“Spacey.” “Forgetful.” “Lazy.”

Generations of girls have grown up stuck with these hurtful labels while struggling to follow along in class, complete homework on time, or finish books and movies. Many don’t understand their behavior might be beyond their control, leading to years of frustration and stress.

Despite being one of the most common pediatric behavioral health conditions, affecting around 6 million young people, attention-deficit hyperactivity disorder (ADHD) is frequently missed in girls and female adolescents. Only 6% of girls ages 3 to 17 are diagnosed with ADHD, compared to 13% of boys in that age group, according to the Centers for Disease Control and Prevention. Girls also are diagnosed an average of five years later in life than boys.

“Girls and female teens who have ADHD can go under the radar for too long,” said Cesar Ochoa-Lubinoff, MD, director of Developmental and Behavioral Pediatrics at Cedars-Sinai Guerin Children’s.

But the tides are finally starting to shift, thanks to viral social media posts educating young people and families on ADHD and a growing medical understanding of the condition’s wide range of presentations. If the uptick in awareness can be translated into care, girls could stand to gain the most.

Read: A Teen Girl’s Keys to a Healthy Life

ADHD is a neurodevelopmental disorder with three forms:

• Impulsive/hyperactive
• Inattentive
• Combined

While people across genders can have any type of ADHD, hyperactivity is five times more common among boys and male teens. Girls and female adolescents are more prone to inattentiveness, which doesn’t include the classic ADHD hallmarks of loud interruptions, fidgeting or hyperactivity.

“You don’t see these young people; they just sit in the back of the classroom, don’t cause trouble and often fall through the cracks,” Ochoa-Lubinoff said.

The inattentive form of ADHD causes attention and executive-function challenges that affect patients’ ability to listen, organize, study, manage time, and keep track of assignments and deadlines. Parents might be bewildered to notice their otherwise competent daughter being easily distracted and having a hard time with simple tasks.

Ochoa-Lubinoff also cautioned against ruling out ADHD among girls and female teens who can focus for hours when reading, drawing or engaging in other activities they love or when pulling an all-nighter for a midterm.

ADHD involves problems in regulating attention, he said. “When they’re motivated, they don’t just focus—they hyperfocus to the point that they tune out everything around them. But focusing on activities that are perceived as hard or boring is like pulling teeth for them.”

Most of what doctors, parents, teachers and the public know about ADHD is skewed because of the longtime focus on boys with the condition.

“There’s a gender bias in the research and general thinking,” Ochoa-Lubinoff said.

Another blind spot: Many girls with ADHD work harder or study more to make up for lapses in attention and planning. This “masking” of and compensating for their ADHD symptoms often leads to a delayed diagnosis when compared with boys.

Girls who are trying to compensate for ADHD often get overwhelmed, but people around them may not notice. Ochoa-Lubinoff noted that anxiety could be the first indicator of ADHD.

Most female patients are referred to specialists because of anxiety and mood disorders, which are common complications of overlooked or misdiagnosed ADHD.

Read: An Inclusive Guide to Puberty and Periods

Depending on how severe a young person’s symptoms are and how rigorous their school is, academic problems such as falling grades, procrastination or missed assignments can be another warning sign of inattentive ADHD. Some girls are looked down upon or punished at school or home for what is viewed as irresponsibility or a poor work ethic.

In turn, many blame themselves or start to doubt their intelligence—beliefs that can last well into adulthood.

“School-age children are constantly comparing themselves with their peers, and they suffer when they see that they have the ability to do better but are underperforming,” Ochoa-Lubinoff said. “Unfortunately, if ADHD isn’t diagnosed and girls go year after year with this sense of underachievement, it takes a toll on their self-esteem.”

The damage can hold them back academically, emotionally, and—in the long term—in their motivation, planning, careers and finances.

Untreated ADHD can also strain communication and social relationships, leaving girls feeling isolated and less accepted by, or different from, their classmates.

By the teen years, low confidence makes them more susceptible to mental health conditions and risky behaviors such as alcohol and drug use.

Despite stigma suggesting that the diagnosis is made-up or an excuse for poor choices, ADHD is hardwired, Ochoa-Lubinoff explained, and frequently runs in families. People with the condition have low levels of dopamine and norepinephrine in the areas of the brain that regulate attention, activity and impulsivity.

Stimulant medications such as Adderall and methylphenidate help restore the brain’s chemical balance, which research has found improves cognitive control and decision-making.

For children over 6 years old, pediatricians recommend medication and behavioral therapy. Treatment helps young girls and female teens strengthen attention, executive function and time management. That can help shield them from low self-esteem and prevent anxiety, depression and other psychiatric conditions.

Yet, around 23% of young people diagnosed with ADHD aren’t in treatment, according to the CDC, while others receive treatment only sporadically. What’s more, an analysis in 2020 found that young girls and female teens were prescribed far fewer ADHD medications than boys and more commonly received none at all.

“It’s really important that parents and professionals stay on top of children’s behavioral health, because we can make a huge difference for these girls,” Ochoa-Lubinoff said.

Read: How to Detect and Treat Allergies in Kids