Dr. Sharon Saline on Understanding and Working with ADHD in Girls

Debbie: 

Hey Sharon, welcome to the podcast.

Sharon Saline: 

Hi Debbie, it is great to be here. Thank you so much for having me on.

Debbie: 

Well, I should actually say welcome back to the podcast, because you are a returning guest and you were on the show. Several years ago, we talked about your book, which I’m sure many listeners are familiar with. It’s called what your ADHD child wishes you knew, working together to empower kids for success in school and life. And it’s a wonderful resource. Listeners, I’ll have a link to that episode in the show notes. So definitely go back and listen to that. But I reached out to you because I’ve been getting a lot of requests to do an episode specifically on the intersection of ADHD and girls. So we’ve talked about autism and girls and I’ve certainly read so many things about similar things happening in terms of misdiagnosis underdiagnosis. But could you kind of set the landscape for us in terms of what is happening with ADHD and girls, Because I think a lot of people do when they think ADHD, their brain kind of pictures that disheveled boy, right?

Sharon Saline:

It’s so important that we’re having this conversation because girls are often diagnosed later than boys. The typical face of ADHD is usually a white male child or adolescent. And it’s important that we really examine how ADHD shows up in girls because it’s different. They show more symptoms of anxiety and depression than boys. There’s a higher tendency for the internal traits of ADHD, forgetfulness, difficulty listening, problems with verbal expression and control, and misreading social cues. It’s also challenging for girls because in general, girls relate through verbal interactions, conversations. And a lot of girls with ADHD miss things. I took a couple notes before our show today. And you know, I have this in my book, known at age 10 . Sometimes I don’t hear exactly all the stuff people say, I really don’t hear it. Then I get in trouble because I miss something. I’ll blank out on what people are saying. Like even if they’re talking for a long time, like a minute or so, I’ll be like, Yeah, yeah. And they’re like, what we didn’t ask you a question. And I forget things. And so there’s this way that there’s a feeling for girls that they can’t keep up. We also know that girls with ADHD tend to be sexually active earlier than their peers without it.

Sharon Saline:

And of course we’ll see more signs of emotional dysregulation. And they might kind of suffer silently, like the girl will be, girls with ADHD might be the person who’s looking out the window and isn’t doing as well in school as she could, but she’s not really being noticed because she’s doing fine enough.

Debbie: 

Yeah, fine enough, right? That is such a powerful statement. I mean, I think with boys especially, that’s where many people’s brains go. A teacher might see these things like, oh ADHD, let’s get that looked at. And so what is really happening with girls? Well, if a girl is, you just shared a bunch of behaviors, that more internal traits, that kind of missing things, maybe being more dreamy, that kind of thing. But what are we then attributing that to like what it actually looks like when a girl is exhibiting those symptoms but they’re not being recognized.

Sharon Saline:

Good question. There are also symptoms on the other side, which is we may not see hyperactivity the way we categorize it with boys or impulsivity, but we might see girls who are big talkers who have a lot of energy, and that should really be considered as well. So, you know, your question is, you know, why, I think your question is like, why is this occurring? And you know, we’d have to zoom out a bit to look at that because what’s happening is that girls have developed a number of ineffective coping strategies to kind of hide the struggles that they’re having. And some of these resemble what girls with autism do and some of them don’t. So one might be, you know, trying to get by and they’re not necessarily understanding what’s going on with peers or in a classroom, but going along with what’s happening and imitating what other people say or do. And so we’ll see some sort of mimicry, which is an okay coping skill in elementary school, but it really falls apart in middle and high school when social nuances and interactions are more complex. And these are girls who work very hard to try to fit in and it’s exhausting for them. And they can be very sensitive to any kinds of peer rejections or exclusion, which happen more for them than for non-ADHD girls. And interestingly, what we see for a lot of girls with ADHD is that it’s easier for them to be friends with neurotypical boys than it is for neurotypical girls, because of missing some of these social nuances and the need to kind of hide socially, whether they’re wearing a mask through self-deprecating humor or trying to be cool with alcohol or marijuana use, or they’re camouflaging, they’re trying to fly below the radar, attempting to be quote unquote normal, compliant, kind of more passive in groups, and yet, you know, coming home and having major meltdowns and emotional dysregulation. 

We also see kind of higher risk vulnerabilities for challenging behaviors that would be like using a substance, drinking, having sexual activity or interactions because someone else wants to, and that’s how you feel like, you can feel better about yourself and like you’re popular. There’s a higher incidence of sexual abuse among girls as they get older because they can and misread flirtatious behaviors. And they can just follow their hormones with that sort of impulsivity and not necessarily understand the dangers. One of the challenges for kids with ADHD is you can ask them outside of a given moment, what is a solid choice to make? What is something that you think makes sense? But in the moment when there’s a lot of peer pressure or a rush of potential gratification, they’re going to lean toward the activity. And that can be really, really difficult. Also these girls experience more rejection from neurotypical girls for being different, for greater faux pas in groups, and they’re more subject to relational aggression like bullying and exclusion. They however can be more accepting of other people because they’re not bothered by the small stuff of relationships. But they do, they can be very perfectionistic, which is something that, you know, really is a black and white thinking. If it’s not perfect, then it’s a failure. And we see that kind of black and white thinking with kids with ADHD. If it’s not right, then it must be totally wrong. And we know that perfectionism is an ineffective attempt to control outcomes. And of course, girls with ADHD and women with ADHD are 3.5 times more likely to have an eating disorder than neurotypical women. And 5.6 times more likely to develop bulimia. 

So there’s a lot going on for these girls and that hiding or not letting you see it or getting angry, particularly intention between mothers and daughters can really cover up all of these issues. And for smart girls with ADHD, those gifted kids, twice exceptional kids, they can be doing great at school and they can have friends and they can be testing limits. And there’s no sense that they might have ADHD because academically, you know, everything starts with a nine. And then, you know, they can, but they can be referred for depression or for anxiety or substance use. And the possibility of ADHD is usually not considered. And what we see is that when girls go to college, one of my clients said to me, but I can’t do school and life. And so there’s a kind of way in which being at college or independent living, things can kind of disintegrate.

Debbie: 

Yeah. Yeah, because especially if they’ve been unidentified and they might benefit from medication or other types of supports, that has never been introduced. And so suddenly they’ve been able to keep things together through these coping mechanisms or the mimicry that you described and other strategies. And then when the pressure ramps up or in this new environment, suddenly everything I could see would just fall apart.

Sharon Saline:

Mm-hmm. And then that’s what happens. And so their grades start slipping, they’re struggling more, and they’re very uncomfortable with their struggles because they’re not used to it. You know, they’re used to doing pretty well at school, and then they get to college and it’s like, oh, you know, I’m kind of overwhelmed all the time. I don’t have a parent around kind of keeping things in check. I don’t have an IEP supporting me or a 504 because in college nobody’s mandated to provide you with anything like it is in high school. It’s about equal access to education and that you have to seek. 

Debbie: 

So going back to the diagnostic process and knowing that we know so many of these girls are missed, just like there’s a lost generation of autistic women, there’s also a lost generation of ADHD women who are either self-identifying or actually getting a formal diagnosis of ADHD as an adult. So where are we in terms of the diagnostic or assessment process, neuropsych evaluators up to speed on having a broader understanding. I mean, we know, we recently talked with Dr. Donna Henderson and Dr. Sarah Whelan, who wrote the book, Is This Autism? And they’re really trying to expand the understanding of how those criteria for autism can be interpreted. And so where are we with ADHD in that way?

Sharon Saline:

Such a great question. I guess my answer would have to be, it depends. So I have someone who came to me for a consultation who lives in California. And I met with them, I met with the daughter and got a history and saw previous report cards. This child had never had a psychological evaluation. And I really stressed, can we please get her a psychological evaluation? And they did. And the evaluator was so behind on the current data about ADHD that she did not diagnose her with ADHD. And I really felt like there was steam coming out of my ears when I read this report. I was very distressed and I actually got the parents permission to consult with a colleague of mine who is a school psychologist and she read the report and she felt like steam was coming out of her ears. So I was sort of comforting. And then we all met with the parents and said, this is what actually is going on that this person really missed. And so I think it’s important if you’re going for a psych eval that the person doesn’t just do a couple of these, but actually specializes in ADHD and is up to date on the current literature. The person who wrote that, um, girls report basically said, well, you know, she’s doing fine in school. And, uh, so, you know, I don’t see ADHD, you know, what I see is anxiety. And yet her, her scores on the various factors of the, uh, the whisk or the waste for older kids were, there was a, there was a differential. And there was a discrepancy and her scores for reading were very low. And yet they weren’t low enough, according to this woman, to meet the diagnosis. But they weren’t high enough not to meet the diagnosis as far as I was concerned. So we recommended more testing with specific evaluation tools. But I think it is important for you as a parent to do some research, like ask the person who’s doing the evaluation. How many evaluations do you do? How much, when is it, what kind of recent training have you had about ADHD? and they may not like you for it, but whatever, you’re, that doesn’t matter.

Debbie: 

I love that advice. And I wanna talk a little bit more about what we might notice as parents and what they should do when their kids are younger. So going back to that girl in school who’s doing okay, right? She’s doing okay. She has friends. She is kind of maybe very active or talks a lot or is kind of more of that stereotypical chatty Cathy or whatever. How would a parent first know? What would the clue be that I think there’s something else going on here. If the ADHD is kind of by itself, because we know it also often co-occurs with other things as well. But yeah, go ahead.

Sharon Saline:

Well, I think that’s important to say because ADHD rarely travels alone. Like rarely. It usually comes with a learning disability. Um, about that’s about like 70% of the time and even higher rates of any co-occurring condition, which would occur, would include anxiety or depression. Um, autism, uh, if, uh, if, um, uh, ASD is your primary diagnosis. 50% of those kids have ADHD, but if ADHD is your primary diagnosis, about 14% of those have ASD. So the thing is usually we wanna look around at the child’s life. And so usually kids might be doing fine enough in school, they probably have a friend or two. I wouldn’t say they have a lot of friends. Sometimes they might have a lot of friends, but then they’re not doing that well in school. Sometimes they may have friends and they’re doing okay in school, but they’re getting into, you know, kerfuffles all the time So there’s an incident with this person and that person They are reactive to receiving feedback It’s hard for them to work in groups They speed through taking a test or a quiz without checking their material So these are some things that we want to notice We also want to notice when kids are actually kind of what I call in the drift. So some people would say spacing out. I don’t like that because it’s so derogative, derogatory. Excuse me. I don’t like that because it’s so derogatory. I prefer being in the drift. You’re drifting off. You see a squirrel. Ah, look, there’s a squirrel. What is that squirrel doing? That is so much more interesting than the social studies lesson that’s happening. And then the social studies teacher will call on you and you’re like, oh my gosh, I don’t know what to say. It’s so embarrassing and everyone knows I don’t know what to say. So we wanna kind of get a sense like, is your child managing in school and then coming home and kind of falling apart? We see that a lot or doing fine at home but not doing fine at school. There usually isn’t a situation where they’re doing fine in all the areas and there’s ADHD until they get a little older. Because what happens is that the stress and the demands on their executive functioning skills get higher as you go into middle and high school. You have to be able to maintain more organization. You have to sort of sustain your attention, be motivated, keep track of your homework things like this. And this is often where the first level of diagnoses will come in, in that transition from elementary to middle school. Now, for some girls whose parents are on it and who may themselves have ADHD, 55, 57% of adults with ADHD have a child with ADHD. They may see the signs earlier and make the referrals. So we sort of see referrals around third grade a lot of the time, because third grade is a year of such integration. It’s, you know, where you shift from reading, from learning to read and learning numbers to reading to learn, to using numbers to solve problems of different kinds. And then we see it again in middle school, all of the transition points, high school, and then of course college.

Debbie: 

Mm-hmm. Yeah, that makes total sense. I want to talk about the social piece a little bit more. I found that mimicry interesting and going along with things and, you know, I imagine that girls with ADHD are more prone to peer pressure. Is that what the research shows?

Sharon Saline:

Yes, and some of the research shows that, you know, girls can become easier targets because of certain behaviors that they tend to exhibit, whether they’re impulsive comments or being clumsy, misperceiving boundaries about personal space, trying too hard to be liked or struggling academically. You know, one in five girls, according to research, say that they’ve been bullied through texting or social media, which is almost double the percentage of boys who were cyber bullied. And so when we think about girls with ADHD, they are more likely to be bullied in a way because they miss things. We also see a pretty solid dependency on screens and social media technology to feel like they can fit in and to be connected. Being connected a lot of the time is very important. 

Debbie: 

So the social media piece is interesting, because as you’re talking, I’m thinking, I think that there are a lot of neurodivergent people who may be primarily autistic teens who might reject traditional social media, like an Instagram, which is very much based on fitting in or conforming. And I’m wondering, are ADHD girls more pulled to things like Instagram where we know the research is showing how harmful that is for teens in general on their mental health and their identity and their sense of self. So can you talk about, I don’t know if it’s the risks, but that interaction of social media, especially things like Instagram and ADHD girls.

Sharon Saline:

Yes, absolutely. So. One thing that we want to really think about is how people with ADHD often, girls in particular, sort of demand or expect an immediate response from peers. Like, what are you doing that I’m not included in? What did I do wrong? And they attach a negative message to a pause or a silence. And that, you know, this social media is a crucible for both positive and negative social influence. Positive, you know, you’re supported by people at your birthday. Hey Happy birthday or way to go on your soccer team win and negative is You know all of the things that we think about, you know not feeling Attractive enough not feeling smart enough. If you’ve seen that people are doing something that you’re not included in because online life is very real for this generation. There’s no real difference actually between online life and in-person life. They’re fused. One feeds the other and one influences the other. And social media can let kids play parts that they may not be able to do in person, which is very helpful for girls with ADHD who might have slower processing or where they can kind of craft a response. And you know, so many people with ADHD are very creative and they can be very creative visually also. So Instagram and things that have to do with art can be a way that they can show a different side of themselves. But the other part that I think is important is like social media has taken things that used to be private and made them public and tangible. And for girls with ADHD, they may forget that they have a digital footprint. You know, if you go to a party and you’re drinking a beverage out of a red plastic cup, that might be a signal that you’re actually drinking an alcoholic beverage that, you know, your aunt may pick up on and let your mother know, or your college may see that photo of you, that you know, the college or the high school that you’re applying to. So, we really have to, you know, educate girls with ADHD because they’re not going to hold these lessons in their memory in the same way that neurotypical girls are because working memory is often compromised with people with ADHD.

Debbie: 

It’s such good information. And I love the statistics. It’s just, I love it. Okay. So we’ve talked about rejection-sensitive dysphoria or RSD on the show, and I know that there is a very high rate of people with ADHD who also have RSD. And so could you kind of bring that into the conversation, you know, and how that impacts girls and maybe in doing that, just take a minute to explain what it is in case listeners aren’t familiar with that.

Sharon Saline:

Of course, I’m happy to do that. So we want to remember that so many people with ADHD struggle with anxiety. About a third of kids with ADHD have a formal anxiety diagnosis, 50% of adults with ADHD. And social anxiety, according to Dr. Thomas Brown, who is a leading expert on ADHD, occurs in about a third of people with ADHD. It’s probably a little bit higher now since COVID, but we don’t have the data to back that up yet. So social anxiety is, there’s a spectrum. I like to call it the umbrella diagnosis. And social anxiety is really a fear of embarrassment or humiliation in a social situation that goes beyond what we might expect. And this fear can be debilitating in order to get the diagnosis of social anxiety disorder. It has to last for a minimum of six months. So what RSD does, Rejection Sensitive Dysphoria, is it takes that fear to another level of worry. And this is worry specifically about ways that you have been rejected, that you perceive that may or may not have actually happened, or ways that you’ve actually been rejected that everyone would agree on is cruel or a taunting or humiliation. And you can’t actually kind of let go of that. And you can become very focused on the possibility of rejection, the fear of rejection. And then that will sort of hold you back from behaving in social situations in ways that you would want to act, you know, comfortable, funny, yourself, whatever, because you’re so worried about this possibility. And so rejection, sensitivity, dysphoria, and social anxiety share two things. One is a core belief in deficiency. I am okay, I’m not okay the way I am. I’m not smart enough. I’m not pretty enough. I’m not athletic enough. I’m not whatever it is. You just add that adjective in and put enough after it and you’re good. The second thing that happens for both of them, particularly for social anxiety, and we do this with rejection sensitivity dysphoria, but is that you think you know what other people are thinking about you. So you’re anticipating a response from people that may or may not exist with social anxiety and with RSD, you’re anticipating rejection. Or you’ve experienced rejection. And so that leads you to have kind of a distorted perspective on things about when it’s gonna occur and how devastating it will be to you. The thing about RSD that’s different from, oh, I’m just, I don’t like rejection, is it’s not like, oh, that feels bad. It’s like you physically feel like you’ve been punched in the gut. Like you sink. There’s a sinking feeling. You maybe want to throw up or you just can’t restabilize. There’s a traumatic aspect to it.

Debbie: 

Yeah. Thank you so much for explaining that it’s something I’ve researched a lot. And because it’s something that impacts people that I love dearly, and I see how powerful and challenging a situation …  I see just the impact and how much harm that can cause. And I wanna throw out a resource that is just for listeners, if this is also resonating, I’ll include in the show notes a link to Dr. Megan Anna Neff’s work on RSD. She focused on it earlier in the fall of 2023 and she shared some great resources. So if you wanna dive in, go to the show notes and I’ll include that. But what I’d love to ask you then is about the impact of all of this, right? So we have done an episode on autistic burnout. And it is, you know, I’ve gotten emails from parents like, can you talk about ADHD burnout and specifically ADHD burnout in girls? So as we’re talking about the anxiety, that strong possibility of rejection sensitive dysphoria, the other, you know, co-occurring mental health challenges that a lot of girls with ADHD have.

Sharon Saline:

Mm-hmm. Well, I think there are a few things that we wanna think about. First of all, I do wanna say not to be shamelessly self-promoting, but I’ve written a lot about RSD for AttitudeMag.com. So check out that resource. And I’ve written about it on my website for my own blog. So that’s another option for you. I think that what we want to really think about in terms of burnout is the difference between stress and burnout. Stress precedes burnout. Stress is a condition of too much. There’s too much this, there’s too much that, and I’m feeling overwhelmed, which is actually a very good sign that your daughter might have ADHD. If they are overwhelmed, most of the time if there are, and there’s nothing sort of outstanding, or if they’re over committed to things, then that’s something that you might want to think about if they get bored quickly. But all of the pressures that we’ve talked about today that are on girls, academic, social, familial, parental expectations for success and what that means, these can increase stress for girls with ADHD across the board. And because girls with ADHD struggle with executive functioning challenges, it’s harder for people with ADHD to manage their emotions. Usually because the emotions are really strong, it’s like a tidal wave that hits them, and the working memory can be weaker. And working memory is directly related to emotional control. So you’re stressed, you’re stressed, you’re stressed. And then what happens is, you’re in a situation of overwhelm. And you’re overwhelmed and your coping mechanisms are not working. And so what starts to happen is that you start to feel burned out. It’s almost like the bucket’s overflowing and then there’s suddenly a hole in that bucket. And all the resources that you have from all the stress that’s filled up is draining the water right out of that bucket and now you’re in burnout, which is not enoughness. I don’t have enough to go around. So as parents, as clinicians, as coaches, as educators, we have to look at what enough is and when people are overwhelmed because it’s that overwhelm that is the signal that you’re heading into burnout. Because persistent overwhelm leads to burnout.

Debbie: 

Thank you. That is such a good explanation. It makes total sense. And I think that is the balancing act a lot of parents struggle with is what is that line and it might look different from day to day, I imagine, because situations, you know, can trigger our kids, they can be more depleted for other reasons, sleep and all the other factors. But I also love that you tied in reminded us about that emotional control that is an executive function. That’s such a good thing for us to remember. So I wanna be cognizant of the time. And first of all, I just wanna say thank you. This has been such an insightful conversation. I’ve learned so much and I so appreciate everything that you’ve shared. For listeners who have daughters with an ADHD diagnosis or who suspect their daughter may have ADHD, besides kind of seeking out more formal information and resources, how can we best show up for and support girls with ADHD?

Sharon Saline:

That’s such a good question. I think the first thing we wanna do is really break things down. That when girls have ADHD, and when, and this is true for boys, but particularly for girls who are attempting to present that they’ve got it together, they can manage things, they often can’t. And so what they’re feeling inside underneath is, You know, I am a bad person because I can’t do this. Or if I mess up, it’s not gonna be okay. So we want to show them that actually, living and learning is what it’s all about, right? And the way we’re gonna live and learn is we’re gonna break things down. We’re gonna break down tasks. We’re gonna break down the stressors. We’re gonna break down emotions. because that flooding happens and the thinking brain goes to the Bahamas and the amygdala is running the show. So we want to do that. We want to really think about collaborating with our kids on making decisions in their lives rather than telling them what to do. Telling them what to do, of course, never works. And particularly for girls with ADHD, they want to have buy-in. They want to have a say. We want to reduce, compare, and despair. And this is difficult because this is kind of what adolescence is all about. You know, the questions of adolescence are, who am I? Where do I belong? And that means I’m gonna be in the peer arena where I’m looking at other people and what they’re doing, what they’re wearing, what they’re saying, and comparing myself. But what happens for girls with ADHD is that they compare themselves to neurotypical boys. And that’s not a fair comparison. Those standards are not the same, which is another thing to think about. When I talk about collaborating, I’m talking about collaborating on expectations, you know, collaborating on a definition of success. So that your child is invested in what that is. If you come to your child and you say, I expect all A’s, everything has to start with a nine, what’s their investment? Because their investment might be, I’m okay if things start with an eight, because that’s kind of what I can do. And notice what goes well. Girls with ADHD will not pay attention to that. They will be focusing on what I didn’t do, what isn’t working. Don’t forget that there is a shame spiral that kids go down really fast. And so we want to decrease the negative self-talk by finding alternative ways to develop an inner ally. And that’s gonna come from you noticing things that go well, not necessarily, you know, giving them $5 because they cleared the table, but really, you know, just, you know, giving them a high five saying thank you. You know, I really appreciate that. You cleared the table when I asked. And wasn’t it fun that we put on some part of some dance music and danced our way through the dishes kind of stuff like gamify activities. Be playful because remember that there is a very large inner critic sitting on their chest. It’s telling them how they’re not good enough.

Debbie: 

Yeah, such good reminders and great strategies for us. And I did want to share before we say goodbye, in addition to your book, What Your ADHD Child Wishes You Knew, which if you have an ADHD kiddo should be on your bookshelf or your Kindle or wherever you read. You’ve also created the ADHD Solutions solution deck, which is wonderful and has a lot of just concrete strategies and ideas for how to support someone with ADHD or support yourself with ADHD. So can you just make sure listeners know the best place to find you and I’ll include links in the resources, but where do you wanna direct listeners?

Sharon Saline:

My website www.drsharonselene.com and social media, it’s at drsharonsaline.com. I’ll be your friend forever. And I want to make sure that people walk away with something that I haven’t said yet, but that’s really important. Resilience is the antidote for shame, anxiety, stress, and burnout. We want to help our girls develop a growth mindset, which is absolutely the opposite of what the culture tells them they should do and need to do, right? All the cultivated images we see online or in magazines or on television about how we’re supposed to look and the models of how we’re supposed to act, that is not related to what girls with ADHD feel, which is a shame about being different. So we want to help them say, you know, instead of, I’m not going to try this because I’m going to fail. We want them to say, I’m going to try it and risk success. We talk a lot about risking failure, but we don’t talk a lot about risking success. And remember that we all in our growing up had to face struggles and overcome them and figure out how to deal with them and disappointments. And this is true for our children, whether or not they have ADHD. And so our reassurance, our fixing things, our making sure that they don’t have pain doesn’t actually teach them what to do when things happen because things happen. And so we wanna remember to validate, I can see that you’re worried, it makes sense that you’re nervous or you’re feeling bad about this situation. Anybody could feel bad in that situation. What could you say to yourself that would help you feel more confident? And this is how we turn burnout into blossoming.

Debbie: 

Yeah. What a great note to end this on. I took so many notes that I will be reflecting on in my own parenting life. So I appreciate that so much. I appreciate the way that you support families and the work that you do in this space. So thank you so much for everything you shared today and for coming by. I hope you’ll be back. 

Sharon Saline:

Thank you for having me. I have so much admiration and respect for you, Debbie, for what you’ve created and your wisdom that you share. It’s a privilege to be here with you. Thank you.