Slowly, ADHD Gender Gap Closes

Focusing on the Female

6 min read

Feb. 12, 2001 -- Becky Stanford loved gymnastics, but she didn't stick with it because she couldn't wait her turn. She had difficulty following rigid formats like long division and essay outlines. She struggled in school and with friends. Even her Sunday school teachers dreaded having her in class.

"I was much louder, much more energetic than my peers. Sometimes it really overwhelmed people," says Stanford, now 28 and living in Helena, Mont. "You had to really gear up to have me over for the weekend or overnight. At sleepovers, I was the one sent to another room because I was keeping people up."

At 13, Stanford was diagnosed with attention deficit hyperactivity disorder (ADHD). Her brother was already seeking treatment for the condition, but even with ever-watchful parents, the disorder did not seem apparent in her because she was a girl.

Indeed, four to five times more boys than girls are referred for ADHD evaluations because their symptoms are easier to spot, according to Kathleen G. Nadeau, PhD, director of Chesapeake Psychological Services in Silver Spring, Md. Boys, she says, tend to pose more problems for their teachers and may appear more hyperactive. Girls with ADHD (or ADD, as it is called when there is no hyperactivity issue) are less rebellious and tend to be inattentive. As a result, she says, many girls with undiagnosed ADHD are dismissed as lazy or spacey, when in fact they simply may not be getting the help they need.

"They are so good at hiding it, disguising it, and compensating for it, a lot of parents and teachers don't know what is going on," Nadeau tells WebMD.

The disorder has been considered two to three times more common in boys than girls, but many believe the numbers are skewed. "It's much closer to one to one," says Peter Jaksa, PhD, president of the National Attention Deficit Disorder Association, and a psychologist with a private practice in suburban Chicago. "But girls have always been underdiagnosed because they are harder to spot."

"Girls seem to work the system a little better. They can become the teachers' pets and the teachers don't have the same expectations," agrees Becky's mother, Paula Stanford, LPC, who now runs an Oklahoma City diagnostic and counseling clinic for children and adults with ADHD and learning disabilities. "Girls can be charming or coy or ditzy, and it can still be kind of cute. The cultural way of looking at females has a lot to do with that."

ADHD is the most commonly diagnosed behavioral disorder in childhood, with an estimated 3% to 5% of the general population suffering from it, according to the National Institute of Mental Health. Symptoms can include hyperactivity, a lack of attention span, and impulsive behavior. People with the disorder often are disorganized, cannot complete tasks, and have trouble following more than one instruction at a time. Symptoms can begin as early as age 3 and usually are noticeable by age 7.

Research conducted at Harvard University and Massachusetts General Hospital suggests that ADHD in girls, like boys, tends to run in families, but because girls are not as likely to act out, their symptoms may go unnoticed. Girls more often have attention problems than the disruptive behavior that boys can exhibit, says Joseph Biederman, MD, who led the study published in the July 2000 issue of the American Journal of Psychiatry. Girls in general are one-third less likely than boys to exhibit conduct disorder, he says.

"Girls tend to be less obvious because they are less disruptive," says Biederman, professor of psychiatry at Harvard Medical School and chief of pediatric psychopharmacology at Massachusetts General. "If you are a girl and sit in the back of the room and smile, no one will pay attention to you."

Hyperactivity in girls often shows verbally instead of physically, in what Nadeau refers to as the "Chatty Kathy phenomenon." These are the girls who talk in the back of the classroom and are extremely social, but often are not diagnosed as having ADHD.

About half of inattentive ADHD children are overlooked despite their gender, says Nadeau, co-editor of ADDvance Magazine, a publication for women and girls with ADD or ADHD. "An inattentive little boy will be more obvious. He's just sitting there drawing airplanes or looking out the window," she says. "A lot of girls will tell you they have learned to look at their teacher while daydreaming because that won't get them into trouble. A lot of this teacher-compliant behavior masks the problem."

Screening guidelines for ADHD are "based mostly on hyperactivity in young boys. These were the kids causing the most problems. They were the most disruptive. It's a matter of the squeaky wheel," says Jaksa.

Unlike boys whose symptoms decrease at puberty, girls' symptoms often increase during this time of hormonal change, Nadeau says. The diagnosing criteria for ADHD, however, require that symptoms begin before age 7, according to the National Institute of Mental Health.

"We need better criteria," Jaksa says. "We need more realistic diagnostic [measures] that address what is going on with girls."

Not everyone agrees. Biederman believes that the diagnosing guidelines are appropriate. Better education on how to recognize inattentive ADHD, and get girls referred for diagnosing, would help resolve the gender gap, he says.

"The issue is more emphasis on clinicians and educators not to rely only on aggression to recognize ADHD," Biederman says. "ADHD in girls may not be as commonly described."

Consider, too, that the most common drug treatment for ADHD is methylphenidate (Ritalin), yet much of the research has been conducted in men and boys. One of the most recent studies, published in the Jan. 12, 2001, online issue of the Journal of Neuroscience, used 11 men as its subjects. In the study, researchers from the Brookhaven National Laboratory in Upton, N.Y., and the University of New York at Stony Brook found that Ritalin amplifies dopamine release in the brain and speculated that this would improve attention and decrease distractibility. They noted, however, that their tests were conducted in healthy adult men who were tested in "stress-free" conditions, and said further research was needed.

More studies are under way to further point out the similarities and differences in symptoms between boys and girls. Left untreated, ADHD can lead to depression, lack of self-esteem, and emotional and academic problems -- including drug experimentation and earlier sexual relations for girls, according to Nadeau. Many children with the disorder are physically active and more prone to injury. Once they reach adulthood, undiagnosed ADHD women often struggle with organization and being consistent as parents, just like ADHD men, she says.

"There are a lot of things that happen and they don't have an understanding of why," says Nadeau, who has authored several books, including Understanding Girls with ADHD. "Everyone just blames them. There is tremendous psychological damage."

Becky Stanford says she felt misunderstood most of her pubescent years. Had she been diagnosed earlier, she says she could have received treatment that would have made life easier for her and those around her.

"Not knowing why you learn differently, and not understanding why things are easier for other people -- I think that does affect your self-esteem," says Stanford, MSW, a social worker who along with her mother has produced a video on ADHD called Dismissed and Undiagnosed Dreamers. "If I had found out earlier, we could have brought in tutors and people to help me with coping skills to help me organize. It would have helped me to get a better sense of myself early on."