ADHD In Boys vs. Girls

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host. ADHD is a term most of us know, but the way it shows up in children isn't always what people expect. For some kids, especially boys, it can be loud and hard to miss. For others, girls in particular, it may be quieter and easy to overlook. These differences play a big role in how we view ADHD and its reach.

Today, we're going to talk through what that means in the big picture with Dr. Carrie Cuffman, a specialist in pediatric developmental behavior. She's one of the many experts at Cleveland Clinic who pop into our weekly podcast to help us make informed decisions about our health. So with that, let's get into what ADHD can look like in kiddos and why recognizing the full range of signs and symptoms is so important.

Dr. Cuffman, welcome back to the podcast. Thanks for setting aside some time today to come in and chat about a topic, ADHD in kids, that always seems to draw attention and questions.

Carrie Cuffman, MD:

Yeah, thanks for having me.

John Horton:

All right. Well, to kind of kick things off, can you explain what ADHD is? I know we all have an idea in our heads, but sometimes those assumptions don't quite match up with reality.

Carrie Cuffman, MD:

Right. Yeah. So ADHD is a neurodevelopmental condition, so a condition where the brain is actually working differently. And so right now we don't have a brain scan or a blood test to diagnose ADHD, so we are really looking at symptoms on the outside. And what we see are kids are inattentive, so not paying attention well, not able to focus on things, having trouble with losing things or getting themselves organized.

There also can be hyperactive symptoms, so you're always moving around, driven by a motor, always on the go. And then you can also be really impulsive, so doing things without thinking, making silly mistakes at school or home. So those are really the biggest signs of ADHD.

John Horton:

Well, just hearing those symptoms, it makes you realize how difficult it can be to identify ADHD, because those all sound like things that we just deal with at times as being human.

Carrie Cuffman, MD:

Yes, especially children, right?

John Horton:

Yeah, absolutely. I had three of them and they were always... Not paying attention is pretty much what they do.

Carrie Cuffman, MD:

The norm, yes.

John Horton:

So we have this wide range of symptoms, and that's, I guess at the core of what we want to focus on today, namely how ADHD looks different in different kids and specifically how it looks different in boys and girls. And that's something that I know can lead to differences in how they're diagnosed and how ADHD is recognized in boys or girls. So let's start, we got to go one way or the other here. Let's start with how ADHD often presents in boys. What are the most common signs that you see there?

Carrie Cuffman, MD:

Yeah, so I'll preface this by saying that there are some boys that look more like the girls that we're going to talk about in a little bit.

John Horton:

These aren't 100%.

Carrie Cuffman, MD:

It's not 100%, right? So you can have crossover, but by and large, a typical boy with ADHD is going to have more disruptive symptoms. So they're more hyperactive, just more difficult behaviors that catch people's attention. They're the ones who are just wild in the classroom, not sitting in their seats. So teachers are really noticing that. They're causing more maybe problems at home as far as parent discipline concerns come up more with these boys with ADHD because they're just so busy and on the go. So they just come up, they're really easy to see because their behaviors are often so disruptive.

So that is the typical boy, but boys also can have a lot of inattention symptoms as well. So trouble focusing and paying attention and daydreaming, that sort of thing that can also be part of the picture, but tend to be just much more disruptive compared to girls.

John Horton:

It seems like it's those large motor skills sort of thing. And I think that's what a lot of us think of with ADHD. You think of run a little wild and you're climbing up trees and jumping around and just blurting stuff out. Those seem to be, I think, how most of us do look at that.

Carrie Cuffman, MD:

Right. Yeah, there's definitely a stereotype of a kid with ADHD being that way, but that's not always the way it is.

John Horton:

Yeah. All right. So that's on the guy side there, you have this big, loud, noisy, active manifestation of ADHD. Now let's talk about girls. How does ADHD typically look for them?

Carrie Cuffman, MD:

Yeah, so girls tend to be less disruptive, so they tend to have more inattention symptoms. So they are the daydreamers, just not paying attention at school. It can be harder at home to really tell if your kid is paying attention because sometimes you're not doing a lot of things that require a lot of attention in the home setting outside of maybe doing homework or that sort of thing as kids get older.

But especially when girls are younger, it can be hard to tell because you're not asking for a lot of attention from them necessarily in the home setting. So yeah, the girls just tend to be more inattentive, less of those hyperactive, disruptive behaviors. So they just get really easy to miss because people aren't noticing those quieter symptoms.

John Horton:

It's hard to notice a symptom that is basically almost a non-symptom because you're kind of invisible.

Carrie Cuffman, MD:

Right. Yeah.

John Horton:

So when you see that, though, that's got to be tough then to identify as like, oh, this is ADHD. I mean, there are kids that are just quiet or shy or things like that. It's got to be tough then to pick that out.

Carrie Cuffman, MD:

Yeah, it really can be because parents aren't always seeing a lot of symptoms at home, like I said, because you're not always doing things that require a lot of attention. And even at school, teachers don't necessarily notice that the kid's not paying attention if they're not being disruptive because they have a lot of kids in their classroom. So it can be really hard to gather the information you need to make a diagnosis of ADHD in that quiet, just inattentive kid, girl or boy. So it is easy to miss.

John Horton:

Now I also saw, like what you mentioned with boys, how you could have quieter signs of ADHD. Girls can also have those hyperactive symptoms too, but I read where those kind of come off a little differently than they do with boys.

Carrie Cuffman, MD:

Right. Yeah. So I think partially just because of, as a culture, the different roles that we give to boys and girls, men and women, and different stereotypes, girls often are just thought of like, oh, that's the chatty girl or the bossy girl. So maybe we wouldn't be thinking ADHD, we just think this is how she is and that's kind of personality when it's actually a disorder that's causing trouble for her, right?

John Horton:

Yeah. It sounds like the girls don't tend to have that physical response to ADHD because boys, they're bouncing off of walls, and two sons and they're more active and more just everywhere. It sounds like girls, you don't quite usually see that as a sign of ADHD?

Carrie Cuffman, MD:

Yeah, they can be, but it is much more commonly not those physical symptoms of all over the place movement that we see with girls compared to boys. Boys are much more often that way with ADHD.

John Horton:

Boys are much more often that way all the time.

Carrie Cuffman, MD:

In general, yeah. I have two boys too, so yes.

John Horton:

We always had a lot of super glue around.

Carrie Cuffman, MD:

Yeah. Yes. Super glue and duct tape.

John Horton:

All right. So clearly when we laid both of these out, there's a big difference in how ADHD typically shows up in boys versus girls. Does this make a difference when it comes to diagnosing kids and getting them help?

Carrie Cuffman, MD:

Absolutely. Yeah. So boys are diagnosed at a much higher rate than girls. It's about two to one in kids. Yeah, it's a huge difference.

That actually, we know we're missing girls because women eventually are diagnosed later. And so in adults, it's actually the diagnosis rate is like one to one. So we're clearly missing these girls. So yeah, it does cause a lot of difficulties for the girls for sure to not get that diagnosis. And there's a big difference in diagnosis between boys and girls.

John Horton:

What does that mean in the big picture when girls don't get that diagnosis and then they're just, I guess, working through their ADHD just on the fly without any sort of assistance?

Carrie Cuffman, MD:

Right. Yeah. So yeah, the basics is you're not getting support for real difficulties that you're having at home and school. So unfortunately, missed diagnoses can lead to other mental health problems because we're not able to do things that other kids can do. And so our self-esteem suffers and that can lead down the road to anxiety and depression concerns. So that is the biggest one big impact.

And then also it can cause challenges at school for not paying attention. It's hard to learn, so grades can suffer. And ultimately, school outcome can suffer from not having a correct diagnosis and correct support for your ADHD. So really, really important to find these girls and get them the support they need.

John Horton:

Yeah. Now, if ADHD does get missed in girls, what kind of challenges does that create? I know you just went over some of them, but I'd imagine they kind of stack up and they just build as time goes on.

Carrie Cuffman, MD:

Yeah, you're right. So for young kids, it's not quite so apparent until they get to the school years, and then maybe we start to struggle some in school. Sometimes girls with ADHD get labeled as lazy or not trying hard enough, when the reality is that they just don't have the skills to do what they're being asked to do.

John Horton:

That lack of focus.

Carrie Cuffman, MD:

Yeah. Right [inaudible 00:11:36].

John Horton:

Like you said, you're kind of zoning out. You're having these sort of—

Carrie Cuffman, MD:

Yeah, you're zoning out. Yeah, exactly. They aren't paying attention, so they are missing things. So they may think they're not as smart as other kids just because they're missing lots of things. Some kids with ADHD just really notice the differences between them and other kids and what they're able to do, and that can really bother kids. And that's a lot of where those mental health challenges that I mentioned can come into play for these kids.

So things do, like you said, stack up. So what in elementary school is just like we're having some troubles in school and we're not quite sure why. And then down the road into high school and adulthood, then you end up with these bigger, more serious mental health problems because you just don't understand why you're not getting things.

John Horton:

And I know you mentioned the mental fatigue that can come with that because it seems like if you are struggling, if you're having difficulties, and you just get blamed for it instead of somebody going, "Hey, there's a physical issue here that's causing these lapses or this inattention." That's a big difference when you look at, I don't want to say blame, or just responsibility for it. Just knowing that you have ADHD seems like a big step to then getting a solution and being able to get the help you need to do your best.

Carrie Cuffman, MD:

That's exactly right. Yeah. So if we know you have it, we can treat it, we can provide support for it. If we don't know you have it, then it does all come down to you're just not trying hard enough, which is not fair at all to the kid.

John Horton:

Yeah, no. And you could see where it'd be so difficult, especially if girls just aren't diagnosed as much just because those signs are a little easier to miss.

Carrie Cuffman, MD:

Yeah, absolutely.

John Horton:

Right. Now, on the flip side of that, I know you mentioned boys get diagnosed far more. Is there any worry sometimes that maybe ADHD is over-diagnosed in boys? I mean, you're just a little rambunctious and just a little too much energy?

Carrie Cuffman, MD:

Right. So that is a good question, and I don't think anybody really knows the answer to this. The best kind of example and evidence we have that maybe this is happening is there was a study that actually looked at the kids in a class divided by birthdate. So within any given year in school, there are kids who, for example, in kindergarten, when they start school, they're almost six or they have just turned five. So you could potentially be in a class with a kid who's almost a full year younger than you.

So the study looked at all these kids across the age spectrum within a grade year of school and found that the kids who were younger, so those summer birthday kids, were more likely to get an ADHD diagnosis if they were a boy. So that means that we're not treating those kids fairly.

Our expectations for them are maybe too high because they're almost a full year younger than the peers they're being compared to.

So I think we need to be careful about looking at ADHD within the context of the age and developmental level of the child because all these symptoms, they need to be unusual and excessive for the developmental level of the child. So that study is the best piece of evidence we have that maybe we're over-diagnosing it, but I think that in individual patients that can be hard to do, hard to know if you're over-diagnosing that individual in the moment until we see how their trajectory looks long-term.

John Horton:

Do you find too, is this a difficult thing for parents to hear? Because your kid's having some trouble, you're having some issues, and all of a sudden this comes out as maybe a thing. Is there a hesitancy sometimes to have a kid labeled as having ADHD and maybe a little pushback?

Carrie Cuffman, MD:

I mean, absolutely. I think parents' own experiences with ADHD are very different. ADHD is very heritable. It's very common to have a parent with ADHD and a child with ADHD. So in those families, there's already a lot of acceptance and knowledge about ADHD typically.

If it's kind of a first encounter with ADHD, then it is a little bit more difficult and can be because in a lot of ways, kids with ADHD, as we said, can look very much like other kids. They just have these other kind of additional challenges on top of what can be typical kid behavior. So it can be really difficult for parents to accept or want to label their child with something that does come down the road with potentially medication treatment and other supports needed basically. That can be really difficult, for sure.

John Horton:

Yeah. And you can see how it's so hard because like you said, you can't just have an x-ray and go, "Oh, look, there's the ADHD right there." I mean, it's kind of a case where there's just kind of a step missing in the process where all of a sudden then your kid's unable to focus or do whatever. But as we know, kids are kids too.

Carrie Cuffman, MD:

They're not robots.

John Horton:

Their focus... Yeah, they're not always locked in. And that's where it gets so hard. And I know a lot of times you just, oh, they just need to focus more or they just need to do this. And you're not realizing that there's a mechanism that's off. And it seems like that's a really big step to take and to realize to get your kid the help that they need.

Carrie Cuffman, MD:

Yeah, it can be. And sometimes it's often for elementary school-aged kids, it's teachers who bring up a concern first because parents, this is the way their kid has always been to some extent. And they look pretty similar to other kids in a lot of different ways.

So it's really important for parents to listen to teachers' concerns and that sort of thing to help them if they're not sure, to get them pointed in the right direction of maybe we need to investigate this a little bit further with our doctor. And that can be really, really helpful for parents if we're not sure. Maybe what's going on is to get input from lots of different people, including the child's teachers.

John Horton:

Yeah. Now, we've been kind of comparing and contrasting ADHD symptoms in boys and girls. Is a diagnosis of ADHD more accepted for one or the other? I mean, do you find that parents are more open to hearing it if they have a son versus a daughter?

Carrie Cuffman, MD:

So I don't necessarily see a difference. I think across society, we're more accepting of boys. That's partly why we see more diagnoses in boys. But I think by the time... I'm a specialist, I'm not a general pediatrician, so by the time they get to me, they're often ready. They've been to several different people. They're really trying to figure this out. So for me, I don't necessarily see that.

But like I said, I think the numbers in this case speak for themselves and that we probably are as a society just more accepting of these diagnoses for boys than we are of girls.

John Horton:

Even think of how we phrase things. I mean, the whole “boys will be boys” is kind of said with a laugh and a ha-ha, this is just the way it is. “Girls will be girls” always kind of comes off a little snarkier and it does not seem like a good thing when you say it.

Carrie Cuffman, MD:

Absolutely. Absolutely. The societal expectations for boys and girls are just really different. We expect girls to sit and pay attention and behave, and boys are just given more latitude to just misbehave to some extent, be hyperactive, maybe not pay attention. And people do just chalk that all up to being a boy versus a girl kind of misbehaving in the same way is not viewed the same way.

John Horton:

And like you said, the way the expectations are just a little different. And then you can see, just judging by that, why then ADHD often gets overlooked in girls because this is like, well, they're supposed to be a little quieter and to be a little more still.

Carrie Cuffman, MD:

Yeah, exactly. So those inattentive girls who are quieter, they're just acting like they should be.

John Horton:

Yeah. All right. So to wrap things up, Dr. Cuffman, if you're a parent and you see signs of ADHD in your son or daughter, what's the first step you should take to try to figure out if there is something going on?

Carrie Cuffman, MD:

Yeah, so I would definitely, as a first step, talk to your pediatrician. They're your first line for your child's health, including ADHD. And general pediatricians see ADHD a lot, so they're a really good first step. They can help gather information from you and from teachers and from any other pertinent adults in your child's life who have information to offer about behaviors and attention and activity level.

So they can help gather all that and help decide whether, yes, clearly ADHD, I can give you the diagnosis right now, or do we need to move on to see a specialist like myself or psychiatry to really try and figure this out a little bit more because there's some other complicating factors. So pediatrician is a really, really great step for anybody wanting to help to navigate these concerns in their child.

John Horton:

Kind of get that process started.

Carrie Cuffman, MD:

Exactly. Yes.

John Horton:

And what might that look like? As you take a step or two, and I know we're not going to get into the whole thing here right now, but what does getting help look like if you suspect a kid has ADHD?

Carrie Cuffman, MD:

Yeah, so what the help looks like does depend a little bit on age of the child. In younger kids, so under 6 or so, we really focus a lot more on behavioral supports. So we work on parenting strategies that work really well for kids with ADHD. We work a lot on getting them support in other settings like school or maybe daycare if they need some extra behavioral support there. So the first interventions are really behavioral interventions for those younger kids.

Starting at age 6, though, medication does become our first line, part of the first line for kids with ADHD because their medications do work really, really well for ADHD. So starting at age 6. No parent has to start ADHD medication, but it is recommended. And I think myself and any pediatrician would be having a conversation with a parent about the benefits and downsides of starting a medication for their child.

But that always needs to be in addition to some supports at school. So maybe things like we sit closer to the teacher or get extra time to do our tests or breaks to move around during the school day. So still putting in those environmental behavioral interventions to help the kid to learn new skills and to help them be successful in whatever their environment is at the current time.

John Horton:

And it sounds like the key is that there are things that can be done to help a child get past ADHD and really succeed and just be their best.

Carrie Cuffman, MD:

Yeah, absolutely. Yeah, there's a lot we can do, and these things are very, very helpful for kids with ADHD.

John Horton:

All right. Well, I think that's a great place to end. I always like ending on an optimistic note. So I think you've kind of given us that. So as always, Dr. Cuffman, we appreciate you coming in and you always have such great information to share, and I love the way you kind of just lay it all out for us.

Carrie Cuffman, MD:

Great. Yep. Happy to be here.

John Horton:

The signs of ADHD don't look the same in every kid. Boys may exhibit more obvious hyperactive and impulsive behaviors. Girls often show quieter signs that are easy to miss, like zoning out or disorganization. Whatever the symptom, if something feels off to you, trust your instincts and talk with the healthcare provider. Getting answers early on can help your child better understand how their brain works and connect them with support at home, at school, and in everyday life. If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.