Girls with Autism and ADHD – Struggling to Fit In and To Be Accepted

ADHD is the most common diagnosis in girls with autism and autistic traits or an autism diagnosis are also common in those with ADHD. Therefore, when meeting individuals with Neurodevelopmental Disorders (ND), it’s essential to consider both ADHD and autism. Girls and women are still sadly underdiagnosed, often because they are better than boys at masking their difficulties. Many parents describe how their girls are overlooked in both school and healthcare, requiring themselves to drive the process of assessment and obtaining the right diagnosis.

Even at a young age, neurodiverse girls often find it challenging to keep it together in preschool, to engage in, and adapt their playing to other children. In my work as a psychologist, I frequently make observations in preschool and school, and despite parents describing significant problems, I often hear from teachers that everything is “just fine”. The girl doesn’t stand out, isn’t visible, isn’t heard.

Meet Hanna – 5 year old girl with Austism

Hanna is 5 years old and the introduction to preschool was difficult. Hanna was crying and struggling when her mother drop-off for several years. The teachers thought that the mother lingered and didn’t want to let go, assuming that’s why Hanna became so upset. However, the mother disagrees; she felt totally ok to leave Hanna but didn’t know how to react when her daughter was so completely inconsolable. The staff describes Hanna as a shy girl who can be active and “run around,” but also enjoys painting, crafting, and playing in the “home corner”. Here, she likes to arrange objects (pots and play food) by color and size. Hanna has no problem with other children wanting to play in the same space; she adapts and follows them. The staff thinks Hanna behaves just like other children, but upon closer observation, I notice that she doesn’t really play with the other children. She mostly stands beside the others, playing with her own toys. When another child wants to borrow something, Hanna shares without complaining. But she is meticulous about getting everything back to arrange it in the right order again. Hanna never gets angry or upset at preschool and is perceived as compliant and pleasant. At home, it’s a different story. Often, she breaks down already in the hallway, especially when her mother picks her up. The staff thinks it’s due to interaction difficulties between Hanna and her mother, but the mother thinks it may be because Hanna has held it together all day at preschool and simply can’t take more. When they come home, “Hanna often misbehaves,” according to her mother. She protests against everything, screams, and throws things.

I would dare say that this is a fairly typical picture of a preschool-aged girl with autism and ADHD. Almost all the girls with autism and ADHD I have met are described by others as compliant, pleasant, good with adults, and so on. Often good at following routines (being routine-bound is also an autism criterion), making them seem to cope well in everyday life. It’s actually not uncommon that their difficulties aren’t detected at all in the preschool and school environment. But beneath the compliant, adaptable surface, the girl often struggles in quicksand of confusion, uncertainty, and shame. Even though the rules in childhood playing are often quite unclear, most children intuitively understand them. However, the girl with autism and ADHD more often misses the subtle nuances, making embarrassing or disruptive “mistakes” in play. She stands on the sidelines, wanting desperately to join, makes an attempt but doesn’t read the situation correctly, tries too hard, talks too loudly, or persists for too long. The shame of having made a mistake is well-known in these girls, even if they don’t show much outwardly. School staff might see the girl who is “part of” the play and not understand how much energy goes into sorting through confusing signals and expectations. Parents see and hear the girl’s meltdown when she comes home. Psychologists, like me, can get two very different stories about what seems to be two completely different children. In this situation, it’s often wise to listen carefully to the parents story.

In the school years, the social challenges often continue for the girl with (undiagnosed) autism and ADHD. However, some girls I meet say that school is an improvement because lessons and learning are more structured than play. Unfortunately, many girls with autism and ADHD will soon struggle with school tasks as well. Meanwhile, as breaks, after-school activities, and other unstructured parts of the day come, children become more exposed to each other, making it increasingly difficult. Girls with combined ADHD who are hyperactive and impulsive can sometimes get a little “boost” from their ADHD and take on the role of “a fun girl who comes up with a lot.” Being an initiator and idea generator is fun for most until someone falls or something breaks. Then negative attention turns to “the fun ADHD girl,” and the shame hits hard. When school staff looks out over the schoolyard, it seems like the girl with autism and ADHD is “with” her friends. But girls with autism “are with others” to a greater extent than boys with autism, who more often end up clearly outside and alone in the schoolyard. It undoubtedly creates great suffering for boys with autism, but it also means that adults notice them and their challenges early. The girls who actually struggle with the same difficulties often become adults before they and others understand what they are really struggling with.

However, it is during the middle school years that girls with ADHD and autism begin to stand out to those around them. By then, social demands have changed and become so high that the girl with autism and ADHD has a chance to keep up longer. The somewhat unstructured play transitions into “hanging out,” which hardly has any explicit rules at all. However, there are many unspoken rules, as it turns out. Because now, one might be expected to walk around the schoolyard and talk about love, relationships, and who did what… The girl with autism and ADHD tries to adapt, but it gets harder and harder. Some desperately try to “buy” a place among friends, offering candy or cash when the group goes to the store. Internally, however, feelings of loneliness often grow, and anxiety usually arrives like clockwork during this time. Confusedly struggling in the social realm without anyone seemingly understanding can lead to growing feelings of resignation and mental health problems. Many girls with ADHD and autism no longer want or can go to school; some start self-harming, and others develop eating disorders. At that point, the adult world usually reacts strongly. But by then, it has already been going on for long…

So what do we do?

To avoid that girls with autism and ADHD  spend years in loneliness and confusion, all adults need to consider this:

  • Be curious about how the girl plays in preschool. Is she participating in play, or is she mostly playing alongside and mimicking what the others do? In play, there are crucial puzzle pieces to understand girls’ social skills.
  • If you suspect the girl might have some difficulty with play and social interaction, help her! Ensure to participate a bit in play at times, help her interpret (“I think the others meant that you should nap because you were all tired”). Afterward, articulate different parts of play through sequential conversations and social stories.
  • If girls break down as soon as they come home and have outbursts at home, take it seriously. It does NOT necessarily mean that something is wrong at home but may be a sign that she can’t hold it together any longer.
  • Having friends doesn’t mean girls can’t have autism. Many with autism and ADHD can mimic others and adapt so they can “be with” them. Try to find out if it comes with a cost, i.e., how exhausting it is for the girl. Most children are not completely drained after a typical day at school or spending time with other children. If you see a pattern, it’s a sign to follow up and investigate further.
  • If your girl’s mental health is getting worse during middle school, map out how she is doing socially. There are plenty of other reasons why children feel bad; but don’t wait too long to map out autism and ADHD either. 

And remember, an assessment and the right diagnosis often become a way out of confusion and shame for girls. They get words for everything they feel they don’t understand and can begin the journey to find their own way through life.

Thank you Maria Bühler

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