Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and impulsivity that begins in childhood and can persist into adulthood. For many years, ADHD was believed to be a condition that mostly affects males, with some estimates putting the male-to-female ratio as high as 9:1. However, more recent research suggests that ADHD is underdiagnosed in females for several reasons.
Symptom Presentation Differences
One of the main reasons why ADHD is harder to diagnose in females is that they often present with symptoms that differ from the “typical” male-dominated portrayal of ADHD. Males with ADHD tend to exhibit more outwardly hyperactive and impulsive behaviors, whereas females often exhibit more inwardly directed symptoms:
Inattentive subtype
Females are more likely to have the inattentive subtype of ADHD, which is characterized by disorganization, forgetfulness, poor time management skills and difficulty staying focused. This contrasts with the hyperactive-impulsive symptoms more commonly seen in males.
Internalized symptoms
Rather than acting out, females with ADHD are more likely to internalize their struggles by exhibiting anxiety, depression or low self-esteem. This causes their ADHD symptoms to be overlooked.
Less disruptive behaviors
Females with ADHD tend to be less disruptive in classrooms and social settings. They are better able to mask their symptoms through socially acceptable behaviors, causing their struggles to be underestimated.
| Symptoms | Males | Females |
|---|---|---|
| Hyperactivity | More common | Less common |
| Impulsivity | More disruptive/externalized | Less disruptive/more internalized as anxiety or depression |
| Inattention | Less common | More common |
Diagnostic Criteria Biased Towards Males
Historically, the diagnostic criteria for ADHD have been based on male-dominated research. As a result, the criteria are skewed towards hyperactive and disruptive behaviors commonly seen in males:
DSM criteria
The DSM 5 criteria for ADHD emphasize behavioral symptoms like inability to sit still, fidgeting and excessive talking – symptoms more often seen in males. This overlooks the inattentiveness, disorganization and internalizing behaviors more common in females.
Research focused on males
Early ADHD research focused predominantly on males, establishing a male-centric portrayal. This caused female symptoms patterns to be overlooked and understudied. Even today, females remain underrepresented in ADHD studies.
Gender stereotypes
There are certain assumptions and stereotypes about how females “should” behave – for example, sitting quietly rather than causing disruptions. This causes ADHD symptoms in females to be overlooked or considered part of their personality rather than a neurobiological disorder.
Misdiagnoses and Late Diagnoses
Due to their different symptom presentation, females with ADHD are often misdiagnosed or diagnosed much later than males:
Misdiagnosed conditions
Females with ADHD are commonly misdiagnosed with conditions like anxiety, depression, learning disabilities or mood disorders. Their core ADHD symptoms can be overlooked.
Late diagnoses
ADHD symptoms in females are often less overt in childhood. They are better able to compensate in early grades, but begin to struggle more in late elementary and middle school as academic demands increase. This can delay their ADHD diagnosis.
Adolescent/adult diagnoses
Up to 75% of females with ADHD are not diagnosed until adolescence or adulthood. By this point, they have developed coping mechanisms that allow them to fly under the radar. Receiving appropriate treatment is delayed.
| Age of Diagnosis | Males | Females |
|---|---|---|
| Childhood (ages 4-11) | More common | Less common |
| Adolescence (ages 12-17) | Less common | More common |
| Adulthood (age 18+) | Less common | More common |
Impact on Females
The underidentification and late diagnosis of ADHD in females can have significant consequences:
Self-esteem issues
When girls and women with undiagnosed ADHD struggle in school or social settings, it can cause them to develop low self-confidence and question their abilities.
Missed opportunities
Without proper diagnosis and treatment, many females with ADHD fall short of their full academic or career potential due to ongoing struggles with executive function deficits.
Higher risk conditions
Females with undiagnosed ADHD are at higher risk for self-medication through substance abuse and conditions like depression, anxiety and eating disorders.
Greater impairment
Studies suggest that females with ADHD may experience greater impairment in academic, social, family and cognitive functioning compared to males with ADHD. Underdiagnosis exacerbates these impairments.
Steps Towards Equal Diagnosis
Progress has been made in identifying and diagnosing ADHD in females, but more work remains. Here are some steps that can improve diagnosis equality:
Revised diagnostic criteria
Revising diagnostic criteria to include examples of how ADHD presents in females would improve diagnostic accuracy. The predominance of male-centric criteria must be counterbalanced.
Training for clinicians
Clinicians, teachers and parents should be trained on female-specific ADHD traits to know what symptoms to look for. They need a full understanding of how ADHD manifests across genders.
More research on females
Ongoing research on ADHD needs to feature more gender balanced participant samples. Understanding patterns in females is key to improving identification.
Empowering girls and women
Outreach and education to help females identify possible ADHD symptoms in themselves is important for improving self-referrals and reducing stigma around diagnosis.
Conclusion
In summary, ADHD has been underdiagnosed and misdiagnosed in females due to gender-biased research and diagnostic criteria, differences in how symptoms manifest across the sexes, and misconceptions around ADHD as a “male” disorder. Progress has been made, but more work is still needed to improve equal diagnosis rates. With improved identification, girls and women with ADHD can get the treatment and support they need to thrive and reach their full potential.