Underdiagnosis

ADHD can be commonly found in children and young people, however how common it is can be debated. Even though ADHD is well-known, there are studies that show that there are various groups in society that are underdiagnosed such as:

  • Older people

  • Different types of ADHD which includes: hyperactive, inattentive and combined types.

  • Women


Underdiagnosis can often lead to undertreatment which may have an impact on a person's mental health. This can be the result of making their behaviour or having unhealthy lifestyle choices to compensate for any ADHD traits they experience.

Underdiagnosis In Older Age Groups

It can be challenging for children to meet the current diagnostic requirements as they get older. Due to the developmental changes children experience when they are becoming teenagers and later into adulthood, they may not meet the required symptoms or fall short of the criteria, leaving them without a diagnosis. Research has shown a decrease in symptoms in adulthood, but those who received an ADHD diagnosis continued to present with more symptoms than the general population. This suggests that after a certain age, people may not receive a diagnosis due to not meeting the full symptom criteria, while still struggling with symptoms.

Underdiagnosis of ADHD subtypes

The different subtypes of ADHD have also been shown to be differently represented, which could account for parts of the underdiagnosis problem. While clinic-based studies present the combined type to be most common, community based research finds the inattentive ADHD to be more frequent. This suggests that many people who fall under the inattentive criteria, may have less of a chance of getting a diagnosis and treatment.


When looking at the subtype prevalence for male compared to female children, Researchers found the gender-differences to be most extensive for the combined subtype. Considering that this subtype is more commonly represented in clinic-based studies, this finding might partially account for the greater underdiagnosis of female individuals. The hyperactive-impulsive subtype has also been found to show larger gender-based differences, compared to the inattentive subtype, especially in young children.

Gender differences and underdiagnosis

The gender-bias in ADHD diagnosis has been reflected in community-based studies that found a much lower prevalence difference between male and female individuals than is represented in clinic-based studies. Illustrating the gender-based underdiagnosis that can lead to damaging masking behaviour and self-esteem issues. The problem is likely to have a number of causes.


Due to boys being much more likely to show more disruptive hyperactive-impulsive symptoms, parents may have an easier time spotting ADHD symptoms and taking them to their GP to be diagnosed. Additionally, the clinical underrepresentation of the inattentive subtype, which presents with the lowest level of gender-differences, ADHD symptoms may go unnoticed in girls. Differences in socially taught behaviours can also lead to symptoms presenting themselves in various ways and not being recognised due to incompatibility with stereotypically drawn pictures of ADHD as a male diagnosis.


Girls have a greater tendency to hide their symptoms in order to fit in and compensate for any impairments, making it difficult to notice them. They are also taught by society to be well-behaved, quiet and nice, which might account for lower levels of hyperactive impulsive-disruptive behaviour that is often spotted in boys. Due to gender-based socialisation girls are therefore more likely to internalise their symptoms and present with inattention or struggling with concentration. Due to the immense effort many female individuals put into masking their symptoms and compensating for any impairments, they often present with a less externally disruptive picture of ADHD, which incentivises teachers and parents less to ask for a diagnosis.

Sources

Bálint, S., Czobor, P., Komlósi, S., Meszaros, A., Simon, V. and Bitter, I., 2009. Attention deficit hyperactivity disorder (ADHD): gender-and age-related differences in neurocognition. Psychological medicine, 39(8), pp.1337-1345.


Coles, E.K., Slavec, J., Bernstein, M. and Baroni, E., 2012. Exploring the gender gap in referrals for children with ADHD and other disruptive behavior disorders. Journal of Attention Disorders, 16(2), pp.101-108.


Klefsjö, U., Kantzer, A.K., Gillberg, C. and Billstedt, E., 2021. The road to diagnosis and treatment in girls and boys with ADHD–gender differences in the diagnostic process. Nordic journal of psychiatry, 75(4), pp.301-305.


Ramtekkar, U.P., Reiersen, A.M., Todorov, A.A. and Todd, R.D., 2010. Sex and age differences in attention-deficit/hyperactivity disorder symptoms and diagnoses: implications for DSM-V and ICD-11. Journal of the American Academy of Child & Adolescent Psychiatry, 49(3), pp.217-228.

Sigler, E., 2021. ADHD Looks Different in Women. Here's How — and Why.. [online] ADDitude. Available at: <https://www.additudemag.com/add-in-women/> [Accessed 8 December 2021].

van Vliet, A., 2021. ADHD. [online] Thisisgendered.org. Available at: <https://thisisgendered.org/entry/adhd/> [Accessed 8 December 2021].