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High School Girls with AD/HD

Kathleen G. Nadeau, Ph.D.

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 AD/HD is added to the mix, high school becomes even more challenging, and may even become a destructive experience.

Diagnosis of ADD or ADHD in teenage girls

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

  • Girls with AD/HD 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 depressed.

  • Girls who are particularly bright are able to compensate for their AD/HD much longer, and are therefore the most likely candidates for a late diagnosis.

The fact that a girl's AD/HD symptoms may not have been apparent in early years renders her AD/HD 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 AD/HD, 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 AD/HD can have her complete the questions our self-questionnaire. If your daughter answers "yes" to many of these questions, a careful assessment for AD/HD should be undertaken.

Troubling challenges faced by teenage girls with AD/HD

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

Social pressures

Girls with AD/HD 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 a greaterimportance. Many women with AD/HD 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 AD/HD 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 AD/HD 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 AD/HD tendencies of many girls.

A teenage girl with AD/HD 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 AD/HD tends to increase 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 AD/HD. 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 AD/HD often feel despair. Depression, common among women with AD/HD, often begins during the pressures of teen years. Such depression is much easier to recognize, and many girls with AD/HD find themselves treated for depression while their AD/HD 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 neurocognitive patterns associated with AD/HD. This doesn't mean that our daughters can't become "mature," but it does mean that maturity needs to be viewed through an AD/HD lens.

High school and AD/HD - 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 ADD-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 AD/HD. In addition, any students with AD/HD 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 AD/HD 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 AD/HD, 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 AD/HD 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 AD/HD, 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 AD/HD have a substance use disorder and one in five smoked cigarettes.

How Can Parents and Professionals Help?

Managing the emotional roller coaster

It is critical that parents and professionals recognize that the intensity so often seen in teenage girls with AD/HD 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 AD/HD alone.

Because peer issues and issues of self-worth are so paramount among most teenage girls with AD/HD, psychotherapy needs to be designed to directly address these. Often, group psychotherapy can be tremendously supportive and effective for teenage girls with AD/HD. 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 AD/HD. While Pre-Menstrual Syndrome (PMS) may be an annoying period of irritability, fatigue, or cramping for many girls, those with AD/HD 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 AD/HD 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 AD/HD 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 AD/HD has careened over the edge into a level of anxiety or depression that requires treatment in tandem with her treatment for AD/HD. Both anxiety and depression are common among teenage girls with AD/HD and can be successfully treated along with the AD/HD. The experienced physician will be aware that stimulant medication for AD/HD 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 AD/HD? Support groups for girls with AD/HD 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 AD/HD and driving

The important message for parents is that their daughters with AD/HD 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 AD/HD 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 AD/HD 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 AD/HD 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 AD/HD through her high school years is to actively help her develop and recognize areas of competence and talent. The more that girls with AD/HD are in touch with their areas of competence the less vulnerable they will be to the criticisms and frustrations that so often accompany AD/HD.

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 AD/HD. 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 AD/HD, 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

High-school years can be very challenging for girls with AD/HD. To meet these challenges, girls with AD/HD need support from peers, parents, and schools, combined with appropriate medical and psychological 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.

Resources for Teenage Girls with AD/HD:

Understanding Girls with ADHD by Kathleen Nadeau, Ph.D., Ellen Littman, Ph.D. and Patricia Quinn, M.D. provides more in-depth information about the issues and challenges of teenage girls with ADHD.

Help4ADD@HighSchool by Kathleen Nadeau, Ph.D. is written for teens in a very readable, ADD-friendly format providing information and coping strategies to help teens meet the challenges of ADD during their high school years.

Adolescence and ADD by Patricia Quinn, M.D. is written for both teens and their parents to help them understand ADD (ADHD) during high school years as well as help them prepare for the transition to college.

The Girls' Guide to AD/HD by Beth Walker is a book for teen girls that covers many important issues including: What ADHD is like for girls; how counseling, coaching, and medications help; ways to cope with school and homework: and how to get along with friends and family.

 

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