The Rare Diagnosis for a Common Condition: The Unnecessary Gender Gap in ADHD

By: Harper Walton-Mouw 

The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), defines attention deficit hyperactivity disorder (ADHD) as a heritable neurodevelopmental disorder containing two main groups for its symptoms– inattention and hyperactivity/impulsivity. These behaviors must be present and impactful in multiple settings of the patient's life (e.g., school, home, work, relationships) (American Psychiatric Association, 2013). Although existing research reveals there to be little influence by sex in the likelihood of inheriting or developing ADHD (McLoughlin et al., 2007), clinical-based studies show the ratio of boys to girls diagnosed with ADHD, as children, to be 4:1 (Cheng et al., 2022). This finding is representative of a larger struggle faced by girls with ADHD; recent studies indicate that parents, caregivers, teachers, and clinicians often fail to recognize signs of ADHD in girls, hindering timely interventions necessary for their early diagnosis and effective treatment (Arcia & Connors, 1998). This article aims to explore the factors influencing perceptions of ADHD that might limit the possibility of its recognition and diagnosis in girls. Additionally, possible methods for increasing clinical awareness and knowledge of unique female ADHD presentations will be identified and discussed. 

While an individual's chromosomal sex might not significantly impact the risk of inheriting ADHD (McLoughlin et al., 2007), studies show that predominant presentations of ADHD between female and male patients consistently differ. Girls with ADHD are diagnosed under the inattentive subtype more often than the combination of hyperactive/impulsive subtypes and report interpersonal symptom presentations that parents and teachers might perceive as less severe (e.g., daydreaming, restless thoughts) (Martin, 2024).

Research also shows that young girls with ADHD struggle significantly more than their male peers with ADHD, and female peers without ADHD maintain more positive relationships and friendships (Young et al., 2020). This contrasts the often task-oriented primary struggles of boys with ADHD, such as physical restlessness and classroom disruption (Quinn & Madhoo, 2014). Despite these well-researched findings, diagnostic manuals have made few amendments in addressing ADHD in females from past publications that utilized studies of nearly homogeneous Caucasian male samples (Martin, 2024). These differences in presentation and shortcomings in research inclusivity are the basis of multiple theories as to why ADHD is recognized and diagnosed less in girls than in boys. 

A study performed in 2012 investigating the roles of ADHD subtype and gender in teachers' ability to identify ADHD found there to be an overall difficulty in recognizing an inattentive student, whether the student was male or female (Moldavsky et al., 2012). Although this study concluded that a student's gender had little to no impact on teachers' likelihood of recognizing ADHD, the findings show there to be a lack of awareness among teachers regarding the inattentive subtype within the disorder (Martin, 2024). This evidence supports the possibility that common stereotypes that represent children with ADHD as disruptive (developed most notably in the mid-1900s during educational reforms that highlighted hyperactive ADHD in classroom settings) may impact teachers' perception of the disorder and, consequently, their ability to identify inattentive ADHD in girls accurately (Cheng et al., 2022). As adults who often have the opportunity to observe a child's reaction to a structured learning environment and the agency to prompt clinical intervention, teachers' reports are instrumental in recognizing and diagnosing ADHD (Sayal & Goodman, 2009). This makes consistent ineffectiveness in the

part of teachers to recognize the predominant presentation of ADHD in girls, a factor preventing the timely diagnosis of females. 

It is valuable to acknowledge symptom subtype presentation, age of onset, and clinician bias as factors impacting females' ability to receive a proper diagnosis (Cheng et al., 2022). However, this article will primarily review research that focuses on symptom severity as a component in ADHD diagnosis criteria. 

A 2015 study investigating the severity of ADHD in boys and girls ages 8-19 found that the male participants with ADHD received higher diagnostic scores more often than the females with ADHD due to higher self-reported and externally perceived symptom severity (Arnett et al., 2015). The Mean Difference Model (Figure 1) demonstrates the problem this finding presents; more females than males that experience ADHD symptoms did not fall within diagnostic thresholds due to their condition being measured as less severe by the study's examiners, parents, and teachers. 

Figure 1. Models representing the ADHD symptom severity of females compared to males (Arnett et al., 2015).

However, a study performed in 2019 evaluating adult self-reports of symptom burden concluded that while fewer females exhibited symptoms that were perceived as severe, they reported that their symptoms caused significantly higher impairment than that of males (Adler et al., 2019). This study is especially valuable in further advancing the theory that it might be plausible to attribute the measured differences in ADHD severity among men and women (such as ones found by the 2015 study) to a bias of external parties– examiners, parents, and teachers– to perceive the predominantly inattentive and internal symptoms of ADHD in girls as less severe than the hyperactive and disruptive symptoms often presented by boys (Martin, 2024).

Therefore, a constant threshold for ADHD scoring that studies observe to be appropriate for diagnosing males might exclude females who experience less severe but equally burdensome symptoms (Adler et al., 2019). A current lack of sex-specific diagnostic thresholds is associated with the use of studies regarding ADHD with insufficient female representation to form past diagnostic criteria that have received little alteration for modern manuals (Gershon, 2002). 

Small-scale studies indicate that the roadblocks in the recognition and diagnosis of ADHD in girls are addressable; O'Connell performed a study that found when primary care physicians received a 20-minute PowerPoint presentation regarding sex differences in ADHD, the frequency of ADHD screenings performed by the providers increased significantly. Figure 2 demonstrates their findings (O'Connell, 2021).

Figure 2. Clinicians' pre-intervention and post-intervention ADHD screening frequencies (O'Connell, 2021).

Applying this method within schools would provide teachers with the necessary resources to learn about and understand ADHD in girls, helping to increase the number of girls who can receive timely interventions and formal screenings. Additionally, the studies regarding ADHD symptom severity and burden presented earlier indicate that current scientific literature might provide the insight necessary to amend diagnostic criteria (McLoughlin et al., 2007). Including sex-specific diagnostic thresholds could allow for the appropriate diagnosis in both boys and girls by accounting for symptom severity differences (Martin, 2024). Both of these possible next steps provide a promising outlook for narrowing the gender gap in ADHD diagnoses.

References

Adler, L. A., Faraone, S. V., Sarocco, P., Atkins, N., & Khachatryan, A. (2019). Establishing US norms for the Adult ADHD Self-Report Scale (ASRS-v1.1) and characterising symptom burden among adults with self-reported ADHD. International journal of clinical practice, 73(1). https://doi.org/10.1111/ijcp.13260. 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. 

Arcia, E., & Conners, C. K. (1998). Gender differences in ADHD?. Journal of developmental and behavioral pediatrics: JDBP, 19(2), 77–83. https://doi.org/10.1097/00004703-199804000-00003. 

Arnett, A. B., Pennington, B. F., Willcutt, E. G., DeFries, J. C., & Olson, R. K. (2015). Sex differences in ADHD symptom severity. Journal of child psychology and psychiatry, and allied disciplines, 56(6), 632–639. https://doi.org/10.1111/jcpp.12337. 

Cheng, A., Illango, A., El-Kadi, A., Ma, H., Mitchell, N., Rajapakse, N., & Robb, C. (2022). Factors Impacting Gender Diagnostic Differences in ADHD: A Review. The Child Health Interdisciplinary Literature and Discovery Journal. https://doi.org/10.15173/child.v1i1.3126. 

Gershon J. (2002). A meta-analytic review of gender differences in ADHD. Journal of attention disorders, 5(3), 143–154. https://doi.org/10.1177/108705470200500302 

Martin, J. (2024). Why are females less likely to be diagnosed with ADHD in childhood than males? The Lancet Psychiatry, 11(4), 303-310. https://doi.org/10.1016/S2215-0366(24)00010-5.

McLoughlin, G., Ronald, A., Kuntsi, J., Asherson, P., & Plomin, R. (2007). Genetic support for the dual nature of attention deficit hyperactivity disorder: substantial genetic overlap between the inattentive and hyperactive-impulsive components. Journal of Abnormal Child Psychology, 35(6), 999–1008. https://doi.org/10.1007/s10802-007-9149-9 

Moldavsky, M., Groenewald, C., Owen, V. and Sayal, K. (2013). Teachers’ recognition of children with ADHD: role of subtype and gender. Child Adolesc Ment Health, 18(1), 18-23. https://doi.org/10.1111/j.1475-3588.2012.00653.x. 

O’Connell, R. E. (2021). Advocating for routine ADHD screening in young girls (Master's thesis). Edson College of Nursing and Innovation, Arizona State University. https://hdl.handle.net/2286/R.2.N.162160. 

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), PCC.13r01596. https://doi.org/10.4088/PCC.13r01596. 

Sayal, K., Goodman, R. (2009). Do parental reports of child hyperkinetic disorder symptoms at school predict teacher ratings?. European Child and Adolescent Psychiatry, 18(6), 336-344. https://hal.science/hal-00478094v1. 

Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9.

Image References

Arnett, Anne B., Pennington, Bruce F., Willcutt, Erik G., DeFries, John C., Olson, Richard K. (2015). Mean Difference Model and Variance Difference Model. J Child Psychol Psychiatry. Retrieved November 22, 2024, from https://pmc.ncbi.nlm.nih.gov/articles/PMC4385512/. 

O’Connell, Roseann E. (2021). The means of pre-ADHD screening and Post ADHD screening. Advocating for Routine ADHD Screening in Young Girls. Edson College of Nursing and Innovation, Arizona State University. Retrieved November 20, 2024, from https://d1rbsgppyrdqq4.cloudfront.net/s3fs-public/dnp/OConnellProjectFinal.pdf? versionId=g7ymjK1vLxn7Wi6_9E6I03vzf8x6nTLM&X-Amz-Content-Sha256= UNSIGNED-PAYLOAD&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz Credential=AKIASBVQ3ZQ4YNQVYJLW/20241108/us-west-2/s3/aws4_reques t&X-Amz-Date=20241108T224140Z&X-Amz-SignedHeaders=host&X-Amz-Ex pires=120&X-Amz-Signature=4db74f9caef21a49289fe352a08d560157227876a3 9246817bae9d03b1e62050.