How girls and boys differ in presentation and diagnosis

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most commonly diagnosed neurobehavioral disorders in childhood, affecting millions of children worldwide. According to a 2022 National Children’s Health survey, an estimated 7 million (11.4%) of U.S. children aged 3–17 years have been diagnosed with ADHD. Traditionally, ADHD has been considered a condition that primarily affects boys, with early diagnostic criteria reflecting symptoms commonly observed in them, such as hyperactivity and disruptive behavior. Studies have shown that boys are diagnosed with ADHD at higher rates than girls, often by a ratio of 2:1 or more. This discrepancy has led to the misconception that ADHD is less common in females. However, as more research emerges, it is becoming increasingly clear that girls are just as likely to have ADHD, but their symptoms often go unnoticed, leading to delays in diagnosis and treatment.

The Traditional Understanding of ADHD in Boys

One reason for the higher diagnosis of ADHD in boys may be due to the classic symptoms of ADHD — hyperactivity, impulsivity and disruptive behaviors — are more readily seen in boys. In a classroom setting, a boy with ADHD may be the child who can’t sit still, blurts out answers or is frequently out of their seat. These behaviors are easy to spot and disrupt the classroom, leading teachers and parents to seek help early on.

The age of diagnosis for boys is typically younger, with many receiving an ADHD diagnosis by age 7. Boys are more likely to fall into the “hyperactive-impulsive” or “combined” subtypes of ADHD, which include outward symptoms that are difficult to ignore. This makes it more likely for boys to be flagged for evaluation and treatment.

The Overlooked Presentation of ADHD in Girls

In contrast, girls with ADHD are often more likely to exhibit inattentive symptoms, which are much less obvious and disruptive than hyperactive behaviors. A girl with ADHD might be the quiet daydreamer in the back of the classroom, struggling to focus but not causing any disruptions. She may have difficulty staying organized, following instructions or completing tasks, but because she isn’t acting out, her difficulties may be dismissed as laziness or simply a lack of motivation.

Boys with ADHD tend to have higher levels of hyperactivity and impulsivity, making their behaviors more conspicuous. This can result in boys being labeled as “troublemakers” or “disruptive” in school, often leading to more immediate interventions, albeit sometimes punitive rather than therapeutic.

On the other hand, girls with ADHD often struggle with attention and organization, which can manifest as difficulty completing tasks, losing items frequently or struggling to follow instructions. Because these behaviors do not disrupt the classroom environment as much, they may be overlooked or attributed to a lack of effort. Girls with ADHD are also more likely to develop coping strategies to mask their difficulties, such as over-preparing for assignments or relying heavily on peers for help. These strategies can further obscure the need for an ADHD diagnosis.

This subtler presentation of ADHD in girls often leads to delayed diagnosis. In fact, many women don’t receive an ADHD diagnosis until adulthood, after years of struggling with academic, social and emotional challenges. A girl with ADHD might be labeled as “chatty” or “spacey” without anyone recognizing that these are signs of a neurodevelopmental disorder. Unfortunately, this can result in girls going without the support they need during critical periods of their development.

Gendered Expectations and ADHD Diagnosis

The way society views gender roles and behaviors also plays a significant role in how ADHD is recognized in girls versus boys. Boys are often expected to be more active and energetic, so when they exhibit hyperactive symptoms, these behaviors are seen as excessive and worthy of concern. On the other hand, girls are often expected to be more compliant, organized and socially adept. When they struggle with attention, executive function or emotional regulation, it may be misinterpreted as a personal failing rather than a sign of ADHD.

Additionally, because girls with ADHD tend to display fewer behavioral problems, they are less likely to be referred for evaluation. Research shows that girls with ADHD are often referred for treatment later than boys, which can delay critical early interventions that could improve outcomes. This gender bias in diagnosis and treatment means that girls may not get the help they need during their formative years, contributing to difficulties in school, friendships and eventually, the workplace.

ADHD Symptoms in Adolescence and Beyond

As children with ADHD grow older, their symptoms may evolve, and this can look different for boys and girls. For boys, hyperactive behaviors may lessen as they enter adolescence, though impulsivity and inattention may remain. Girls, meanwhile, may begin to experience more pronounced difficulties during puberty, when hormonal changes — particularly fluctuations in estrogen — can exacerbate ADHD symptoms. This can lead to increased challenges with mood regulation, self-esteem and anxiety.

Adolescence is often a time when many girls begin to struggle with the social and academic pressures of growing up. While boys with ADHD may be more likely to face academic challenges, girls may internalize their difficulties, leading to issues such as anxiety, depression and low self-worth. This internalized distress may further obscure the underlying ADHD, as it’s easy for parents, teachers and even clinicians to miss the signs amidst these other emotional struggles.

The Consequences of Underdiagnosis

The differences in symptom presentation between genders also contribute to distinct social and emotional challenges. Boys with ADHD are more likely to engage in risky behaviors and may struggle with peer relationships due to their impulsivity and hyperactivity. They may also face disciplinary actions in school, leading to feelings of frustration and low self-esteem.

Girls with ADHD, however, are more prone to internalizing their struggles. They may experience significant anxiety, depression and low self-esteem, often as a result of feeling inadequate or “different” from their peers. The social challenges for girls with ADHD can be subtle yet profound, including difficulties in maintaining friendships and increased susceptibility to peer pressure. The emotional toll of these struggles can lead to long-term mental health issues if not addressed.

The consequences of undiagnosed and untreated ADHD in girls can be profound. Without proper support, girls with ADHD may experience academic underachievement, difficulty maintaining friendships and struggles with self-esteem. These challenges often continue into adulthood, where they can affect a woman’s ability to maintain a career, manage relationships and build independence.

Moving Toward Better Diagnosis and Treatment

Recognizing the unique ways that ADHD presents in girls is crucial for improving diagnosis and treatment. Girls with ADHD need early intervention just as much as boys, but they often require a different approach. Teachers, parents and clinicians need to be aware of the more subtle signs of ADHD in girls — such as inattentiveness, forgetfulness and difficulty managing time or tasks — so that they can receive the proper evaluations.

Additionally, it is important to understand that gender expectations can shape how ADHD is perceived and treated. Girls with ADHD may require not only behavioral and academic support but also emotional support to help them navigate the shame and frustration they may feel as a result of their struggles.

Conclusion

ADHD affects both boys and girls, but the way it manifests can look very different between genders. Recognizing these differences is essential for ensuring that all children receive the diagnosis and support they need to succeed. Understanding the unique presentation of ADHD in girls and challenging the biases that contribute to their underdiagnosis can lead to better outcomes for girls as they grow into confident, capable adults. The goal is not just to manage symptoms but to empower individuals with ADHD to reach their full potential, regardless of gender.

Michelle Yetman, Ph.D., is an associate professor and clinical psychologist at LSU Health Shreveport School of Allied Health Professions.