Some research shows that the diagnosis rate of ADHD in males is as much as nine times higher than it is in females. But, there’s an increasing amount of research that suggests the prevalence of the disorder is about the same in males and females. So what’s the explanation for this glaring disparity? Why are medical professionals disproportionately under-diagnosing ADHD in the female population? Research shows that stereotypes, misconceptions and a lack of understanding about gender-specific symptoms are to blame.
As defined by the DSM-5, attention-deficit/hyperactivity disorder is “a common neurobehavioral disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity.” It’s long been thought of as a predominantly male disorder; a national survey found that 58% of the general public and 82% of teachers believe that ADHD is more prevalent in males. That same survey found that four out of ten teachers admit they have a harder time recognizing ADHD symptoms in girls than they do in boys.
The Primary Care Companion for CNS Disorders, a medical journal in the National Library of Medicine, reviewed over forty clinical studies and journal articles to uncover the reasons for why these misconceptions and diagnostic errors exist. The findings concluded that the symptomatic presentation of ADHD in women and girls is distinctly different than the symptomatic presentation in men and boys, and the typical symptom profile that teachers use for referrals and doctors use for diagnosis is directly aligned with the male symptomatic presentation profile.
The common symptoms of ADHD are divided into two categories: externalized and internalized. The review found that males typically exhibit more externalized symptoms such as impulsiveness, hyperactivity and overt aggression, very often resulting in classroom disruption, low academic achievement and frequent disciplinary issues. These symptoms are rarely overlooked by teachers and generally always result in referral for testing because they’re obviously quite difficult to fail to notice.
Females, however, are far more likely to present with internalized symptoms like inattentiveness, anxiousness and compulsive behaviors, all of which are also common symptoms of an anxiety disorder and often get misdiagnosed as such. The covert aggression that more frequently presents in females manifests as aggression turned inward, resulting in symptoms like low self-esteem and poor self-image, both of which often get misdiagnosed as depression. The review also found that women and girls are more likely to develop coping mechanisms for managing their ADHD than men and boys are, so satisfactory academic performance is not always an indicator for excluding the possibility of ADHD in females.
Since anxiety and depression share some key symptoms with the presentation of ADHD in women and girls, it definitely complicates the clinical process of diagnosing which disorder a female patient is suffering from. But ADHD isn’t actually that hard to rule out with testing, especially now because the testing process has gotten a lot more refined and comprehensive in the past decade. I experienced the modern method of ADHD testing fairly recently, and it consisted of a grueling eight-hour session of IQ/cognitive testing and continuous performance testing, some of which was computerized while the rest was done with blocks, pencils and paper like it was ten years ago.
Mood disorders like anxiety and depression typically have a much less comprehensive diagnostic process. Generally, a psychiatrist, psychologist or even just your primary care physician will conduct an hour-long interview session with you and maybe have you fill out a few self-reporting questionnaires. Based on the doctor’s brief evaluation of your responses, you could be leaving the office just one hour since you arrived with a diagnosed mood disorder and an antidepressant prescription.
The root of the problem is that stereotypes and misconceptions held by parents, teachers and primary care physicians about ADHD symptomatic presentation prevent women and girls from ever getting a testing referral. So, they go to see a psychiatrist about issues they’re having with organization, academic success or interpersonal relationships, and walk away with a misdiagnosed mood disorder.
If you’ve been diagnosed with an anxiety disorder or depression and prescribed medication like an SSRI or MAOI and feel like it’s not helping at all, or maybe even making life harder for you, talk to your doctor about an ADHD testing referral. It’s definitely something that’s worth ruling out because stimulant medications prescribed for ADHD cause a completely different reaction in your brain than antidepressants. So if that’s the chemical reaction that your brain is missing, it could be completely life-changing for you to finally get the correct answer for your problems with cognitive and executive functioning.