ADHD in Women: Gender Differences in DIVA-5 Symptom and Impairment Endorsement

Study: Platania, N. M., Starreveld, D. E. J., Wynchank, D., Beekman, A. T. F., & Kooij, S. (2025). Bias by gender: Exploring gender-based differences in the endorsement of ADHD symptoms and impairment among adult patients. Frontiers in Global Women’s Health, 6, 1549028. Full study / DOI

Research question

The researchers examined whether men and women diagnosed with ADHD differed in the symptoms, examples, and areas of impairment they endorsed during the DIVA-5, a structured diagnostic interview for adult ADHD.

This was an exploratory study, not a study designed to prove that ADHD diagnostic tools are biased against women. (Frontiers study)

Sample and method

The study analyzed DIVA-5 assessments from 2,257 adults diagnosed with ADHD in Dutch mental-health clinics between 2021 and 2024. Approximately 61% were classified female. The researchers examined current adult ADHD symptoms, retrospectively reported childhood symptoms, functional impairment, and the specific examples participants endorsed during the interview. (Frontiers study)

An important limitation is that this was already a diagnosed clinical population. Women whose ADHD had gone unrecognized or who never reached assessment were therefore largely absent from the study. (Frontiers study)

Main finding: men and women were more similar than different

The researchers' primary finding was that ADHD presented in remarkably similar ways in diagnosed men and women overall.

Most gender differences were statistically significant only because the study was large enough to detect relatively small differences. Nearly all effect sizes were small, and the authors explicitly caution that their clinical significance is uncertain. (Frontiers study)

This study therefore does not support the claim that women have an entirely different form of ADHD.

It suggests something more subtle: the same underlying ADHD difficulties may sometimes become visible through different behaviors, coping strategies, and areas of impairment.

Adult ADHD symptoms

When significant differences appeared in current adult symptoms, women consistently endorsed the symptoms more frequently than men.

Some of the larger differences included:

• Feeling restless: about 88% of women vs. 78.5% of men
• Losing things: about 80% vs. 71%
• Talking excessively: about 63% vs. 52%

Women had higher endorsement rates for six adult hyperactive/impulsive symptoms, which complicates the common assumption that hyperactivity is primarily characteristic of men. The researchers suggest that adult hyperactivity may include less externally visible experiences such as internal restlessness and other forms of activity that are not captured by the childhood stereotype of the physically disruptive boy. (Frontiers study)

Childhood ADHD looked somewhat different

Retrospective childhood reports showed a different pattern. Men endorsed several childhood symptoms more frequently.

The authors noticed that many childhood DIVA-5 examples emphasize visible classroom behaviors such as leaving one's seat, not completing homework, or receiving negative comments about schoolwork.

They raise the possibility that these examples may make ADHD easier to recognize in children whose difficulties appear in traditionally externalized ways. The authors specifically suggest that adding examples more representative of girls' experiences could reduce potential measurement bias. (Frontiers study)

This is a hypothesis generated by the study, not proof that the DIVA-5 systematically misses girls.

A particularly important finding: coping can become the evidence of ADHD

One of the most useful findings involved the specific examples people chose to describe inattention.

Men were more likely to endorse examples reflecting visible difficulty or failure, such as inaccurate work, missed deadlines, or forgotten chores.

Women were more likely to endorse examples reflecting attempts to prevent those failures, including:

• rigid reliance on lists
• needing to adhere closely to schedules
• creating schedules even when they could not consistently use them

For example, approximately 30% of women versus 19.5% of men endorsed rigid use of lists to make sure things were not forgotten. (Frontiers study)

The researchers interpret this pattern as consistent with the possibility that women develop greater organizational or compensatory strategies that can conceal ADHD-related difficulties. (Frontiers study)

PKM connection

A clinically useful inference from this finding is:

Sometimes the evidence of ADHD is not the visible failure. It is the amount of structure a person has built to prevent the failure.

A woman who rarely misses appointments because she uses several calendars, alarms, written lists, repeated checking, and significant mental effort may still be managing substantial ADHD-related difficulty.

That interpretation goes beyond what the study directly proved, but it follows closely from the pattern the authors identified.

Self-confidence stood out

The largest difference among broad impairment categories involved self-confidence.

In adulthood:

• 89% of women
• 81% of men

reported ADHD-related impairment in self-confidence.

Retrospectively in childhood:

• 77% of women
• 65% of men

reported self-confidence difficulties. (Frontiers study)

Women also reported somewhat greater impairment in free time and social contacts, although these differences were small. (Frontiers study)

The researchers discuss whether ADHD behaviors may conflict with gendered expectations placed on girls and women, potentially contributing to negative self-evaluation. They also note that other research has not consistently found gender differences in self-esteem, so this finding needs replication. (Frontiers study)

Perfectionism and overextension appeared frequently

Several specific impairment examples are notable for understanding ADHD women.

Compared with men, women more frequently endorsed:

• Perfectionism: 63% vs. 50% in adulthood
• Fear of failure when starting new things: 51% vs. 40%
• Being continually busy and becoming overtired: 47% vs. 34%

Women also retrospectively endorsed childhood perfectionism more frequently: approximately 44% vs. 29%. (Frontiers study)

These findings do not establish perfectionism or overworking as ADHD symptoms. They show that these experiences were relatively common impairment examples among people already diagnosed with ADHD, particularly women.

Some traditional ADHD impairment examples may be poor representations of typical adult ADHD

The researchers also examined which DIVA-5 examples were rarely endorsed.

More dramatic externalized outcomes—such as police involvement, losing a driver's license because of reckless driving, or certain severe behavioral consequences—were relatively uncommon.

More frequently endorsed problems included internalized experiences such as perfectionism and internal tension. (Frontiers study)

The researchers suggest that some rarely endorsed examples may need to be replaced with examples that better represent the experiences of typical ADHD patients.

This matters beyond gender. Diagnostic interviews may become more accurate when clinicians ask about everyday functional demands and internal experiences rather than relying heavily on dramatic evidence of impairment.

Possible implications for ADHD assessment in women

The study supports asking not only:

“What goes wrong?”

but also:

“What do you have to do to keep it from going wrong?”

Relevant areas to explore may include:

• elaborate planning systems
• heavy reliance on lists and reminders
• inflexibility around routines because structure feels necessary
• perfectionistic checking
• overpreparation
• chronic busyness
• exhaustion associated with keeping things functioning
• fear of making mistakes
• internal restlessness
• verbal rather than primarily physical hyperactivity

These should not be treated as diagnostic criteria themselves. They may provide context for identifying the underlying ADHD symptoms and functional demands.

Important limitations

This study should not be used as proof that current ADHD diagnostic systems systematically underdiagnose women.

The authors emphasize several limitations:

• Participants already had an ADHD diagnosis.
• This means people whose ADHD presentation prevented recognition may be missing from the sample.
• The sample came from clinical settings and may represent people with more obvious or severe difficulties.
• Childhood symptoms were assessed retrospectively and are vulnerable to recall problems.
• Gender was recorded only as male or female based on legal gender, inadequately representing transgender and gender-diverse people.
• The study was exploratory rather than hypothesis-testing.
• Most gender effects were small.
• The authors explicitly state that the study was not intended to generate clinical recommendations. (Frontiers study)

Core takeaway for PKM

The strongest finding is not that ADHD is fundamentally different in women. It is that similar ADHD difficulties may sometimes be expressed, compensated for, and experienced differently.

Women in this diagnosed ADHD sample were somewhat more likely to describe organizational compensation, perfectionism, internal restlessness, overextension, and self-confidence difficulties. Some childhood diagnostic examples, meanwhile, emphasized more visible behaviors that were endorsed more frequently by men.

For assessment, this raises an important question:

Are we looking only for evidence that the person failed, or are we also looking at how much work the person is doing to prevent failure?

Citation

Platania, N. M., Starreveld, D. E. J., Wynchank, D., Beekman, A. T. F., & Kooij, S. (2025). Bias by gender: Exploring gender-based differences in the endorsement of ADHD symptoms and impairment among adult patients. Frontiers in Global Women’s Health, 6, 1549028. https://doi.org/10.3389/fgwh.2025.1549028