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 Humanities and Social Science Research; Vol. 6, No. 2; 2023 
ISSN 2576-3024   E-ISSN 2576-3032 

https://doi.org/10.30560/hssr.v6n2p30 

 30 Published by IDEAS SPREAD 
 

Issues Which Marginalize Females with ADHD - A Mixed Methods 
Systematic Review 

Sarah Cilia Vincenti1, Michael Galea1 & Vince Briffa2 
1 Department of Mental Health, Faculty of Health Sciences, University of Malta 
2 Department of Digital Arts, Faculty of Media and Knowledge Sciences, University of Malta 
Correspondence: Sarah Cilia Vincenti, University of Malta, Malta. E-mail: sarah.cilia-vincenti.99@um.edu.mt 
 
Received: July 5, 2023; Accepted: July 24, 2023; Published: July 31, 2023 
 
Abstract 
Background 
Marked disadvantages of females with ADHD were identified by previous narrative reviews. Factors side-lining 
females with ADHD appear to be both biological and sociological in nature. Some published systematic reviews 
have focused on circumscribed aspects of female ADHD. An all-inclusive systematic review of the inequities 
which confer a status of marginalization to females with ADHD is required, to comprehensively understand all 
implications of female ADHD. 
Objectives 
The aim of this review was to identify and synthesize quantitative and qualitative evidence of issues which 
marginalize females with ADHD. 
Methods 
A mixed methods systematic review following a convergent integrated approach, as outlined by the Joanna Briggs 
Institute’s manual for evidence synthesis was undertaken. Databases were accessed through the Hydro Data 
Initiative platform of the University of Malta. All types of studies were considered for inclusion. Extracted 
quantitative findings were transformed into qualitative findings prior to synthesis. The review protocol was 
registered with PROSPERO CRD42022384055. 
Results 
34 papers were included in the review. Synthesis led to the emergence of five themes, namely ‘The gender gap in 
ADHD recognition, diagnosis and treatment’, ‘ADHD-related problems in females’, ‘Female ADHD and negative 
mental health sequelae’, ‘ADHD and female sexual and reproductive health issues’ and ‘The influence of ADHD 
on motherhood’. 
Conclusions 
Critically appraised, synthesized findings conclude that females with ADHD are disadvantaged in a number of 
ways. Clinicians and policy makers have access to latest evidence on all issues marginalizing females with ADHD 
in this mixed methods systematic review. Recommendations for policy and practice are advanced, together with 
directions future research ought to follow.  
Keywords: ADHD, females, marginalization, mixed methods systematic review, convergent integrated design 
1. Introduction 
Historically, Attention Deficit Hyperactivity Disorder (ADHD) was considered a disorder only affecting male 
children. Yet, accumulating research has evidenced that it often persists in adulthood, thus, efforts to promote 
awareness of adult ADHD and optimize adult patient outcomes have been instituted in the last two decades (Kooij 
et al., 2010). Moreover, Nussbaum (2012) highlighted that the disorder affects many females too, although they 
are likely to be diagnosed later than males. Indeed, Quinn (2005) described ADHD as a ‘hidden disorder’ in 
females, whilst Waite (2010) warned that many women with ADHD are suffering in silence.  
Symptoms of inattentiveness are generally more conspicuous and problematic than those of hyperactivity and 
impulsivity in girls, whose resulting presentations are often labelled as ‘subthreshold’. This was suggested by 
Quinn and Madhoo (2014) as one reason which explains why the disorder is often missed in girls. Additionally, it 



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has been pointed out that girls and women with ADHD may develop psychiatric comorbidities, notably depression 
and anxiety, which complicate ADHD recognition (Quinn, 2008). Meanwhile, an initial qualitative exploration of 
the experiences of women with ADHD diagnosed as seniors confirmed that the delay in diagnosis and treatment 
sets women up for a lifetime of struggles, and gender role expectations exacerbate the impact of ADHD on girls 
and women (Henry and Hill Jones, 2011).  
Since gender had not been recognized as an important marker of an adult ADHD profile, Williamson and Johnston 
(2015) narratively reviewed the literature on gender differences in adults with ADHD. It was concluded that 
similarity between genders must not be presumed in view of variations in prevalence, impairments and comorbidity 
(Williamson and Johnston, 2015). More recently, there have been calls for ADHD research to finally start ensuring 
an equal representation of females in research samples (Hinshaw et al., 2022), and for studies to analyze and report 
data for males and females distinctly (Kok et al., 2020). Furthermore, it has been recommended that future research 
priorities related to this phenomenon should not only investigate precise sex differences in symptomatology and 
impairment, but broaden the perspective to elucidate other female specific concerns such as self-harm, challenging 
relationships, unplanned pregnancies and parenthood (Hinshaw et al., 2022).  
In response to an emergent subset of ADHD research, indicating a marked disadvantage of females with this 
disorder, a Participatory Action Research Study using the Photovoice method was conceived. This current review 
forms part of the foundational work carried out for this ongoing project entitled “Empowering Maltese Adult 
Women with ADHD using Photovoice.” Being increasingly lauded as an effective method to empower 
marginalized communities, Photovoice was chosen to that end (Evans-Agnew and Strack, 2022).  
The primary objective of this review was to situate this project within the extant research on female specific ADHD 
issues. To categorically ascertain that side-lining of this community is indeed a concrete phenomenon, a systematic 
review providing critically appraised, synthesized evidence was required. The preliminary literature search failed 
to locate previously published systematic reviews covering the full range of inequities which confer a marginalized 
status to females with ADHD.  
Instead, a number of systematic reviews were identified which targeted circumscribed aspects of this phenomenon. 
For instance, Kok et al. (2016) reviewed the evidence pertaining exclusively to problematic peer-functioning in 
girls with ADHD. Similarly, Camara et al. (2021) chose the relationship between sex hormones, reproductive 
stages and ADHD as the focus for their review. Furthermore, the systematic review of Kok et al. (2020) targeted 
pharmacotherapy for female ADHD. Alternatively, Surendran et al. (2022) solely addressed treatment of ADHD 
in pregnant women. Attoe and Climie (2023) lately reviewed evidence centering around the issue of misdiagnosis 
of females with ADHD. 
To date, one needed to sift through several systematic reviews, each yielding evidence pertaining to different 
elements, in order to gain an appreciation of all the nuances and implications of female ADHD. Increasingly, 
decision-making in health care is becoming complex and expeditious. This current review aimed to serve clinicians 
working with girls and women with ADHD, or policymakers planning services for them, by presenting a pragmatic 
and all-inclusive set of critically appraised, synthesized findings on the inequities of female ADHD. However, the 
preliminary overview of research indicated that both biological and social factors contribute to the oversight of 
females with ADHD in clinical and research settings. Thus, it was anticipated that both quantitative and qualitative 
studies would be located. This meant the resulting heterogeneity would defy the positivist model of conducting 
systematic reviews. 
Ultimately, it was decided to undertake a Mixed Methods Systematic Review (MMSR) since it had the capacity 
to systematically provide evidence to ascertain marginalization of females with ADHD, whilst catering for the 
anticipated heterogeneity of study designs. The review question, which can be answered by both quantitative and 
qualitative evidence, was thus set, and reads “What are the female specific ADHD issues which render adult 
women with ADHD a marginalized group?” 
2. Methodology 
This MMSR was conducted in accordance with the Joanna Briggs Institute methodology for MMSRs following a 
convergent integrated approach (Lizarondo et al., 2020). The convergent integrated approach is indicated to answer 
a broad review question that can be addressed by any type of study, involves transformation of extracted 
quantitative data into qualitative data, or transformation of extracted qualitative data into quantitative data, and 
integration of transformed data (Lizarondo et al., 2020). A protocol for this review was registered with PROSPERO 
International Prospective Register of Systematic Reviews registration number CRD42022384055. Reporting of 
the review followed the guidelines of the adapted PRISMA for reporting systematic reviews of qualitative and 
quantitative evidence (Appendix I).  



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2.1 Information Sources and Search Strategies 
An intensive search in the Hydro Data Initiative (HyDi) platform of the University of Malta was undertaken. This 
platform provides access to several databases including PubMed, Embase, CINAHL, Medline, BioMed Central, 
PsychInfo, ProQuest and Wiley Online Library. The search engine Google Scholar was subsequently accessed to 
supplement the HyDi search. The search was initially limited to articles written in the English Language and 
articles covering the period between 2012 and 2022. Moreover, a feature of the HyDi platform allowed filtering 
of records to identify solely those from peer-reviewed journals.  
The Population, Exposure and Outcome (PEO) framework, first proposed by Khan et al. (2003), was consulted to 
guide selection of keywords for the search and develop eligibility criteria. This framework lent itself best to the 
broad review question. Table 1 illustrates components of the PEO framework and concepts they identified. 
Synonyms and alternative terms for concepts identified by the PEO framework were recognized to ensure a more 
exhaustive search. Databases were instructed to retrieve records with keywords identified from the Population and 
Exposure components of the PEO framework only, to determine the breath of the body of knowledge on female 
specific ADHD issues. Boolean Operators “AND” and “OR” were employed. Whenever possible, truncated roots 
were used. The number of records identified permitted a thorough scrutiny of all records, without the need to 
further narrow the search strategy by adding keywords identified from the Outcome component of the PEO 
framework. This decision guaranteed that no relevant research would have been missed because of failure to 
identify all possible synonyms resulting from the Outcome component of the PEO framework. Thomas and Harden 
(2008) argue that in conservative statistical meta-analysis bias is introduced if any relevant study is not located, 
whilst in MMSRs bias is imported when important concepts are not identified.  
Searches were re-run just before the final syntheses (full electronic search strategies available in Appendix II). The 
HyDi and Google Scholar searches yielded a total of 2,334 potential records, which were loaded on the 
bibliographic software ‘RefWorks’. 569 of these were duplicates. A subsequent 1,657 records were removed as 
they were deemed irrelevant after screening through their titles and abstracts. Inclusion and exclusion criteria listed 
below guided screening of the remaining 108 potential records identified. Reference lists of these records were 
subsequently inspected to ascertain that no other relevant research had been missed. 
 
Table 1. The components of the PEO framework (Khan et al., 2003) and the concepts and synonyms identified to 
guide the search 

REVIEW QUESTION 
What are the female specific ADHD issues which render adult women with ADHD a marginalized group? 
FRAMEWORK COMPONENT CONCEPTS IDENTIFIED & SYNONYMS 
POPULATION 
 

WOMEN, FEMALES, GIRLS, MOTHERS, DAUGHTERS, 
SPOUSES, GENDER, SEX 

EXPOSURE ATTENTION DEFICIT HYPERACTIVITY DISORDER,  
ADHD 

OUTCOME EXPERIENCES, STRUGGLES, DISADVANTAGES, CONCERNS, 
ISSUES, FEELINGS 

The keywords developed through this exercise: women, females, girls, mothers, daughters, gender, sex, 
‘attention deficit hyperactivity disorder,’ ADHD, experiences, struggles, disadvantages, concerns, issues, 
feelings 

 
2.2 Eligibility Criteria 
Studies had to indicate disadvantage of females with ADHD to be included. Inclusion was not restricted by ADHD 
severity or subtype of study participants. Moreover, studies where participants were minors were also considered 
for inclusion, since problematic female specific ADHD issues may be at play since childhood. Quantitative, 
qualitative, primary mixed methods studies and systematic reviews were all considered for inclusion, as were 
studies from all geographical and socio-economic areas. Mixed methods studies were only considered if data from 
their quantitative or qualitative components could be clearly extracted. 
Studies were excluded if they were not from peer-reviewed journals. Studies involving only male participants or 
involving male and female participants without making any comparisons were excluded. Studies involving 
participants with ADHD with comorbid conditions other than depression, anxiety, self-harm and suicidal ideation 
were excluded. To ensure a manageable corpus of studies, few sensible post-hoc decisions about exclusion of 



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studies were made just before commencing data extraction, as advised by McKenzie et al. (2019). Thus, 
publication before 2015 and very low methodological quality were added to exclusion criteria. Eligibility was 
ascertained by the primary reviewer under the supervision of the other reviewers. Any disagreements were resolved 
through discussion. 
2.3 Quality Appraisal Process 
Studies which met inclusion criteria were appraised critically for methodological quality using the standardized 
instrument Mixed Methods Appraisal Tool (MMAT) version 2018 (Hong et al., 2018). MMAT version 2018 was 
selected because it provides methodological quality criteria for quantitative, qualitative, and mixed methods 
research and is relatively simple and time efficient to use, since it is restricted to core criteria. The developers of 
MMAT version 2018 do not advise reviewers to solely present an overall score, as that would not indicate which 
features of the study are problematic. Therefore, an overall quality score for each study was supplemented with a 
descriptive outline based on MMAT version 2018 criteria. Furthermore, Hong et al. (2018) discourage exclusion 
of studies from a review on account of low methodological quality. However, as stated previously, it was decided 
post-hoc to exclude studies with very low methodological quality to ensure manageability of the corpus of studies 
to appraise. A cut-off overall quality score of two out of five on the MMAT version 2018 was determined. Thus, 
studies obtaining a score of 1 were excluded. 
The JBI Checklist for Systematic Reviews and Research Syntheses was selected to appraise systematic reviews 
included in this MMSR, as it is congruent with the broader perspective of what constitutes evidence underpinning 
MMSRs. Authors of papers were contacted when the need arose to request missing or additional data. The quality 
appraisal process was performed solely by the primary reviewer. Uncertainties were discussed with the other 
reviewers, with any disagreements regarding inclusion of a paper, on the basis of methodological quality, being 
resolved through discussion. The level of evidence provided by each paper was appraised using the John Hopkins 
evidence-practice grading system for nurses and healthcare professionals (Dang et al., 2021). Results of the 
appraisal process were used in the synthesis to describe methodological quality and for sensitivity analysis.  
2.4 Data Extraction 
Quantitative and qualitative data were extracted from studies independently by the primary reviewer. The other 
reviewers assessed the meticulousness of extraction. By means of Excel, a data extraction template was designed, 
after agreement among the three reviewers regarding which specific details had to be extracted was reached. As 
suggested by Ryan et al. (2018), refining of this template was ongoing right until completion of data extraction. 
For all types of studies, extracted data subsisted of specifics about the author, year of publication, country of origin, 
study design, study aims, population and sampling techniques, context, phenomena of interest, study methods, 
outcomes of relevance to the review question, recommendations, level of evidence and assessment of 
methodological validity.  
For quantitative studies, extracted data pertaining to outcomes consisted of descriptive or inferential statistics 
(whether statistically significant or not). Information related to any measurement instruments employed was also 
extracted. With regards to qualitative studies, the recommendation of Adams et al. (2022) was adhered to, and 
extraction of data was undertaken in such a way so as to maintain fidelity to the themes as they were reported by 
the primary researchers. Moreover, all theories, models, conclusions from primary researchers and some 
participant excerpts were included in the outcomes category of the data extraction template. The primary outcome 
of interest was any female specific issue which renders adult women with ADHD a marginalized group.  
2.5 Data Transformation 
The data extraction process described yielded quantitative and qualitative data which had to be transformed into a 
mutually compatible configuration prior to being integrated. For this MMSR, data conversion involved qualitizing 
quantitative data. This decision was made in view of considerable heterogeneity in the designs, variables and 
measurement instruments employed by quantitative studies. Secondly, as Pearson et al. (2015) assert, codification 
of quantitative data is less likely to involve errors than quantification of qualitative data. 
Pearson et al. (2015), moreover, discuss considerations of rigour relating to conversion of quantitative data into 
qualitative themes. Following these guidelines, reviewers had to ‘bracket’ any pre-conceived understandings 
which could impinge on trustworthiness of this process. Data-based outcomes of any descriptive and/or inferential 
statistical tests were transformed into textual descriptions through thematic analysis by the primary reviewer. Any 
uncertainties were forwarded to other reviewers. Resulting discrepancies were resolved through discussion.  
 
 



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2.6 Data Synthesis 
Thematic synthesis, as expounded by Thomas and Harden (2008), was initiated by line-by-line coding of 
qualitative data extracted directly from qualitative studies and qualitized quantitative data. This operation was then 
followed by organization of these codes into categories according to similarities and differences in meaning. Until 
now, the review question was disregarded, and the focus was narrowed on the study findings to be coded and 
classified. The third and most challenging stage consisted of development of analytical themes. Here one had to 
go beyond the emergent categories by interpreting them with respect to the review question. The final product is 
a comprehensive aggregation of unified findings. 
Pearson et al. (2015) suggest that rigour in the thematic synthesis of data is ensured by making sure that findings 
from primary studies are adequately contextualized. By outlining study aims, methods used, sampling and setting 
details and methodological quality assessment, the review retained the context of primary findings. Tables 
outlining study aims are provided in section 3. Methodological considerations of included studies are illustrated in 
Appendix III. Additionally, rigour throughout the process of synthesis was ascertained through continuous 
discussions within the reviewing team. 
2.7 Sensitivity Analysis 
As stated previously, it was decided post-hoc to exclude studies with very low methodological quality to ensure 
manageability of the corpus of studies to appraise. The influence of this resolution on synthesis of findings was 
explored by inspecting the input of individual studies on analytical themes, as suggested by Thomas and Harden 
(2008). After thematic synthesis, reviewers noted whether primary studies of a lower methodological quality 
contributed to a lesser extent to synthesis than studies which were ascribed high methodological quality 
assessments. This exercise determined whether findings of the review are sensitive to inclusion or exclusion of 
studies with weaker methodologies. 
3. Results 
A PRISMA flow diagram giving numbers of studies screened, assessed for eligibility and included in the review 
with reasons for exclusion is provided in Figure 1. 
3.1 Study Characteristics 
The 34 papers included in this review subsisted of 26 quantitative studies, six qualitative studies and two systematic 
reviews. A description of main characteristics of these papers (authors, year of publication, country of study, aims, 
design, level of evidence, methodological quality score and categories informed by each), is provided in Tables 2, 
3 and 4. Overview of methods and a detailed result of appraisal of these studies is available in Appendix III. 
Eventually all qualitized quantitative and qualitative findings were organized into 16 categories, which were then 
grouped into five themes or synthesized findings. Each synthesized finding is described in more detail in coming 
sections. To ensure trustworthiness, a table illustrating how findings from individual studies constructed categories, 
and how in turn categories built themes is provided in the text for the fifth theme. 
 
 



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Figure 1. Flow diagram describing the screening process, modelled after Moher et al. (2009) 



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Table 2. Description of the main characteristics of included quantitative studies 
Authors & 
Year of 
Publication 

Country of 
Study 

Aim(s) Design Level of 
Evidence 

Method-
ological 
Quality 

Categories 
informed 
by this 
study 

Snyder et al. 
(2015) 

United 
States 

To estimate the prevalence of 
ADHD among a national sample of 
college women, to compare sexual 
victimization rates of women with 
ADHD to those without ADHD and 
to examine ADHD as a 
hypothesized risk factor of sexual 
victimization among college 
women along with commonly 
assessed predictors under the 
lifestyle/routine activities 
framework. 

Quantitative 
Cross- 
Sectional 

III 2 11 

Fuller-
Thomson et 
al. 
(2016) 

Canada To develop a comprehensive profile 
of the sociodemographic, mental 
health and physical health 
characteristics of women with an 
ADHD diagnosis in a nationally 
representative sample of Canadians.

Quantitative 
Cross- 
Sectional 

III 3 1, 3, 4, 5, 7, 
8, 11 

Guendelman 
et al. 
(2016) 

United 
States 

To draw from a longitudinal sample 
of girls followed prospectively into 
young adulthood, comparing 
those with and without childhood 
ADHD in terms of their risk for 
physical Intimate Partner Violence 
by 17–24 years of age. 

Quantitative 
Longitudinal
Cohort 
Study 

III 4 5 

Owens et al. 
(2017) 

United 
States 

To ascertain adult outcomes in ten 
domains reflecting 
symptomatology, attainment, and 
impairment as a function of both 
childhood diagnosis of ADHD and 
persistence of ADHD symptoms 
across time by prospectively 
following grade school-aged girls 
with rigorously diagnosed 
childhood ADHD and matched 
comparison girls for 16 years. 

Quantitative 
Longitudinal
Cohort 
Study 

III 4 3, 4, 5, 7, 8, 
12 

Jones et al. 
(2018) 

United 
States 

To investigate the relationship 
between ADHD symptom clusters 
(Inattention, Hyperactivity and 
Impulsivity) and engagement in 
healthy as well as unhealthy 
prenatal behaviours in a sample of 
pregnant women presenting to an 
urban women's clinic. 

Quantitative 
Cross- 
Sectional 

III 3 12 

Kakuszi et 
al. 
(2018) 

Hungary To study how gender influences the 
risk of suicidal ideation in adult 
ADHD and whether the 
psychopathological profiles that 
underlie suicidal ideation differ 
between male and female patients. 

Quantitative 
Case Control
Study 

III 4 1, 8 



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Martin et al. 
(2018) 

Sweden To examine whether in individuals 
who had anxiety, depression or 
ADHD diagnoses, females had a 
higher burden of ADHD genetic risk 
than males using polygenic risk 
scores. 

Quantitative 
Cohort  
Study 

III 3 2 

Perez 
Algorta et 
al. (2018) 

United 
States 

To evaluate whether there are 
significant differences between 
biological mothers who have a child 
with combined ADHD and those 
with a child without ADHD with 
respect to how maternal 'Big Five' 
personality traits, maternal ADHD 
or their interaction contribute to 
mothers' experience of parenting 
stress. 

Quantitative 
Case Control
Study 

III 4 15 

Solberg et 
al. (2018) 

Norway To determine whether gender 
modified associations between 
ADHD and psychiatric 
comorbidities and whether the 
proportion of psychiatric disorders 
among men and women in the 
population that could be attributed 
to comorbid ADHD. 

Quantitative 
Cross- 
Sectional 

III 4 1, 7 

Yoshimasu 
et al. (2018) 

United 
States 

To evaluate the psychiatric 
comorbidities among adults whose 
childhood ADHD has persisted into 
adulthood, with explicit assessment 
for gender differences in the rates 
and pattern of psychiatric 
comorbidities. 

Quantitative 
Case Control
Study 

III 3 7 

Ersoy & 
Ersoy 
(2019) 

Turkey To examine 'gender roles' in couples 
where one partner has ADHD in an 
attempt to find out whether gender 
roles mediate negative effects of 
ADHD on relationships. 

Quantitative 
Cross- 
Sectional 

III 2 3, 5 

Eryilmaz & 
Ustang-
Budak 
(2019) 

Turkey To examine the gender bias in 
recognition of ADHD by teachers at 
Turkish school settings. 

Quantitative 
Cross- 
Sectional 

III 2 2 

Hayashi et 
al. 
(2019) 

Japan To investigate clinical 
characteristics and gender 
differences in adults with ADHD in 
a Japanese Clinical Sample. 

Quantitative 
Cross- 
Sectional 

III 3 2, 3, 5, 7 

Mowlem et 
al. (2019) 

Sweden To investigate sex differences in 
ADHD using a large population-
based sample linked to Swedish 
National Patient Register data on 
clinical ADHD diagnosis and 
prescribed ADHD medication. 

Quantitative 
Cross- 
Sectional 

III 3 1, 2 

Park & 
Johnson 
(2019) 

Canada To investigate attributions for child 
behaviour in a community sample of 
mothers with mothers' ADHD 
symptoms assessed dimensionally. 

Quantitative 
Cross- 
Sectional 

III 4 14 

Skoglund et 
al. (2019) 

Sweden To explore the prevalence of birth in 
young women and teenage girls 

Quantitative 
Retrospective

III 3 3, 12 



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with ADHD and to address 
modifiable risk factors associated 
with adverse obstetric & perinatal 
outcomes, such as smoking, BMI & 
substance use disorder in these 
women and girls. 

Cohort 
Study 

Vildalen et 
al. (2019) 

Norway To investigate the Adult ADHD 
Self-Report Scale (ASRS) scores in 
female and male adults with ADHD 
and in the general population. 

Quantitative 
Case Control
Study 

III 3  3, 7 

Babinski et 
al. (2020) 

United 
States 

To examine prevalence of 
depression and suicidal behaviours 
among young adult men & women 
with and without ADHD (ages 18-
25) using a large claims database. In 
addition, patterns of health care 
utilization for depression and 
suicidal behaviour as well as related 
health costs are examined. 

Quantitative 
Case Control
Study 

III 4 1, 8 

Meyer et al. 
(2020) 

United  
Kingdom 

To examine differences in parent & 
teacher ADHD ratings of boys and 
girls matched for levels of directly 
observed ADHD behaviours.  

Quantitative 
Cross- 
Sectional 

III 3 2 

Babinski et 
al. (2020) 

United 
States 

To examine optimal ADHD 
symptom count cut-offs for the 
diagnosis of ADHD in girls & boys 
using ROC analysis and to compare 
the severity & prevalence of co-
occurring internalizing & 
externalizing problems in girls in 
the sex-specific group to girls 
without ADHD, girls meeting 
DSM-5 ADHD criteria & boys with 
ADHD. 

Quantitative 
Cross- 
Sectional 

III 4 2, 7 

Behesti et al. 
(2021)  

Iran To investigate whether ADHD is 
over diagnosed in Iran, whether 
Iranian psychiatrists reveal a gender 
bias when diagnosing boys and girls 
with ADHD and whether ADHD 
overdiagnosis has an impact on 
treatment recommendations. 

Quantitative 
Cross- 
Sectional 

III 2 2 

Dorani et al. 
(2021) 

The 
Netherlands

To gain a first insight into self-
reported mood symptoms in women 
with ADHD during the pre-
menstrual period, the postpartum 
period, and the menopausal 
transition. Additionally, to assess 
the sleep-wake rhythm preference 
(chronotype) in order to examine 
any associations between sleep 
characteristics, ADHD and the 
mood symptoms. 

Quantitative 
Cross- 
Sectional 

III 3 9, 12 

Klefsjo et al. 
(2021) 

Sweden   To examine if there are any gender 
differences in the diagnostic 
assessment procedure and in the 
received treatment prior to and after 

Quantitative 
Retrospective
Case Series 

III 4 1, 2, 7 



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ADHD diagnosis in Swedish 
Outpatient Child & Adolescent 
Psychiatric Units. 

London & 
Landes 
(2021) 

United 
Kingdom 

To examine ADHD prevalence rates 
among adults using the 2007 
and 2012 U.S. National Health 
Interview Survey and to document 
inter- and intra- cohort changes in 
adult ADHD and examine whether 
they vary by gender. 

Quantitative 
Prevalence 
Study 

III 4 1 

Szep et al. 
(2021) 

Germany To investigate Hair Cortisol 
Concentration (HCC) and mothers' 
perceived chronic stress in mothers 
of children with ADHD, while 
considering the effects of child 
ODD/CD symptoms & maternal 
ADHD & maternal depressive 
symptoms. 

Quantitative 
Cross- 
Sectional 

III 4 15 

Zaidman-
Zait & Shilo 
(2021) 

Israel To examine how the association 
between maternal ADHD 
symptoms and parenting varies 
across mothers' inhibitory control 
and their children's ADHD. 

Quantitative 
Cross- 
Sectional 

III 3 14 

 
Table 3. Description of the main characteristics of included qualitative studies 

Authors & 
Year of 
Publication 

Country 
of Study 

Aim(s) Design Level of 
Evidence 

Method-
ological 
Quality 

Categories 
informed by 
this study 

Holthe & 
Langvik 
(2017) 

Norway To obtain in-depth 
understanding of complex 
ways in which ADHD might 
affect the everyday lives of 
adult women through 
exploring and illustrating 
how both clinical symptoms 
and encounters with stigma 
shape and translate into lived 
experiences. 

Qualitative III 4 2, 3, 6, 7, 13, 
16 

Stenner et al. 
(2017) 

United 
Kingdom 

To examine how women 
make sense of ADHD from 
their own perspective, but 
with particular attention to 
the situated temporal 
dynamics of identity change.

Qualitative 
Discourse 
Analytic 
Research 

III 4  5, 6, 7, 8, 14, 
16 

Young et al. 
(2020) 

United 
Kingdom 

To provide guidance on 
presentation of ADHD in 
females and triggers for 
referral, to improve 
identification, treatment and 
support for girls and women 
with ADHD across the 
lifespan among medical and 
mental health practitioners. 

Qualitative 
Expert 
Panel 

IV 3 1, 2, 3, 5, 6, 7, 
9, 10, 11, 12, 
13, 16 

Lassinantti & 
Almqvist 

Sweden To explore motherhood 
ideals as they are 

Qualitative 
Narrative 

III 4 13, 15 



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(2021) experienced and negotiated 
by mothers with ADHD 
through the theoretical lens 
of able-mindedness and 
responsibility. 

Research 

Lynch & 
Davidson 
(2022) 

Ireland To explore daily life and 
academic experiences of 
young women living in 
Ireland with medical 
diagnosis of ADHD. 

Qualitative III 3 2,5, 6 

Wallin et al. 
(2022) 

Sweden To deepen the understanding 
of young women's own 
experiences of sexual and 
reproductive health by using 
a qualitative approach. 

Qualitative III 4 2, 5, 8, 10, 11

 
Table 4. Description of the main characteristics of included systematic reviews 

Authors & 
Year of 
Publication 

Country of 
Study 

Aim(s) Design Level of 
Evidence

Method-
ological 
Quality 

Categories 
informed by 
this study 

Kok et al. 
(2020) 

The 
Netherlands

To investigate sex differences in 
prescription rates, effectiveness 
and efficacy of pharmacotherapy 
treatment in girls and women with 
ADHD, and to identify gaps in the 
scientific knowledge on this topic.

Systematic
Literature 
Review 

III 8 1 

Camara et al. 
(2022) 

Canada To identify the available evidence 
on the relationship between sex 
hormones on symptoms of 
ADHD, with an emphasis on the 
reproductive life stages, including 
adrenarche in males and females 
and menarche, menopause and 
postpartum in females. 

Systematic
Literature 
Review 

III 7 9 

 
Considerable discrepancy was noted within quantitative studies. As can be observed from Table 2, different aspects 
of female ADHD were targeted and aims varied. Even among studies addressing kindred elements of the 
phenomenon, primary outcomes of interest still differed extensively. Another notable difference was the use of 
either a clinical (Hayashi et al., 2019) or a population based (Skoglund et al., 2019) sample. As had been anticipated, 
there was diversity in gender and age of samples too, with some studies using an all-female sample (Dorani et al., 
2021) and others comparing males to females (Vildalen et al., 2019). Likewise, some of the research studied minors 
(Klefsjo et al. 2021), other research studied adults (Babinski et al., 2020), whilst some followed children into 
adulthood (Guendelman et al., 2016). Some studies recruited professionals as participants to elicit their ability to 
recognize ADHD in both genders (Eryilmaz and Ustang-Budak, 2019).  
Lastly, another feature of this body of knowledge which defined its heterogeneity is measurement or ascertainment 
of ADHD status. ADHD was measured with an array of clinician, parent, teacher and self-report rating scales for 
children and/or adults. Moreover, a number of studies used proxies for ADHD status (London and Landes, 2021; 
Solberg et al., 2018). 
The few qualitative studies in this body of knowledge were published more recently than their quantitative 
counterparts, suggesting that qualitative discernment of this phenomenon is in its infancy. The qualitative approach 
employed was not specified for three studies. Heterogeneity was observed in samples and data collection 
procedures of qualitative studies. 
 
 



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3.2 The Gender Gap in ADHD Recognition, Diagnosis and Treatment 
A percentage of females, particularly those with inattentive ADHD presentation, may not be clinically diagnosed 
early in life. Gender differences in prescription rates of ADHD medication in childhood are no longer observed 
for adults. Teachers, parents and mental health professionals do not always recognize the internalized presentation 
of ADHD in females, which is often overshadowed by emotional problems, and diagnostic criteria were not 
designed to capture it. Moreover, it appears females engage in more effective compensatory behaviours which 
hide the severity of their ADHD. Undiagnosed female ADHD keeps reaffirming that ADHD is more common 
among males and this belief in turn consolidates the bias in ADHD recognition. This synthesized finding subsisted 
of two categories. 
3.2.1 Category 1 – Evidence of a Gender Gap which Still Prevails but is Narrowing with Increased Awareness 
The higher male to female ratios of child ADHD prevalence found in the clinical versus the population-based 
sample in the study of Mowlem et al. (2019), coupled with the comparatively smaller male to female ratio of 
ADHD noted in the adult clinical sample employed by Solberg et al. (2018), indicate that a percentage of girls 
with ADHD at population level may be missed and later diagnosed as adults. Supplementary evidence was 
advanced by Vildalen et al. (2019), who stated that within a clinical sample of Norwegian adults with ADHD, the 
percentage of males who were diagnosed as children was significantly higher than that of females. 
Increases in adult ADHD diagnoses, observed between 2007 and 2012 by London and Landes (2021) in their 
prevalence study, were disproportionately larger for women and have narrowed the gender gap. Fuller-Thomson 
et al. (2016) corroborated the notion that awareness of female ADHD is gaining traction, by reporting that women 
with ADHD in Canada were more likely to be in their 20s than those without ADHD. In spite of a narrowing 
gender gap, retrospective review of clinical data of boys and girls eventually diagnosed with ADHD by Klefsjo et 
al. (2021) suggested that even when girls are diagnosed as minors, they are still older than boys when diagnosed. 
As to sex differences in prescription rates of ADHD medication, a panel of ADHD experts was reported by Young 
et al. (2020) to have established that there is a gender gap disfavouring girls too in this regard. This resonates with 
findings provided by a systematic review of sex differences in prescription rates, which concluded that in adulthood 
these rates level off (Kok et al., 2020). Indeed, Kakuszi et al. (2018) claimed that clinically diagnosed adult males 
and females were equally likely to be receiving methylphenidate, a stimulant medication for ADHD. 
3.2.2 Category 2 – Reasons for the Gender Gap 
Mowlem et al. (2019) asserted that at population level significantly more females meet symptom criteria for the 
less conspicuous inattentive ADHD presentation, whilst the more conspicuous hyperactive ADHD symptoms were 
significantly higher in men as documented by Hayashi et al. (2019). Women interviewed by Lynch and Davidson 
(2022) explained how their hyperactivity manifests as racing thoughts which cannot be perceived by others. 
Primary school teachers’ difficulty in recognizing vignettes describing girls with the inattentive ADHD subtype 
was also documented by Erylimaz and Ustang-Budak (2019). 
Furthermore, Meyer et al. (2020) suggested parents in their study systematically rated girls as having less severe 
ADHD than boys, even when they had previously exhibited an equivalent degree of observed ADHD-related 
behaviour. Young et al. (2020) concluded that there may be biases in parent and teacher ADHD ratings which are 
interfering with referrals.  
During the 2018 convention of ADHD experts, it was implied that clinicians should steer away from adhering 
strictly to cut-offs when using rating scales, due to compromised specificity and sensitivity of diagnostic criteria 
when diagnosing females (Young et al., 2020). Babinski et al. (2021) identified a sex-specific ADHD symptom 
cut-off for girls that was lower than the symptom threshold afforded by DSM-5 criteria.  
Young et al. (2020) remarked that psychiatric comorbidities in females with ADHD are more internalized, and 
although they may often be secondary to ADHD itself, they may be diagnosed as primary disorders. Indeed, some 
women interviewed by Stenner et al. (2017) attest to being diagnosed with ADHD after seeking help for anxiety 
or depression. Reviewed clinical notes of girls eventually diagnosed with ADHD, disclosed that most of them had 
been referred for “emotional symptoms” (Klefsjo et al., 2021). Moreover, Martin et al. (2018) suggested that 
ADHD genetic risk more likely shows up as anxiety or depression in females. 
ADHD experts noted from professional experience that girls with ADHD engage in more effective compensatory 
behaviours or coping strategies than boys, thus masking their ADHD (Young et al., 2020). In the same vein, lived 
experiences of young women with ADHD captured by Wallin et al. (2022) intimated that there was a perceived 
need to hide aspects of oneself to be accepted in social situations, which required a considerable and unsustainable 
effort in the long term.  



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3.3 ADHD-Related Problems in Females 
In contrast to childhood, reported severity levels of ADHD symptoms are higher for adult females than males. 
Moreover, females with ADHD are more likely to experience educational underachievement and problems at work. 
Females with ADHD may be more likely to smoke and to be physically active, thus overall health may be affected 
in different ways. Additionally, ADHD symptoms were reported by females to impinge negatively on their 
interpersonal relationships. More research is needed to understand the extent to which ADHD is problematic to 
females and any interrelations between problematic domains. This synthesized finding subsisted of three categories. 
3.3.1 Category 3 – Overall Functioning 
Inattentive and hyperactive/impulsive ADHD symptoms are allegedly more severe among females than males in 
adulthood (Ersoy and Ersoy, 2019; Vildalen et al., 2019). Owens et al. (2017) reported that for highest degree 
earned and years in education, female comparisons significantly outperformed females with ADHD. Similarly, 
Fuller-Thomson et al. (2016) stated that females with ADHD were less likely to hold a post-secondary degree and 
more likely to belong to a low-income category than female comparisons. More recently, Skoglund et al. (2019) 
testified that females with ADHD were more likely to have had only ten years of education or less than female 
comparisons (48.6% vs. 14.5%). The panel of ADHD experts endorsed the notion that females with ADHD tend 
to struggle with intellectual functioning and noted that these difficulties are more predictive of the inattentive 
subtype, which is associated with the female sex (Young et al, 2020).  
Regarding functioning in relation to employment, Owens et al. (2017) concluded that although there were no 
differences in objective employment measures, females with ADHD significantly claimed more problems at work 
than female comparisons. Moreover, Hayashi et al. (2019) determined that compared to men with ADHD, the odds 
of not being gainfully employed full-time were nearly threefold greater for women with ADHD. The interplay 
between ADHD and gender roles in the employment domain was hinted at by women with ADHD interviewed by 
Holthe and Langvik (2017). These women argued that men were more likely to be exclusively assigned creative 
and stimulating tasks at work, whilst boring, repetitive tasks were added to women’s workloads. 
3.3.2 Category 4 – Overall Health 
Significantly lower Body Mass Indexes were observed among females with persistent ADHD than female 
comparisons, whilst differences in poor sleep quality were considered statistically non-significant (Owens et al., 
2017). Contrastingly, Fuller-Thomson et al. (2016) reported a significantly higher prevalence of sleep problems in 
females with ADHD in comparison to those without (43.9% vs. 12.2%). 
Other objective health measures for which statistically significant differences were observed disfavouring females 
with ADHD by Fuller-/Thomson et al. (2016) were chronic pain (28.0% vs. 8.5%) and current smoking status 
(40.9% vs. 21.9%). Interestingly, higher physical activity levels were reported by females with ADHD than those 
without, in the same study (52.8% vs. 39.7%). 
3.3.3 Category 5 – Relationship Difficulties 
Interviewed women with ADHD consistently reported that relationships with significant others have been 
problematic since childhood. Participants revealed to Stenner et al. (2017) that being continuously unable to match 
parents’ expectations made them feel they belonged to wrong families. By the same token, Lynch and Davidson 
(2022) imparted that adolescent women with ADHD experienced strained relationships with many teachers who 
thought they were not interested in learning. 
The panel of ADHD experts declared that physical, socio-relational and cyber bullying is commonly seen in girls 
and women with ADHD (Young et al., 2020). Previous to this convention, Guendelman et al. (2016) had 
established that in relation to women not exposed to Intimate Partner Violence (IPV), IPV-exposed women 
displayed significantly more severe ADHD symptoms, and the association of IPV status and ADHD severity is 
significantly and partially mediated by academic achievement. 
Romantic relationships and complications within them featured more actively in narratives of women with ADHD. 
Examples include relationships never seemed to last long or succeed (Stenner et al., 2017), relationships and sex-
life got boring after the initial excitement subsided (Wallin et al., 2022), and emotional impulsivity resulted in 
partners feeling hurt by insensitive comments and participants feeling guilty for saying whatever comes to mind 
(Holthe and Langvik, 2017). Notwithstanding purported concerns about romantic relationships, Owens et al. (2017) 
revealed differences in dissatisfaction with current romantic relationship between women with ADHD and those 
without did not reach statistical significance.  
 



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3.4 Female ADHD and Negative Mental Health Sequelae 
Evidence suggests that in comparison to females without ADHD and males with ADHD, females with ADHD are 
more likely to develop psychiatric comorbidities, particularly depression and anxiety. Internalization of negative 
feedback and having gone undiagnosed for longer may partially explain this increase in prevalence. Suicidal 
behaviour is likewise more common in females with ADHD than females without ADHD and males with ADHD, 
and preliminary evidence suggests it may be rooted in problems with self-concept. This synthesized finding 
subsisted of three categories. 
3.4.1 Category 6 – Negative Feedback and Self-Concept 
Recollections of school days were imbued with experiences of ongoing negative feedback among women with 
ADHD (Lynch and Davidson, 2022; Stenner et al., 2017). Hyperactive behaviour is considered more deviant in 
girls than boys, therefore girls with ADHD likely receive more negative feedback than boys with ADHD (Young 
et al., 2020). Holthe and Langvik (2017) suggested internalization of negative feedback may have lasting effects, 
as adult women interviewed admitted to being highly critical of themselves with issues like procrastination. 
Kakuszi et al. (2018) report that for adult women with ADHD, suicidal ideation was most closely associated with 
scores on the self-concept subscale of the Conners’ Adult ADHD Rating Scales (CAARS; Conners, 1999), whilst 
for men the strongest association was with scores on the impulsivity subscale. This suggests internalization of 
negative feedback is more deleterious to women with ADHD. ADHD professionals stressed ADHD treatment for 
teenage girls must include psychological interventions to unpack ways in which ADHD has become embedded in 
their self-concept (Young et al., 2020). 
3.4.2 Category 7 – Anxiety, Depression and other Comorbidities 
In comparison to females without ADHD, females with ADHD were reported to have twice the odds of having a 
substance use disorder or a major depressive disorder at some point in their lives, and four times the odds of 
developing generalized anxiety disorder (Fuller-Thomson et al., 2016). Owens et al. (2017) confirmed there were 
statistically significant differences between females with ADHD and those without for depression. However, 
differences for substance abuse did not reach statistical significance. 
Higher overall psychiatric comorbidity rates for women in comparison to men with ADHD were extensively 
reported (Hayashi et al., 2019; Solberg et al., 2018; Vildalen et al., 2019; Yoshimasu et al., 2018). Two studies 
analyzed the combined effect of the two exposures (ADHD and gender). Solberg et al. (2018) report prevalence 
differences for all disorders were significantly larger for women with ADHD, with the exception of schizophrenia 
and substance use disorder. Yoshimasu et al. (2018) revealed statistical significance for dysthymia in women with 
ADHD. 
Interviewed women with ADHD confirm anxiety and depression have permeated their lives, but also clearly 
articulate how living with ADHD precipitates these conditions. Holthe and Langvik (2017) explain how inability 
to settle into routines means one never feels in control of situations or of oneself and this provokes anxiety. 
Additionally, the hopelessness which ensues from putting in a lot of effort and never being able to manage ADHD 
symptoms casted participants into depressive states. Likewise, Stenner et al. (2017) relays that women with ADHD 
feel depressed because they perceive their lives as a course of consecutive futile attempts and fiascos. Young et al. 
(2020) suggests girls and women with ADHD may go to great lengths to compensate for ADHD symptoms, to the 
extent that perfectionism and anxiety develop. 
3.4.3 Category 8 – Self-Injury and Suicidal Behaviour 
After employing psychometrically evaluated tools, Owens et al. (2017) report self-injury was present in 66.0% of 
females with persistent ADHD and 24.4% of comparison females. Statistical significance was not reached for 
suicide attempts possibly because of small cell sizes. Fuller-Thomson et al. (2016) concluded that females with 
ADHD had more than four times the odds of having considered suicide, from replies to one question asking 
participants if they ever considered suicide.  
Babinski et al. (2020) inspected the effects of ADHD and sex on suicidal behaviour employing commercial claims 
data among a large sample of adults with ADHD and matched comparisons. Whilst a significant ADHD by sex 
interaction was not observed for suicide attempts, one for suicidal ideation emerged. The magnitude of the 
association between ADHD and suicidal ideation was greater for women (odds ratio of 2.21) than men (odds ratio 
of 1.61). Kakuszi et al. (2018) used one item from the Beck Depression Inventory (BDI; Beck et al., 1975) as 
standalone measure for suicidal ideation among adults with ADHD and matched controls. The study reported a 
16-fold increase in likelihood of suicidal ideation for females with ADHD in comparison to controls. Contrastingly, 
in males the modest increase failed to reach statistical significance. 



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3.5 ADHD and Female Sexual and Reproductive Health Issues 
Reviewed evidence indicates females with ADHD are at risk for teenage/unplanned pregnancies and sexual 
victimization. Females with ADHD find it harder to engage in healthy prenatal behaviours and this can precipitate 
adverse perinatal outcomes. Preliminary evidence suggests there may be a bi-directional relationship between 
ADHD and hormonal shifts during female reproductive life stages. Moreover, research to ascertain categorical 
safety or otherwise of ADHD medication during pregnancy and breastfeeding is needed. When specifically probed, 
some females with ADHD talked about engaging in casual sex and the shame it provokes. Future studies should 
be designed to encourage females with ADHD to discuss their sexuality. This synthesized finding subsisted of four 
categories. 
3.5.1 Category 9 – Sex Hormones 
In 2018, ADHD experts advised ADHD symptoms in females may be exacerbated by hormonal fluctuations during 
certain stages of the menstrual cycle, in the perinatal period and during menopausal years (Young et al., 2020). A 
few years later, Dorani et al. (2021) reported that prevalence of premenstrual dysphoric disorder and postpartum 
depression and severity of climacteric mood symptoms were higher in a sample of females clinically diagnosed 
with ADHD, than those previously reported for the general population in other publications (Barentsen et al., 2001; 
Gavin et al., 2005; Gelaye et al., 2016; Hylan et al., 1999). 
Camara et al. (2022) set out to identify evidence exploring the relationship between sex hormones in both males 
and females and ADHD. Few papers were located, indicating this area of research is still in its infancy. ADHD 
symptoms were noted to worsen before menses in a clinical case study involving one patient, and it was proposed 
that ADHD treatment may result in improved management of pre-menstrual syndrome (Quinn, 2005, as cited in 
Camara et al., 2022, p. 3). Aside from this, a weak association between early pubertal onset in females and 
difficulties with attention and emotional regulation and a propensity for risky behaviour was reported (Ostojic and 
Miller, 2016, as cited in Camara et al., 2022, p. 3). 
3.5.2 Category 10 – Casual Sex 
The guidance provided by the ADHD expert consensus statement mentions that girls with ADHD may become 
sexually active earlier, have more sexual partners and be more prone to aftermaths in the matter of sexually 
transmitted diseases and teenage pregnancies (Young et al., 2020). Young women with ADHD intimate they 
engage in casual sex because of substantial difficulty in resisting sexual desire, as an outlet for channeling extra 
energy and because they have given up on long-term relationships. Casual sex evoked shame and a resentment 
towards a society which does not tolerate this behaviour among women. Health services may not be approached 
for screening tests pertaining to sexually transmitted diseases because of this shame (Wallin et al., 2022).  
3.5.3 Category 11 – Sexual Victimization 
Snyder et al. (2015) concluded that in comparison to college women without ADHD, those with ADHD had 1.41 
greater odds of being touched in an unwanted manner and 1.85 greater odds of being raped. Correspondingly, 
Fuller-Thomson et al. (2016) determined that females with ADHD had a significantly higher likelihood to have 
sustained sexual abuse before the age of 16 years, than those without ADHD (35.8% vs 10.9%). Young women 
with ADHD claimed inattentiveness creates inability to recognize sexual innuendos or to perceive danger cues, 
whilst impulsivity dictates an intrinsic tendency to rush into action without any prior deliberation (Wallin et al., 
2022).  
3.5.4 Category 12 – Perinatal Issues 
Among all nulliparous females who gave birth in 2014 in Sweden, those receiving ADHD medication had a six-
fold increased risk of being younger than 20 years when giving birth (Skoglund et al., 2019). Owens and her 
colleagues in 2017 had already established that females with persistent ADHD had higher rates of unplanned 
pregnancies than comparisons (39.2% vs. 10.6%). 
Jones et al. (2018) reported a significant and negative relationship between inattentive ADHD symptoms and 
healthy eating during pregnancy, a significant and negative relationship between hyperactivity symptoms and 
prenatal vitamin use, and a positive and significant relationship between impulsivity and emotional lability and 
physical strain and poor eating during pregnancy. Skoglund et al. (2019) reported that pregnant women with 
ADHD had twice the odds of having a body mass index more than 40.00 and more than six times the odds of 
smoking in the third trimester of pregnancy, in comparison to women without ADHD.  
Dorani et al. (2021) stated that out of a sample of women clinically diagnosed with ADHD, 40.7% had had at least 
one child and 62.4% of the latter reported perinatal or obstetric complications. Young et al. (2020) report that in 



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view of inconclusive evidence, ADHD medication is by and large not recommended during pregnancy or 
breastfeeding. 
3.6 The Influence of ADHD on Motherhood 
Gender role expectations are harder to keep up with for some mothers with ADHD, who struggle to maintain 
structure and find childcare and household tasks boring. Preliminary evidence suggests that variation in maternal 
inhibitory control, in the context of maternal ADHD, determines negative and supportive parenting behaviours. 
Mothers with ADHD reported feeling inadequate as parents upon comparisons to other mothers. In multiplex 
families, mothers may feel guilty for passing on ADHD to children and experience considerable stress. Research 
still has to elucidate to what degree maternal and child ADHD each contribute to maternal stress. This synthesized 
finding subsisted of four categories. 
3.6.1 Category 13 – Managing Motherhood Tasks 
Mothers with ADHD explained children aggravate an already innate problematic distractibility with spontaneous 
and continuous interruptions. The absence of externally imposed structures in the home context, as opposed to a 
workplace, was vexing because it meant they had to struggle to institute some order and routines themselves 
(Holthe and Langvik, 2017). Moreover, gender role expectations were reported to place heavier childcare demands 
on women, whose responsibility to their families is described as ‘omnipresent’ (Lassinantti and Almqvist, 2021).  
3.6.2 Category 14 – Parenting Behaviours 
Park and Johnson (2019) suggest impulsive mothers with ADHD may struggle to regulate parenting responses for 
children’s negative behaviours and inattentive mothers may not be attuned to positive behaviour. This finding may 
shed some light on strained relationships in multiplex ADHD families (families where multiple individuals are 
affected by ADHD). However, Zaidman-Zait and Shilo (2021) concluded that maternal inhibitory control buffers 
the effect of high maternal ADHD symptomatology on negative parenting. This protective effect was such, that 
higher scores of maternal ADHD and maternal inhibitory control predicted increased supportive parenting during 
observations. 
3.6.3 Category 15 – Parenting Stress 
Mothers of children with ADHD self-reported higher adult ADHD scores than comparisons, supporting the belief 
that ADHD is a highly heritable disorder which often runs in families (Perez-Algorta et al., 2018). Intriguingly, in 
the same study, maternal ADHD was reported to exacerbate perceived parenting stress of comparison mothers but 
not of mothers of children with ADHD. Correspondingly, Szep et al. (2021) concluded that maternal ADHD does 
not moderate the association of child ADHD with maternal perceived chronic stress. However, Szep et al. (2021) 
compellingly also observed that maternal ADHD and depressive symptoms were more predictive of maternal 
perceived chronic stress, than child ADHD and oppositional defiant disorder symptoms. 
3.6.4 Category 16 – Parenting Guilt 
Lassinantti and Almqvist (2021) reported mothers with ADHD compared their own untidy home to an imagined 
uncluttered home environment maintained by a good, organized mother. Correspondingly, women with ADHD 
interviewed by Holthe and Langvik (2017) put themselves down for only managing to fit in a bare minimum of 
necessary activities with their children in their schedules. Zaidman-Zait and Shilo (2021) revealed that when 
interactions of mothers with ADHD and their children were observed, it transpired that the mothers’ previous self-
reports of negative parenting behaviours overestimated these behaviours. Holthe and Langvik (2017) also 
uncovered how mothers with ADHD may keep tormenting themselves for having passed on ADHD to their 
offspring, thus condemning them for life with this challenging condition.  
 
Table 5. Findings, categories and synthesized findings for the fifth theme 

Synthesised finding Categories Findings 
Gender role 
expectations are harder 
to keep up with for 
some mothers with 
ADHD who struggle to 
maintain structure and 
find childcare and 
household tasks 

Category 13 
– Managing 
motherhood 
tasks 

-Swedish mothers with ADHD reported they resist traditional gendered expectations and 
sometimes find tasks typically assigned to fathers more stimulating than repetitive and boring 
chores (Lassinantti & Almqvist, 2021).  
-Swedish mothers with ADHD resented the fact that responsibility is omnipresent for mothers 
and their executive functioning resources get depleted, while fathers get more time away from 
the family unit for themselves (Lassinantti & Almqvist, 2021). 
-Norwegian mothers with ADHD explained that the responsibility for establishing structure and 
routines at home with their children rests solely on them unlike in a work environment (Holthe 



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boring. Preliminary 
evidence suggests that 
variation in maternal 
inhibitory control in 
the context of maternal 
ADHD determines 
negative and 
supportive parenting 
behaviours. Mothers 
with ADHD reported 
feeling inadequate as 
parents upon 
comparisons to other 
mothers. In multiplex 
families, mothers may 
feel guilty for passing 
on ADHD to children 
and experience 
considerable stress. 
Research still has to 
elucidate to what 
degree maternal and 
child ADHD each 
contribute to maternal 
stress.  

& Langvik, 2017). 
-Norwegian mothers reported that children continuously distract them from the task at hand and 
they struggle to return back to a task once interrupted (Holthe & Langvik, 2017). 
-Expert ADHD panel concluded that parenting and household duties may overwhelm mothers 
with ADHD (Young et al., 2020). 

Category 14 
– Parenting 
behaviours 

-Canadian mothers with ADHD offered less child-responsibility attributions for positive child 
behaviour and more child-responsibility attributions for negative behaviour than mothers without 
ADHD (Park & Johnson, 2019). 
-Canadian mothers with more ADHD symptoms showed a weaker relationship between valence 
of child behaviour and child behaviour attributions given (Park & Johnson, 2019). 
-Maternal ADHD symptoms were positively associated with self-reported overreactive parenting 
and self-reported lax parenting in an Israeli cross-sectional study (Zaidman-Zait & Shilo, 2021).
-Self-reported overreactive parenting of Israeli mothers with ADHD was not supported by 
observed parenting negativity during mother-child conflict discussions (Zaidman-Zait & Shilo, 
2021). 
-Inhibitory control served as a protective factor against parenting negativity in the context of high 
maternal ADHD symptoms in the Israeli cross-sectional study (Zaidman-Zait & Shilo, 2021).  
-Higher levels of maternal inhibitory control and maternal HA/IM symptoms predicted increased 
supportive parenting in the Israeli cross-sectional study (Zaidman-Zait & Shilo, 2021).  

Category 15 
– Parenting 
stress 

-US mothers of children with ADHD rated themselves higher on adult ADHD self-rating scales 
than mothers of children without ADHD in a case control study (Perez Algorta et al., 2018). 
-Maternal ADHD did not exacerbate the perceived stress of parenting a child with ADHD in the 
case control study conducted in the US (Perez Algorta et al., 2018). 
-Maternal ADHD symptom level had a significantly stronger association with parenting stress 
for the US mothers of children without ADHD than for mothers of children with ADHD in the 
case control study (Perez Algorta et al., 2018). 
-Maternal perceived chronic stress positively correlated with child and maternal ADHD in a 
cross-sectional study conducted in Germany (Szep et al., 2021). 
-Maternal ADHD and maternal depressive symptoms were more predictive of maternal perceived 
chronic stress than child ADHD and child Oppositional Defiant Disorder & Conduct Disorder 
symptoms in the cross-sectional study conducted in Germany (Szep et al., 2021). 
-Maternal ADHD did not moderate the association between child ADHD symptoms and maternal 
perceived chronic stress in the cross-sectional study conducted in Germany (Szep et al., 2021). 

Category 16 
– Parenting 
guilt 

-Expert ADHD panel concluded that mothers with ADHD may experience feelings of guilt over 
perceived inadequacy as a parent (Young et al., 2020). 
-Mothers from the UK reported reminding themselves they knew no better when they start feeling 
guilty about how they parented differently before they were diagnosed (Stenner et al., 2017). 
-Swedish mothers reported they compare their messy homes with ‘ideal homes which are tidy’ 
and themselves with ‘good mothers which are organized’ (Lassinantti & Almqvist, 2021). 
-Norwegian mothers reported they wished they knew how to find time to plan more activities for 
their children like other mothers (Holthe & Langvik, 2017). 
-Norwegian mothers reported feeling guilty for passing on ADHD to their children (Holthe & 
Langvik, 2017).  

 
3.7 Results of Sensitivity Analyses 
The contribution of the four studies (Behesti et al., 2021; Ersoy and Ersoy, 2019; Eryilmaz and Ustang-Budak, 
2019; Snyder et al., 2015) with a methodological assessment score of 2 on synthesized findings was evaluated. 
Ersoy and Ersoy (2019) and Snyder et al. (2015) provided important contributions to synthesized findings that 
were endorsed by few other studies. The review was, therefore, partially sensitive to inclusion of studies with low 
methodological quality. Subsequently, exclusion of studies which had a methodological assessment score of 1 may 
have biased synthesized findings. 
4. Discussion 
A description of integration of quantitative and qualitative evidence, an outline of the contribution of this review 
and an acknowledgement of its limitations are dealt with in this section.  
 



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4.1 Integration of Quantitative and Qualitative Findings 
Quantitative and qualitative findings were markedly supportive of each other. There was only one instance when 
one paradigm discredited the other. This rebuttal was presented by Owens et al. (2017), who quantitatively 
concluded there was no statistical difference in satisfaction with current relationship between females with ADHD 
and those without. Meanwhile, females with ADHD had confided in most of the included qualitative studies that 
romantic relationships were highly problematic for an array of reasons.  
The review is additionally replete with cases where the qualitative evidence not only confirms quantitatively 
derived results but extends, refines and deciphers them. The most notable examples include women describing 
how they experience their hyperactivity as racing thoughts which cannot be controlled (Lynch and Davidson, 
2022). This revelation explains why symptoms of hyperactivity, as captured by rating scales which typically ask 
about always being on the go and fidgetiness, are significantly higher in men than women with ADHD, as reported 
by Hayashi et al. (2019). Another illustration is provided by the narrative of a woman with ADHD interviewed by 
Stenner et al. (2017), who shed light on the relationship between low self-concept and suicidality in females with 
ADHD. This relationship was quantitatively advanced by Kakuszi et al. (2018). The woman recalled how self-
criticism and self-destruction began to feed off each other in her youth, until they climaxed into serious attempts 
to take away her own life.  
The categories for which quantitative testing was not complemented by qualitative explorations were overall health, 
sex hormones, perinatal issues and parenting behaviours. Conversely, the casual sex category was derived 
exclusively from findings extracted from qualitative studies. This implies quantitative inquiries are required to 
consign width to the depth already attained for this category. A less discernible, but arguably more important, 
implication is the realization that more qualitative research may unearth aspects of female ADHD which have 
never been recognized by quantitative researchers.  
4.2 Contribution of the Review 
The question set for this review read “What are the female specific ADHD issues which render adult women with 
ADHD a marginalized group?” There was an ethical commitment towards the community of females with ADHD 
to ascertain that extant research affirms their disadvantage, prior to embarking on a photovoice project to empower 
them. A preliminary search had also established that inequities arise both from biological and social factors. 
Therefore, an MMSR was chosen because it could provide critically appraised, robust evidence to verify concrete 
marginalization if it existed, whilst at the same time capturing all the nuances of the phenomenon through 
integration of quantitative and qualitative findings. These two imperative aims were achieved. Synthesized 
findings presented are useful to clinicians working with girls and women with ADHD or policy makers planning 
services for them. To this end, a set of recommendations for policy and practice have been proffered hereunder. 
Increased awareness on the inattentive ADHD subtype, particularly among girls, is sorely needed among health 
care professionals and educators. The failure to recognize the predominantly inattentive subtype is unacceptable, 
considering that it has been officially recognized in DSM-IV since 1994 (APA, 1994). Additionally, clinicians 
must be cognizant of the fact that girls may report their ADHD symptoms as emotional problems and experience 
hyperactivity as an internal restlessness. 
Similar to how age-specific ADHD symptom criteria were introduced in DSM-V, indicating how symptoms 
manifest differently in adulthood (APA, 2013), DSM guidelines ought to consider providing sex-specific criteria. 
Until these guidelines are made available, Young et al. (2020) advise females should be screened for ADHD using 
rating scales inclusive of female norms. In the absence of the latter, a stronger reliance on collateral information 
from parent or school reports is essential. 
Earlier recognition of ADHD in girls ensures educational school support, which is required to attenuate negative 
educational outcomes reported by literature. Moreover, Guendelman et al. (2016) hinted that lower academic 
achievement may in turn predispose girls with ADHD to subsequent negative outcomes, possibly through 
interference with their self-confidence and social empowerment. A negative self-concept has furthermore been 
associated with suicidal behaviour in females with ADHD (Kakuszi et al., 2018). Consequently, timely recognition 
of female ADHD may disrupt the cascading effect of a series of chain events which is impinging on the quality of 
life of women with ADHD. 
Psychiatric comorbidity is so pervasive among females with ADHD, that it is advocated that all females diagnosed 
with ADHD should be routinely screened for anxiety and depression. Conversely, females struggling with 
treatment resistant anxiety or depression or presenting with these issues in the context of a family history of ADHD, 
should be screened for ADHD. In particular, Babinski et al. (2021) allude that among girls with subthreshold levels 



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of ADHD, symptoms of depression or oppositional defiant disorder may be considered indicators which prompt 
for further screening. 
Camara et al. (2022) suggest evaluation of hormonal status in females with ADHD should be a component of 
holistic treatment plans. Dorani et al. (2021) propose dosage of ADHD medication might need to be adjusted 
during the premenstrual week and perimenopausal years. Females attending their first antenatal visit should be 
routinely asked if they have ADHD. Midwives providing antenatal care ought to be mindful and non-judgmental 
of challenges this client group may face in adhering to prenatal health behaviours. 
Programmes and interventions for young female adults with ADHD targeting issues such as low self-esteem, social 
skills, risk of victimization in interpersonal relationships and contraceptive counselling would be beneficial. 
Psychoeducation for mothers with ADHD should stress the value of avoiding comparisons with neurotypical 
mothers, delegating tasks to supportive persons in one’s social network, accepting one’s limitations and attenuating 
guilt, addressing inhibitory control and boosting supportive parenting by training oneself to be on the lookout for 
positive behaviour from children. 
4.3 Limitations 
Conducting this MMSR required significant methodological skill for which clear and universally approved 
guidance is not available to date. Petticrew et al. (2013) purport the interpretative process embedded in a MMSR 
is highly iterative and subsequently reproducibility is compromised. In this case, this was aggravated by the fact 
that the whole process was tackled primarily by one reviewer. The other reviewers oversaw the venture and 
actively participated by pondering uncertainties, which were eventually resolved through discussion. 
Although efforts to limit publication bias were made, its actuality cannot be ruled out. Studies providing results 
which did not reach statistical significance or findings which had antagonistic implications were not excluded. 
That being said, inclusion and exclusion criteria set a priori and post hoc may have contributed to publication bias. 
Developers of the MMAT version 2018 recommend it requires subsequent validation research (Hong et al., 2018). 
Moreover, periodically it was observed that the tool’s five questions for each study design did not always fully 
capture all the methodological considerations worthy of note.  
In view of the convolutedness involved in synthesizing evidence derived from studies with different 
epistemological foundations, Lizarondo et al. (2020) indicate that currently the practice of assessing certainty of 
evidence using approaches such as GRADE (Terracciano et al., 2010) or ConQual (Munn et al., 2014), is not 
recommended by the JBI manual of evidence synthesis. Although, this circumstance was beyond the agency of 
the reviewers, it is being acknowledged as a limitation, which further stresses the evolving nature of MMSR 
development. 
5. Conclusion 
Females with ADHD have been side-lined not only clinically but also in research settings, with almost all research 
on ADHD focusing on boys and men up until recently. Quantitative research endeavours have been predominantly 
cross-sectional, and comparisons have been hampered because of considerable variation in measures assessing 
ADHD status. Additionally, control groups from the general population have not been consistently recruited in 
studies comparing males and females with ADHD. This renders conclusions questionable as differences may be 
attributable exclusively to gender. A conspicuous dearth of qualitative explorations among women with ADHD 
persists. 
Future investigations need to include longitudinal, prospective studies to inspect gender differences in 
developmental aspects of ADHD symptomatology. The existence or otherwise of a genuine sex difference in 
ADHD onset requires ascertainment. A necessity for mediation analyses research, to distinguish any mediators 
and moderators involved in significant associations reported in this review, subsists. There is an urgency for more 
research on ADHD medication for girls and women, particularly on its interaction with female sex hormones, as 
proposed by Camara et al. (2022). Optimal, female-specific doses need to be identified together with clear 
guidelines on how they can be adjusted during periods of hormonal fluctuations. Safety or otherwise of ADHD 
medication during pregnancy and breastfeeding requires categorical determination. 
Mothers with ADHD have been studied primarily with the intent of ensuring they can help their children with 
ADHD experience better outcomes. However, the needs and wellbeing of mothers with ADHD ought to also be 
investigated with the sole resolute of garnering findings which can inform psychoeducational programmes tailor 
made specifically for them, apart from their children. Research still has to identify to what extent child ADHD and 
maternal ADHD contribute to maternal stress in multiplex families. Szep et al. (2021) refer to the work of 
Psychogiou et al. (2008) as the origin of the similarity-misfit and similarity-fit hypotheses. These respectively 



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propose that either a child’s ADHD augments the stress of mothers with ADHD, or shared traits between mothers 
and children with ADHD result in enhanced mutual understanding. These hypotheses require further testing and 
exploration. 
Disadvantage of females with ADHD has been ascertained by this MMSR. Factors side-lining females with ADHD 
with respect to their male counterparts include the way the disorder manifests itself differently, biases in diagnostic 
processes, risks of psychiatric comorbidities, hormonal influences and gender role expectations. Intriguingly, the 
way the social marginalization, interfering with access to treatment and missed opportunities, is mirrored in 
perceptions women with ADHD have of themselves, transpired very strongly. A problematic self-concept emerged 
as a predicament females with ADHD grapple with from a young age. Moreover, mothers with ADHD were 
noticed to engage in comparisons with neurotypical mothers and fathers with ADHD, and to overestimate their 
negative parenting behaviours. This MMSR has, therefore, warranted empowerment of this population. 

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https://doi.org/10.1177/1087054718808063 
 
Appendices 
I – Adapted PRISMA for reporting systematic reviews of qualitative and quantitative evidence 

 
 

 



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II – Search Strategies 

HyDi Platform Search Strategy 
Filters Applied- 
• Publication date within the last 10 years 
• Records in the English Language only 
• Records only from peer-reviewed journals 
Keywords Records 

Yielded 
Links (last re-run on 14/04/2023) 

adhd AND women 
OR female* OR 
girl* 

139 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,adhd,AND&query=title,contains,women,OR&query=title,contain
s,adhd,AND&query=title,contains,female*,OR&query=title,contains,adhd,AND&query=title,contains
,girl*,AND&pfilter=lang,exact,eng,AND&pfilter=creationdate,exact,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i
nclude,peer_reviewed&lang=en_US&mode=advanced&offset=0 

attention deficit 
hyperactivity 
disorder AND 
women OR 
female* OR girl*  

93 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,attention%20deficit%20hyperactivity%20disorder,AND&query=t
itle,contains,women,OR&query=title,contains,attention%20deficit%20hyperactivity%20disorder,AN
D&query=title,contains,female*,OR&query=title,contains,attention%20deficit%20hyperactivity%20d
isorder,AND&query=title,contains,girl*,AND&pfilter=lang,exact,eng,AND&pfilter=creationdate,exa
ct,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i
nclude,peer_reviewed&lang=en_US&mode=advanced&offset=0 

adhd AND 
mother* OR 
daughter* OR 
spouse* 

108 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,adhd,AND&query=title,contains,mother*,OR&query=title,contai
ns,adhd,AND&query=title,contains,daughter*,OR&query=title,contains,adhd,AND&query=title,conta
ins,spouse*,AND&pfilter=lang,exact,eng,AND&pfilter=creationdate,exact,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i



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 55 Published by IDEAS SPREAD 
 

nclude,peer_reviewed&lang=en_US&mode=advanced&offset=0 
attention deficit 
hyperactivity 
disorder AND 
mother* OR 
daughter* OR 
spouse* 

73 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,attention%20deficit%20hyperactivity%20disorder,AND&query=t
itle,contains,mother*,OR&query=title,contains,attention%20deficit%20hyperactivity%20disorder,AN
D&query=title,contains,daughter*,OR&query=title,contains,attention%20deficit%20hyperactivity%2
0disorder,AND&query=title,contains,spouse*,AND&pfilter=lang,exact,eng,AND&pfilter=creationdat
e,exact,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i
nclude,peer_reviewed&lang=en_US&mode=advanced&offset=0 

gender AND adhd 
OR attention 
deficit 
hyperactivity 
disorder 

134 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,adhd,AND&query=title,contains,gender,OR&query=title,contains
,attention%20deficit%20hyperactivity%20disorder,AND&query=title,contains,gender,AND&pfilter=l
ang,exact,eng,AND&pfilter=creationdate,exact,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i
nclude,peer_reviewed&lang=en_US&mode=advanced&offset=0 

sex AND adhd OR 
attention deficit 
hyperactivity 
disorder 

126 https://hydi.um.edu.mt/primo-
explore/search?query=title,contains,adhd,AND&query=title,contains,sex,OR&query=title,contains,att
ention%20deficit%20hyperactivity%20disorder,AND&query=title,contains,sex,AND&pfilter=lang,ex
act,eng,AND&pfilter=creationdate,exact,10-
YEAR,AND&tab=default_tab&search_scope=all&sortby=rank&vid=356MALT_VU1&facet=tlevel,i
nclude,peer_reviewed&mode=advanced&offset=0 

 
Google Scholar Search Strategy 
 
 
Filters Applied- 
• Publication date within the last 10 years 
• Records in the English Language only 
 
Keywords Records 

Yielded 
Links (last re-run on 14/04/2023) 

adhd AND women OR 
female OR girl 

182 https://scholar.google.com/scholar?as_q=adhd&as_epq=&as_oq=wo
men+female+girl&as_eq=&as_occt=title&as_sauthors=&as_publicat
ion=&as_ylo=2012&as_yhi=2022&hl=en&as_sdt=0%2C5 

adhd AND women OR 
females OR girls 

249 https://scholar.google.com/scholar?as_q=adhd&as_epq=&as_oq=wo
men+females+girls&as_eq=&as_occt=title&as_sauthors=&as_public
ation=&as_ylo=2012&as_yhi=2022&hl=en&as_sdt=0%2C5 

attention deficit 
hyperactivity disorder 
AND women OR female 
OR girl 

109 https://scholar.google.com/scholar?as_q=attention+deficit+hyperacti
vity+disorder&as_epq=&as_oq=women+female+girl&as_eq=&as_o
cct=title&as_sauthors=&as_publication=&as_ylo=2012&as_yhi=202
2&hl=en&as_sdt=0%2C5 

attention deficit 
hyperactivity disorder 
AND women OR 
females OR girls 

122 https://scholar.google.com/scholar?as_q=attention+deficit+hyperacti
vity+disorder&as_epq=&as_oq=women+females+girls&as_eq=&as_
occt=title&as_sauthors=&as_publication=&as_ylo=2012&as_yhi=20
22&hl=en&as_sdt=0%2C5 

adhd AND mother OR 
daughter OR spouse 

56 
 

https://scholar.google.com/scholar?as_q=adhd&as_epq=&as_oq=mot
her+daughter+spouse&as_eq=&as_occt=title&as_sauthors=&as_pub
lication=&as_ylo=2012&as_yhi=2022&hl=en&as_sdt=0%2C5 

adhd AND mothers OR 
daughters OR spouses 

238 https://scholar.google.com/scholar?as_q=adhd&as_epq=&as_oq=mot
hers+daughters+spouses&as_eq=&as_occt=title&as_sauthors=&as_p
ublication=&as_ylo=2012&as_yhi=2022&hl=en&as_sdt=0%2C5 

attention deficit 
hyperactivity disorder 
AND mother OR 
daughter OR spouse 

25 https://scholar.google.com/scholar?as_q=attention+deficit+hyperacti
vity+disorder&as_epq=&as_oq=mother+daughter+spouse&as_eq=&
as_occt=title&as_sauthors=&as_publication=&as_ylo=2012&as_yhi
=2022&hl=en&as_sdt=0%2C5 



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 56 Published by IDEAS SPREAD 
 

attention deficit 
hyperactivity disorder 
AND mothers OR 
daughters OR spouses 

214 https://scholar.google.com/scholar?as_q=attention+deficit+hyperacti
vity+disorder&as_epq=&as_oq=mothers+daughters+spouses&as_eq
=&as_occt=title&as_sauthors=&as_publication=&as_ylo=2012&as_
yhi=2022&hl=en&as_sdt=0%2C5 

adhd AND gender OR 
sex 

276 https://scholar.google.com/scholar?as_q=adhd&as_epq=&as_oq=gen
der+sex&as_eq=&as_occt=title&as_sauthors=&as_publication=&as
_ylo=2012&as_yhi=2022&hl=en&as_sdt=0%2C5 

attention deficit 
hyperactivity disorder 
AND gender OR sex 

190 https://scholar.google.com/scholar?as_q=gender+OR+sex&as_epq=a
ttention+deficit+hyperactivity+disorder&as_oq=&as_eq=&as_occt=t
itle&as_sauthors=&as_publication=&as_ylo=2012&as_yhi=2022&hl
=en&as_sdt=0%2C5 

 
III – Overview of Methods and a Detailed Result of Appraisal of Included Studies 
Methodological considerations of the included quantitative studies. 

Authors, 
Year of 
Publication 
& Design 

Sample & setting Study Methods Methodological Quality 
Comments Based on MMAT  

Snyder et al. 
(2015) 
 
Quantitative 
Cross-
Sectional 
Study 

-Secondary analysis of data from 
the American College Health 
Association’s national bi-annual 
survey of college students.  
-For the current study the sample 
was limited to females aged 18 to 
24 years (n=14,816) within 22 
educational institutions located in 
the Northwest, Midwest, South and 
Western parts of the US.  
-Schools in the sample used 
randomly selected campus 
classrooms for paper 
administration of survey and 
randomly selected students for 
web-based surveys. 

-The survey employed the National College 
Health Assessment (NCHA-II) tool. 
-The tool included items to measure the 
following variables: Exposure to risky 
situations (such as binge drinking), 
proximity to motivated offenders (such as 
relationship status), ADHD status and 
sexual victimization (unwanted sexual 
touching in the past 12 months & attempted 
or completed rape in the last 12 months). 
-Capable guardianship (receipt of sexual 
assault, violence and injury preventive 
information) was not measured by the 
original survey, so a measure was created 
for this study. 
-Bivariate analyses tested whether women 
with ADHD were sexually victimized at 
significantly higher proportions than 
women without ADHD. 
-A binary logistic regression model 
estimated effects of ADHD, 
lifestyles/routine activities & demographic 
characteristics on unwanted sexual 
touching and rape conducted. 

-Large nationwide sample. Random 
selection of classrooms & students 
from selected schools. Sample 
described in detail but information 
on how it compares to strata in the 
general population not provided.  
-For all measures, variables were 
dichotomized (Yes/No replies). This 
binary system may not fully capture 
respondents’ answers.  
-ADHD status measured from 1 self-
report item. 
-Information on existence of any 
missing data not provided. 
-Confounders not accounted for in 
analysis. 

Fuller-
Thomson et 
al. 
(2016) 
 
Quantitative 
Cross-
Sectional 
Study 

- Secondary analysis of data from 
the 2012 Canadian Community 
Health Survey.  
-Women aged 20 to 39 years with 
complete data on all variables of 
interest recruited as sample to 
current study.  
-107 reported being diagnosed 
with ADHD, 3801 reported not 
being diagnosed. 

-Face to face or telephone interviews 
during which participants were asked 
questions about sociodemographic 
characteristics, health related behaviours, 
coping strategies, health related outcomes 
and adverse childhood experiences. 
Depression and anxiety measured as 
meeting the WHO-CIDI lifetime criteria. 
-Chi-Square tests to compare 
sociodemographic and health profile of 
women with ADHD in comparison to those 
without. 
-Logistic regression analyses calculated for 

-Large nationally representative 
survey. 
-Measurement of exposure (ADHD 
diagnosis) relied on self-report of a 
health professional’s diagnosis only. 
-Each logistic regression analysis 
controlled for race, age, education 
and household income. 
-All percentages and p-values were 
weighted to take into account the 
probability of selection & non-
response.  



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7 outcomes: lifetime substance abuse, sleep 
problems, limitations in activities of daily 
living, chronic pain, lifetime suicidal 
ideation, lifetime major depressive disorder 
and lifetime generalized anxiety disorder. 

Guendelman 
et al. 
(2016) 
 
Quantitative 
Longitudinal 
Cohort Study 

-Secondary analysis of data from 
the Berkeley Girls with ADHD 
Longitudinal Study (BGALS).  
-Present study included 193 girls 
(114 with ADHD & 79 matched 
comparisons) with data on physical 
Intimate Partner Violence (IPV) at 
Wave 3. 

-Physical IPV measured from a) single 
question from the Health & Sexual 
Behaviour Questionnaire, b) clinician post-
interview summary and c) year by year 
information sheet filled by parents & 
participants.  
-Childhood ADHD measured by parent-
reports of the (DISC-IV; Shaffer et al. 
2000) & (SNAP-IV; Swanson, 1992) 
scales. 
-Persistence/Remittance of ADHD 
measured at different waves using the 
(DISC-IV; Shaffer et al. 2000) scale.  
-Following measures also assessed: 
externalising behaviour, internalising 
behaviour, academic achievement and 
covariates (IQ, Socioeconomic status, etc.).
-Chi-Square test & parallel logistic 
regression to assess group differences 
among young women with persistent 
ADHD, transient ADHD or lifetime non 
diagnosed comparison group. 

-Ecologically valid sample 
described in detail. 
-Physical IPV determined via a 
single self-report question plus chart 
review not a standardized 
instrument.  
-Retention rate very good. Reasons 
why some participants from original 
sample were lost given. 
-Covariates well accounted for in 
design & analysis. 
-Change in exposure status (ADHD 
persistence) measured and 
accounted for. 

Owens et al. 
(2017) 
 
Quantitative 
Longitudinal 
Cohort Study 
 
 

-140 girls with ADHD from San 
Francisco, US, aged 6 to 12 years 
were recruited. 
-88 comparison girls without 
ADHD and matched to ADHD 
sample on age and ethnicity 
recruited.  
-Measures taken in four waves: 
W1 (baseline, W2 (5 years from 
baseline), W3 (10 years from 
baseline) and W4 (16 years from 
baseline).  

-ADHD diagnosis measured using parent 
and participant self-report on the (DISC-
IV; Shaffer et al. 2000) & the (SNAP-IV; 
Swanson, 1992). At W4, age-specific 
criteria were adopted.  
-At different waves, scales were 
administered to measure the following: 
externalising & externalising problems, 
depression, substance use, self-injury, 
overall impairments, academic 
achievement, BMI, overall sleep quality, 
social relationships and driving behaviour. 
The following covariates were also 
measured: family socioeconomic status, 
child IQ, comorbid diagnoses and stimulant 
medication use.  
-Computed 35 ANOVAs and 8 Chi-
Squared tests regarding the 43 dependent 
measures at W4 by the independent 
variable (ADHD status & persistence).  

-Findings generalisable to 
population of urban & suburban 
community-referred girls of various 
ethnicities & family income status. 
-Measures clearly defined, valid & 
appropriate. 
-Retention rate very good. Retained 
sample evaluated to ascertain 
representativeness.  
-Covariates considered. 
-Change in exposure status (ADHD 
persistence) measured and 
accounted for. 

Jones et al. 
(2018) 
 
Quantitative 
Cross-
Sectional 
Study 

-198 participants (aged 18 to 43 
years) recruited from women's 
health clinic located on medical 
campus of university in South-
eastern US. (n=198) 
-Inclusion criteria - currently 
patients at the clinic, older than 18 
years of age, pregnant and 
proficient English speakers. 

-Current ADHD symptoms measured via 
the (CAARS-S:S; Conners et al., 1999).  
-Frequency & degree of general health 
behaviours & pregnancy-specific health 
behaviours assessed via the (PHBS; Lobel, 
1996). 
-Depressive symptoms (confounder) 
assessed via 2 items of the (PHQ-2; 
Kroenke et al., 2003). 

-No mention of how many 
participants were eligible, therefore 
no indication of non-response bias. 
-No information provided re any 
missing data. 
-Confounders identified through 
previous literature considered in 
analyses.  
-Pregnancy could have been an 



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-Pearson product moment correlations 
performed to investigate univariate 
associations among ADHD symptom 
clusters & prenatal health behaviours.  
-Multivariate relations among all variables 
examined with a multivariate path model, 
using all 3 ADHD symptom clusters as 
predictors of all 7 prenatal health 
behaviours in one simultaneous analysis. 

unexpected co-exposure affecting 
CAARS scores, since participants’ 
previous ADHD status not known. 

Kakuszi et al. 
(2018) 
 
Quantitative 
Case-Control 
Study 

-103 ADHD patients (aged 18 to 
65 years) recruited from an 
outpatient service for adults with 
ADHD in Budapest. 
-103 controls matched for gender, 
age & educational attainment 
recruited from the office and 
medical staff at Semmelweis 
University, Budapest and their 
acquaintances. 

-Suicidal thoughts assessed via 1 item of 
the (BDI; Beck et al.1979) scale. 
-Severity of psychopathology described 
using total score on the (SCL-90R; 
Derogatis & Cleary, 1977).  
-ADHD symptoms assessed via the 
(CAARS; Conners, 1999) scale.  
-Logistic regression applied with presence 
of Suicidal Ideation used as dependent 
variable & grouping (ADHD vs control), 
gender & their interaction as independent 
variables. Age was a covariate. 
-Also investigated whether the presence of 
comorbidities & medication status 
influenced the findings.  

-Clinically referred sample provides 
added strength via availability of 
detailed psychopathology but limits 
generalisability.  
-Sample size determined by 
consideration of statistical power. 
-Measures appropriate & valid. No 
mention whether incomplete data 
was an issue. 
-Groups were matched & key 
clinical variables controlled for.  

Martin et al. 
(2018) 
 
Quantitative 
Cohort Study 

-Participants from “The Child & 
Adolescent Twin Study in 
Sweden” (CATSS) – a population 
study of all twins born in Sweden 
since 1992. Since 2008, DNA 
samples from saliva were 
collected. (n=13,472 CATSS 
children with genotyped samples 
which underwent imputation 
procedures). 
-Participants from “The Avon 
Longitudinal Study of Parents & 
Children” (ALSPAC) – a large, 
longitudinal study of children from 
Avon, UK. (n=8,215 ALSPAC 
children with genotyped samples 
which underwent imputation).  

-For the CATSS sample, information on 
ADHD, anxiety & depression available 
from registry based clinical diagnosis and 
parent & twin rated screening measures 
[(A-TAC; Larson et al. 2010), (ABCL; 
Achenbach et al. 2003), (SCARED; 
Birmaher et al. 1997) & (CES-D; Radloff, 
1977)].  
-For the ALSPAC sample, information on 
ADHD, anxiety & depression only 
available from parent & child rated 
screening measures [(DAWBA; Goodman 
et al. 2000) & (CIS-R; Lewis et al. 1992)] 
which were used to derive algorithm-based 
research diagnoses. 
-Polygenic risk scores calculated for each 
individual by scoring number of alleles 
across the ADHD discovery set of Single 
Nucleotide Polymorphisms. 
-Associations between ADHD polygenic 
risk scores and sex in children with 
diagnosed ADHD, anxiety, depression or 
other disorders tested using generalised 
estimating equations and logistic regression 
models. 

-Researchers acknowledged that 
sample sizes of those with 
psychiatric disorders were low. This 
limited statistical power and effect 
sizes were low. 
-Information from ALSPAC sample 
only available from screening 
measures and measures used not 
similar to both cohorts.  
-Attrition bias declared. 
-Confounders controlled for through 
regression. 
-Any changes to cohorts during 
study period not reported. 

Perez Algorta 
et al. (2018) 
 
Quantitative 
Case Control 
study 

-Secondary analysis of data from 
the Multimodal Treatment Study 
of Children with ADHD – (MTA 
Cooperative Group, 1999, 2004) 
including the auxiliary LNCG 
(Local Normative Comparative 
Group). 

-Big Five personality traits assessed via the 
(Neo Five-Factor Inventory; Costa & 
McCrae, 1992) scale. 
-Maternal ADHD symptoms assessed via 
the first 3 factors of the (CAARS; Conners 
et al., 1999) scale. 
-Maternal stress was measured via the (PSI-

-Participation in original study 
required considerable effort, so 
mothers in this study may not be 
representative of mothers from 
ADHD families.  
-Baseline measures for the two 
groups occurred 2 years apart. 



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-MTA children were 7 to 9.9 years 
old & diagnosed with ADHD. 
LNCG children were recruited 
from the same schools as MTA 
children & matched for sex & 
grade. 
-430 MTA mothers & 237 
biological LNCG mothers filled 
out measures at baseline.  
-31 LNCG children were later 
excluded because they had ADHD. 

Short Form; Abidin, 1995) scale.  
-Hierarchical regression analyses used to 
see whether maternal personality traits 
and/or maternal ADHD interact with the 
relationship between mothers' group 
(MTA/LNCG) & parenting stress. 

-For the MTA group, (n=57) had 
incomplete CAARS data, however 
multiple imputation procedure was 
employed, imputing 5 sets of values 
for all measures. 
-Significant sociodemographic 
moderators were considered as 
potential confounders in analyses.  

Solberg et al. 
(2018) 
 
Quantitative 
Cross-
Sectional 
Study 

-Cross-sectional analysis of a 
cohort of adults in Norway 
performed by linking information 
from 4 national population-based 
registries. 
-Study included all individuals 
born between 1967-1997, alive & 
resident in Norway at record 
linkage in 2015. 
-40,103 adults identified with 
ADHD (44.4% women) through 
registers & 1,661,103 non-ADHD 
adults. 

-Two regression models ran to evaluate 
how risk factors for both ADHD & other 
psychiatric disorders influenced ADHD 
prevalence rates. Covariates included.  
-Absolute prevalence differences of 
psychiatric disorders between persons with 
and without ADHD among men & women 
were calculated. 
-Association between ADHD and other 
psychiatric disorders examined on a 
multiplicative scale. 
-Estimated the proportion of psychiatric 
comorbidities attributable to ADHD among 
men & women with ADHD. 

-Large sample allowed evaluation of 
less prevalent disorders & 
comparison of psychiatric 
comorbidity in men and women with 
representative numbers in both 
groups. 
-Mandatory, prospective reporting 
in Norway minimized selection bias 
and loss to follow-up and eliminated 
recall bias. 
-Possibility of bias - adults with 
ADHD could more easily be 
diagnosed with other psychiatric 
disorders than non-ADHD adults 
because they are already in contact 
with health services. 
-Prescribed & dispensed ADHD 
medication used as proxy for ADHD 
diagnosis. For those patients who do 
not take medication, ADHD status 
identified from the Norwegian 
Patient Registry, but data only 
available from 2008 onwards.  
-Registered data was available to 
adjust for covariates. 

Yoshimasu et 
al. (2018) 
 
Quantitative 
Case-Control 
Study 
 

-Target population consisted of 
5,718 children (2,956 boys & 
2,762 girls) born in Rochester, 
Minnesota between 1976 and 1982 
& who still lived in Rochester at 
age 5 years.  
-350 childhood ADHD cases were 
identified & accepted to 
participate.  
-Random sample of 801 adults 
from the same population-based 
birth cohort was invited to 
participate. 

-Persistence of ADHD in adulthood & 
presence of psychiatric disorders were 
determined via the (M.I.N.I.; Sheehan et al. 
1998).  
-Healthcare record linkage system of all 
residents in Rochester was available and 
included a detailed history of all healthcare 
encounters. 
-Presence of each comorbid psychiatric 
disorder was compared between males and 
females with persistent ADHD using the 
Chi-Square test. 
-Logistic regression models evaluated the 
association of a) persistent ADHD (vs non-
ADHD), b) persistent ADHD (vs non-
persistent ADHD) and c) non-persistent 
ADHD (vs non- ADHD) with each of the 
comorbid psychiatric conditions for both 
genders combined and separately by 
gender. 

-Rochester was a primarily white, 
middle-class community so 
inferences to other populations may 
be limited. 
-No significant differences in 
sociodemographic factors between 
participating and non-participating 
childhood ADHD cases.  
-Limited number of females in the 
study which limits comparison with 
males. 
-Distribution of numbers of 
symptoms endorsed by non-ADHD 
controls were used to establish cut-
offs to diagnose persistent ADHD. 
-Cannot ascertain if persistent 
ADHD preceded the development of 
comorbidities. 



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Ersoy & 
Ersoy 
(2019) 
 
Quantitative 
Cross-
Sectional 
Study 

-61 married patients (18 females & 
43 males) who came for ADHD 
evaluation & treatment at the 
Psychiatric Department of a 
Turkish University Hospital were 
recruited together with their 
spouses. 

-Gender role attitudes for patients & 
spouses measured via the (GRAS; 
Zeyneloglu & Fusun, 2011) scale. 
-ADHD status & severity of patients & 
spouses measured via Turgay’s adult 
ADD/ADHD DSM-IV-Based Diagnostic 
Screening & Rating Scale.  
-Assessment of patients’ and spouses’ 
perceptions of effects of ADHD-related 
behaviours on marriage via the (MIC; 
Robin & Payson, 2002) scale.  

-Clinic situated in culturally 
Westernized city of Turkey, so 
results not generalisable to Turkish 
population.  
-Moreover, the sample was clinical, 
included only married couples and is 
characterised by a disparity between 
genders.  
-Study lacks a comparison group – 
cannot determine if reported 
dissatisfaction of female non-
ADHD spouse is attributed to 
ADHD or follows the general trend 
of women being more 
psychologically affected by 
relationship problems. 
-No information provided to allow 
assessment of non-response bias.  
-Confounding factors not 
considered. 

Eryilmaz & 
Ustang-
Budak (2019) 
 
Quantitative 
Cross-
Sectional 
Study 

-Schools within reach asked to 
participate. 
-Sample of 103 primary school 
teachers from schools from 4 
different regions of Istanbul city.  
-3 excluded because they had a 
child with ADHD. 

-6 vignettes produced for this study based 
on requirement of symptoms of ADHD 
according to DSM-V criteria. All vignettes 
taken by all participants. 
-Participants answered demographic 
questions (experience & education in 
relation to ADHD) together with questions 
about recognition, referral and intervention.
-Chi Square Tests performed to analyse 
recognition of ADHD. 

-Small sample size limits 
generalisability and did not allow 
hierarchical regression analysis. 
-Mixture of public/private schools 
from different regions and teachers 
teaching different grades.  
-First vignettes ever created based 
on DSM-V criteria after consultation 
with authors of previous vignettes 
(based on DSM-IV criteria). 
-Risk of non-response bias high – 
some schools chose not to 
participate. 

Hayashi et al. 
(2019) 
 
Quantitative 
Cross-
Sectional 
Study 

-Patients who visited ADHD 
specialist clinic in Tokyo between 
April 2015 and March 2016 
recruited consecutively if they 
fulfilled ADHD DSM-V criteria. 
- 470 eligible participants, 335 
included in the study. 

-Following data collected during 
assessment interview: current problems, 
medical history, daily living & social 
situations, history of psychiatric 
consultations, history of substance misuse 
and current medication.  
-ADHD diagnosis ascertained via the 
[DSM-IV(CAADID); Conners et al. 2001] 
scale.  
-Current ADHD symptoms measured via 
the [(CAARS-S:SV-J); Conners et al. 
2010] scale. 
-Between gender comparisons made using 
Chi-Square test and student’s t-test by 
setting gender as independent variable & 
other demographic/clinical items as 
dependent variables. 
-Candidates for explanatory variables in 
logistic regression analyses chosen from 
items that were statistically significant in 
univariate analysis.  

-Clinical sample not accurately 
representing Japanese ADHD 
population (only severe cases likely 
to be referred). 
-Reasons why certain participants 
chose not to participate not explored.
-Little detail provided re assessment 
interview. 
-No confounders accounted for in 
the analysis. 
-Study lacked a control population, 
and only provided an approximate 
comparison to national demographic 
statistics.  

Mowlem et 
al. (2019) 

-Participants were from “The Child 
& Adolescent Twin Study in 

-2 modules assessing ADHD from the (A-
TAC; Larson et al. 2010) scale 

-Large sample but findings may not 
be generalisable to singletons. 



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Quantitative 
Cross-
Sectional 
Study 

Sweden” (CATSS) – an ongoing, 
prospective, longitudinal cohort 
study targeting all twins in Sweden 
born since 1992. 
-For present study, data from 
19,804 parents of CATSS children 
assessed at 9 years were available 
for analysis. 

administered to parents over the phone.  
-Personal identifier numbers enabled data 
from participants to be linked with 
information from the National Population-
Based Registers. So, it was possible to 
determine if participants in CATSS had 
been referred to clinics and diagnosed or 
treated for ADHD. 
-Descriptive statistics used to describe 
ADHD symptoms in males and females 
with/without clinical ADHD. 
-Series of logistic regression models used 
to assess predictive associations of 
different ADHD symptoms with clinical 
diagnosis in males & females. 

-Relied solely on parent ratings 
which may be biased by sex-specific 
expectations.  
-Risk of non-response bias not 
discussed. 
-Only a reduced number of parents 
completed items measuring co-
occurring internalising problems.  
- Cluster robust sandwich estimator 
used to correct for inclusion of 2 
study children in each family. 

Park & 
Johnson 
(2019) 
 
Quantitative 
Cross-
Sectional 
Study 

-79 mothers with sons aged 6 to 12 
years recruited throughout Canada 
from advertisements on social 
media. 
-Eligibility criteria- mothers 
currently living with their sons & 
with their son’s other parent.  

-Online Questionnaire. 
-Child responsibility attributions measured 
via the Attribution Rating Scale (ARS; 
Halligan et al., 2007) which depicted 
scenarios & mothers rated the reason for the 
child’s behaviour in the scenario.  
-Mothers’ ADHD symptoms measured via 
the (BAARS; Barkley, 2011) scale. 
-Behaviour of the mother’s own child 
(hyperactivity, emotional symptoms, 
conduct problems, peer problems & 
prosocial behaviour) measured via the 
(SDQ; Goodman, 2001) scale. 
-Multilevel modelling examined relations 
among mothers' ADHD symptoms & 
mothers' attribution scores controlling for 
mothers' ratings of their own child's 
behaviour. 

-Results not generalizable to clinical 
populations, fathers, parents of girls 
or single parent families. 
-BAARS typically used as screening 
tool for adult ADHD & not as a 
diagnostic measure. 
-Response times were correlated 
with mothers' ADHD symptoms to 
check whether those with ADHD 
were impulsively rushing through 
questionnaire.  
-It was reported there were no 
missing data. 
-Other psychopathologies of 
mothers may have been important 
confounding variables which were 
not measured.  

Skoglund et 
al. (2019) 
 
Quantitative 
Retrospective 
Cohort Study 

-All Swedish nulliparous females 
who gave birth in 2014 identified 
from the Medical Birth Register 
and included in the study 
(n=384,103). 
-From the Prescribed Drug 
Register, females with ADHD 
treated with medication for ADHD 
between 2005 & 2014 were 
identified (n=6410). 
-All other females in the cohort 
served as control group 
(n=377,693). 

-Maternal age at birth, BMI, smoking 
habits, clinical variables, demographic 
data, information on reproductive history, 
complications during pregnancy, birth & 
perinatal period identified from the 
Medical Birth Register. 
-Information on psychiatric comorbidities 
collected from the Patient Register. 
-Antidepressant treatment use identified 
from the Prescribed Drug Register. 
-Maternal education data identified from 
the Education Register. 
-Logistic regression models were used to 
estimate magnitude of associations 
between age at first pregnancy, risk factors 
for adverse obstetric/perinatal outcomes, 
psychiatric comorbidities and ADHD 
diagnosis - presented as odds ratio (ORs) 
with 95% CI. 
-Differences in risk factors explored in 
distinct age at birth subgroups of females 
with ADHD (<20yrs vs > 20 yrs.) 

-Large nationwide sample. Findings 
may not be generalisable to 
populations outside Swedish/Nordic 
context which are characterized by a 
very low rate of teenage 
pregnancies.  
-Retrospective analysis of registers 
circumvented issues with non-
response. 
-Prescribed ADHD medication used 
as proxy for ADHD status – this may 
have underestimated true ADHD 
prevalence.  
-Missing data were excluded from 
analysis but no indication of amount 
of missing data.  
-Emphasis was on total burden of 
disease & no adjustments for 
psychiatric comorbidities were 
made. 

Vildalen et -682 adults with ADHD recruited -Severity of Inattentive & -Large sample but no mention of 



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al. (2019) 
 
Quantitative 
Case-Control 
Study 

from the national registry of adults 
diagnosed with ADHD in Norway 
from 1997-2005. 
-882 controls randomly recruited 
from the Medical Birth Registry of 
Norway. 

Hyperactive/Impulsive ADHD symptoms 
measured via subscales of the (ASRS; 
Kessler et al. 2005). 
-Main effects of gender and group and their 
interaction effect on the symptom scales 
investigated by univariate ANCOVA’s. 
-Significant effects were followed by 
independent sample t-tests. 
-Chi-Square statistics used to investigate 
gender differences in dichotomized ADHD 
reports (severe vs not severe) within the 
ADHD & control group. 

efforts to ensure representativeness 
or procedures to explore why 
eligible participants refused to be 
included. 
-Lack of formal diagnostic 
procedure may have resulted in 
some possible cases within the 
control group.  
-Incomplete data was not an issue. 
-Control group not matched for age 
and gender, but age included as one 
of the covariates in the analysis.  

Babinski et 
al. (2020) 
 
Quantitative 
Case-Control 
Study 

-387,968 adults with ADHD aged 
18 to 25 years were identified 
within the 2014 MarketScan 
Commercial Claims and 
Encounters database maintained 
by Truven Health in the US 
(162,263 females & 225,705 
males). 
-An age and sex matched group of 
young adults without ADHD was 
also constructed. 
-Claims contained information on 
inpatient, outpatient and 
prescription drug service use, as 
well as age, gender, geographic 
location and type of health 
insurance plan. 

-Using claims data from 2014, depression 
and suicidal ideation were identified by 
ICD-9 codes. Psychiatric treatment 
delivered in 2014 and costs were examined.
-Logistic regression models to examine 
effects of sex & ADHD on the prevalence 
of depression & suicidal behaviour 
included ADHD diagnosis & sex, as well as 
ADHD by sex interaction.  
-Chi-Square tests and t-tests were used to 
compare service utilization and cost 
between young adults with and without 
ADHD. 

-Large sample with high statistical 
power. Matched control group. 
-Use of claims data may have 
excluded people with ADHD who 
cannot maintain a full-time job 
(although ADHD prevalence from 
claims data was consistent with that 
of general population).  
-Impossible to ascertain whether 
diagnoses of ADHD or other 
psychopathologies were done using 
best practices.  
-Only claims data from 2014 used. 
-Analyses were conducted 
controlling for socioeconomic 
variables. 

Meyer et al. 
(2020) 
 
Quantitative 
Cross-
Sectional 
Study 

-Secondary analysis of data from 
another study (assessing effects of 
food additives on children) using 2 
samples of 3/4-year-olds 
(n=153,79 male) and 8/9-year-olds 
(n=144,75 male) from 
Southampton, UK.  

-Samples divided in 3 groups based on 
observed ADHD behaviours using the 
measure Classroom Observation Code 
(COC; Abikoff & Gittelman, 1985).  
-These groups then compared on parent & 
teacher ADHD reports using various 
clinical rating scales.  
-Tested if there were different proportions 
of males and females in COC groups and 
whether sexes differed in levels of observed 
ADHD once allocated to a COC group. 
-Sex & COC group entered as independent 
variables in four 2-way ANOVAs with 
parent & teacher ratings as dependent 
variables.  

-Secondary analysis – data not 
collected with this analysis in mind.
-Sample representative of socio-
economic background of 
community as number of 
participants receiving free school 
meals (index of disadvantage) was 
proportional to city as a whole. 
-A greater focus on hyperactive vs 
inattentive behaviours was reported 
in COC coding. 
-No means of assessing possibility 
of non-response bias. 
-Statistical analyses appropriate to 
answer research question. 

Babinski et 
al. (2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-Parents/caregivers of children 
ages 5-12 years in the US invited 
to participate in online survey 
(n=1050). 
-Sample representative of US 
population in terms of gender, 
race, income & geography.  

-Parents rated their children’s ADHD, 
ODD & Conduct Disorder symptoms via 
the (DBDRS; Pelham et al. 1992) scale, 
their overall impairment via the (IRS; 
Fabiano et al. 2006) scale, their depression 
via the (SMFQ; Messer et al. 1995) scale 
and their anxiety via the (SCARED; 
Birmaher et al. 1997) scale. 
-ROC analyses then conducted to examine 
optimal ADHD symptom count cut-offs for 
girls & boys. Criterion defined as an 
impairment score of 5 or more on the IRS. 

-Sample representative of US 
population. 
-Only parent ratings used. 
-The chosen criterion variable in 
ROC analyses was overall 
impairment as captured by the IRS. 
So, it was not a criterion measure 
reflecting ADHD per se.  
-Respondents & non-respondents 
could not be compared to check if 
they are different on the variables of 
interest. 



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-Analysis conducted separately for girls & 
boys & individually for Inattentive & 
Hyperactive/Impulsive symptoms. 
-Girls with ADHD sex specific criteria, 
girls with ADHD DSM-V criteria, girls 
without ADHD & boys with ADHD 
compared on measures of depression, 
anxiety, ODD & conduct disorder. 

-Statistical analyses appropriate to 
answer the research question. 

Behesti et al. 
(2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-165 psychiatrists from Isfahan, 
Iran completed a questionnaire 
which was distributed during two 
of their monthly gatherings.  
-179 psychiatrists from Tehran, 
Iran completed the questionnaire 
which was sent to psychiatrists’ 
offices.  
-Response rate of 44.10%. 

-Each psychiatrist received 1 of 8 vignettes 
and a questionnaire.  
-Vignettes were constructed on ICD-10 & 
DSM-IV criteria. Vignette 1 described a 
youth with ADHD with all the criteria. 
Vignettes 2 & 3 had 2 & 3 missing criteria 
respectively. Vignette 4 described a youth 
with Generalized Anxiety Disorder but no 
ADHD. For each Vignette there was a 
version for a boy and one for a girl for a 
total of 8 vignettes. Psychiatrists asked to 
determine whether youth had ADHD and 
whether any interventions should be 
recommended.  
-Chi-Square test applied to compare the 
proportion of false positives to false 
negatives. 
-Multiple logistic regression analysis 
applied to evaluate the role of gender in 
therapists’ diagnostic decision.  

-Non probability sampling. 
-Vignettes based on DSM-IV 
criteria but DSM-V criteria had 
already been issued. This meant that 
in reality vignette 2 now had one 
missing criterion.  
- Study had low ecological validity. 
In real life when unsure the 
psychiatrist would test further not 
mark “unsure” option.  
-Risk of non-response bias high. 

Dorani et al. 
(2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-Female patients from a psychiatric 
outpatient clinic for Adult ADHD 
in the Hague, the Netherlands in 
care in April & May 2016 were 
approached (n=316).  
-Participants had to be at least 18 
years of age and meet DSM-IV 
criteria for ADHD. 
-209 participants completed the 
study – Response rate of 66%.  

-Premenstrual dysphoria questions from the 
(M.I.N.I. plus; Van Vliet & De Beurs, 
2007) were used to assess for Premenstrual 
Dysphoric Disorder. 
-Postpartum periods after the birth of the 
first biological child were assessed for 
prevalence of Post Partum Depression 
symptoms using the (EPDS; Cox et al. 
1987). 
-Climacteric symptoms were assessed 
using the (GCS; Greene, 1998). 
-Norm scores from 504 women aged 45-65 
years from Dutch population used for 
comparison (Barentsen et al. 2001). 
-Categorical variables were compared 
between groups using Chi-square and odds 
ratio. For continuous variables, t-tests and 
ANOVAs were used. 

-Reasons why eligible participants 
chose not to participate not 
provided. 
-Measures relied on retrospective 
self-report so possibility of recall 
bias. 
-Associations between premenstrual 
dysphoria symptoms & covariates 
were examined using regression 
analysis correcting for age and 
education level. 
-In the absence of a matched control 
group, comparisons with the Dutch 
general population need to be 
interpreted with caution. 

Klefsjo et al. 
(2021) 
 
Quantitative 
Retrospective 
Case-Series 

-100 cases (50 boys & 50 girls) of 
registered ADHD randomly 
identified from 6 Child & 
Adolescent Psychiatric 
Outpatients Care Units in Western 
Sweden.  
-Inclusion Criteria: Patients had 
received ADHD diagnosis & were 
still in treatment at clinic, any 
ADHD subtype considered & 

-Following data collected: first registered 
ADHD subtype diagnosis, referral instance, 
reason for referral, age at first visit to clinic, 
number of visits before receiving ADHD 
diagnosis, age when receiving ADHD 
diagnosis, type of professionals involved in 
diagnostic procedure, received 
psychotherapy prior/after diagnosis, 
received medication prior/after diagnosis 
and inpatient care prior/after diagnosis. 

-Random sampling but limited 
number of participants. 
-Retrospective nature of study 
guaranteed that diagnostic processes 
were not influenced by the study. 
-Complete data available for all 
cases. 
-Statistical analyses appropriate to 
answer research question. 



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patients had at least one registered 
visit during 2015 at the age of 17.  
-Those diagnosed with ADHD 
prior to referral to clinic were 
excluded. 

-Mann-Whitney U test used for continuous 
variables since data not normally 
distributed. Chi-Square test for 
independence used for categorical 
variables. In all 2x2 tables, Yates 
Continuity Correction used. In cases with a 
low expected cell frequency, Fishers Exact 
Probability test used. 

London & 
Landes 
(2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-Data from 2007, 2012 US 
National Health -Interview Survey 
used.  
-2007 sample (n=75,764; 
Response rate 87.1%). -2012 
sample (n=108,131; Response rate 
77.6%).  
-Participants aged 18-34 at time of 
study. 

-Synthetic cohorts based on birth year were 
constructed & individuals were assigned to 
an appropriate age category in 2007 and 5 
years later in 2012. Thus, changes over 5 
years at specific ages within each cohort 
could be measured.  
-Inter cohort changes compared percentage 
of adults of a given age who self-reported 
ADHD from one birth cohort to the 
percentage of same aged adults who self-
reported ADHD in another cohort. 
-Intra cohort changes compared the 
percentage of adults with self-reported 
ADHD at a given age to that same group 
when they were 5 years older.  

-Stratified random sampling. 
-Sample representative of US 
population. 
-ADHD diagnosis only measured as 
self-reported dichotomous indicator 
of lifetime ADHD diagnosis status. 
-ADHD measure only available for 
2007 & 2012 so cannot make 
inferences as to whether changes 
reported extend beyond these years.

Szep et al. 
(2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-Data from first wave of ongoing 
longitudinal study used (Pauli-Pott 
et al. 2017, 2019; Schloss et al. 
2019).  
-Community based sample 
recruited from childcare facilities 
in Marburg, Germany. 
-124 mother-child dyads.  
-40 children had scored above the 
lower bound of 95% CI of clinical 
cut-off score & 84 scored below 
this point from the ADHD 
screening questionnaire (Pre-
PACS; Daley 2010) rated by 
mothers. 

-Child ADHD status further ascertained by 
parent and kindergarten teacher ratings of 
the (FBB-ADHS-V; Dopfner et al. 2008) 
scale. 
-Child ODD/Conduct Disorder assessed at 
4/5 years by the (FBB-SSV; Dopfner et al. 
2008). 
-Maternal ADHD symptoms assessed via 
the (WRI; Rosler et al. 2007) & the 
(CAARS-K; Christiansen et al. 2014) 
scales.  
-Maternal depressive symptoms measured 
via the (CES-D; Hautzinger et al. 2012) 
scale.  
-Maternal perceived chronic stress 
measured via the (TICS-SSCS; Schulz et 
al. 2004) scale. 
-Mothers’ hair cortisol concentrations 
(HCC) accessed using hair samples. 
-Hierarchical multiple regression analyses 
conducted with mothers' perceived chronic 
stress & HCC as outcome variables. 

-Cannot estimate how many 
participants were eligible for 
inclusion or non-response bias.  
-When 2 scales captured the same 
variable, composite scores created 
by summing up z-transformed 
scores of the scales & internal 
validity declared. 
-Clear indication of amount of 
missing data. Statistical description 
of how variables of participants 
whose data were missing differed 
from those who had complete data 
provided. 
-Impact of child & maternal ADHD 
symptoms on maternal perceived 
chronic stress examined while 
controlling for child ODD/CD & 
maternal depressive symptoms. 

Zaidman-Zait 
& Shilo 
(2021) 
 
Quantitative 
Cross-
Sectional 
Study 

-141 mothers aged 29 to 52 years 
& their 8- to 12-year-old biological 
children (72 boys & 69 girls; 61 
with ADHD & 80 without) 
recruited. 
-Recruitment through 
advertisements, parent support 
groups, mailings to local ADHD 
advocacy groups, & professionals 
working with children with ADHD 
& 

-2 Inhibitory Control Neurocognitive 
Computerized tasks given to mothers. 
-Maternal ADHD symptoms measured via 
the (ARS; Kessler et al., 2005). 
-Negative & supportive maternal parenting 
measured via the (Parenting Scale; Arnold 
et al., 1993) & observations of mother-child 
discussions.  
-To control for children’s disruptive 
behaviours, mothers completed the 
Conduct Problem subscale of the (SDQ; 

-Target population not delineated & 
cannot estimate how many 
participants were eligible for 
inclusion.  
-Negative & supportive maternal 
parenting measured using both a 
self-report tool & observations.  
-No information provided re missing 
data. 
-Confounders accounted for in 
analysis. 



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families. Goodman, 1997) scale.  
-To control for mothers’ parenting distress, 
mothers completed the Parenting Distress 
subscale of the (PSI-SF; Abidin, 1995). 
-Hierarchical linear regressions to examine 
independent & interactive effects of 
maternal ADHD symptoms, maternal 
inhibitory control & child diagnostic status 
on observed and self-reported maternal 
parenting. 

-Any maternal psychopathology 
could possibly have been a co-
exposure. 

 
Methodological considerations of the included qualitative studies. 

Authors, 
Year of 
Publication 
& Design 

Sample & Setting Study Methods Methodological Quality 
Comments Based on 
MMAT Criteria 

Holthe & 
Langvik 
(2017) 
 
Qualitative 

-5 females (32 to 50 years) diagnosed 
with ADHD in adulthood 
interviewed. 
-All had university degrees, all were 
married or in a relationship, all had 
one or more close relatives with 
ADHD & three of them were mothers 
and had children diagnosed with 
ADHD. 

-Semi-structured in-depth interviews on the 
following topics: factors/events leading to 
diagnosis, most prominent symptoms, 
challenges, issues associated with 
relationships, motherhood & gender norms, 
experiences of stigma, helpful treatments & 
coping strategies and personal strengths.  
-Thematic analysis with combination of 
deductive and inductive strategies. 

-Distinct qualitative approach 
used not specified. 
-Sample described in detail, 
so inferences re 
transferability can be made. 
-Analysis performed solely 
by one researcher. However, 
member-checking enhanced 
rigour. Analytical strategy 
described in detail. 
-Findings sufficiently 
substantiated by data & direct 
participant quotes.  

Stenner et al. 
(2017) 
 
Qualitative 
Discourse 
Analytic 
Research 

-16 women with either a formal or a 
self-diagnosis of ADHD (9 self-
diagnosed, 5 formally diagnosed in 
adulthood & 2 formally diagnosed as 
teenagers).  
-Recruited via an online support 
group for people with ADHD & 2 
local community support groups in 
the UK. 

-Participants chose whether to be interviewed 
face-to-face or by telephone. 
-Semi-structured interview guide asking how 
ADHD may have impacted their identities and 
lives at different moments. 
-Initial thematic analysis, then data subjected 
to “thematic decomposition” i.e. a search for 
interview content that speaks about 
transformative events & re-interpretations of 
the past. The outcome is a theoretically 
nuanced but data grounded interpretation of 
interview content.  

-Qualitative approach used 
specified. 
-Issues of rigour not 
discussed. 
-Numerous direct participant 
quotes provided to justify 
themes. 
-Coherency between data 
sources, collection, analysis 
& interpretation.  

Young et al. 
(2020) 
 
Qualitative 
Expert Panel 
Method 

-Professionals specialising in ADHD 
convened in London on the 30th of 
November 2018 for a meeting hosted 
by the UK ADHD Partnership. 
-ADHD experts from wide range of 
professions attended (nursing, GPs, 
Child & Adolescent Adult 
Psychiatrists, Clinical & Forensic 
Psychologists, Counsellors and 
Educational & Occupational 
Specialists). Service-users & ADHD 
charity workers also attended.  

-Meeting commenced with presentation of 
preliminary data from research on ADHD sex 
differences.  
-Attendees then allocated to one of three 
breakout groups and tasked with providing 
practical solutions to assigned topic. Topics 
were explored using lifespan perspective and 
comprised: Identification & assessment of 
ADHD in females, Interventions & treatment 
for ADHD in females & Multi-agency liaison.  
Discussions facilitated by group leader & 
summarised by note-takers. 
-Groups re-assembled & findings presented for 
another round of debate until consensus 

-Assessment, treatment & 
multi-agency support features 
reflect clinical practice & 
legislature in UK & may 
differ in other countries. 
-Triangulation of methods: 
transcripts, small group notes 
and extant literature. 
-Member-checking enhanced 
rigour.  
-Data analysis not discussed. 
-Interpretation of results 
supported by extant research 
but it is not clear how 



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reached.  
-All consensus proceedings recorded & 
transcribed. Notes circulated to each group 
leader for review & agreement. 
-Consensus report circulated to all authors for 
agreement & approval. 

recommendations were 
derived from professional 
experience (excerpts were 
needed).  

Lassinantti & 
Almqvist 
(2021) 
 
Qualitative 
Narrative 
Research 

-11 Swedish mothers with ADHD 
aged 35 to 49 years recruited through 
an association for people with 
neuropsychiatric disabilities.  
-All diagnosed with ADHD as adults 
& all were medicated. 

-In-depth interviews guided by Narrative 
Interview Methodology. 
-Codes & themes generated abductively 
through reflexive thematic analysis focusing 
on the explicit semantic contents of the data & 
more latent meanings.  
-Analysis underpinned by concepts of able-
mindedness and responsibility. 

-Specific qualitative approach 
used & described. 
-Topics included in semi-
structured interview guide 
provided. 
-Interpretation of findings 
sufficiently substantiated by 
data and direct participant 
quotes. 
-Issues of rigour & limitations 
of the study not discussed.  

Lynch & 
Davidson 
(2022) 
 
Qualitative 

-Participants were 17 adolescent 
young women (13 to 20 years) living 
in Ireland with a medical diagnosis of 
ADHD. 

-Participants interviewed in person by means 
of a semi-structured interview guide and 
additionally asked to complete an online 
questionnaire since they may have experienced 
difficulties sustaining attention throughout the 
interview.  
-Both measurements explored topics relating 
to daily life with ADHD, receiving a diagnosis, 
social experiences and future goals.  

-No specific qualitative 
approach used. 
-Interviews supplemented 
with online questionnaire. 
-Analytical strategy not 
discussed. 
-Interpretation of findings 
supported by the data 
collected and excerpts 
included effectively.  

Wallin et al. 
(2022) 
 
Qualitative 

-15 women aged 15 to 29 years 
recruited from 2 psychiatric 
outpatient clinics, 2 youth health 
clinics specialising in sexual & 
reproductive health & from 3 social 
media groups for people  with 
ADHD.  
-Clinics were from different regions 
in Sweden. 

-12 individual interviews & 1 focus grp with 3 
participants. 
-Due to sensitive topic being discussed, a focus 
group was conducted online using the written 
chat forum & interviews were held over the 
phone. 
-Data analysed by thematic analysis. 

-No specific qualitative 
approach was employed. 
-Description of how the semi-
structured interview schedule 
evolved provided.  
-Data analysis process well 
described. 
-Interpretation of findings 
sufficiently substantiated by 
data and direct participant 
quotes. 
-Issues of rigour and 
positioning of the researcher 
discussed. 

 
Methodological considerations of the included systematic reviews. 

Authors, 
Year of 

Publication 
& Design 

Sample & Setting Study Methods Methodological Quality Comments 
Based on JBI Checklist for SRs 

Criteria 

Kok et al. 
(2020) 

 
Systematic 
Literature 
Review 

 

-Inclusion criteria – English 
Language studies, studies with an 
ADHD sample formally diagnosed, 
studies providing data explicitly 
sorted by sex, studies with data on 
prescription rates/efficacy or 
effectiveness of stimulant or non-
stimulant treatment. 

-For analysis of results on 
efficacy/effectiveness, effect sizes of 
group differences derived from 
original studies or calculated by hand 
to determine the size of between-sex 
differences. 
-For studies with all-female samples, 
efficacy/effectiveness investigated by 

-Review question clear and inclusion 
criteria appropriate. 
-Search strategy defined & sources 
adequate. 
-Study appraisal criteria not provided 
& not informed how many reviewers 
independently appraised studies. 
-Recommendations provided and 



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-14 articles on 
efficacy/effectiveness included. 
-7 articles on prescription rates 
included. 

using treatment vs placebo group. 
-In studies on prescription rates, 
percentages mostly used to compare 
sex-differences in prescription rates. 

supported by reported data. 

Camara et al. 
(2022) 

 
Systematic 
Literature 
Review 

-Inclusion criteria – studies 
published in the last 30 years, 
studies investigating at least one 
group of patients with a clinical 
diagnosis of ADHD or an equivalent 
assessment and studies examining 
the association between sexual 
hormones or reproductive life stages 
on ADHD.  
-4 titles matched inclusion criteria 
(2 observational studies, 1 narrative 
review and 1 case study).  

-Heterogeneity of study aims, designs 
and samples did not allow for any type 
of pooling and findings for each study 
were discussed separately. 

-Review question & inclusion criteria 
explicitly stated and appropriate.  
-Search strategy defined and sources 
adequate. 
-Level of evidence assigned but no 
mention of assessment of 
methodological quality. 
-Articles screened by 2 reviewers 
independently, 3rd reviewer consulted 
in cases of disagreement. 
-Recommendations for practice put 
forward could not be fully supported 
by the ‘small’ synthesis of 4 
heterogenous studies. Directions for 
future research provided were 
adequate. 

 
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