Narratives around autism and gender are changing. While autism was once seen as a condition predominantly affecting boys, we now know that there are more girls with autism than we previously thought, as Professor Barry Carpenter and Jo Egerton point out in their 2016 guide to girls with autism, Flying Under The Radar.
If we have been failing to recognise girls with autism, what other neurodevelopmental conditions could we also be missing?
Take attention deficit hyperactivity disorder (ADHD), for example. This is also predominantly associated with boys but it is clear that far more research is needed about ADHD in girls.
Current evidence suggests that ADHD is potentially under-diagnosed in girls, and/or that girls are more likely than boys to display the inattentive presentation of ADHD, which tends to persist longer throughout development (Hinshaw et al, 2012).
As a result, many women only get diagnosed with ADHD as adults (Nussbaum, 2012; Quinn, 2008).
A late or missed diagnosis doesn’t just mean that girls don’t get the academic support that could help them succeed; undiagnosed ADHD can also jeopardise girls’ and young women’s self-esteem and, in some cases, their mental health.
Hinshaw’s 2012 study found that girls with combined-type ADHD have significantly higher rates of attempted suicide and self-harm later in life than those without, as the “lack of social and academic skills - the cumulative effect of what they missed when they were younger - take a toll”.
What’s more, the effects of under-diagnosis begin to show early on. Whereas boys with ADHD tend to externalise their frustration - angrily blaming the “stupid test”, say - researchers have found that girls with ADHD are more likely to blame themselves (Mahone, 2012). They often present as people pleasers, doing all they can to fit in.
They may also suffer more from internalising symptoms, which means the condition can go unnoticed for longer, and they live with other stigmas, often labelled as “disorganised”, “daydreamers”, “social butterflies” and “space cadets”.
Even teachers, who are often the first to identify the signs of ADHD in children, can overlook girls, who are more willing to put in extra hours of studying to keep up their grades and to ask their parents for help. This is the same type of “masking” that we see in girls with autism, which makes it so much harder to identify the condition.
Patterns of behaviour that girls with ADHD display may include forgetfulness, disorganisation, feeling anxious and sad, shy and inattentive, talking incessantly or having trouble maintaining friendships.
So, what can we do to help teachers identify these patterns? To start with, we need more professional development to improve awareness.
Schools also need to be working closely with clinicians and parents to make sense of the learning behaviours we see in our classrooms, and to understand medication or behaviour therapies.
There are small steps we can take to help girls with ADHD: allowing movement breaks, being alert to signs of distress and sharing strategies for coping with anxiety may all help.
Most importantly, we must notice, respond and treat these behaviours with respect. With or without a diagnosis, if we can “notice” more, then we can support and we can refer on.
Margaret Mulholland is the special educational needs and inclusion specialist at the Association of School and College Leaders
This article originally appeared in the 2 April 2021 issue under the headline “Why are we still missing ADHD in girls?”
