ADHD has traditionally been believed to be much more common in boys than girls, but there is growing concern that the discrepancy is really an artifact of inaccurate diagnostic practices. Clinical referral rates for boys under 18 exceed those for girls by an estimated 3:1 to 16:1 (Young et al., 2020, p. 2), yet recent studies have shown that the prevalence of ADHD in males and females evens out in adulthood. These trends suggest that diagnoses in women are severely delayed, resulting in the loss of years of potential treatment and support (Chronis-Tuscano, 2022, p. 1).
In keeping with these findings, boys are more commonly diagnosed with the hyperactive / impulsive subtype of ADHD which tends to result in disruptive behaviors that prompt referrals. Girls more often have the inattentive type and may be underperforming or struggling in quieter ways that can easily be missed. Considering that hyperactivity and impulsivity decline in both genders with neurocognitive maturity, adulthood may level the diagnostic playing field.
Another important factor to consider is that society at large is more primed to see emotional disturbances in females and neurodevelopmental disorders in males. Studies have found that teachers, when presented with vignettes describing children with ADHD, were more likely to refer the child for additional support if male names and pronouns were used (Young et al., 2020, p. 4).
There are also some indications that girls tend to develop more effective coping strategies to compensate for their ADHD and thus are less likely to have learning difficulties or trouble at school (Mowlem et al., 2019, p. 482). In combination with the lower prevalence of hyperactivity, this makes it all the less likely that girls will be referred for testing or receive support.
Furthermore, girls and women are more likely to internalize their struggles leading to symptoms of anxiety and depression, while boys more often externalize their experience which tends to manifest behaviorally. What a boy may call “restlessness” a girl may describe as “anxiety” (Klefsjo et al., 2021, p. 305). Thus, it is not surprising that studies have shown that girls are three times more likely than boys to have been treated with antidepressants prior to being diagnosed with ADHD (Quinn et al., 2004, p. 2), suggesting they are being diverted to treatment for mood disorders before their underlying ADHD is identified.
Likely a result of their propensity to internalize, girls and young women with ADHD have been found to be at higher risk than their male counterparts for mood disorders, self-harm, suicidality, and psychiatric hospitalization (Chronis-Tuscano, 2022, p. 2). While anxiety and depression may warrant treatment in their own right, it is important to consider if they may be the result of undiagnosed ADHD.
Girls’ struggle to get help with their ADHD does not end with diagnosis. Studies have shown boys are likely to be prescribed medication solely on the basis of an ADHD diagnosis, while diagnosed girls tend to be medicated only if they exhibit disruptive behaviors (Mowlem et al., 2019, p. 487). Girls under 18 diagnosed with ADHD have been found to be significantly less likely to be medicated, with stimulants being reserved for girls with only the most severe symptoms (Kok et al., 2020, p. 2). As treatment with stimulants has been shown to improve long-term outcomes in children with ADHD, we are placing girls at a significant disadvantage by failing to diagnose and treat them.
While there is much we still don’t understand about the development and identification of ADHD in girls and women, compiling relevant research findings makes clear that we are failing to meet their needs. By ignoring, misdiagnosing, and undertreating them we are increasing their emotional distress and their risk for serious adverse outcomes.
While energetic boys are being erroneously diagnosed with ADHD and unnecessarily medicated in an attempt to minimize class disturbances, inattentive girls with ADHD are suffering in silence without the support they desperately need. It is critically important that we redirect the focus away from disruptive behavior that irritates adults and towards children and young adults who are truly struggling. While it can be difficult to untangle the root causes of their distress, ADHD should not be discounted even in the absence of a traditional presentation.
Analysis of the potential barriers to diagnosing ADHD in girls and women reveals considerable overlap with the challenges in diagnosing adults. In both cases the most obvious symptoms resulting from hyperactivity tend to be absent. Young females and adults of both genders often develop coping mechanisms that at least partially compensate for, and mask, their deficits. Furthermore, both populations tend to exhibit symptoms of emotional distress, anxiety, and depression that opacify the diagnostic picture. While these factors make ADHD diagnoses less clear in both girls and adults, there may be some utility in identifying the patterns in presentations.
Lastly, it must be noted that the general trends described above are just that: general trends. Categorical analyses can be a valuable tool but can also cause great harm if we become blind to the exceptions. There are girls with ADHD whose hyperactivity causes disruptive behavior in class, just as there are inattentive boys who internalize their struggle and mask their distress. To ensure we see the individual in front of us as objectively as possible, we must maintain awareness of our biases and their impact on our perceptions.