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26 Sep 2020

Young S et al. BMC Psychiatry 2020; 20: 404

Sex differences in the prevalence of ADHD have been well established in the literature. Females with ADHD are less likely than males to be identified and receive treatment, leading to poor long-term social, educational and mental health outcomes. Differences in behaviours, symptoms and comorbidities have been noted between females and males with ADHD (Gershon, 2002) complicating diagnosis and referral. The goal of this analysis was to provide guidance to improve identification, treatment and support for girls and women with ADHD across the lifespan.

A group of ADHD clinical experts including nurses, general practitioners, psychiatrists, psychologists and counsellors; as well as academic, educational and occupational specialists attended a meeting hosted by the United Kingdom ADHD Partnership (UKAP). Service users and ADHD charity workers were also represented. Data from an ongoing systematic review on clinical and psychosocial presentation of females in comparison with males with ADHD and epidemiological research of sex differences in self-reported ADHD symptoms in population-based adolescent cohorts were presented. Attendees were divided into breakout groups and discussed the following topics:

  1. Identification and assessment of ADHD in females.
  2. Interventions and treatments for ADHD in females.
  3. Multi-agency liaison.

Key points for detection of ADHD in females: symptoms, comorbidity and associated features

Females with ADHD may present with both inattentive and hyperactive-impulsive symptoms, but the latter may be less severe in females than males. Inattention may manifest as being easily distracted, disorganised, overwhelmed and lacking motivation. In females, symptoms are pervasive and impairing, may become more apparent later in life, and may be influenced by hormonal fluctuations during the menstrual cycle, pregnancy and menopause. Gender-based biases in teachers and parents as well as the less overt nature of ADHD symptoms in females than males may deter or delay referral. Adult women may become aware of their own symptoms leading them to present to primary care.

Comorbid conditions in girls and women with ADHD are more commonly internalised rather than externalised. Externalising conditions such as conduct disorder are more commonly observed in males than females with ADHD (Gaub & Carlson 1997), while internalising disorders such as emotional problems, anxiety and depression are more commonly reported in females (Gershon, 2002; Cortese et al, 2016; Mowlem et al, 2019; Skogli et al 2013; Edvinsson D et al, 2013). Females with ADHD have more general impairments in intellectual functioning than males, and both males and females are at risk of substance use disorders. Internalising symptoms secondary to ADHD or comorbid with ADHD may be misinterpreted as primary conditions. Low mood, emotional lability or anxiety may be especially common in females with ADHD. The experts agreed that ADHD should not be discounted in females because they do not display the behavioural problems commonly associated with ADHD in males.

Features associated with ADHD in females include difficulties with emotional lability and emotional dysregulation. Girls with ADHD may be more vulnerable to social problems and bullying than boys. Females with ADHD tend to become sexually active earlier, have more sexual partners, higher rates of sexually transmitted infections and unplanned pregnancies compared with peers. Antisocial behaviour is also common in females with ADHD. Increased school dropout, academic underachievement, low self-esteem and increased accident rates are observed in girls with ADHD versus their peers. It should be noted that, compensatory behaviours may mask impairments and delay referral. Alcohol and marijuana may be used to cope with ADHD and some girls may join gangs or engage in criminal activities to build social support. The rate of ADHD among prisoners is similar between males and females.

Co-occurring functional problems, features or conditions in females with ADHD

Functional problems in girls and women with ADHD in the educational and vocational settings that may help identify individuals who may require ADHD assessment include frequent detentions, academic difficulties, poor attendance/truancy, low self-esteem, suspensions/expulsions, anxiety related to education transitions, frequent lateness, and difficulties with organisation. Social problems including involvement in bullying, difficulties maintaining relationships with peers, social rejection/isolation and addictive behaviours such as substance use/misuse, gambling and compulsive shopping may also trigger referral. Early sexualised behaviour, risky sexual behaviour, unwanted pregnancy, delinquent or criminal behaviour, financial difficulties and traffic accidents are also features of ADHD in girls. Comorbidities such as language disorder, learning disability, and obesity/eating disorders are additional factors that may trigger referral.

Treatment and support for girls and women with ADHD

The consensus panel agreed that the same medications should be used to treat ADHD in girls and boys. Stimulant medications have demonstrated comparable efficacy in males and females (Sharp et al, 1999). However, girls with ADHD are less likely to be prescribed stimulants than boys with ADHD, and are more likely to start treatment at an older age (Dalsgaard, 2014). Treatment monitoring, psychoeducation with more emphasis on functional and emotional aspects of the disorder and multi-agency liaison should be considered in females with ADHD. Raising awareness and providing education on ADHD in various institutions will help to improve identification of ADHD in girls and women and reduce the stigma associated with this condition.

In summary, this consensus statement informs effective identification, treatment and support of girls and women with ADHD. The panel noted that in order to improve diagnosis of ADHD in girls and women, clinicians must be familiar with the more subtle and internalised presentation of ADHD in females.

Read more about ADHD in girls and women here

Cortese S, Faraone SV, Bernardi S, et al. Gender differences in adult attention-deficit/hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related conditions (NESARC). J Clin Psychiatry 2016; 77: e421-e428.

S, Leckman JF,  Nielsen HS, et al. Gender and injuries predict stimulant medication use. J Child Adolesc Psychopharmacol 2014; 24: 253-259.

Edvinsson D, Lindström E, Bingefors K, et al. Gender differences of axis I and II comorbidity in subjects diagnosed with attention-deficit hyperactivity disorder as adults. Acta Neuropsychiatr 2013; 25: 165-174.

Gaub M, Carlson CL. Gender differences in ADHD: a meta-analysis and critical review. J Am Acad Child Adolesc Psychiatry 1997; 36: 1036-1045.

Gershon J. A meta-analytic review of gender differences in ADHD. J Atten Disord 2002; 5: 143-154.

Mowlem F, Agnew-Blais J, Taylor E, et al. Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms. Psychiatry Res 2019; 272: 765-773.

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.

Sharp WS, Walter JM, Marsh WL, et al. ADHD in girls: clinical comparability of a research sample. J Am Acad Child Adolesc Psychiatry 1999; 38: 40-47.

Skogli EW, Teicher MH, Andersen PN, et al. ADHD in girls and boys – gender differences in co-existing symptoms and executive function measures. BMC Psychiatry 2013; 13: 298.

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