Female presentations of ADHD have been largely overlooked in clinical and research settings (Young et al, 2020). This annual research review covers the issues of prevalence, diagnostic practices, diversity, comorbidity, causal factors and forces limiting awareness of ADHD in females.
The authors concluded from their review that females meet diagnostic criteria for ADHD at just under half the rate for males; however, this disparity reduces by adulthood and the ratio becomes much closer to equal. The authors proposed that females with ADHD have been historically underrepresented because of less overt (but still impairing) symptom manifestations in girls and women, and their frequent adoption of suppressive, compensatory behaviours. Furthermore, the authors found that females are more likely to present inattentive symptoms and associated internalising problems, and highlighted the differences in males, who display greater levels of hyperactive–impulsive symptoms and associated externalising problems.
Another finding of the review was that conclusions about sex differences in ADHD symptoms, impairments and other outcomes are dependent on the referral source, and differ greatly depending on the referral nature of the individuals being investigated. The authors also discussed the impairments of ADHD in females, concluding that females are likely to experience serious impairments regarding major domains in life, which persist from childhood through to adolescence. In particular, the authors noted the prevalence of relationship problems and self-harm in females with ADHD. The authors reviewed potential predictors and mediators of adult outcomes, finding that heterotypically continuous pathways in girls with ADHD, starting from early impulsivity or high levels of inattention, is prominent. In relation to this, the authors highlighted the prevalence of developmental progressions to self-harm, intimate partner violence, unplanned pregnancy and comorbid psychopathology in females with ADHD.
The authors recommended that a thorough, evidence-based assessment is essential in females with ADHD, including behavioural, emotional and learning issues. Within this, they highlighted the importance of developmental histories and the need to evaluate the strengths in the assessment process of females with ADHD. Regarding treatment, the authors suggested that parent and school-based management programmes, promotion of social skills and education around relationships are needed. The authors encouraged future research into the exploration of developmental pathways and causal mechanisms linking female presentation of ADHD to long-term outcomes, in order to further scientific understanding and improve responsive intervention methods.
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Hinshaw SP, Nguyen PT, O’Grady SM, et al. Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. J Child Psychol Psychiatry 2021; Epub ahead of print.
Young S, Adamo N, Ásgeirsdóttir BB, et al. Females with ADHD: an expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry 2020; 20: 404.