52. ADHD in Girls - All of the things you should know

In this episode, Dr. Fallucco dives into the nuances of ADHD in girls, explaining  why it is so important to recognize girls with ADHD, how girls with ADHD present with different symptoms than boys, and why girls often go undiagnosed. 

She highlights the importance of early recognition and treatment to reduce risks like suicide, drug abuse, accidents, and social struggles. Dr. Fallucco also discusses the subtle inattentive symptoms in girls, genetic risk factors, and ADHD 'superpowers' such as hyperfocus and creativity. 

Tune in to learn why it's crucial for clinicians to identify and treat ADHD early, especially in girls, to help them thrive academically, socially, and in life.

00:00 Introduction to ADHD in Girls

00:49 Why ADHD in Girls Matters

02:35 Challenges in Diagnosing Girls

03:19 Importance of Treatment

04:31 Recognizing ADHD in Girls

04:39 ADHD Subtypes and Gender Differences

04:54 Subtle Symptoms in Girls

06:25 Hyperactivity and Impulsivity in Girls vs. Boys

08:38 Which KIDS you should worry about who may have unrecognized ADHD

13:27 ADHD Superpowers

15:58 Final Thoughts and Pearls

17:17 Conclusion and Contact Information

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Transcript

Dr. Elise Fallucco: 0:21

Welcome back to Child Mental Health for Pediatric clinicians, the podcast formerly known as Psyched for peds. I'm your host, Dr. Elise Fallucco, child psychiatrist, and mom. Today I'm really excited to talk about. All of the things you should know about A DHD in girls. First we're gonna talk about why this is important, and second, we'll talk about how girls with A DHD look differently than boys with A DHD, and also how why that makes it so hard to be able to detect them. Then we'll talk about which kids you should worry about in your practice, who might have undiagnosed A DHD. And finally, I'm gonna share a little bit about A DHD superpowers. So let's get started. First, let's talk about why you should care about A DHD in girls. As you may already know, A DHD is the most common neurodevelopmental disorder. Affecting youth. About one in nine kids, ages three to 17 have A DHD. And the prevalence of A DHD has been rising over the past decade, which you could probably tell from your own practice. And at one point in time, really decades ago, A DHD was thought to be a disorder almost exclusively affecting boys. With 25 times as many boys diagnosed with A DHD as girls. And over time, this gender ratio has significantly narrowed to the point that now we think it's about twice as many boys have a DHD as girls. And then when you get into adulthood, this ratio narrows even further where you see that There are almost as many women with diagnosis of A DHD as there are men, so it makes you wonder what is going on here with this change in the ratio. Of males to females with a DHD over time., Is it a boys are really that much more likely to have a D, H, D than girls? B. Girls just present with symptoms of A D, H, D later in life. C. We're just really not good at detecting symptoms of A DHD in girls compared to boys, and that's why we don't see as many girls with a DHD in childhood. Or is it D? All of the above. And just as a side note, the studies I'm gonna refer to in this episode talk about boys and girls from a biological sex perspective. So lots of questions, but the bottom line is that as far as what we know now, Girls are much less likely to be diagnosed than boys with a DHD, even at the same levels of impairment. And oftentimes girls who have a DHD symptoms are under recognized. And even when girls are diagnosed, these diagnoses are made often, much later in their lives compared to boys. On top of that, even when girls are diagnosed with A DHD, they're less likely to be prescribed medication than boys, even when you control for symptom severity. So that means even when a given girl and a boy both have symptoms that are causing the same amount of impact and problem on their functioning at school or at home or with friends. Girls are less likely to be given treatment but treatment is so important for so many reasons. Treatment with A DHD meds can be highly effective. Helping kids with A DHD do their best, perform at their highest level at school. Or ultimately in work as they age. But the biggest, most important thing that I hope you'll remember as a take home from this is that treatment for A DHD reduces the risk of some of the leading causes of death in teens, which includes suicide, drug abuse, accidents, and injuries related to accidents. So this is really why you should care, because. So many girls with A DHD are going without a diagnosis or are not being treated, and that in turn increases their risk for all of these bad outcomes. So the bottom line is it's really important to be able to recognize all kids with A DHD, but particularly girls who tend to be underdiagnosed and under recognized. And when you recognize those symptoms, it is really important to have discussions about treatment. We've talked about why it's important to recognize A DHD in girls, and now we're gonna talk about how to do that. So. What does A DHD look like in girls? And why are girls with a DHD so challenging to detect and so easy to miss? So the first thing that we need to know about girls with A DHD is they're more likely to present with the subtle inattentive symptoms as opposed to the boys who are more likely to present with the hyperactive impulsive symptoms or the combined hyperactive impulsive plus inattentive symptoms. So think about it this way, the stereotypical girl with A DHD is much more likely to show inattentive symptoms and less likely to have the obvious hyperactivity and impulsivity. These girls may have trouble staying focused when they're asked to listen to long lectures in class, or they're asked to read a long passage or even when they're engaged in a longer conversation with their friends or family, Girls with a DHD. With this inattentive subtype often start projects or start tasks, but then they easily lose focus and they're quickly sidetracked and wanna do something else that's a little bit more interesting or exciting. Sometimes these girls with the inattentive subtype don't seem to be paying attention when you're talking to them, and you often have to repeat yourself to get a response from them. So they sometimes seem to be a little spaced out. So that's the stereotypical form of predominantly inattentive subtype. And you can see when you've got these subtle symptoms, you're much less likely to draw attention from teachers or parents. Yeah, because these are things that the girls are experiencing in their head, in their minds, and it's really hard to tell that from the outside. Whereas the boys with A DHD are more likely to present with the mainly hyperactive, impulsive subtype or the combined subtype they're very hyper. They're climbing on the furniture in the office. They're spinning around on your chair. They're physically busy, even more so than you would expect for a neurotypical boy. Of the same age or the same developmental level So the second thing to know about girls with A DHD is Girls express their hyperactivity or express their impulsivity in a way that's different compared to boys. So boys with A DHD are more likely to have very physical hyperactivity and impulsivity. For example. Boys are more likely to have trouble sitting still to often leave their seat in the classroom. They're more likely to be fidgeting with their hands or feet or to run around or climb excessively, which is one of the criteria for A DHD climb excessively. So, in other words, boys with a DHD really like to move their body. They're showing physical impulsivity, manifesting it through their body, which again makes it easier for us to detect from the outside. Whereas girls with a DHD express their hyperactivity and impulsivity in more of a verbal way than in a physical way. So girls are more likely. To be called the chatty Cathys, they talk excessively. They're more likely to interrupt, and even when you've got girls and boys with the same level of hyperactivity and impulsivity, the girls are more likely to endorse these verbal symptoms, whereas the boys are more likely to show physical hyperactivity and impulsivity. And let's say even if girls are interrupting in class or maybe you're talking a lot in class, that's certainly less disruptive than having a stereotypical boy who is popping out of his seat or hitting another child near or running around the classroom or climbing excessively. That's my favorite symptom. It makes, helps us understand why girls are less likely to be recognized than boys because some of their symptoms are less disruptive to a classroom setting, to a family, et cetera, than girls' symptoms are. So now that we've talked about the differences between boys and girls with a DHD, now let's talk about which kids you should worry about who may have unrecognized A-D-H-D-I. So we'll start with the more straightforward things First, you wanna look out for obvious academic problems in school where their grades are slipping or they're spending an inordinate amount of time on schoolwork, or the opposite, they're totally avoiding it or rushing through it. And then of course you wanna look out for social problems because kids with A DHD, who tend to be more impulsive. May show this when they're having conversations with their friends by interrupting or blurting things out, or even may exhibit these symptoms in class, and then they'll be flagged as unusual. There's also a particular developmental stage where we tend to see a second wave of kids with a DH d in our office, and that would be the transition to middle school. Now developmentally, this is a time where the academic load massively increases compared to elementary school and also the social demands are much higher. And so kids who maybe have been able to skirt along through elementary school just fine, begin to have problems in middle school with their grades dropping or having more obvious social impairment. As developmentally at this time, girls tend to connect with one another verbally and through conversation. So if you're a girl with a lot of a DHD related impulsivity and you're interrupting conversations or talking nonstop or blurting out answers, you may have trouble seamlessly connecting with other girls. So we've talked about some signs that somebody could be struggling with a DHD, and those are namely having academic problems, having social problems, or somebody who's struggling through the transition from elementary school to middle school. Now, let's shift gears and talk a little bit about genetic risk factors and other clinical factors that could indicate somebody maybe at high risk for A DHD. The first types of kids who are high risk are kids whose parent has a DHD. We know that A DHD runs in families. It's highly heritable, so it's passed down from parents to kids, just like hair color and eye color, and some other traits. So when I make a new diagnosis of A DHD, I often ask the family, which parent does the child seem to take after in this respect? And almost always universally, one parent will either name themselves or their partner and say, oh my gosh, my child is just like their father or their mother So we look out for kids if we have a known diagnosis of a parent with A DHD. So this would be great and really helpful, except for the fact that there are a ton of parents running around who also have undiagnosed A DHD. And so we can't always rely on the parents having gone through the process of being diagnosed and and treated and being able to recognize symptoms in themselves and therefore be able to see and recognize the symptoms in their child. So the other type of kids we wanna look out for are kids whose siblings have a DHD. Again, because it's highly genetic and highly heritable, just having a sibling with A DHD increases your risk. And in fact, one large study published in JAMA Peds found that kids whose sibling had A DHD were 13 times more likely to be diagnosed with A DHD than kids who didn't have a sibling with a DHD. And in the same study, they estimated that if a child has a sibling with A DHD, they have about a one in two or a one in four chance of being diagnosed with A DHD themselves. So the bottom line is we need to look out for siblings of kids who already have a DHD. And since we know that boys are more likely to be diagnosed with A DHD, I would say. If you have a child in your office whose brother has a DHD, you need to be thinking about A DHD in them. Okay? Third, potential clue that this child's at higher risk for A DH. D would be a child that already has a diagnosis of anxiety or some type of learning difference, or even a mood disorder. Because we know that kids with A DHD are at high risk of having comorbid anxiety, mood disorders, learning challenges, and also substance use, uh, later in life. And there's this concept with a really beautiful name called diagnostic overshadowing, which basically means that. When somebody has more than one mental health diagnosis, oftentimes one of the diagnoses is more obvious to us as clinicians, and so we're more likely to diagnose them with that and then potentially miss this other diagnosis that they may have. So something to think about And then finally, another clue that you may be working with a kid who has undiagnosed A DHD would be the presence of A DHD superpowers. And I wanna let you know before I tell you about these superpowers that a lot of this is based on clinical and anecdotal evidence. But we don't have a ton of systematic studies that are looking at this. So just as a disclaimer, but some of the A DHD superpowers are the ability to hyperfocus. So these would be kids who can pay attention to some task or activity, whatever it is that's really interesting to them. Maybe it's Minecraft, maybe it's video games, or maybe it's even a sport that they're really, really interested in and they can. Pay attention for a really long period of time and be incredibly successful in this area. And unfortunately, this superpower that we see in a lot of kids with A DHD, this ability to hyperfocus is one of the parts that makes it really hard to diagnose them, because as a parent or even as a clinician, you see, oh, well look, they can pay attention to this for a really long period of time. And so they can't have problems with their attention and concentration. But again, their ability to hyperfocus is based on their high motivation. So for all of us, when we're motivated or really excited about something, we can zoom in or. Super focus because our motivation is kind of helping us. The difference is that in neurodivergent kids who have a DHD. When they don't have that motivation, when something's not as interesting, that's when you see the differences and where it's much more difficult for them to sustain attention because it's boring and they like things that are very exciting and how can you blame them? The other superpower with A DHD you sometimes see is high degrees of creativity or artistic ability. Neurodivergent people with A DHD have incredible ways of solving problems, at looking at the world, at being able to build and create things. And have incredible imaginations because they're not necessarily constrained to linear step-by-step processes in their thinking. Another superpower with A DHD is high amounts of energy. It takes a lot for them to be worn out, and often they have trouble falling asleep because they are just so busy and they wanna be on the go again. This is kind of an amazing superpower, but sometimes makes it hard when you're the parent of a child with lots of energy. So to recap, we've talked about why it is so critically important to recognize kids with A DHD, particularly those with the inattentive subtype, and to get them treatment promptly to decrease the risk of negative outcomes and help them to be their best at school and in life. We've also talked about how boys and girls differ in terms of their A DHD, with girls presenting with more inattentive symptoms and girls also presenting with more verbal impulsivity as opposed to boys who present with more physical impulsivity as well as hyperactivity. We've talked about which kids you should worry about, and briefly to recap those with academic problems, social challenges, Or kids with recognized learning differences, anxiety or mood disorder. Also be on the lookout for those kids with a first degree relative with A DHD, usually a parent or a sibling. And of course, we wanna have our eyes wide open for all of our patients during the transition of middle school.'cause this is often when we begin to see a second wave of unrecognized A DHD. And finally have a high degree of suspicion among kids with some of the A DHD superpowers like the ability to hyperfocus high amounts of energy, and lots of creativity. Thank you so much for taking this time to listen. I really appreciate it. If you have any questions or any ideas or mystery cases of your own, please feel free to reach out to me at Instagram at psyched the number four peds, or on our website at psyched the number four peds.com. Thanks so much. See you next time.