Understanding ADHD
ADHD is a neurodevelopmental disorder characterised by a persistent pattern of behaviours that interfere with functioning or development (as defined by The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013).
According to a 2018 study conducted by the National Institute for Health and Care Excellence (NICE) in the UK, approximately 3.62% of children and young people aged 5-19 years have a diagnosis of ADHD, with the worldwide figure standing at between 5% and 10% (Barkley, 2014). A meta-analysis of 35 studies (Polanczyk et al, 2014) estimates the global prevalence of adult ADHD to be 2.8%, with the UK having a similar prevalence range. The UK figure is based on a relatively small sample of data collected between 1996 and 2013 and may not accurately reflect the true prevalence of ADHD in the UK. The ADHD Foundation (2019) estimates that up to 5% of school-aged children in the UK may have ADHD, and that many individuals with ADHD may remain undiagnosed or untreated. In 2021, UK experts discussed shortfalls in ADHD service provision in the UK and found under-diagnosis and under-treatment of ADHD (Young et al., 2021).
Symptoms of ADHD can persist into adulthood and do so in up to 60% of individuals diagnosed in childhood, these symptoms been shown to have a negative impact on academic performance - students with ADHD show poor academic outcomes relative to their general cognitive abilities - and occupational functioning, social relationships, and mental health (Barkley, 2015). Moreover, an investigation into the prevalence of ADHD in a sample of male prisoners in England found that 31% met the diagnostic criteria, indicating a higher prevalence than in the general population (Young et al., 2015). Furthermore, research suggests that the prevalence of ADHD in the UK is such that specific populations may be at a higher risk of developing the disorder as evidenced by a study of individuals seeking treatment for substance abuse disorders in which 23% met the ADHD diagnostic criteria (Zulauf et al.,2014).
A Lifelong Condition
The prevalence of ADHD in girls is estimated to be lower than in boys. It is believed that ADHD is underdiagnosed in girls due to the presentation of symptoms that may not fit the traditional diagnostic criteria (Lai, Lin and Ameis., 2022) as girls with ADHD may be more likely to present with symptoms of inattention, rather than hyperactivity and impulsivity (Hinshaw et al., 2022), which are more commonly associated with boys, and exhibit symptoms that are not traditionally associated with ADHD, such as social withdrawal (Rucklidge and Tannock, 2017), anxiety, and academic underachievement.
Girls are less likely to be referred for assessment and treatment for ADHD because they are more likely to internalise or ‘mask’ their symptoms (Hinshaw et al., 2006). This is supported by Brown et al. (2022) who investigated the prevalence of ADHD in a UK primary care population over time, analysing data from 83,318 patients aged 5 - 17 years old, who were diagnosed with ADHD between 2006 and 2016. The results showed that the prevalence of ADHD increased over time, with an overall increase of 1.86% in 2016. The authors also found that boys were more likely to be diagnosed with ADHD than girls, and that the average age at diagnosis was 8.9 years. This is an increase from Sayal et al. (2020) who analysed data from over 5 million patients aged 3-17 years old and found that the prevalence of UK ADHD was 1.4%, with boys more likely to be diagnosed with ADHD than girls.
The Challenges of Finding Effective Treatment
This gender difference in ADHD diagnosis has been reported in other countries, such as the United States (e.g., Visser et al., 2014). Worryingly, Hartman et al. (2019) found that girls with ADHD were less likely to be diagnosed and treated compared to boys with the disorder, even when their symptoms were equally severe. The professional reason for this gender difference is not entirely clear but may be related to differences in symptom presentation, referral patterns, and societal expectations for boys and girls; the diagnostic criteria for ADHD have historically been based on male symptoms.
ADHD symptoms in girls tend to be less overt and more internalised, which can make it difficult for clinicians and parents to identify and address the disorder (Quinn et al., 2014; Nigg et al., 2016). Mowlem et al. (2019) found females with ADHD may be more likely to present with predominantly inattentive symptoms and have fewer comorbidities compared to males with ADHD and Slobodin and Davidovitch (2018) asserted that ADHD diagnosis in females may be complicated by their ability to compensate for symptoms, leading to late diagnosis and increased risk for negative outcomes.
Treatment for ADHD in females may be complicated by comorbidities, hormonal changes, and stigma surrounding mental health and ADHD in females. Quinn et al. (2019) found that females with ADHD were more likely to be diagnosed with anxiety and mood disorders before receiving a diagnosis of ADHD; a study by Charach et al. (2014) found that females with ADHD were less likely to receive medication than males. Moreover, research on ADHD medications has primarily been conducted on males, and there is limited information on the safety and efficacy of these medications in females (Slobodin and Davidovitch, 2018). This is concerning, given that females may metabolise medications differently than males and may experience different side effects. Aagaard et al. (2017) found that stimulant medication was effective in reducing ADHD symptoms in females during puberty, but the optimal dose and timing of medication may differ from that for males. A further study by Quinn et al. (2018) found that females with ADHD reported more negative side effects from medication than males.
Gender Bias
Girls with ADHD are less likely to receive medication treatment compared to boys with ADHD, despite similar symptom severity, highlighting the need for healthcare providers to be aware of the potential for gender bias in ADHD diagnosis and treatment (Zheng et al., 2019; Skogli et al., 2020). Furthermore, girls with ADHD are at a higher risk for impairments in executive function, such as planning and decision-making - which can further impact their academic and social functioning (Sánchez-Mora et al., 2020) - and response inhibition (Rucklidge et al., 2014).
Cognitive functioning is an important area of development during adolescence; adolescents with ADHD may experience difficulties with attention, working memory, and executive functioning (Barkley, 2014) and girls with ADHD may be more likely to experience difficulties with attention and working memory, which may impact their academic performance as well as being more likely to experience difficulties with organisation and planning, which may impact their ability to complete tasks and meet deadlines (Mphahlele, Meyer and Pillay, 2022).
Furthermore, a meta-analysis by Graziano and Garcia (2016) highlighted that girls with ADHD may also experience social difficulties and problems with emotion regulation, which may be linked to impairments in executive functions. Females with ADHD may be more likely to have a history of trauma and adverse childhood experiences compared to males with ADHD (Rucklidge et al., 2014).
We have come some way towards understanding the female experience of ADHD. But, we still have so far to go.
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