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It’s a concerning reality that many girls with undiagnosed ADHD grow up hearing themselves mislabeled as “spacey,” “way too talkative,” and “disorganized.”

As teenagers, they may fall behind academically, even though their frustrated parents and teachers know these young women are intelligent and capable. And in adulthood, many still struggle due to increased responsibilities and different roles.

In an era of growing awareness about wage gaps and social inequities, researchers are devoting more energy to health disparities such as this one: Boys are still diagnosed with ADHD much more often than girls — 12.9 percent compared with 5.6 percent — according to the Centers for Disease Control and Prevention (CDC). Is it just that boys have ADHD more often than girls do?

Increasingly, researchers are realizing it’s more complex than that.

The reasons boys with ADHD are more likely to be diagnosed than girls are varied and complex. Here are just a few of the main factors:

  • Until recently, most studies have focused on boys, so more is known about how boys experience ADHD and how their lives are shaped by it.
  • ADHD presents differently in different people. Sex, gender, and hormones may influence which symptoms are dominant.
  • Gender norms may force girls to mask and hide symptoms of ADHD. Stereotypes around neatness, organization, cooperation, compliance, and social behaviors may encourage girls and women to deny or compensate for ADHD symptoms in classrooms and family structures.
  • Gender norms may also keep teachers from recognizing symptoms as ADHD in girls. Because symptoms can be more subtle in girls, healthcare practitioners may be less likely to diagnose girls with ADHD unless they also show symptoms of emotional disorders.
  • Medical professionals may be more apt to treat anxiety and depression in girls without recognizing co-existing ADHD.

ADHD is a mental health disorder that affects the ability to do some or all of these tasks:

  • pay attention, focus, or concentrate for prolonged periods
  • notice some details
  • break activities and goals into steps or stages
  • stay organized
  • manage schedules
  • remember things
  • sit still
  • manage impulses

People with ADHD typically have symptoms that fall into one of three categories:

  • Inattentive. Inattentive is characterized by difficulty concentrating, easily distracted, making many careless mistakes, and often losing necessary items.
  • Hyperactive/Impulsive. Hyperactivity/impulsivity is characterized by restlessness, difficulty remaining seated, excessive talking, and often interrupting.
  • Combined. Combined is characterized by both inattentive and hyperactive symptoms

To receive an ADHD diagnosis, an individual must have at least six of nine major symptoms listed in The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) for a specific type of ADHD. These symptoms must be present and disruptive to everyday life for at least 6 months and must be present in more than just one setting — at home and at school, for example.

Some researchers believe females may be underdiagnosed because they often have more symptoms of inattentive ADHD than of hyperactive/impulsive ADHD.

Because the symptoms of hyperactive/impulsive ADHD can be louder and more disruptive, the comparatively quiet distractibility of inattentive ADHD doesn’t capture the attention of parents, teachers, and healthcare professionals as readily.

ADHD symptoms vary from person to person. Generalizations based on sex or gender aren’t always helpful in making sure each individual gets the right care.

Here’s what recent research has revealed about gender differences in ADHD symptoms.

ADHD and hormones

In all sexes, changes in hormone levels can influence ADHD symptoms. Regardless of gender, individuals may experience a shift in symptoms around puberty when sex hormones influence physical symptoms and behavior. Fluctuating hormones can affect symptoms in other ways:

  • Changing hormone levels in pregnancy and menopause can also increase symptoms.
  • Inattention can increase after the ovulation phase of your menstrual cycle.
  • Changes in estrogen levels across your cycle can increase ADHD symptoms, especially for women with ADHD who may experience more impulsivity.

Psychological and emotional effects of ADHD on women

  • Multiple studies of girls with ADHD have shown that their self-esteem is often lower than boys with ADHD — even well into adulthood.
  • Research that compares girls with ADHD with girls who do not have ADHD suggests those with ADHD often have more conflict in their social relationships than those without ADHD.
  • Research of women and girls suggests women diagnosed with ADHD are at a higher risk of experiencing symptoms consistent with diagnoses of disorders such as depression, anxiety, and eating disorders. Additionally, borderline personality disorder is more likely to be reported among women previously or concurrently diagnosed with ADHD, hyperactive/impulsive type.

When children and teens have diagnosed ADHD, doctors often prescribe stimulant or nonstimulant medications to manage symptoms and improve functioning. Research shows that doctors routinely prescribe less medication to treat females with ADHD than they do males.

This difference in prescription rates is sometimes surprising since studies show that both stimulant and nonstimulant medications improve most symptoms in girls as much as or more than they do in boys. Again, these differences may be attributed to behavioral differences between girls and boys that may cause boys to receive more treatment than girls.

In adults, prescription rates are more equal. Women still receive less medication than men, but the difference is not as dramatic.

More research needs to be done to understand differences in how male and female bodies process ADHD medications and how rising and falling hormones alter the effectiveness of medication.

For example, studies have shown that stimulant medications “wear off” earlier in the day for girls. Understanding these differences may help doctors tailor treatment to what each woman needs.

Medications aren’t the only treatment for ADHD. Psychotherapy, cognitive behavioral therapy, and social skills training can also help.

Health experts recommend that girls and women talk with therapists about extra risks they could face. Studies show that girls and women with ADHD are more likely to develop substance use problems, behaviors that increase the likelihood of negative outcomes, disordered eating, and self-harming. Educating girls and women about ADHD may help them avoid:

  • feeling shame and blaming themselves
  • seeking stimulation that can negatively affect them
  • coping skills that can do more harm than good

When a clear diagnosis and effective treatments are delayed, people can experience worse outcomes over the course of a lifetime, including:

  • less academic and career achievement
  • more anxiety and depression
  • more conflict in relationships
  • lower self-esteem
  • physical symptoms like headaches and abdominal distress
  • sleep problems
  • higher healthcare costs

Girls and women are often underdiagnosed or misdiagnosed when it comes to ADHD.

It could be because they’ve become good at compensating for or masking their symptoms. Or it could be because parents, teachers, and health professionals don’t recognize symptoms of inattention as readily as they do more boisterous and disruptive symptoms.

Women are also more likely to:

  • experience changes in symptoms because of fluctuating hormones
  • develop anxiety disorders and depression because of ADHD
  • have lower self-esteem and higher conflict in relationships because of ADHD

As more research focuses on the lived experiences of women with ADHD, women can look forward to treatments that work more effectively for them as individuals.

For now, here’s something to consider.

If you have ADHD, you’re not lazy. You’re not scatterbrained. Like 4.4 percent of adults in the United States, you have a mental health condition that makes paying attention, resisting impulses, preparing, organizing, and completing tasks challenging or sometimes impossible.

Getting the right kind of treatment can be like flipping a tapestry art-side up. The tangle of knots and threads can begin to make beautiful, colorful sense.