How ADHD differs in males and females

Differences or overlaps in symptoms of ADHD

A 2019 study aimed to explore the sex differences in subjective and objective measures of ADHD among children referred to clinics.

The study’s researchers found that certain subjective and objective measures of ADHD may capture different symptoms in males and females. Parents and teachers report that girls have more inattention problems, but objective measures reveal that boys have more serious impulsivity problems.

A 2018 study found that the higher male-to-female diagnosis ratio is seen in clinical samples but not in population samples, suggesting a possible sex bias in the diagnostic process of ADHD.

This research shows that people with ADHD are more likely to receive a diagnosis and treatment when they show prominent externalizing symptoms. This includes females.

Further, research from 2020 corroborates that females are more likely to be inattentive, while males are more likely to have combined symptoms with higher rates of impulsivity and hyperactivity.

Children with ADHD

Roughly 7 million children ages 3 to 17 years in the United States are diagnosed with ADHD.

Doctors diagnose the condition as early as age 3 to 7 years. Often, it lasts into adulthood. ADHD is also three times more common in males than females, and subtypes tend to have a different prevalence.

Due to this discrepancy in the prevalence of ADHD among males and females, researchers have undertaken studies to explore the sex differences in ADHD and the possible cause of the discrepancy.

Sex differences in ADHD remain poorly understood because most previous studies relied on subjective measures of ADHD, a methodology prone to bias. These studies also included a limited proportion of girls.

Evidence suggests that this diagnostic discrepancy and subsequent referral bias is partly due to differences in how ADHD presents in females. According to a 2020 report, females with ADHD display an altered set of behaviors, symptoms, and comorbidities.

Comorbidity

Females with ADHD may experience more significant subjective impairment than males. In a 2016 study, females with ADHD report more severe symptoms of inattention than males.

Males and females also show different patterns of comorbidity, which is when another condition occurs alongside ADHD. Males are more likely to have externalizing disorders, such as:

• substance misuse
• conduct disorders
• antisocial personality disorders

Meanwhile, females are more likely to have internalizing disorders, such as:

• anxiety
• depression
• somatic symptom disorders
• bulimia

Differences in the diagnosis of ADHD across sexes

As males tend to exhibit hyperactive symptoms that may be bothersome and disruptive to others, they tend to receive a diagnosis earlier than females.

Meanwhile, females may not display this inattentive behavior prominently so doctors may miss the condition.

Additionally, inattention symptoms in females with ADHD are more likely to occur in structured educational environments, such as college, which may delay the diagnosis. And females may develop better coping strategies to compensate for their ADHD-related difficulties.

A 2018 study found that ADHD risk is more likely to manifest or be diagnosed as anxiety or depression in females than in males.

As ADHD symptoms are less overt in females, experts are more likely to diagnose them with personality or internalizing disorders, further delaying diagnosis and treatment.

Diagnostic criteria

There is no single test to diagnose ADHD. Instead, a doctor will make a diagnosis after a detailed assessment. This assessment typically involves collecting information from relevant informants, such as parents, caregivers, and teachers.

To receive a diagnosis of ADHD, a child or teenager must have six or more symptoms of inattention or 6 or more symptoms of hyperactivity and impulsivity. These should be present continuously for at least 6 months. They should also be present in two or more settings, such as the child’s home and school. Several symptoms should also manifest before the age of 12 years.

A 2019 study showed that ADHD in girls might need to have more emotional or behavioral problems to meet the full diagnostic criteria of ADHD.

The same study found that parents may also underestimate the severity and impairment of hyperactivity and impulsiveness in girls while overrating these symptoms in boys.

Further, a 2018 study found that females were more likely to show increases in symptoms in early adolescence compared with boys, who may show elevated symptoms from childhood. Therefore, doctors are more likely to exclude girls from diagnosis because of the age of onset criteria.

Treating ADHD

A combination of therapy and parent training for children with ADHD who are younger than 6 years old is typically recommended. For children older than this, doctors may start to recommend medication as part of a treatment plan.

Medical professionals commonly treat a person with ADHD with two types of medications: stimulants and nonstimulants.

Stimulants are the mainstay treatment for ADHD and include amphetamines and methylphenidate. Doctors prescribe nonstimulants to children who cannot tolerate stimulants or have anxiety. These medications include antidepressants and alpha agonists.

Treatments and sex differences

Treatment recommendations only vary by age but do not differ by sex.

Doctors prescribe significantly fewer medications to females with ADHD than males. Medical professionals are also less likely to prescribe medications to females unless they have prominent externalizing issues.

Are medications effective?

In a 2015 study, parents and clinicians reported that girls demonstrated lower symptom severity after receiving methylphenidate than boys. Meanwhile, teachers stated that only the boys improved. These findings suggest that the effectiveness of methylphenidate may vary in different settings, but it also may be a result of gender bias.

Levels of progesterone and estrogen that fluctuate throughout the menstrual cycle also seem to influence the effect of stimulants at different points of the cycle.

Further research needs to explore the effectiveness of treatments and sex differences.

Summary

ADHD affects both males and females. There is a high discrepancy in the prevalence of the condition among males and females.

Many factors can contribute to this, including referral bias, differences in how symptoms manifest in males and females, the effects of hormonal changes, and differences in comorbidity patterns.

These may cause underdiagnosis or misdiagnosis of ADHD in females, leading to a lack of or delayed treatment.

Better awareness and recognition of these differences can help parents, teachers, and medical professionals detect ADHD in girls, allowing them to receive the proper diagnosis and treatment earlier.