Attention-Deficit/Hyperactivity Disorder has never been a one-size-fits-all condition. Beneath the umbrella term lies a spectrum of cognitive styles, behavioural expressions, and emotional struggles. For decades, however, the scientific narrative was shaped by one group more than any other: boys.

Boys with ADHD tend to shout their symptoms into the world—restlessness, impulsivity, classroom disruptions, unfinished homework. Girls, on the other hand, often learn the art of quiet struggle. Their symptoms whisper. They internalise. They compensate. And because society associates silence with coping, these girls grow into women who were simply “never diagnosed.”

Understanding ADHD through the lens of gendered expression is not just an academic exercise; it’s a matter of improving detection, care, and long-term well-being.

The Biological Groundwork: Same Circuitry, Different Expression

ADHD is rooted in the neurobiology of the prefrontal cortex, dopamine circuitry, and default mode network. These networks regulate attention, motivation, impulse control, working memory, and cognitive flexibility.

While the core circuits are shared across genders, emerging research suggests that:

• Females may show more dysregulation in emotional processing networks (insula, limbic circuits).
• Males often show more overt dysregulation in motor and inhibitory circuits (basal ganglia, premotor areas).
• Hormonal factors—especially estrogen, which modulates dopamine—may buffer or mask symptoms in girls during childhood, only for them to emerge sharply during puberty or adulthood.

The hardware is similar; the software patterns diverge.

Externalising vs Internalising: The Great Divide

The clearest distinction in gendered ADHD lies in these two psychological styles.

Males: The Externalising Profile

Boys often show dominant externalising behaviours, which are outward and observable:

• Hyperactivity
• Impulsivity
• Fidgeting and restlessness
• Interrupting others
• Risk-taking behaviours
• Academic underperformance due to behavioural issues

Teachers notice these behaviours quickly, leading to earlier referrals.

Females: The Internalising Profile

Girls more often show internalising symptoms, which live inwardly:

• Inattention mistaken for daydreaming
• Quiet disorganisation
• Slow work pace misinterpreted as lack of interest
• Emotional sensitivity
• Anxiety or perfectionism masking ADHD
• People-pleasing patterns
• Social withdrawal when overwhelmed

Because these symptoms do not “disturb the classroom,” girls often escape detection until adulthood—usually when responsibilities exceed their compensatory skills.

Why Girls Are Underdiagnosed (And Misdiagnosed)

The diagnostic disparity is staggering. Boys are diagnosed 2–3 times more often than girls in childhood. But in adulthood, the male-female ratio narrows dramatically. In clinics, we see women who quietly carried their ADHD into their 20s, 30s, and 40s—mislabelled as:

• Anxiety
• Depression
• Borderline personality traits
• “Low motivation”
• “Lack of discipline”
• “Emotional issues”

Internalising ADHD masquerades as emotional dysfunction.

The tragedy is that untreated ADHD increases the risk of:

• Low self-esteem
• Chronic stress
• Burnout
• Academic underachievement
• Relationship instability
• Eating disorders
• Substance use in later years

Not because these women are weak—but because they have been invisible.

Social Conditioning: The Mask Girls Are Taught to Wear

A boy who is disruptive is “naughty.”
A girl who is distracted is “daydreamy.”
A woman who forgets tasks is “irresponsible.”
A man with the same symptoms is “busy.”

From childhood, girls receive stronger social pressure to be:

• polite
• organised
• emotionally attuned
• socially compliant
• academically consistent

This creates a perfect storm: they mask their ADHD, often unconsciously.

Masking feels like:

• over-apologising
• rehearsing conversations
• making endless lists
• overachieving out of fear
• hiding the chaos beneath a calm exterior

Masking delays diagnosis, but more importantly, it drains emotional energy. Many women experience exhaustion not from ADHD itself, but from containing ADHD for society’s comfort.

Executive Function Differences: Two Sides of the Same Coin

ADHD affects executive functions in both genders, but the profile varies.

In Males:

More deficits in impulse inhibition and motor regulation.
Common issues include:

• blurting answers
• interrupting
• difficulty waiting
• physical restlessness

In Females:

More deficits in working memory, planning, prioritisation.

Common issues include:

• losing track of tasks
• forgetting deadlines
• difficulty organising
• procrastination driven by overwhelm
• emotional spirals from perceived “failure”

Both profiles are valid expressions of ADHD, shaped by brain circuits and social training.

Emotional Dysregulation: The Hidden Symptom in Women

Many women with ADHD describe emotion as a sudden wave rather than a gradual tide. Research suggests stronger impairments in:

• rejection sensitivity
• emotional reactivity
• rumination
• stress intolerance
• interpersonal guilt

This can lead clinicians to mislabel ADHD as personality pathology in women, because emotional dysregulation—though common in ADHD—is often overlooked in traditional diagnostic frameworks.

In men, emotional dysregulation tends to express as irritability or impulsive outbursts, which are more recognisable as ADHD-linked behaviour.

Puberty, Menstruation & Hormonal Amplifiers

Estrogen enhances dopamine signalling.
Progesterone dampens it.

This creates a changing landscape across a woman’s life:

• Before menstruation: ADHD symptoms often worsen.
• During adolescence: masked ADHD may suddenly intensify.
• Postpartum: many women report dramatic onset of attention issues.
• Perimenopause: ADHD symptoms frequently flare, leading to late diagnosis.

Hormones do not cause ADHD, but they dramatically shape its lived expression.

Adult ADHD: When the Mask Finally Slips

Many women walk into the clinic only after:

• job transitions
• postgraduate studies
• leadership roles
• new motherhood
• caregiving burdens

When life demands rise, their well-rehearsed coping strategies collapse. What follows is confusion:

“I was always a bright student. Why can’t I manage now?”
“Why do simple tasks drain me?”
“Why does stress feel like chaos?”

These are classic signs of previously undiagnosed ADHD emerging under pressure.

The Road to Better Diagnosis: What Clinicians Must Do

To bridge the gender gap, ADHD assessment must include:

• thorough developmental history
• emotional profile analysis
• executive-function testing
• academic/work performance review
• QEEG or neurocognitive testing (where appropriate)
• evaluation for comorbid anxiety/depression

Girls and women deserve more than symptom checklists; they deserve a diagnostic framework that reflects their lived reality.

Final Thoughts: ADHD Is Not a Character Flaw

It is a neurodevelopmental pattern with diverse expressions. Boys externalise; girls internalise. Boys get noticed; girls get missed. Boys get interventions early; women often get them late.

Recognising these gendered expressions is the key to rewriting that story.

About the Author

Dr. Srinivas Rajkumar T, MD (AIIMS), DNB, MBA (BITS Pilani)
Senior Consultant Psychiatrist & Neurofeedback Specialist
Mind & Memory Clinic, Apollo Clinic Velachery (Opp. Phoenix Mall)
✉ srinivasaiims@gmail.com 📞 +91-8595155808