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I recently read a fascinating article about the pattern of young women receiving ADHD diagnoses after first displaying symptoms in their late teens or early twenties, typically corresponding to college and post-college years. While very interesting, it was written from an informal, personal perspective. I'd like to know more about the subject from a research perspective.

Has there been much research regarding gender differences in ADHD, specifically about different presentation and age of onset? Within this subject, has there been any research into the effects of estradiol levels on ADHD-like symptoms? I know that consensus is not very common in the research community, especially with a diagnosis as controvertial as ADHD, but I would still like to know whether late-onset in young women is at all commonly accepted.

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  • $\begingroup$ Underdiagnosed in females? $\endgroup$
    – Jack Bauer
    Oct 5 '15 at 18:30
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A quick Google Scholar search revealed the following primary article and 2 meta-analytical reviews.

Primary Article

Arcia, E., & Conners, C. K. (1998). Gender differences in ADHD? Journal of Developmental and Behavioral Pediatrics, 19(2), 77–83. https://doi.org/10.1097/00004703-199804000-00002

Abstract:

Examined possible gender differences in children and adults (aged 5–60 yrs) with attention deficit hyperactivity disorder (ADHD). Results indicated that adult self-ratings differed significantly by gender. Adult women reported fewer assets and more problems than did male counterparts, but there was no gender difference with respect to age at referral, intelligence quotient, indicators of neuropsychological performance, or parent or teacher ratings of behavior. Referral bias against girls is a possible reason for previously reported gender differences, so the authors interpreted their results in light of the participants' referral patterns. There was a nonsignificant trend for girls with relatively more severe ratings of hyperactivity, conduct disorder, or inattention to be referred earlier than boys. Overall, results suggest no evidence of cognitive or neuropsychological differences by gender in samples that are sensitive to behavioral deviance in girls (as evidenced by early referral), but adult women's self-perception is comparatively poorer than that of adult men.

1997 Meta-Analysis

Gaub, M., & Carlson, C. L. (1997). Gender differences in ADHD: A meta-analysis and critical review. Journal of the American Academy of Child & Adolescent Psychiatry, 36(8), 1036-1045. https://doi.org/10.1097/00004583-199708000-00011

Abstract:

Objective

To quantitatively review and critically evaluate literature examining gender differences in attention-deficit hyperactivity disorder (ADHD).

Method

A meta-analysis of relevant research based on 18 studies meeting inclusion criteria was performed. Domains evaluated included primary symptomatology, intellectual and academic functioning, comorbid behavior problems, social behavior, and family variables.

Results

Gender differences were not found in impulsivity, academic performance, social functioning, fine motor skills, parental education, or parental depression. However, compared with ADHD boys, ADHD girls displayed greater intellectual impairment, lower levels of hyperactivity, and lower rates of other externalizing behaviors; it was not possible to evaluate the extent to which referral bias affected these findings. Some gender differences were clearly mediated by the effects of referral source; among children with ADHD identified from nonreferred populations, girls with ADHD displayed lower levels of inattention, internalizing behavior, and peer aggression than boys with ADHD, while girls and boys with ADHD identified from clinic-referred samples displayed similar levels of impairment on these variables.

Conclusions

The need for future research examining gender differences in ADHD is strongly indicated, with attention to methodological limitations of the current literature, including the potential confounding effects of referral bias, comorbidity, developmental patterns, diagnostic procedures, and rater source.

2002 Meta-analysis

Gershon, J., & Gershon, J. (2002). A meta-analytic review of gender differences in ADHD. Journal of attention disorders, 5(3), 143-154. https://doi.org/10.1177%2F108705470200500302

Abstract:

The present study examined gender differences in ADHD through a meta-analysis. Effect size estimates for the primary symptoms and correlates of ADHD were calculated in an attempt to replicate and extend a previous meta-analysis on gender differences in the disorder. Relatively lenient inclusion criteria were used in order to maximize the number of studies included in the effect sizes.

The results indicated that in comparison to ADHD boys, ADHD girls had lower ratings on hyperactivity, inattention, impulsivity, and externalizing problems. In addition, ADHD girls had greater intellectual impairments and more internalizing problems than ADHD boys. Overall, the results of the current meta-analysis indicated general agreement with the previous meta-analysis. The clinical implications of these gender differences and future research considerations are discussed.

There is also a 2014 review looking at the implications for psychosocial treatments.

Rucklidge, J. J. (2008). Gender differences in ADHD: implications for psychosocial treatments. Expert Review of Neurotherapeutics, 8(4), 643-655. https://doi.org/10.1586/14737175.8.4.643

Abstract:

Attention-deficit/hyperactivity disorder (ADHD) has now been recognized to exist in both males and females, albeit the literature supports a higher prevalence in males. However, when girls are diagnosed with ADHD, they are more often diagnosed as predominantly inattentive than boys with ADHD. This paper provides a review of gender differences noted across the lifespan in terms of psychosocial functioning, cognitive abilities and psychiatric comorbidities. Males and females with ADHD are more similar than different, and generally symptoms of ADHD are not sex specific. Small gender differences have been found: adolescent girls with ADHD have lower self-efficacy and poorer coping strategies than adolescent boys with ADHD, but these differences tend to disappear by adulthood; rates of depression and anxiety may be higher (especially in adolescence) while physical aggression and other externalizing behaviors may be lower in girls and women with ADHD, although not all studies support these findings (e.g., non-referred samples show similar rates of coexisting psychiatric disorders between boys and girls with ADHD). However, many studies suffer from small sample sizes, referral biases, differences in diagnostic procedures and possible rater influences. Psychosocial treatments are reviewed and discussed with reference to the reported gender differences in functioning as well as the global deficits noted in all samples. Although the data available so far suggest that psychosocial treatments are likely to be equally effective in males and females, this conclusion is based more on the small number of gender differences noted in overall functioning and less on empirical research on treatment by sex effects and the moderating role of sex, an effect only investigated by the Multi-modal Treatment Study of ADHD group, to date. Future research should include equal representation of both sexes in samples such that treatment analyses by gender can be routinely conducted.

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