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Women and Girls with Attention Deficit/Hyperactivity Disorder:
The Hidden Diagnosis
Attention-Deficit/Hyperactivity Disorder (ADHD), is defined, as a persistent pattern of
inattention and/or hyperactivity-impulsivity that interferes with functioning or development. The
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), does not discuss
symptoms and how they could present differently between males and females. The diagnostic
criteria per the DSM V, is derived mostly from male samples (Kok, F. M, 2016). That doesn’t
mean that more males have ADHD than females, more adolescent boys are diagnosed with
ADHD than adolescent girls, but the number of adult women is nearly equal to that of adult men
diagnosed with the disorder. (Quinn, P. O., 2014). There is research to support that girls present
unique symptoms that boys do not, that would explain why girls have been overlooked and
referred less for diagnosis unless they presented more severe symptoms. There are a few reasons
for those unique symptoms in girls: female gender role expectations, inattentiveness more than
hyperactivity, the internalizing of symptoms, hormones, comorbidity of disorders, and lack of
awareness by clinicians, teachers and parents. (Kok, F. M, 2016) (Littman, E., 2018).
Female gender role expectations are one possible explanation for the lack of referrals for
diagnosis of young girls and the rise in diagnosis of adult women. Girls and women alike are
expected to meet the social normal of “feminine” behavior, they should be empathetic, nice,
accommodating, compliant, good mothers and home organizers (Glaser Holthe M. E., 2017). If
girls deviate from what is socially normal, it is often viewed as more social unacceptable, than it
would be for boys. This is a reason why girls with ADHD sometimes withdrawal from social
interactions and activities. They will do whatever is necessary
can keep from violating those social norms. Since most girls learn to mask their symptoms from
an early age most teachers and even parents miss the early signs of ADHD (Quinn, P. O., 2014).
For adult women as they enter the workforce, get married, and start having children, symptoms
can become more increasingly difficult to mask. They start experiencing increased amounts of
anxiety, depression, and lowered self-esteem, which leads them to seek clinical help, and this
would explain why more adult women are diagnosed with ADHD than young girls (Canela C,
Since there have been more young boys diagnosed than young girls, the diagnosing
criteria contained in the DSM V, have been taken from mostly male samples, this has
unintentionally led to gender bias (Kok, F. M, 2016). The DSM V has two main
categories/criteria for diagnosing ADHD, the first is inattentiveness and the second is
hyperactivity/impulsivity. Girls are more likely to have problems with inattention, these
symptoms are much less disruptive in a classroom or home setting, than hyperactivity and
impulsivity which is more often displayed by males externally. This leads to teachers referring
boys more often than girls for diagnosis. That doesn’t mean that girls are less hyper than boys
when it comes having ADHD, girls tend to internalize their symptoms, more than boys do and
because of the gender differences their hyperactivity isn’t always manifested in the same ways.
The most common symptoms of hyperactivity in females are: hyper-talkativeness, high
arousal, fidgeting, flight of thoughts, internal restlessness, and emotional reactivity (Glaser
Holthe M. E., 2017). The most common symptoms of inattention in females are: forgetfulness,
internalizing symptoms, daydreaming, disorganization, low arousal, impulsivity by the way of
interrupting others, they say may say whatever comes to mind, and suddenly change directions in
life (Glaser Holthe M. E., 2017). These symptoms are usually thought to be signs of emotional
difficulties, disciplinary problems, and learning or attention difficulties, rather than symptoms of
ADHD (Glaser Holthe M. E., 2017) . It is not uncommon for females to be diagnosed with
anxiety or depression and put on an antidepressants before they receive treatment for ADHD
(Quinn, P. O., 2014). The reason for this is because of the ADHD symptoms that females
present, and were discussed previously. An example of this would be a female patient diagnosed
with a persistent depressive disorder, based on symptoms of low arousal, which is also a
symptom that stems from inattention a characteristic ADHD (Quinn, P. O., 2014).. Females may
also present to their clinician symptoms of impulsivity and having unusually high energy and be
diagnosed as being bipolar instead of having ADHD (Quinn, P. O., 2014). It’s this comorbidity
along with the bias of gender that can keep girls and women from receiving the proper diagnosis
of ADHD. According to Quinn, P. O. (2014), “a nationwide survey reported that more young
girls than young boys were treated with antidepressants before receiving ADHD treatment (14%
vs 5%), reinforcing the notion that pharmacotherapy in female patients tends to be targeted
toward non-ADHD conditions” (p.4).
Hormones are another possible explanation for why more women are diagnosed as adults
versus young girls who are often not diagnosed at all. There is an overproduction of dopamine in
boys before and after puberty which may be the cause of hyperactivity (Nussbaum, N. L., 2012).
Once boys mature and enter adulthood there is a 55% decrease in receptor density (Nussbaum,
N. L., 2012). Girls have that same increase in dopamine, but it’s in response to the hormone
estrogen, which is at its highest for girls during puberty (Nussbaum, N. L., 2012). According to
Nussbaum, N. L. (2012), “boys symptoms may be starting to decline, girls symptoms are
beginning to increase and may be part o the explanation for the approximately 3:1 ratio of males
to females in childhood compared with the 1:1 ratio in adulthood” (p. 92).

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