6 Reasons for Misdiagnosis of ADHD in Women
Despite the increased attention on women with ADHD, underdiagnosis and misdiagnosis of ADHD in women remains a significant concern.
6 reasons Women can be Misdiagnosed or Underdiagnosed with ADHD
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Reporting bias can result in fewer diagnoses
Gender-biases can infiltrate diagnostic biases. A critical part of receiving an ADHD diagnosis in childhood is reliant on impairment and symptoms presentation in several settings, such as school. However, studies suggest that parent and teacher reports are more likely to over-rate boys symptoms of ADHD and under-rate girls symptoms of ADHD (Mowlem et al., 2019). An ADHD diagnosis requires symptoms to be present in multiple settings and that may not be the case for girls, especially if teachers are underreporting symptoms.
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Less hyperactivity and impulsivity can result in fewer referrals
Women are less likely to display overt symptoms of hyperactivity and impulsivity than men. Inattentive symptoms of ADHD, without hyperactivity and impulsivity, are generally less disruptive and result in fewer referrals (Hinshaw et al., 2022).
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Symptoms can onset or worsen later in development
Women are more likely to see an increase or onset of hyperactivity or impulsivity symptoms later than men. For men, hyperactivity or impulsivity symptoms commonly onset in childhood, whereas there is a larger rise in these symptoms for women around puberty (Murray et al., 2019). This may be one reason that the largest sex/gender difference in diagnosis is within childhood.
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Gender biases can influence symptom presentation
Gender biases can influence the presentation of symptoms from a young age. For example, women are more likely to internalize their hyperactive symptoms (e.g., restlessness, fidgeting, but remain seated), which can result in less overt or disruptive behavior (Young et al., 2020). Gender bias can also influence perception of hyperactive symptoms. Women are more likely to verbalize and men are more likely to physicalize their overactivity (Young et al., 2020). Stereotypes presume girls/women are more social, so “excessive talking” or giggling (hyperactive symptom) can be missed in women (Mowlem et al., 2019).
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Comorbidities can mask ADHD symptoms
Many symptoms of ADHD are shared across other mental health disorders and therefore differential diagnoses can be difficult. Women are also more likely to be diagnosed with a comorbid anxiety or depression disorder, which can mask symptoms of ADHD and be misattributed to another disorder. For example, inattention can also be a symptom of anxiety or depression (Hinshaw et al., 2022).
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Compensatory strategies mask symptoms
Women are more likely to have developed compensatory strategies to cope with their symptoms of ADHD (Young et al., 2020). From the outside, this may look like being very orderly, neat, or an overachiever. However, maintaining that level of organization or success can be overwhelming and take a lot of effort.
Advocating for Proper Evaluation
It’s important for women and their loved ones to be proactive in seeking an accurate evaluation when ADHD is suspected. Initiating conversations with healthcare providers and advocating for thorough assessment can help bridge the gap in understanding and ensure that women with ADHD receive the support and treatment they need to thrive.
Note, while this article predominantly discusses differences in terms of men and women, it is important to note that there are both sex and gender influences on ADHD presentation. Scientific papers vary on which term they use. There is a significant gap in scientific research on ADHD symptoms for individuals that do not identify with their sex assigned at birth.
About the Author
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Jessica E. Flannery, PhD is the Associate Director of Clinical Science at Akili. She is a clinical licensed psychologist, an ADHD-Certified Clinical Services Provider (ADHD-CCSP), and a developmental social neuroscientist. She has published over 50 peer-reviewed articles, received prestigious fellowships and awards and is a prior TEDx speaker.
