It seems as if nature and society have conspired to pack the high school years with so many daunting challenges that even the most adept and well-adjusted adolescent feels overloaded. When ADHD is added to the mix, high school becomes even more challenging, and may even become a destructive experience.

Diagnosis of ADHD in teenage girls

The accurate diagnosis and appropriate treatment of girls with ADHD is acutely important in these challenging years, however many teenage girls with ADHD go undiagnosed or misdiagnosed for a number of reasons:

• Girls with ADHD often behave very differently than boys, falling into the much harder to diagnose category of “primarily inattentive type;”

• Girls typically work harder to hide their academic difficulties and to conform to teacher expectation; and

• Girls are often misdiagnosed as anxious and/or depressedGirls who are particularly bright are able to compensate for their ADHD much longer, and are therefore the most likely candidates for a late diagnosis

The fact that a girl’s ADHD symptoms may not have been apparent in early years renders her ADHD no less real when it rears its head in adolescence, a time when the demands for planning, organization, recall, and focus intensify. There have been numerous discussions of the need for gender-based diagnostic criteria for ADHD, but for now, professionals continue to rely on criteria that serve much better to identify boys than girls.

Parents who may suspect that their teenage daughter may have ADHD can refer to the questions at the end of this article. If your daughter answers “yes” to many of these questions, a careful assessment for ADHD may be called for.

Troubling challenges faced by teenage girls with ADHD

Many of the issues discussed below also present challenges for girls without ADHD. However, these issues seem to be more intense and more frequent among girls who face the double challenges of adolescence and ADHD.

Social pressures

Girls with ADHD experience social deficits as early as preschool years, but they seem to reach their greatest impact during adolescence as girls begin to separate from family and social life takes on an intensified importance. Many women with ADHD recall feeling “different” from other girls when growing up. The need for peer acceptance during high school years is intense and may lead to dangerous or self-destructive behavior in an effort to “belong.”

Low self-esteem

Family support and acceptance is critical, but can never entirely counteract the damage that can be done to teenagers who feel rejected by their peer group. Girls with ADHD may develop low self-esteem in high school years that can haunt them for years afterwards.

Inability to meet social expectations

While teenage years are full of self-doubts for most girls, the special challenges of ADHD greatly intensify those feelings. For example, girls are typically encouraged to be neat, “feminine” (controlled and passive), carefully groomed (in order to be attractive to the opposite sex), sensitive to the feelings of others, and compliant with adults. These very expectations are often in direct opposition to the ADHD tendencies of many girls.

A teenage girl with ADHD may respond anxiously, even obsessively, to the expectation that she be well groomed and fashionably dressed, yet be unable to organize her room or her life well enough to have clean, color-coordinated clothing available on a given school morning.

Emotional reactivity/ Hormonal Fluctuations

The typical hyper-reactivity of ADHD tends to be intensified in adolescence as hormonal fluctuations complicate and escalate reactivity. As a result, the self-doubts and competitiveness so common among teenage girls are often more intense for girls with ADHD. Their hurt feelings can escalate more rapidly into impulsive remarks or over reactions. Once the drama is over, she may be ready to forgive and forget. The friends and family who are stung by her comments, however, often become intolerant of her outbursts.

Depression

Social pressures are intense during adolescence, with enormous energy expended on peer analysis: watching, imitating, relating, comparing, and conforming. In addition to this exhausting list, girls with ADHD often feel despair. Depression, so common among women with ADHD, often begins during the pressures of teen years. Such depression is much easier to recognize, and many girls with ADHD find themselves treated for depression while their ADHD goes unrecognized.

Growing Pressures to “mature”

Pressure to grow up and become responsible increase during adolescence. Sometimes parental expectations for their daughters to demonstrate “maturity” can come into direct conflict with the neuro-cognitive patterns associated with ADHD. This doesn’t mean that our daughters can’t become “mature,” but it does mean that maturity needs to be viewed through an ADHD lens.

High school and ADHD — not a good “fit”

Academic pressures seem to reach a crescendo in high school, as well. High school is designed in a way that seems almost diabolically structured to be ADHD-unfriendly. The day starts too early and lasts too long — with demands for focus and concentration that far exceed the capacity of most students, even those without ADHD. In addition, any students with ADHD are placed in the position of being forced to read and study about subjects that hold little or no interest for them — something they will be strongly advised against doing once they have graduated from high school!

Sexual risks

Teenage girls with ADHD may be at greater risk for pregnancy than are other teenage girls (Arnold, 1996). This may be true for a number of reasons. Teenage girls who struggle with low self-esteem, as do many girls with ADHD, often seek affirmation through the sexual attentions of boys in an effort to compensate for feelings of inadequacy in other areas of their life. Furthermore, due to difficulties with impulse control, poor planning ability, and inconsistency, many of these girls are prone to have unprotected sex, use birth control inconsistently, and/or have multiple partners.

Risks associated with driving

Studies of teens with ADHD have shown that, in general, they have a greater likelihood of being involved in traffic accidents. Most studies have only examined the driving behavior of boys with ADHD, but one study in New Zealand (Nada-Raja et al, 1997) studied both boys and girls and found that girls with attentional difficulties were at high risk for both traffic crashes and driving offenses.

Risk for substance abuse and addictive behaviors

The risk for substance abuse and other addictive behaviors (cigarette smoking, eating disorders) typically begins in the middle school years and intensifies during high school. A recent study (Biederman et al., 1999) reports that 14% of girls with ADHD have a substance use disorder, and one in five smoked cigarettes.

How Can Parents and Professionals Help Teenage Girls with ADHD?

Managing the emotional roller coaster

It is critical that parents and professionals recognize that the intensity so often seen in teenage girls with ADHD has a neurological basis, and that reactions tend to become even more extreme during times of stress, fatigue, hunger, or PMS. Both the teenage girl and her parents need to recognize the added vulnerability that she has, and begin to identify and manage the potential stresses that can worsen her reactions.

Both medication and psychotherapy, used in conjunction, seem to be the most effective treatment program. Medication regimens often need to address a complex set of issues, including anxiety and/or depression, rather than ADHD alone.

Because peer issues and issues of self-worth are so paramount among most teenage girls with ADHD, psychotherapy needs to be designed to directly address these. Often, group psychotherapy can be tremendously supportive and effective for teenage girls with ADHD. Such a group might be conducted at school by a school counselor, or might be found in a private clinic setting.

Treating Pre Menstrual Syndrome (PMS)

Tremendous hormonal changes occur, and the hormonal fluctuations of the menstrual cycle intensify and complicate the confusion and unpredictability that are part and parcel of growing up with ADHD. While Pre-Menstrual Syndrome (PMS) may be an annoying period of irritability, fatigue, or cramping for many girls, those with ADHD may feel such an increase in the intensity of their emotional reactions, irritability, and low frustration tolerance, that they require active intervention. Physicians, therapists and others who treat adolescent girls with ADHD should be aware of this added vulnerability, and take steps to keep up-to-date on research on PMS and new approaches for minimizing its impact. The use of anti-depressant medication to combat the effects of PMS is fairly well-known, but recent research has suggested that there are a number of ways to reduce PMS symptoms in the more vulnerable ADHD population.

Reducing the risk of anxiety and depression

Emotions can tip quickly when environmental stresses suddenly overwhelm the teenage girl’s already distressed system. An accidental pregnancy, the breakup of a relationship, a failed exam, a rejection letter from a college — any of these might be enough to push her into levels of anxiety or depression that may require both medication and psychotherapy. Parents and professionals need to be watchful during the teenage years to assess whether the “normal” emotional roller coaster for girls with ADHD has careened over the edge into a level of anxiety or depression that requires treatment in tandem with her treatment for ADHD. Both anxiety and depression are common among teenage girls with ADHD and can be successfully treated along with the ADHD. The experienced physician will be aware that stimulant medication for ADHD may tend to increase anxiety, and should prescribe appropriate anti-anxiety medication accordingly.

Reducing Sexual Risks

What can parents and professionals do to help reduce sexual risks for girls with ADHD? Support groups for girls with ADHD can help them feel more accepted and less alone without them having to seek male sexual attention. Helping them become involved in structured, constructive activities will give them other outlets to develop self-esteem. Recent studies confirm what common sense tells us: adolescents who are kept busy in extracurricular activities, sports, church groups, and so on are less likely to get in trouble during high school. In addition, an open, supportive relationship with their parents gives them somewhere to turn for advice if they do become sexually active — either to help them make a wise choice of birth control or to help make the best decision if they do accidentally become pregnant.

Reducing risks associated between ADHD and driving

The important message for parents is that their daughters with ADHD may need more practice in driving so that driving skills become more automatic and require less concentrated effort and attention. Secondly, since attention problems seem to be strongly implicated in traffic accidents, girls (and boys) with ADHD should take care to drive in less distracting situations during their first years as a driver. They should avoid heavy traffic, social distractions, such as excited, talkative peers, and maintain more conscious awareness of their need to “keep their eyes on the road.” Even in adulthood, individuals with ADHD may find themselves distracted by conversation while driving. For less experienced drivers, such a distraction could be all it takes to trigger a chain reaction leading to an accident. Thirdly, situations that may lead to impulsive reactions should be discussed in advance and avoided, if possible. Such situations might include driving with peers who have been drinking and who may encourage a teenage girl with ADHD to take a risk “for fun.” Parents who have reason to suspect that their daughter engages in alcohol or drug abuse should carefully consider whether it is safe to allow their daughter to begin driving independently as early as her peers.

Learning to recognize and to embrace her strengths

Girls who have developed ability or talent in some area seem to be much better inoculated against clouds of self-defeating gloom. One of the most constructive approaches in helping a girl with ADHD through her high school years is to actively help her develop and recognize areas of competence and talent. The more that girls with ADHD are in touch with their areas of competence the less vulnerable they will be to the criticisms and frustrations that so often accompany ADHD.

There are many arenas in which to develop a sense of competence and ability: part-time work after school, volunteer work, helping to build props for the school play, participating in a community beautification project, learning to ride horseback — many such activities can be enormously beneficial in helping her to build a sense of self-confidence.

Learning assertiveness and self-advocacy

The high school years are the time in which a girl needs to develop the self-advocacy skills needed for more independent life beyond high school — whether in an educational setting or in the workforce. She will need to be able to express her needs confidently and convincingly to professors or employers who are ill- informed about ADHD. She needs validation of her right to express her opinion, and help in learning to express it in a constructive, effective manner.

The benefits of structure

As with girls of all ages with ADHD, teenage girls need support, encouragement, and structure. Because teenage girls are trying to develop more independence, sometimes it is more helpful when someone other than her parents provides structure. This could be a therapist, coach, or school guidance counselor. These are the years when the teenage girl needs to take on the notion that learning to be on time, developing tools to improve her organization, setting priorities rather than staying in a reactive mode, are for her own benefit, not something imposed by parents.

Conclusion

The high school years are among the most challenging years of life for an individual with ADHD, and especially for girls with ADHD. To bridge the challenges of high school, they need support from peers, parents, and schools, combined with appropriate medical treatment, depending on their particular needs and issues. With the right supports and interventions, these girls can make the crucial transition from the chaos and self-doubt of adolescence to a sense of growing strength, efficacy, and competence as they enter their young adult years.

More information about teenage girls with ADHD can be found in Understanding Girls with AD/HD by Kathleen Nadeau, Ph.D., Ellen Littman, Ph.D. and Patricia Quinn, M.D.This article is copyrighted and cannot be used, copied, or distributed without the written consent of Advantage Books, LLC.