Attention-deficit/hyperactivity disorder (ADHD) can manifest differently in girls than it does in boys which can explain why so many girls are underdiagnosed. We can see certain differences in symptom presentation and the course of the disorder in girls versus boys.
Why do so many girls go undiagnosed?
There are many reasons why girls and women are often underdiagnosed with ADHD. For starters, there is a long-standing history of the assumption that ADHD was “rare” in girls and more common in boys. Another reason is that inattentive symptoms are more prominent in girls than boys which are easier to miss versus hyperactive symptoms that are common for boys to present (Hinshaw et al., 2022). A third reason being girls have lower rates of co-occurring disruptive behaviour disorders, with these behaviours developing later in life versus earlier in boys (Uchida et al., 2018). Females also have higher rates of compensatory behaviours than males causing ADHD symptoms to be masked.
Lastly, ADHD symptoms in girls go underrecognized and reported, with girls being less referred than boys. A study by Meyer et al. (2020) found that parents and teachers underreport observed ADHD behaviours in girls versus boys which contributes to the under recognition in females. Further, another study found that teachers are more likely to refer boys for treatment for ADHD than girls, even if both boys and girls are demonstrating the same symptoms (Sciutto et al., 2004).
Symptom presentation
The presentation of symptoms is a major way that ADHD can differ between boys and girls. Girls and women most often appear to present with predominantly inattentive symptoms of ADHD which can be easily missed by teachers and parents.
Examples of inattentive symptoms include:
o Fails to give close attention to details or makes careless mistakes.
o Has difficulty sustaining attention, does not appear to listen.
o Struggles to follow through with instructions.
o Avoids or dislikes tasks requiring sustained mental effort.
o Loses things easily and has difficulty with organization.
o Is easily distracted and forgetful in daily activities.
Externalizing problems, such as impulsive, aggressive, or acting-out behaviours, are more likely to present at an early age in boys with ADHD, whereas in girls they are either less likely to present or they present later in life (Hinshaw et al., 2022). Internalizing problems, like depression and anxiety, are more common in girls with ADHD which can become diagnosed before ADHD and can mask ADHD symptoms (Skogli et al., 2013).
The course of ADHD for females
Females with ADHD are more likely to adopt compensatory strategies that help mask or limit ADHD symptoms and behaviours (Young et al., 2020). Some women become so good at masking their ADHD symptoms that it causes them to minimize their symptoms. Also, these strategies can be functional like finding ways for them to remain focus, disguise stress, and be socially competent. However, the behaviours can also be negative, like avoiding certain things or people, not getting help when needed, and turning to substances.
Children and adolescents with ADHD are more likely to experience peer rejection and maintain fewer friendship, with girls with ADHD having more disruptive relationships with family members and peers (Young et al., 2020). Further, girls with ADHD experience more interpersonal difficulties with lower satisfaction with relationships and self-esteem causing them to apply compensatory strategies to combat difficulties.
ADHD symptoms can be overlooked or misinterpreted in females in highly structured environments, receiving high levels of support, and those who use masking strategies to compensate for their ADHD (Young et al., 2020). As one gets older, their environmental demands like, education, work, finances etc. become more challenging with their level of support declining (Young et al., 2020). Many women with ADHD begin to struggle once they reach adulthood with their symptoms becoming more apparent. Additionally, hormonal fluctuations (e.g., associated with start of menstruation, perimenopause) can exacerbate symptoms. Furthermore, periods of transition cause individuals with ADHD to be more vulnerable, overwhelmed, anxious, and can impact their self-esteem by exacerbating symptoms (Young et al., 2020). Although, there is an increase in more self-referrals in adulthood as women become more aware of their symptoms and difficulties.
Risk factors for females with ADHD
There are many risk factors and impairments that can persist into adulthood for women with ADHD. One being increased problems in close relationships and engagement in self-harm and suicidal behaviour (Hinshaw et al., 2022). There are also higher rates of co-occurring disorders such as, antisocial, substance abuse, mood, anxiety, and eating disorders (Biederman et al., 2010). Further, women with ADHD are more likely to have anxiety and mood disorders (depression, bipolar etc.) (Biederman et al., 2008). Studies have also found impairments in academic performance, internalizing disorders, poor executive function, and employment, with higher rates of unplanned pregnancy and risk of intimate partner violence (Hinshaw et al., 2022).
Overall, ADHD in women and girls is associated with different symptom presentation, risk factors and experiences that can be different in males with ADHD. Individuals should contact their healthcare practitioner if they are experiencing difficulties or if they think they might have ADHD.
References
Biederman, Ball, S. W., Monuteaux, M. C., Mick, E., Spencer, T. J., Mccreary, M., Cote, M., & Faraone, S. V. (2008). New Insights Into the Comorbidity Between ADHD and Major Depression in Adolescent and Young Adult Females. Journal of the American Academy of Child and Adolescent Psychiatry, 47(4), 426–434. https://doi.org/10.1097/CHI.0b013e31816429d3
Biederman, J., Petty, C.R., Monuteaux, M.C., Fried, R., Byrne, D., Mirto, T., … & Faraone, S.V. (2010). Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. American Journal of Psychiatry, 167, 409–417.
CHADD. (2023). Symptoms of ADHD in Women and Girls. CHADD. https://chadd.org/for-adults/symptoms-of-adhd-in-women-and-girls/
Hinshaw, Nguyen, P. T., O’Grady, S. M., & Rosenthal, E. A. (2022). Annual Research Review: Attention‐deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. Journal of Child Psychology and Psychiatry, 63(4), 484–496. https://doi.org/10.1111/jcpp.13480
Meyer, Stevenson, J., & Sonuga-Barke, E. J. S. (2020). Sex Differences in the Meaning of Parent and Teacher Ratings of ADHD Behaviors: An Observational Study. Journal of Attention Disorders, 24(13), 1847–1856. https://doi.org/10.1177/1087054717723988
Sciutto, Nolfi, C. J., & Bluhm, C. (2004). Effects of Child Gender and Symptom Type on Referrals for ADHD by Elementary School Teachers. Journal of Emotional and Behavioral Disorders, 12(4), 247–253. https://doi.org/10.1177/10634266040120040501
Skogli, Teicher, M. H., Andersen, P. N., Hovik, K. T., & Øie, M. (2013). ADHD in girls and boys--gender differences in co-existing symptoms and executive function measures. BMC Psychiatry, 13(1), 298–298. https://doi.org/10.1186/1471-244X-13-298
Uchida, Spencer, T. J., Faraone, S. V., & Biederman, J. (2018). Adult Outcome of ADHD: An Overview of Results From the MGH Longitudinal Family Studies of Pediatrically and Psychiatrically Referred Youth With and Without ADHD of Both Sexes. Journal of Attention Disorders, 22(6), 523–534. https://doi.org/10.1177/1087054715604360
Young, Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry, 20(1), 404–404. https://doi.org/10.1186/s12888-020-02707-9
Author: Barbara Ledezma, Undergraduate Student Volunteer