Misdiagnosis of Females with ADD (ADHD)
Patricia O. Quinn, MD
ADD (ADHD) is probably the most common psychiatric diagnosis
in children with between 6-12% of the population affected
by symptoms of the disorder that impair functioning. DSM-IV
(APA, 1994) did much to help focus the world on the fact that
ADD (ADHD) is a disorder of both attention and hyperactivity,
and that one or the other pattern may predominate in individuals.
However, it did little to clarify the diagnostic picture for
females with ADD (ADHD). When the DSM was revised in 1994,
experts were still primarily engaged in research and had developed
their clinical experience treating children (specifically
elementary school-aged boys). Those symptoms proposed as diagnostic
criteria for the disorder reflected this focus, often referring
to behaviors that are developmentally inappropriate for an
adult (e.g., schoolwork, climbing activities, leaving seat,
etc.) or a female. Results of a recent study confirm that
these diagnostic criteria may be more descriptive of males
than females (Ohan & Johnston, 1999), suggesting that
if more gender-sensitive, gender-appropriate diagnostic criteria
were adopted, we may find that yet another long-held belief
about ADD (ADHD)-that it is a disorder primarily affecting
In addition, Criterion E of DSM-IV is meant to prevent the
misdiagnosis of ADD (ADHD) when another disorder is responsible
for the symptomatology. However, the diagnosis of ADD (ADHD)
is frequently accompanied by coexisting conditions. Biederman
and his colleagues (Biederman, Newcomb, & Sprich, 1991;
Biederman, Faraone, & Lapey, 1992; Biederman, Faraone,
Spencer, & Wilens, 1993) have presented evidence indicating
that the majority of persons with ADD (ADHD) have a least
one and sometimes more than one additional psychiatric disorder
In the United States, nearly twice as many women (12 percent)
as men (6 percent) are affected by depressive illness (NIMH).
The explanation for the gender gap in susceptibility to depression
may lie in a combination of biological, genetic, psychological,
and social factors. Thus, women with low-esteem, pessimistic
views, and tendencies towards stress are often prone to clinical
depression. Women and girls with ADD (ADHD) clearly fit this
Girls with ADD (ADHD) are often misdiagnosed with depression.
In a recent nationwide survey conducted in April, 2002 by
Harris International, girls with ADD (ADHD) were found to
have been commonly diagnosed as depressed prior to their ADD
(ADHD) diagnosis with 14% of these girls treated with antidepressants
compared to only 5% of males with ADD (ADHD). These results
underscore the importance of looking at ADD (ADHD) as a diagnosis
and the importance of ascertaining why girls with ADD (ADHD)
are often overlooked or have symptoms that are misinterpreted
resulting in a missed or misdiagnosis. Research, as well as
clinical experience, suggests that girls and women with ADD
(ADHD) continue to suffer from high rates of anxiety and depression,
and that it is these secondary conditions, rather than the
underlying ADD (ADHD), which are most likely to be diagnosed
and treated. Factors contributing to misdiagnosis include
Girls with ADD (ADHD) tend to internalize symptoms (Brown
et al, 1989; Gaub & Carlson, 1997) and become socially
Family members, teachers and peers misinterpret symptoms
of inattention; anxiety and depressive disorders may also
obfuscate underlying ADD (ADHD) in women.
The following brief case report illustrates this diagnostic
dilemma. "Lacy" is 23 and a recent college graduate.
She was referred for evaluation because of psychological stress
associated with her first year of law school. During the initial
psychiatric interview, rating scales were completed, for mood
and/or ADD (ADHD) symptomatology. Lacy's scores showed elevations
of distractibility, procrastination, and daydreaming. Vegetative
symptoms of depression, such as sleep and appetite disturbances,
were within normal limits. Psychiatric history revealed that
her ADD (ADHD) symptoms rather than her depressive symptoms
were historically her problem. Lacy's father had been treated
for ADD (ADHD) for several years and this also made the diagnosis
more clear. Treatment with stimulants was instituted and her
mood and academic performance improved dramatically
This case demonstrates that emotional distress is not synonymous
with depression. It was ADD (ADHD) symptoms, not depressive
symptoms that caused self-doubt, generalized anxiety and confusion
in this woman. Treatment for ADD (ADHD) promoted productivity
and afforded self-awareness. Had ADD (ADHD) screening not
been obtained on initial presentation, it is likely that her
treatment would have focused on depression alone, underscoring
the importance of routine screening for ADD (ADHD) in women
who present with anxiety and/or depression.
In conclusion, the recognition of ADD (ADHD) symptoms as
they present in females is crucial. Appropriate and timely
diagnosis and treatment would help prevent delayed diagnosis
in females when depression, as a result of ADD (ADHD) symptoms,
becomes more profound. In addition, incorrect or missed diagnosis
leads to delayed treatment with stimulants and may result
in the substitute or inappropriate use of antidepressants
as seen in the Harris survey population. Stimulant medications
should be considered the first line therapy for ADD (ADHD)
in girls and women with antidepressants reserved for those
with true coexisting depression.
Resources on women and ADHD:
AD/HD Self-Assessment Symptom Inventory (SASI) written
by Kathleen Nadeau, Ph.D. and Patricia Quinn, M.D.
and ADHD edited by Patricia Quinn, M.D. and Kathleen Nadeau,
Women with ADHD edited by Kathleen Nadeau, Ph.D. and Patricia
American Psychiatric Association. (1994). Diagnostic
and statistical manual for mental disorders (4th ed.).
Washington, DC: Author.
Biederman, J., Newcomb, J., & Sprich, S. (1991). Comorbidity
of ADHD with conduct, depressive, anxiety and other disorders.
American Journal of Psychiatry, 148, 564-577.
Biederman, J., Faraone, S., Spencer, T., & Wilens, T.
(1993). Patterns of psychiatric comorbidity, cognition, and
psychosocial functioning in adults with ADHD. American
Journal of Psychiatry, 150, 1792-1798.
Biederman, J., Faraone, S.V., & Lapey, K. (1992). Comorbidity
of diagnosis in attention-deficit hyperactivity disorder.
In G. Weiss (Ed.), Attention-deficit hyperactivity disorder,
Child & adolescent psychiatric clinics of North America.
Brown, R.T., Madan-Swain, A., & Baldwin, K. (1991).
Gender differences in a clinic referred sample of attention
deficit disorder children. Child Psychiatry and Human Development,
Gaub, M., & Carlson, C. (1997). Gender differences in
ADHD: A meta-analysis and critical review. Journal of the
American Academy of Child and Adolescent Psychiatry, 36,
Ohan, J.L., & Johnston, C. (1999). Gender appropriateness
of diagnostic criteria for the externalizing disorders. In
M. Moretti (Chair), Aggression in girls: Diagnostic issues
and interpersonal factors. Symposium conducted at the
biennial meeting of the Society for Research in Child Development,