Before Diagnosis, Women With ADHD Often Blamed Themselves

What the review found

For most of the period in which ADHD was defined, described and tested, the children studied were boys. Hartung and Widiger counted this in 1998, across six years of the Journal of Abnormal Child Psychology: of 243 empirical studies, seventy concerned ADHD, and 81 percent of their participants were male. Of the 243 studies that reported participant gender, 29 percent enrolled a single sex, and 99.6 percent of those single-sex studies were studies of boys.

The composite that emerged from those samples is the one teachers and clinicians still carry. In childhood, boys receive an ADHD diagnosis roughly three times as often as girls; in adulthood the ratio approaches one to one. When Ohan and Visser presented teachers and parents with identical symptom descriptions in 2009, both groups were less inclined to seek or recommend services when the child in the description was a girl.

Darby Attoe and Emma Climie, at the Werklund School of Education at the University of Calgary, set out to describe what that omission looks like from the inside. Their review, published in the Journal of Attention Disorders in 2023 under the title Miss. Diagnosis, screened 484 records and retained eight articles, all concerning women over eighteen who received their diagnosis in adulthood. Studies of people diagnosed as children were excluded by design. This is a thematic analysis rather than a meta-analysis, so it reports no pooled sample and no effect sizes, and the authors note that the included studies had relatively small samples.

Four themes came out of the eight papers. The one that reaches furthest concerns where these women located the cause of things. They described an external locus of control: successes credited to luck or to the intervention of someone more capable, and failures credited to something internal and permanent, named in their own words as stupidity or laziness. Every one of the eight papers reported harm to social and emotional wellbeing, including low self-esteem, self-blame, shame and negative automatic thoughts. Seven of the eight described strained relationships with teachers, peers and family.

The evidence is testimony, gathered mostly through interview and self-report, and much of it asks women to recall a childhood decades gone. The authors say plainly that definitive conclusions are not possible from a literature this thin, and they note that the first author identifies as a woman with ADHD, describing the iterative coding used to keep that from shaping the themes. What eight independent sets of interviews produced was one account, told again and again.

What this means for you and your child

A child who cannot account for her own difficulty will account for it anyway. With no diagnosis available and no adult offering another explanation, the explanation she reaches is the one nearest to hand, which is that she is the problem. That self-attribution is what the eight sets of interviews described, arrived at quietly, over years, and never recorded as a symptom.

The signs it leaves are easy to read as something else. Quinn reported in 2005 that 14 percent of girls with ADHD were prescribed antidepressants before receiving any treatment for ADHD, against 5 percent of boys. Teachers themselves know the difficulty is real: in work by Quinn and Wigal the year before, 40 percent reported greater trouble identifying ADHD symptoms in girls, and 85 percent expected girls to go undiagnosed.

Adult women with ADHD carry more of nearly everything hard. Fuller-Thomson and colleagues found in 2016 that women aged twenty to thirty-nine with ADHD had twice the prevalence of depressive disorders and severe poverty, and three times the prevalence of insomnia, chronic pain and generalized anxiety, compared with women without it. That is an association measured at one point in time. Nothing in the comparison shows that a missed diagnosis produced those outcomes, and the Calgary review, qualitative and retrospective, is not designed to settle the question. The women interviewed believe it did, and their belief is evidence of a different kind.

What the review does support is narrower and more useful. Six of the eight papers found that diagnosis in adulthood brought relief, external validation of an experience these women had carried alone, reduced self-blame and a growing sense that the condition included capacities worth having. The diagnosis left the years themselves untouched and replaced a theory of personal defect with an accurate account, and the women reported that the exchange mattered.

A girl who is struggling will build an explanation of herself out of whatever material the adults around her provide. Yours can be the voice that gives her a better one.