Why ADHD Still Looks Different in Girls and How We Can Finally See It

Nerissa Bauer, M.D., MPH

Credit: Doctors on Social Media

Attention-deficit/hyperactivity disorder (ADHD) awareness has come a long way, but girls are still being left behind. For every two boys diagnosed, there’s a girl quietly slipping through the cracks, her struggles dismissed as stress, anxiety or perfectionism. The data tell the truth: 15% of boys are diagnosed with ADHD, compared with just 8% of girls.

This gap represents far more than a data point. It illustrates years of confusion, frustration and self-doubt for girls who are working twice as hard to hold things together. This is not only true for my patients, like Maddie, whose ADHD had been masked by her anxiety, but for myself, an overachieving, high-performing woman who received her own diagnosis later in life.

When most people picture ADHD, they still imagine the classic “hyperactive” symptoms: fidgety, impulsive and disruptive. But for many girls, ADHD looks nothing like that. Instead of bouncing off the walls, they’re daydreaming, zoning out, rereading the same page again and again. They might be perfectionists and people pleasers, anxious to get it right and exhausted from trying.

Because their struggles may not disrupt others, girls’ symptoms often go unseen. Teachers describe them as “bright,” “quiet” and “helpful.” Parents see a hardworking child who melts down at home but assume it’s just stress or teenage mood swings. And the girls themselves? They internalize it all, believing they’re lazy, broken or just not trying hard enough.

How Anxiety and Perfectionism Hide ADHD

By adolescence, many girls become experts at masking their difficulties. They organize meticulously, overprepare and push themselves to maintain control. But that control comes at a cost of anxiety, burnout and a deep sense of never being enough.

In my practice, I often meet girls who seem composed in public but unravel in private. They come home from school, close the door and cry. Parents see the emotional toll, but teachers see only the polished surface. The disconnect leads to missed opportunities for help, and the longer it takes to identify what’s really happening, the more entrenched the anxiety becomes.

ADHD and anxiety are frequent companions. Anxiety can mask ADHD, creating a hyperfocus on doing well that conceals the inattention underneath. When we treat only what’s visible, we miss what’s really driving the struggle.

Why Our Current Tools Aren’t Enough

Unfortunately, ADHD has no blood test or brain scan. Diagnosis depends largely on subjective rating scales generated by forms filled out by parents, teachers and sometimes teens. These scales are useful, but they capture perception, not performance.

A teacher who sees a polite, engaged student may rate “no concerns.” A parent might focus on emotional distress without recognizing its cognitive roots. And the child herself might not have the words to describe the effort it takes just to stay afloat.

We end up trying to build a diagnosis from incomplete snapshots. And because girls’ symptoms often show up internally (e.g., fatigue, perfectionism, zoning out), they simply don’t trigger the same alarms as the “classic” hyperactive profile.

Making the Invisible Visible

To see beyond what subjective observation uncovers, I integrate objective testing into my diagnostic process. Objective assessments are U.S. Food and Drug Administration (FDA)-cleared tools that measure attention, impulsivity and activity in real time. I tell my patients, “This isn’t a test of how smart you are; it’s a way to see how your brain works when something is very boring.”

For girls especially, this can be revelatory. Objective data translate their invisible effort into something tangible. Parents can visualize the lapses in focus, and teens can finally see that what they’ve been describing isn’t “all in their head.”

It’s not about replacing professional judgment; it’s about enhancing it. Objective testing provides another data point, helping us separate what’s anxiety, what’s attention, what’s impulse control and what’s all three.

Maddie’s Story: Finding Validation in Data

One of my patients, Maddie, illustrates this perfectly. She was a high-achieving, anxious teen who had always seemed “put together.” Her first test results were mixed, nothing that screamed “ADHD.” But as I listened, it was clear that anxiety was driving much of her struggle.

I suggested we start by treating her anxiety, then repeat the ADHD test later. When we did, the difference was striking. The second test revealed clear attention challenges that had been masked by her anxiety.

When I showed Maddie the graphs, she started to cry, not from sadness, but relief. “This is what I’ve been trying to tell people,” she said. For the first time, her experience was visible, measurable and understood.

My Own Diagnosis at 47

I know exactly how Maddie felt. I wasn’t diagnosed with ADHD until I was 47 years old, after decades of working with children who had the same condition.

Looking back, the signs were always there: chronic overwork, perfectionism, imposter syndrome, the feeling that I had to sprint just to keep pace. When my psychologist friend confirmed the diagnosis, I cried. Not out of surprise, but because it finally made sense. I grieved the time I’d lost not knowing.

Where We Go From Here

The underdiagnosis of ADHD in girls is about bias, masking and tools that weren’t built to capture the full picture.

To close the gap, we need to do the following:

• Look beyond behavior. Calm doesn’t mean capable.
• Pair subjective insights with objective data. See what perception alone can’t.
• Listen to girls’ lived experience. Believe them when they say they’re trying and still struggling.

Girls don’t need to “try harder.” They need adults who recognize that effort isn’t the problem, understanding is.

Every girl we see sooner changes the story not only for herself but for the generation behind her. Because the sooner we start seeing ADHD for what it really looks like in girls, the sooner we stop asking them to disappear just to fit in.

Bauer is a behavioral pediatrician and founder of Let’s Talk Kids Health, where she empowers families to understand and manage behavioral health challenges. She serves as an adviser to Qbtech and is a member of the company’s Expert ADHD Consortium. Bauer is also a contributor to FindtheADHDgirls.org.