According to recent CDC data, girls ages 3-17 are diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) at roughly half the rate of boys (7% vs. 13%) and wait an average of five years longer to get diagnosed.
“It is underdiagnosed and a problem,” says Child and Adolescent Psychiatrist Suzanne Reiss, MD. “Many girls are experiencing significant internal suffering that we could prevent with better recognition and earlier diagnosis.”
Dr. Reiss, a longtime REACH faculty member, has spent years seeing this pattern firsthand. We asked her to explain the reasons behind this diagnostic gap, why current screening approaches miss girls, and what primary care clinicians can do to support their female patients who may be silently struggling.
Why Girls Are Overlooked: A History of Externalized Criteria
The diagnostic gap starts with clinical terminology. Historically referred to as “minimal brain dysfunction” and later “hyperkinetic disorder of childhood,” in previous versions of the DSM, the medical understanding of ADHD has been constructed around observable, outward disruption.
“The lexicon describing this condition emphasizes external behaviors we can witness, rather than the internal executive functioning struggles,” Dr. Reiss explains.
Standard diagnostic screening tends to mirror this historical bias because of how symptoms manifest. Current DSM-5-TR criteria lists an equal number of criteria for both inattentive and hyperactive-impulsive presentations (requiring 6 of 9 symptoms in either category for a diagnosis). However, hyperactive behaviors like squirming or the inability to stay seated are overtly disruptive, making them far easier for teachers and parents to recognize. In contrast, the inattentive criteria that girls more often display (like misplacing things or being sidetracked by external stimuli) are quiet and non-disruptive.
“A lot of girls do well academically because they push through it,” says Dr. Reiss. “Combine this with the fact that most have inattentive symptoms rather than hyperactive, it goes under the radar. Many people say, ‘They’re doing well in school, they don’t have ADHD.’” And ADHD is not only a school-based problem. It affects patients outside that arena.
The Executive Function Story and the Toll of Masking
When discussing why girls are often missed, Dr. Reiss points out that the core challenge comes down to how we view the condition itself. “It is a disorder of dysregulated attention, not a lack of attention,” she explains. “Youth with ADHD don’t regulate attention in a way that fits into a linear world.”
In clinical work, Dr. Reiss sees this dysregulation show up not as classroom disruption, but with issues related to executive functioning: planning and time management, organization, and task initiation, difficulty with transitions, and overlooking details. Because these struggles are internal, many girls adapt by subduing their outward behavior to meet expectations.
This drive to remain compliant usually stems from societal pressures. “There is such an imperative for girls to be well-behaved,” Dr. Reiss reflects. This internalized societal expectation to appear composed, organized, and high-achieving can come at a cost.
“A child can be doing extraordinarily well in school, and often those youth come home and let it all out,” Dr. Reiss explains. “There is often a lot of internal distress that girls with ADHD have and all that self-doubt and masking can lead to clinically significant anxiety.”
The Hormonal Dynamic: A Key Variable in Symptom Fluctuations
Sex hormones play a role in regulating the neurotransmitter systems tied to ADHD. As Dr. Reiss explains, estrogen directly influences dopamine and serotonin sensitivity in the brain, meaning that when estrogen levels drop, dopamine availability decreases, which can trigger a noticeable increase in executive function challenges.
“We have data for adult women showing that fluctuating estrogen levels affect ADHD symptoms,” Dr. Reiss explains. “During the menstrual cycle, there can be a worsening of symptoms and mood because fluctuations in estrogen affect dopamine and serotonin sensitivity, and can even make medications feel less effective.”
While formal research in pediatric populations remains limited, patient experiences and patient self-reporting show that adolescent girls face similar challenges. And because of this, Dr. Reiss notes that PCPs should be extra attentive during these key developmental windows:
- The Onset of Puberty: The initial surge and sudden monthly fluctuations of estrogen can disrupt previously effective coping strategies.
- The Luteal Phase: Cyclical drops in estrogen during the late luteal phase can cause premenstrual exacerbations of executive dysfunction.
What PCPs Can Do: Maintaining Curiosity Beyond the DSM
When evaluating female patients, Dr. Reiss emphasizes that one of the most powerful tools a PCP has is maintaining clinical curiosity: to be able to look past hyperactive presentations and explore what’s happening both externally and internally.
“Having questions that focus more on those aspects of ADHD versus just the checklist of the DSM-5 criteria can be helpful,” Dr. Reiss explains. “Just because a child is doing well in school doesn’t mean they’re not suffering internally.” Here are some specifics: Asking questions about social and emotional functioning as well as how girls manage in other areas outside the academic area is important.
1. Stay Curious About the Root Cause of Anxiety
When adolescent girls present with anxiety, Dr. Reiss advises clinicians to ask questions.
“If they’re coming to you with anxiety as their chief complaint, look into whether they’re struggling with executive functioning,” Dr. Reiss recommends. “If you’re getting all this negative feedback in school and at home… you internalize it, and of course you’re going to be anxious. But when we recognize the ADHD, provide adequate treatment, and build skills, that secondary anxiety often subsides.”
2. Ask Conversational Questions About Executive Functioning
Instead of relying solely on symptom checklists, use open-ended questions during routine check-ups to assess task execution, focus, and internal strain. Some good ones could be:
- “Is it hard to start a project once you sit down to do it?”
- “Do you find yourself getting distracted or daydreaming during class or when you are with friends?”
- “Do you chronically underestimate how long assignments or doing tasks at home will take?”
- “Do you ever finish your homework but forget to hand it in?”
- “Have you ever been called on in class when your mind was somewhere else, and did that make you feel anxious?”
- “Do you have problems with transitioning from one task to another and get easily sidetracked and wander from one task to the next?”
3. Note Physical Disorganization
Dr. Reiss points out that physical disorganization often mirrors cognitive disorganization. Find out how patients keep track of their daily items and look for patterns like lost assignments and lost items (keys), misplaced belongings in different environments as subtle visual cues of executive dysfunction.
Ultimately, shifting the clinical conversation and raising awareness around how ADHD uniquely presents in girls can change the trajectory of their care. “A late diagnosis makes one regret that a patient had internal distress not understanding their strengths and relative weaknesses,” says Dr. Reiss. The earlier we intervene with a comprehensive assessment and accurately diagnose the better.
Dr. Reiss’s Recommended Resources to learn more:
- Duke Center for Girls & Women with ADHD (specifically the Resources in the menu)
- Learn Smarter Podcast, episode 220 (45 minutes): “ADHD and Girls with Interview with Kathleen Nadeau Ph.D”
- The Neurodiversity Podcast with Emily Kircher-Morris (36 minutes): “Revisiting Girls and ADHD.” Features an interview with Stephen Hinshaw, Ph.D who has researched ADHD in girls since the 1990s and pioneered the Berkeley Girls with ADHD Longitudinal Study.
- BERA UK Podcast (British Educational Research Association) (50 minutes): “Rethinking ADHD: Episode 6: Masking in Women and Girls with ADHD”
