ADHD in women and girls: why it can be missed

ADHD in women and girls may be overlooked because its signs are less obvious and many girls and women build their own ways of compensating (Hinshaw, 2021). Girls and women with ADHD also more often struggle with attention than with hyperactivity (Hinshaw, 2021). Males and females with ADHD are more alike than different (Rucklidge, 2010).

Why is ADHD easier to miss in girls?

A team of experts led by Hinshaw (2021) reviewed research on ADHD in girls and women from childhood through adulthood, looking most closely at childhood through the mid-teens. This was a review of earlier studies, not new data, and the authors didn't say how they chose what to include.

In childhood, girls meet the criteria for ADHD at just under half the rate of boys. By adulthood, the gap is much closer to even. The reviewers also describe girls and women with ADHD as more often having trouble with attention than with restlessness or acting on impulse. Their difficulties also tend to turn inward, while boys and men more often show the hyperactive, impulsive side and outward, disruptive behavior.

The reviewers also give two reasons ADHD may be overlooked in girls and women. The first is that it can look less obvious.

The second reason is compensating. Many girls and women build their own ways of working around their difficulties, and the reviewers say that can make the signs harder for clinicians to see.

Who gets studied matters too. Hinshaw's team concluded that differences between the sexes depend heavily on whether a study recruited people who had been referred to clinics or people who had not. A separate expert review by Rucklidge (2010), covering studies of all ages, made a related point: if only girls with substantial problems get sent to clinics, studies built on clinic patients may hide the real differences between girls and boys. Rucklidge also reported that girls and women with ADHD are less likely than boys and men with ADHD to be referred for treatment.

ADHD in women and girls: more alike than different

It's easy to read about differences between the sexes and conclude that ADHD in women is a different condition. An expert review by Rucklidge (2010), covering studies of boys, girls, men and women, concluded otherwise: males and females with ADHD are more similar than different, and ADHD profiles generally aren't specific to one sex.

The differences Rucklidge described were small. Girls diagnosed with ADHD are more often diagnosed with the mainly inattentive type than boys with ADHD. In studies of teenagers, girls with ADHD had lower confidence in their own abilities and weaker coping strategies than teenage boys with ADHD. Depression and anxiety may be more common, and physical aggression less common, in girls and women with ADHD than in boys and men with ADHD. Rucklidge also cautioned that many of the studies were small and used different ways of diagnosing ADHD, and that the few differences some studies found in thinking skills could be down to chance.

One long-running study in Hinshaw's review, from Massachusetts General Hospital, followed girls with ADHD, recruited through psychiatric and pediatric referrals, into early adulthood. By then, many no longer met the full criteria for ADHD, but most of the girls still had more symptoms than is typical and real problems in daily life. That's a finding about girls followed as they grew up.

Rucklidge's review doesn't suggest a separate condition in girls and women, and Hinshaw's team points to the way ADHD tends to show in girls and women, which can make it easier for clinicians to overlook.

The Hinshaw (2021) review concluded that ADHD can bring serious difficulties for girls and women, with a raised risk of problems in close relationships and of self-harm. In another long-term study it reviewed, from Berkeley, girls with ADHD followed into early adulthood had higher rates of self-harm than girls without ADHD. If you're in crisis in the US, call or text 988.

If you're having thoughts of harming yourself, please reach out to a clinician or a crisis line now.

What do women diagnosed as adults report?

Attoe (2023) carried out a systematic review, a structured search with set rules for which studies to include, of eight studies of women who were diagnosed with ADHD as adults. The studies relied on interviews and women's own accounts of their lives.

Four themes came through. The first was that living undiagnosed until adulthood can harm social and emotional wellbeing, a main finding of every study in the review. The second was difficult relationships, with family and with partners, which nearly every study described. The third was a sense of lacking control. The fourth was more hopeful: most of the studies reported relief and self-acceptance after diagnosis.

If you were diagnosed late, that last theme may sound familiar.

The limits are real, though. The studies in Attoe's review were small, and they relied on women recalling their own pasts, which the review says can bias the results. The review's authors say research on this topic is limited and that firm conclusions aren't possible.

The Hinshaw (2021) review recommends that evaluations of girls and women be thorough. That includes asking about other emotional, behavioral or learning difficulties, subtle inattention, ways of compensating, big life transitions such as school or university, and a person's history from childhood on. These are things to raise with a qualified clinician, not to check off on your own.

Try this today: Write down one workaround you've relied on for years to get through a hard part of your day, so you have a concrete example ready if you talk about your ADHD with a clinician.

Hinshaw and Rucklidge wrote expert reviews and didn't say how they chose studies. Hinshaw's team focused mainly on childhood through the mid-teens, and findings about girls don't automatically describe adult women. Attoe's review used set rules, but its studies were small. A qualified clinician is the right person to talk any of this through with.