Transcript ADHDCC01
Today we're going to talk about what ADHD looks like in girls. And some of you may be wondering, "Well, why do we need to talk about girls versus boys? It's ADHD. " And that is true, to a point, but one thing that we know is that ADHD continues to be under diagnosed in girls. Well, why is that? It's a little complicated, but one of the issues is that females more often have the inattentive form of ADHD. And that's just not as likely to be noticed in different environments as the hyperactive form. Boys are more likely to have the hyperactive form.

 Now, let me just say before I dig into this (because we're going to dig into about eight different girls and describe eight different girls with ADHD and what they look like) that if a boy has inattentive ADHD, well, that could very likely look like him as well. I just have a lot of experience working with females, and I specialize in working with women who have been diagnosed with ADHD as adults, so my experience is very girl heavy. I have ADHD. I have two daughters with ADHD. And one of the things that I've seen clinically and in my work as an occupational therapist, is that a lot of times these girls get missed. 

I thought it'd be helpful if I introduce you to eight different girls who have ADHD. You can see how it shows up, what it looks like in their lives. A lot of the women I work with are trying to piece together their history as they're trying to figure out whether or not they have ADHD. They're getting help now as adults. A lot of times we're looking back at childhood because it's really important to do that, because ADHD is a neurodevelopmental disorder. That means if you have ADHD, it shows up in childhood. If it's something that suddenly shows up in adulthood, it's likely to be something else. There's a lot of overlap with ADHD and different diagnoses. 

The problem with that is that a lot of ADHD gets missed, especially for girls, and especially for those who have the inattentive form of ADHD. So I thought it'd be helpful if we just dove in today and rather than me list a bunch of symptoms and a bunch of scenarios, I want to introduce you to girls. These girls are based on real people, people that I know, people that I love, people that I've worked with, people I'm related to. These girls are very near and dear to me and these are real people. I think that if you see yourself in these girls, if you see people you love in these girls, it's worth digging a little deeper and seeing if ADHD is a factor. 

I'm not saying that seeing yourself in one of these girls it's a slam dunk. It just gives you information and for a lot of the women I work with, it gives them kind of a missing childhood piece. We're going to see more about that in just a minute. 

The first girl that I'm going to introduce you to is Ellie. How does ADHD show up for Ellie? Ellie is a crier. Ellie cries when she's angry, she cries when she's sad, she cries very easily.  The adults in her life tell Ellie that she's "too sensitive" and she needs to toughen up. And she does cry easily. She cries for things that don't make her peers cry. She's easily frustrated. She's not able to stop herself from crying and this embarrasses her. She doesn't want to be "overreacting" and it's causing her to strike out with friends. She's not getting invited places. She's not having people accept her invitations. It's jamming her up a little bit and it's not something that she wants to be true. She gets frustrated. 

She cries at home and at school,  but she's usually able to keep her anger kind of loosely in check at school. At home, it's not possible.  At home, she comes home and not only does she cry, but she has tantrums, she has fits, she throws things, and she melts down. Her mom says she goes from 0 to 60 with no warning and she doesn't even know what's going set her off. Of course, this causes friction in her house and friction with her siblings.

 So what is going on with Ellie? You already know she has ADHD. Why is it showing up this way for her? Because Ellie has problems with emotional regulation. And for those of you who are not familiar with emotional regulation, that means that emotions for Ellie show up in an overwhelming way- she gets flooded with them. This is probably most problematic with what we would think of as "negative" emotions like anger or frustration. This causes the most disruption, but even happiness and joyful emotions are almost too much for her.

 Another thing going on with Ellie is impulsivity. Now we all have impulses. So when you say impulsivity, you're talking about the impulse that all of us have, "I'm so frustrated that I want to throw this thing across the room", but Ellie is missing that little pause that more typical brains have between the impulse and an action. So there's an impulse, a pause, then action. Impulse "I want to throw this thing because I'm frustrated", Pause- I'm going to take a second, just a millisecond to think, "Well, how's this going to end? What are the likely outcomes? What do I want to happen? How worth it is it to do this?" This pause could also include going back to your impulse and saying, "Oh, that made me really mad. Is that the way she meant to say that? Could there be something else going on?". 

That pause lets you think about what happened before your impulse. Ellie doesn't have that. She has no pause, or very little pause. So she has an impulse and then an action. So she has this emotional regulation stuff going on and this, impulsivity going on- that's what it looks like for Ellie. It's really easy to look at an Ellie and think, "Okay, well, the goal is that she just stops behaving this way." And of course, that would be better,  we want her to stop having tantrums, we want her to be able to connect with her friends and not break into tears for every little hiccup. 

But if we only focus on this, here's the tricky part: most of our Ellie's are going to reach a point in their lives (some sooner than later) where the consequences are so great that if they can, if it's available in any way to them, they're going to stuff down those emotional reactions, in order to be accepted or in order to not get in trouble. Very often social rewards are the most important, so Ellie might reach an age where she decides or attempts to really rein this in so she's not rejected by her peers. The problem with that is that just because we're not seeing that Ellie is not regulating emotionally, doesn't mean that she's actually regulating. So what happens? All that stuff gets bottled inside, stuffed down. 

And there you have a high risk for Ellie, where's she at risk of? Well, many of you already know that she's at risk of addictions. What a lot of people don't know is that Ellie is also at risk, as a female with ADHD, of developing an eating disorder. Both addictions and eating disorders can be tied in to difficulty with regulation in that people are seeking out methods to regulate. These are not typically yoga, right? They're grabbing what's available to them without much conscious thought of this. So we want to be careful with an Ellie that we're not just saying, "Hey, let's just get her to shut up and calm down" because there's a lot going on that she needs help for. 

Our next girl is Natalia. Natalia is friendly, she's outgoing, she's fun, and she's always had a really easy time making friends. Lately, she's having a hard time keeping friends. Why? Well, Natalia tends to interrupt her friends. She gets so excited if they're sharing a story, she gets so excited about what she wants to share that she just jumps in blurts her story out and doesn't even really acknowledge that they said anything and kind of hijacks the conversations. She does this a lot. She doesn't really mean to be rude. She knows she should probably listen to her friends and let them at least finish a little bit, but she gets so excited and she's also pretty sure she's going to forget what she wants to say. One day Natalia is kind of walking down the hallway and she sees her group of friends but they don't see her. She overhears them talking about her. They're saying "She's so selfish. She's so annoying. She only cares about herself. " Natalia is devastated. She didn't see that coming. She's just floored. So what's happening?

So what's up with Natalia, how does ADHD play into this? Well, Natalia is impulsive. That whole pause that we were talking about with Ellie is a really mini to no pause for her. She wants to share a story. She shares her story. She doesn't have this minute where she's thinking "Oh, what's this going to make my friend feel like? Will it seem like I'm interested, will it seem like I care?" She does care. She is interested, but that perception matters with friends, that they feel cared about as well, not just that that exists within you. So that's an issue for Natalia, but a really big issue for Natalia, that we don't really think about, is working memory. That's a huge issue for many people with ADHD. 

What does that mean for her? It means when she said "I'm kind of afraid I'm going to forget this story.", she's going to forget the story! A minute down the road,when it's the right time to to share her story, after she's acknowledged her friend and let her friend understand that she heard her and cares about what she's saying, she's forgotten it. She doesn't have it anymore. So there's those two things are working together that are really kind of cramping her socially. 

The third thing going on with Natalia (and this is a huge thing going on for our girls and our boys with ADHD) is that she's not attending to, paying attention to, the social cues around her. So a lot of her friends with more common brains, more typical brains, they're getting feedback all the time. And there's been feedback from Natalia but she hasn't seen it. She hasn't noticed it. When she's cutting her friends off, she's getting rolled eyes, arms crossed across the chest, exchanged glances with friends, awkward pauses, there's all kinds of clues that are letting a Natalia know to change course correct course here. She doesn't get them. So when she hears her friends talking about her, it's out of nowhere for her. She's had no chance to correct course, she's had no chance to adjust what she's doing. She's just kind of thrown in there with this result and no understanding of how she got there. And of course, that's really tough. 

Next we're going to meet Meg. You're going to meet 8 girls today, you've already met two, Meg is our third. I will tell you that Meg is one of the two girls who are the least likely to get diagnosed as a child.  Meg is a child who worries. She worries about everything. Worrying actually helps this child remember. She relies on her worry so she's not forgetting things. She also relies on something else, especially in the classroom. She relies on a friend. Her little friend Anna sits next to her and always knows what's going on. And so she asked Anna, what's going on? What were the instruction she just missed? What's something she didn't understand? She leans really heavily on Anna. Normally, that's fine for Anna; she's patient, she's paying attention. Sometimes it annoys Anna. She's trying to listen to the next thing and it's actually disrupting her in the classroom. So she's not always so happy to help.

Now, Meg is worrying about all the things. She's worrying about saying the wrong thing in class. She's worrying about forgetting things. This child is so worried about getting in trouble...Meg is never in trouble, but that doesn't stop her worrying about getting in trouble. She's super sensitive to any kind of feedback or doing things wrong, and so this child is constantly second guessing herself. And that happens socially, too, maybe even more so socially. She's quiet in groups. She's hesitant to join in conversations. She's second guesses the things that she says socially and in class all the time. What does that mean? Well, a Meg ends up being kind of invisible in the classroom. You don't see her, she's definitely not causing trouble. She's working really hard to blend in. 

What's up with Meg?  Meg is tricky. Here's the thing about anxiety and ADHD: Anxiety can look like ADHD, ADHD can look like anxiety, and they can coexist. So we know, we get the cheat sheet, Meg has anxiety and ADHD. Her anxiety is helping mask the ADHD traits. She is compensating that way. Her constant worry keeps her on top of things. Is it good for her body and her energy and her life? No, she's got this constant state of hyper vigilance that's just exhausting. She's got cortisol flooding her body all the time, she is in this constant state of exhausting hypervigilance. Another thing that Meg is doing is  leaning on her friend Anna to compensate. Meg has inattention, which we know is really common. Obviously, one of the pillars of ADHD is that you're not attending and so she knows she's missing things. She doesn't want to embarrass herself and she doesn't want to get in trouble, so she's leaning really heavily on Anna to figure out what she's missed. 

But it's not just inattention. She has difficulty with her working memory just like Natalia. If her teacher just listed out three things, she just got the last one. Holding that information in her head (is difficult). These kids are especially going to have a hard time with auditory instructions and directions if there's no visual backup. The third thing for Meg is that she has executive functioning issues. If you have ADHD, you have issues with executive functioning. Some people have them severely, some people have them marginally, but it's impacted.

She has deficits in executive functioning skills, these are the skills that help you plan things, break things down, organize things, make decisions, prioritize, etc. These are really heavy skills for the classroom. With instructions that require her to figure out something, sequence something, have steps, she's lost.  So she's also leaning on her friend to do that for her. Anxiety and ADHD are keeping her from making connections with her friends, are keeping her from being a part of her classroom, and they really cause her to live kind of on the fringes. She's very unlikely to stand out as being someone who actually needs help- maybe for the anxiety, but not for the ADHD.

 Now we have Jesse. Jesse is who you picture when you say "My daughter has ADHD." It's Jesse. She has ants in her pants, she's constantly moving. Even if she's doing something that's seated, like watching a show, she's flipping off the couch. She rushes through everything that's boring. What's boring for Jessie? Everything that she doesn't want to do. She rushes through the shower nad she leaves with shampoo in her hair. She wants to leave the dinner table before her family even sits down.

 She's constantly rushing through things like homework with sloppy handwriting, missing questions, and making what we call "careless" mistakes. She talks fast, (like I'm doing now, so I'll try to slow down). She talks fast and she's hard to understand. She she talks fast and she mumbles. She's constantly being told to "talk slower, talk quieter, and slow down". She has a hard time controlling her volume and she has a hard time controlling her speed. 

This is home, right? I just described home for Jesse. Imagine school for Jessie. She has a hard time staying in her seat. She'll get up and leave the room without permission. And so what does that look like? Well, it can kind of look like she's defiant. She's not defiant, but she she looks like it. She's not following directions and she distracts her classmates all the time. She makes noises, she's touching them, she's drawing on her desk, she's whispering to them, she's pulling their clothing when they're in line. Jesse is always fiddling with someone, annoying someone, and she needs constant reminders to not touch other people, to stay on task, especially if they're moving between classrooms. 

What's going on with Jessie? We already talked about impulsivity. Jesse's impulsive. We didn't talk as much about hyperactivity, but that's the ADHD trait that everybody pretty much can figure out and see in Jesse. She's impulsive and she's hyperactive.This child is much more likely to get diagnosed with ADHD, and that's working in her favor, because maybe she's going to get tools. But she's also really likely to have constant negative feedback about her behaviors. This is at school, with her family, her friends, her teacher...She's going to get a lot of "You're too much" and that's going to have a pretty big impact on Jessie. 

 I mentioned before that her impulsive behaviors can look like intentional defiance and this can end up being a really bad cycle for her. If (her behavior) is being interpreted as defiance then people respond as if it's defiance (when in reality) this child is just seeking out constant movement and dealing with impulsivity. Another thing about Jessie is that the consequences and rewards that really work well for every other kid in her classroom don't work well for Jessie. She is in the moment and so these rewards and things that are extended away out of the moment, and consequences that are not in the moment, they're not going to work for her. That gets really complicated because that's how most rewards and consequences work. They're a little more removed from the moment and that's tough for Jesse.

 The next girl we're going to meet is Shreya.  Shreya needs to move to focus but not like Jessie. She's kind of wiggly and fiddly and fidgety. What would that look like in the classroom? She's doodling on paper, she's playing with her hair, fidgeting with little things on her desk, chewing on her pencil, tipping her chair back, and doing all these things thatmight be a little annoying, but they're not a huge disruption. These are the ways she's trying to focus. 

This child is seeking out a lot of sensory input, a lot of movement to help her focus. At home it can be kind of frustrating  because she's playing with her food (that annoys her mom), fiddling with napkins, and not really doing the things that mom wants her to do, like eat her food and move on. Also at home, when she's doing schoolwork at the table with her with her siblings, she's humming or singing while she's working. This really annoys her siblings because they can't focus, but Shreya isn't even aware that she's doing this. She doesn't realize that she's humming and singing. 

So what's up with Shreya? She has some behaviors that aren't as as easy to recognized with ADHD. But she is actually using these to pay attention: her fiddling, her doodling, or humming are all ways she's getting sensory input in order to focus. These behaviors can be misinterpreted. They're not as disruptive as Jessie's, but if they're going on, they can be irritating to people. More importantly, this is how her ADHD is showing up for Shreya. It's not showing up with fireworks. It's easy to miss sometimes and if she's not struggling at this moment with her classwork, it's easy to think that this isn't really a big deal. We need to look deeper with Shreya, though, and see what's going on with her and what is a big deal for her. How is ADHD impacting her? We're seeing that she's struggling to focus, what does that mean for Shreya? 

I already mentioned that you're going to meet two girls that are not likely to be identified as having ADHD.  Meg was our first girl (with anxiety and ADHD) and Faith is our second girl. Faith is probably, out of everyone, the least likely to stand out in the classroom. So what's up with Faith? Faith is  low energy, especially in the classroom and in school. She's got her head propped up in her hand and sometimes she looks like she's half asleep. Maybe she's going to rock back in her chair and get some movement or bounce her leg, but maybe not. She might not do that at all. She might just look super low energy. Her thoughts drift and she's not always ready to answer in class, but she's not disruptive in any way. And if she doesn't get called on, it's not really going to show up. She also tries to avoid eye contact, and can be almost invisible in the classroom.

 This is another kid who's going to be flying under the radar, especially in the classroom. She doesn't want to draw attention to herself. She knows she's not always focused and so she's trying to fly under the radar. Here's the thing about Faith, though: Faith is super intelligent. She knows the answers to the questions that are being asked, but she can't answer quickly. 

She looks kind of low energy, but she also processes slowly and so she's not as quick to answer as her classmates. That means that a lot of times people yell out the answer before she even knows if she knows it. She's not really sure what she knows sometimes because she's slower and that rhythm is not a good fit for most classrooms. A lot of classrooms equate "fast" with knowledge, with mastery, and that's not Faith. She also spends more time than her classmates on her assignments. Pressure and timed work can actually cause her to slow down even more.

The fast pace of the classroom is exhausting for Faith. What does that mean for home? By the time she comes home, that child is toast. She's tired, she's irritated, and she's going to be more likely to melt down (just like Ellie was). She might look really different at home because she's just exhausted at that point. 

So what's up with Faith? Why is ADHD showing up for her this way?She has problems regulating her attention and energy levels just like all the people with ADHD, but for her this looks different. For her, it's low energy. And what's the worst thing for her in the world? Sit in the same place for a couple hours. By the time that's done, that child has tanked. 

So when we see Faith moving and kind of fiddling, rocking in her chair, she's not hyperactive. She's trying to get sensory input to get her attention level to come up, her nervous system level to come up where she can actually pay attention. She is slow to process auditory information, part of that is because she's inattentive and can't filter out sounds around her and also that she drifts in her thoughts. She's rarely able to show what she knows in the classroom. 

She's just not quick enough and of course that ends up impacting the kind of student she is and the kind of student she thinks she is. Even is able to get the extra time she needs for the test, it embarrasses her to ask fo an accomodation. She doesn't want to have that attention drawn to her. Honestly, she's not likely to get diagnosed at this point her life and she's not likely to get that help. So that's Faith- she's another tricky girl. 

Our next girl is Jada. Jada is a sensory kid. Now you already know Jada has ADHD, so this is not going to be confusing for you, but it can be confusing. Just like anxiety and ADHD, sensory issues and ADHD can be confusing. Why? Because sensory regulation issues, sensory processing issues, can affect your energy and your attention. They can look like ADHD and they can co-exist with ADHD. 

So this is not clear cut all of the time. But we already know Jada has ADHD and sensory issues, and that happens often that those two things show up together. Noisy places like the lunchroom, bathrooms, indoor gym, they're all overwhelming to her. She can't hear her friends and she can't filter out the noises. She can't focus.

 Not only that, but it gets her elevated, irritated, agitated, and that doesn't just go away when the sound goes away. She's in that agitated state for a long time once she's been overloaded with sensory info,and that makes her not very available for learning throughout her day. She's always managing these sensory assaults. She has tags on clothes that bother her, seams on our socks that bother her and she doesn't like a lot of different food textures. She's a picky eater. This child also appears kind of grumpy and even controlling when she's trying to avoid some of the her sensory triggers in her day.

 So what's up with Jada? Jada has sensory regulation issues and this is not a small thing. You know, sometimes we have a little sensitivity, but for a kid (or an adult) who's really affected by this, it can have a huge functional impact for them. The presence of sensory issues doesn't mean that she has ADHD. But we know that she does, so we know that she's dealing with both ADHD and sensory issues. Honestly, there's only so many sensory inputs that Jada is going to be able to avoid in her day. She may be able to avoid many of them at home because you can alter things a little bit more at home, but in the classroom she doesn't have as much control over what she's taking in sensory wise. So, school is tough for Jada.

Now we have Lily. Lily's dad calls her the "master of disaster" because every environment for Lily is kind of a disaster. Her bedroom is trashed, her locker has things falling out of it, her backpack has papers crammed into it, she loses things and constantly misplaces things.

 She can't really do her homework unless someone's sitting with her (and that's if she can even find the papers and her bags and stuff). She's constantly in a cyclone of chaos, not because of any hyperactivity, but because of the mess and the disorder around her. If dad says, "Hey, go clean your room", it just doesn't happen- it absolutely doesn't happen. She can't do this on her own. It looks like she won't do it on our own. That's what it appears like to the adults in her life. Even if she has a reward promised afterwards, she still doesn't get it done. She might end up crying or being upset in her room because she's not making any progress in cleaning this room. Dad eventually goes in and cleans it for her, step by step and what happens the next day? It's back to a trashed mess. 

What's going on with Lily? Well, Lily has executive functioning issues. She has deficits in that area. If you have ADHD, these will be impacted. Executive functioning skills are the ones that help you break down your tasks. We talked about that before, these are the goal directed skills. So with things like organizing her room, she's got to figure out where do all of the things go? Where's their home? What are the steps? What's the priorities? What can she keep and throw away? This seems obvious to some of us, but if you have executive functioning issues, this is a minefield. This is really frustrating, challenging, and difficult stuff. 

Even if you have somebody who comes in and does all of it for you, you're still lacking the skills that help you maintain it. Another thing going on with Lily is that she has inattention and poor working memory. That shows for her in two ways. Number one, she doesn't pay attention or remember the homes for things. This child is best served by having labels on things. You may think she would remember where they would go, but she's not remembering. Also, her inattention and poor memory mean that she comes in the door, she takes off her shoes, and since they don't have a home, she's not paying attention to where she takes off her shoes. She's on to the next thing in her mind. She doesn't remember where she put her shoes because she has memory issues  and so this child is always looking for things. 

She's always losing things and looking for things, because things don't have a home in her world. She doesn't pay attention to where she's placing them and since she doesn't remember where she puts them, she's always losing things. This makes it really hard for her to get to an organized state. And the same thing is true with her papers and her schoolwork. She's not able to prioritize and decide "What can I throw away? What do I keep?" so everything ends up being overwhelming and she keeps all of it. It's not that she won't clean her room or that she's sloppy and messy, it's that she doesn't have the skills to allow her (at this point) to do this. She needs a lot more support than you would think a child her age would need.

 The last factor for her is that she is so visually overwhelmed in her environment that she just shuts down. So when you see somebody who's operating in a really chaotic, crazy mess, it's very likely that they don't see it. They're not seeing it because they've already crossed over to this total overwhelm and they're kind of protecting themselves, they've shut down. They're not getting all that input. That's actually what's happening with Lily, she doesn't even see the level of her the chaos in her room, in her backpack, and in all the places that she's operating.

That brings us to the end of the eight girls that we met today. All of these girls have ADHD, and they are all showing up in different ways. If none of these girls are diagnosed, they're not likely to have the support that they need to thrive with ADHD. They're really not, even if they have adults who are loving and connected and trying to support them (oftentimes by doing a lot of things for them). They may not be giving them what they need to be able to bridge the gap later in life. What are they going to believe about themselves when they're not able to meet expectations? That might happen sometime in school for these girls or that might happen way beyond school, with the wrong kind of job for them and their abilities. 

A lot of women experience not being able to close the gap when they become moms. When they become parents it just becomes too much and all of these strategies and ways that they have managed to stay afloat, working very hard to stay afloat (don't work). It just becomes more than they're able to compensate for and manage. I think it's really important that we understand and educate people that ADHD doesn't always look like the stereotype. It can, but it can look like a lot of things that are more nuanced, more subtle, more complicated. This is a complicated subject. 

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