Diagnostic challenges with ADHD

There are various challenges that need to be considered when diagnosing ADHD.
In addition to differentiating between ADHD and other disorders and taking into account the various comorbidities that can occur more frequently, especially in adults with previously untreated ADHD (see the articles in the section on Comorbidity in ADHD), special features arise, for example, in the diagnosis of women, giftedness or intellectual disability.

• 1. ADHD diagnostics for girls and women
  • 1.1. Boys diagnosed more frequently
  • 1.2. Externalizing symptoms easier to recognize and more unpleasant
  • 1.3. Symptoms in women tend to be underestimated
  • 1.4. Tests for ADHD in childhood assess internalizing symptoms more weakly
  • 1.5. Women compensate better for ADHD with social traits
  • 1.6. Hormones protect girls
• 2. ADHD diagnostics for giftedness

1. ADHD diagnostics for girls and women¶

1.1. Boys diagnosed more frequently¶

Boys are diagnosed with ADHD much more frequently than girls. The ratio is reported to be between 2:1 and 10:1,¹
In adulthood, on the other hand, the diagnosis rate is balanced.² However, as only new diagnoses are equalized in adulthood, i.e. the over-diagnosis of men in childhood and adolescence persists, overall 2.3 times more men than women are diagnosed with ADHD.

It remains to be seen whether the strong catch-up of women in ADHD diagnosis compared to men in adulthood to the then balanced diagnosis frequency² is based solely on unrecognized ADHD in childhood and adolescence, or whether there are also cases of late onset ADHD. More on this at Late Onset ADHD: first occurrence in adulthood

1.2. Externalizing symptoms easier to recognize and more unpleasant¶

Independent of ADHD, boys show significantly more externalizing disorders (ODD, conduct disorder), while girls show more disorders with internalizing symptoms (depression, anxiety). Even within the ADHD spectrum, boys more frequently show presentation forms (formerly: subtypes) with externalizing symptoms, i.e. ADHD-H or ADHD-C, while girls show ADHD-I more frequently than boys.³
Externalizing symptoms (hyperactivity, impulsivity, aggressiveness) are more stressful for other people than internalizing symptoms and are perceived as more serious.⁴ However, hyperactivity was rated by parents as lower than it actually was in girls diagnosed with ADHD and higher than it actually was in boys diagnosed with ADHD.¹ This could be interpreted as hyperactivity being perceived as more unpleasant in boys than in girls.
Therefore, the environment of boys with ADHD is more likely to seek a diagnosis of the child than the environment of girls with ADHD, or it takes stronger symptoms in girls for parents to seek a diagnosis.⁵

Motor hyperactivity is a symptom that is also recognizable to people who do not know a person well. Hyperactivity can also be observed from a distance. To detect inattention, you need to be closer. This means that the circle of people who can perceive externalizing symptoms is larger than the circle that can perceive internalizing symptoms.

1.3. Symptoms in women tend to be underestimated¶

Relatives of women with ADHD have a higher risk of ADHD than relatives of men with ADHD.⁵

1.4. Tests for ADHD in childhood assess internalizing symptoms more weakly¶

In adulthood, the presence of ADHD symptoms in childhood/adolescence must be established.
The WURS (free, 6 - 10 years) or the WURS-K (chargeable, part of the HASE, 8 - 10 years) can be used for this purpose.
At 86%, the WURS-K shows a diagnostic accuracy for ADHD in childhood that is 10% worse than the WURS⁶

The WURS-K is said to systematically lead to diagnostic problems, as women and girls in particular, as well as men with the predominantly inattentive presentation form ADHD-I, fall minimally below the scores despite otherwise clear ADHD symptoms⁶
The WR-SB self-report questionnaire is also designed not to recognize the predominantly inattentive ADHD-I presentation form⁶
Even if the score is only slightly below the required level, the automated evaluation via the Hogrefe test system determines that the ADHD criteria are not met.
The same applies to the widespread Wender-Reimherr interview.⁶

1.5. Women compensate better for ADHD with social traits¶

On average, women are more socially oriented than men. Personal interaction with other people is more important to girls than boys. On average, girls and women find it easier to take the other person’s point of view and anticipate the expectations of others. ⁷ On average, girls and women have stronger pro-social skills.⁸
This correlates with the “tend and befriend” stress response, which occurs significantly more frequently in women than in men. When under great stress, women seek the closeness of the group more often and assure themselves that they belong to it. More on this under Tend and befriend in the section Self-esteem problems in the article Perceptual symptoms in the chapter Symptoms of ADHD.
This causes women to use greater resources in social interaction with other people in order not to burden others. This leads to coping with their own ADHD symptoms.

1.6. Hormones protect girls¶

Girls are better protected from mental disorders than boys due to their gender-specific hormonal make-up in childhood.
More on this at Gender differences in ADHD In the chapter on neurological aspects.

2. ADHD diagnostics for giftedness¶

A more detailed description can be found in the article Giftedness and ADHD.

That high intelligence excludes ADHD is unfortunately still a common misconception. The incidence of ADHD in gifted people is at least as high as in those with normal intelligence.
More on this at ADHD more common with giftedness? in the article Giftedness and ADHD.

However, it is true that higher intelligence is associated with an increased ability to cope with problems. Highly gifted people often have an increased ability to circumvent psychological impairments through special behaviors - so-called coping (compensation strategies).⁸ ADHD can therefore be more difficult to recognize in gifted individuals.
The view that people who are coping with ADHD do not need treatment for their ADHD is unethical. To expect someone to live with treatable symptoms of a mental Disorder and to deny them treatment when they are suffering from it is against the duty of doctors and psychologists to help. It is ethically correct to allow gifted people to use their giftedness for more meaningful things than neutralizing a deficit that is much easier to treat than any other mental health problem.
It should also be taken into account that treating an existing ADHD can unlock an IQ potential of 5 to 15 points.

Highly gifted people with ADHD can perform like non-affected normal gifted people.⁹ This means that alarm signs are not visible, which could otherwise promote the timely initiation of a diagnosis.⁸

One challenge in the differential diagnosis of giftedness and ADHD is the numerous very confusable character traits of giftedness and ADHD. However, as with all other problem cases in differential diagnosis, this can be easily solved if the confusable characteristics of giftedness and ADHD are known.
A detailed description of the similarities and differences between the character traits typical of ADHD and giftedness can be found at Similar character traits of gifted people and persons with ADHD in the article Giftedness and ADHD.
In addition to similar character traits, an accumulation of increased sensitivity can also be observed.

The similarity of the character traits could possibly be due to the parallel delayed first maximum of the brain’s cortex thickness. More on this under Delayed cortex maturation in ADHD as in giftedness in the article Giftedness and ADHD.

The feeling of not belonging also occurs more frequently with giftedness, as it does with ADHD. Here, however, the causes could be different.
Weak social skills in combination with giftedness can have serious consequences. Gifted people usually have a different sense of humor, different interests and different ways of thinking than normal gifted people. If this is compounded by weak social skills, gifted people can easily become victims of bullying. Bullying can trigger severe chronic stress, which can cause symptoms similar to ADHD.

Working memory is also often impaired in gifted people with ADHD. IQ tests that evaluate the test areas that make demands on working memory separately often show a serious dip in these areas. This dip can be a good indication of existing ADHD.

ADHD treatment can increase the available IQ (not only in gifted people). We assume an increase of 5 to 10 IQ points. More on this under ADHD puts a strain on IQ / ADHD treatment can release IQ In the article Giftedness and ADHD.