That is a good question, for although girls may have the same symptoms as boys, the symptoms may often look quite different. I will illustrate by telling you about Stephanie, who was first brought to see me when she was eight.
Stephanie, an eight-year-old third-graderStephanie’s mother was not aware of any possibility of ADHD, but had been persuaded by her daughter’s school to bring her in for assessment because of her tendency to daydream, fabricate stories, and not complete academic tasks. Her mother was concerned about her daughter’s emotional welfare, as she was a single parent and felt her daughter worried too much about her, frequently talking about the possibility of either her mother’s or her own death.Upon meeting Stephanie, I was struck by several things: She was very fidgety and restless and seemed unaware of herself in space, frequently bumping into furniture, knocking over a chair, or bumping into me. Neither her mother nor the school had been concerned about this, but upon careful questioning, I found that indeed, she was very physically active, always climbing on furniture, up trees, and “even walls,” her mother proudly asserted. In fact, both school and home environments were exceedingly supportive and flexible, so her activity level had never posed a problem.The next thing that struck me was Stephanie’s use of language. Like Peter, she spoke constantly. Her speech was clear, and she used an astonishing vocabulary. At times she used phrases and expressions that made her seem uncannily grown up. In many ways she came across as a small adult, very poised, articulate, and proper except for her physical activity level. Finally I was struck by a strange inauthenticity, a feeling that the true Stephanie was somehow hidden. Not only did she tell me stories about her life which I knew to be quite untrue, but her entire demeanor and affect seemed to be an act. She was charming, obviously very intelligent, and incredibly watchful. She remembered every detail of our play and sessions and would refer to them the next time I saw her. If she noticed any changes in me or my office she would speak of them or ask about them. She often tried to direct our conversations by asking me detailed questions about my life.You may wonder why I speak of Stephanie as an illustration of ADHD when she seems so vastly different from Peter, who demonstrated such an obvious and extreme case. While I do not think that ADHD describes the whole problem (in fact, it almost never does), as I began to work with Stephanie in therapy, it became clearer to me that some of her difficulties could well be the result of some of the deficits of ADHD and their impact on her early development. As the academic demands increased at school, she began to have more difficulty, fell behind in math and couldn’t focus on homework, and her impulsivity sometimes caused her social troubles. Neuropsychological testing was able to pinpoint definite attention deficits and distractibility as well as some specific visual-spatial problems that were affecting her math abilities.I soon saw that Stephanie’s superior verbal skills were masking her inability to use language to gain a clear and firm picture of herself and her emotional states. She seemed unable to use language internally to understand and process interactions with other people. The false stories and feelings she created (sometimes borrowed whole from others or from books or television) acted as a substitute for a real sense of her self and her own story. She used this “as if” world to try to impose some order on her scary and confusing mental life, with its overwhelming states of loneliness, feelings of inadequacy, and fears of abandonment and rage. Her own states frightened her, for she had no secure sense that they could be managed or understood. Her mother had suffered some significant periods of depression and traumas in her own life. Stephanie had been a challenging baby who cried a lot. Her mother had often felt overwhelmed by her and at a loss as to how to calm her. While she tried to protect Stephanie from her own despair, she feared that it must be involved in Stephanie’s sense that emotions were dangerous and had to be replaced by fiction. Stephanie experienced her emotions as overwhelming states of confusing, intense distress that could not be understood or tolerated. Instead, they had to be hidden and denied by erecting her false world. In addition, she feared that her mother was vulnerable and would be hurt or perhaps even destroyed by these emotions. I do believe these factors have been active from the beginning of Stephanie’s life and have been much compounded by the kind of problems posed by the deficits of ADHD.*22\173\2*
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