According to the Centers for Disease Control and Prevention (CDC), boys are far more likely to be diagnosed with ADHD than girls. Boys are also more likely to receive a diagnosis at a younger age.

But many women and girls with ADHD go undiagnosed (or misdiagnosed) for years. Why is that?

ADHD, or attention deficit hyperactivity disorder, is a neurodevelopmental condition that affects learning and behavior. There are three distinct subtypes of ADHD:

  • Primarily hyperactive and impulsive: characterized by excessive fidgeting, high levels of energy, and difficulty with impulse control
  • Primarily inattentive: characterized by difficulty with attention, organization, and focus (formerly called attention deficit disorder, or ADD)
  • Combined: characterized by both hyperactivity and difficulty with attention

In popular media, ADHD is often framed as a male disorder. But in reality, the condition affects both boys and girls. It often just looks different in girls.

When you hear the term ADHD, you probably think of the primarily hyperactive and impulsive subtype. That describes the kid who’s constantly bouncing off the walls, talking nonstop, and seemingly unable to sit still or play quietly. This image is the stereotypical presentation of what a child with ADHD looks like.

But more often, the girls with ADHD present with the primarily inattentive subtype. That describes the kid sitting quietly in class, lost in their own thoughts.

A child with primarily inattentive ADHD probably isn’t squirming around in their seat or disrupting the class. Instead, they’re facing the board, appearing deep in thought. Or they might be scribbling intently in their notebook. You may assume they’re paying attention, but inn reality, they’re staring off into space, daydreaming, or doodling.

Compare that with the little boy constantly shouting out answers without remembering to raise his hand or getting up every 5 minutes to throw something away or sharpen his pencil.

Who’s more likely to be noticed by a teacher?

Of course, girls with ADHD don’t always have the primarily inattentive subtype. They often do present with combined or primarily hyperactive and impulsive ADHD. But even then, the disorder tends to look different.

Regardless of the subtype, girls often display internalized rather than externalized symptoms.

While externalized hyperactive behaviors are overt — such as fidgeting or shouting out in class — internalized hyperactivity is not. Instead, it can look like:

  • excessive talking
  • doodling in class instead of taking notes
  • racing thoughts
  • feelings of anxiety
  • emotional sensitivity or reactivity
  • difficulty making or keeping friends

Again, these internalized symptoms are much harder to recognize for many parents and teachers. As a result, these kids often don’t receive the evaluations they’d need for diagnosis.

Gender expectations can also cause adults to overlook ADHD in girls. Girls are expected to be gentle, soft-spoken, and calm. Being shy is also more common — or at least more socially acceptable — in girls.

So, let’s say there’s a female student who never raises her hand in class. One day, the teacher does call on her. Suddenly, a look of panic flashes on her face — she doesn’t know the subject they’re talking about, let alone the question, because she hasn’t been paying attention at all.

The teacher, though, sees her expression and assumes she’s just shy.

Girls are also viewed as being more social and emotional than boys. So a girl with ADHD who’s overly sensitive, cries easily, or talks too much in class may not cause concern. As disruptive as her behavior may be, she’s more likely to be labeled as a “chatty Cathy” than a struggling student.

Gender expectations don’t just impact how symptoms are interpreted. They can also play a role in how symptoms are managed.

Girls with ADHD have a tendency to mask their symptoms.

For example, they might try to rein in their own hyperactive behaviors because they’ve been socially conditioned to believe that girls aren’t supposed to behave that way. Instead of fidgeting and squirming in class, they might cope with their restless feelings by drawing in their notebook to keep their hands busy.

Because girls are often people-pleasers, they may hide their struggles more. To cope with inattentiveness and difficulty focusing in school, they might spend more time studying or doing homework to maintain good grades.

On the outside, a girl with ADHD may be perceived as a perfectionist or a bookworm. But in reality, she’s simply trying to compensate for her ADHD.

This can often lead to increased levels of stress and anxiety. Girls with ADHD may blame themselves for their perceived failures and develop low self-esteem as a result.

Because of these differences in symptoms, social expectations, and coping strategies, ADHD in girls often goes unnoticed and undiagnosed.

Many women receive an ADHD diagnosis much later in life, especially compared to men, who are likely to be diagnosed in childhood.

Even though women do show signs and symptoms of ADHD during their younger years in school, it’s frequently overlooked by parents and teachers. Girls with ADHD might be labeled ‘ditzy’ or ‘spacey,’ their symptoms reduced to a stereotype rather than taken seriously.

In other cases, though, symptoms are noticed, but they’re attributed to something else. Many women with ADHD are diagnosed with other disorders, such as anxiety or depression. It’s worth noting that both anxiety and depression are comorbid (coinciding) conditions of ADHD.

Of course, it’s entirely possible that years of undiagnosed ADHD could contribute to these mood disorders in women. And given that women with ADHD are more likely than their male counterparts to also be diagnosed with anxiety, depression, eating disorders, self-harm, and substance misuse, that could very well be the case.

What can be done to ensure that future generations of girls have their symptoms and needs recognized? And how can the women who weren’t diagnosed in their younger years find the support they need for their continuing challenges?

Researchers have acknowledged that a key part of addressing the underdiagnosis of girls with ADHD is educating teachers, parents, and healthcare professionals regarding what ADHD can look like in girls.

However, it’s also crucial that the research into ADHD adjusts. Researchers must recruit female participants for studies and consider how gender stereotypes and bias may impact results.

It’s not just pediatricians but family doctors and physicians who should be open to recognizing and identifying ADHD symptoms. The CDC noted that between 2003 and 2015, the number of women ages 15 to 44 with private insurance who filled an ADHD prescription rose by 344%.

As more women are diagnosed, it’s essential to have healthcare professionals who can offer resources and information to help them learn to manage their condition safely and effectively.