We applaud the American Professional Society of ADHD and Related Disorders (APSARD) initiative to develop guidelines for the diagnosis and treatment of adult ADHD and urge APSARD to seize the opportunity to simultaneously address the long and widely recognized underdiagnosis of females. Let us not miss this opportunity to advance the important work of recognizing gender differences as adult ADHD guidelines are developed.  

Since a 1994 NIMH Conference on Sex Differences in ADHD, the need for more gender-sensitive diagnostic criteria and for research on gender differences has been repeatedly highlighted in the clinical literature (1).  Despite this, when the recent World Federation of ADHD consensus statement set forth 208 evidence-based conclusions about ADHD, none adequately addressed the presence of gender differences in the presentation of ADHD or in the subsequent diagnosis of ADHD (2). Females with ADHD remain at risk of late diagnosis, missed diagnosis, and misdiagnosis with significant negative mental health, general medical, and economic outcomes (2-8), yet many in the ADHD research community believe that their hands are tied due to lack of evidence to support broadly recognized gender differences.  

To quote Carl Sagan, “Absence of evidence is not evidence of absence.”  We urge the APSARD Guidelines Committee to escape the circular trap we’ve been caught in for so long.  We call on APSARD to initiate, promote, and prioritize the gathering of needed evidence on gender differences.  Such an effort is consistent with APSARD’s core mission of supporting the needs of all that are affected by ADHD. 

Let APSARD begin, just as we did in the development of the original diagnostic criteria, by seeking a consensus statement on more gender-equitable criteria. Once this consensus has been reached, we have a clear path to gathering evidence to test the consensus-based gender-sensitive recommendations. 

It is incumbent upon today’s generation of ADHD experts to advance the long-overdue process of documenting gender differences in ADHD. We call on APSARD to develop more gender-sensitive diagnostic criteria by consensus—through a process parallel to the initial development of the existing male-focused criteria—and then promote the research necessary for these criteria to become "evidence-based." 

Authors:

Kathleen Nadeau, Ph.D.

Michael Morse, M.D. M.P.A.

Co-authors and Contributors:

Stephen P. Hinshaw, Ph.D.

Patricia Quinn, M.D.

Andrea Chronis-Tuscano, Ph.D.

Citations:

       1) Arnold, L. Eugene. "Sex differences in ADHD: Conference summary." Journal of abnormal child psychology 24 (1996): 555-569. 

       2) Faraone, Stephen V., et al. "The world federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder." Neuroscience & Biobehavioral Reviews 128 (2021): 789-818.

       3) Nadeau, Kathleen G., and Patricia O. Quinn. Understanding women with AD/HD. Advantage Books, 2002.

       4) Quinn, Patricia O., and Manisha Madhoo. "A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis." The primary care companion for CNS disorders 16.3 (2014): 27250. 

       5) Lai, Meng-Chuan, Hsiang-Yuan Lin, and Stephanie H. Ameis. "Towards equitable diagnoses for autism and attention-deficit/hyperactivity disorder across sexes and genders." Current Opinion in Psychiatry 35.2 (2022): 90-100. 

       6) Young, Susan, et al. "Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women." BMC psychiatry 20.1 (2020): 1-27.

       7) Hinshaw, Stephen P., et al. "Annual Research Review: Attention‐deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions." Journal of Child Psychology and Psychiatry 63.4 (2022): 484-496.

       8) Kooij, J. J. S., et al. "Updated European Consensus Statement on diagnosis and treatment of adult ADHD." European psychiatry 56.1 (2019): 14-34.

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Note: We are aware of the limitations and interconnections of the terms “gender” and “sex” and that these terms do not reference binary phenomena.   For simplicity, we use the term “gender” to refer to the combined broader construct that could also be named “sex/gender”.­­