Universal Design for Learning: Supporting Females with Undiagnosed Attention Deficit

Hyperactive Disorder
Literature Review

Alyssa Faiczak
Department of Curriculum, Teaching and Learning, OISE
CTL 7006: Research I
Dr. Kyoko Sato
February 13, 2022

Word Count: 4124

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Introduction

Attention hyperactive deficit disorder (ADHD) is a common neurodevelopmental

disorder (CDC, 2021; Polanczyk et al., 2014). ADHD relates to debilitating issues with

impulsivity, hyperactivity, and inattention (Quinn & Madhoo, 2014). ADHD has, until recent

years, only been considered by the symptoms of young males (Quinn & Madhoo, 2014).

Considering the long standing sexism in medicine and medical research (Keville, 1993), this is

no surprise. Females and males, described on the basis of biological sex, are different in internal

and external anatomy, hormone cascades, and chromosomal composition (Ngun, et al., 2011).

This biological difference leads to significant differences when considering health and medical

treatment. As such, we now know that females often present with different ADHD symptoms

than do males (Quinn & Madhoo, 2014). With ADHD diagnosis criteria based on the symptoms

of young males (Coles et al., 2010; Ohan & Johnston, 2005), females with ADHD are not getting

diagnosed properly and therefore not receiving the treatment and support they need. One

important consideration for ADHD is that it negatively affects academic performance

(Biederman et al., 1999; Breslau et al., 2011; Fleming et al., 2017). While ADHD treatment can

improve academic performance (Jangmo et al., 2019), females do not always have access to

treatment as they are often not diagnosed. As teachers, we aim to support our students and

address their varied needs. However in the case of females with ADHD, their needs will not

always been known to us as their presentation of ADHD symptoms are overlooked and not

diagnosed. Here lies the problem: how can we as teachers help students who are experiencing

academic barriers that are not diagnosed? In my research, I aim to explore classroom strategies

that will leverage the universal design for learning so that female students with undiagnosed

ADHD can be better supported while non-ADHD peers benefit as well. I will use research from
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medical journals, psychiatry and psychology journals, and educational research databases to

support my literature review.

Positionality Statement & Sex Disclaimer

I am a female with ADHD. I have the combined presentation, inattentive and hyperactive,

with a higher presentation of the inattentive type. I was not diagnosed until adulthood. I have

suffered from anxiety, depression, self-harm, and multiple eating disorders as comorbidities. I

struggled in school until symptom masking which is commonly observed in females begun in

Grade 6. At this point I had high levels of academic achievement, furthering the case for my

ADHD to be overlooked. I am Caucasian and from a middle class socioeconomic background. I

would like to acknowledge the privileges I have experienced in dealing with my situation that

came as a result. These include but are not limited to access to diagnoses programs and access to

medication and treatment. Being a female who experienced the difficulties of academics with

undiagnosed ADHD, I hope to add to the research field as a member of the affected group. I

acknowledge the conflict of interest of my positionality being rooted directly in the research

topic, but would also like to mention the value that exists in having the voices of the affected

group contribute to the research.

In this review, I examine ADHD in females and look differences between the male and

female populations. Here, male and female are used to refer to biological sex, not gender, gender

identity or gender expression. Biological sex refers external and internal anatomy differences,

hormonal differences, and chromosomal differences that exist between males and females (Ngun

et al., 2011).
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What is ADHD?

Attention Deficit Hyperactive Disorder (ADHD) is a neurodevelopmental disorder that

impairs focus and impulse control in a debilitating way (CDC, 2021). Common symptoms of

ADHD include impulsiveness, difficulty prioritizing tasks, disorganization, time-

blindness/difficulty managing time, restlessness, frequent and extreme moods swings, difficulty

following through and completing tasks, trouble coping with stress, and difficulty focusing on

tasks (Mayo Clinic, 2019). Meta-analysis studies have found that an average of 5% of the

population worldwide have ADHD (Polanczyk et al., 2014). There are many stigmas around

ADHD. Mueller et al. (2021) summarize common stigmas as, “… an underestimated risk factor;”

essentially the questioning of the validity of the disorder based on the perception that ADHD is

not a real disorder. This stigmatization affects, “treatment adherence, treatment efficacy,

symptom aggravation, life satisfaction, and mental well-being of individuals affected by

ADHD,” (Mueller et al. 2021). While stigmas underestimate risks associated with ADHD, there

are very real risks observed. ADHD is associated with negative life outcomes such as increased

crime and delinquency, poor academic performance, substance abuse disorders, financial

difficulties, and mood disorders including depression, anxiety, and bipolar disorder (Faraone et

al., 2021). As well, accidental injury causing death, suicide, and homicide against individuals

with ADHD are 2-fold higher in individuals with ADHD compared to non-ADHD individuals

(Chen et al., 2019). ADHD is a real and debilitating neurodevelopmental disorder affecting about

5% of the population globally (CDC, 2021; Polanczyk et al., 2014; Sayal et al., 2018). Despite

the challenges, proper diagnosis, treatment, and support can lead to improved symptoms and

quality of life (Faraone et al., 2021).

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Sex Bias in Medical Research

Women have historically been excluded from medical research. This has lead to gross

oversights in understanding women’s health and ultimately putting women at risk. Consider as

an example that since the early 1900s, heart disease has been among the top causes of death in

America (Dalen, 2014). To address this so called ‘silent killer’ now famous research was

conducted to ameliorate medical interventions for heart disease. Notably, the studies that

examined the use of aspirin to prevent heart attacks, the link between caffeine and heart disease

and relation of cholesterol levels and heart disease were conducted; all of which had 100% male

participants (Palca, 1990). This is just one of an endless list of examples of female exclusion

from medical research that put female’s health at risk. When considering females and males on

the basis of biological sex, they differ on internal and external anatomy, hormonal regulation,

and chromosomal composition (Ngun, 2011). As such, both male and female participants should

be considered in medical trials since findings for one population may or may not be true for the

other. Yet there is a distinctive and intentional exclusion of female participants in medical

studies, going so far as to exclude females in animal models as well. The two main reasons for

exclusion of females from medical studies are; one, that the menstrual cycle makes research too

difficult, and two, that females might become pregnant during the course of the study. As argued

by Keville in her 1993 report, the first reason implies that women’s health is not important

enough to expend the effort and the second argument reduces women to their reproductive

abilities, excluding all women outside of reproductive ages, excluding all women at any time not

with child, and de-validating a women’s ability to make decisions about her own body (Keville,

1993). It was not until 1986 that the National Institutes of Health (NIH) put out a policy that

encouraged the inclusion of women in medical research by their grant recipients (Palca, 1990).
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This policy did not mandate female inclusion, it only asked for a statement to be present

explaining the reason for excluding females in a study (Keville, 1993).

Today, we see that gradual progress has been made in terms of inclusion of females in

medical research. Much more is needed to be done, and knock down effects are seen in the

medical system today. ADHD is one disorder where the male-biased research has impacted the

female population’s access to diagnoses, treatment, and support. As a result, today we see a

significant underdiagnoses of ADHD in females, with diagnosis in boys being 2 – 9-fold higher

compared to girls (Nussbaum, 2011). It is worth mentioning that the dismissal of medical

concerns expressed by females (Munch, 2006) likely contributes to the lower diagnosis rates as

well. In the following section, we will examine sex based differences in ADHD symptoms and

how they contribute to the significant differences in male-female ADHD diagnoses.

Symptoms, Diagnosis and Treatment: The Sex Based Gap

ADHD is now known as having three main types; hyperactive, inattentive and

combination, which is a mix of both hyperactive and inattentive. Males and females can have

any of the three types, however there is a sex bias observed in symptomology. This includes a

higher degree of externalized symptoms in males, namely hyperactivity, impulsiveness, and

aggression, categorized as the hyperactive type; and a higher degree of internalized symptoms in

females, inattentiveness and mood disorders including depression and anxiety, categorized as the

inattentive type (Quinn & Madhoo, 2014). It is the externalized symptoms presented in the male

ADHD population that gain attention of adults and lead to diagnoses, treatment, and support

(Coles et al., 2010).

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This image of a hyperactive young boy is the caricature to which all individuals with

ADHD are assessed. Externalized symptoms representative of young boys have been the

benchmark against which females were diagnosed (Ohan & Johnston, 2005), leading to severe

underdiagnoses in females (Gaub & Carlson, 1997). In fact, many academic reports will claim

that ADHD is more common in males due to the diagnosis ratio of males to females ranging

form 2:1 – 9:1 (Gaub & Carlson, 1997; Ramtekkar et al., 2010). Beyond externalized symptoms

in males, different expectations based on sex inhibits that likelihood that females will be referred.

A study provided teacher and parent participants with a synopsis of a child exhibiting ADHD

symptoms. Some used a male name for the child while other used a female name for the child.

Participants were less likely to recommend support services when the synopsis used a female

name compared to when it used a male name (Ohan & Visser, 2009).

ADHD comorbidities common among women include depression, anxiety, low self-

esteem, impaired academic performance, higher drop out and teen-pregnancy rates, substance

abuse and eating disorders (Quinn & Madhoo, 2014). Further, the inattentive subtype which is

more common in females, is, “…more strongly associated with academic impairment, low

self-esteem, negative occupational outcomes, and lower overall adaptive functioning,”

(Faraone et al., 2021). Females tend to develop better coping mechanisms compared to males

that mask their symptoms (Quinn & Madhoo, 2014). Overall, the less disruptive symptoms,

better coping mechanisms, gender-biased assessments, and overdiagnosis of comorbidities in

females all contribute to the underrepresentation of females in ADHD diagnoses. This

considered, it is my opinion that ADHD might not be more common in males but rather more

easily diagnosed in males.

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ADHD and Academic Performance

Among the many symptoms, ADHD affects academic performance. Breslau et al. (2011)

found that students with ADHD were twice as likely as non-ADHD students to take longer to

graduate high school in the U.S.. In a Scottish study, Fleming et al. (2017) found that school

aged children with ADHD were 3-times as likely to have low academic achievement and 2-times

as likely to drop out of school before the age of 16 compared to their non-ADHD peers. Further,

a study by Biederman et al. (1999) found that females with ADHD were more likely to have

lower IQ and achievement scores and more impaired functioning in school compared to females

without ADHD.

Females with ADHD were found to suffer more from self-esteem issues (Rucklidge &

Kaplan, 1997). Considering the link between self-esteem and academic achievement (Aryana,

2010), there is likely a negative self-perception of academic abilities in females with ADHD.

Although some studies have found that ADHD treatment can help improve academic difficulties

observed in individuals with ADHD (Jangmo et al., 2019), we have also seen how diagnosis of

ADHD in females in not as prevalent as it needs to be. This limits the option for academic

improvement via ADHD treatment for females.

Research Directions: Universal Design: ADHD in Girls Approach

There is a long standing connection between ADHD and teachers, with many diagnoses

arising from classroom issues and/or teacher referrals (Ohan & Visser, 2009). This relationship

has and continues to be centred around diagnosing young males (Quinn & Madhoo, 2014). Due

to the internalized presentation of ADHD symptoms common in females, the lack of widespread

education on female ADHD and the more easily identifiable comorbidities of female ADHD,
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suggesting that we as teachers get better at spotting female students with ADHD is beyond the

scope of our role as teachers in the present landscape. Even if properly identified, access to

diagnoses, treatments and support is not always available to all students. Undiagnosed and

unsupported ADHD negatively impacts academic performance (Biederman et al., 1999; Breslau

et al., 2011; Fleming et al., 2017). Not only is this detrimental to access to further academic and

work opportunities, but it is associated with higher rates of dropping out of school and lower

self-esteem (Biederman et al., 1999; Breslau et al., 2011; Fleming et al., 2017). With a global

estimate of 5% of the population having ADHD (Polanczyk et al., 2014; Sayal et al., 2018), it is

probable that you will have at least one student with ADHD in a regular sized class (20-30

students).

As teachers, we want to support our students and address their varied needs. There is

literature that looks at teaching strategies to support learners with ADHD; Miranda et al., 2006;

Carbone, 2001; are some examples, among others. Some of the suggested interventions are male-

symptom focused while most to all interventions are diagnosis dependant. Without equitable

access to diagnoses in females, these strategies are not helpful. The result is that female students

with undiagnosed ADHD struggle academically and likely develop a negative self-image in

academics.

As teachers, we cannot take on the role of psychiatrist or medical professional and

address the sex-bias in ADHD diagnosis. What we can do as teachers is make changes to our

teaching practices in and effort to support all types of students. I want to examine ways that we

can use a universal design for learning as explained in the learning for all document

(Government of Ontario, 2013) as a framework to help female students with undiagnosed

ADHD. Universal design for learning (UDL), “…accommodates people with disabilities, older
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people, children, and others who are non-average, in a way that benefits all users.” (OWP/P

Architects et al., 2010). I want to investigate what teaching strategies could make academic

achievement more accessible to females with undiagnosed ADHD while simultaneously helping

their non-ADHD peers. The underlying goal of these strategies is to help students see that they

are capable and provide additional supports in areas where their disorder may cause them

difficulties, even in the absence of a diagnosis.

Considerations: Age & the Pandemic

Age Specificity of Research

Particular struggles with ADHD symptoms change as individuals age. For example, at the

onset of adolescence hyperactivity reduces but inattention remains a consistent barrier (Faraone

et al., 2006). The strategies I will examine will be targeted to benefit students in grades 7-12,

ages 12-18, when more academic autonomy is expected.

Learning for All: Considering the Pandemic

It is evident that technology is becoming increasingly embedded in our daily lives. The

use of screens has increased dramatically since the start of the COVID-19 pandemic in early

2020. One study found that adolescent’s screen time before the pandemic was on average 3.8

hours/day (Ngata et al., 2022). A year later in late 2021, average adolescent screentime had

jumped to 7.7 hours/day (Ngata et al., 2022). While we cannot predict how screen time averages

will change in the aftermath of the pandemic, the reliance on technology for entertainment, social

connectedness and support of everyday tasks point to the likely continuation of high screen times

(Ngata et al., 2022). A study by Twenge & Campbell (2018) found a connection between high

screen time (defined as 7 or more hours a day) and a myriad of issues including distractibility,
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lower self control, reduced emotional wellbeing and difficulty completing tasks. These

symptoms overlap directly with symptoms of ADHD that limit academic performance. Thus,

considering that increased screen time has been observed during the course of the pandemic and

that increased screen time has been found to manifest personal outcomes that mirror ADHD

symptoms, a UDL for students with undiagnosed ADHD has a high likelihood of benefiting non-

ADHD peers in today’s landscape.

Most support strategies in existing literature address specific symptoms. Following this

structure, my UDL will be designed to address symptoms common in females with ADHD.

Below are my preliminary recommendations for a UDL for females with undiagnosed ADHD.

These recommendations were made based on sifting through suggestions made for students that

have diagnoses, research on symptomology, evaluating the legally mandated accommodations

that must be made available if requested by students with ADHD, and based on my personal

experience as a female who went through school with undiagnosed ADHD. Benefits for ADHD

students and non-ADHD peers are explained.

1. Establish Routines. People with ADHD have trouble getting organized and staying on task

(Ougrin et al., 2010). Having an established classroom routine can help take some guess work

out of the day and cue students for the learning tasks ahead. Classroom routines are regarded as

being beneficial for all students (Woolfolk et al., 2020, pp. 348-392).

2. Break Down Larger Tasks. Task prioritization and time management are difficult for people

with ADHD (Quinn & Madhoo, 2014). When there is a big assignment, breaking it into steps

where the steps are due at intervals spaced over time can provide the structure needed to manage

time and prioritize sub-tasks in an assignment. Smaller tasks can help alleviate overwhelm and

produce higher quality work in non-ADHD peers (Cheng et al., 2015).

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3. Provide Options. When giving an assignment, providing options on how that assignment can

be submitted will gain more authentic engagement from individuals with ADHD. Having options

in how assignments are curated can be an entry point for ADHD students as they can add a part

of themselves to academic work. ADHD involves deregulation in dopamine pathways,

commonly referred to as reward pathways (Ougrin et al., 2010). This puts ADHD individuals in

constant search of dopamine, in search of that rewarding feeling. Rigid assignments might not

trigger reward centres of the brain, but approaching an academic task in combination with a

personal interest can activate reward centres and draw on intrinsic motivation. The choice to

combine personal interest with academic content is a buy-in element that promotes investment in

academic activities for all students and is a suggested practice for critically relevant/responsive

pedagogy (Jackson & Boutte, 2018).

4. Use Visual Cues. ADHD can manifest as stimulation seeking behaviours (Anthrop et al.,

2000). Further, ADHD is associated with working memory issues, commonly observed as

forgetfulness (Beck et al., 2010). In the classroom, this can mean that listening on its own might

not be enough. Some ways to provide additional stimulation and help students remember key

information are the use of visual aids in lessons, posting the learning goals for the unit in the

classroom, using colours or colour coding systems in class or content organization, posting the

class schedules, class rules, homework and due dates. Physical classroom design and visual cues

are psychologically important for all types of people and students (Barrett et al., 2015).

5. Interactive Class Participation. Building on the idea of stimulation, class participation can be

made to be interactive and foster more engagement. This idea tackles the inattention that

accompanies many individuals with ADHD and prevails as a common symptom even as

individuals age (Faraone et al., 2006). Some ways to do this is to have students write out their
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solutions to class questions on individual whiteboards, use programs like Plickers, or do a class

blast where everyone shouts out their answer in unison.

6. Reduce Potential Distractions. For many people, when our house is messy, our head space

cluttered and distracted as well. People with ADHD are easily and uncontrollably distracted

especially by their environment (Quinn & Madhoo, 2014). Limiting clutter, keeping the

classroom organized, having rules about the use of personal electronics and volume in the class

and creating intentional seating arrangements can help to reduce distractibility. Considering that

we have observed increased screen time over the years and expedited by the pandemic (Ngata et

al., 2022) and that studies have found high screen time leading to increased distractibility in

school aged children (Twenge & Campbell, 2018), reducing distractions is helpful to all students

in a class.

7. Allow for Movement. ADHD has an element of hyperactivity (Ougrin et al., 2010). Although

the hyperactive element reduces with age (Faraone et al., 2006), there is still a significant amount

of excess energy in ADHD students. It can take a lot of focus to sit still and contain the energy,

focus that could be otherwise directed to pay attention to the lesson. By working in opportunities

for students to move, by having group work, scheduled community walks, DPA, learning

centres, or tactile projects that use your hands (art or building projects for example), motion can

be leveraged to create meaningful engagement.

8. Support Mental Health and Wellbeing. Females have a high occurrence of anxiety and

depression as comorbidities of ADHD (Quinn & Madhoo, 2014). Adolescents in general have

high rates of mental health issues (Ghandour et al., 2019) as they navigate coming of age in

tangent with societal and personal life issues. Taking time to address mental health is important

for the care of students. It is also helpful to create mental space for more effective learning. We
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can address and support mental health of students in many ways. Some examples include class

mediations, journaling activities, dedicated classroom time and spaces for sharing/discussion or

establishing class rules allowing students to take what they need; listen to music, take a walk or

put your head down when needed.

Preliminary Ideas for Methodology

Taking into consideration the options available for conducting research in the masters of

teaching program at OISE, I feel that my research would be best suited to the interview option. I

would like to interview teaching professionals that have experience with female students with

ADHD. I want to learn what strategies work well for them and inquire about which strategies

could be made universal and benefit the whole class. I would be happy if the parameters of what

is allowed in our research would permit me to have teachers who have female student(s) with

ADHD in their class use one or more of the strategies I have outlined above and then answer

follow up questions about how the strategies affected academic engagement and performance of

all students in the class, with special attention the female(s) with ADHD.

Conclusion

ADHD impairs academic performance (Biederman et al., 1999; Breslau et al., 2011;

Fleming et al., 2017). Without equitable access to diagnosis and therefore treatment and support

(Coles et al., 2010; Ohan & Johnston, 2005; Quinn & Madhoo, 2014), females with undiagnosed

ADHD will experience many academic difficulties. The universal design for learning approach

to teaching is one that caters to learners that are non-average or have exceptionalities in a way

that benefits all students in a class (Government of Ontario, 2013). I aim to investigate classroom

strategies that can be implemented to support the academic achievement of females with
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undiagnosed ADHD in a way that will also support their non-ADHD peers. Further research will

be needed to address the efficacy of my suggestions and realism of their implementation.

A Note on Citational Practices

Representation from various countries such as the USA, Switzerland, and Taiwan as well

as census data from global ADHD associations (The World Federation of ADHD, EUropean

NETwork for Hyperkinetic DIsorderS (Eunethydis), the American Professional Society of

ADHD and Related Disorders, the Canadian ADHD Resource Alliance, the Asian Federation of

ADHD, the Latin American League of ADHD, the Australian ADHD Professionals Association,

the Israeli Society of ADHD, the Saudi ADHD Society, the ADHD Guidelines Group of the

Association of Medical Scientific Societies in Germany, the ADHD Network of European

College of Neuropsychopharmacology, the Chinese Society of Child and Adolescent Psychiatry

and the ADHD Section of the World Psychiatric Association; (Faraone et al., 2021)) were

included to give a more ethnically and culturally representative view of ADHD. While ADHD is

a disability, this review and its citations did not explicitly represent the voices of individuals with

ADHD in combination with other disabilities aside from mood disorders. As well, the voices of

those that are at the intersection of racial or ethnic groups that face additional levels of exclusion

and profiling in addition to being female and having ADHD were not explicitly represented. This

was not done intentionally and is an element that should be investigated in further research. The

majority of articles were drawn form medical and psychology journals. This could lend to a more

clinical tone of citation, though I feel it is justified considering the subject of the review being a

neurodevelopmental disorder.
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References

A note for Kyoko; I have indicated which articles are empirical by adding a * at the start. This is

simply since we are required to have10 empirical studies, and this way you don’t have to sift

through all my references to find them. I recognize that this is not in alignment with the strict

APA guidelines, but I was hoping it would be helpful to you!

*Antrop, I., Roeyers, H., Oost, P. V., & Buysse, A. (2000). Stimulation seeking and

hyperactivity in children with ADHD. Journal of Child Psychology and Psychiatry, 41(2),

225–231. https://doi.org/10.1111/1469-7610.00603

*Aryana, M. (2010). Relationship between self-esteem and academic achievement amongst pre-

university students. Journal of Applied Sciences, 10(20), 2474–2477.

https://doi.org/10.3923/jas.2010.2474.2477

Barrett, P., Davies, F., Zhang, Y., & Barrett, L. (2015). The impact of classroom design on

pupils' learning: Final results of a holistic, multi-level analysis. Building and Environment,

89, 118–133. https://doi.org/10.1016/j.buildenv.2015.02.013

*Beck, S. J., Hanson, C. A., Puffenberger, S. S., Benninger, K. L., & Benninger, W. B. (2010). A

controlled trial of working memory training for children and adolescents with ADHD.

Journal of Clinical Child & Adolescent Psychology, 39(6), 825–836.

https://doi.org/10.1080/15374416.2010.517162

*Biederman, J., Faraone, S. V., Mick, E., Williamson, S., Wilens, T. E., Spencer, T. J., Weber,

W., Jetton, J., Kraus, I., Pert, J., & Zallen, B. (1999). Clinical correlates of ADHD in

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referral sources. Journal of the American Academy of Child & Adolescent Psychiatry,

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*Biederman, J., Faraone, S. V., Spencer, T., Wilens, T., Mick, E., & Lapey, K. A. (1994).

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*Breslau, J., Miller, E., Joanie Chung, W.-J., & Schweitzer, J. B. (2011). Childhood and

adolescent onset psychiatric disorders, substance use, and failure to graduate high school

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*Chen, V. C.-H., Chan, H.-L., Wu, S.-I., Lee, M., Lu, M.-L., Liang, H.-Y., Dewey, M. E.,

Stewart, R., & Lee, C. T.-C. (2019). Attention-deficit/hyperactivity disorder and mortality

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*Cheng, J., Teevan, J., Iqbal, S. T., & Bernstein, M. S. (2015). Break it down. Proceedings of the

33rd Annual ACM Conference on Human Factors in Computing Systems.

https://doi.org/10.1145/2702123.2702146

*Coles, E. K., Slavec, J., Bernstein, M., & Baroni, E. (2010). Exploring the gender gap in

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*Fleming, M., Fitton, C. A., Steiner, M. F., McLay, J. S., Clark, D., King, A., Mackay, D. F., &

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