Table 1 Summary of key points for detection of ADHD in females

ADHD symptoms:

• Females present with both inattentive and hyperactive-impulsive symptoms

• Symptom severity may be lower in females than in males, particularly for hyperactive-impulsive symptoms.

• Inattention in girls and women with ADHD may present as being easily distracted, disorganised, overwhelmed and lacking in effort or motivation.

• Symptoms are pervasive and impairing rather than transient or fluctuating.

• ADHD symptoms may become more obvious later in females, often during periods of social or educational transition.

• Adult women may develop awareness of their difficulties leading them to self-present to primary services.

• Symptoms may be exacerbated by hormonal changes during menstrual cycle, pregnancy and menopause.

• Gender-based biases in teachers and parents appear to affect referral likelihood.

• Less overt ADHD symptoms are less likely to lead to referral which means that inattentive girls are more often missed.

Comorbidity:

• In girls and women with ADHD common comorbidities appear more internalised in nature.

• Whilst externalising behaviours and conditions may present in females with ADHD, these are less common than in males with ADHD.

• Females may suffer more general impairments in intellectual functioning.

• Risk of substance use disorders is elevated for both males and females with ADHD.

• Internalising symptoms secondary to, or comorbid with ADHD may be misinterpreted as primary conditions. Low mood, emotional lability, or anxiety may be especially common in females with ADHD.

• The key message is not to discount ADHD in females because they do not display the behavioural problems commonly associated with ADHD in males.

Associated features and vulnerabilities

• Difficulties with emotional lability and emotional dysregulation may be more severe or common in girls and women with ADHD.

• Social problems may be particularly impairing.

• Girls with ADHD are vulnerable to bullying, including physical and social-relational bullying, and cyberbullying.

• Females with ADHD tend to become sexually active earlier than their peers and have an increased number of sexual partners. Rates of contraction of sexually transmitted infections and rates of teenage, early and unplanned pregnancies are elevated.

• Antisocial behaviour may also be present in females with ADHD. The rate of ADHD among prisoners is similar for male and female offenders.

• Increased school dropout, academic under-achievement.

• Decreased self-esteem and self-concept

• Increased rate of accidents.

Compensatory and coping behaviours:

• Compensatory behaviours may mask behaviour and impairments, and delay time to referral.

• Dysfunctional strategies, such as drinking alcohol or smoking cannabis may be used to cope with emotional turmoil, social isolation and rejection.

• Some girls may seek to build social support through high risk activities (e.g. joining a gang, promiscuity, criminal activities).