Beyond the Stereotype: Rethinking Sex Differences in ADHD Presentation

This article explores how ADHD presents differently across sexes and why traditional diagnostic models may overlook symptoms in females.

Attention-deficit/hyperactivity disorder (ADHD) has historically been viewed through a predominantly male lens, with rates among boys roughly twice those observed in girls.^1-3 It remains unclear whether this disparity reflects true sex-based differences in prevalence or underdiagnosis in females driven by differences in clinical presentation.^1,4 For clinicians, this raises an important consideration: ADHD may be present even when it does not align with the “classic” or more readily recognized presentation.⁵ 

Current Diagnostic Frameworks

In the absence of definitive biological markers, ADHD diagnosis relies on the assessment of symptoms of inattention and hyperactivity/impulsivity.^6,7 Inattention is characterized by difficulties with sustained focus, organization, and task completion. Hyperactivity involves excessive movement and restlessness, and impulsivity is demonstrated by actions taken without first considering the consequences.⁸ Based on the relative distribution of these symptoms, ADHD is characterized into 3 main presentations: inattentive, hyperactive/impulsive, and combined.^5,8  

Symptom-based diagnostic frameworks may partially explain sex differences in diagnosis. Boys are more likely to display hyperactive/impulsive symptomology (eg, restlessness/fidgeting, running or climbing excessively, and oppositionality) that is more disruptive and therefore more likely to prompt earlier evaluation.^4,5,9 In contrast, females are more likely to present with inattentive symptoms, which tend to be less externally visible and more easily overlooked.^1,4 Compounding this issue, initial studies informing ADHD diagnostic criteria included a disproportionately low percentage of females, raising the possibility that existing symptom descriptors may be less sensitive to female presentations.⁴

Sex Differences in ADHD Presentation

Clinical evidence suggests that differences extend beyond symptom visibility to include variation in both symptom expression and developmental trajectory. Females may exhibit hyperactivity in less overt ways, such as increased talkativeness, and impulsivity may not peak in females until adolescence, in contrast to earlier presentation in males.⁵ Because diagnostic criteria require the presence of symptoms before age 12, these differences in timing may contribute to delayed or missed diagnoses in females.^5,7 Additionally, ADHD may differentially affect executive functioning and neuropsychomotor skills.⁵ Some studies suggest that females with ADHD demonstrate greater impairments in planning, visuospatial processing, and fine and gross motor skills relative to their typically developing peers, whereas males with ADHD may show more pronounced deficits in response inhibition.⁵ 

Sex differences are also observed in comorbidity profiles and broader psychosocial impact. Males with ADHD are more likely to exhibit externalizing behaviors, including hyperactivity and aggression, while females more commonly experience internalizing symptoms such as anxiety and depression.⁵ Females may also experience more frequent stomach-aches—a psychosomatic response to their symptoms—and lower quality of life.⁵ 

Increasing ADHD Diagnoses

Recent epidemiological data suggest that ADHD diagnoses among certain subgroups of females have increased over the last 2 decades. This retrospective study of almost 2.75 million children and young adults (3 to 29 years of age) in British Columbia showed an increasing incidence of ADHD diagnoses between 2003 and 2023, which accelerated following DSM-5 updates and the COVID-19 pandemic and was most pronounced among high school-aged female adolescents and female young adults.¹⁰ This trend could be attributed to updated diagnostic criteria that place greater emphasis on functional impairments and/or the unequivocal effects of pandemic-related social disruption on females compared with males.¹⁰ 

Closing the Diagnostic Gap

Though the trajectory of recognition and ADHD diagnoses among females represents progress, important gaps remain. Greater representation of females in research is needed to determine whether current diagnostic criteria fully capture the range of ADHD presentations across sexes.⁴ As understanding of ADHD continues to evolve, increased awareness of sex-related differences may support earlier identification and more individualized care.¹⁰

References

1. Ayano G, Demelas S, Gizachew Y, Tsegay L, Alati R. The global prevalence of attention deficit hyperactivity disorder in children and adolescents: an umbrella review of meta-analyses. J Affect Disord. 2023;339:860-866. doi:10.1016/j.jad.2023.07.071
2. Danielson ML, Claussen AH, Bitsko RH, et al. ADHD prevalence among US children and adolescents in 2022: diagnosis, severity, co-occurring disorders, and treatment. J Clin Child Adolesc Psychol. 2024;53(3):343-360. doi:10.1080/15374416.2024.2335625
3. Huynh G, Masood S, Mohsin H, Daniyan A. The impact of late ADHD diagnosis on mental health outcomes in females. SSHO. 2024;10:100977. doi:10.1016/j.ssaho.2024.100977
4. Martin J. Why are females less likely to be diagnosed with ADHD in childhood than males? Lancet Psychiatry. 2024;11(4):303-310. doi:10.1016/S2215-0366(24)00010-5
5. Dimitri D, Delia G, Cavallo F, Varini M, and Fioretto F. Sex differences in children and adolescents with attention-deficit/hyperactivity disorder: a literature review. Front Child Adolesc Psychiatry. 2025;4:1582502. doi:10.3389/frcha.2025.1582502
6. Koutsoklenis A, Honkasilta J. ADHD in the DSM-5-TR: what has changed and what has not. Front Psychiatry. 2023;13:1064141. doi:10.3389/fpsyt.2022.1064141
7. Centers for Disease Control and Prevention. Diagnosing ADHD. October 3, 2024. Accessed April 22, 2026. https://www.cdc.gov/adhd/diagnosis/
8. American Psychiatric Association. What is ADHD? October 2025. Accessed April 22, 2026. https://www.psychiatry.org/patients-families/adhd/what-is-adhd
9. Mestres F, Richarte V, Crespin JJ, et al. Sex differences in adults with attention-deficit/hyperactivity disorder: a population-based study. Eur Psychiatry. 2025;68(1):e90. doi:10.1192/j.eurpsy.2025.2441
10. Cui Z, Ambasta A, Thompson W, Bassett K, Carney G, Dormuth C. DSM-5 changes, COVID-19, and ADHD diagnosis rates in individuals younger than 30 years. JAMA Netw Open. 2026;9(4):e265775. doi:10.1001/jamanetworkopen.2026.5775