Annual Research Review: Attention‐deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions

Abstract

Attention‐deficit/hyperactivity disorder (ADHD) – and its underlying behavioral dimensions of inattention and hyperactivity–impulsivity – have been understudied in females. We first cover the conceptual issues of prevalence, diagnostic practices, diversity, comorbidity, and causal factors, plus forces limiting awareness of ADHD in females. After a narrative review of cross‐sectional and longitudinal findings, we conclude the following. (a) Girls meet diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by adulthood. (b) Girls and women with ADHD show a predominance of inattention and associated internalizing problems; boys and men display greater levels of hyperactive–impulsive symptoms and associated externalizing problems. (c) Sex differences in ADHD symptoms and related outcomes depend heavily on the clinical versus nonreferred nature of the samples under investigation. (d) Females with ADHD experience, on average, serious impairments, with a particularly heightened risk for problems in close relationships and engagement in self‐harm. (e) Clinicians may overlook symptoms and impairments in females because of less overt (but still impairing) symptom manifestations in girls and women and their frequent adoption of compensatory strategies. Our review of predictors and mediators of adult outcomes highlights (a) the potential for heterotypically continuous pathways in females with childhood ADHD and (b) developmental progressions to self‐harm, intimate partner violence, unplanned pregnancy, and comorbid psychopathology. Focusing on ADHD in females is necessary to characterize causal and maintaining mechanisms with accuracy and to foster responsive interventions, as highlighted in our closing list of clinical implications and research priorities.

Incidence of Attention Deficit Hyperactivity Disorder (ADHD) Diagnoses in Navarre (Spain) from 2003 to 2019

“…Gender differences in ADHD diagnosis have also been documented, with girls being less likely to be diagnosed [11]. In childhood, the prevalence of ADHD in boys is 2-2.5 times higher than its prevalence in girls, and by adulthood this ratio becomes closer to equal [12].…”

Serum Interleukin-2 Level in Children with Attention-Deficit Hyperactivity Disorder (ADHD)

“…Regarding residence (p<0.001) (Table 1). Duration Of illness (mean ± SD) 2.5 ± 1.04 ---------Table (1) shows that there was no statistically significant difference between ADHD patients' group and control group regarding age, sex, Consanguinity, family history of ADHD and order among siblings. There was a very high statistically significant difference Regarding residence (p<0.001).…”

“…a Department of pediatrics, Attention Deficit Hyperactivity Disorder (ADHD) is a sustained attention deficit and/or hyperactivity and impulsive behavior patterns that are more severe and more common than it is commonly seen in children and adolescents with similar growth levels (1).…”

ADHD in girls and women: a call to action – reflections on Hinshaw et al. (2021)

“…Externalizing problems, present from an early age in many boys with ADHD, are less likely or later emerging in girls, whereas internalizing problems such as depression and anxiety are prominent, often masking the presence of ADHD in girls and women. Despite these frequent comorbidities, ADHD symptoms in girls are uniquely associated with virtually every domain of impairment-from academic engagement/learning to friendships with peers, strained family relationships, self-concept, vocational achievement and ultimately, suicidal thoughts and behaviours (Hinshaw, Nguyen, O'Grady, & Rosenthal, 2022).…”