The following question was received during the LD@school webinar, Recognizing and Understanding Girls with ADHD; click here to view the webinar recording.
Answered by Dr. Laura Gerber, Consultant Pediatrician, Beech Tree Medical Centre
There were so many great questions being asked during the Q&A of the webinar, and I wish we could cover them all. I think this question provides an opportunity to review and expand upon many of the points covered in the webinar. Many of these are flags for ADHD in general – regardless of gender. However, in girls, we tend to rely more heavily on these relatively subtle clues, and educators are often in the best position to observe them.
Although girls with ADHD will tend to struggle in all areas of functioning, my focus will be the ways in which ADHD might present in the academic setting:
Difficulty following multistep instructions, especially when given verbally
A teacher may notice that their student struggles to follow multistep instructions verbally, but when the instructions are provided in writing or on the board, she seems to be much better able to follow the instructions. In this instance, it may not be a matter of inattention or disinterest, but simply her inability to remember the instructions long enough to execute them. This is a reflection of poor working memory, and this scenario is a common subtle sign of ADHD.
Easily distracted by auditory or visual stimuli
Classrooms are unavoidably noisy, but if your student regularly complains about the noise levels in the classroom – especially if she’s more bothered than her classmates who are working in the same conditions – think about ADHD (and have the student try out noise-cancelling headphones). She also might complain about background noises that other classmates don’t even notice, let alone find irritating. Examples might be the buzz of the fluorescent lights, the distant whir of the grass being cut in the field next door, or (for those of you who watched the webinar) the soft breathing of a resuscitation dummy during CPR training!!
In a child with Primarily Inattentive ADHD, difficulties with reading may be one of the earliest signs. Because of poor working memory, she often needs considerably more repetition before information will stick. For instance, she might need to decode the word cat fifteen times before remembering it, whereas a child without ADHD may only need to decode it five times. She also might seem to forget the word just seconds after successfully decoding it.
A teacher might notice that she’s always the last kid to finish reading a passage when everyone is asked to silently read the same thing in class. She might need to re-read the passage in order to process the information adequately; this may be the result of slower processing speed, inattention or distractibility.
A common scenario for kids with ADHD is that their reading comprehension lags behind their decoding ability. For instance, I can read a story to my kids, complete with voices and inflection, and have absolutely no idea what the story was about at the end. Although I was reading it, I wasn’t actually paying attention enough to comprehend what I was reading. So, if you find that your student’s reading comprehension doesn’t seem to match their ability to read the words, think about ADHD.
Finally, the classroom environment can affect the results of reading assessments. Given that kids with ADHD will struggle more to pay attention in a distracting environment, assessing their reading ability in a setting free of visual and auditory distractions can make a significant difference in their performance. Of course, that’s not always possible, but if you notice that your student performs considerably better when you can find a quieter moment to test them, think about ADHD.
Most kids with ADHD are stronger visual learners than verbal; they will usually have an easier time learning math using manipulatives and pictures. Math can unmask ADHD in several ways, mainly related to the common weaknesses of poor working memory and slow processing speed. Students with ADHD will likely need more repetition to make new information stick. Word problems present a unique challenge because they need to be able to read to learn (rather than still learning to read), and students need to process what they’re reading at a reasonable pace. Furthermore, they need to be able to hold what’s really being asked in their working memory while they figure out the answer, then hold that answer in their minds long enough to record it accurately. All of this can create obstacles for a child who struggles with ADHD, and their performance on word problems may be more reflective of those obstacles than their true understanding of the math curriculum being assessed.
Another common math challenge is when kids are asked to read a question on page 2, then look at a visual representation (such as a graph) on page 1, determine the answer and hold it in their mind while returning to page 2 to find the correct spot to record the answer. The teacher may notice that the child seems to understand the concept of graphs when it’s being taught, but when the information is presented in this format, it requires much more working memory capacity, and the child with ADHD may struggle much more with this type of activity.
Anxiety about school performance in general
Kids with ADHD are often quite aware that school doesn’t come as easily to them, and they often have low self-esteem and feelings of inadequacy as a result. They are reminded of their academic under-performance in a variety of ways, including comments about being lazy, or statements such as “you could do so much better if you only applied yourself”. As they get older, they often have a sense that they are capable of doing better, but something inexplicable is standing in their way and they can’t seem to unlock it.
Girls are often eager-to-please, and as they progress through elementary school, any overt signs of ADHD are often masked by their increasing anxiety. Although it becomes harder to assess, there are many subtle clues that an astute educator might flag as potential signs of undiagnosed ADHD. A student may put excessive time and effort into projects/assignments that they can complete outside of class – especially those that are creative/visual in nature. This may be the result of hyperfocus, but often it’s an effort to excel at the things that are within their control (as opposed to tests/exams, see the section below). She may take seemingly excessive notes compared to peers, and might use different coloured markers or index cards to assist her in remembering the information – however, she’s unlikely to realize that’s why she’s doing it.
Simply speaking, succeeding in school with ADHD requires more effort – more repetition, more time, more mental energy – and this often results in anxiety. If you have a student who seems to work unusually hard in order to meet our expectations of them academically (especially if this results in the student sacrificing leisure time, extracurricular activities, social activities, exercise or sleep in favour of schoolwork), think about ADHD.
Anxiety specifically about tests/exams
Tests and exams are often a specific source of anxiety for girls with ADHD. They have run out of time on tests in the past, so they worry about running out of time on upcoming tests. If your student seems to be in a panic as a test progresses because they can’t get through it fast enough, and she’s always the last one to hand the test in, think about ADHD. It’s important to recognize that giving a student with ADHD extra time can make a HUGE difference in their marks if they know the material, but just can’t regurgitate it in the time given. If a student doesn’t know the material, extra time won’t make them know it any better or achieve better results.
Part of the reason why students with ADHD might go above and beyond on assignments and projects is that they know their marks on tests/exams usually bring their course mark down, even though they were as prepared (or more prepared) than their classmates. In contrast, many students without ADHD rely on tests to bring their marks up. The student with ADHD knows that if she goes into an exam with high marks because she’s aced every project/assignment in her control, she might still end up with a decent overall mark in the course, despite her usual mediocre performance on the exam.
If you find yourself puzzling about a student who seems to know the material being taught, but her marks on tests/exams consistently don’t seem to reflect her actual knowledge base, think about ADHD. Finally, as discussed in the webinar, multiple-choice tests can be problematic for some (but not all) kids with ADHD. Most kids prefer multiple-choice tests; if your student seems more anxious, hates the format, is the last to hand the test in, and seems to get better marks with other testing formats, think about ADHD.
There are many reasons that girls with ADHD may struggle socially, and these difficulties may be easier to detect than academic challenges. On the surface, they often seem like social butterflies. They are often the “Chatty Kathy” who is talking to friends rather than getting down to work.
However, they might not pay attention to social cues, whether verbal or nonverbal. They might lack the impulse control to know when to stop, and may take things too far. The emotionality of ADHD, combined with a tendency to react impulsively to those big feelings, often results in social discord, and interpersonal difficulties with others as well. When social interactions don’t go well, poor cognitive inflexibility makes it harder for them to let things go. Although they’re friendly and seem to make friends easily, they often struggle to maintain friendships, and over time they lack opportunities to learn and practice social skills.
In reality, there are myriad ways in which ADHD presents in girls. We diagnose boys: girls at a ratio of 3:1, but we know that ADHD is a neurodevelopmental disorder, and girls are equally affected – we just aren’t recognizing them as readily. Educators are in a unique position to identify these girls, and my hope is that this webinar and article have enriched your understanding of ADHD, which will help to improve the quality of life and the long-term outcomes of these children.
About the author:
Dr. Laura Gerber has been a consulting pediatrician in Burlington, Ontario since 2003. She completed medical school at McMaster University and her residency training at the Children's Hospital of Western Ontario and the Hospital for Sick Children. The main focus of her consulting practice is the assessment and treatment of children and adolescents with developmental, learning, behavioural, and mental health issues.
Dr. Gerber is particularly passionate about ADHD; she is dedicated to advocating for the recognition and treatment of ADHD across the lifespan. She has presented to a range of audiences, including family physicians and psychiatrists, fellow pediatricians, elementary, secondary and university educators, as well as parents. She has been a speaker at the National ADHD conference and the Annual Scientific Assembly of the Ontario College of Family Physicians. In 2017, she was invited to be featured in a documentary about adult ADHD on CBC Television’s “The Nature of Things with David Suzuki”. She is a founding member of the Steering Committee of “Caroline Families First”, an expanding pilot project which examines the impact of High-Fidelity Wraparound Care on mental health outcomes in the community.