Dr. Elizabeth Roberts is a psychologist and the founder of Village Psychology. This post is part of a series on reading neurological and psychological profiles in the classroom.
Throughout this piece, "girls" refers to those assigned female at birth, as the research cited reflects studies conducted on this population. The clinical patterns described, however, may resonate for any child whose emotional experience has been dismissed.
If you're a stats nerd like me, you know that in real life, streaks happen. In my case, that looked like 4 cases in a row this month with the same issue: girls, aged 8-12, doing well in school. No "obvious" problem or difficulty, except for this reason for referral: manipulative and attention seeking.
A girl who is fine one moment and explosive the next, so clearly she can control it.
A girl who seems "obsessed" with social drama, so clearly she's creating it.
A girl who can hold it together in some settings and completely falls apart in others, so clearly it's a performance.
A girl who can be sweet but then combative when pushed, so clearly she's dishing it out, but she can't take it.
The common thread: For years, nobody paid close attention to these girls, as their grades were fine. Then they hit a wall, right around the time that puberty, as well as increasing academic and social complexity hit. The inconsistency is what makes people land on manipulative. If she can manage herself sometimes, she must be choosing not to the rest of the time, right?
This is exactly where we go wrong: We punish the collapse of coping mechanisms, without even bothering to ask how she was holding it up all this time.
If you're a stats nerd like me, you know that in real life, streaks happen. In my case, that looked like 4 cases in a row this month with the same issue: girls, aged 8-12, doing well in school. No "obvious" problem or difficulty, except for this reason for referral: manipulative and attention seeking.
A girl who is fine one moment and explosive the next, so clearly she can control it.
A girl who seems "obsessed" with social drama, so clearly she's creating it.
A girl who can hold it together in some settings and completely falls apart in others, so clearly it's a performance.
A girl who can be sweet but then combative when pushed, so clearly she's dishing it out, but she can't take it.
The common thread: For years, nobody paid close attention to these girls, as their grades were fine. Then they hit a wall, right around the time that puberty, as well as increasing academic and social complexity hit. The inconsistency is what makes people land on manipulative. If she can manage herself sometimes, she must be choosing not to the rest of the time, right?
This is exactly where we go wrong: We punish the collapse of coping mechanisms, without even bothering to ask how she was holding it up all this time.
Why We Get It Wrong
Two big studies on ADHD came out recently that deserve our attention.
Girls experience a significant delay in diagnosis due to differences in presentation: less hyperactivity, more internalizing: A new JAMA Psychiatry study of 580,000 children found that girls are diagnosed on average 3 years later than boys: boys at age 11, girls at age 14. A major driving factor was the girls' tendency to internalize their experiences, show less hyperactivity, and have better grades. Note that age of diagnosis was directly positively related to school success: even a 2-year delay in diagnosis resulted in a significant increase in school dropout.
Brain scans revealed three reliable subtypes of ADHD with distinct neural profiles: predominantly inattentive, predominantly hyperactive/impulsive, and a third subtype marked by a combination of these symptoms in addition to significant emotional dysregulation as mediated by the medial prefrontal cortex.
Here's the profile:
A girl who is bright and disciplined, enough that you don't notice her processing challenge or the way she has to re-direct her attention 4x as often as most. Big emotions that come on fast, almost with Ferrari engine speed, but Toyota brakes. She's internalizing those difficulties all day long, meaning she's watching the room like a full-time job: adapting, adjusting, doing anything to remain part of the cool kids group or get the teachers praise. She's working exponentially harder to produce the same output and fighting an internal battle to keep emotions at bay. And it works, until it doesn't.
When I speak to these girls, the narrative is often abundantly clear.
I said I had difficulty, and nobody believes me.
It's heartbreaking how many times I have heard this. Even when the words come out that simply, adults resist. Sometimes even my testing scores get scrutinized. She's choosing to do it, how come she can do it here but not there? The bias runs deep, and we completely miss the ADHD until she hits a wall and explodes.
Girls experience a significant delay in diagnosis due to differences in presentation: less hyperactivity, more internalizing: A new JAMA Psychiatry study of 580,000 children found that girls are diagnosed on average 3 years later than boys: boys at age 11, girls at age 14. A major driving factor was the girls' tendency to internalize their experiences, show less hyperactivity, and have better grades. Note that age of diagnosis was directly positively related to school success: even a 2-year delay in diagnosis resulted in a significant increase in school dropout.
Brain scans revealed three reliable subtypes of ADHD with distinct neural profiles: predominantly inattentive, predominantly hyperactive/impulsive, and a third subtype marked by a combination of these symptoms in addition to significant emotional dysregulation as mediated by the medial prefrontal cortex.
Here's the profile:
A girl who is bright and disciplined, enough that you don't notice her processing challenge or the way she has to re-direct her attention 4x as often as most. Big emotions that come on fast, almost with Ferrari engine speed, but Toyota brakes. She's internalizing those difficulties all day long, meaning she's watching the room like a full-time job: adapting, adjusting, doing anything to remain part of the cool kids group or get the teachers praise. She's working exponentially harder to produce the same output and fighting an internal battle to keep emotions at bay. And it works, until it doesn't.
When I speak to these girls, the narrative is often abundantly clear.
I said I had difficulty, and nobody believes me.
It's heartbreaking how many times I have heard this. Even when the words come out that simply, adults resist. Sometimes even my testing scores get scrutinized. She's choosing to do it, how come she can do it here but not there? The bias runs deep, and we completely miss the ADHD until she hits a wall and explodes.
What's Actually Driving It
ADHD is implicated with emotion regulation. We've known this for a long time, and the recent study cited above on brain scans confirms it: big emotional reactions are often involuntary for these kids. When they must hold it together all day against their neurology and demands continuously increase, eventually their coping temporarily collapses and the big emotions come outward.
For girls, that intensity goes inward first. Many girls with ADHD report racing thoughts, social anxiety, difficulty sleeping, blurting out random comments and regretting it, feeling like they're just not getting it right. The distractibility can manifest as internal preoccupation and doesn't look like our traditional image of someone bouncing off the walls.
Puberty complicates things. Right as academic demands spike, so do social dynamics and hormones. What happens next looks sudden: years of pent-up aimless energy and frustration turned inward collapses outward into a fight.
Adults often say: she isn't like this all the time, though. Correct. She isn't, because she temporarily loses her footing, feels ashamed, and then recalibrates, and the cycle repeats. The talking back or tears that look like manipulation are a secret bid for understanding: I can't take this anymore.
For girls, that intensity goes inward first. Many girls with ADHD report racing thoughts, social anxiety, difficulty sleeping, blurting out random comments and regretting it, feeling like they're just not getting it right. The distractibility can manifest as internal preoccupation and doesn't look like our traditional image of someone bouncing off the walls.
Puberty complicates things. Right as academic demands spike, so do social dynamics and hormones. What happens next looks sudden: years of pent-up aimless energy and frustration turned inward collapses outward into a fight.
Adults often say: she isn't like this all the time, though. Correct. She isn't, because she temporarily loses her footing, feels ashamed, and then recalibrates, and the cycle repeats. The talking back or tears that look like manipulation are a secret bid for understanding: I can't take this anymore.
What Happens When We Get It Wrong
The diagnosis needed at age eight gets postponed to age 14, if it arrives at all.
I can't tell you how shocked I was when I evaluated these girls and found glaring deficits in processing and working memory, sustained attention and focus. Years of being overlooked for a real neurological and developmental difficulty, chalked up to she wants to control or just plain old bad behaviour. That learning doesn't leave easily, and we must ask ourselves how far reaching the consequences are. What would it do to a child when what is reflected back to her, year after year, is: you're over the top and controlling? You could just choose to be better?
I can't tell you how shocked I was when I evaluated these girls and found glaring deficits in processing and working memory, sustained attention and focus. Years of being overlooked for a real neurological and developmental difficulty, chalked up to she wants to control or just plain old bad behaviour. That learning doesn't leave easily, and we must ask ourselves how far reaching the consequences are. What would it do to a child when what is reflected back to her, year after year, is: you're over the top and controlling? You could just choose to be better?
But What If She Really Is Just Being Difficult?
Ask yourself: have you ever known a single happy, secure person who chronically manipulates? Pain drives behavior, find the pain.
Here's what we can do instead.
Ask how and what questions. Chances are, this internalizing, over-thinking ADHD brain can explicitly tell you what isn't working if you take the time to listen. After the next explosion, really ask what happened. How long has this been bothering you? What upset you most? Believe her that it matters, because to her, it does.
Take the social preoccupation seriously. Social dynamics are not a distraction, they become a real job. Her nervous system may be consumed by relational pain in a way that feels overwhelming and immediate. Dismissing this does not teach empathy, it teaches her to hide.
She dishes it out? Great. Now teach her to do it well. Assertive energy is a strength to be shaped. Rather than focusing only on what she did or said wrong, teach healthy assertiveness scripts (e.g., DEAR MAN), clean boundary-setting (e.g., if you do X, I will do Y), and how to speak with power rather than attack (e.g., I don't like that). Give her better tools than what she is improvising with.
Stop policing her tone before you hear her message. When any human has their needs routinely dismissed, they eventually explode. We are programmed to come in with a reminder that the tone was rude or disrespectful. I invite you to consider the bigger pain behind the expression and allow for imperfect expressions. Once the moment has settled, you can revisit how to say it in a way that people can actually receive.
Connect power to goals. Agency and assertiveness can be fuel for growth and change. Teach her that her emotions are powerful signals: about what matters, her values, about what's wrong in her world. Analyze that more carefully to advocate for change where and how it is needed or learn to accept what we cannot change. Use it as a catalyst to get what she wants, whether that be positive movement or peace.
Name what's good in the hard moment. The goal isn't to de-escalate through authority. It's to reflect the child's intensity back to them as something legitimate, just needing a different channel. These scripts work because they don't ask the child to stop feeling what they're feeling. They locate something real and valid in the behaviour and name it out loud.
Here's what we can do instead.
Ask how and what questions. Chances are, this internalizing, over-thinking ADHD brain can explicitly tell you what isn't working if you take the time to listen. After the next explosion, really ask what happened. How long has this been bothering you? What upset you most? Believe her that it matters, because to her, it does.
Take the social preoccupation seriously. Social dynamics are not a distraction, they become a real job. Her nervous system may be consumed by relational pain in a way that feels overwhelming and immediate. Dismissing this does not teach empathy, it teaches her to hide.
She dishes it out? Great. Now teach her to do it well. Assertive energy is a strength to be shaped. Rather than focusing only on what she did or said wrong, teach healthy assertiveness scripts (e.g., DEAR MAN), clean boundary-setting (e.g., if you do X, I will do Y), and how to speak with power rather than attack (e.g., I don't like that). Give her better tools than what she is improvising with.
Stop policing her tone before you hear her message. When any human has their needs routinely dismissed, they eventually explode. We are programmed to come in with a reminder that the tone was rude or disrespectful. I invite you to consider the bigger pain behind the expression and allow for imperfect expressions. Once the moment has settled, you can revisit how to say it in a way that people can actually receive.
Connect power to goals. Agency and assertiveness can be fuel for growth and change. Teach her that her emotions are powerful signals: about what matters, her values, about what's wrong in her world. Analyze that more carefully to advocate for change where and how it is needed or learn to accept what we cannot change. Use it as a catalyst to get what she wants, whether that be positive movement or peace.
Name what's good in the hard moment. The goal isn't to de-escalate through authority. It's to reflect the child's intensity back to them as something legitimate, just needing a different channel. These scripts work because they don't ask the child to stop feeling what they're feeling. They locate something real and valid in the behaviour and name it out loud.
- I want to be near you even when you're angry.
- It's important that you take charge right now.
- You can tell me directly what you need.
- I won't respond to insults, but I'm not going anywhere and I want to hear what happened.
The One Thing to Remember
We pathologize the collapse of the coping strategy rather than asking how long she's been holding it together and we love to apply our she's choosing to do it lens. Find out what's going on underneath, and you'll find the girl who needed help years before anyone bothered looking.
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