Introduction
What is ADHD?
Symptom profiles
Biological and neurological factors
Psychosocial influences
Diagnosis and treatment gaps
References
Further reading
ADHD doesn’t look the same in everyone; boys tend to show outward hyperactivity, while girls often internalize symptoms. This article explains the science behind these gender differences and their impact on diagnosis and care.
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Introduction
This article explains why attention-deficit/hyperactivity disorder (ADHD) symptoms differ between boys and girls due to biological, hormonal, and social differences to reduce underdiagnosis and improve care. It highlights that symptoms frequently persist from childhood into adolescence and adulthood.2
What is ADHD?
ADHD is one of the most common neurodevelopmental conditions worldwide, affecting ~7.6% of children aged 3–12 years and ~5.6% of adolescents aged 12–18 years1 with symptoms often persisting into adulthood and contributing to functional impairment across the lifespan.2 Historically, diagnostic criteria and research on ADHD were developed largely from male samples, which led this condition to be traditionally characterized by hyperactivity, disruptive, and other externalizing behaviors.5
As a result, quieter presentations, such as daydreaming, inattention, and internalizing symptoms, many of which are typical in girls, were not considered. Girls were subsequently misdiagnosed with anxiety or mood issues, or recognized only when academic, occupational, or mental-health difficulties persisted into adolescence or adulthood.
Correcting this bias requires sex-sensitive screening, teacher and clinician training, as well as the establishment of criteria that capture inattentive phenotypes across the lifespan. In childhood, the male-to-female ratio is roughly 2.5–4:1, but becomes more balanced by adulthood, reflecting referral and recognition biases, as well as developmental factors.2
Symptom profiles
In classrooms and clinics, ADHD has historically been characterized by behaviors often observed in boys, some of which include restlessness, impulsive actions, and rule-breaking that disrupts lessons and triggers referral. This visibility helps explain why, during childhood, more boys are identified than girls, partly because hyperactivity and behavior problems lead teachers and parents to seek assessment. The sex ratio narrows with age, suggesting early referral bias rather than a true absence of girls with ADHD.2
Girls with ADHD present much differently than boys, with quieter behaviors, sustained inattention, daydreaming, and subtle social withdrawal. These features align with presentations sometimes described as “sluggish cognitive tempo” or “cognitive disengagement”, which is characterized by excessive daydreaming, slow, underactive behaviors, and poorer social functioning.2
ADHD was initially determined based on clinical observations of male children, which contribute to thresholds and symptoms that better capture externalizing presentations. As a result, girls may require more severe impairment to meet criteria and are more likely to be recognized later than boys.2,5
ADHD in Girls and Boys: Is It Different?
Biological and neurological factors
ADHD arises due to atypical connectivity across attention and reward circuits, particularly in the fronto-striato-parietal and cerebellar networks that support inhibition, sustained focus, and task switching. In ADHD, these communication pathways may be less synchronized, making it more challenging to filter distractions, delay gratification, or transition efficiently between tasks.2
Earlier studies have reported different gray and white matter patterns and default-mode task-positive interactions in girls as compared to boys, which implies that ADHD may affect different neural structures. This may account for why females often show proportionally more inattentive symptoms and working-memory/executive challenges than overt hyperactivity, on average.2
Hormones such as estrogen and progesterone interact closely with dopamine and other neurotransmitters involved in attention and reward. In phases of relatively lower estrogen (e.g., the late luteal/premenstrual and early follicular phases), dopamine tone and prefrontal efficiency may decline, thereby amplifying ADHD symptoms like distractibility, emotional lability, and executive-function ‘fog.’3
During perimenopause and menopause, fluctuating and ultimately declining estrogen levels can intensify cognitive complaints affecting working memory and sustained attention, as well as sleep disruption, which further reduces executive control. These hormonal transitions also intersect with broader health risks like rising cardiometabolic burden in perimenopause, thus emphasizing the importance of individualized strategies.3 Emerging approaches include cycle-aware stimulant titration and, in selected cases, adjunctive treatments for premenstrual symptom exacerbations, alongside careful consideration of hormonal therapies.3
Psychosocial influences
From early childhood, ‘active boys’ are expected to be loud and restless, whereas ‘quiet girls’ who daydream, over-organize, or talk a lot are described as conscientious or emotional, rather than symptomatic. Teachers and even clinicians may interpret lateness, overwhelm, or emotion as laziness, depression, or poor attitude, with some family members dismissing difficulties as diet-related or personality. These gender-based biases delay recognition, cause girls to self-doubt, and reduce access to accommodations and treatment.4,5
As a result, many girls with ADHD will adopt social coping strategies such as suppressing fidgeting, rehearsing ‘organized’ behavior, or mirroring peers. Perfectionism becomes a compensatory mechanism through overpreparing, overworking, and achieving high grades as a means of validation.4
Comorbidities such as anxiety and depression are common in females with ADHD and can mask core symptoms, delaying diagnosis and care.4,5 Ironically, strengths like empathy, creativity, and persistence often reappear after diagnosis when validation, medication, and scaffolds allow female patients to replace masking behaviors with realistic planning and self-compassion. Early, gender-informed recognition can reduce the duration required to reach this phase, enabling the conversion of masking into sustainable support.4
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Diagnosis and treatment gaps
Girls are often underdiagnosed or misdiagnosed with anxiety or depression instead of ADHD. As ADHD remains unrecognized, practicing masking behaviors increases the risk of comorbid anxiety and low mood, which subsequently become the primary clinical focus.4,5
ADHD screening that relies on disruptive behavior or equates high grades with good executive function systematically misses many girls who are living with ADHD. Accurate assessment should evaluate lifelong inattentive traits, fluctuating organization, rejection sensitivity, and the ‘cost’ of performance, such as late nights, burnout, and somatic complaints.5,2
Females are typically diagnosed with ADHD during adolescence or adulthood, when academic load, work demands, or caregiving roles exceed coping strategies. These diagnoses and treatment delays increase the risk of avoidable distress, self-esteem problems, strained peer and family relationships, as well as inefficient study and work habits that solidify over time.4,5
Hormonal transitions - including puberty, premenstrual phases, pregnancy, postpartum, and menopause - can transiently worsen inattentiveness, emotional lability, and sleep problems, complicating recognition and timing of evaluation. Clinicians should normalize late diagnosis, take multi-informant histories, and retrospectively identify early signs that may have been masked by effortful compensation.3,5
Gender differences also appear in response patterns to stimulant and behavioral interventions; however, studies making these comparisons reported modest effect sizes with high individual variation. For example, although stimulants and non-stimulants are effective in females, dosing may need to be finely titrated across the menstrual cycle and other hormonal phases to minimize side effects that affect appetite, sleep, and irritability.3
Since ADHD in girls often presents with anxiety, perfectionism, and social-relational stress, combining medication with behavioral therapy like organizational skills, cognitive-behavioral strategies, sleep hygiene, and parent/teacher coaching yields better functioning than either approach alone. Schools should offer quiet testing spaces, deadline flexibility, and executive-function supports.5
References
- Salari, N., Ghasemi, H., Abdoli, N., et al. (2023). The global prevalence of ADHD in children and adolescents: a systematic review and meta-analysis. Italian Journal of Pediatrics 49(1). DOI:10.1186/s13052-023-01456-1, https://ijponline.biomedcentral.com/articles/10.1186/s13052-023-01456-1
- Sonuga‐Barke, E. J., Becker, S. P., Bölte, S., et al. (2023). Annual Research Review: Perspectives on progress in ADHD science–from characterization to cause. Journal of Child Psychology and Psychiatry 64(4); 506-532. DOI:10.1111/jcpp.13696, https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13696
- Kooij, J. J. S., de Jong, M., Agnew-Blais, J., Amoretti, S., et al. (2025). Research advances and future directions in female ADHD: the lifelong interplay of hormonal fluctuations with mood, cognition, and disease. Frontiers in Global Women's Health 6. DOI:10.3389/fgwh.2025.1613628, https://www.frontiersin.org/articles/10.3389/fgwh.2025.1613628
- Morley, E., & Tyrrell, A. (2023). Exploring Female Students’ Experiences of ADHD and its Impact on Social, Academic, and Psychological Functioning. Journal of Attention Disorders 27(10); 1129-1155. DOI:10.1177/10870547231168432, https://journals.sagepub.com/doi/10.1177/10870547231168432
- Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The Primary Care Companion for CNS Disorders 16(3). DOI:10.4088/PCC.13r01596, https://www.psychiatrist.com/pcc/review-attention-deficit-hyperactivity-disorder-women/
Further Reading
Last Updated: Nov 6, 2025