Why Girls with ADHD Are Still Overlooked: Inside the Gap Between Research and Clinical Practice

An Interview with Dr. R. Elizabeth Capps

In a previous article, I looked at why girls and women with ADHD are still underdiagnosed and misdiagnosed with anxiety and depression even though research has shown that their symptoms often look different from the male-centered picture of the disorder. I argued that part of this problem is in translation: diagnostic criteria, screening tools,  and clinician training haven’t kept up with what we know. However, this raises a question I did not answer. How solid is the research itself? To study sex differences in ADHD symptoms requires finding equal numbers of girls and boys with ADHD, but many girls have never been diagnosed. This means that studies may draw mostly on the girls who were already identified, with known symptoms, and the cycle continues. Though existing research suggests that ADHD presents differently in girls and women, not enough studies have been replicated with substantial sample sizes to confirm this.

To understand how this plays out from both sides, I had the opportunity to sit down with Dr. R. Elizabeth Capps, a psychology professor and researcher at Case Western Reserve University. Her research focuses on adolescents with ADHD and identifying factors that influence their academic and social functioning to develop effective interventions. Through her involvement in both active research and clinical practice, Dr. Capps’ perspective merges the clinical and research worlds that often seem separated.

What Does the Current Research Tell Us About Girls with ADHD?

Dr. Capps worked on a study with Dr. Melissa Dvorsky to look at school engagement in 5th graders with ADHD. School engagement includes students' participation in schoolwork, sense of belonging, and use of effective learning strategies. This is an important factor to look at, as those who struggle with school engagement are also at risk for substance use, depression, and anxiety. The participants were 50% male and 50% female, ensuring that both sexes were fairly represented in the findings, and they found that school engagement challenges weren’t as pronounced in girls as the majority of existing literature suggests. This may be because the literature does not adequately represent the experiences of ADHD, but having a sufficient sample size is complicated. It is extremely difficult to recruit young girls with ADHD due to underdiagnosis, and having a smaller sample size limits how far findings can be generalized. This creates a cycle: underdiagnosis makes girls with ADHD hard to find, and their absence from studies keeps the research narrow.

The general diagnostic criteria, says Dr. Capps, look at developmentally inappropriate levels of inattention and hyperactivity. However, researchers think that girls tend to exhibit problems with inattention more often than hyperactivity or impulsivity. This makes diagnostic procedures more complex, as hyperactivity is an easily observable behavior, but inattention is not, making symptoms easier to mask. Another layer that adds to this complexity is societal standards put on young girls, contributing further to masking. In order to prevent delayed diagnosis, psychologists then need to better understand how to characterize these more internal states. 

Could the diagnostic criteria change to better recognize symptoms in girls and women? Dr. Capps shares that with sufficient scientific evidence, they certainly can. She mentions that psychologists now use rating scales, which are standardized questionnaires completed by a variety of different people, such as those with ADHD, those without, teachers, and parents. This is also given to people of different ages and sexes. Based on this scale, psychologists are able to identify norms of certain groups. For example, they are able to know the norm of responses in girls with ADHD in this age range. They can also compare someone’s signs to the norms for girls without ADHD in their age group when diagnosing.

Why Is There a Gap And How Can We Close It?

According to Dr. Capps, the gap between research and clinical practice isn’t simply a disconnect between two separate worlds. Several factors work together. First, findings need to be replicated because repeating studies is what strengthens existing results. Second, researchers need to communicate their findings more effectively so that teachers, counselors, and healthcare professionals can put them to use. This matters especially for educators because ADHD is a neurodevelopmental condition, where symptoms often begin during childhood, and teachers are often the first to notice them. Third, clinicians need ongoing education to keep up with new research. Closing this gap won’t come from researchers or clinicians alone. It will take stronger evidence, clearer communication, and ongoing education working together, so that girls with ADHD are recognized earlier and finally become visible in the research too.