Attention, Deficit, Hyperactivity Disorder, (ADHD) remains a controversial topic for all sorts of reasons. Research illuminates just by how much the ADHD debate is a can of worms; multi-layered, emotive, and complicated. But who wants to open that can? Especially when the worms inside include, gender perceptions, societal and cultural differences, individual presentations, expectations, comorbid conditions, differences in research perspectives and a lack of research in key areas, to name a few equally loaded topics.
Thankfully, Asa Olsson, in one such review of research, ‘Teachers’ gendered perceptions of attention deficit hyperactivity disorder’ (2022), has highlighted key areas for us. I had a read and can’t cover all aspects here, but it’s certainly long past time we all began to challenge what we think we know about ADHD, and so consider what we may be missing.
What is agreed about ADHD?
The science is there, ADHD exists. It always did. Mount Everest existed before we discovered it, we just couldn’t see it. Thankfully, like many developmental differences, ADHD is now a well-recognised neuro-developmental disorder (we all hate the word), with characteristic features. There are three subtypes:
- Combined Type-both inattention and hyperactivity.
- Predominantly inattentive type-mainly attentional difficulties or poor impulse control.
- Predominantly Hyperactive Type-central difficulties are hyperactive and impulsive
How prevalent is ADHD?
Between 5-10% of all children are said to have ADHD. Like many neuro-developmental conditions, it is a spectrum disorder, rooted in the brain. That being the case, it doesn’t have a look, you can’t physically see it. We still don’t always see it, just the impact of it. And often only as the impact affects us, and not as it is affecting the individual. There is no one single cause, many factors contribute, inherited and otherwise. No two children will have the same combination of features. Each display a different pattern, varying in severity, varying across different situations.
It is NOT caused by poor parenting, although more effective parenting can often helps matters. It can persist into adulthood. And, lastly, a key point of Olsson’s review, ADHD is not just for boys! Girls have ADHD but are often overlooked, misdiagnosed, and, as a result, poorly-supported with long-lasting, often devastating impacts.
Negative tropes case harm
Many negative, outdated, and dismissive comments about ADHD are as pervasive as the disorder itself and they don’t help matters. ADHD invites strong positional views and (uninformed) opinions. Many views seem to persist as a legacy of some bygone age, now viewed through both rose-tinted and self-delusional glasses equally. The ‘it didn’t exist in our day’ brigade can be quite loud. This thinking blocks progress and promotes myths.
Additionally, the general fixation around the mythical norm and stereotypical gender behaviours provokes criticism of any individual who deviates off this mythical track. Comments like, “He is doing it on purpose”, “She just likes drama”, “He can sit still, he just won’t”, “S/He is just naughty”, “If parents did this, that or the other, he would behave”, “She just doesn’t listen/try hard enough”. These all leave parents berated and blamed, and leave teachers confused about what to think, what works, and how best to proceed and support. It is a lazy narrative that leaves girls particularly and horribly overlooked and unsupported.
To top it off, schools face a barrage of unrelenting, externally imposed expectations, imposed leadership and policy demonstrating little understanding of ADHD or any other SEND. Schools then don’t, can’t or won’t adjust curriculums and environments. Worse still, in the centre of all this, Olsson’s review suggests the individual child is blamed. It is the child with ADHD who is considered the problem, and never the setting. That is also clear from exclusion data.
Why are boys diagnosed with ADHD more often than girls?
Despite all the facts, many people simply do not take ADHD seriously enough, nor understand it well enough. Perceptions of hyperactivity being only physical are outdated. While it is hard to miss the child who is bouncing off the walls in a physically active way, girls are usually (though not always) less likely to demonstrate physically hyperactive/impulsive symptoms. Fidgety, squirmy boys who demand attention have historically featured large in diagnostics and prevalence. They still do. Teachers can’t ignore them; they provoke emotional states in parents, teachers and school leaders that drive action. By contrast, girls tend towards inattention, or misdirected attention more than boys (but again, not always). Yet it is often attentional difficulties that really hold people back in school and in life. Because, while the teacher has failed to notice the child, the child has missed all the teaching.
It seems girls have better masking skills, they suppress ADHD traits, as they do with Autism. Girls internalise symptoms, leading to anxiety, depression, and social withdrawal. They often have a Dr Jekyll and Mr Hyde presentation. Parents note aggression at home when schools do not, for example. All the while, girls are suffering the detrimental impact that unmet needs gift them. They often suffer lifelong, going on to have misdiagnosis and secondary mental health difficulties.
Added to that, Olsson’s review highlights that sometimes teachers assess boys and girls with the same symptoms differently. They’re more likely to offer learning support to boys than girls who are struggling in the same way. Girls were less frequently put forward for intervention and for treatment with medication. Teachers report feeling less confident to deal with girls’ behavioural challenges. There is also less research around what works for girls, and so fewer gender-sensitive strategies and interventions to offer, where those may be needed.
How do we improve things?
For ADHD in general, much of what is offered to schools tends towards behaviour modification strategies, although this is divisive equally across research, education, and within parenting circles. Research exists both for and against interventions and there isn’t time for that debate here. In the end, it is about what works for an individual.
The fact is, what works for one, does not for another. So, it seems to me that nothing should be discounted and nothing should be promoted exclusively. But regardless of your view of them, behaviour modification interventions will never be sufficient for the quiet, masking, inattentive girls. Schools typically focus on observable behaviours, particularly those that challenge adults or school structures. The girls will still be missed.
Besides, there is so much more we can do than get stuck on any one approach. Research often suggests that an eclectic mix, fully integrated across the school day, is best practice for many neuro-developmental conditions.
Resources that can help support children with ADHD
The ADHD Foundation offers teachers and parents many helpful resources. They have produced many useful booklets including, ‘Refocusing on ADHD in Education’ (free PDF download) that shares a wealth of tips where everybody benefits. For example:
- Establish Routines- create clarity and visual order wherever you can.
- Build Engagement-this leads to motivation.
- Build talk into every stage of the lesson-it helps reflection.
- Build in movement-it helps attentional regulation.
- Support executive function and working memory-without this nothing is learn and there is a myriad of ways to support it.
- Externalise what not is happening internally-visually gather thoughts, organize, and sequence.
- Support self-management-actively teach for it.
- Create a ‘planning friendly classroom’.
- Reduce learner anxiety-be consistent, tell them what you want, show them how to use the supports, and focus on the positives.
- Work with attentional dysregulation and not against it.
So much can be done to support ADHD, and in doing so undiagnosed ADHD in girls. Like most advice, the whole class benefits when implemented. No one is harmed by following the above tips.
Reviewing our own biases
At the very least, we can all nudge our own thinking, check in with our own emotional state, take responsibility in our opinions, and make sure they are rooted in a deeper understanding. The more we fear and misunderstand dysregulation, the less likely we are to accept it, understand it is part of the experience of being human, and so cater for it. By understanding dysregulation better, maybe we can stop blaming the child. Maybe we can spot quieter presentations too and cast a different eye over how our girls are doing.
We all want children to grow into successful adults with high self-esteem. Self-esteem is the extent to which we accept, like, value and approve of ourselves. It is essential for a good quality of life. Argyle (2008) gives us four main factors that influence the development of self-esteem: the reaction of others, comparison with others, social roles, and identification. Teachers and parents are critical in this.
With that in mind, it's time to challenge how we perceive ADHD, to understand different presentations, and support girls better. It’s time to get rid of the myths and get to work celebrating the many strengths of individuals with ADHD.
- Åsa Olsson (2022) Teachers’ gendered perceptions of attention deficit hyperactivity disorder – a literature review, European Journal of Special Needs Education, DOI: 10.1080/08856257.2022.2076476
- Michael Argyle: Social Encounters: Contributions to Social Interaction
- Creative reasonable adjustments for SEND learners that don’t have to cost a thing
- It’s not just SEND teacher training that’s needed. How we educate all children is broken
- I’m a Dad with ASD and ADHD. Here’s why I’ll never give up fighting for my neurodiverse children’s educational rights
- How I learned to take the best advice (and ignore the rest) when raising my ADHD son
- Balancing the needs of siblings, when one has ADHD
- It’s not ADHD, it’s Sluggish Cognitive Tempo
- A mother’s top tips for parenting your ADHD child
- Using a different lens for neurodivergent children: Don’t treat them as younger, give them the tools to achieve
- Helping our disabled children understand that difficult experiences don’t define them or their future
- Ofsted asks: How well do mainstream schools support SEND?
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- Gendered misperceptions: Research shows girls with ADHD miss out on school support - September 22, 2022
- Déjà vu: How will the #SENDReview end the over-promising and under-delivering cycle of support for disabled children? - April 20, 2022
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