Girls with ADHD: the risks that don't show up on the report card

When a girl has ADHD, almost every conversation at home revolves around school: grades, the homework she didn’t hand in, the planner she lost again. That makes sense, because it is what you can see. But in my practice I have learned that, beyond the report card, in a teenager with ADHD it is worth looking at other things that are harder to see: her mood, how she treats herself, and how she looks after her health and her body. This article is for mothers and fathers who want to know what studies say about those risks, without panicking and without looking away.

If your daughter talks about not wanting to live or is hurting herself, don’t wait: call Línea 113, option 5 (free, 24 hours, in Spanish), 106 (SAMU) or go to the nearest emergency room.

Why does ADHD go unnoticed in girls?

The classic image of ADHD is a boy who can’t sit still. Many girls don’t fit that image: they are dreamy, get distracted, forget things, but don’t disrupt the class. And that changes how people look at them.

A 2009 study with primary school teachers in England offers a clue. They were given the made-up case of a 9-year-old girl with ADHD. Almost all of them (98%) noticed that something was going on with the girl. But when the girl was mainly distracted, only 14% thought of possible ADHD, compared with 43% when she was also restless and impulsive. And when they described her problem as “attention difficulties”, they saw less need to refer her to a specialist. The study has limits: it did not include boys for comparison, and only half of the teachers invited responded. But it matches a phrase many families recognise: “she’s scatterbrained, but she doesn’t cause trouble”.

Another study, with almost 20,000 twins in Sweden, reached something similar by another route: girls were diagnosed mainly when they also had behaviour problems; in boys, that weighed less. The authors conclude that a girl with ADHD may more easily go unnoticed if she has no obvious behaviour problems.

And in a database that brings together the medical records of the Stockholm region, ADHD was first recorded in women at an average age of 23.5; in men, at 19.6. It does not measure exactly how much diagnosis is delayed, but it points in the same direction. If you want to know what ADHD looks like in a woman, I explain it in ADHD in adult women, and how I work with teenagers in adolescent psychiatry.

Does ADHD raise the risk of depression in girls?

This is one of the risks that is least visible from the outside.

In a large Swedish study of girls and young women aged 15 to 24, those with ADHD had more than three times the risk of receiving, for the first time, a diagnosis of depression or an antidepressant prescription compared with those without ADHD. In the Stockholm database, moreover, half of the women with ADHD had had a diagnosis of anxiety or stress, compared with one in four men with ADHD, and more than a third one of a mood disorder, compared with one in five. Those figures cover all ages, not only teenagers, but they draw a pattern.

There is a detail that helps in understanding how to look at it. In the California study I describe below, which followed girls with ADHD for about ten years, their parents did notice more emotional distress in them than in girls without ADHD. But what the girls themselves answered on mood questionnaires was not very different, and even so those diagnosed as children with the combined type had more self-harm and suicide attempts. The authors propose, as a hypothesis, that difficulty controlling impulses could play a central role. That is why it is worth asking directly about hurting herself, and not only about sadness.

And self-harm or suicidal thoughts?

This is the hardest part to read, and that is why I want to say it carefully.

An analysis that brought together 57 studies found that, in people with ADHD, suicidal thoughts and suicide attempts are reported more often than in people without ADHD. That analysis combines children, teenagers and adults, and could not separate the results for women and men.

To learn something specific about girls, you have to turn to a smaller study. In California, Hinshaw and colleagues followed girls diagnosed with ADHD as children for about ten years, until they were between 17 and 24. In that California group, among those diagnosed as children with combined-type ADHD (distraction plus restlessness and impulsivity), 22% had made a suicide attempt at some point, compared with 6% of girls without ADHD. Put another way: even in that group, almost eight in ten never attempted it. Self-harm without the intention to die, which in that study was measured with a broad question about having hurt oneself on purpose, was also more frequent: 51% compared with 19%. In those diagnosed as children with the mainly inattentive type, the difference was not clear, but it was a group of about 40 girls and the type of ADHD changes over the years: it does not rule out a higher risk, so the invitation to ask applies to all of them.

These figures should be read with their limits. It is a small group, from another country, recruited for summer programmes organised by the researchers, and the authors themselves warn that it is not representative. The figures for attempts count what happened at some point up to age 17 to 24, not only in adolescence. And there is something that applies to this whole article: the studies I describe in detail were carried out in Sweden, England and California, and none of them is only about teenagers; they are about young girls, girls aged 15 to 24 or women of all ages. The analysis of 57 studies gathers data from several countries, but gives no figures of its own for girls or for Peru. The exact number does not carry over as it is to a girl in Lima; what does hold is the invitation to ask.

The authors of the analysis of 57 studies recommend exactly that: that professionals ask about suicidal thoughts and behaviours at the first visit and at every ADHD follow-up, because the usual ADHD questionnaires do not usually include those questions. If your daughter already has a professional supporting her, ask that professional whether they are talking about it with her.

If your daughter tells you (this is clinical judgement, it does not come from the studies):

• Thank her for telling you and listen calmly, without scolding or punishing her. Telling you is already an important step.
• Don’t play it down (“it’s a phase”) or promise to keep it secret: tell her you are going to help her find support.
• If she talks about wanting to die, don’t leave her alone, lock away the medicines and toxic products in the house, and seek help immediately: Línea 113, option 5, or the nearest emergency room.
• If she hurt herself without the intention to die and has no wound that needs urgent care, ask for an assessment in the next few days. Even if it seems minor, it is worth having a professional see her.

Self-harm and suicidal thoughts can be treated, and with professional support and a family that listens, many girls come through.

Don’t wait for the next appointment if your daughter talks about not wanting to live, is hurting herself or has a wound that needs care, says she is a burden, says goodbye or gives away her things: call Línea 113, option 5, 106 (SAMU) or go to the nearest emergency room. These lines answer in Spanish.

What do studies say about teenage births?

In Sweden, among women who had their first birth between 2007 and 2014, 15.3% of those with ADHD were under 20 when they gave birth, compared with 2.8% of those without ADHD: more than five times more frequent.

That figure lends itself to misunderstanding, so let me explain it. It does not mean that 15% of girls with ADHD will have a baby as teenagers: the study looks at women who had already given birth and counts how many did so before 20, so it cannot tell what proportion of all girls with ADHD has a birth in adolescence. In Sweden, in general, births before 20 are rare: 3% of the first births in the study. Also, in that study “having ADHD” meant having received ADHD medication, which leaves mainly the more marked cases, and the researchers did not account for the weight of other factors, so it shows an association, not a cause.

What stands out is that it happened even though contraception is widely available in Sweden. That is why the authors recommend that care for girls with ADHD include active efforts to prevent teenage pregnancy. This says nothing about her values or her character: it is part of her care, just as you talk about school or sleep. And if your daughter is already pregnant or a mother, in my experience supporting her without blame and also looking after her mood helps a great deal.

Can contraceptives affect her mood?

If your daughter uses a hormonal contraceptive, there is one more piece of information worth knowing, calmly.

In the same large Swedish study of girls and women aged 15 to 24, among those with ADHD, using the contraceptive pill was associated with a higher risk of depression, something not seen in girls without ADHD. The other hormonal methods, the ones that are not pills, were also associated with slightly more depression, but equally in girls with and without ADHD. It is a study based on medical records and prescriptions: it shows an association, it does not prove that the pill causes depression. The authors suggest also discussing long-acting methods, but what suits your daughter is decided with her doctor, according to her case.

The practical point is this: if you notice changes in her mood, she should not stop the contraceptive on her own, because stopping without another method exposes her to an unwanted pregnancy. Encourage her to talk it over with her doctor or gynaecologist. It is normal and healthy for her to want to discuss some topics alone with her doctor; in my experience, that confidential space also protects her.

How can you talk about it at home?

This part does not come from the studies, but from what I see in my practice with families.

• Separate the person from the symptom. Forgetting, getting distracted or acting on impulse is not laziness or bad intent. A girl who hears that at home becomes less defensive and shares more.
• Ask about her mood the way you ask about her grades. Naturally and more than once. In my experience, a direct and calm question (“have you thought about hurting yourself or about not wanting to live?”) does not give her the idea: it opens the door for her to tell you.
• Also ask, without interrogating her, how she is sleeping, how things are with her friends and on social media, and whether anyone is pressuring her or making her feel bad. If there is use of alcohol or other substances, or signs that someone is hurting her, seek help soon.
• Talk about sexuality and contraception before it is needed. Not as a warning, but as information, and let her doctor be part of that conversation.
• Make sure ADHD is not the only thing people talk about when they talk about her. What she does well also needs space.

When should you seek help?

An assessment, or resuming follow-up if it was dropped, is worthwhile when:

1. Your daughter is very distracted, forgetful or disorganised, even if she “doesn’t cause trouble” at school, and it costs her in her grades, with her friends or in her mood.
2. You notice that she withdraws, is more irritable or has stopped enjoying what she used to like.
3. She has had mood changes since starting a contraceptive.
4. She already has an ADHD diagnosis and no one has talked with her about mood, self-harm or sexuality.

In my practice I see teenagers from age 15; for those under 15, the right step is an assessment with child psychiatry. In the consultation, your daughter has a confidential space; the exception is situations of serious risk, which are explained from the start.

And if she talks about not wanting to live or hurts herself, don’t wait for an appointment: call Línea 113, option 5, 106 or go to an emergency room.

Frequently asked questions

Will every girl with ADHD have these problems?
No. Studies talk about group averages: they say these risks are more frequent, not that they will happen to your daughter. Knowing them is useful for asking in time, not for living in fear.

What does ADHD look like in a teenage girl?
Often, more distracted than restless: she gets distracted, forgets things and is disorganised, even if she "doesn't cause trouble" at school. That is why many girls go unnoticed. Only a professional can assess it.

Why does ADHD go unnoticed in so many girls?
Because many are more distracted than restless. In a study with teachers, only 14% thought of ADHD for a mainly distracted girl, compared with 43% when she was also restless and impulsive.

Should I ask my daughter whether she has thought about hurting herself?
Yes, calmly and without interrogating her: in my experience, a direct question does not give her the idea. In addition, the authors of an analysis of 57 studies recommend that professionals ask about suicidal thoughts and behaviours at every ADHD follow-up, because the usual questionnaires do not usually include it. If there is risk right now: Línea 113, option 5, or 106.

If you notice changes in her mood, does she have to stop the contraceptive?
Not on her own: stopping without another method exposes her to an unwanted pregnancy. Encourage her to talk it over with her doctor or gynaecologist.

This article is for information only and does not replace an individual medical assessment or create a doctor-patient relationship. No treatment should be started, changed or stopped without discussing it with her doctor.

References

1. Groenewald C, Emond A, Sayal K. Recognition and referral of girls with Attention Deficit Hyperactivity Disorder: case vignette study. Child: Care, Health and Development. 2009;35(6):767-772. doi:10.1111/j.1365-2214.2009.00984.x
2. Mowlem FD, Rosenqvist MA, Martin J, Lichtenstein P, Asherson P, Larsson H. Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. European Child & Adolescent Psychiatry. 2019;28(4):481-489. doi:10.1007/s00787-018-1211-3
3. Skoglund C, Sundström Poromaa I, Leksell D, et al. Time after time: failure to identify and support females with ADHD. Journal of Child Psychology and Psychiatry. 2024;65(6):832-844. doi:10.1111/jcpp.13920
4. Lundin C, Wikman A, Wikman P, Kopp Kallner H, Sundström-Poromaa I, Skoglund C. Hormonal Contraceptive Use and Risk of Depression Among Young Women With ADHD. Journal of the American Academy of Child & Adolescent Psychiatry. 2023;62(6):665-674. doi:10.1016/j.jaac.2022.07.847
5. Septier M, Stordeur C, Zhang J, Delorme R, Cortese S. Association between suicidal spectrum behaviors and ADHD: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews. 2019;103:109-118. doi:10.1016/j.neubiorev.2019.05.022
6. Hinshaw SP, Owens EB, Zalecki C, et al. Prospective follow-up of girls with ADHD into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology. 2012;80(6):1041-1051. doi:10.1037/a0029451
7. Skoglund C, Kopp Kallner H, Skalkidou A, et al. Association of ADHD With Teenage Birth Among Women and Girls in Sweden. JAMA Network Open. 2019;2(10):e1912463. doi:10.1001/jamanetworkopen.2019.12463

Note on conflicts of interest: studies 2, 3, 4 and 7 have authors with declared ties to manufacturers of ADHD medication (in study 2, unrelated to that work), and studies 4 and 7 also to manufacturers of contraceptives. The analysis in study 3 received support from a manufacturer of ADHD medication, and its lead author runs a private ADHD clinic.