ADHD often has the stereotype of the ‘naughty boy syndrome’ which means ADHD is often missed in young girls. and also in older age (men and women). The stereotype exists for various reasons, not in the least due to historical biases, gender differences in presentation of symptoms and also societal expectations / out-dated associated stigma.
- Historical Bias: Historically, ADHD was predominantly studied and diagnosed in boys, leading to a skewed understanding of the disorder. Because of this, 4/1 children referred to and studied in clinics are still boys, whilst meta-analyses show that the gap is much closer at a 2:1 ratio boys:girls, as per the Institute of Psychiatry (IoP) King’s College London. Unfortunately, this bias lingers, further influencing how ADHD is perceived, who is referred and who is more likely to be officially diagnosed.
- Gender Differences in Symptoms: Whilst there are individual differences in ADHD symptoms between everyone, there are specific gender-based differenced which impact the presentation of ADHD in males vs. females. Males with ADHD tend to exhibit greater “oppositional defiance” disorders and hyperactivity, whilst females tend to exhibit less defiant symptoms, tend to show generally less disruptive behaviours and also tend to show more inattentiveness vs. the hyperactivity seen more in males. Whilst all individuals with ADHD are pronte to emotional dysregulation such as anxiety and depression, females tend to be more at risk of developing these in teenage years, and even perhaps as young as childhood, which may show itself through less obvious “anxious behaviours” such as perfectionism, rejection sensitivity disorder and phobias.
- Societal Expectations: There is a societal expectation that females should be more attentive, organized, and well-behaved compared to males, which may foster masking behaviour in women. This means that females with ADHD, especially young and teenage girls, may “mask” their symptoms by finding coping strategies such as putting in extra effort (which can foster burnout) and learning “social masks”, which again impacts diagnosis.
- Diagnostic Bias: Diagnostic criteria was historically geared towards symptoms most impacting parents and educators, and so those that were most disruptive in a learning or home environment e.g. defiance in school, difficulty “staying seated”, hyperactivity in a school setting and difficulty managing children at home.Whilst these are certainly presentations of ADHD, the presentations are those that we tend to see more amongst males, meaning wider presentations including female-specific and presentations have been overlooked. And this doesn’t even count adult-onset ADHD, wherein the criteria has not historically been suitable. Whilst criteria has been updated in the most recent DSM 5 (Diagnostic & Statistical Manual for Mental Health), it is still very narrow in its framework and doesn’t well take into account e.g. the propensity for burnout amongst those with ADHD, especially in women; the impact of hormonal changes during times such as puberty, menopause and andropause; or wider presentations such as pyper-focus, cycling through various interests and hobbies, propensity for anxiety (which might show up in anxiety-driven behaviours such as perfectionism and rejection sensitivity disorders) and other more age-specific presentations.
All of the above delays diagnosis or means that both men and women, of all ages, go undiagnosed, which can severely impact the quality of life of those with ADHD. Not only that, but it is a matter of safety that we become more aware of the differing presentations of ADHD as a society, including the general public and those raising children; those teaching children, teenagers and adults alike; in the workplace; and clinicians who might be more prone to mis-diagnoses (e.g. depression) and psychiatrists who directly diagnose ADHD.
But how can we change the stereotype to promote earlier diagnosis, earlier management and better quality of life for those with ADHD?
Several steps can be taken:
- Public Awareness: Public awareness campaigns promoting education on neurodivergence, including the wider variety of presentations in ADHD (and other neurodivergent conditions) is key. This will allow caregivers to recognise the potential ADHD-driven characteristics earlier on. This will mean more diverse and inclusive representations of ADHD in the media to chip away at stereotypes and out-dated stigma..
- Training In Educational Institutions: Similarly to the above, it’s key that pre-schools, primary schools, secondary schools, colleges and even universities are properly educated on neurodivergent presentations so that any potential “red flags” outside of the outdated “naughty boy” stigma aren’t missed.
- Training for Healthcare Professionals: Ensuring all healthcare professionals are aware of the various presentations of ADHD, including wider characteristics, gender-specific and those that may adapt with age, is key. This includes GPs who may be more prone to mis-daignose ADHD as e.g. anxiety or depressive disorder or stress, alongside psychiatrists actively diagnosing ADHD. Encouragement of consideration of ADHD amongst anyone presenting with co-morbid behaviours, such as anxiety, depression, hyper-focused, phobias, circular thinking, etc. should be encouraged.
- Empower Women of All Ages: Youngs girls, teenagers and women can be prone to anxious thinking, internalisation, depression and burnout, which is even moreso the case in those with ADHD. Educating girls and women on the symptoms of ADHD so that they can recognise the symptoms in themselves, including provision of resources and encouraging them to seek help is important. Support groups, school psychologists and advocacy organisations have a crucial role to play here.
- Shift Societal Expectations: Of course, challenging the typical gender roles expectations is also key to combat stereotypes which can lead to ADHD going missed. Allowing for more acceptance of neurodiverse characteristics and also less confirmation to a gender “norm” may help reduce masking-type behaviours to promote earlier diagnosis.
- Research and Diagnostic Criteria: Continuing research into ADHD presentations, including gender and age-related differences and updating the DSM in line with this is key. Updating the educational material, guidelines and diagnostic instruments is so important to ensure that the full range of presentations is taken into account, including those specific to adulthood, and how these may change with age and age stages (e.g. menopause).
- Alternative Methods of Management: Not all of those diagnosed with, or trying to manage undiagnosed ADHD, will want to rely on pharmaceutical medications, and this is actually one reason why many may struggle to manage ADHD (and neurodivergent) symptoms. Whilst medications have been revolutionary and have turned around the lives of so many people living with neurodivergent conditions, they also come with side-effects, and some may not like taking medications. Embracing the role of nutrition in brain health, including foods, supplements and lifestyle changes is key. This is a deep conversation which poses questions for public discourse, media, literature, research studies, clinicians and the educational model as a whole.
Overall, changing the stereotype of ADHD as "naughty boy syndrome" will require a multi-faceted approach, including educational changes, public awareness campaigns, updated diagnostic criteria and a shift in public awareness and outdated societal attitudes toward neurodiversity. Through acknowledging and actively addressing these issues, we can work towards earlier diagnosis, better management, and improved quality of life for all individuals with ADHD, regardless of their age or gender.
