ADHD has long been framed through a male lens, leaving many girls and women overlooked, misunderstood, and unsupported. Photo credit: Hiki App via Unsplash
ADHD (attention deficit hyperactivity disorder) is a neurodevelopmental disorder characterised by ‘a persistent pattern of inattention, and/or hyperactivity-impulsivity, that interferes with functioning or development’. There are two sets of criteria assessed for an ADHD diagnosis: inattentive criteria, and impulsive/hyperactive criteria. This gives rise to three classes of ADHD: inattentive type, impulsive/hyperactive type, and combined type. In childhood, the ratio of boys to girls diagnosed with ADHD is about 4:1. In adulthood, the rate of female diagnosis sees a relative increase, with the ratio of adult women to men with ADHD being almost 1:1. This data suggests that many girls are slipping through the net in their younger years. There are numerous credible theories as to why this occurs, and there can be serious long-term implications for these misunderstood girls.
…many girls are slipping through the net in their younger years.
Why women go under the radar
It is now understood that ADHD manifests differently in men and women. Women are generally more ‘inattentive-type’, whereas men are more likely ‘impulsive/hyperactive-type’. In other words, women often present with internalising symptoms, while men present with more externalising symptoms. A suggested contributing factor is the societal pressure on women to show stereotypically feminine qualities (homemakers, good organisational skills, obedience) which often conflict with ADHD symptoms. Studies suggest that these social expectations mean that externalising symptoms of hyperactivity and disruption are punished more severely by authority figures in girls than in their male counterparts. Girls are not shielded by the “boys will be boys” attitude to problematic behaviour. It is also seen that higher levels of ADHD symptoms in children are indicative of a greater level of peer dislike in girls compared to boys. These factors are thought to compel women with ADHD to develop strategies to “mask” their symptoms, especially the externalising ones, to align with society’s expectations of “ladylike” behaviour. Therefore, the stereotypical image of ADHD—the boisterous and disruptive young boy—is more easily spotted than the inattentive girl, especially when she has evolved compensatory strategies.
Another factor contributing to the underdiagnosis of girls is the gender-bias associated with diagnostic criteria. 70 empirical studies published in the Journal of Abnormal Child Psychology between publication of Diagnostic and Statistical Manual of Mental Disorders (DSM) DSM-III-R (1987) and DSM-IV (1994) concerned ADHD. Overall, 81% of these participants were male, while only 19% were female. Naturally, this skewed the diagnostic criteria to more male-focused symptoms of ADHD. This is evident in the normative data for ADHD Rating Scale-IV, showing a general lower threshold for females than males.
A significant increase in the diagnosis of girls was observed in 2013, when the diagnostic criteria was updated.
A significant increase in the diagnosis of girls was observed in 2013, when the diagnostic criteria was updated. DSM-IV (1994) categorised ADHD as a disruptive behavioural disorder of childhood. DSM-5 (2013) raised the cutoff age for symptom presentation from 7 to 12. Hyperactivity is generally seen to decline through puberty, while inattention remains. Therefore, the raised age limit allowed greater recognition of inattentive-type ADHD.
Nevertheless, the issue of underdiagnosis of women persists, partly due to a lack of understanding by many clinicians as to how ADHD presents in women. A study by Robinson (2008) found that women with ADHD scored higher on rating scales for symptoms of anxiety, depression, and difficulty managing emotions, than men with ADHD. These mood-related symptoms often occlude the root cause being ADHD. Many young girls presenting with anxiety or depressive symptoms are exclusively treated for these issues, without considering if they could be comorbid disorders of ADHD. 14% of young girls, versus 5% of young boys with ADHD, are initially prescribed antidepressants before receiving ADHD treatment. Women on average have more admissions to psychiatric care facilities prior to diagnosis, and are prescribed non-ADHD medication at a higher rate before and after diagnosis.
The issue does not solely lie with health professionals. Referral bias also contributes to the slower rate of diagnosis of young girls with ADHD. Lynch and Davison (2022) showed that both teachers and clinicians struggled to identify potential ADHD symptoms in young women. In the experiences of the 17 young women with ADHD participating in the study, teachers sometimes recognised symptoms of talkativeness or inattention, but not the potential benefit of a further assessment. In terms of their clinical experiences, the study concluded four main patterns. Physicians would assess for a range of other conditions, but not ADHD; diagnose with a range of other conditions, but not ADHD; test for ADHD but give a false-negative result; rule out ADHD without any investigation.
Referral bias also contributes to the slower rate of diagnosis of young girls with ADHD.
Multiple studies have explored these gender biases in the context of ADHD diagnoses. One survey found that the general public thought ADHD was more common in boys than girls. A 2009 investigation gave a series of descriptive scenes about children with ADHD for parents and teachers to read. The only difference was the use of a girl’s or boy’s name, and the respective pronouns. A pattern emerged wherein both parents and teachers were less likely to seek ADHD support services when a girl’s name was used. This helps to explain evidence that childhood referral rate for boys is much greater than that for girls. Meanwhile, female ADHD diagnosis often comes from a self-prompted visit to see a healthcare professional in adulthood.
The long-term effects of dismissal
There are certain risk factors associated with ADHD, some affecting both men and women proportionally, others affecting one sex more significantly than the other. Women with ADHD often display lower self-esteem and greater difficulty with social interaction than both women without ADHD, and men with ADHD. This trend is seen from childhood, persisting into adulthood. A review exploring the impact on women of living undiagnosed until adulthood, described undiagnosed women feeling ‘stupid’, and ‘lazy’, battling feelings of inadequacy in comparison to their peers. This is linked to greater societal expectations placed on women than men, to bear the brunt of parental and household duties, alongside a successful career. Many women also reported difficulty forming and maintaining close emotional relationships, in all familial, platonic, and romantic contexts.
Nevertheless, upon diagnosis of their ADHD, the women reported a greater sense of control and self-acceptance over their life. Having access to treatment, being able to understand the way their mind worked, and being able to research healthy coping mechanisms were all vital to their improved life satisfaction.
A study comparing girls with and without ADHD over a five-year period, showed that ADHD was associated with a significantly increased lifetime risk of major depression, multiple anxiety disorders, bipolar disorder, and nicotine drug dependence. At a mean age of 16, the girls with ADHD were at a substantially higher risk for antisocial, mood, anxiety, and addictive disorders. A similar study comparing women between the ages of 20-39, with and without ADHD, found that the women with ADHD had twice the prevalence of substance abuse, current smoking, depressive disorders, severe poverty, and childhood physical abuse. The prevalence of insomnia, chronic pain, suicidal ideation, childhood sexual abuse, and generalised anxiety disorder triple when compared to women without ADHD.
Impulsivity associated with ADHD can manifest itself in women through engagement in riskier sexual behaviour than their male ADHD and non-ADHD female counterparts. On average, they have an earlier onset of sexual activity, more sexual partners, a greater rate of STI contraction, teenage pregnancy, and unplanned pregnancy. One Finnish study showed that girls with externalising symptoms of ADHD during childhood had a significantly increased risk of becoming mothers before the age of 20. This factor, combined with the low self-esteem common amongst women with ADHD, means that they are considered more vulnerable to sexual exploitation and abusive relationships. It is also suggested that women with ADHD are at higher risk of suffering consequences of societal stigma associated with promiscuity, further developing peer ostracisation.
Educational and professional attainment are well-documented issues for people with ADHD, but teenage pregnancy and sexual exploitation act to limit opportunities of these women further. A lack of ability to plan for the future can also leave women with ADHD with less fulfilling adulthoods, or constructive occupations.
Of course, many women with ADHD do lead successful lives. However, particularly for high-achieving women who are undiagnosed, perceived personal failures, as well as increased emotional dysfunction, can result in a host of unhealthy coping strategies. This can include issues with substance abuse and self-harm, as well as an overall dissatisfaction with life.
The impact of ADHD can even be fatal. People with ADHD have an elevated mortality rate compared to non-ADHD individuals, with this trend being predominantly driven by accidental death. People who received a diagnosis in childhood or adolescence had a lower risk of death than those diagnosed in adulthood. This may contribute to the observation that the increase in mortality rate for women with ADHD (relative to individuals without ADHD) is almost double than that for men with ADHD. The authors also speculate that another contributing factor arises from women with ADHD being less likely to be pharmacologically treated than men.
Ultimately, the consensus among experts is that earlier intervention and treatment in girls’ lives can have a substantial effect in negating academic underachievement, social-relationship and psychosexual issues, and psychiatric comorbidities.
Sex Hormones and ADHD
The majority of ADHD research has been conducted on men and thus we have little in-depth understanding of how fundamental female biology can shape the presentation of the disorder. Dopamine is one of the most recognised neurotransmitters in ADHD pathology and has interactions with oestrogen and progesterone. These interactions indicate that female hormonal fluctuations could have implications on ADHD symptoms. Theories also suggest that sex hormones are likely to modulate other neurotransmitters, such as serotonin and noradrenaline, implicated in ADHD.
…female hormonal fluctuations could have implications on ADHD symptoms.
This provides a potential explanation for changes in ADHD symptoms and stimulant medication efficacy during the menstrual cycle. Bürger (2024) reported severe exacerbation of ADHD symptoms during the mid-luteal phase and menses. Executive dysfunction, emotional dysregulation, and attention dysregulation were particularly aggravated. The study also noted reduced efficacy of ADHD medication at this time. de Jong (2023) reported similar trait exacerbation pre-menstrually, tracking within-person effects of increasing stimulant medication dosage around the pre-menstrual phase. All nine participants reported an improvement of emotional regulation and energy levels after 6 to 24 months of the increased dosage. The menstrual cycle is something most women experience for a significant proportion of their life: prioritising further research, as well as educating clinicians on what is already known, is a paramount next step.
One of the few studies into the relationship between ADHD and female sex hormones investigates ADHD symptoms in women with PCOS (polycystic ovary syndrome). PCOS is a hormonal disorder in women of reproductive age. The cause is unknown, but it results in an excess of male hormones and ovaries containing underdeveloped sacs, often unable to release eggs. In women with PCOS, hyperactivity, impulsivity, total adult ADHD symptom scores, and childhood behavioural issues were significantly elevated compared to those without PCOS. These findings point towards a key relationship between endogenous sex hormones and ADHD.
Despite this, there is limited evidence on the effect of hormonal contraception, pregnancy, the postpartum period, and menopause on ADHD. Clinicians’ experiences and non-peer- reviewed preliminary findings suggest that many women report an exacerbation of ADHD symptoms during menopause. But without further research, it is difficult to know whether this is just a reflection of effects associated with menopause. Menopause is associated with general feelings of “brain fog” and executive dysfunction due to declining oestrogen.
Although understanding social influences and the role they play in gender differences in ADHD is a vital piece of the puzzle, we cannot ignore the control of innate biology. In order to properly support women with ADHD throughout their lives, science must first assimilate the full picture of the female experience of ADHD.
The Long Road to Healthcare Equality
Perhaps being missed out and misunderstood is not a feeling unique to women with ADHD.
ADHD diagnosis and research is but one example of a plethora of areas in healthcare where women are let down, often fighting a greater uphill battle than their male counterparts. It takes women on average eight years to be diagnosed with endometriosis, while women are 50% more likely than men to receive an incorrect diagnosis following a heart attack. Perhaps being missed out and misunderstood is not a feeling unique to women with ADHD. It is instead a feeling woven through all women who receive inadequate support for their conditions as a result of gender-biased research, and systematic failings of a healthcare system that by design favours men.
