Elsevier

Clinical Psychology Review

Volume 40, August 2015, Pages 15-27
Clinical Psychology Review

Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review

https://doi.org/10.1016/j.cpr.2015.05.005Get rights and content

Highlights

  • We review gender differences in adults with ADHD in a number of areas

  • Many apparent gender differences are likely due to social processes and methodological issues

  • Women with ADHD may feel more impaired than men with similar levels of symptoms

  • Gender is not often considered in ADHD research despite evidence of its relevance to several outcomes

Abstract

Certain characteristics of attention-deficit/hyperactivity disorder (ADHD) in children have long been known to differ by gender. What has not been as widely studied is whether gender is similarly associated with ADHD differences in adults. In this review, the relation between gender and adult ADHD prevalence, persistence, impairment, comorbidity, cognitive functioning, and treatment response was examined across 73 studies. Although gender was related to several characteristics and correlates of adult ADHD, it appeared that many of these gender differences may be at least be partially attributed to methodological artifacts or social and cultural influences, rather than fundamental differences in the expression of ADHD in men and women. We highlight how understanding the nature of the relation between gender and ADHD across the lifespan is complicated by a number of methodological difficulties, and offer recommendations for how emerging research and clinical practice can better incorporate gender into the conceptualization of ADHD in adulthood.

Section snippets

The importance of gender

Understanding the relation between gender and ADHD is important not only from theoretical and research perspectives, but also to facilitate clinical understanding of the experiences of individuals with ADHD. As a central aspect of identity, gender has implications across numerous domains of functioning including physical, interpersonal, scholastic and vocational performance (Hyde, 2014). For example, a recent meta-synthesis of 106 independent meta-analyses found an average effect size of gender

Methodological approach

Studies comparing adult men and women with ADHD were identified through a search of English language, peer-reviewed articles in PsycINFO using the following search terms: adult AND ADHD AND (gender OR sex). As the adult ADHD literature is comparatively young, to maximize the number of studies included, the literature search was not restricted by date. This resulted in 277 papers which, after omitting inappropriate studies (e.g., exclusively child-sample, no ADHD group), 132 remained. Given the

Prevalence

The majority of research on gender differences in adult ADHD has addressed the prevalence of ADHD diagnosis and symptoms. Of the 24 studies reporting on gender differences in adult ADHD symptoms, half found significant differences, most showing greater ADHD prevalence in men. In studies conducted with large community samples, prevalence rates of ADHD diagnosis for males range between 2.1% (Bitter, Simon, Bálint, Mészáros, & Czobor, 2010) and 5.4% (Kessler et al., 2006), and between 1.1% (Bitter

Persistence

In contrast to prevalence, less research has investigated gender differences in the rate of persistence of ADHD from childhood into adulthood and the majority of gender-specific persistence estimates derive from retrospective self-reports of adults. Three large studies of retrospectively-reported ADHD symptoms have yielded rates of persistence from childhood to adulthood ranging from 36.3% in a nationally representative survey of 3,197 people (Kessler et al., 2005) to 55.3% in a community-based

Impairment

ADHD is significantly impairing in the lives of both children and adults. Adults with ADHD report lower educational and vocational achievement, social functioning, and self-care compared to adults without ADHD (Barkley et al., 2008, Kessler et al., 2006, Mannuzza et al., 2011). Thirteen studies have reported gender comparisons of this impairment (see Table 1). Of these studies, nine reported at least one aspect of impairment that differed by gender, with females being more impaired than males

Comorbidity

Most of the 11studies of comorbidity report that women with ADHD, compared to men with ADHD, have higher lifetime prevalence rates of anxiety, depression, somatic symptoms, and bulimia. In contrast, lifetime rates of substance use disorders and problems with alcohol, as well as antisocial personality disorder and conduct disorder are higher in men with ADHD. Although five studies found no substantial evidence of gender differencesin comorbid conditions in adults with ADHD (see Table 1), these

Cognitive functioning

The linkage of ADHD to cognitive deficits in both childhood (Seidman, 2006) and adulthood (Woods, Lovejoy, & Ball, 2002) combined with the evidence of hormonal and biological influences on cognitive functioning (Bromberger & Kravitz, 2011) renders obvious the need to consider whether the pattern of cognitive deficits in adults with ADHD differs by gender. Fifteen studies were found that compared males and females with ADHD on at least one measure of cognition, although few measures have been

Pharmacological treatment

Investigations into pharmacological treatments for ADHD in adults have focused primarily on four medications: three stimulants (methylphenidate, mixed amphetamine salts, dexamphetamine) and one selective presynaptyic norepinnephrine inhibitor (atomoxetine). Fourteen studies have compared men and women’s response to these medications. In the14studies of stimulants, 7 found no gender differences in symptom reduction (Buitelaar et al., 2012, Paterson et al., 1999, Spencer et al., 1995, Spencer et

Understanding gender differences

One of the most prominent and puzzling findings that emerged in this review is the difference in the gender ratios of ADHD in children (more males than females by ratios up to 10to 1) compared to adults (more males than females, but ratios up to only 2.73 to 1). There are three broad categories of explanation for this narrowing of the gap in male to female prevalence rate, and it is probable that all three contribute to some degree. First, there may truly be differences in the prevalence and

Conclusion

This review illustrates sufficient evidence of gender differences in adult ADHD in prevalence, comorbidity, psychosocial impairment, and potentially cognitive functioning, that parity across genders should not be assumed. Further, as this paper focused exclusively on intrapersonal characteristics of adults with ADHD, greater work is needed to address potential gender differences in the interpersonal characteristics of adults with ADHD (Johnston et al., 2012, Rucklidge et al., 2007, Williamson

Role of funding sources

Funding for this paper was provided by the University of British Columbia. The University of British Columbia had no role in the study design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication.

Contributors

David Williamson and Charlotte Johnston jointly conceived of, reviewed the literature, and wrote the manuscript in each iteration.

Conflict of interest

Both authors declare no conflicts of interest

Acknowledgements

This research was supported by the University of British Columbia. We thank our lab colleagues who offered comments.

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