11 Gender Bias in Diagnosing and Treating ADHD

Many people assume that ADHD is something that only affects males. In this paper, I will discuss what ADHD is and look at various reasons why people may make this assumption. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder described as inattention and/or hyperactivity-impulsivity that affects development and interferes with functioning (American Psychiatric Association, 2013). There is no definite known cause, although research shows genetics may play a factor. There are a variety of risk factors, from talking too much, to executive functioning problems, social problems, and impulsiveness (Centers for Disease Control and Prevention, 2019). There are three different types of ADHD: 1) ADHD – impulsive/hyperactive; characterized by impulsivity and hyperactive behaviors without distractibility/inattention, 2) ADHD – inattentive and distractible; characterized by distractibility and inattention without hyperactivity and 3) ADHD – combined type; characterized by hyperactivity and impulsiveness with distractibility and inattention (Hopkins Medicine (2022). ADHD can affect any gender but studies show that boys are diagnosed with ADHD anywhere from 2:1 to 10:1 in male-to-female ratios (Slobodin & Davidovitch, 2019). With the higher proportion of boys being diagnosed, we will take a look at the differences in symptoms between genders, referral rates, gender socialization, any treatment differences, gender differences in adults with ADHD, and stigma.

Do more boys have ADHD than girls or are symptoms different resulting in boys being diagnosed more times than girls? A 2002 meta-analysis from Gershon (2002) found that boys rated significantly higher in hyperactivity, impulsivity, and inattention. Boys were also found to be significantly more likely to externalize problems, like impulsivity and running, whereas girls were significantly more likely to internalize problems, like inattentiveness and low self-esteem. Due to more girls internalizing problems, there is a higher risk for them to develop anxiety and depression. In regards to intellectual functioning, girls scored lower than boys on Verbal IQ (the ability to understand concepts framed in words) and Full-Scale IQ (overall cognitive and intellectual functioning), with no difference found for Performance IQ (overall visuospatial intellectual abilities). It should also be noted that there were no differences found in social functioning or neuropsychological functioning. Coles et al. (2012) also found that boys with ADHD had higher rates of conduct disorder, oppositional defiant disorder, and higher aggression, whereas girls had higher intellectual impairments. Due to the disruptive nature of hyperactivity, boys are often attended to, to correct their behaviors, resulting in inattentive behaviors from girls being ignored. This can potentially lead to a bias in under-identifying girls with ADHD. This can also create a bias in academic support, leading girls to be diagnosed with a learning disability rather than ADHD, providing more academic support but no support for ADHD (Gershon, 2002).

Differences in the expression of ADHD symptoms, resulting in significantly more disruptive behaviors in boys, find girls are less likely to be referred to a school psychologist by a teacher, even though they meet all the other criteria for a diagnosis of ADHD (Gershon, 2002). This results in boys being referred for a diagnosis between 6:1 to 9:1 times more than girls (Sciutto et al. 2004). Many teachers had higher referral rates for boys due to their belief that medication would be more effective and work more quickly for boys with ADHD, whereas they felt that behavior intervention would be more effective and work more quickly for girls (Coles et al. 2012, Sciutto et al. 2004). Teachers were measured on their referral rates on the symptoms of hyperactivity, inattentiveness, and hyperactivity plus aggression. Sciutto et al. (2004) found that teachers referred more boys than girls in each of these categories but referred boys significantly more than girls in the hyperactivity category by approximately 1.5 times. Overall, teachers were found to refer more boys than girls based on gender, regardless of symptom type or population sample size. These findings tell us that the “squeaky wheel gets the grease”, and that due to boy’s symptom expression of hyperactivity, causing increased classroom disruption, they will consistently be referred for an ADHD diagnosis over girls.

With so many more boys being diagnosed with ADHD due to the symptom expression of hyperactivity, we need to take a closer look at the role that gender socialization plays. Many parents treat their children differently based on gender, buying different clothes and toys, as well as providing opportunities for different extracurricular activities, such as socialising activities for girls and sports for boys (Blakemore & Hill, 2008). Parents also tend to interact differently with their children based on their gender, Blakemore & Hill (2008) noted that when parents interact with girls, their interactions tend to provide tolerance of emotional vulnerability and focus on language and social relationships. On the other hand, when parents interact with boys, they are more likely to be permitted to express mild aggression and anger and take bigger physical risks, but not show emotional vulnerability. They also noted that boys tend to be punished more harshly than girls and therefore have had more aggression modeled toward them. With more emphasis on sports and aggression and less on emotions and vulnerability, parental interactions may play a role in why boys express ADHD symptoms differently than girls. In their research, Mowlem et al. (2019) also found a gender bias regarding parents’ perception of ADHD being that it only affects boys. Parents may refer their boys for testing when impulsive behaviors and hyperactivity are observed, however when the same behavior is seen in girls, there is no concern with the behavior and therefore, no referral for testing.

Helicopter parenting may also play a factor, Buchanan & LeMoyne (2020) found that males and females interpreted this parenting style differently. Males may feel that their parents were executing administrative tasks leading to them feeling more empowered, for example, if a parent were to contact a teacher due to a low grade, a male may feel like their parent is cleaning up their mess, whereas females are more likely to feel like they did not perform well and internalize that they are unsuccessful at correcting the problem. In regards to socialization, it should be noted that while it is mostly boys that are being diagnosed with ADHD, it is mostly mothers and female teachers that make the “first determination that the child’s behavior falls outside the normal range of what little boys do” (Rosenfeld et al., 2006). They also noted that from this point of view, ADHD can be seen as a resistance to submission and a lack of motivation to engage in learning acceptable social skills. Medication is then given to boys to enforce emotional control and self-discipline.

Research by Bergey et al. (2022) focused on intersectionality and ADHD, and found that more children from lower-income families were diagnosed, compared to moderate and high-income families. Children from high-income families being the least diagnosed. They also found that African American children and Caucasian children were the highest groups of children to receive diagnoses.

Studies have shown that there is no gender-specific treatment for boys and girls with ADHD. Studies like that of Rucklidge (2008) have found good outcomes with operant conditioning, suggesting that the neurotransmitter pathways can be modified by behavioral management. Medication is often prescribed for children with ADHD and studies have shown that for children with additional comorbidities, like those of anxiety and disruptive disorders, adding behavioral management treatments to the medication has statistically improved the child’s outcomes. It should be noted that adding behavioral management treatments to medication did not show improved outcomes in children that did not have additional ADHD comorbidities. Behavioral treatments have been shown to have such an improvement, that it has the potential for a decrease in the dose of medication prescribed. Parents that use both treatments for their children have reported that their children closer relate to neurotypical children more than those parents whose children have only been prescribed medication. This treatment is useful for boys and girls, however, due to the increase in girls having the comorbidities of anxiety and depression, dual treatment is more likely to be used for girls, giving girls an increase in dual treatment compared to boys.

Although there are no reported gender differences in treatment, with boys being diagnosed 2:1 to 10:1 over girls (Slobodin & Davidovitch, 2019), it tells us that a lot of girls are going undiagnosed and therefore are not receiving any treatment. Rucklidge (2008) mentions that with each year that passes that a child goes undiagnosed, the higher the likelihood that secondary emotional problems will start to arise, resulting in relationship problems, feelings of under-achievement, and misattributions, thus further increasing the risk of girls developing anxiety and/or depression. If the gender referral bias were able to be removed, and girls were equally referred for diagnosis and treatment, they would be able to greatly benefit from Cognitive Behavioural Therapy (CBT) as it can take into account the individual’s circumstances, experiences, frustrations and belief systems and tailor a unique approach to help effectively manage ADHD (Rucklidge, 2008). Klefsjo (2021) confirms that there is no specific gender difference in the treatment of ADHD, but does state that girls tend to have increased non-ADHD medication prescribed due to emotional symptoms as well as more psychiatric problems than boys, before an ADHD diagnosis.

With girls being underdiagnosed in childhood, it can lead to further concerns in adulthood. Rucklidge (2008) points out that many adult mental health professionals do not believe that ADHD is a psychiatric disorder that affects adults, compounding this is that women often present with very different histories than men do, for example, less hyperactivity, history of receiving abuse, and greater mood instability. It is also noted that continuing education regarding the presentation of ADHD symptoms in women needs to be done in the psychiatric field. There is an added gender stereotype for women that they are supposed to be organized, be able to multitask, keep themselves and their surroundings tidy, and overall run the household (Rucklidge, 2008). When women are unable to meet those expectations, they are left feeling like a failure, creating feelings of low self-esteem and shame. The longer that ADHD in adult women goes undiagnosed, the more likely these women are to attribute their “shortcomings” to a character flaw, further increasing feelings of guilt and low self-esteem (Rucklidge, 2008).

While undiagnosed adult women suffer from negative stereotypes, undiagnosed men have a higher likelihood of entering the prison system. According to Rosler et al. (2004), 64% of male prison inmates suffer from ADHD. Having better access to ADHD treatment while in the prison system, could potentially help inmates with ADHD have a better understanding of themselves and thus reduce the reoccurrence of crime in the future. Both adult men and women with ADHD report being victims of child abuse, with women, also reporting being victims of sexual abuse (Rucklidge, 2008), this can further exacerbate the likelihood of women with undiagnosed ADHD having emotional problems and men with undiagnosed ADHD ending up in the prison system.

One of the reasons that many people with ADHD go undiagnosed is because of stigma. Canadian Sociologist Erving Goffman defines stigma as an “attribute which is deeply discredited by their society and is rejected as a result of the attribute” (Goffman, 1963). Many parents may feel that they do not want this stigma to follow their child, and rather than get them diagnosed, they may avoid assessment and believe that they will grow out of it. Parents are not wrong in feeling like their child will face stigma, Metzger et al. (2020) found that teachers’ assessments of their students may be persuaded by their perceptions of their students. The stigma around ADHD can follow the child into their classroom. Since children with ADHD are often assumed to be more likely to get into trouble and to be more violent and lazy than non-ADHD children, teachers may perceive the student’s academic abilities more negatively causing an implicit bias. Students with ADHD have a full range of academic abilities, matching those of non-ADHD students, yet when a teacher knows that a student has ADHD it is difficult for the teacher to remain objective in their evaluations (Metzger et al. 2020). When teachers view students with ADHD less positively than their peers and they tend to have lower expectations and lower evaluations for those students, these lowered expectations and evaluations may lead to a self-fulfilling prophecy by the students, creating a downward spiral as each year passes. This research is consistent with the Modified Labeling Theory, which shows that the process of stigmatization begins as soon as an individual receives a diagnosis. The individual is then labeled and linked to negative cultural beliefs associated with the diagnosis. In the case of ADHD, it is often labeled as a stable condition and is linked to being a troublemaker. This can cause assumptions about what school work a student is able and willing to do in an academic setting and fewer educational opportunities are provided (Metzger et al. 2020). Children are not the only ones who can face stigma from an ADHD diagnosis, adults can too. The research from Canu et al. (2008) found that adults tend to have greater hesitation when initiating a social relationship with a peer who has ADHD compared to a peer that does not. This research also found that males were judged more harshly than females, especially when it came to the prospect of dating, this may be because society still views ADHD as a disorder that mainly affects males. Interestingly, adult females were shown to believe that ADHD is a legitimate psychological disorder, however, they were not shown to be tolerant towards others who have the diagnosis (Canu et al. 2008). This can create a potential problem with bringing awareness for adults to seek to get an ADHD diagnosis, on one hand, it would be highly beneficial for adults to have a course of action and treatment for ADHD and the comorbidities that exist, but on the other hand, the increased stigma could prohibit many adults from talking about it as they wish to have their diagnosis stay confidential.

Dual stigma is an added concern to individuals who identify as transgender. Individuals who identify as transgender and who have also been diagnosed with ADHD are more susceptible to bullying, depression, and other psychological problems than an individual with one of these stigmas. This poses a greater risk of isolation, dropping out of school, and substance abuse (Bowman-Campbell, 2013). More research needs to be done regarding the dual stigma between transgender and ADHD individuals, as there is currently very little information.

It is clear that there is a gender bias in diagnosing and treating ADHD. Continued education is needed in the professional and public sectors when it comes to ADHD. Professionals need to be made aware of the different gender expressions of ADHD and the benefits of combined behavioral and medical therapies. The public needs to be made aware of what ADHD is and how stereotypes can create an unfounded bias toward individuals with ADHD. Further research should be done in regards to girls and women who suffer more emotional problems with ADHD, specifically if these emotional problems are directly due to ADHD or develop due to living with undiagnosed ADHD for years. With greater education at all levels, individuals with ADHD will be able to understand their individual needs and difficulties, have access to the treatments that they need, and see a reduced stigma in society. This education will help more girls to be correctly diagnosed and help in reducing mental health problems later in life.

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