Boys aren’t the only people who develop attention-deficit/hyperactivity disorder (ADHD). It also affects girls and young women and adults of both genders. Yet females with ADHD are chronically underdiagnosed and undertreated.
Individuals with this condition die about 10 years earlier than those without it. They are also up to three times more likely to experience a variety of nonfatal negative life events, such as serious car accidents, unintended teen pregnancy, episodes of anxiety and depression, and suicide attempts. The use of medication can reduce the risks of many of these non-fatal events. Two recent studies demonstrated that treating ADHD with medications improves outcomes and can also save lives.
But it is harder for females than males to access appropriate diagnosis and treatment for ADHD, and national shortages of medication further reduce access.
Like other stigmatized conditions, ADHD continues to foster controversy. Questions about whether ADHD is “real” and a perseverative focus on the risks of ADHD “overdiagnosis” are common in digital and social media. But these concerns often emerge from ignorance about the scientific foundations of ADHD.
While the symptoms of attention-deficit/hyperactivity disorder have been recognized in medical textbooks for hundreds of years, the American Psychiatric Association’s publication of the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) manual in 1980 provided increasingly clear and reliable criteria for the diagnosis of ADHD. Since then, medical research has shown that ADHD is highly genetic, is associated with consistent abnormalities on brain scans, and, as noted earlier, increases the risk of negative life events and early death.
According to the Centers for Disease Control and Prevention, boys (13%) are more likely to be diagnosed with ADHD than girls (6%). Those numbers reflect chronic underdiagnosis and undertreatment among girls. This problem has multiple sources. First, ADHD diagnostic criteria as originally published in DSM-III were initially developed through the observation of disruptive boys and contain descriptions that better identify males with ADHD than females with ADHD. Although the criteria have improved over time, they still contain phrases such as behaving as though one were “driven by a motor,” which is less helpful in identifying some girls and women.
Women and girls are more likely to have symptoms of inattention — associated with challenges like organization, task completion, and daydreaming — and subtle impulsive symptoms such as verbal interruptions. The current criteria are not fine-tuned to identify more subtle presentations of ADHD in females.
Since girls are less likely to be disruptive in class and at home, they are less likely to be identified as a problem by teachers and parents, and so less likely to be referred to a clinician for diagnosis or treatment. But the fact that females with ADHD may not be a problem for others doesn’t mean that they are not suffering in silence.
Compounding the problem is that access to mental health care in the U.S. continues to be highly unequal. Minoritized women with inadequate access to health care are in a uniquely difficult position.
The ongoing national shortages of stimulants, which are the most commonly-prescribed and effective ADHD medications, do not seem to concern the Drug Enforcement Agency and Food and Drug Administration. They describe these shortages as “understandably frustrating,” which substantially understates the emergency faced by patients with severe ADHD. Scarred from the ongoing opioid crisis and appropriately concerned about real harms associated with stimulant misuse, these agencies emphasize the importance of limiting production of stimulants to protect public health.
To be sure, misuse of stimulants is a serious problem in certain populations. But so is undertreatment of ADHD. Tight production quotas produce predictable medication access issues that are disproportionately discriminating against disadvantaged people. We call on the DEA and FDA to directly and forcefully address the inequitable negative consequences of these regulations.
With regard to advancing appropriate ADHD diagnosis, there is hope on the horizon. The American Professional Society of ADHD and Related Disorders has convened national and internationally regarded researchers and clinicians to develop guidelines for diagnosing and treating ADHD in adults. These guidelines will help address ADHD experts’ and regulators’ legitimate concerns that unscientific diagnostic practices could contribute to overdiagnosis and medication misuse.
As we clarify in a recent petition to the American Professional Society of ADHD and Related Disorders, if these guidelines include a focus on women, they have the potential to address longstanding inequities in the diagnosis and treatment of ADHD. ADHD experts and the government must act in unison to increase gender-equitable access.
Michael Morse is an associate professor of psychiatry at Georgetown University and director of psychiatric education and training at The Chesapeake Center, a private group that specializes in the diagnosis and treatment of ADHD. Kathleen Nadeau is the founder and director of The Chesapeake Center.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.