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How ADHD differs in males and

Medically reviewed by Karin
Gepp, PsyD — By Rachel

females
Ann Tee-Melegrito on
October 31, 2022

Differences in children Symptoms Other possible conditions Diagnosis

Diagnostic criteria Treatments Summary

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Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized

by developmentally atypical levels of:

inattention
hyperactivity
impulsivity

This article explores the differences in ADHD symptoms and presentation, diagnosis, and
treatment between males and females.

A note about sex and gender

Sex and gender exist on spectrums. This article will use the terms “male,” “female,”
or both to refer to sex assigned at birth. Click here to learn more.

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Children with ADHD

According to the Centers for Disease Control and Prevention (CDC) , roughly 6 million children
ages 3–17 years in the United States are diagnosed with ADHD.

Doctors diagnose the condition as early as age 3–7 years. Often, it lasts into adulthood. ADHD
is also three times  more common in males than females, and subtypes tend to have a
different prevalence.

Due to this discrepancy in the prevalence of ADHD among males and females, researchers
have undertaken studies to explore the sex differences in ADHD and the possible cause of the
discrepancy.

Sex differences in ADHD remain poorly understood because most previous studies relied on
subjective measures of ADHD, a methodology prone to bias. These studies also included a
limited proportion of girls.

Evidence suggests  that this diagnostic discrepancy and subsequent referral bias is partly due
to differences in how ADHD presents in females. According to a 2020 report, females with
ADHD display an altered set of behaviors, symptoms, and comorbidities.

Read more on the importance of ADHD awareness here.

Differences or overlaps in symptoms of

ADHD
A 2019 study aimed to explore the sex differences in subjective and objective measures of
ADHD among children referred to clinics.

The study’s researchers found that certain subjective and objective measures of ADHD may
capture different symptoms in males and females. Parents and teachers report that girls have
more inattention problems, but objective measures reveal that boys have more serious
impulsivity problems.

A 2018 study found that the higher male-to-female diagnosis ratio is seen in clinical samples
but not in population samples, suggesting a possible sex bias in the diagnostic process of
ADHD.

This research shows that people with ADHD are more likely to receive a diagnosis and
treatment when they show prominent externalizing symptoms. This includes females.

Further, research from 2020  corroborates that females are more likely to be inattentive, while
males are more likely to have combined symptoms with higher rates of impulsivity and
hyperactivity.

Read more about the early signs of ADHD.

Symptoms and comorbidity

Females with ADHD may experience more significant subjective impairment than males. In a
2016 study, females with ADHD report more severe symptoms of inattention than males.

Males and females also show different patterns of comorbidity, which is when another
condition occurs alongside ADHD. Males are more likely  to have externalizing disorders, such
as:

substance misuse
conduct disorders
antisocial personality disorders

Meanwhile, females are more likely to have internalizing disorders, such as:

anxiety
depression
somatic symptom disorders
bulimia

Hormones can also worsen ADHD symptoms in females. These changes in symptoms may
delay diagnosis.

Differences in the diagnosis of ADHD

across sexes
As males tend to exhibit hyperactive symptoms that may be bothersome and disruptive to
others, they tend to receive a diagnosis earlier than females.

Meanwhile, females may not display this inattentive behavior prominently so doctors may miss
the condition.

Additionally, inattention symptoms in females with ADHD are more likely to occur in structured
educational environments, such as college, which may delay the diagnosis. And females may
develop better coping strategies to compensate for their ADHD-related difficulties.

A 2018 study  found that ADHD risk is more likely to manifest or be diagnosed as anxiety or
depression in females than in males.

As ADHD symptoms are less overt in females, experts are more likely  to diagnose them with
personality or internalizing disorders, further delaying diagnosis and treatment.

Diagnostic criteria
There is no single test to diagnose ADHD. Instead, a doctor will make a diagnosis after a
detailed assessment. This assessment typically involves collecting information from relevant
informants, such as parents, caregivers, and teachers.

To receive a diagnosis of ADHD, a child or teenager must have six or more symptoms of
inattention or 6 or more symptoms of hyperactivity and impulsivity. These should be present
continuously for at least 6 months. They should also be present in two or more settings, such
as the child’s home and school. Several symptoms should also manifest before the age of 12
years.

A 2019 study showed that ADHD in girls might need to have more emotional or behavioral
problems to meet the full diagnostic criteria of ADHD.

The same study found that parents may also underestimate the severity and impairment of
hyperactivity and impulsiveness in girls while overrating these symptoms in boys.

Further, a 2018 study  found that females were more likely to show increases in symptoms in
early adolescence compared with boys, who may show elevated symptoms from childhood.
Therefore, doctors are more likely to exclude girls from diagnosis because of the age of onset
criteria.

Find out more about who can diagnose and treat ADHD.

Treating ADHD
The American Academy of Pediatrics Children (AAP)  recommends therapy and parent training
for children with ADHD who are younger than 6 years old. They recommend medications and
behavior therapy in children 6 years and older.

Medical professionals commonly treat a person with ADHD with two types  of medications:
stimulants and nonstimulants.

Stimulants are the mainstay treatment for ADHD and include amphetamines and
methylphenidate. Doctors prescribe nonstimulants to children who cannot tolerate stimulants
or have anxiety. These medications include antidepressants and alpha agonists.

Read more about ADHD medications here.

Treatments and sex differences

Treatment recommendations only vary by age but do not differ  by sex.

Doctors prescribe significantly fewer  medications to females with ADHD than males. Medical
professionals are also less likely to prescribe medications to females unless they have
prominent externalizing issues.

There has been a 344%  increase in privately insured females filling their prescription
medications for ADHD from 2003–2015. This data implies that females are finally receiving a
diagnosis of ADHD and receiving prescriptions.

Are medications effective?

In a 2015 study , parents and clinicians reported that girls demonstrated lower symptom
severity after receiving methylphenidate than boys. Meanwhile, teachers stated that only the
boys improved.

These findings suggest that the effectiveness of methylphenidate may vary in different settings,
but it also may be a result of gender bias.

Levels of progesterone and estrogen that fluctuate throughout the menstrual cycle also seem
to influence  the effect of stimulants at different points of the cycle.

Further research needs to explore the effectiveness of treatments and sex differences.

Summary
ADHD affects both males and females. There is a high discrepancy in the prevalence of the
condition among males and females.

Many factors can contribute to this, including referral bias, differences in how symptoms
manifest in males and females, the effects of hormonal changes, and differences in comorbidity
patterns.

These may cause underdiagnosis or misdiagnosis of ADHD in females, leading to a lack of or

delayed treatment.

Better awareness and recognition of these differences can help parents, teachers, and medical
professionals detect ADHD in girls, allowing them to receive the proper diagnosis and
treatment earlier.

Last medically reviewed on October 31, 2022

ADHD / ADD

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