Underdiagnosis of ADHD in Adult Women: Uncovering the Impact of Gender Bias

ADHD has historically been viewed as a predominantly male disorder, and that bias continues to this day. The underdiagnosis of ADHD in adult women, and the lack of awareness that they may need different treatment approaches, is an ongoing medical equity issue with serious consequences. Decades ago, researchers in Scandinavia reported that undiagnosed females had much worse outcomes than did their undiagnosed male counterparts, with higher rates of suicide attempts and psychiatric hospitalizations.

Patricia Quinn, M.D., and I coauthored two groundbreaking books nearly a quarter-century ago, Understanding Girls with ADHD and Understanding Women with ADHD, and yet there has been, disappointingly, little new research in the intervening years. An entire generation of females with ADHD has been born and reached adulthood since our books were published.

The recognition of inattentive ADHD has led to the diagnosis of more females. And we’ve gradually learned that combined-type females may present in unique ways; for example, being hypertalkative rather than physically hyperactive, or verbally impulsive rather than physically impulsive. Unfortunately, the diagnostic criteria for ADHD have barely changed over the decades, resulting in the continuing underdiagnosis or misdiagnosis of girls. Recent graduates from well-regarded child psychiatry fellowships have reported to me that they were not taught about any gender differences in ADHD.

Similarly, teachers don’t receive adequate training in identifying ADHD in students. One study found implicit bias among educators: In the experiment, educators were given written descriptions of fictional elementary school students with ADHD symptoms. They were much more likely to refer the male students for an ADHD assessment rather than the female students.

In the mid 1990s, following the sudden and widespread recognition of adult ADHD, several universities opened adult ADHD clinics and noted that more females than males sought diagnosis and treatment. Some attributed the gender gap to women being generally more comfortable seeking a mental health diagnosis. While this may be true, I propose another reason: Women finally had the opportunity to seek an assessment—and seek it they did!

We now know that fluctuating female hormones worsen ADHD symptoms, yet this important issue is largely neglected. Gynecologists are not educated about ADHD; psychiatrists don’t study the effects of female hormones on the condition; and many females feel minimized and mistreated.

Social challenges are also formidable for females. Stephen Hinshaw, Ph.D., a professor of psychology at the University of California, Berkley, is shining a light on females who have ADHD with his research. In one study, Hinshaw observed the social interactions of girls with and without ADHD at a summer day camp. He found that the girls with ADHD were either ignored or excluded by their peers. We need to focus more on treatment to address these painful social struggles among this group.

Today, females with suspected ADHD are better informed and more likely to seek diagnosis, but very little attention has been paid to their unique challenges and their different treatment needs.

We’ve come a long way, baby, but we’ve still got far to go.

Kathleen Nadeau, Ph.D., is the founder and clinical director of the Chesapeake ADHD Center of Maryland. She and Patricia Quinn, M.D., shared the CHADD Hall of Fame Award in 1999 for their groundbreaking work on women and girls with ADHD.

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