Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment

Eur Child Adolesc Psychiatry. 2019 Apr;28(4):481-489. doi: 10.1007/s00787-018-1211-3. Epub 2018 Aug 10.


In youth, ADHD is more commonly diagnosed in males than females, but higher male-to-female ratios are found in clinical versus population-based samples, suggesting a sex bias in the process of receiving a clinical diagnosis of ADHD. This study investigated sex differences in the severity and presentation of ADHD symptoms, conduct problems, and learning problems in males and females with and without clinically diagnosed ADHD. We then investigated whether the predictive associations of these symptom domains on being diagnosed and treated for ADHD differed in males and females. Parents of 19,804 twins (50.64% male) from the Swedish population completed dimensional assessments of ADHD symptoms and co-occurring traits (conduct and learning problems) when children were aged 9 years. Children from this population sample were linked to Patient Register data on clinical ADHD diagnosis and medication prescriptions. At the population level, males had higher scores for all symptom domains (inattention, hyperactivity/impulsivity, conduct, and learning problems) compared to females, but similar severity was seen in clinically diagnosed males and females. Symptom severity for all domains increased the likelihood of receiving an ADHD diagnosis in both males and females. Prediction analyses revealed significant sex-by-symptom interactions on diagnostic and treatment status for hyperactivity/impulsivity and conduct problems. In females, these behaviours were stronger predictors of clinical diagnosis (hyperactivity/impulsivity: OR 1.08, 95% CI 1.01, 1.15; conduct: OR 1.43, 95% CI 1.09, 1.87), and prescription of pharmacological treatment (hyperactivity/impulsivity: OR 1.24, 95% CI 1.02, 1.50; conduct: OR 2.20, 95% CI 1.05, 4.63). Females with ADHD may be more easily missed in the ADHD diagnostic process and less likely to be prescribed medication unless they have prominent externalising problems.

Keywords: Attention-deficit/hyperactivity disorder/ADHD; Clinical diagnosis; Population-based study; Sex differences.

Publication types

  • Twin Study

MeSH terms

  • Adolescent
  • Attention Deficit Disorder with Hyperactivity / diagnosis*
  • Attention Deficit Disorder with Hyperactivity / drug therapy*
  • Attention Deficit Disorder with Hyperactivity / epidemiology
  • Attention Deficit Disorder with Hyperactivity / psychology
  • Central Nervous System Stimulants / pharmacology
  • Central Nervous System Stimulants / therapeutic use
  • Child
  • Cohort Studies
  • Female
  • Humans
  • Impulsive Behavior / drug effects
  • Impulsive Behavior / physiology
  • Longitudinal Studies
  • Male
  • Parents / psychology
  • Predictive Value of Tests
  • Prospective Studies
  • Sex Characteristics*
  • Sweden / epidemiology
  • Treatment Outcome
  • Twins* / psychology


  • Central Nervous System Stimulants