ADHD in Women and Girls: Why Female Symptoms Slip Through Diagnostic Cracks
We are failing girls and women with ADHD. Research and clinical practices are built around male presentations of ADHD, and science has historically paid little attention to female manifestations and impairments. As a result, many girls and women still battle to receive proper referral, diagnosis, and treatment – and face dire consequences when these medical rights are denied. To right these gender wrongs, it’s time to seriously rethink the way ADHD is assessed, diagnosed, and treated.
ADHD in Women and Girls Is Still Inadequately Understood
For too many years, women with ADHD have been routinely dismissed, disregarded, and misdiagnosed when they pursue evaluations and diagnoses for impairments like distractibility, executive dysfunction, and emotional dysregulation. Despite a growing canon of research on attention deficit hyperactivity disorder (ADHD or ADD) in girls and women, many clinicians continue to get it wrong — misattributing symptoms of ADHD in females to anxiety, mood disorder, or even hormones.
Partially to blame is clinical and research bias that has long centered and overvalued male presentations of ADHD. When women present non-conforming symptoms of ADHD – which we know is a highly impairing and highly stigmatized disorder in females – those symptoms are often not recognized or treated properly, with serious consequences.
Empirical evidence on female manifestations of ADHD – including findings on self-harm, peer relationships, trauma, and more – reveal crucial aspects of the condition that are as devastating as they are under-appreciated. Along with a recognition of general sex and gender differences, these factors must inform future research practices and clinical approaches for this group.1
The bottom line: Our approach to ADHD in women and girls has been broken for too long. To fix it, we must challenge everything we know about the assessment, diagnosis, and treatment of ADHD today.
ADHD in Women and Girls: Why Current Approaches Are Flawed
The Problem of Bias
Sex bias that favors male over female research subjects exists across many medical and mental disorders; it is a widespread problem that extends even to basic animal research.2 3 Traditionally, many scientific efforts excluded women entirely from clinical trials. Although the 1993 National Institutes of Health (NIH) Revitalization Act requires NIH-funded research to include women in clinical studies and analyze results by sex or gender, bias continues to be a problem.4
As it relates to ADHD in females, bias contributes to missed diagnoses and misdiagnosis in the following ways:
1. Self-fulfilling prophecies perpetually deny help to women: The prevailing notion has been that girls and women don’t “get” ADHD, so they have been habitually overlooked for diagnosis and study. It’s a vicious cycle that has resulted in a gaping hole in clinical research, literature, and knowledge that we’re still trying to fill.
This pattern helps to explain why diagnostic criteria have historically downplayed female manifestations of ADHD, focusing on overtly behavioral indicators like hyperactivity and the externalizing symptoms that are more common in males. Though the DSM-5 increased the maximum age of onset from 7 to 12, this is still too young for many females, who may experience significant, previously unexpressed ADHD impairments after that range. Things are intensified, too, when demands get more difficult and parental scaffolding decreases. Previous strategies of ‘overcompensation’ no longer suffice.
2. An overemphasis on comorbidities blinds clinicians to ADHD. Clinicians, wrongly convinced that ADHD in women and girls is outside the arena of possibility, tend to explain more easily observable symptoms through other conditions, including anxiety and depression as well as conduct problems.5 Of course, these diagnoses may well accompany ADHD in both females and males, but the default, too often, is that they pre-empt a diagnosis of ADHD.
3. Diagnostic tools favor male presentations of ADHD. Instruments like the Conners’ 10-item screener, commonly used for ADHD assessment, focus more on restlessness, fidgeting, and other signs of hyperactivity – symptoms typically associated with ADHD in boys and men – than they do on signs of inattention and emotional lability. And most screeners overlook the underlying executive dysfunctions that affect a clear majority of females with ADHD.
4. Clinical samples rarely mirror representative samples. The nature of a study sample can greatly influence outcomes, and what’s true in representative samples may not pertain at all to clinical samples (and vice versa). The “combined” ADHD presentation, which is often associated with the greatest impairment, is overrepresented in clinical samples of both boys and girls.6 But in more representative, community-based samples, girls are more likely than boys to show the exclusively inattentive presentation of ADHD.6 The result is that girls and women with severe impairments comprise a significant portion of the subject pool for most research on ADHD in this population. Lost in the data may well be inattentive girls and women who are better able to compensate and hide their symptoms, at least through childhood — even though girls and women with the inattentive presentation can be highly impaired.
ADHD in Girls and Women: Salient Findings and Important Considerations
1. Females with ADHD Are More Likely to Engage in Self-Harm and Suicidality
Teen girls and women with ADHD are at a significantly higher risk for self-harm than are boys and men with ADHD or than girls without ADHD. This finding comes from the ongoing Berkeley Girls with ADHD Longitudinal Study (BGALS), comprising 140 participants with ADHD (and a matched comparison group) who have been assessed across childhood, adolescence, and adulthood.
By the time they reached early adulthood (average age of 20), about 23% of the girls with combined type ADHD and 8% of girls with inattentive ADHD had made a serious suicide attempt.7 In contrast, suicidality was found in only 6% of the BGALS study participants without ADHD (which also matches national rates).
Furthermore, rates of moderate to severe Non-Suicidal Self-Injury (NSSI) were high for the combined and inattentive groups – about 50% and 30%, respectively, compared to about 20% in the neurotypical group.7 NSSIs, which may include behaviors like cutting and burning, are linked to poor emotional regulation and are strong predictors of later suicidality.8 The following factors in childhood and adolescence increased risk for suicidality and NSSIs in adulthood for the BGALS participants:
- Externalizing ADHD symptoms as well as poor response inhibition and impulsivity significantly predict NSSI severity.9
- Internalizing symptoms – anxiety, depression, social withdrawal, somatic complaints – predict suicide attempts.10
- Peer relationships: Bullying and peer victimization predict NSSI severity, while poor social acceptance and peer rejection predict suicide attempts.10
- Trauma: About 23% of the girls with ADHD had experienced at least one type of maltreatment (physical abuse, sexual abuse, or neglect) by the time they reached adolescence – a rate double that of the comparison group.11 These girls (with ADHD plus maltreatment showed a 33% risk of attempted suicide by early adulthood compared to 14% for the girls with ADHD who had not experienced trauma.11 Maltreatment is also associated with increased internalizing and NSSI symptoms and low self-esteem.11
2. Girls with ADHD Experience Poor Academic and Vocational Outcomes
Compared to the neurotypical group, girls with ADHD experienced fewer years of education and lower achievement scores by the time they reached their mid to late 20s, and they had more work-related problems.12 These factors could further contribute to low self-esteem in girls and women with ADHD.
3. Women with ADHD More Likely to Face Unplanned Pregnancy
By the time they reached their mid to late 20s, about 43% of participants in the ADHD group had one or more unplanned pregnancies compared to about 10% of individuals in the comparison group.12 Poor academic achievement during adolescence was linked with unplanned pregnancy.12
4. Women with ADHD Endure More Intimate-Partner Violence
Females with ADHD are at increased risk for physical victimization by an intimate partner by adulthood (about 30% of participants with ADHD reported victimization compared to about 6% of participants in the neurotypical group.)13
- Although little systematic research exists on differential treatment responses, one recent review suggests that females with ADHD may be more likely than their male counterparts to experience adverse responses to stimulants, and to respond favorably to non-stimulants like atomoxetine.14 (More robust research, however, is needed on this topic.)
- Many studies highlight the problem of rater/informant bias in parent and teacher reports. Some show that teachers are more likely to refer boys for ADHD treatment, even when such boys show equal or lower levels of impairment compared to female students.15
- Despite comparable symptoms, ADHD exacts a major toll on females. As noted above, girls and women with ADHD experience high levels of functional impairments and, often, different patterns of long-term maladjustment than do males with ADHD.6
ADHD Complications: Compensatory Behaviors, Gender Norms, and Stigma
Gender norms and expectations dictate that girls and women should excel socially and academically, and that they should demonstrate few or no problems with self-regulation. These standards may explain why girls with ADHD are more likely than boys with ADHD to devise and exhibit compensatory behaviors for their symptoms.16
Girls are also more likely than boys to exhibit perfectionistic behaviors and to be more achievement-motivated.6 At the cost of high anxiety, many girls don’t want to admit that they’re struggling or that something may be wrong. Inattentive girls and women, often driven to mask their difficulties, are usually better able to compensate and control their internalized symptoms than are inattentive boys and men.6 Complicating this pattern are developmental milestones and transitions including puberty, childbirth, and menopause, both of which may reveal previously “invisible” vulnerabilities.
Gender norms and expectations also heighten stigma and shame for girls and women with ADHD. There’s no room for ADHD when society expects girls and women to be perfect — nurturing, competitive, and sexualized — a pernicious triple bind accentuated during adolescence.17 In addition, society is less likely to forgive attributes believed to be under one’s personal control18 – a problem when it comes to the inconsistent, heterogeneous presentation of ADHD.
People who receive public stigma are also more likely to internalize such stigma.18 Longstanding myths about ADHD – that it’s caused by poor parenting, for example – is another example of stigma at work. Together, these forms of denigration further compel girls and women with ADHD to hide or even deny their symptoms.
Girls and Women with ADHD and Diagnostic Criteria
Recommendations for Clinicians
- Recognize that diagnostic criteria and assessment tools continue to reflect and screen for traditional male behavioral symptoms of ADHD, which may lead to under-recognition in females Rater bias may also taint assessments.
- Do not discount symptoms of hyperactivity and impulsivity when they present in females not so much as stereotypical conduct or “behavioral” problems, but instead as social-relational and psychosexual problems, or even as hyper-verbality and inner restlessness.
- Especially when evaluating teen girls and young adults for ADHD, screen for NSSIs, along with suicidal thoughts and behaviors.
- Teen girls and young women prioritize social relationships, discussion, and harmony. If we know that girls with ADHD are more likely to be rejected and bullied, then assessment should involve questions about peer interactions and challenges in the social realm. To girls, the emotional impact of these troubles may be more impairing than other ADHD difficulties. Girls may benefit from group interventions that focus on social skills, though more research is needed to confirm this hypothesis.
- Ask about and target academic performance, given the high likelihood ADHD will affect school performance. Building and scaffolding executive functions, and interventions focused on academic remediation may help. Young girls may benefit from the Child Life and Attention Skills (CLAS) Program, a behavioral parent training intervention specifically for children with inattentive ADHD.19
- Probe for and help to develop a patient’s strengths to help promote a real sense of positive self-worth, which may mitigate risk for other impairments.
- Conduct trauma-informed assessments, as trauma is a marker for poorer prognosis and risk for NSSI and suicidal thoughts and behaviors.
- Ask about sexual behavior and employment history, as appropriate, as these experiences may also uncover impairments.
- Promote sex education and advocacy, given high rates of unplanned pregnancy in this group.
- Be on the lookout for compensatory behaviors from patients and families – e.g., long hours spent on homework, staying late at work, symptoms of anxiety and depression, highly structured environments, high levels of stress, putting on a “brave” face. Even asking, “Are you overwhelmed?” may elicit responses that can indicate underlying ADHD. Ask about periods of transition, including developmental changes, as they may expose or exacerbate symptoms.
Recommendations for Researchers
- Examine sex differences in existing datasets, even if that’s not the original priority for study. This practice could raise consciousness with respect to potential male vs. female aspects of ADHD (and many other conditions).
- Prioritize and broaden evidence-based assessments, which should reflect trajectories and major impairments associated with ADHD in girls and women. Qualitative research – involving the narratives and lived experiences of girls and women with ADHD – can help translate those answers into more valid quantitative questionnaires, interviews, and other assessments.1
- Consider sex-specific versus sex-general norms. Should we be diagnosing ADHD in girls and women relative to other girls and women, and not according to general, cross-gender norms (as is current practice)? This has been a longstanding, controversial question. In all likelihood, more girls and women would qualify for ADHD diagnoses, but what consequences would follow (e.g., potential overdiagnosis)?
- Work to understand the near 1:1 sex ratio of ADHD in males and females by adulthood. Boys are more likely than girls to be diagnosed with ADHD, but the ratio nearly evens out in adulthood. Why? Is it possible due to greater persistence of symptoms (especially inattention) in girls and women? A greater willingness to disclose and self-report as an adult? Greater ADHD understanding over time?
- Research the apparent stimulant versus non-stimulant discrepancy between the sexes. Why may females, on average, react better to the latter? Could it have to do with the presence of the inattentive presentation more often seen in girls and women, or the higher likelihood of co-occurring anxiety and depression?
ADHD in Girls and Women: Conclusions
ADHD in females is understudied and often overlooked, but we do know this: ADHD is a highly impairing condition for girls and women, linked in research to self-harm, internalizing symptoms, peer difficulties, and other female-specific impairments. Standing in the way of more accurate diagnosis and more effective treatment for women are longstanding research and clinical practices that favor male presentations of ADHD and ignore female-specific manifestations. Stereotypes, gender norms, and stigma also compel girls and women to mask and overcompensate for their ADHD symptoms — resulting in an atypical presentation of ADHD unfamiliar to many clinicians and a lack of willingness to seek treatment.
It is imperative that researchers and clinicians commit to facilitating recognition of female presentations of ADHD. Doing so may mean rethinking current approaches to diagnosis, including refining assessments and rating scales to highlight female-specific aspects of ADHD and re-engineering clinical interviews to do the same.1 Finally, clinicians should prioritize treatments that target known impairments and risk factors in girls and women with ADHD.
The content for this article was derived with permission from “ADHD in Girls and Women: Historical Perspectives, Current Realities,” presented at the APSARD 2022 Annual Conference by Stephen P. Hinshaw, Ph.D., and featuring Ellen Littman, Ph.D., and Andrea Chronis-Tuscano, Ph.D., as panelists. Dr. Hinshaw is the author of the forthcoming book, “Straight Talk about ADHD in Girls: How to Help Your Daughter Thrive,” which will be available in August 2022.
ADHD in Women: Next Steps
- Self-Test: ADHD Symptoms in Women and Girls
- Read: Why ADHD in Girls Is Often Overlooked
- Read: Why Women with ADHD Feel Disempowered — And What We Can Do About It
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