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The prevailing stereotype that ADHD manifests only as rough and tumble schoolboys with skinned knees, dizzying energy, and a penchant for mischief has kept untold numbers of females with ADHD from critical diagnosis and treatment.
Proven Research Bias
For years, the majority of patients referred for ADHD diagnosis and treatment were hyperactive young boys. After all, these were the children causing trouble at school--- the "squeaky wheels" so to speak. Since researchers pulled data from patients presenting for treatment and patients referred to treatment were mostly hyperactive schoolboys, this led to unintentional yet far-reaching and harmful biases that still impede appropriate diagnoses of ADHD today (Littman, Gender Myths and ADHD).
It wasn't until 2013 that the diagnostic criteria shifted to account for this bias. While the heart of the diagnostic criteria did not change, it provided examples of possible manifestations of the disorder that may not have been considered by providers previously. For example, hyperactivity was described not only as climbing and running about, but also as excessive chattiness. This shift was critical for many females and inattentive males whose level of impairment from ADHD matched the rowdy schoolboys but whose symptoms presented differently. The gap between boys and girls diagnosed closed dramatically, but, even now, males are 2 to 3 times more likely to receive a diagnosis and treatment than females.
Different Symptom Presentation
Contrary to popular belief, males and females with ADHD experience hyperactive, inattentive, and impulsive symptoms similarly, but gender strongly influences ADHD symptom presentation. The majority of young boys seem to externalize ADHD symptoms while most young girls internalize them. Externalized symptoms refer to disruptive or physical behaviors easily visible to others. Internalized symptoms refer to symptoms that play out on the inside like racing thoughts, inattention, and absent-mindedness. Whether a person internalizes or externalizes symptoms does not change the symptoms themselves, it just changes what the symptoms look like.
For example, an adult experiencing hyperactivity may clean out the cupboards, run on a treadmill for an hour, or lay awake at night. A child experiencing hyperactivity may become overly chatty, climb all over the couch, or shout. The hyperactivity symptom does not change, but how the person displays the symptom might.
What Do Symptoms Look Like in Girls?
Internalizing ADHD symptoms, which seems to be the norm for girls with ADHD, can make hyperactive, impulsive, and inattentive symptoms more difficult to spot. They do not make symptoms any less impairing, though.
Here's how hyperactive, impulsive, and inattentive symptoms can present in girls:
-Perfectionism
-Anxiety
-Daydreaming
-Interrupting
-Speaking quickly/loudly/without thinking
-Withdrawing
-Reacting overly emotionally (slamming doors, crying easily)
-Getting easily distracted
-Shyness
-Disorganization/messiness (self or spaces)
-Excessive silliness
-Jumping from activity to activity or topic to topic
-Needing time to process information
-Forgetfulness
-Needing constant reminders
-Fidgeting (with hands/feet/hair/clothes/pencils)
-Trouble maintaining friendships
-Appearing unmotivated or uncaring
-Making "careless" mistakes
-Stirring up trouble or "drama" with siblings/friends
-Mood swings
Unfair Gender Expectations
While there is no clear cut explanation yet for why ADHD symptoms present differently in boys and girls, one theory is that differing gender expectations influence symptom expression. Early on, boys and girls pick up on social cues to figure out how to fit in. When social cues tell girls hyperactive/impulsive behavior is unladylike, boyish, weird, or obnoxious, they try and hide it to fit in. For example, a boy feeling hyperactive on the playground might tackle his friend. A girl feeling hyperactive can tackle her friend, but her friend would likely look at her as if she were from outer space. The hyperactivity and impulsivity do not disappear, they just get pushed inward and leak out in more subtle ways like hair twirling, chattiness, daydreaming, silliness, and mood swings.
Symptoms Look Different with Age
Gender norms are not the only factor involved in ADHD symptom presentation: age can also shift how one expresses his or her symptoms. In fact, ADHD was once considered a childhood disorder because most of the hyperactive young boys studied seemed to outgrow symptoms by puberty. It wasn't until later that researchers realized some had not outgrown symptoms, but that their symptom presentation had simply evolved. Instead of running and climbing about, these grown up hyperactive boys were getting speeding tickets, arguing, or jumping from project to project.
At some point, it seems, these boys learned running around their classrooms and jumping from great heights would have to stop. Their hyperactivity did not cease, but they no longer expressed it in the same ways they had before.
Perhaps this is the same kind of process girls with ADHD undergo, but it happens much sooner than it does with boys because of different social pressure. After all, one can imagine how a loud, wild, pushy, hyperactive girl might receive different social feedback from teachers, parents, or peers than a loud, wild, pushy, hyperactive boy.
The Effects of Gender Bias
Because their symptoms go undetected by parents, teachers, and medical professionals, most females suffer a lot longer with undiagnosed and untreated ADHD symptoms than males. In fact, on average, girls with ADHD receive their diagnoses 5 years later than boys and many never get diagnosed.
Girls and women with ADHD are also much more likely than boys with ADHD to get misdiagnosed with anxiety and depression. Further complicating diagnosis, females may actually develop mood disorders as a result of untreated ADHD. When they do seek treatment, females with undiagnosed ADHD often receive treatment only for the secondary mood disorder and not for the underlying ADHD.
Leaving ADHD undiagnosed and untreated can have serious repercussions. Not only
can it lead to self-esteem issues, problems in school, and conflicts at home, but it can also increase one's chances of developing substance abuse or psychiatric disorders, getting in car accidents, participating in self-harm, engaging in risky behaviors like gambling or unsafe sex, and having problems at work or in relationships.
Other Factors
Females are not the only demographic affected by bias in ADHD research. Not only have the majority of patients presented for ADHD treatment hyperactive young boys, but they are also white. You can read more about racial bias in ADHD diagnosis here.
Young boys with inattentive type ADHD are also likely to fall through the cracks of ADHD diagnosis. In fact, girls with hyperactive symptoms are more likely to get a diagnosis than boys or girls with inattentive but few or no hyperactive symptoms.
What Can Be Done?
Fortunately, the old stereotype that ADHD describes only overactive schoolboys is on its way out. Having identified the gender bias in ADHD research, medical communities have taken steps to diversify studied patients and understand the myriad ways hyperactivity, impulsivity, and inattention can present in patients with ADHD.
Social media has exploded in recent years with information about various mental health disorders, including ADHD. While sharing ADHD information over social media is not without its pitfalls (like the risk of unintentionally spreading misinformation), it has led many previously undiagnosed females with ADHD to treatment.
Still, many women and girls suffer with ADHD and don't know. They may incorrectly feel their behaviors stem from moral defects and wonder why life feels so hard. They may even self harm or fall into depression as life becomes unmanageable. Sharing information about what ADHD symptoms look like in females can lead struggling girls and women to the critical support they need.
Think you or your daughter might have ADHD? Talk with a licensed healthcare provider about your concerns.
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