January 21, 2025
Cindy Lopez: Welcome. My name is Cindy Lopez, the host of this CHC podcast, Voices of Compassion. We hope you find a little courage, feel connected and experience compassion every time you listen.
The data shows that ADHD is diagnosed in boys more often than girls. I wonder why that is? Join us today as we talk with Dr. Marjan Ebadi and Dr. Dylan Stewart, both psychologists at CHC, as we explore the factors behind this disparity. We’ll discuss how ADHD often looks different in girls, manifesting as inattentiveness or emotional sensitivity or even perfectionism rather than hyperactivity, and why these signs are frequently overlooked. And finally, we’ll share practical strategies for parents, educators, and caregivers to recognize and support girls with ADHD, empowering them to thrive.
Welcome Dr. Ebadi and Dr. Stewart. We’re really excited that you’re here today to talk about this really important topic with us. I just wonder before we start our conversation about ADHD in girls, why don’t you take a minute to tell our listeners a little bit more about you?
Dylan Stewart, PsyD: My name is Dr. Dylan Stewart. I’m one of the clinical psychologists here at CHC. And I specialize mostly in the assessment of neurodiversity. So, you know, looking at things like ADHD, learning differences, autism, that’s how I tend to spend most of my time.
Marjan Ebadi, PhD: I’m Dr. Marjan Ebadi. I’m also one of the clinical psychologists here. And I also focus on assessment, but mostly on ADHD and anxiety and mood disorders at CHC.
Cindy Lopez: Yeah, talking about ADHD and girls, we’ve done quite a few podcast episodes on ADHD in general, or ADHD and medication or interventions or ADHD and superpowers of ADHD, all of that. We haven’t really talked about girls, so I’m excited for this topic today. And before we dive into that, the specific girl topic, let’s start by defining ADHD. What is it? How does it impact our youth?
Dylan Stewart, PsyD: Yeah, that’s a great question, you know, it’s helpful to set those parameters certainly here at the beginning. So, when we think about ADHD, we know that it’s a form of neurodiversity, which means that there are certain ways that the brain is working, which can lead to challenges, you know, at home, at school, throughout their everyday life. And when we’re thinking about ADHD, you know, some of the most common challenges we tend to see are things like hyperactivity, which is needing to move your body around really often, things like impulsivity, you know, quick kind of reactive behavior someone might be having, moments of inattention, moments where maybe they kind of have this hyper-focus or really focusing intensely on one thing, certainly we’ll see things like, difficulties with organization or planning, maybe, challenges starting tasks, kind of initiating school work or, you know, an assignment that they’re doing. We can see challenges with things like time management, certainly, some difficulties with emotional regulation. And, sometimes we’ll see things like forgetfulness as the symptoms we’re kind of, you know, trying to understand with regards to ADHD.
Cindy Lopez: As you’re going through that list. I’m like, “Oh, that’s me. Oh, that’s me.”
Dylan Stewart, PsyD: We all have moments similar to this in our everyday life, but you know, sometimes they’re a little bit more pronounced for some individuals and that’s where we would want to start to learn more about what’s going on for them.
Marjan Ebadi, PhD: And also depending on which symptom you have because there’s different types. So as you said, like, people will look at the list like, “Oh, I don’t have this,” or “I have that.” So you could have like the inattentive type that is mostly for difficulty with paying attention or being distracted often. There’s hyperactive and impulsive type, which is more of the fidgety and the more observant behavior that most people tend to see. And then you can also have the combined type, which just has all of the above. And with most kids or people with ADHD, usually presents in childhood. So you’ll be able to see some of the symptoms before the age six, but you can’t really diagnose it before age six, but you start seeing some of those symptoms.
And then it becomes a lot more significant when they start school or when they start kind of growing up and then there’s more structure and how your symptoms and the studying may not match. So then it starts to become a lot more present for people to be able to notice it. And it can impact throughout your life, it can impact your academic work, relationship, your sense of self, because you start noticing things about yourself and it can find challenges across your life, right? So it’s lifelong.
Cindy Lopez: So as I’ve read about ADHD, the data does indicate that more boys than girls are diagnosed with ADHD. So why do you think that is?
Marjan Ebadi, PhD: So the medical field has been studying ADHD for a long time, but a lot of our early research is on ADHD that was done with the male population, right? So because of that, a lot of clinicians become more aware of how ADHD symptoms present in boys. And again, they tend to present with more hyperactive-impulsivity symptoms, which is a lot more noticeable, right? Parents will notice it more because your kid’s running around or they’re more disruptive in the classroom. So they usually move toward like either getting assessed faster or for teachers to flag it to parents faster. So it gets noticed a little quicker.
For girls, however, it tends to be more subtle because even if they’re impulsive and hyperactive, it’s more contained, right? They can like fidget in their seat or play with their hair tie, kind of tap their feet. So it’s a little less disruptive. And then sometimes for some girls, they can also start masking it really well. So they can like be zoning out, but they got like the full face of like absolutely paying attention. So their brain is doing something else. And then some of them get really good at, this could happen for boys too, but I think because most girls will have inattentive where it’s more subtle, they have these like trigger words that sometimes their brain can tune in right back when somebody says “I have questions,” or “We have a pop quiz,” so then they just start paying attention really quickly so it doesn’t get flagged as fast.
And then with also a lot of their like impulsivity or dysregulation, right? Because there’s a piece of emotion dysregulation that tends to come with ADHD as well. And sometimes for girls, that gets flagged as more like, “Oh, they’re being sensitive,” or “They’re just feeling really anxious.” And then they’re having difficulty with managing it because they’re just an anxious person, rather than to have some neurodiversity with it. And then again with impulsivity too, it can look like more, they’re just–middle of talking to you, they’ll cut you off or they could kind of talk a lot faster. So disruptivity looks more into like relationships and kind of being slightly disruptive than running around in the class. Which again, that could happen for girls as well, but I think for a majority of them, it’s a little bit more subtle.
Cindy Lopez: Yeah. That’s so interesting. And as you’re talking, I think, well, boys could do that too. Why don’t they? Why is it that more boys don’t? And I don’t know, you know, how much our societal norms affect that too.
Marjan Ebadi, PhD: The gender roles and cultural roles can play a lot into it, right? Because traditionally for a lot of girls are encouraged to be like more agreeable on minimizing your problem compared to boys. They tend to also internalize because of that one. So most often they get very good at behavioral management in settings, right. Cause then again back in the day, like, you don’t want to be heard, or it’s good to be graceful. So I think for a lot of that, it’s still within the norms, even though we’re kind of shifting.
So for some of the girls that tends to be more contained than whereas with the boys is like, well, boys will be boys anyway, or they’re just fighting each other. So it’s okay, whereas with the girls is more like, you know, be graceful and calm. So it’s more, tend to get misdiagnosed as, like, “Oh, they’re anxious or depressed, or they just can’t learn this stuff.” You can certainly have all three and have ADHD, but I think those tend to get flagged more and then lead to more misdiagnosis and not being able to catch ADHD earlier.
Cindy Lopez: Interesting. I’m wondering if there are some differences in brains between boys and girls?
Dylan Stewart, PsyD: Yeah. We actually know quite a bit about that. We do these really big brain scan studies, and we can see that even like the physical development of a girl with ADHD’s brain is different than a boy with ADHD’s brain. So, some parts of a girl with ADHD’s brain will develop more compared to a boy. So we tend to see more kind of cognitive development in some of maybe like the language centers of the brain, maybe somewhere kind of referred to as like the temporal lobes.
There’s this area of the brain called the basal ganglia, which is used for things like motor control, planning, memory. And we tend to see that those parts of the brain actually develop quite a bit more for girls than they do compared to boys. And you know, that might explain why we might see a little bit more of the hyperactivity-impulsivity symptoms in a male population versus girls with ADHD because they have a little bit more control over some of these behaviors, the motor control, the motor planning, they may not feel like they need to be doing cartwheels down the aisles of their classroom every single day.
Cindy Lopez: Yeah. The brain is fascinating.
Dylan Stewart, PsyD: Yeah, well, you know, by comparison, there are some areas in the brain for girls where that’s actually underdeveloped compared to boys as well. So, there’s a type of connective tissue in the brain called gray matter. And you know, gray matter sort of at the most simple level is what helps our brain regions communicate with one another. So, you know, it plays a role in sort of like processing information and then sending that to the other parts of the brain. And for girls, we actually tend to see that their brains have a little bit less gray matter compared to boys within this ADHD population. And so, that is one of the reasons we can maybe hypothesize that some of the emotional symptoms show up a bit more quickly.
We do know that gray matter plays a really important role in terms of being able to regulate your emotions, kind of keep things under control a little bit more often. And if you have less of that, some of those emotional symptoms might just be prone to showing up a little more quickly for girls than they might be for boys.
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Cindy Lopez: So, I know that ADHD can go undetected or undiagnosed, or even, Dr. Ebadi, you said misdiagnosed in girls. Can you talk a little bit more about that?
Marjan Ebadi, PhD: The gender roles and cultural norms can play a part in it again, because they traditionally are encouraged to kind of go with the flow of things or not be disruptive, right? So then also on top of it, I think they also tend to internalize a lot of symptoms, so girls tend to be more anxious, and it matches more what people expect of girls to happen, right? So even if you complain about something, they’re always like, “Oh, you’re just feeling a lot more anxious or they’re emotional or manage your emotions,” right? So more often people tend to see it that way too. And then it kind of gives you the message that you need to contain everything, right? Or be able to manage it on their own.
So it tends to be misdiagnosed or labeled as again like you’re anxious or moody instead of they’re inattentive or impulsive and like I said earlier, you can certainly have ADHD and mood disorders together, right? That doesn’t mean it’s not one or the other, but because girl symptoms are often less disruptive in classroom, it tends to get flagged later unless it like, you know, sometimes we have kids coming in that they’ve been having these symptoms for a long time, but they’re in high school, and they’re finally like, I’m working really hard, but it’s not working, right? I feel like I’m studying triple the amount that everyone else is, but I’m still not getting the result. So sometimes we’re getting them really late because they’re really smart or they can adjust really well, but then academic work just becomes too much for them to be able to manage it. So then because of that, it becomes a lot later, or even if it gets flagged, sometimes the questions that comes in is like, “Oh, we think they have a learning disorder, right? Or they’re not learning this stuff because they missed half of the information. So they’re not building the building blocks that everyone else is doing. And they also can have like coming in with like, “Oh, she’s very anxious.” And then while mid testing is like, let’s also look for ADHD because I feel like you’re very inattentive, or you’re also hyperactive and no one’s catching it because you’re very subtle. So I think definitely it gets called out later, than if you have more externalized behavior.
Cindy Lopez: So my background is education and early childhood, and I know that young kids can be very active, and they’re still learning self-regulation skills. So I’m wondering, how does that play into ADHD or not?
Dylan Stewart, PsyD: We know that needing to move your body around and, you know, especially for younger children, that’s how they learn. That’s how they play is they kind of express themselves through moving around their environments and all the ways that they’re able to, you know, the kind of turning point is when it becomes maybe more clinical is when that movement or that hyperactivity is getting in the way of them being able to participate in school, doing things at home. I know that it’s maybe natural for a five or six year old to want to get up from the dinner table and only sit for a couple of minutes at a time. But if they can’t sit down for any meal at any time, and it’s making it so that they can’t actually get the right number of calories into their body to grow and be healthy that’s when we would start to say that maybe these hyperactivity symptoms are a little bit more pronounced for them. It’s really impacting them. And similarly at school, in most kindergarten classrooms, we expect there to be a lot more play, a lot more movement involved during the day, but if, you know, they’re in fourth grade, seventh grade, and they’re needing to move their body that same amount, it might make it difficult for them to actually participate in the classroom. And so, you know, we try and really think about what their age range is when we’re looking at some of these symptoms. And this is, as Dr. Ebadi alluded to, you know, we want to be careful of diagnosing it before six because child under six, we’re expecting them to actually have that much movement and that’d be just a regular part of their typical development.
Marjan Ebadi, PhD: One more thing like you said, because emotional regulation can be contained or matched to any other disorders as well, right? For ADHD wise, we want to make sure that it’s across the lifespan so it’s not based on one setting, and it happens at home, it happens at school, it happens at work. So it’s a little bit more like with all the settings than just a one-time event that is making you dysregulated or because life happens and then things can become very difficult to manage at times too.
Cindy Lopez: We’ve talked about for girls, they can go undiagnosed, undetected, or even misdiagnosed. What are the implications of not recognizing ADHD?
Dylan Stewart, PsyD: Yeah, this is a really important question because we want to hopefully be able to recognize these needs as early as possible. One of the big implications there is they may miss out on those opportunities for early intervention, and we know that the sooner we can recognize these things, the sooner we can provide treatment, the better the long term progress usually tends to be. You know, similarly, as Dr. Ebadi was alluding to if they’re given a diagnosis that doesn’t as accurately capture what their needs are, they may not be receiving, you know, the most effective treatment. Maybe if they’ve been given a dyslexia diagnosis, they may be getting academic intervention when maybe they really would be benefiting from some more of the ADHD specific interventions moving forward.
So, similarly, if it takes a long time for them to kind of access the right interventions, you know, we start to see some of those consequences build up for them. For girls, this tends to be a lot more in the emotional symptoms. So they become more prone to having experience of like lowering their self-confidence, higher levels of anxiety and depression, just because as they’re continuing to try and, you know, match what the world is asking of them. And it feels like their neurodiversity is really holding them back. They start to become more self-critical. A lot more of that stress kind of finds its way into their experience. And, you know, kind of practically, we do see them falling behind very often in school, they can be very, very smart, very capable students, but they may not be able to accurately demonstrate what they know, what they’ve learned on a test or in an in class assignment if they’re easily distracted in those environments, you know, they tend to become burnt out pretty quickly and easily if they’re working so hard, especially as you get to the middle school, high school range where the academic demands just go up and up and, you know, it really can start to again, just create more room for that stress to sneak in for them.
Cindy Lopez: What strategies can you share with our listeners to help them effectively support girls with ADHD?
Dylan Stewart, PsyD: Yeah, well, you know, different strategies are going to work best in different environments. So maybe I can share some for school to think about initially here. The first is really making sure that the educators are aware of the neurodiversity of their students as they know that these are the specific needs of the students in my class, and this is how I might be able to support them.
Some of the practical things they might be able to do might be making sure that, you know, students have a way to kind of see and hear all the information that they’re talking about. You know, kind of combining that auditory and visual information together may help some students; brains just process it in the way that works best for them. So it might be something like, you know, giving the student the lecture slides ahead of time so they can just write small notes instead of having to copy down every word that is up on the board or that the teacher is saying at the same time, you know, really helping them to focus on just one thing that works as well for them as it possibly can.
You know, similarly in the classroom, we really want to attend to those hyperactivity needs as much as possible. So, you know, giving students fidgets, adaptive seatings like a wobbly chair to sit, on a standing desk, kind of that hands on learning. So they can kind of integrate the movement into their day is really going to help with retaining some of that information too, as well as some of the, you know, kind of organizational sides of it. So, you know, maybe providing rubrics, helping them organize their approach to the project, which part am I going to do first, which part am I going to do next so they can know the next steps there. And you know, sometimes even just breaking a test or a project into smaller chunks might make it feel a little bit more manageable for these students, kind of providing those overall executive functioning skills that might be harder for the student to come up with on their own. It really will vary so much from student to student. So, you know, really communicating with them, communicating with the family, just making sure everybody’s kind of on the same page is gonna be a real big help, I think, for the educators.
Marjan Ebadi, PhD: Parents wise, what parents can do for a while, basically the more you can become their executive functioning part of their brain. So in a way they’re able to observe and learn these skills from you cause they can observe it. You’re sort of playing like an external executive functioning drive. So you kind of like hanging out outside their brain. You can do that by making observational comments for the behavior, such as like, I can see your body’s fidgeting a lot right now. It looks like you need a break or let’s plan for breaks ahead of time. So all of those can help a lot. Some practical things like creating reminders, checklists, helping them organize it on their calendars, help them with time management, like how much time you need for this essay or this project. And let’s break it out, kind of like how we do at school, but we’re transferring it to home. You can also model good organization and time management because kids tend to learn a lot through observation and modeling. And then it’s a good opportunity for them to be able to see the strategy you use at home and how that works for you. And then they can also start adapting it for themselves, definitely encouraging them to take breaks so they don’t get burned out during homework. And again, those planned breaks. So this is where your observational comments come in place. If your kid’s doing math homework and you start noticing the fidgets happen within 10, 15 minutes, plan for a 15 minute break. So then you can give him those movements.
And then I think talking with your child about how they’re doing, validating their feelings and experiences, right? If it’s frustrating, naming it for them and kind of helping them understand what’s happening with them and demonstrating good coping skills too. So, kind of again going with modeling like regulating what you deal with when frustrated about a project because we all also get frustrated at work or with things that we can’t work the way we want to, so how do you regulate and then help them co-regulate with them? And also collaborate with them to problem solve, like collaboration is kind of important because you still want their input in it, right? And you just want them to also be able to find things that works for them so they can adapt it and use it later on.
Cindy Lopez: As you’re thinking about the school setting for students with ADHD or neurodiversity of any kind, you might want to take a look at something called Universal Design for Learning, which is created, published by CAST, and you can find that online. We can also add that to our resources, so you can see it in our resources and show notes section. Also think about executive function that Dr. Ebadi mentioned, we do have some other episodes on executive function. You can learn more about that. And executive function can be related to ADHD, but they’re also not. So, we know that kids with ADHD can be challenged and not have fully developed executive function skills, but that’s true for all of us.
And then also thinking about validation, that’s also a really good skill for all of us to have, and especially between parents and their kids. And there is another podcast episode on validation if you’re interested in finding out more about that.
So, we’ve talked about school setting, home setting, ideas for parents. Are there additional resources that could help?
Dylan Stewart, PsyD: Absolutely. Yeah. You know, we really want to help an individual with ADHD access the right supports, whatever environment they’re in, if we’re able to do that. So, sometimes that might be a clinical recommendation for something, like occupational therapy, you know, maybe medication management through something like a psychiatrist service, you know, certainly individual therapy, psychotherapy might be a really helpful way to support some of those emotional symptoms as they’re coming up, making sure to work really closely with your pediatrician so that the medical needs are kind of monitored and addressed as the child is going through the course of their development.
Also things in the community like connecting with sports teams, social groups, you know, extracurricular activities can be really wonderful ways to kind of feel that sense of belonging and really mastering some skills that might be different than, you know, the long division that you’re practicing all day in your math class,really helping them feel well there. And certainly we know that lots of things like games and playing can be a really important way to learn some of these executive functioning skills. So just making sure to provide opportunities for that instead of all of the after school hours need to be dedicated to making up for the neurodiversity that they’re navigating through the school day, really providing opportunities for them to develop skills where they feel like they’re gaining those strengths in ways that are important to them, too.
Cindy Lopez: There’s so much that you’ve shared, and we really appreciate you taking the time today to join us and for this conversation and Dr. Stewart and Dr. Ebadi, thank you for sharing your insights and expertise to our listeners. Thank you for joining us as well. And as we wrap up this episode, Dr. Stewart and Dr. Ebadi, I’m just wondering if there is anything else you want to make sure that our listeners hear from you today on this topic of girls with ADHD?
Dylan Stewart, PsyD: The field of research for, you know, girls and women with ADHD is growing so much at this time. We’re really starting to understand that it presents so differently than maybe we’ve even understood it before. And so there’s a lot of effort and energy going into understanding this as clearly as we can. So, you know, I hope that as we’ve talked about maybe some of the more nuanced ways that we understand ADHD and girls, that the listeners will know that they can find clinicians out there who specialize in this, like we do here at CHC, to be able to say, we can get the right treatment, we can access the right information so we know how to support our children. And, that’s something where if you’re able to learn that information as early as possible, you just have a longer runway to be able to support them. So that’s always what we would hope for parents and children to be able to learn.
Marjan Ebadi, PhD: I think it’s never too late to be evaluated for ADHD. It’s better late than than never, because it’s a lifelong condition. And the sooner you learn about how your brain works, your strength, your areas of need, the better you can get the targeted help. And I think it’s very important for kids and parents to learn to advocate for themselves, right? If you start noticing, they’re working twice as much, or they’re very frustrated, and their symptoms is impacting their school, social life, and just overall quality of life, get the help you need to get assessed or talking to the expert that can help you determine what’s the next steps. What will be helpful for your kids? So I think advocacy is very important.
Cindy Lopez: Yeah. And Dr. Ebadi, you just said it’s better late than never, which is absolutely true and also just think about how it could help your child if you get the help they need now. And Dr. Stewart mentioned early intervention, earlier in our conversation, the earlier you can get help, the better and the easier it will be for your child. So that’s something to think about and as Dr. Stewart said, we do have ADHD services here at CHC. Your child can be assessed. You can take part in therapy. So please reach out to us if you are in that situation, and you need some help or just some guidance. We also provide parent coaching. So, maybe your child has ADHD, and you’re trying to figure out the best way to communicate and really support your child. Parent coaching also could be a good option for you. So you can reach us at CHC at chconline.org. You can reach our care team at 650-688-3625, or you can email them at careteam@chconline.org. So thank you again, Dr. Ebadi and Dr. Stewart for joining us today and to our listeners, thank you.
Dylan Stewart, PsyD: Thanks for having us.
Marjan Ebadi, PhD: Thank you.
Cindy Lopez: Visit us online at podcasts.chconline.org. Make sure to subscribe to Voices of Compassion so you never miss an episode, and we’d love it if you’d leave us a rating and review. Have a question? Send us an email or a voice memo at podcasts@chconline.org. We’re here for you when you need us.
