Attention Deficit Hyperactivity Disorder (ADHD) in Females – Gender Differences in Neurobiology, Assessment & Management
Females with ADHD constitute a silent minority, with a propensity towards underdiagnosis and undertreatment.
There is evidence to suggest that there is a significant discrepancy in the ratio of males to females diagnosed with ADHD. [Berry et al., 1985]
ADHD is a childhood condition which in some cases, persists in adulthood.
ADHD consists of the following key symptom domains:
- Hyperactivity – Impulsivity
- Both of the above
The symptoms tend to decline with increasing age, with a greater reduction in hyperactivity-impulsivity domains with the persistence of inattention. [Faraone et al., 2006]
Evidence suggests that approximately two-thirds of children continue to have impairing symptoms, with approximately one-third of childhood cases continuing to meet full criteria into their twenties. [Biederman J et al., 2000]
Regarding referral patterns, the male to female ratio in terms of clinical referrals ranges from 3:1 to 16:1, with community samples showing a ratio of 3:1 of boys to girls. [Nøvik et al., 2006] , [Willcutt EG, 2012]
Compared with boys, girls had significantly more parent-rated emotional symptoms and prosocial behaviour. They were more likely to be the victim of bullying and less likely to be the bully. [Nøvik et al., 2006]
This divergence highlights that many girls with ADHD are likely to remain unidentified and untreated, which can have a significant long-term impact on their social, occupational, psychiatric, educational and vocational outcomes.
For example, in studies where teachers were presented with ADHD-like vignettes and the child’s name and pronouns were changed from male to female, boys’ names were more likely to be referred for additional support and considered more suitable for treatment. [Young et al., 2020]
Reasons for differing referral patterns may be:
- Parents may underestimate the severity of hyperactivity and impulsivity in girls.
- Compensatory behaviours in girls, e.g. socially adaptive behaviour, increased coping strategies and resilience.
Results from a naturalistic study in Europe showed that compared with boys, girls had significantly more parent-rated emotional symptoms and prosocial behaviour and were more likely to be the victim of bullying and less likely to be the bully. [Nøvik et al., 2006]
Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., … & 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), 1-27.
Villemonteix, T., De Brito, S. A., Slama, H., Kavec, M., Balériaux, D., Metens, T., … & Massat, I. (2015). Grey matter volume differences associated with gender in children with attention-deficit/hyperactivity disorder: a voxel-based morphometry study. Developmental cognitive neuroscience, 14, 32-37.
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