By Patricia Quinn, M.D., and Kathleen Nadeau, Ph.D.
We understand far too little about girls with AD/HD. How are they similar to boys? How do they differ? We know that a higher percentage of women than girls receive treatment, which strongly suggests that girl are being under-diagnosed. A critical question to ask is why this is the case? What prevents more girls from being identified and helped earlier in their lives? Most women with AD/HD were only able to seek help for their struggles after many years of feeling frustrated, inadequate and misunderstood. We don't want this to be the fate of girls withAD/HD growing up today. One very important issue is how AD/HD is diagnosed in children. We've come a long way in understanding AD/HD over the past 15 to 20 years, dispelling the myths that hyperactivity was the of AD/HD and that AD/HD is "outgrown." But we are still living with the myth that AD/HD is primarily a boys' disorder. We continue to diagnose children according to criteria that were developed by studying hyperactive boys. Until we develop gender-sensitive diagnostic criteria, we will continue to overlook most girls with AD/HD, only identifying those who are "just like the boys." Although there is much overlap between girls and boys with AD/HD, there are also important differences. What about the internalizing tendencies of girls? In this article, we address preschool girls with AD/HD — how we can identify them and begin to help them.
The Preschool Years
AD/HD in most cases is a congenital disorder meaning present from birth — but symptoms may not always be apparent from birth. Some girls with the hyperactive/ impulsive type of the disorder may display the more classic symptoms of increased motor activity and impulsivity: however, not all girls with AD/HD present this clear-cut picture. Some may be shy and withdrawn. Others are irritable and dysphoric, with mood swings and temper tantrums. No matter what type of AD/HD a girl demonstrates, the most important point is to recognize the condition early in order to obtain access to appropriate treatment. Early identification can prevent or greatly reduce problems with poor self-esteem, peer rejection and academic difficulties. But how do we recognize these girls as toddlers or preschoolers? To date, several subtypes of AD/HD have been identified in girls. These include the hyperactive/impulsive, the shy/withdrawn, or the dysphoric girls with temper tantrumsand mood swings.
Hyperactive Subtypes
"Tomboy Tara" is easy to spot. Like many boys her age, she is hyperactive and always on the go. She doesn't sleep through the night and gives up her naps early. She may crawl or fall out of her crib before she can walk and is always exploring or getting intothings. She frequently engages in dangerous activities involving climbing. "Chatty Cathy" is more hyper-verbal than hyperactive. She talks early and her language development is often precocious. However, she cannot stop talking and comments on everything. While this appears cute at first, it quickly becomes a problem for peers and family members, who are often overwhelmed just trying to keep up. This type of chatter is also very disjointed and frequently off the target of the conversation. While everyone else is discussing what he or she would like to order at the restaurant, Cathy is talking about why "Ronald McDonald has a red nose" or the present she wants you to buy her for her birthday!
Shy/Withdrawn Subtype
In the early 1970s, researchers at NIH studying a population of preschoolers found that some girls with AD/HD presented with behaviors that were the opposite of those expected and were actually shy and withdrawn. "Shy Samantha" is just such a preschooler. Very placid and adaptable as a baby, she does not make great demands on her world. When she becomes a toddler, she does not readily join in with the other children, but rather watches from the sidelines. She tends to have isolated play and to over-focus on one activity. She can play by herself for hours when engaged in a favorite or familiar activity. However, when presented with multiple stimuli, she seems overwhelmed and unable to focus on one thing. When given directions or tasks to perform, she tends to get distracted or "lost along the way," playing with something else that catches her eye. If sent on an errand, she may get to the destination but then "forget" what she was sent for. Too many directions at one time overwhelm her and she frequently looks like a "deer caught in the headlights."
Dysphoric/Mood Disordered Subtype
This subtype of AD/HD in girls is not as prevalent, but frequently causes the most distress for parents and teachers. "Crybaby Christine" is typical of this subtype. As an infant, she is extremely difficult. She has colic and cries a great deal, is not adaptable and sleeps in "fits" and "starts." Early feedings do not go smoothly andthis child seems insatiable and difficult to please. Her mother quickly becomes frustrated and depressed, often thinking that she is a failure as a mother. Many nights are spent walking Christine and trying to soothe her. In the toddler phase, she enters the "terrible twos" but they never seem to end. She can become very out of control and may have prolonged temper tantrums during which she falls on the floor or bangs her head. Her parents become desperate and admit that at times they wish they never had a child. Marital discord may result or contribute to the tension. Eating and toilet training issues may also be part of the picture. Christine becomes the child that you can never please. She doesn't want orange juice; she doesn't want her glass on the side of her plate; and maybe she doesn't even want that glass. She demands her favorite mug (which is in the dishwasher) and refuses to drink unless she has it. Christine is quickly becoming a tyrant with her parents dancing to her tune to keep the "peace." As one parent put it, she felt that she was being held hostage by a three-year-old. As you can see from the brief description of the subtypes above, there is far more to AD/HD in preschoolers than "hyperactivity." If you are the parent of a preschool girl and suspect that she may have AD/HD, here is a list of questions to ask yourself:
• Is your child aggressive?
• Does she have difficulty with transitions?
• Do certain textures or types of clothing bother her?
• Does she have difficulty falling asleep or staying asleep?
• Is she difficult to console, or is her reaction out of proportion to a given situation?
• Are tantrums unprovoked?
• Does she crave movement?
• Does she engage in risk-taking or dangerous behaviors?
• Is she highly impulsive?
• Does she have problems with eating or toileting?
• Is she excessively withdrawn?
• Can she follow directions?
Does the normal oppositional behavior of the "terrible twos" continue as she becomes three, four and beyond? (A more extensive questionnaire can be found at the end of the preschool chapter in Understanding Girls with AD/HD.) Many parents wonder if preschool is "too soon" to identify AD/HD, and parents are often told by schools that it cannot be diagnosed until a child is as old as 7, 8 or 9. Sadly, many parents wait, when research strongly suggests that children who are identified and helped early benefit greatly. Understanding your daughter and what her needs are can only benefit her, allowing you to make better choices for her in her preschool years. With the benefit of early identification, you can make more appropriate choices for child care and preschool settings, and can structure your household in a way that will be more appropriate for and supportive of your child's needs.
Handling the Situation
Once a preschool girl has been diagnosed with AD/HD, several positive steps can be taken to make things better at home and in school. The most important first step is seeking help. Girls with AD/HD are difficult to handle in any setting. Whether the little girl is hyperactive or shy, irritable or stubborn, parents and teachers need to become aware of how to assist her in becoming better integrated into a program and relating positively to others. Parents and teachers may also need to become more knowledgeable about the disorder, its manifestations, what works, and what doesn't work by reading many of the good books available on this subject. Clare Jones has written one of these, Sourcebook for Children with Attention Deficit Disorder: A Management Guide for Early Childhood Professionals and Parents (1994, Communications Skills Builders, San Antonio, Texas).
Parents, caretakers and teachers also need to remain positive. Remember that it is the girl's behaviors that are the problem, not the girl herself. Many girls grow up feeling that they are "bad" or "not very smart" or that there was "something wrong with them" because of all the negative comments they have heard from when they were very young. It is also important to read about AD/HD and how to parent a difficult child.
Attend parenting classes or seek the help of a therapist or family counselor to assist you in the important process of learning new behavior management strategies. They can help you better deal with your child's behaviors and help address or eliminate problem situations such as transitions. Working with an expert can also help you choose appropriate activities for your daughter/ student based on her developmental level. In working with a girl with AD/HD, it is also always important to anticipate difficult situations. Girls with AD/HD should be offered fewer choices to avoid power struggles.
When a girl with AD/HD has very "out of control" behaviors or is a danger to herself or others, the issue of holding often arises. Using this technique, the adult in charge of the situation will hold the girl tightly until she has calmed down. Girls are often able to tell you if they are "okay" and no longer need to be held. Time-out may also work if the girl is sufficiently "in control" at the time or once she has calmed down. Physical punishment or spanking is rarely appropriate under any circumstances.
For girls with a high level of hyperactivity or impulsivity or who are dangerous to themselves or others, the use of medication even at this young age may be indicated.
Aggressivity and uncontrolled temper tantrums may negatively affect family and/or peer relationships, and for these girls the use of medication can be a lifesaver. Studies have shown that medication can decrease activity levels, improve compliance and improve mother-child interactions.
Additional therapies may be necessary to address motor or language delays. The girl with AD/HD may already be experiencing learning difficulties based on her "cognitive style;" she doesn't need the additional burdens of other developmental delays. An occupational or physical therapist and/or a speech pathologist may be necessary as adjuncts to her educational program.
Proper classroom placement is also important. Girls with AD/HD do better in a structured setting, but it is always important to seek out as good a "match" as possible. Placement should take into account the individual needs of each girl. This includes such issues as activity level, organizational skills, fine and gross motor development, and the need for structure and creativity. The teacher's attitude and education regarding learning difference, the school's philosophy and individual teaching styles all need to taken into consideration. Classrooms — as well as the home — should be childproofed to protect the impulsive girl.
Preschool is not too early to begin working to understand your daughter's needs. Women whose AD/HD was not diagnosed and treated until adulthood, express a common regret: "I wish they'd understood when I was a girl." If AD/HD "runs" in your family and your preschool daughter seems to demonstrate a number of the traits identified in the list of questions above, an evaluation of your daughter by a highly experienced child psychologist, psychiatrist or developmental pediatrician may be in order so that you can begin to develop some of the AD/HD-friendly supports that can help your daughter reach her potential.
In future articles, girls in elementary, middle and high school will be discussed, and the Girls' AD/HD Self-Report Questionnaire will be presented.
This article is based on information contained in the recently published book, Understanding Girls with AD/HD, by Kathleen Nadeau, Ph.D., Ellen Littman, Ph.D., and Patricia Quinn, M.D..
Attention!® Magazine Volume 6, Number 5, Page 42
By Patricia Quinn, M.D., and Kathleen Nadeau, Ph.D.
We understand far too little about girls with AD/HD. How are they similar to boys? How do they differ? We know that a higher percentage of women than girls receive treatment, which strongly suggests that girl are being under-diagnosed. A critical question to ask is why this is the case? What prevents more girls from being identified and helped earlier in their lives? Most women with AD/HD were only able to seek help for their struggles after many years of feeling frustrated, inadequate and misunderstood. We don't want this to be the fate of girls withAD/HD growing up today. One very important issue is how AD/HD is diagnosed in children. We've come a long way in understanding AD/HD over the past 15 to 20 years, dispelling the myths that hyperactivity was the of AD/HD and that AD/HD is "outgrown." But we are still living with the myth that AD/HD is primarily a boys' disorder. We continue to diagnose children according to criteria that were developed by studying hyperactive boys. Until we develop gender-sensitive diagnostic criteria, we will continue to overlook most girls with AD/HD, only identifying those who are "just like the boys." Although there is much overlap between girls and boys with AD/HD, there are also important differences. What about the internalizing tendencies of girls? In this article, we address preschool girls with AD/HD — how we can identify them and begin to help them.
The Preschool Years
AD/HD in most cases is a congenital disorder meaning present from birth — but symptoms may not always be apparent from birth. Some girls with the hyperactive/ impulsive type of the disorder may display the more classic symptoms of increased motor activity and impulsivity: however, not all girls with AD/HD present this clear-cut picture. Some may be shy and withdrawn. Others are irritable and dysphoric, with mood swings and temper tantrums. No matter what type of AD/HD a girl demonstrates, the most important point is to recognize the condition early in order to obtain access to appropriate treatment. Early identification can prevent or greatly reduce problems with poor self-esteem, peer rejection and academic difficulties. But how do we recognize these girls as toddlers or preschoolers? To date, several subtypes of AD/HD have been identified in girls. These include the hyperactive/impulsive, the shy/withdrawn, or the dysphoric girls with temper tantrumsand mood swings.
Hyperactive Subtypes
"Tomboy Tara" is easy to spot. Like many boys her age, she is hyperactive and always on the go. She doesn't sleep through the night and gives up her naps early. She may crawl or fall out of her crib before she can walk and is always exploring or getting intothings. She frequently engages in dangerous activities involving climbing. "Chatty Cathy" is more hyper-verbal than hyperactive. She talks early and her language development is often precocious. However, she cannot stop talking and comments on everything. While this appears cute at first, it quickly becomes a problem for peers and family members, who are often overwhelmed just trying to keep up. This type of chatter is also very disjointed and frequently off the target of the conversation. While everyone else is discussing what he or she would like to order at the restaurant, Cathy is talking about why "Ronald McDonald has a red nose" or the present she wants you to buy her for her birthday!
Shy/Withdrawn Subtype
In the early 1970s, researchers at NIH studying a population of preschoolers found that some girls with AD/HD presented with behaviors that were the opposite of those expected and were actually shy and withdrawn. "Shy Samantha" is just such a preschooler. Very placid and adaptable as a baby, she does not make great demands on her world. When she becomes a toddler, she does not readily join in with the other children, but rather watches from the sidelines. She tends to have isolated play and to over-focus on one activity. She can play by herself for hours when engaged in a favorite or familiar activity. However, when presented with multiple stimuli, she seems overwhelmed and unable to focus on one thing. When given directions or tasks to perform, she tends to get distracted or "lost along the way," playing with something else that catches her eye. If sent on an errand, she may get to the destination but then "forget" what she was sent for. Too many directions at one time overwhelm her and she frequently looks like a "deer caught in the headlights."
Dysphoric/Mood Disordered Subtype
This subtype of AD/HD in girls is not as prevalent, but frequently causes the most distress for parents and teachers. "Crybaby Christine" is typical of this subtype. As an infant, she is extremely difficult. She has colic and cries a great deal, is not adaptable and sleeps in "fits" and "starts." Early feedings do not go smoothly andthis child seems insatiable and difficult to please. Her mother quickly becomes frustrated and depressed, often thinking that she is a failure as a mother. Many nights are spent walking Christine and trying to soothe her. In the toddler phase, she enters the "terrible twos" but they never seem to end. She can become very out of control and may have prolonged temper tantrums during which she falls on the floor or bangs her head. Her parents become desperate and admit that at times they wish they never had a child. Marital discord may result or contribute to the tension. Eating and toilet training issues may also be part of the picture. Christine becomes the child that you can never please. She doesn't want orange juice; she doesn't want her glass on the side of her plate; and maybe she doesn't even want that glass. She demands her favorite mug (which is in the dishwasher) and refuses to drink unless she has it. Christine is quickly becoming a tyrant with her parents dancing to her tune to keep the "peace." As one parent put it, she felt that she was being held hostage by a three-year-old. As you can see from the brief description of the subtypes above, there is far more to AD/HD in preschoolers than "hyperactivity." If you are the parent of a preschool girl and suspect that she may have AD/HD, here is a list of questions to ask yourself:
• Is your child aggressive?
• Does she have difficulty with transitions?
• Do certain textures or types of clothing bother her?
• Does she have difficulty falling asleep or staying asleep?
• Is she difficult to console, or is her reaction out of proportion to a given situation?
• Are tantrums unprovoked?
• Does she crave movement?
• Does she engage in risk-taking or dangerous behaviors?
• Is she highly impulsive?
• Does she have problems with eating or toileting?
• Is she excessively withdrawn?
• Can she follow directions?
Does the normal oppositional behavior of the "terrible twos" continue as she becomes three, four and beyond? (A more extensive questionnaire can be found at the end of the preschool chapter in Understanding Girls with AD/HD.) Many parents wonder if preschool is "too soon" to identify AD/HD, and parents are often told by schools that it cannot be diagnosed until a child is as old as 7, 8 or 9. Sadly, many parents wait, when research strongly suggests that children who are identified and helped early benefit greatly. Understanding your daughter and what her needs are can only benefit her, allowing you to make better choices for her in her preschool years. With the benefit of early identification, you can make more appropriate choices for child care and preschool settings, and can structure your household in a way that will be more appropriate for and supportive of your child's needs.
Handling the Situation
Once a preschool girl has been diagnosed with AD/HD, several positive steps can be taken to make things better at home and in school. The most important first step is seeking help. Girls with AD/HD are difficult to handle in any setting. Whether the little girl is hyperactive or shy, irritable or stubborn, parents and teachers need to become aware of how to assist her in becoming better integrated into a program and relating positively to others. Parents and teachers may also need to become more knowledgeable about the disorder, its manifestations, what works, and what doesn't work by reading many of the good books available on this subject. Clare Jones has written one of these, Sourcebook for Children with Attention Deficit Disorder: A Management Guide for Early Childhood Professionals and Parents (1994, Communications Skills Builders, San Antonio, Texas).
Parents, caretakers and teachers also need to remain positive. Remember that it is the girl's behaviors that are the problem, not the girl herself. Many girls grow up feeling that they are "bad" or "not very smart" or that there was "something wrong with them" because of all the negative comments they have heard from when they were very young. It is also important to read about AD/HD and how to parent a difficult child.
Attend parenting classes or seek the help of a therapist or family counselor to assist you in the important process of learning new behavior management strategies. They can help you better deal with your child's behaviors and help address or eliminate problem situations such as transitions. Working with an expert can also help you choose appropriate activities for your daughter/ student based on her developmental level. In working with a girl with AD/HD, it is also always important to anticipate difficult situations. Girls with AD/HD should be offered fewer choices to avoid power struggles.
When a girl with AD/HD has very "out of control" behaviors or is a danger to herself or others, the issue of holding often arises. Using this technique, the adult in charge of the situation will hold the girl tightly until she has calmed down. Girls are often able to tell you if they are "okay" and no longer need to be held. Time-out may also work if the girl is sufficiently "in control" at the time or once she has calmed down. Physical punishment or spanking is rarely appropriate under any circumstances.
For girls with a high level of hyperactivity or impulsivity or who are dangerous to themselves or others, the use of medication even at this young age may be indicated.
Aggressivity and uncontrolled temper tantrums may negatively affect family and/or peer relationships, and for these girls the use of medication can be a lifesaver. Studies have shown that medication can decrease activity levels, improve compliance and improve mother-child interactions.
Additional therapies may be necessary to address motor or language delays. The girl with AD/HD may already be experiencing learning difficulties based on her "cognitive style;" she doesn't need the additional burdens of other developmental delays. An occupational or physical therapist and/or a speech pathologist may be necessary as adjuncts to her educational program.
Proper classroom placement is also important. Girls with AD/HD do better in a structured setting, but it is always important to seek out as good a "match" as possible. Placement should take into account the individual needs of each girl. This includes such issues as activity level, organizational skills, fine and gross motor development, and the need for structure and creativity. The teacher's attitude and education regarding learning difference, the school's philosophy and individual teaching styles all need to taken into consideration. Classrooms — as well as the home — should be childproofed to protect the impulsive girl.
Preschool is not too early to begin working to understand your daughter's needs. Women whose AD/HD was not diagnosed and treated until adulthood, express a common regret: "I wish they'd understood when I was a girl." If AD/HD "runs" in your family and your preschool daughter seems to demonstrate a number of the traits identified in the list of questions above, an evaluation of your daughter by a highly experienced child psychologist, psychiatrist or developmental pediatrician may be in order so that you can begin to develop some of the AD/HD-friendly supports that can help your daughter reach her potential.
In future articles, girls in elementary, middle and high school will be discussed, and the Girls' AD/HD Self-Report Questionnaire will be presented.
This article is based on information contained in the recently published book, Understanding Girls with AD/HD, by Kathleen Nadeau, Ph.D., Ellen Littman, Ph.D., and Patricia Quinn, M.D..
Attention!® Magazine Volume 6, Number 5, Page 42
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