Understanding the Underdiagnosis of ADHD in Girls

By: Maya Mazumder
Edited by: Priya Gajjar

More boys are diagnosed with ADHD than girls. This is a well-established fact among researchers, with some estimating as much as a 10:1 ratio in the rates of clinical diagnosis. However, there is far less understanding of why such a striking pattern persists. For many years, doctors and psychologists simply viewed this as an aspect of the condition, characterizing the disorder as something primarily affecting grade-school boys who have difficulty sitting still and staying focused. Recent research suggests that it is not the case that ADHD only affects boys. It has become increasingly clear that both the perception and diagnostic criteria of ADHD have led many girls to go undiagnosed for years, often with massive repercussions. ​

DSM-V and DSM-IV criteria for ADHD. Link to source: https://www.researchgate.net/figure/Comparison-of-the-Diagnostic-Criteria-for-ADHD-DSM-5-and-DSM-IV-TR_tbl1_317396322

One of the main factors contributing to the gap in diagnosis is that symptoms of ADHD  manifest differently in girls, usually with less emphasis on the hyperactivity aspect, and more on inattention. Essentially, girls are less likely to fit the typical archetype of ADHD, exhibiting fewer symptoms of aggressive and impulsive behavior, and instead internalizing their dysregulated attention and emotions. Girls with inattentive type ADHD may be described as spacey or prone to daydreaming, both traits that are far less disruptive than the hyperactivity typical of boys, and therefore more difficult to detect. Even if a girl suffers from the same impairment that a boy does, if she does not present externally, her struggle is more likely to fly under the radar and go untreated. Additionally, the DSM-IV, the diagnostic manual used for psychological disorders, describes ADHD symptoms in a way that several studies have demonstrated is biased towards boys. Even if a girl suffers from ADHD and is referred to be evaluated, she is more likely to score lower than a boy on diagnostic criteria, further contributing to the gap in diagnosis and treatment.

​Furthermore, girls with ADHD often suffer from other psychological disorders like anxiety and depression. The presentation of these comorbid conditions can mask ADHD symptoms, and make the disorder more difficult to identify. It is unclear whether untreated ADHD can lead to feelings of anxiety and depression or if there is just a correlation, but it seems that all three are intertwined in some way. ADHD can affect people more broadly than just in a classroom setting, and girls with ADHD exhibit lower self esteem and often struggle with social skills and maintaining relationships. ADHD is much more than a struggle to focus, and impacts almost every area of one’s life, which is why it is so critical to rectify the underdiagnosis of girls.

The  general misunderstanding of ADHD as a disorder is also related to the underdiagnosis of ADHD in girls. Rather than simply a lack of attention, ADHD is a dysregulation of attention. People of all genders with ADHD struggle to shift and focus attention, especially on tasks that seem uninteresting, and can also struggle to regulate emotions. Someone with ADHD may have difficulty sitting still in class, but they may also work on an interesting project for hours and be unable to stop. Rather than focusing on ADHD as a disorder primarily affecting students, it is better to think of it as something that affects people of every age in multiple domains of life. 

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