ADHD and Self-Harm: How to Help the Girls Who Suffer Most

We’ll say it one more time, for the people in back: ADHD is gender neutral.

Boys are no more likely to have it than are girls. But they are much more likely to get diagnosed. In fact, boys diagnosed with attention deficit hyperactivity disorder (ADHD or ADD) outnumber girls by roughly three to one. And this disparity is fueling a serious public health problem for girls with ADHD.

Unlike boys, who are more often diagnosed with hyperactivity or impulsivity and can draw more attention to themselves, girls tend to show fewer outward symptoms of ADHD. These differences fuel the erroneous belief that girls don’t have ADHD as often as do boys. The truth is that traits of ADHD can look different in girls: daydreaming in class, silliness or spaciness, shyness, picking at self, perfectionism, feeling anxious or sad, forgetfulness, emotional dysregulation, and trouble keeping friends. When girls receive early and appropriate diagnoses, they will benefit from effective interventions and flourish. There is plenty of hope and promise for girls with ADHD.

Still, it’s important for caregivers and educators to be aware of studies from the University of California, San Francisco (UCSF) that paint a sobering picture of possible outcomes, especially for untreated girls with ADHD. Compared to young women without ADHD, those with ADHD are less likely to complete their college degrees and more likely to have unplanned pregnancies.¹ Most concerning, especially for impulsive girls, is their potential for self-harm, which is significantly higher than for girls without ADHD.

“Our findings of extremely high rates of cutting and other forms of self-injury, along with suicide attempts, show us that the long-term consequences of ADHD in females can be profound,” says head researcher, UCSF psychologist Stephen Hinshaw, Ph.D., author of the 2014 book The ADHD Explosion.

Taken as a whole, these findings are a wake-up call for both parents and clinicians, and they underscore the fact that, even as girls with ADHD mature and appear less symptomatic, they continue to suffer silently, says clinical psychologist Ellen Littman, Ph.D., who has worked with girls and women with ADHD for more than 30 years.

[Think Your Daughter Might Have ADHD? Take This Test]

“Girls often hold all of these feelings of anxiety and shame and fear and frustration in, so too often, no one is aware of how bad they’re feeling about themselves until it’s too late,” says Littman, author of Understanding Girls With ADHD (#CommissionsEarned).

As with many adverse effects of ADHD, timely intervention, diagnosis, and treatment can make an enormous impact. But, left unrecognized and untreated, symptoms of ADHD in girls can cause significant, life-long struggles. To help their daughters maximize their potential, parents must get informed, act early, and obtain necessary support services.

Follow these steps:

1. Know that ADHD symptoms may be diagnosed as young as age 4.

If you suspect your daughter may have ADHD, don’t wait to seek help, Hinshaw says.

“Each year without a diagnosis, she loses access to treatments that can help her gain social, academic, and self-regulation skills,” he says. “As girls fall farther behind, it’s harder to catch up, making them more likely to face greater challenges later on.”

Even if your daughter has a diagnosis and seems to have her ADHD symptoms under control, stay vigilant, Littman says. For many girls, internalizing symptoms like anxiety and depression blossom around puberty, as estrogen levels increase. As hormone levels fluctuate throughout the month, medications may vary in effectiveness. Even with a prescriber knowledgeable about the hormonal effects on girls with ADHD, finding the optimal regimen can take time and patience.

[Read This Next: Stop The Cycle of Shame for Women and Girls]

“Be watchful for small changes in behavior, that can be subtle but rapid,” Littman cautions. “A girl might be doing great when she’s 13 and a half, but at age 14, a change in her peer group can trigger emotions that can derail her. Girls are not comfortable revealing the extent of their difficulties, but a good clinician will know the right questions to ask and how to ask them in order to help girls navigate some of these complex transitions.”

2. Build an ADHD treatment team that understands girls’ symptoms.

From conducting a thorough assessment to monitoring medication to tracking ongoing behavior-management training, your daughter’s ADHD treatment team can play a huge role in improving her well-being and long-term outcomes. The first step is ensuring she receives a thorough assessment, Hinshaw says.

“A 10-minute visit with a general pediatrician is not going to cut it,” he says. Instead, parents need to find a provider experienced in treating girls with ADHD who will build an in-depth developmental history using parent and teacher rating scales, as well as family conversations. Experience with related conditions such as generalized anxiety disorder and depression is also critical.

“A lot of things, including seizure disorders or maltreatment, look like the inattention and impulsivity of ADHD,” Hinshaw notes. “Unless you rule out differential diagnoses, you may think its ADHD when it’s not.”

Once a diagnosis is in place, the evidence consistently shows that the most effective treatment is ADHD medication combined with a range of behavioral treatments, including family-management training, consultation with teachers, and social-skills therapy, Hinshaw says.

Littman adds that a mental health professional who has experience with girls with ADHD can provide ongoing monitoring and support to the family during the tough transition years.

“It can be difficult to find someone as not many professionals have a lot of experience in treating girls, but it’s worth the extra effort,” Littman says. These professionals can contribute significantly during the later teen years and early adulthood, when young women entering the workforce need to develop better organizational and time-management skills, as well as emotional regulation, Hinshaw says.

Open communication among providers and parents is also important so that the family has a dependable network of support, Littman notes.

“I tell parents to send me an email anytime they see anything that might be out of the ordinary,” she says.

3. Make home a ‘safe place’ with family therapy.

Research suggests that individual therapy for children with ADHD isn’t particularly effective. Nadeau and other experts agree that ADHD therapy often works best when it involves parents, particularly mothers. This can help ensure everyone in the family is doing all they can to support the child with ADHD, who may also feel less alone.

“I really try to work on the mother-daughter relationship with my clients because home should be a safe place, not just another place where someone is annoyed at you because you forgot something,” she says. Nadeau will often coach mothers of girls with ADHD about how to be more supportive and less critical at home, and help them have more realistic expectations about their daughters’ difficulties with keeping an organized room organized, completing homework, and keeping track of time.

“Since ADHD often can be genetic, I never assume that the mother has it all together herself,” she says. “I try to encourage moms and daughter to help each other stay organized because that helps normalize the process for everyone.”

4. Work closely with school staff.

School is often a source of intense frustration and shame for girls with ADHD. Because girls often exhibit symptoms of inattention rather than hyperactivity, they aren’t as likely as restless, disruptive classmates to be identified and referred for help by their teachers, Littman says. She encourages parents to set up a meeting with their daughter’s teacher at the beginning of every school year to discuss the concerns they might have. During this meeting, explore goals for the year and how to work together collaboratively to meet them.

“You don’t have to mention ADHD specifically, but describe the challenges to make [the teacher] more aware that, even though your daughter might seem passive and doesn’t participate in class, she wants to be successful and is trying her best.  When you help the teacher better understand your daughter, the teacher will be more attentive to her problems and be able to offer you concrete solutions,” Littman says. Hinshaw also reminds parents that instituting a 504 plan or an Individualized Education Program (IEP) is the best way to establish school accommodations to help a child thrive in the classroom.

“Don’t be afraid to pursue this,” he says. “You’re not asking for your kid to be coddled, you’re simply asking that accommodations for a mental health disorder be recognized.”

The school setting can also be an excellent place for group therapy, given how common ADHD has become, notes psychologist Kathleen Nadeau, Ph.D., director of the Chesapeake ADHD Center of Maryland. She adds that some school counselors host a “lunch bunch” group for girls with ADHD. Lunch can be an ideal time for this because it doesn’t involve taking the girls out of class and mealtime is a more natural social setting.

“Many of these girls go into the lunchroom and feel ignored,” she says. “This type of group is so easy to form in the school environment because it’s free and convenient.” If your school does not offer a social group such as this, Nadeau encourages parents to talk to their school principal and/or counselor.

5. Promote her strengths.

To build resilience, help your daughter find things she likes to do and at which she excels. Name and nurture her interests so she develops a sense of competency. Support her in whatever ways you can in pursuing that strength, Hinshaw says. Whether it’s playing soccer or the piano, drawing, writing or singing, help your daughter cultivate her passion and encourage her to make time for it by carving out time in your own schedule — a signal that these pursuits matter.

This becomes particularly important during a girl’s menstrual cycle, Nadeau says, when emotions are heightened and she is in need of positive coping mechanisms. “Too often, teachers and other adults in a girl’s life focus only on her weaknesses,” Nadeau says. A passion project or hobby can offer a self-esteem boost, a refuge from challenges, and a positive vessel for intense emotions.

This can also be important later in life when your child begins exploring career paths. Parents and school counselors must work as a team to support girls with ADHD to consider pursuing careers that play to their strengths — and interests.

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The Latest Research on Girls and Women with ADHD

Led by Hinshaw, the Berkeley Girls with ADHD Longitudinal Study (BGALS) has tracked the behavioral, emotional, and academic development of 140 ethnically and socioeconomically diverse girls with “rigorously diagnosed ADHD” from childhood to adulthood since 1997. Some study participants were taking stimulant medications to treat their ADHD symptoms, whereas others were not. Even controlling for treatment disparities, Hinshaw and his team found that — similar to boys with the condition — the girls with ADHD were more likely to struggle academically and face peer rejection during childhood than was a demographically similar group of 88 girls without ADHD.

In adolescence, however, gender disparities emerge between boys and girls with ADHD. While research shows that fidgety and restless symptoms tend to subside in middle and high school, the learning gap between girls with ADHD and their non-ADHD peers often widens — and eating disorders, risky sexual behaviors, and substance use issues begin to surface.

As the study participants — who were recruited from schools, mental health centers, pediatric practices, and via advertisements — moved into their later teenage years and early adulthood, Hinshaw said follow-up interviews with the girls and their families offered other important conclusions. While participants with ADHD reported average rates of high school graduation, their test scores were significantly lower and they were more likely to have failed a grade, gotten suspended or expelled from school, and dropped out of college.

For some girls, self-esteem continues to suffer and self-doubt grows. These girls are despairing, ashamed, isolated, and can’t always see a way forward. More than one-fifth of the BGALS study participants with ADHD had attempted suicide, compared to only 6 percent of the girls without a history of ADHD.² And more than half of the participants with a history of inattention and impulsivity reported that they’d engaged in moderate to severe self-harm, including cutting, burning, or other forms of self-mutilation, compared to 19 percent of typically developing young women. The risk for self-harm was particularly high among those who had symptoms of inattention plus high rates of hyperactivity and impulsivity.

In the team’s most recent follow-up, when participants’ average age was 26, they found that about 45 percent of the girls with ADHD had experienced an unplanned pregnancy, compared to 10 percent of the control group.³ More research of girls with ADHD, including larger studies across diverse geographies, is warranted.

ADHD and Self-Harm in Girls: Next Steps

• Read: Why We Can’t Ignore the Quiet Girls Any Longer
• Free Download: Understand Inattentive ADHD
• Learn: Nearly One in Four Women with ADHD Has Attempted Suicide

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