Abstract: 

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder traditionally diagnosed more frequently in males than females. (Rowland, Lesesne, & Abramowitz, 2002). However, more recent studies suggest that ADHD in females often goes undiagnosed, leading to distinctive challenges in their personal lives. This research studies females with ADHD within relationships, specifically during traumatic moments. Researching the unique experiences of females with ADHD is crucial in understanding how social interactions, which are critical during adolescent years, are impacted. This research would also help address the possibilities of trauma intensifying ADHD symptoms, affecting relationships, and overall disrupting their social and emotional development. Females are often underrepresented in ADHD studies, and more gender-specific data can lead to more tailored support systems, interventions, and growth. It is hypothesized that females with ADHD would internalize their experience and seek out less support, ultimately suppressing their emotions and affecting their quality of life. 

Analysis:

ADHD, one of the most common mental disorders in children, is marked by inattention (affecting attention, organization, etc), hyperactivity (characterized by excessive movement, etc), and/or impulsivity (Elmaghraby & Garayalde, 2022). Females tend to present more internalizing symptoms, which in contrast to males’ externalizing ones,  lead to delayed diagnoses and unique challenges, particularly regarding trauma and sexual victimization (Hosain, Berenson, Tennen, Bauer, & Wu, 2012). This delayed identification leaves females vulnerable, often compelling them to mask symptoms to conform to societal expectations, which can exacerbate the impact of traumatic experiences (Geraldo da Silva, Malloy-Diniz, Garcia, & Rocha, 2020).  The significant overlap between ADHD and PTSD symptoms found by (Famularo et al., 1992, p. 866), makes accurate diagnosis complex, and suggests that individuals with neurodevelopmental delays, including ADHD, face a higher risk of coercive sexual victimization (Hosain, Berenson, Tennen, Bauer, & Wu, 2012). 

It is recognized that adolescents with ADHD experience significant disadvantages in educational environments primarily designed for neurotypical students. Within the broader context of disadvantage, females with ADHD often face even greater challenges than boys, due to factors such as internalized symptomology, lower self-esteem and underdiagnosis (Lau, Lim, Lim-Ashworth, Tan, Acharryya, & Fung, 2021). Therefore, while ADHD itself is a source of marginalization, the intersection of the gender and ADHD results in compounded or “double” disadvantages for females. 

To take this a step further, treatment status also plays a role in disadvantage: among those with the two identities (ADHD and female gender), those who remain un-diagnosed or untreated are at a greater risk of poor outcomes compared to those who receive support and treatment. Even with treatment, however, females with ADHD continue to face more challenges than males with ADHD—yet intervention is a possible solution to mitigating the disadvantages associated with their dual identity (Mikami, Chi, & Hinshaw, 2004).

With this however, certain environments can shift these disadvantages. For example, elementary school girls with ADHD experienced rejection rates of 62% (a rejection that follows into adolescence). In addition to peer neglect, girls with ADHD were also disliked by teachers more than girls with ADHD (Mikami, Chi, & Hinshaw, 2004). In a classroom setting, a girl with ADHD may be perceived as more compliant while a boy with ADHD may be perceived as more disruptive: however, this ‘compliancy’ can simultaneously contribute to ADHD being overlooked. 

At the same time, socioeconomic status introduced another layer to this disadvantage. Higher-income girls, for example, may have better access to medical support, and educational accommodations, positioning them more favorably than a lower-income boy with ADHD—challenging the trend of female under-recognition (Matza, Paramore & Prasad, 2005). The intersection of numerous identities—gender, socioeconomic status, treatment status, etc—underscores the multidimensional nature of disadvantages in the context of ADHD. 

Although frequently diagnosed later in life, as emotional dysregulation rises, ADHD is an exceedingly common neurodevelopmental disorder in both childhood males and females. ADHD in men was found to present more with externalizing symptoms such as hyperactivity, whereas females presented more internalizing symptoms such as inattention (Lau, Lim, Lim-Ashworth, Tan, Acharryya, & Fung, 2021). Genetically, having a relative with this disorder means the chance of inheriting ADHD is higher (60%-90%). In addition, environmental risks such as early deprivation, familial conflicts, and nutritional factors have consistently been associated with ADHD (Thapar, Cooper, Eyre, & Langley, 2013; Thapar, 2018). Psychopathology, these internalized symptoms may be regarded as mood disorders and lead to a significant amount of misdiagnoses; these internalizing symptoms in females often result in a delayed diagnosis, and a major development of strategies to mask core symptoms “because they understand that such symptoms violate norms of expected femininity” (Geraldo da Silva, Malloy-Diniz, Garcia, & Rocha, 2020). 

Given such, a female diagnosed with ADHD (defined above) could likely be a victim of sexual victimization but emerge more resilient due to the habit of suppressing their internal struggles. (Basile & Saltzman, 2002) defines consent as “words or overt actions by a person who is legally or functionally competent to give informed approval, indicating a freely given agreement to have sexual intercourse or sexual contact.” Although any woman can be a victim of sexual victimization at any time, the chance of suffering this violence appears to be greater among young girls and adolescents. In a study of 462 low-income women (56% African American; 22% White; 21% Hispanic) with a mean age of 24 years, participants were interviewed using the ASRS-v1.1 (to report inattentive and hyperactive symptoms) as well as an adapted Sexual Risk Behavior Assessment Schedule (to obtain high risk sexual behavior information). Results noted out of the population, higher means of ADHD symptom scores were observed among women with risky sexual behavior for inattentive participants but not for hyperactive/impulsive participants (Hosain, Berenson, Tennen, Bauer, & Wu, 2012). 

Within a study of 216 probands of ages 5-12 who met the DSM-IV for any subtype of ADHD and siblings of ages 5-17 who did not have to meet the DSM-IV criteria, 52.8% were classified with the combined subtype, 36.6% with the predominantly inattentive, and 10.6% with the predominantly hyperactive-impulsive subtype. Compared to those without ADHD (15.38%), those with ADHD displayed significantly higher rates of emotional lability (46.92%). When correlating the emotional lability subscale and the BASC-2, higher levels of emotional lability were “associated with greater impairment in social skills concerning overall adaptive function” (Anastopoulos et al., 2011).  The adverse outcome of the adaptive skills composite was significantly greater among those with ADHD (38.27%) compared to those without ADHD (9.09%). The prevalence of emotional lability in adverse outcomes—especially adaptive function—indicates that individuals with ADHD may have trouble navigating through demands that are placed on them. This could account for why those with ADHD (specifically females) may comply with social demands that may be detrimental, such as coercive ones.

In a clinical review (Weinstein, Staffelbach, & Biaggio, 2000), it was noted that what seems to be ADHD symptoms may result from anxiety associated with PTSD and be a result of maltreatment (Famularo et al., 1992, p. 866). Maltreatment and experiencing violence during upbringing have been shared risk factors for both IPV and childhood ADHD among women. Internalizing behavior of females with ADHD may further impair these women when it comes to being at risk for IPV. In a study (Guendelman, Ahmad, Meza, Owens, & Hinshaw, 2015) of 140 females with ADHD and 88 age and ethnicity matched comparison females, functioning was tracked and after 10 years, when compared to the comparison group (6%), the young women with childhood ADHD experienced exceedingly higher IPV victimization rates (~30%).  Sexually abused children, at a heightened risk of PTSD, could likely be misdiagnosed with ADHD rather than the likely development of PTSD. This differentiation is complex because of shared symptoms between ADHD and PTSD, such as irritability, difficulty concentrating, and hypervigilance. (McLeer et al., 1994) Found ADHD (33.3%) to be the primary diagnosis of PTSD (44.4%). Children who have been sexually victimized might display what seems to be ADHD symptoms of any of the three types of ADHD, while the disturbance is a recurring traumatic memory. 

Although traumatic experiences affect each individual differently, initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, physical arousal, and blunted affect. Trauma can also lead to the development of PTSD, a variety of other psychiatric disorders like depression, generalized anxiety disorder, panic attacks, borderline personality disorder, and substance abuse (Lubit, Rovine, DeFrancisci, & Eth, 2003). In another study of females ages 8-18 primarily of Hispanic and African American backgrounds, children with ADHD experienced 1-4 incidences that disrupted their upbringing: of those females, 62% witnessed violence or parental substance abuse at home when compared to 58% of non-ADHD counterparts (Conway, Oster, & Szymanski, 2015). This often led to Developmental Trauma disorders, where one would experience aggression, anger, dissociative states, and other functional impairments: these symptoms (in response to trauma cues) overlapped with those of ADHD.  As such, it is acknowledged that females during their adolescent years are likely to experience trauma. Moreover, based on this study, females who experienced trauma were also likely to display ADHD symptoms and related impairments. 

The correlation between the neurodevelopmental delay (NDD) and an evocative gene could likely account for a high chance of coercive sexual victimization, such that sexual perpetrators actively target NDD individuals. In a study of 4,500 children participating in the (CATSS), those with ADHD or ASD were rated by their parents on NDDs at age 9 or 12. At age 18, those children self-reported experiences of coercive sexual touchy and/or coercive sex. Results noted out of the population, females with ADHD appeared to have a double risk of sexual victimization (Gotby, Lichtenstein, Långström, & Pettersson, 2018). In another study of 4,910 adolescents in the Swedish county of Västmanland, 15 and 18-year-old students answered a screening instrument including questions on the ADHD self-rating scale (ASRS) and ones on sexual abuse. Of those with co-occurring symptoms,  48% of boys and 47% of girls with ADHD symptoms reported experiencing sexual abuse (Sonnby, Åslund, Leppert, & Nilsson, 2011). Although both studies followed around 4,000 children, (Gotby, Lichtenstein, Långström, & Pettersson, 2018) followed up on the same individuals after their adolescent years, giving more quality data, however, in both studies, the percentage of those subject to coercive touching was significantly higher for those with ADHD than those without. Given these results, it was suggested that screening for co-occurring symptoms of ADHD could help identify students at risk of sexual abuse. As such, it is acknowledged that females during their adolescent years who experienced trauma were also likely to show ADHD symptoms. 

Discussion: 

The reviewed literature highlights the complex relationship between ADHD in women and girls and their increased risk for trauma, especially sexual victimization. To understand this link, it is crucial to understand the gender-specific presentation of ADHD in females, often leading to a missed or delayed diagnosis (Quinn & Madhoo, 2014; Klefsjö et al., 2021). Women and girls tend to exhibit internalizing symptoms (such as inattention and emotional dysregulation) rather than external behaviors, which are commonly observed in boys (Lau et al., 2021). It has been largely recognized that internalized symptomatology can delay intervention. However, many also suggest it leaves young girls more vulnerable to exploitation due to their development of coping mechanisms that mask their struggles to conform to societal expectations of femininity (Geraldo da Silva et al., 2020).

The heightened risk of females with ADHD experiencing sexual victimization has been consistently shown; Gotby et al. (2018) found that females with ADHD had a doubled risk of coercive sexual victimization compared to their peers. Similar studies noted above link ADHD symptoms, particularly inattentiveness, with increased susceptibility to comply with coercive demands. It is hypothesized that due to the employment of masking behaviour, these individuals would respond to coercion with a fawn response, resulting from the “inability to use verbal symbolizations to express emotion” (Sugarman, 2006).

What is especially noteworthy is the overlap between trauma and ADHD symptomatology, complicating diagnosis and intervention. (Weinstein et al., 2000 & McLeer et al., 1994) Note that PTSD and ADHD symptoms often co-occur, especially in sexually abused children. This overlap underscores the importance of trauma-informed care when assessing and treating patients in order to avoid misdiagnosis and provide appropriate care. 

Although the intersection between ADHD in girls and women and coercion is not yet clear, several implications emerge from these findings. First, early and gender-sensitive screening for ADHD in young females is vital to identify those at risk and provide timely intervention. School-based awareness is crucial in ensuring that faculty can identify symptoms in young girls that may have previously been dismissed. Secondly, healthcare providers must be trained to recognize the presentation of ADHD in females in order to effectively diagnose and prevent future, potential co-occurrences of trauma. Third, given that current studies primarily establish association rather than causation (Langevin et al., 2023), further research on the specific symptom profile of ADHD in women and girls is worth further investigation to disentangle the causes behind such rates of child sexual abuse among females with ADHD. In general, schools and other providers should integrate trauma-informed care to build emotional regulation skills, empower self-advocacy, and ultimately reduce the risk for victimization and promote resilience.