Gender Differences in 2 Clinical Trials of Adults With Attention-Deficit/Hyperactivity Disorder: A Retrospective Data Analysis
Abstract
INTRODUCTION: Studies show that, in childhood attention-deficit/hyperactivity disorder (ADHD), boys have the combined type with externalizing behaviors more frequently, and girls have the inattentive type with increased internalizing disorders more frequently. METHOD: This study explored gender differences in adults with ADHD in 2 large, placebo-controlled, multicenter studies conducted from 2000 to 2001. Information collected included 2 measures of ADHD, multiple psychological measures, general physical symptoms, and treatment response. RESULTS: Thirty-four percent of the subjects were female. Women were rated as more impaired on every measure of ADHD symptoms including total Conners' Adult ADHD Rating Scale-Investigator Format (CAARS-INV), total Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), and most subscales of both measures. More women (75%) had combined type compared with men (62%). Women showed a more complex presentation, with higher scores on the Hamilton Rating Scale for Anxiety (HAM-A) and the Hamilton Rating Scale for Depression, 17-item version (HAM-D(17)), more sleep problems, and more past DSM-IV Axis I diagnoses. Both sexes displayed substantial impairment on 3 Psychological General Well-Being Schedule factors: tension-anxiety, life satisfaction, and vitality-drive. Women experienced significantly (p = .003) greater rates of emotional dysregulation (37%) versus men (29%) as defined by a cluster of symptoms on the WRAADDS. The emotional dysregulation factor is derived by combining 3 symptoms--temper control, mood lability, and emotional overreactivity--from the Utah Criteria for ADHD in adults. These symptoms are considered associated symptoms in the DSM-IV description of ADHD. Women also experienced greater improvement (p = .011) on this symptom factor. CONCLUSION: In contrast to the results from childhood studies, women were more impaired than men on ADHD scales in our study. The higher level of emotional symptoms and more complicated presentation in women may obscure the diagnosis of ADHD. Thus, the assessments of adults with ADHD should include an exploration of the emotional dimensions of the illness.
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Women with ADHD, when compared to men with ADHD, seem to have more mood, anxiety and eating disorders, a higher level of emotional symptoms, and relational instability.
“As previously described, women with ADHD, when compared to men with ADHD, seem to have more mood [8,9,10], anxiety and eating disorders [9], a higher level of emotional symptoms [11] and relational instability [12].”
From A Female-Specific Treatment Group for ADHD—Description of the Programme and Qualitative Analysis of First Experiences (2024) · cites this paper as [11]
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“32 These women tend to respond to life stressors with emotion and feel a lack of control over their situation,. 28,32 which translates into difficulties in coping with home life, 29 feelings of disorganization, 61 somatization (including headaches, stomachaches), 62 and/or sleep difficulties.”
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Nussbaum, N. L. (2012) · Journal of Attention Disorders · doi:10.1177/1087054711416909 · Cited by 241 · see citing works
“Relatedly, women were found to have a higher symptom load, including emotional dysregulation, than did men in a large retrospective study (Robison et al., 2008).”
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“Unlike these results, women were more affected than men on different ADHD scales in another retrospective study (Robison et al. 2008).”
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“…multicenter studies of adults with ADHD showed significant sex differences in clinical presentation of symptoms, with females more impaired on all measures, including two measures of ADHD, multiple psychological measures, general physical symptoms, and treatment response (Robison et al., 2008).”
BackgroundMiss. Diagnosis: A Systematic Review of ADHD in Adult Women
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“Robison et al. (2008) looked at gender differences in ADHD symptoms, psychological functioning, physical symptoms, and treatment response.”
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“The meta-analysis of the five trials on atomoxetine (Adler et al., 2014a,b; Brown et al., 2011; Goto et al., 2017; Robison et al., 2008) showed a low effect size (SMD = 0.”
InfluentialIs emotional dysregulation part of the psychopathology of ADHD in adults?
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“Emotional dysregulation symptoms seems to be more frequently in patients diagnosed with combined type ADHD (Reimherr et al. 2005, 2010; Robison et al. 2008).”
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“Further, subtype distributions appear to change in adulthood; studies indicate women are diagnosed with the combined subtype more frequently than men and suffer greater impairment on several measures of ADHD symptoms (Robison et al., 2008; Rucklidge, 2010).”
BackgroundSex Differences in the Manifestation of ADHD in Emerging Adults
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BackgroundSimilarities between emotional dysregulation in adults suffering from ADHD and bipolar patients
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“This finding is contrary to previous studies in adults with ADHD, which have not reported marked gender differences in the response to MPH treatment (Kooij et al. 2004; Spencer et al. 2005; Robinson et al., 2008).”
ResultLoss of T cells influences sex differences in behavior and brain structure
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“Our data disclose few gender differences for axis I, but confirm the results of previous studies of adult ADHD, where mood and eating disorders were more frequent in women (23,27) and a higher prevalence of substance-use disorders in men (25–27).”
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“The other reason is women were found to have more mood or internalizing symptoms than men (Robison et al., 2008).”
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Health Care Trajectories for Children With ADHD in France: Results From the QUEST Survey
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“However, clinicians may have been misled by gender bias (Nussbaum, 2012) as ADHD in girls is more frequently associated with emotional dysregulation symptoms (Robison et al., 2008) and a higher rate of comorbidity with internalized disorders (Koyuncu et al.”
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“In relation to comorbidities, participants in the study group also showed higher rates of all comorbid disorders, in the line of prior investigations that also reported higher rates in the group with EL (Anastopoulos et al., 2011; Biederman, Spencer, Lomedico, et al., 2012; Reimherr et al., 2005; Reimherr et al., 2007…”
ResultUpdate on adult attention-deficit/hyperactivity disorder
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“Moreover, recent data from two large, placebo-controlled, multicenter studies of adults with ADHD suggest that there may be a signifi cant sex difference in clinical presentation, including comorbidity [ 29 ].”
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“These results do not corroborate recent findings supporting the notion that women are more impaired on several ADHD scales and have a higher level of emotional symptoms than men ( Robison et al. 2008 ).”
BackgroundResultInfluentialThe Relationship Between Neuropsychological Deficits and Emotional Lability in Adults With ADHD
Gisbert, L., Vanesa Richarte, B., Montse Corrales, F., Ibáñez, P., Bosch, R., Bellina, M., Fadeuilhe, C., Casas, M., & Ramos‐Quiroga, J. A. (2018) · Journal of Attention Disorders · doi:10.1177/1087054718780323 · Cited by 12 · see citing works
“…in line with prior investigations that also reported higher rates in the group with EL (Anastopoulos et al., 2011; Biederman, Spencer, Lomedico, et al., 2012; Reimherr et al., 2005; Reimherr et al., 2007; Robison et al., 2008; Skirrow, McLoughlin, Kuntsi, & Asherson, 2009; Surman et al., 2013).”
ResultClinical Characteristics of Women with ADHD in Japan
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“The results that women were more likely to have a past diagnosis of bipolar disorder and to be prescribed mood stabilizers may support the higher prevalence of affective problems in women, as reported in previous studies.(29,30) T b le 2 Lo gi st ic R eg re ss io n A na ly se s of Em pl oy m en t St at us ,M ar ita ls…”
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“As previously described, women with ADHD, when compared to men with ADHD, seem to have more mood [8–10], anxiety and eating disorders [9], a higher level of emotional symptoms [11] and relational instability [12].”
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“2 Unlike the findings from research in girls, in which the inattentive type is diagnosed more often than in boys, in a clinical trial, adult women were diagnosed more often with the combined type than men (Robison et al. 2008) .”
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“Because women with ADHD may have more severe symptoms (Robison et al., 2008; Fedele et al., 2012) andmay experience more symptomatic relief with stimulant treatment (Weiss Neurotoxicology and Teratology 47 (2015) 125–136”
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Soliman, A., & Elfar, R. M. (2017) · Journal of Attention Disorders · doi:10.1177/1087054714556814 · Cited by 9 · see citing works
“Moreover, several studies (e.g., Biederman et al., 2002) have indicated that females diagnosed with ADHD are more likely to have ADHD-IA; other studies (e.g., Biederman et al., 2005; Robison et al., 2008) have documented that females diagnosed with ADHD are equally or more impaired than males.”
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Drug Class Review: Pharmacologic Treatments for Attention Deficit Hyperactivity Disorder
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Treating Adult ADHD with Stimulants
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The role of physical activity in the association between ADHD and emotional dysregulation
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“In addition, we hypothesize that this association is stronger in girls than boys, as female sex has been associated with higher ED and emotional symptoms (Astenvald et al., 2022; De Ronda et al., 2023; Robison et al., 2008).”
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“…with a higher prevalence of ADHD diagnoses in males than in females in children (male/female ratio of 9 – 4:1) (Biederman et al., 2004; Bitter et al., 2010; Robison et al., 2008), with a more even sex balance towards adulthood (American Psychiatric Association, 2013; Kessler et al., 2006).”
Absent or Hidden? Hyperactivity in Females With ADHD
Wettstein, R., Navarro-Ovando, V., Pirgon, E., Kroesen, J., Wettstein, K., Kroesen, H., Mâthot, R., & Dumont, G. (2024) · Journal of Attention Disorders · doi:10.1177/10870547241273152 · Cited by 3 · see citing works
“…is, males are more likely to present hyperactive symptoms while females are more likely to present inattentive symptoms, is likely an artefact of comparing females to males, rather than indicating a variance in the severity or burden (Arnett et al., 2015; Faheem et al., 2022; Robison et al., 2008).”
Sex differences in the response to treatment of attention deficit hyperactivity disorder
Müller, E. D., & Fender, A. C. (2025) · Naunyn-Schmiedeberg s Archives of Pharmacology · doi:10.1007/s00210-025-04716-5 · Cited by 4 · see citing works
“ADHD manifests somewhat differently between male and female subjects (Robison et al. 2008), as also exemplified by the two cases, Henry and Emilia, described in Box 1.”
Gissandaner, T. D., Stearns, M. A., Sarver, D. E., Walker, B. H., & Ford, H. A. (2023) · Clinical Child Psychology and Psychiatry · doi:10.1177/13591045231156342 · Cited by 4 · see citing works
“Similarly, adult women with ADHD in another study reported high rates of sleep problem histories, including disrupted sleep and increased sleepiness during the day ((Robison et al., 2008).”
BackgroundPsychostimulanzien und verwandte Substanzen bei psychisch Kranken
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- Authors
- Robison, R. J., Reimherr, F. W., Marchant, B. K., Faraone, S. V., Adler, L. A., & West, S. A.
- Affiliations
- University of Utah (US)
- SUNY Upstate Medical University (US)
- New York University (US)
- CNS Healthcare (US)
- Venue
- The Journal of Clinical Psychiatry
- Publisher
- Physicians Postgraduate Press, Inc
- Published
- 2008-02-15
- Volume
- 69
- Issue
- 2
- Pages
- 213-221
- ISSN
- 0160-6689 (ISSN-L)
- OpenAlex
- W2007132150
- Cited by
- 101
- References
- 0
- Citations by year
- 2026: 3 · 2025: 11 · 2024: 5 · 2023: 2 · 2022: 2 · 2021: 3 · 2020: 6 · 2019: 3 · 2018: 2 · 2017: 6 · 2016: 6 · 2015: 3 · 2014: 11 · 2013: 6 · 2012: 5
- FWCI
- 6.31
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Clinical Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
- Keywords
- adult ADHD, gender differences, emotional dysregulation, combined type ADHD, inattentive type ADHD, anxiety, depression, sleep disorders, psychological well-being, treatment response
- MeSH terms
- Atomoxetine Hydrochloride, Adult, Attention Deficit Disorder with Hyperactivity, Emotions, Female, Humans, Male, Middle Aged, Propylamines, Retrospective Studies, Sex Factors, Multicenter Studies as Topic, Randomized Controlled Trials as Topic, Women's Health, Treatment Outcome, Adrenergic Uptake Inhibitors
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