Gender bias in ADHD evaluation – Do boys and girls with ADHD look the same in the classroom?

1-minute summary: This is part three of guest author Simon Kitson’s series on identifying and assessing ADHD in children. Part one examined what adults should look out for in a school setting when it comes to ADHD. In part two, Simon explored the role of ‘birthdate bias’ in ADHD assessment.

In this latest instalment, Simon examines the data behind the disparity in ADHD diagnosis between boys and girls, and how to lessen gender bias in ADHD assessment.

Simon Kitson is an Educational Psychologist based in Bristol who specializes in working with children with ADHD and Autistic Spectrum Disorder (ASD).

In a previous blog article, I touched upon the differences between boys and girls who have the same underlying condition, but different presentations I was aware that I had scratched the surface of the subject and was pleased to be asked to add more for this latest post

The NICE Guidelines—evidence-based recommendations for health and care in England—make the following points, in section 1.2.2:

“Be aware that ADHD is thought to be under-recognised in girls and women and that:

• They are less likely to be referred for assessment for ADHD
• They may be more likely to have undiagnosed ADHD
• They may be more likely to receive an incorrect diagnosis of another mental health or neurodevelopmental condition. [2018]” [1]

The notion of the underdiagnosis of girls and women with regard to ADHD is now gaining traction, particularly in relation to the NICE guidelines listed above. There is also a considerable amount of anecdotal evidence from adult women who received a later diagnosis and subsequently experienced enlightenment, and an explanation of their formative experiences. They frequently talk of their symptoms being labelled as “gender based anxiety”, “hormonal”, “a chatty girl” or a “daydreamer.”

Data from a US study (Health, United States, 2019, table 12 – Health conditions among children under age 18, by selected characteristics: United States, average annual, selected years 1997–1999 through 2016–2018) confirms this. Note: ethnicity data has been omitted due to complexity of interpretation, as has health insurance status at the time of data collection. “[Data are based on household interviews of a sample of the civilian noninstitutionalized population]”):

Source: https://www.cdc.gov/nchs/data/hus/2019/012-508.pdf

Whilst it must be accepted that this research is likely to be subject to sampling bias (respondent self-report and survey engagement), it provides several interesting insights. In the period between 1997-1999 the number of girls described as having ADHD was one third that of boys.). In the period 2016-2018 the number of girls described as having ADHD was half that of boys. This is a positive trend in terms of recognition of the prevalence of the condition in girls.

More recent research data from the United States re-iterate this:

Source: https://www.cdc.gov/nchs/data/hus/2019/012-508.pdf

The above clearly demonstrates that fewer girls/young women are diagnosed. The effect of social media–where women who describe the positive impact of their later diagnosis–is gradually implanting the notion of ADHD and women into public consciousness.

The presentation of boys with ADHD is well documented elsewhere, so does not bear reiteration. In essence, when we consider girls and young women in an academic setting, it is important that we do not adopt gender stereotypes to account for observable and (pejoratively) ‘problematic’ presentations. In this context problematic refers to behaviour that is inconsistent with teacher expectations for learning) .

Variously and at different times girls might appear to demonstrate some of the following symptoms. It’s important to note that girls will not necessarily demonstrate all of these characteristics, and they can develop compensatory strategies:

• Verbally impulsive
• Shy (as a compensatory strategy)
• Becomes easily emotionally dysregulated
• Attention ‘flits’ from activity to activity
• Responds slowly to direction or processes information slowly
• Slow/unable to complete tasks
• Appears to daydream
• Problems with personal and academic self-organisation
• Executive functioning (planning and integrating multimodal tasks) difficulties
• Calls out answers–unable to self-regulate
• Poor time management, even with the prospect of sanctions for noncompliance
• Appears unmotivated/not trying

This is a good starting point for raising awareness of ADHD in girls/young women. It might be useful to use this short article as a starting point or focus for a staff meeting which results in the development of a whole school policy for becoming an ‘ADHD Aware’ school.

Interested in adding objective testing to your own practice? Book a call with one of our experts to learn more about objective testing to reduce gender bias and improve patients outcomes for ages 6-60.

References:

1. nice.org.uk

Suggested Further Reading:

Hinshaw et al. ADHD in girls and women: a call to action – reflections on. JCPP. Volume63, Issue 4, April 2022, Pages 497-499.

José J. Bauermeister et al. ADHD and gender: are risks and sequela of ADHD the same for boys and girls? JCPP. Volume48, Issue 8, August 2007, Pages 831-839.

Mira Elise Glaser Holthe and Eva Langvik. The Strives, Struggles, and Successes of Women Diagnosed With ADHD as Adults. Sage publications. March 29, 2017.

Patricia O. Quinn, MD corresponding author and Manisha Madhoo, MD. A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis. Prim Care Companion CNS Disord. 2014; 16(3): PCC.13r01596.

Susan Young et al. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry. 2020; 20: 404.