REPORT: ADHD IN FEMALES, CORRECTING MYTHS AND IMPROVING DIAGNOSES

AUTHORS: SHAWNA HOPPER, EXAUCE NGADANDE, SAMAN RAIS-GHASEM, NICK ZAMBROTTA

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common human
neurodevelopmental disorders. Generally, ADHD is characterized by a decrease in attention and
concentration and an increase in activity level or impulsivity beyond a threshold that interferes
with functioning or development.

Researchers estimate the worldwide prevalence of ADHD at 5.3%; with the global prevalence of
ADHD being higher (3.4%) in children and adolescents than in adults (2.6%). In Canada, the
prevalence of ADHD is estimated for all provinces at 2.9% among adults, while it is 8.6%
among children and youth in five provinces. Whether in youth or in adults, we note here that the
prevalence of ADHD in Canada is above the world average.

While many studies have focused on ADHD in Canada, few have addressed the issue of its
management for females, and even fewer have had equal female representation within their
samples. Thus, the purpose of this brief is to assess the current policies surrounding diagnosis
and management of ADHD for females in Canada. An analysis of gender differential access to
ADHD care in Canada will be conducted. Based on our findings, some recommendations will be
made to policy makers to reduce inequalities in access to diagnostic tools and management
methods for ADHD between females and males.

OVERVIEW OF THE ISSUE: FEMALES WITH ADHD

ADHD has long been thought of as a male-only issue, with ADHD being reported nearly twice
as much in males (3.7-13.3%) than females (1.5-7%). However, emerging research shows that
ADHD is far more prevalent in females than previously thought but has consistently been
misdiagnosed. One critical reason for this is that ADHD symptoms present differently in school-
aged females versus males. Females tend to internalize their struggles resulting in symptoms like
forgetfulness, disorganization, and demoralization. In contrast, males show a tendency towards
externalization resulting in the more recognizable symptoms of excessive motor activity.

Misdiagnosis of ADHD is a significant long-term health issue. ADHD has a myriad of

comorbidities and health risks over the long-term. Females with ADHD that are undiagnosed
until adulthood struggle with self-esteem and self-image often due to repeated experiences of
failure and inadequacy. Therefore, individuals with a late diagnosis are at significant risk of
developing comorbidities like depression, anxiety, eating disorders, sleep disorders and
substance use disorders.

By the numbers, globally:

● Females with ADHD scored comparatively lower than males with ADHD on scales of
mental well-being and self-esteem.
● While both school-aged females and males with ADHD show impairment in relationships
with peers, this impairment was stronger in females.
● Suicidal ideation is significantly increased in adult ADHD patients compared to controls
at 28.16% and 7.77% respectively.
● This increased risk of suicidal ideation is considerably higher in females than males.
There was a 16-fold increase in suicidal ideation for ADHD women relative to controls,
compared to no significant increase in males with ADHD.
● 36% of young adults with ADHD has a lifetime alcohol use disorder, compared to 19% in
controls.
● Based on the 2012 Canadian Community Health Survey, young adults with ADHD have
38% higher odds of developing alcohol use disorders, 46% cannabis use disorders and
more than double the odds of developing other drug use disorders compared to controls.

It is unclear to what extent untreated ADHD may contribute to the development of

comorbidities, or whether they are independent. Regardless, the presence of comorbidities like
depression, anxiety, and bi-polar disorder means that ADHD is less likely to be correctly
diagnosed. Therefore, psychological and pharmacological treatment will target non-ADHD
conditions, and miss the root cause of the symptoms. This problem disproportionately affects
females, who were 3 times more likely to have been prescribed antidepressants before being
diagnosed with ADHD.

CURRENT POLICIES AND DIAGNOSTIC METHODS

As demonstrated, it is clear that school-aged females are less likely to be diagnosed with ADHD
than males, in large part due to the symptomatic differences across genders. In Canada, the
Canadian ADHD Resource Alliance (CADDRA) sets specific and actionable guidelines for
mental health professionals to identify and diagnose ADHD. In addition, CADDRA provides
families with the resources necessary to support their family members with ADHD. According to
CADDRA’s ADHD practice guidelines (4th ed.), the overarching goal of the ADHD treatment
plan is to provide information about this disorder that is durable, individualized, and pertinent
based on the individual's needs. Additionally, CADDRA’s guidelines also expand upon existing
healthcare counsel in Canada. In regard to CADDRA’s diagnostic policies, the organization
utilizes the Diagnostic and Statistical Manual (DSM-5) for criteria. Below are the 18 common
symptoms associated with ADHD for which the individual must present with a minimum of 6 in
each category:

What becomes increasingly clear is that the DSM-5 diagnostic criteria for ADHD does not
account for school-aged female specific ADHD symptomatology, including low self-esteem and
difficulty making and maintaining friendships. However, it is apparent that the criteria does
account for school-aged male specific ADHD symptoms (e.g. impulsivity, hyper-activity, lack of
focus, physical aggression), which may explain the significant difference in diagnosis rate
between females and males.

Beyond assessments and questionnaires, the process through which an individual is diagnosed
with ADHD follows 4 crucial stages: information gathering, medical referral, ADHD specific
interview, and feedback/recommendations. And while this process is successful in identifying
struggling students, in the information gathering stage, symptoms must be correctly identified.
Currently, the symptoms used for diagnosis are those more commonly seen in school-aged males
and not females. Therefore, improving the process through which ADHD is identified and
diagnosed for females is an important next step in supporting our future generations.
RECOMMENDATIONS

As research shows that school-aged females with ADHD are more likely to be
undiagnosed, diagnosed later, or misdiagnosed, it is evident that a gender disparity exists.
Although ADHD can be easily treated, when females are not diagnosed, they lack the
opportunity to understand, treat, and manage their symptoms which can impact their daily lives
and future health.

Since current scales used in the DSM-5 focus on male-presenting symptoms, school-aged
females who are struggling with ADHD may not score above the threshold for a diagnosis.
Gender-specific tools and assessments should be developed, validated, and widely distributed to
the medical community that include the more subtle ADHD symptoms that are commonly
present in female populations. Similarly, further research should be done that includes a greater
proportion of female participants as existing literature is dominantly male focused. Increased
representation in research will allow for the development of more finely-tuned diagnostic criteria
for females. Additionally, since many school-aged females are misdiagnosed with a mood
disorder instead of ADHD, more medical training should be provided so that doctors can better
recognize ADHD symptoms in females.

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