Until 2013, ADHD was still grouped with the Disruptive Behavior Disorders of Childhood in the DSM-IV. Early clinic referrals revolved around the management of hyperactive, impulsive young boys. Treatment focused on minimizing the negative impact of their behaviors on others. Over time, criteria were modified and exemplars constructed in efforts to reflect the changing literature. As long as observable behaviors serve as our yardstick, the females presenting most similarly to hyperactive boys are most likely to be diagnosed. Indeed, in the early 90’s, a keynote speaker concluded that so few girls were diagnosed because girls were simply “ADD wannabees”. In other words, most girls failed to meet the male-based criteria by age 7. Still, the presumption is that the criteria pertain as accurately to females as to males.
We come by this unintended gender bias honestly—and it is embedded in the very fabric of our science. Unfortunately, one of the consequences of this bias is that combined type females are still more likely to be diagnosed than inattentive females because they are more likely to meet criteria by age 12. They are also more likely to comprise the majority of female clinic subjects chosen for study samples. As a result, we’re honing our skills in recognizing the impulsive girls; however, recognizing the subtle and complex presentations of inattentive females remains far more elusive.
The research says that there are no significant gender differences in terms of number of symptoms, severity, persistence, academic achievement, number of comorbidities, efficacy and tolerability of meds; even the manifestations of symptoms are similar. Indeed, the disorder itself does not differ by gender–but the genders themselves differ–physiologically, psychologically, socio-culturally. For example, women with ADHD exhibit more anxiety and depression than men with ADHD, but women in general exhibit more anxiety and depression than men. The same symptoms are experienced, but females perceive greater impairment than males. Some wonder if females are more vulnerable to the impairing effects of ADHD symptoms because it is often their functional challenges rather than the symptoms themselves that cause them to seek treatment. Misattributing their difficulties to characterological flaws, females judge themselves harshly and label themselves as inadequate relative to peers.
A unique trajectory
Several factors contribute to our diagnostic challenges. The greater likelihood of inattentive symptoms results in subtler gender-typical presentations. Internalized symptoms like anxiety and depression often contribute to misdiagnosis. Gender role expectations reward those conforming to the feminine ideal without complaint. Women with poorly choreographed executive functions mask their struggles and are too ashamed to ask for help. Ironically, the result of compensating successfully is that their plight remains secret but no less damaging to their sense of self.
Stable over time?
Historically, ADHD has been considered a neurodevelopmental disorder that is stable over time, but the women’s story is more complex. Actually, across the lifespan, symptoms tend to improve, as do executive functions. However, their qualitative experience varies considerably in response to hormonal fluctuations. Diagnosis is often delayed until girls’ symptoms intensify after puberty. Within a given month, the motivated and assertive woman presenting 4 days after her period has little resemblance to the insecure and demoralized woman presenting 4 days before her period. Hormones also mediate the emotional volatility of adolescent girls, exacerbating observable anxiety and depression, which can easily lead to misdiagnosis. Estrogen exacerbates ADHD symptoms while also affecting sleep, verbal memory, mood, and the dopamine reward system.
Undiagnosed, dysfunctional coping strategies segue into comorbid disorders that are cumulative over time across multiple domains; self-esteem plummets, anxiety paralyzes, depression deepens, and stigma is internalized. Demoralization can lead to despair, which contributes to the shocking gender differences in impact: poor self-care, self-harm, intimate partner violence, suicidality, and early mortality. The severity of these potential outcomes underscores our responsibility to address this public health crisis.
Despite the fact that girls are less frequently referred, less frequently identified, and less frequently meet DSM criteria, more females than ever are being diagnosed. However, rather than disrupt, most struggle with increasingly complex quality of life issues that primarily affect them and their sense of self. The daunting array of potential negative outcomes highlights a developmental trajectory that differs significantly from those of control women and ADHD men. Recent studies compare females with ADHD to female controls, with an eye towards reducing bias. Using population samples may enlarge the subset of females that are studied. Perhaps the behavior of one gender cannot be the standard by which the other is measured. By assessing functional impairment and internalized symptoms in addition to behavior, it may be possible to create a system that can recognize symptoms in a far greater percentage of our population with equal accuracy and simultaneously allow us greater attunement to the impairments that color their quality of life.
Haimov-Kochman, R., & Berger, I. (2014). Cognitive functions of regularly cycling women may differ throughout the month, depending on sex hormone status; a possible explanation to conflicting results of studies of ADHD in females. Frontiers in human neuroscience, 8, 191.
Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of consulting and clinical psychology, 80(6), 1041.
Nadeau, K. G., Littman, E., & Quinn, P. O. (2015). Understanding girls with ADHD: How they feel and why they do what they do. Advantage Books: Washington, DC .
Rucklidge, J. J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics, 33(2), 357-373.
Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3).
Williamson, D., & Johnston, C. (2015). Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review. Clinical psychology review, 40, 15-27.