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Credit: Ben Michelman
Attention deficit hyperactivity disorder (ADHD) is harder to detect in girls than in boys. Julia Schechter, a clinical psychologist at the Duke Center for Girls & Women with ADHD in Durham, North Carolina, explains why girls with ADHD are harder to diagnose, and how undiagnosed girls face higher risks of bad outcomes than boys do, ranging from relationship issues to eating disorders and self-harm.
What are the current rates of ADHD diagnosis in women and girls?
In the past couple of years, there has been a rise in the number of women who have requested assessment and been diagnosed with ADHD. This means that the diagnosis rate in adult women is about the same as in men. However, there is a big discrepancy in diagnosis rates in children. The ratio differs depending on the study, but there are at least two to three times as many boys diagnosed with ADHD as girls1.
Nature Outlook: ADHD
Why are girls underdiagnosed?
In girls and women, ADHD tends to show up as inattentiveness — that is, difficulty remaining focused on a task, getting easily distracted or having trouble with organizing. Boys and men with ADHD, by contrast, characteristically display hyperactivity and impulsivity: they often fidget and have trouble staying seated. Girls can also have these symptoms, although they are less commonly reported. The latest research suggests that hyperactive behaviours in girls can show up as hyper-verbal tendencies, such as being excessively talkative2.
We also suspect that girls mask or downplay their symptoms. It might be that they have internal restlessness and a drive to be physically active, but that strong social pressures in the environment and in society more generally lead them to work extra hard to tamp them down. So, because their symptoms are less obvious or familiar to others, girls tend to not meet the diagnostic criteria.
Do we need better diagnostic criteria?
When we look at the studies that helped to inform the diagnostic criteria, most of the participants were male. This is problematic, because we cannot get a complete picture of the range of symptoms we might see across the sexes. We need more science to better understand how these symptoms present in everyone. The problem is circular. For example, researchers say that we need to study more girls. However, it can be difficult to enrol girls with ADHD in studies because they are diagnosed less often and are harder to find.
Girls with ADHD also tend to have more psychiatric conditions than girls without ADHD do. And when we compare them with boys who have ADHD, girls are more likely to have conditions such as depression and anxiety. This makes it harder to discern what is and is not ADHD. It also affects who’s involved in research. In an effort to isolate ADHD symptoms for study, some researchers screen out girls, or anyone, with these co-occurring conditions. We need to better study these girls so that we can potentially consider different diagnostic criteria. In the meantime, we need to work out how to use the criteria we have to broaden our understanding of how these symptoms show up in girls, and how this can impair their functioning.
What are the risks of undiagnosed ADHD?
Untreated, unmanaged ADHD for anybody can be problematic, but there are many unique risks for girls and women compared with those without ADHD. They are much more likely than boys and men to experience social difficulties, such as bullying. They are at higher risk of relationship problems, including violence from an intimate partner. They are six times more likely to experience a teenage pregnancy, and are twice as likely to engage in self-harm. There are data showing higher rates of eating disorders, and higher rates of both suicidal ideation and suicide attempts. People of both sexes with ADHD are more likely to die prematurely, but that tendency is slightly more pronounced in women than in men3.
How can we provide better treatment?
The short answer is more funding for science and research to explore this question, along with better access to diagnostic tools. Some tools for evaluating ADHD allow care providers to compare scores from their female patients with other female-specific data. But these tools are often proprietary, expensive and not available in primary-care offices.
We also need to increase awareness. When a girl presents with anxiety, it is important to assess that, but health-care providers could also consider an ADHD assessment, because we know that they often come together. Even when girls are diagnosed, they are much less likely than boys to receive ADHD medication, even though these treatments are currently thought to be just as effective in girls and women. We’re not sure why there is this prescribing pattern. It might be that girls’ ADHD symptoms are often less overtly disruptive than those in boys, that providers have biases against ADHD medications for girls, or that co-occurring conditions such as anxiety overshadow the ADHD treatment. We’re still working this out.
We need a better understanding of how medications are working in girls and women, and whether there might be particular psychosocial and behavioural interventions that could be tailored for their unique experiences. For example, girls could be better able to manage their ADHD if they are tracking the connection between symptoms and hormonal fluctuations. We could also look at management strategies that account for both ADHD and co-occurring symptoms, such as anxiety.
