She also has difficulty regulating her emotions, melting down easily and demonstrating over-dramatic reactions to situations. Loud noises like concerts can be overwhelming for her and she gets worked up over the idea of large crowds. Her behavioral issues in and out of the classroom are mild and she is succeeding without medication. I would rather not meddle with her success. She will soon experience a lot of hormonal changes that I don’t want masked with other chemicals. For now, we will continue with therapy and school accommodations to develop her coping skills. However, I am open to the recommendation for medication if things should change.

We’re doing well. This past summer, after two days of auditions, Anna was offered a lead role in her theater camp’s production of Frozen, Jr. The day the cast list was released I took a deep breath because I knew the demands of the play would make for a long six weeks. Could Anna handle memorizing her lines, focus enough to learn scene blocking and, oh my God, manage all that singing!?! Will she be able to deal with the pressure of opening night, followed by three more performances? Or will anxiety take over and paralyze her? If I have butterflies in my stomach, what is she feeling?

We coped by doing calming exercises she learned in therapy and crossed our fingers and prayed for the best when the curtain opened. By the way, Frozen Jr. is a story of true love and acceptance between sisters, one who is named, coincidentally, Princess Anna.

***

Postscript: Anna did great in Frozen Jr. Her big musical role helped her develop coping skills for life outside of the classroom, including the hard work of being an adolescent. She started sixth grade with a positive outlook. We are grateful for the drama coaches who gave her the chance to perform and to the early observations of her teachers who, despite her subtle symptoms, pushed us to take a closer look at her behaviors.

1Webmd.com, “What is Auditory Processing Disorder?”
2Healthline, “Gender Differences in ADHD Symptoms”
3Centers for Disease Control and Prevention, “Data and Statistics About ADHD”
4Understood.org, “Signs That Kids Struggle with Executive Function”
5CHADD, “Women and Girls”
6National Institutes of Health, “Attention-Deficit/Hyperactivity Disorder and Suicide

Download the Article PDF

More Resources

ADD Resource Center: “Proven, Practical Programs and Services”
ADD Resource Center: “Importance of ADHD Treatment Monitoring”
Centers for Disease Control and Prevention, “Data and Statistics About ADHD”
WebMD,” Understanding ADHD — Diagnosis and Treatment”

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