Unveiling Gender Disparities in ADHD: A Literature Review on Factors and Impacts of Late Diagnosis in Females (2010-2023)

One of the key factors associated with the underdiagnosis of ADHD among girls is symptom presentation differences. A review found that 3.10% of the adult population had inattentive ADHD, followed by hyperactive (2.95%) and combined (2.44%) ^{5, 50}. Hyperactive/impulsive ADHD includes fidgeting, difficulty staying seated, excessive talking, interrupting conversations, hand, and feet tapping, and impatience; and inattentiveness may include the inability to pay attention to details, difficulty focusing, not following instructions, not listening, poor organization, avoiding tasks that require significant mental effort, frequently losing items, easily distracted, and forgetting daily tasks (APA, n.d.). A growing body of research shows that females are likely to report inattentiveness, and males exhibit greater externalized hyperactivity and impulsivity symptoms, facilitating explicit identification and diagnosis by professionals ²⁴. From childhood into adulthood, research shows that inattentive symptoms, more common among girls, tend to persist, and impulsive and hyperactive symptoms decrease over time ⁴⁵. Greater externalized symptoms may lead to greater referrals, assessment, and diagnosis and thereby treatment for boys vs. girls ^{50, 5, 29, 45}.

Comorbid conditions have also shown to contribute to the underdiagnosis of ADHD in females. A common occurrence of the inattentive subtype in female ADHD diagnoses is often accompanied by concurrent internalizing disorders like anxiety and depression. More than 53.5% of females and 48.5% males with ADHD had one or more of the six psychiatric comorbidities, compared to 13.7% of women and 9.1% of men in the remaining population ⁴³. Females vs. males with ADHD have significantly higher rates of anxiety, depression, bipolar, and personality disorders; for example, 24.4% of females with ADHD vs. 13.1% of males with ADHD have depression ⁴³. Girls and adolescent females with ADHD are at higher risk of self-harm than their counterparts ²⁸. More than 67.3% of adolescents with ADHD had self-destructive behaviors such as non-suicidal self-harm, significantly higher among girls (71.4%) than boys (28.60%) (p < .001) ⁶. This is especially important as physicians report that care does not include an adequate method of treatment for self-destructive girls, resulting in their placement of compulsory care as treatment ⁴⁶.

It is not only types of symptoms that differ by gender, but also severity of symptoms. ADHD symptoms diagnosed tend to be more severe among boys than girls. In a study with 153 (64%) children met the diagnostic criteria for ADHD per DSM-5 guidelines, 79% were boys and 21% girls, with a 3.8:1 male-to-female ratio. Within the high-symptom group of 130 children, 62% were male and 38% were female ²⁹. The ratio of diagnosed to high- symptom girls stood at 0.65:1, in contrast to the ratio of 1.5:1 for boys. In comparison to boys with high ADHD symptoms, fewer girls with high ADHD symptoms were diagnosed with ADHD ²⁹. Females exhibited higher levels of emotional symptoms ²⁹.

There are also biological differences between male and female children diagnosed with ADHD. A study showed that sex differences in frontal white matter microstructure may contribute to neurocognitive outcomes in children with ADHD. They concluded that boys with ADHD present greater abnormalities in frontal motor regions ³⁵. This suggests that boys struggle with cognitive difficulties, while girls struggle with complex, higher- order behaviors ³⁵.

Some studies have shown differences in parental referral for boys vs. girls ^{29, 20}. A comprehensive study showed that parents rated higher scores for inattentiveness among girls than boys (p = .021), while teachers rated higher scores for hyperactivity (p=0.085) and combined symptoms in boys (p = .070) ²⁰. Teacher ratings for inattentiveness among girls were lower than parents. Teachers indicated that it is within their realm to deal with students' mental health issues but lack the knowledge and resources to do so ⁴. Others have also shown gender bias among parental perceptions of ADHD ²⁹, highlighting a lack of education or community awareness of gender differences  in ADHD symptomatology. More studies examining what works to educate and shift parents’ perceptions, and underlying beliefs of boys vs. girls behaviors need to be further examined. Certainly, the role of teachers, school staff, and peers particularly during adolescent years may be a critical area of discovery for identifying and referring more girls for ADHD diagnosis and treatment.

There is sufficient evidence to conclude gender bias among mental health and medical providers, in terms of assessment, diagnosis, and treatment of ADHD differentially by gender ^{9, 27, 50}. The diagnostic criteria is outdated, as it is better able to detect externalizing symptoms more common among boys, and thus leads to is diagnosis of ADHD among girls. The persistence of outdated diagnostic criteria could be a contributing factor to the misdiagnosis of ADHD in girls ⁵⁰. Limited studies have found that boys are more prone to receiving an ADHD diagnosis by psychiatrists, even when they did not meet all the DSM-5 diagnostic criteria, leading to false positives ⁹. Conversely, girls were less likely to receive an ADHD diagnosis even when they did meet all the diagnostic criteria, resulting in false negatives. Boys had more than twice the odds of being diagnosed (Odds ratio = 2.45, p < 0.05), and receiving false positives (p < 0.01) ⁹.

It is important to highlight that girls and women within specific cultures have even lower odds of being referred, let alone diagnosed, and receive appropriate treatment. Research shows that ethnic minority children are less likely to be recognized and treated for ADHD than their non-minority counterparts ⁴¹. Some cultures view hyperactivity and impulsivity in boys as typical and gender-preferred behaviors ⁴¹.

This could explain why some cultures have lower rates of a mental illness as they may not consider certain behaviors atypical. Minority adults are less likely to be diagnosed than non-minority adults ⁴¹. Blacks have 47% lower odds of being diagnosed with inattentive ADHD than whites. Odds are even lower for black females by 63% compared to their counterparts ³⁹. Given the growing diversity of ethnicities and cultures within the US, this is an important area of inquiry to better understand cultural and ethnic disparities, pathways, interventions, and interplay between ethnicity, culture and gender for ADHD diagnosis, referrals, and treatment ⁴¹.

One study found white children were more likely to receive ADHD treatment, with Asian children having the lowest odds of receiving any treatment by 64% ⁴⁰. Reasons for clinician visits varied by ethnicity, with Asian children having higher rates of speech-language disorder and autism, and white children having more anxiety and adjustment disorders. Another study found higher levels of ADHD among Hispanics, and lowest among whites, with inattentive symptoms declining with age. Several factors contribute to minorities not seeking healthcare or mental health care. Among these, distrust in the government and healthcare, experiences of racism, social and professional stigma, insufficient knowledge or awareness, and cultural and language barriers influence the decision-making process for minorities when it comes to seeking treatment. Racism certainly may play a role in influencing willingness to approach the health care system, as well as parents’ care-seeking behaviors by culture, particularly for girls ⁴⁰.

The relationship between ADHD and culture is not well established, with differing opinions in ADHD prevalence, and differences potentially resulting from differential tolerance of hyperactive behavior across cultures ¹⁸. Cross-cultural differences in authoritative parenting styles could be relevant, as tolerance for deviant behaviors is more prominent among European American groups in comparison to other culture-specific groups ¹⁸. Stigma may also play a role in not identifying mental illness appropriately in specific cultures, among the Asian community ⁴⁰. Understanding how different groups rate ADHD as a mental health issue can help inform future research and practitioners screen, assess, diagnose, and tailor culturally responsive interventions.

Next, we summarize the multidimensional impacts of ADHD on girls and women. Underdiagnosed ADHD among girls during childhood and adolescent years has shown to have significant social-emotional, behavioral, academic short and long-term impacts. A recent study by Young et al (2020) found that undiagnosed girls had a higher risk of academic underachievement compared to their peers. They found that girls with ADHD symptoms, but no diagnosis were significantly more likely to experience difficulties with organization, time management, and completing schoolwork. Many girls with ADHD experience social and emotional difficulties. Another study found increased risk of self-injury and suicide attempts and social difficulties among girls with ADHD undiagnosed ¹⁹. Additionally, girls with undiagnosed ADHD tend to experience greater disruptive behavioral issues at home and at school, and increased rates of oppositional behavior, defiance, and conflicts with family and friends ^{13; 19}. Girls with undiagnosed ADHD were more likely to experience peer rejection, social isolation, and low self-esteem compared to girls without ADHD ⁵⁰. Studies show that adolescent girls with undiagnosed ADHD are more likely to engage in risky behaviors including higher rates of substance use, reckless driving, and early sexual activity ^{32, 13, 50}. Additionally, a number of studies and meta-analysis have revealed that girls with undiagnosed ADHD are at an increased risk of developing comorbid mental health disorders, such as anxiety and depression ^{14, 50, 19}. Finally, there are long-term implications of untreated ADHD with enduring effects into adulthood. Girls with undiagnosed ADHD have shown to be at higher risk of academic and occupational impairment, interpersonal difficulties, and mental health disorders in adulthood compared to girls without ADHD ⁵⁰. Greater evidence of stage-specific outcomes, for instance during early to late adolescent years as contexts broaden, and protective factors in different settings such as peer or parental support deserve much greater attention.

Numerous studies have shown adverse outcomes of ADHD, diagnosed and undiagnosed, on women and mothers during adulthood years. Research indicates that mothers with ADHD are at an increased risk of experiencing birth complications and adverse reproductive outcomes, risk-taking behaviors, maternal mental health issues, and challenging parenting practices. A study found that ADHD was related to higher levels of stress, depressive symptoms, lower social support from significant others, and unwanted pregnancies ³⁰. ADHD was associated with risky sexual behaviors and higher rates by four times of unplanned pregnancy than non-ADHD peers ³². Inattentiveness and hyperactivity have shown to affect pregnancy outcomes including poor eating, depression, decreased prenatal vitamin use, or additional caffeine intake ²¹. Another study found that women with ADHD were 20%-30% more likely to undergo cesarean deliveries compared to those without ADHD ³⁶. Furthermore, children born to mothers with ADHD had a higher risk of needing breathing support, particularly when the mother’s ADHD remained undiagnosed during pregnancy.

The association between maternal ADHD and mental health issues and disorders is well- established. Bartelt, Piff, Vitek, & Barkley (2023) reported a 24% higher prevalence of postpartum depression among mothers with underdiagnosed ADHD. Murray et al. (2022) found elevated levels of stress and depressive symptoms among mothers with ADHD. Comorbidities significantly amplify the burden of ADHD on maternal health. ¹⁷ reported that females with ADHD exhibited markedly elevated rates of comorbid health and mental health issues, including insomnia, chronic pain, substance abuse, depressive disorders, and anxiety disorders. These findings highlight the complex interplay between ADHD and various comorbid conditions, compounding the challenges faced by affected mothers. The heightened risk of adverse mental health outcomes among mothers with ADHD is well-documented in the literature ^{3, 30}. Fuller-Thomson, Lewis, & Agbeyaka (2016) reported higher rates of lifetime major depressive disorder (31.3% vs. 14.1%), generalized anxiety disorder (35.6% vs. 9.9%), substance abuse and suicidal ideation (45.8% vs. 13.8%) among females with ADHD compared to those without. They had significantly higher rates of childhood abuse. These findings underscore the urgent need for targeted interventions to address the mental health needs of mothers with ADHD and mitigate the risk of adverse outcomes.

Research has consistently shown challenges parents with ADHD face when managing their children's behavior and emotional needs. ⁴⁸ observed that maternal ADHD symptoms were linked to lower levels of positive parenting and higher levels of inconsistent discipline. Mothers reported higher levels of harsh responses to their children's negative emotional expressions. This research shows the impact of ADHD on motherhood and parenting with potential long-term effects on their offspring, family dynamics, and other facets.

Furthermore, ²² found that parents with ADHD reported diminished sleep quality and heightened levels of parenting distress during the first year of their infants' lives, underscoring the strain experienced in fulfilling parental responsibilities.

The social challenges faced by individuals with ADHD extend to maternal roles, impacting interpersonal relationships and social functioning. ²³ found that adults with ADHD were more likely to experience marital difficulties and dissatisfaction with personal, professional, and social lives. These social challenges can exacerbate feelings of isolation and in adequacy among mothers with ADHD, contributing to heightened stress and emotional distress.

The economic burden of ADHD on affected individuals and society at large is substantial. ³⁸ estimated the annual economic burden of ADHD on adults in the United States to be $122.8 billion, encompassing unemployment costs, productivity losses, and healthcare expenses. Excess cost of $2.26 billion was found among men and $1.20 billion among women, attributable to lost wages, healthcare costs, overall productivity and effects of education and judicial system ¹. Individuals with ADHD have been shown to have poorer work performance, less job stability, lower occupational status, and increased absence days ¹. Moreover, ²³ reported a reduction in income of $8,900 to $15,400 annually for individuals diagnosed with ADHD, highlighting the financial strain associated with the condition. They struggle more with impulsive buying and financial decisions ⁷. These economic challenges not only impact individual financial stability but also have broader implications for societal productivity and healthcare expenditures.

In summary, ADHD in women not only affects their own health and well-being but also has far-reaching consequences for their children, families, and society as a whole, underscoring the importance of early diagnosis, intervention, and support. The evidence presented underscores the significant and multifaceted impact of ADHD on mothers, encompassing physical health, mental well-being, parenting dynamics, social relationships, and economic stability. Addressing the complex interplay of ADHD symptoms, comorbidities, and social-economic factors requires a comprehensive and integrated approach that incorporates targeted interventions, support services, and policy initiatives. By recognizing and addressing the challenges faced by mothers with ADHD, it becomes possible to enhance their well-being, improve family functioning, and mitigate the broader societal impacts of the condition.

Gender bias in ADHD referrals and diagnosis, presentation symptomology differences, and cultural or socialization differences by gender need to be recognized and addressed using multi-pronged strategies. We need more training and education on differential presentation of ADHD among girls vs. boys, a clear criterion for referrals, including a reassessment of behaviors warranting consideration for ADHD referrals. All parents, especially those with girls need to learn about ADHD symptomatology, and comorbidity. They need to advocate with providers for thorough assessment of symptoms and proper diagnosis and subsequent treatment. It could save years of mental health, social, and academic consequences.

Primary care providers, including pediatricians and nurse practitioners, play a crucial role in diagnosing ADHD and should receive adequate training to recognize symptoms in females (CHADD, n.d.). We need more training for healthcare professionals on ADHD symptom presentation in both young girls and adult females. This includes awareness education and updated diagnostic criteria for girls and females in various healthcare settings, such as obstetrics/gynecology, pediatrics, midwifery, nursing, general practice, and mental health.

A consensus meeting in the United Kingdom of healthcare professionals who specialize in the care of girls and adult females with ADHD, recently discussed symptom presentation, criteria for referral, assessment protocols, treatment modalities, and the establishment of collaborative efforts among multiple agencies to ensure comprehensive care for females with ADHD. The experts underscored the importance of abandoning outdated biases and clinician predispositions within the realm of mental health diagnosis for ADHD ⁵⁰.

They emphasized that clinicians should refrain from exclusively seeking the stereotypical disruptive behavioral components of ADHD and instead, incorporate an understanding of the internalized presentation commonly observed in female patients. This approach is crucial for supporting a more nuanced and developmentally challenging manifestation of ADHD in females ⁵⁰.

Addressing bias within the healthcare sector, particularly within the realm of mental health, is a matter of paramount importance. Gender bias, whether overt or unconscious, permeates various facets of healthcare. Research has illuminated the existence of unconscious biases among physicians ²⁷ particularly concerning individuals with mental health concerns. While this phenomenon may not be as pronounced among psychiatrists, it underscores the critical need for general practitioners and other healthcare providers to possess both knowledge and empathy when confronted with patients presenting mental health complaints, ensuring patients receive appropriate referrals to specialists ²⁷. When female patients exhibit symptoms of ADHD, healthcare providers often are challenged with a shortage of current information pertaining to gender-specific symptomatology, which may inadvertently contribute to bias and gender disparities when managing individuals with mental health conditions.

It is imperative to provide teachers and school counselors with appropriate up-to-date information on ADHD and its prevalence differences in males and females to discern the prevalent symptoms of ADHD in girls. This is essential to discern prevalent symptoms of ADHD in girls, thereby mitigating the potential over-referral of male students and the inadvertent oversight of ADHD symptoms in female counterparts. Symptoms such as inattentiveness, depression, anxiety, obsessive-compulsive disorder, and perfectionist behavior can hide ADHD symptoms and delay diagnosis, impacting outcomes in adulthood, including socio-economic status, pregnancy, and motherhood ³⁴.

The primary intervention for mothers would be to include some mental health assessment, perhaps by collaborating or partnering with mental health clinicians, or integrating assessment of ADHD and other mental health comorbidity conditions during prenatal and postnatal care visits. Current postnatal care typically focuses on the child, with limited attention to maternal mental health beyond postpartum depression, and mothers receiving care the first six weeks post childbirth ⁴⁹. Having an ADHD diagnosis increases the risk for both postpartum depression and anxiety disorders, highlighting the critical need for ADHD screening to be included in postpartum maternal care ³. Including screening for ADHD symptoms during postnatal visits can aid in early identification and support for mothers experiencing ADHD-related challenges. This intervention is particularly vital for females from lower socioeconomic backgrounds who may face barriers to accessing healthcare services.

In conclusion, addressing gender bias, enhancing professional training and awareness, educating teachers and school counselors, and integrating ADHD monitoring into prenatal and postnatal care are essential steps to mitigate underdiagnosis of ADHD in adult females. By implementing these strategies, we can improve outcomes for females struggling with undiagnosed or underdiagnosed ADHD and promote their overall well-being across the lifespan.

Prompt identification and diagnosis in the early stages can enhance the quality of life for females, leading to improvements in education, economic prospects, social and family relationships, as well as fostering heightened self-awareness and self-esteem. Thus, it is vital to have comprehensive validated assessment tools that incorporate common female phenotypes and work well with high accuracy and precision in female cases.

The spectrum of ADHD symptoms is inherently diverse, yet the available body of research and literature often falls short in elucidating this complexity to clinicians. Clinical practice has predominantly centered around recognizing the overt and hyperactive manifestations of ADHD, which are more readily observable in males and a specific subset of females who exhibit pronounced external symptoms. Conversely, there remains a notable shortage of research focusing on internalized ADHD symptoms and the expansive breadth of ADHD's clinical presentation. This knowledge gap underscores the need for a more comprehensive understanding of ADHD's multifaceted nature amongst healthcare professionals. Addressing gender bias within the realms of mental health, particularly among diagnosing clinicians, should entail a fundamental paradigm shift from solely evaluating overt externalizing behaviors to a holistic assessment of individuals' lifelong functional impairments. To achieve a more equitable diagnostic framework, it is recommended to incorporate the operationalization of emotional dysregulation, internalizing symptomatology, as well as indicators of trauma and self-harm, alongside traditional behavioral criteria. This approach holds the potential to enhance diagnostic accuracy and facilitate the transition from subthreshold conditions to formal diagnosis ²⁵.

There are various assessment tools for screening of ADHD in children and adults. However, there are currently no gender-specific assessment tools for ADHD. Assessment tools like the Behavior Assessment System for Children -3 (BASC-3) and the Conners Comprehensive Behavior Rating Scales for children (CBRS) involve parent and teacher rating forms, with some including self-reports.

Assessment tools for adults like the Adult ADHD Self-report Scale (ASRS) involving self reports, and the Conners Adult ADHD Rating Scales (CAARS) involving self-report, observations, and interviews are common tools used to screen for adult ADHD. With no existing gender-specific ADHD assessment tools coupled with existing bias among teachers, parents, and clinicians, this underscores the significance of abandoning a one-size-fits-all diagnostic approach and implementing more gender-specific criteria in the evaluation of ADHD in girls and women.

This review was limited by lack of data from healthcare professionals, as ADHD is not seen as a primary mental health disorder for females, and thus diagnostic information and symptoms are not recorded in patients’ medical records to access for research studies. Second, patients may not be willing to participate as they have not been diagnosed with ADHD or do not want to acknowledge mental health symptoms, that is associated stigma. Third, clinicians may have limited time and capacity to accurately assess ADHD symptoms. Limited access or quality of healthcare, particularly among low-income minorities, would limit the data available as more females with ADHD are unreported.

This review increases awareness of ADHD prevalence in females and the factors associated with undiagnosed cases in females. It also highlights the tendency to overlook ADHD in girls during childhood, resulting in a rise in undiagnosed adult females with ADHD symptoms. This study also brings special attention to the negative effects of undiagnosed ADHD among mothers. The results show that there is a common misconception that ADHD is a male centered mental health disorder. Public health professionals can enhance their awareness of the presence of ADHD in females, recognize the diversity in gender differences in symptomatology, address gender bias and gender and racial disparities, and promote education for clinicians on female ADHD for earlier and more effective diagnosis.

Anticipated results show that ADHD is drastically under-detected in females. We anticipate an increase in ADHD diagnosis in females which may be accompanied by a decrease or similar results in postpartum depression. This is due to symptoms commonly associated with postpartum depression that may be related to females trying to cope with undiagnosed ADHD symptoms as well as the beginning of motherhood and the effects of comorbidity with ADHD. The anticipated increase in ADHD diagnosis rates should be met with resources for females, including mothers with ADHD. These resources may include referrals to healthcare providers who can prescribe medication, referrals to psychological counseling, and support groups which can provide necessary social support, and education about what ADHD is and coping mechanisms ²⁶.

We conclude that females are commonly under-referred, underdiagnosed, and undertreated with ADHD, resulting in significant health, social, and economic impacts. The findings call for much greater effort and investments to educate and train teachers, parents, and healthcare and mental health providers in different realms to be more sensitive and vigilant in screening for and diagnosing ADHD among females. Greater investments, training, research, and systems need to be in place. Funding this research would provide the development of necessary education and training for healthcare providers, resulting in better outcomes in females with ADHD.