Posted October 23rd 2024
Attention deficit hyperactivity disorder, also known as ADHD, is a neurodevelopmental condition that affects 1 in 20 young people and 1 in 25 adults.
It is well documented that some people with ADHD aren’t diagnosed until they reach adulthood. This can be seen even more frequently in girls, young women and people whose sex was assigned female at birth (AFAB), with research suggesting that on average, females are diagnosed with ADHD later than males. But why is this?
There are several potential reasons for delayed or missed diagnosis in girls and young women:
- Masking and compensation
- Alternative diagnosis
- Perceptions of ADHD and gendered expectations
- Expression of ADHD symptoms
1. Masking and compensation
Some young people may receive a later ADHD diagnosis due to masking or compensation. Masking can be defined as the conscious or unconscious act of suppressing ADHD symptoms to appear more neurotypical. Compensation can be defined as engaging in active strategies to overcome ADHD symptoms.
Individuals may engage in masking or compensation to fit in, avoid getting in trouble, or to disguise any difficulties. Qualitative research in adults has suggested that both males and females with ADHD may mask their ADHD difficulties.
Examples include:
- Making lists to aid forgetfulness
- Suppressing the urge to fidget or move
- Overcompensating time management and organisation, getting to events very early or over-preparing
- Staying quiet to avoid saying things impulsively
There is limited research examining masking and compensation, especially in young people, and if it contributes to delays in individuals receiving an ADHD diagnosis, and how this differs in males and females. Although it has been suggested by experts that females with ADHD may develop better coping or masking strategies than males with ADHD. If future research studies support this, it could contribute to missed or delayed diagnosis in females.
2. Alternative diagnosis
Recent research looking at healthcare records in Wales has suggested that females may receive later recognition and treatment of ADHD due in part to diagnostic overshadowing, where symptoms from one condition (e.g. ADHD) are attributed to another condition (e.g. anxiety), from other mental health conditions and possibly even initial misdiagnosis.
In this study, females with ADHD were more likely than males with ADHD to be recognised for a diagnosis of conditions, such as depression or anxiety, before ADHD diagnosis. These diagnoses may lead to diagnostic overshadowing, therefore delaying the recognition of ADHD.
3. Perceptions of ADHD and gendered expectations
There are often many perceptions and stereotypes surrounding ADHD, with the condition being viewed as occurring more commonly in males. As such, there are often gendered expectations surrounding ADHD.
Research has found that knowledgeable informants (for example, parents, teachers) may be more likely to overlook ADHD in females, and therefore are less likely to refer them for an ADHD diagnosis. One study found that when parents and teachers read vignettes of children’s behaviour, which only differed in the description of the child’s gender, they were less likely to say they would refer females for ADHD than males.
This suggests that perceptions of those supporting young people may influence who gets referred for ADHD assessment and could explain why girls and young women may miss, or receive a late, ADHD diagnosis.
4. Expression of ADHD
Research suggests that there may be sex differences in the presentation of ADHD symptoms. There are three ADHD subtypes: hyperactive or impulsive, inattentive and combined type.
Females are more likely to present with the inattentive subtype, including symptoms of forgetfulness and inattention, which are less overt and disruptive to others than hyperactive-impulsive symptoms.
As such, females with the inattentive subtype may be less visible and readily recognised than the other ADHD subtypes, leading to them being overlooked for referral and treatment for ADHD.
Overall, there are a variety of reasons why someone may be diagnosed with ADHD later than others. A timely diagnosis of ADHD is important as it helps the individual understand their brain better and gives them access to treatment and educational or workplace support.
Our research at Cardiff University
As part of our research project, which is funded by Health and Care Research Wales, we are studying why people might have their ADHD missed or diagnosed later and what can be done to improve this.
We are examining why some people are diagnosed earlier than others and why some people have ADHD symptoms, but no diagnosis, using large datasets in the UK and Sweden.
We are also using qualitative methods to explore the manifestation of ADHD symptoms in females, by talking to women and non-binary individuals.
Research into this topic is important because it will raise awareness of the underdiagnosis and potential misdiagnosis of ADHD in girls and women. This research will hopefully allow us to develop screening tools that are better able to identify symptom presentations typical of female ADHD and allow for earlier diagnoses of ADHD and support for those who might benefit from it.
Read more
- Conditions we study: ADHD
- NCMH Blog | Symptoms of ADHD in women and girls
- NCMH Blog and podcast episode | Exploring ADHD in girls, young women, and non-binary people
Watch
Watch this animation we developed with young people with ADHD and their families, researchers, and health professionals.
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