Perceptions of Girls and ADHD: Results From a National Survey

Patricia Quinn, MD; Sharon Wigal, PhD

In This Article

Abstract and Introduction

Objective: The purpose of this survey is to explore perceived gender differences in attention-deficit/hyperactivity disorder (ADHD).
Methods: Online Harris Interactive interviews were conducted with 1797 adults (general public), 541 parents of children with ADHD, 550 teachers, and 346 children aged 12 to 17 years with ADHD. Responses were examined to determine perceptions of ADHD.
Results: Most of the general public (58%) and teachers (82%) think ADHD is more prevalent in boys. The general public and teachers think boys with ADHD are more likely than girls to have behavioral problems (public: 52% vs 26%; teachers: 36% vs 18%, respectively), while girls with ADHD are thought to have less noticeable problems than boys, such as being inattentive (public: 19% vs 11%; teachers: 29% vs 10%, respectively) or feeling depressed (public: 16% vs 1%; teachers: 12% vs 0.0%, respectively). Four out of 10 teachers report more difficulty in recognizing ADHD symptoms in girls. An overwhelming majority of teachers (85%) and more than half of the public (57%) and parents (54%) think girls with ADHD are more likely to remain undiagnosed. ADHD was reported to have a negative effect on self-esteem, more so in girls. Girls who were taking medication for their ADHD were nearly 3 times more likely to report antidepressant treatment prior to their ADHD diagnosis. Girls were more likely to feel it was "very difficult" to focus on schoolwork and get along with parents.
Conclusions: Survey responses suggest that gender has important implications in the diagnosis and treatment of ADHD. Responses by ADHD patients demonstrate gender-specific differences in the personal experience of the condition. Future prospective clinical trials are warranted to clarify the unique needs and characteristics of girls with ADHD.

ADHD is a well-recognized, chronic behavioral disorder that is characterized by persistent symptoms of impulsivity, hyperactivity, and/or inattention and is frequently diagnosed during childhood.[1] According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition, ADHD is defined as the presence of at least 6 symptoms of inattention or hyperactivity/impulsivity that persist for at least 6 months in a way that is maladaptive or developmentally inappropriate. Symptoms of inattention include poor attention to details, limited attention span during tasks or play, forgetfulness, distractibility, and failure to finish assigned activities. Symptoms of hyperactivity/impulsivity include fidgeting, extreme restlessness, excessive motor activity, difficulty taking turns, and a tendency to blurt out answers or interrupt others. In order to meet diagnostic criteria, the symptoms of ADHD must cause clinically significant impairment in school and at home.[1] With an estimated prevalence of 4% to 12% in school-age children, ADHD is believed to be more common in males.[2] Male-female ratios range from 9:1 to 6:1 in clinical samples but are about 3:1 in community-based population studies.[3]

There may be several reasons for the disparity between male-female ratios in clinical and community-based studies. Clinical samples only capture patients who have been referred for treatment, whereas population samples are more representative of the true prevalence and characteristics of ADHD. Clinical samples are therefore more likely to be biased toward more severe, easily recognized cases, whereas community samples are more likely to include a range of severities and clinical presentations. Because girls tend to be inattentive rather than hyperactive/impulsive,[4,5] they may not be captured by diagnostic criteria that focus primarily on the excess kinetic activity and disruptiveness typical of boys with ADHD, and therefore may not be recognized in the community setting. Also, girls with ADHD are less likely than boys with ADHD to exhibit conduct disorder, aggression, or delinquency, so they are less likely to be referred for disruptive behavior.[5,6,7,8] Moreover, their symptoms do little to raise community awareness of the disease. Thus, ADHD may be missed or its severity may be underestimated in girls, leading to fewer specialist referrals and underrepresentation in clinic-based studies.[9]

The atypical presentation of ADHD in girls may be a barrier to treatment, either because the condition is not recognized or because it is not seen as serious enough to warrant intervention. Paradoxically, when problematic behavior is identified in girls, the degree of deviation from the norm (compared with other girls) is thought to be much greater than it is for boys because girls are inherently less prone to inattention and hyperactivity than are boys.[7] Girls who are referred for psychiatric evaluation often show unusually disruptive behaviors, but they are probably not typical of most girls with ADHD.[8]

There is also evidence that ADHD takes a different type of toll on girls vs on boys. Although they do not differ from boys in measures of impulsivity, school performance, or social interactions, they have greater cognitive and attentional impairment[3] and may be rejected more often by their peers (particularly if they have the inattentive subtype).[7] Needing to repeat a grade in school is also more common among girls than among boys, which supports the observation that they experience more cognitive and academic problems.[10] In a study of adults, females with ADHD showed a higher prevalence of depression, anxiety, and conduct disorder when compared with a control population, as well as cognitive impairments and academic problems.[6] The heavy social and personal impact of ADHD on females points to the importance of early identification and treatment.

Because ADHD is usually first suspected or recognized by a child's parents, teachers, and peers, the attitudes of people around these children can be important determinants of whether and how the child's condition is treated. In order to clarify perceived differences between girls and boys in the incidence and presentation of ADHD and in how ADHD is perceived by those around them, a large-scale survey was conducted. This survey examines gender variations in the disorder and explores how having ADHD is viewed by older children with ADHD, by their families and teachers, and by the general adult public.