There are well-documented issues around girls and women being overlooked, disregarded, and misdiagnosed when it comes to ADHD. Despite awareness of this ongoing issue, female presentations of ADHD continue to be misunderstood and neglected – why is this?
Attention Deficit Hyperactivity Disorder (ADHD) is classified as a neurodevelopmental condition characterised by persistent and pervasive inattention and/or hyperactivity-impulsivity that interferes with functioning or development. While these core symptoms indicate key areas of difficulty for individuals with ADHD, a sole focus on these concepts does not wholly capture the scope of the challenges associated with this condition. Difficulties associated with ADHD include executive dysfunction, emotional dysregulation, and impaired psychosocial functioning. Such challenges can make aspects of day-to-day functioning exceedingly difficult, and the implications of this can touch all aspects of a person’s life on a long-term basis. ADHD has been historically conceptualised as a childhood disorder, though it is now recognised as a condition that can often persist into adulthood. While many people associate ADHD with the stereotypical idea of ‘the hyperactive little boy,’ this condition is found in people of varied age and gender.
ADHD is diagnosed 2 to 9 times more often in boys than girls; however, research suggests that this gender disparity significantly decreases with age, and near equivalent numbers of men and women are reported with ADHD in adulthood. There are notably higher rates of women who receive a diagnosis in adulthood. This is reflective of the ongoing trend of missed and late diagnosis of ADHD in women. It is supported in the available literature that there are poorer long-term outcomes typically observed in untreated individuals with ADHD, which strongly supports the importance of timely diagnosis and effective support.
Given our awareness of this diagnostic trend and the growing base of research and understanding around ADHD, it is valid to wonder, ‘Why is this an ongoing issue?’ There are various theories that contribute to our understanding of this diagnostic pattern: issues around systemic gender biases, unrepresentative diagnostic practices, a lack of awareness around female presentations of ADHD, comorbid psychiatric conditions, and greater use of compensatory strategies in girls and women have been highlighted as key contributors. This article seeks to provide an overview of some of these contributing factors, and highlights considerations around how the interplay of these elements can contribute to misdiagnosis and missed diagnosis amongst girls and women with ADHD.
Female Presentations of ADHD
While specific manifestations of ADHD look different from person to person, the primary “types” of presentation fall along the spectrums of hyperactivity/impulsivity and inattentive symptomology. ADHD presentations are often understood as predominantly hyperactive, predominantly inattentive, and combined type. Research supports that girls and women more typically exhibit higher rates of inattentive symptomology while boys and men more frequently present with hyperactivity/impulsivity. Inattentive symptoms can be reflected in struggles with forgetfulness, distractibility, poor time-keeping, and disorganisation; hyperactivity/impulsivity is often more disruptive and observable in nature such as interrupting others, excessive physical movement, and risky behaviours. It is theorised that the more conspicuous nature of typical male presentations of ADHD is linked to the lower referral and diagnostic rates amongst girls and women, as their struggles do not attract as much notice and perhaps are not viewed to be as problematic by others. Interestingly, research supports that inattentive symptoms are more likely to persist into adulthood which suggests women could be prone to more persistent experiences of ADHD, and perhaps links to the rising number of late diagnoses received by women in adulthood.
The difficulties associated with ADHD are varied and pervasive in nature, and such difficulties can lead to a wide range of negative outcomes including reduced well-being, impaired psychosocial functioning, relationship issues, and greater risk of receiving additional psychiatric diagnoses. It is supported in the available research that women with ADHD are more prone to problems that are “internalising” in nature. This means that they are likely to struggle with less observable issues such as feelings of inadequacy, shame, low self-esteem, anxiety, and depression. Males with ADHD are more prone to “externalising” problems, which include conduct issues and oppositional behaviours such as disruption, defiance, and impulsive behaviours. Again, typical male presentations are perhaps more noticeable and more likely to lead to a referral for ADHD assessment. Female presentations can be more easily missed due to the internalisation and are more likely to lead to differential diagnoses such as anxiety and depression. Awareness of female presentations is vital in ensuring that girls and women are not overlooked and left to struggle without support and understanding.
Biased Diagnostic Practice
Biases that impact referral behaviours, diagnostic practice, and clinical work are understood to play an important role in the underdiagnosis of girls and women with ADHD. The diagnostic tools and research base for ADHD are built on an inherent bias towards male presentations of this condition and so girls and women are underrepresented in the literature. Early research into ADHD centred on young boys, and so the diagnostic criteria and assessment tools were developed primarily based on studies with this population. Screening tools such as the Conner’s 10-item tend to focus on identifying hyperactive symptoms rather than the inattention and executive dysfunction that is more typical in female populations. Studies focusing on female presentations of ADHD are fortunately increasing in numbers, and this has supported many clinicians in developing and evolving their diagnostic and clinical practice accordingly. Not only do we have a greater awareness and understanding of inattentive symptomology, but research has also highlighted how ADHD symptomology can present in different ways. For example, someone may be hyper-talkative and verbally impulsive as opposed to this manifesting solely in physical activity. The diagnostic criteria for ADHD has seen very minor changes over the decades that it has been included in the diagnostic manuals, despite advancements in research and practice. As such, it is important that clinicians are aware of evidence-based female presentations to ensure that they can appropriately attend to this in the diagnostic process to protect girls and women from being overlooked and misunderstood. Detailed history taking, clinical interviewing with awareness and sensitivity to female presentations and less overt symptoms, exploration of compensatory strategies, and vigilance around comorbid conditions can support clinicians in effectively assessing ADHD.
Sociocultural Gender Biases
While some of the barriers to diagnosis for girls and women are rooted in a lack of awareness and the under-representation of females in research and diagnostic practice, research supports that the sociocultural context can further constitute obstacles for women with ADHD. Though ADHD is a neurodevelopmental condition with clear biological underpinnings, the impairments associated with ADHD must be understood within the prevailing social and cultural contexts in which they occur. Some studies have demonstrated that parents, teachers, and professionals can be more likely to recognise ADHD symptoms in boys than girls, and are more likely to refer boys for additional support/treatment even when they present with equal or lower levels of impairment compared to girls.
Gender expectations rooted in the prevailing sociocultural context can impact not only how the behaviours of others are perceived, but also how we learn to present ourselves and manage our own behaviours. For example, while there tends to be a stereotypical expectation for young boys to be “wild” and rambunctious, young girls are typically expected to be more gentle and compliant in their natures. As such, it is possible that young girls with ADHD experience more negative feedback and corrections around hyperactive and impulsive presentations, leading to greater levels of internalisation and the development of compensatory strategies that ultimately reduce their chances of being identified for referral and diagnostic assessment.
Compensatory Strategies and Masking
Varying degrees of compensation and masking can be found across many neurodivergent individuals as they attempt to navigate a world that often does not function with their needs in mind. The literature around neurodevelopmental conditions such as ADHD supports that individuals with greater cognitive abilities, protective lifestyle factors, and higher psychosocial functioning are likely to have greater capacity for coping with the challenges associated with ADHD. ‘Compensatory strategies’ are defined as the behaviours, methods, and adaptations used to mitigate the impact of ADHD-related difficulties and symptoms. ‘Masking’ is the term most often used to describe efforts to hide, suppress, and disguise symptoms/ behaviours/ difficulties/ emotional reactions in order to better “camouflage” and fit in with others – this is typically not a conscious act.
It is theorised that there may be greater societal pressure underpinning masking and compensatory behaviours in girls and women, and that they may be more adept in this due to differences in socialisation and expectations within a social context. While such strategies can support individuals with ADHD to “fit in” better with peers and perhaps be seen to function better across different environments (e.g. school, work), this is also understood to be highly demanding for the individual and can serve to hide the extent of their difficulties, making diagnosis and subsequent support less likely. Changes in circumstances can unravel long-standing compensatory strategies and lessen capacity for masking and coping. For example, studies have highlighted that many women make self-referrals for ADHD assessments when they become mothers, pursue further education, and as they advance in their career as such changes to their circumstances places greater demand on them and reduces the efficacy of the protective factors and practices that they previously depended on, typically resulting in impaired functioning that touches many aspects of their lives. Many neurodivergent individuals have shared their experiences of ‘burnout’ following extended periods of their life in which they worked extremely hard to “keep up appearances”. Some have shared feelings of shame and self-loathing experienced at having to work so hard to do things that seemed so easy to others and how important receiving a diagnosis was in helping to reframe these struggles in the context of ADHD as opposed to their lifelong narrative of being “broken”, “lazy” and “less than”. Awareness of masking and compensatory strategies is vital in supporting effective diagnostic and referral practice as professionals should be mindful that the extent of difficulties observed may be mitigated by the extensive efforts of the client and that such efforts are often not without “cost”. Attention to protective factors can assist in seeing beyond the veil of compensatory strategies and masking.
Conclusion
In conclusion, there is no one reason for the trend of missed and late diagnosis of ADHD in women, rather it is an intricate interplay of many factors. There is a complex landscape of sociocultural influences, inherent biases, diagnostic practices, and limitations around awareness that can serve as obstacles to ensuring that girls and women with ADHD are noticed, listened to, and appropriately supported. While this is not an exhaustive summation by any means, there is a need for increasing awareness around this important issue - and the key factors in play - to ensure that meaningful change and growth can occur. Despite the challenges, many individuals with ADHD live full and gratifying lives and this can be further supported by ensuring that we continue to strive towards awareness, understanding, and inclusivity. Awareness around ADHD is greater than ever and there are continuously expanding resources for support and community, particularly online. In tackling the issues with late and missed diagnosis of ADHD in girls and women, I would emphasise that we need to continue with inclusive research efforts, listen to the lived experiences of women, and be mindful of the various influences and biases that can come into play in our roles as practitioners, referrers, and supporters.
Written by Aylish McFarlane,
Studio 3 Counselling Psychologist
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