What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent childhood diagnoses with a worldwide prevalence of 7.2% in children under the age of 18 (Thomas et al., 2015). However, women with ADHD have a propensity to be underdiagnosed and undertreated. Though symptoms of ADHD in males and females are more alike than different, lived experiences often appear to differ between genders. What appears to be a gender gap in diagnosis and treatment, often leaves females without services and to struggle with symptoms longer than their male counterparts.

ADHD is a condition often diagnosed in childhood, that persists into adulthood. With symptoms that fit into a few key domains for a period of 6 months or more including: inattention, hyperactivity-impulsivity, or a combined presentation.

Inattention Symptoms include:

• Difficulty with attention to detail/makes careless mistakes
• Difficulty sustaining attention in tasks/play activities
• Difficulty listening when spoken to directly
• Often does not follow through on instructions and fails to finish tasks
• Difficulty organizing tasks and activates
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
• Commonly loses things needed to complete tasks or activities
• Often easily distracted by extraneous stimuli
• Often forgetful in daily activities

Hyperactivity and impulsivity include:

• Often fidgets with or taps hands
• Commonly leaves a seated area when seated is expected
• Often runs around or climbs in situations where it is inappropriate
• Difficulty engaging in leisure activities quietly
• Often times feels “on the go” or “driven by a motor”
• Often talks excessively
• Blurts out an answer before a question has been completed
• Often interrupts or intrudes on others
• Has difficulty waiting their turn

Why is ADHD misdiagnosed in women?

With ADHD, symptoms tend to decline with age. Research has found that about two-thirds of childhood cases experience impairing symptoms, while about only one-third of that population continues to meet full criteria for ADHD (Biederman et al., 2000).

At a young age, girls tend to display inattentive symptoms (e.g., forgetfulness, difficulty paying attention, challenges with organization, etc.). In contrast, young boys tend to display hyperactive/impulsive symptoms (e.g., blurting out answers in class or difficulty sitting still). Symptoms associated with inattention and internalization might be less likely to cause a disturbance in the classroom and ultimately lead to fewer referrals, diagnosis, and treatment of ADHD in school-age girls. Furthermore, inattentive symptoms might commonly present in a structured educational environment (i.e., high school or college) and/or often be misdiagnosed as anxiety, leading to a delay in diagnosis. Additionally, women may develop better-coping strategies to mask the impact of their ADHD related difficulties to sustain positive performance.

Moreover, recognizing ADHD-related symptoms appears to be more difficult in girls than boys, according to multiple research studies that looked at the prevalence of identifying and referring children for treatment among parents, teachers, and professionals (Glass and Wegar, 2000; Bruchmüller et al., 2012). Due to multiple sources of information that are needed to diagnose ADHD, self-report scales and parent/teacher reports are open to bias. This can lead to underdiagnosis or overdiagnosis of ADHD in minority groups including females and ethnic minorities (Lambert et al., 2002).

ADHD symptoms in women

Though it is important to consider the impact of sex differences on ADHD presentation, it is also important to examine the role that gender-based expectations have on influencing the strengths and challenges of the individual with ADHD. Most often women and girls are diagnosed with anxiety and/or depression before being diagnosed with ADHD. This might be due to the influence of socio-cultural norms (nurture) and the tendency for women to exhibit internalizing behaviors (i.e., people pleasing vs. disruptive behaviors) and/or the impact of neurology (nature).

Women often experience societal gendered expectations that do not align with the challenges and strengths of an ADHD brain. Examples of this include:

• A young girl being praised for her quietness when in fact she is lost and not tracking the school lesson.
• A teenage girl being told she is “overly sensitive” or “emotional” as she struggles with interrupting conversations and is more talkative about her feelings than her male peers.
• A woman feeling ashamed of her emotional reactivity, may censor herself rather than risk inappropriate responses in public. However, when at home and feeling less guarded, she might direct her frustration towards her partner or children. Unintended episodes leave the woman to feel regretful and demoralized, and without a neurobiological understanding, attributes her outbursts to a flawed character. Commonly she leads to low self-esteem and internalized shame.

Additionally, brain chemicals like estrogen can fluctuate in girls due to age and menstrual cycle; because of the relational impact of estrogen on dopamine (brain chemical most prominently implicated in ADHD), ADHD presentation can vary among women.

The fluctuation in symptom experience can delay diagnosis for women and if symptoms aren’t noticeable, a diagnosis might not happen until symptoms are severe or until the individual is overwhelmed by the life-long efforts of overcompensating for their struggles. Unfortunately, this could mean that a woman has been struggling with ADHD silently for years. Additionally, the brain reaches about 80% of its adult brain size by age 2, with sex differences attributed to the rate of glial maturation in the brain which happens to be faster in females than males (Gilmore et al., 2018; Hanamsagar, 2015). It is hypothesized that because female brains are growing at a faster rate, females might need to reach a higher threshold of genetic and environmental exposures for ADHD to be expressed. While those with slower brain development experience more vulnerability to neurodevelopmental insults.

Since females present with a specific neurobehavioral profile, females might face being undiagnosed, misdiagnosed, and/or undertreated. As ADHD symptoms in women are often more internalized, diagnoses like personality disorders or mood disorders are often common. If a female presents with emotional dysregulation and challenges with emotional lability, they are quicker to be diagnosed with a personality disorder rather than ADHD. For example, females with hyperactive-impulsive symptoms and self-harming behaviors, are often misdiagnosed with Borderline personality traits.

Adult ADHD diagnosis in women

“Understanding female ADHD presentation is the first step towards improving detection, assessment, and treatment, and ultimately enhancing long-term outcomes for girls and women with ADHD” (Young et al., 2020).

Women with ADHD make up a silent minority of individuals who are underdiagnosed and undertreated. Current diagnostic systems and services need to change and adapt to not only account for the ADHD externalizing behaviors often found in males. Clinicians must recognize the internalized presentation of ADHD behaviors in women and find ways to incorporate ADHD assessment across the lifespan. Additionally, treatment needs to include specific gender differences (e.g., hormonal changes) for optimal care and treatment of women with ADHD.

Though it is important to continue to consider the impact of sex differences on ADHD presentation, it is also important to question the impact gender-based biases might have in influencing the perception of strengths and challenges for those with ADHD. At this time, the field has limited research on the experiences of people with ADHD who don’t identify as cis-gender. More diversity and presentation are needed to be able to accurately diagnose and treat ADHD, so people with ADHD might be able to live well with their differences instead of living in spite of them.

Get tested for ADHD

For those local to the Seattle area who want to learn more about if ADHD testing is right for you, please feel free to reach out to Relational Psych. We have a team of licensed psychologists and post doctoral residents that specialize in helping people like you understand your functioning (and potentially your ADHD) so you can thrive in life. We offer comprehensive assessments to gather in-depth data about your experiences and integrate these into a holistic understanding of your sense of self with practical recommendations and a thorough report. We also have a team of therapists that can help support you after the evaluation if therapy is a recommended portion of your treatment.

Learn more about how to get tested for ADHD here, and if you’re ready to get help and are an adult in the Seattle area, schedule a free consultation today!

‍

References:

Biederman, J., Mick, E, Faraone, SV. (2000). Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. The American Journal of Psychiatry 157(5),816–818. doi: 10.1176/appi.ajp.157.5.816.

Bruchmüller, K., Margraf, J., and Schneider, S. (2012). Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis. J. Consult. Clin. Psychol. 80, 128–138. doi: 10.1037/a0026582

Gilmore, J., Knickmeyer, R. & Gao, W. Imaging structural and functional brain development in early childhood. Nat Rev Neurosci 19, 123–137 (2018). https://doi.org/10.1038/nrn.2018.1

Glass, C. S., and Wegar, K. (2000). Teacher perceptions of the incidence and management of attention deficit hyperactivity disorder. Education 121, 412–420.

Hanamsagar, Richa. “Sex differences in neurodevelopmental and neurodegenerative disorders: a largely ignored aspect of research.” Curr Neurobiol 6 (2015): 15-16.

Lambert, M. C., Rowan, G. T., Lyubansky, M., and Russ, C. M. (2002). Do problems of clinic-referred African-American children overlap with the child behavior checklist? J. Child. Fam. Stud. 11, 271–285. doi: 10.1023/A:101681600

Thomas, R., Sanders, S., Doust, J., Beller, E. M., and Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics 135, e994–e1001. doi: 10.1542/peds.2014-3482