Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately

ADHD is a neurological disorder characterized by a persistent pattern of inattention — with or without hyperactivity and impulsivity — that interferes with daily functioning. While the prevalence rates are increasingly similar by gender, the diagnosis rate among American men is nearly 69% higher than it is among American women (5.4% of men in the U.S. have an ADHD diagnosis vs. just 3.2% of women.¹)

Why? ADHD in women does not comply with stereotypes. Its distinct symptom presentation is skewed toward inattentiveness – a feature that explains, in part, why ADHD in women is still largely misunderstood, overlooked, and inadequately studied.

Despite improved ADHD awareness in general, science still stands to learn and untangle much about ADHD in women — particularly the influence of biology, neurology, and gender constructs on the condition’s appearance, trajectory, and treatment course.

ADHD in Women: Historical Perspectives

Our understanding of ADHD has evolved significantly. Once considered a condition defined by measures of hyperactivity in children, ADHD is now understood to include inattentiveness and to potentially last a lifetime. Still, many outdated ADHD stereotypes persist both in and outside the medical community, hampering the study, detection, and treatment of ADHD in women today. Recent research predicts serious mental and physical health outcomes for women who are inadequately evaluated and treated due to noxious ADHD myths like the following:

• ADHD is a male disorder. Hyperactive boys, deemed disruptive and unmanageable, were the ones referred to clinics. Early studies were based on the behaviors of these white hyperactive boys; these findings helped shape the diagnostic criteria and assessment scales still in use today.
• ADHD is a childhood disorder. ADHD was long classified as a Disruptive Behavior Disorder of Childhood, based on the hallmark of hyperactivity. Over time, it has become clear that ADHD does not resolve at puberty, and that inattentive symptoms persist longer than hyperactive symptoms.

[Checklist of ADHD Symptoms in Women]

ADHD Symptoms in Women

ADHD in women primarily means a greater likelihood for the following:

• inattentive symptom presentation, including, per the DSM-5
  • failing to give close attention to details or making careless mistakes in activities
  • trouble holding attention on tasks
  • not following through on instructions and failing to finish duties (e.g., losing focus, getting side-tracked)
  • trouble organizing tasks and activities
  • getting easily distracted
  • forgetfulness in daily activities
• internalizing symptoms, including mood and anxiety.

ADHD Symptoms in Women: Gender Role Expectations

ADHD in women is complicated by gender role expectations. Society’s long list of expectations for women — managing the self, the family, and the home — requires consistent coordination of executive functions.

Women with ADHD are not well-wired for these demands. But in seeking social acceptance, they are often determined to meet them, typically by masking symptoms and problems. Shame and self-blame fuel the dynamic interplay between societal expectations and ADHD’s executive dysfunction. To understand women with ADHD, clinicians cannot underestimate the extent to which women measure their self-worth and self-esteem according to their success in conforming to gender expectations.

ADHD in Women: Social Deficits

Women with ADHD, compared to men with ADHD, struggle more with socialization.

• Women are often overwhelmed with the demands of relationships and tend to have fewer meaningful relationships as a result. They rarely initiate friendships, and have trouble maintaining them. Isolation protects from discomfort and confusion.
• They often struggle with rejection sensitivity, an intense emotional response to real or perceived rejection, which can make social interaction a potential source of pain.
• They are more likely to engage in risky sexual behaviors compared to women without ADHD. One theory for this is early recognition of sexuality as a shortcut to social acceptance. It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD. While common, these experiences are aspects of ADHD that elicit shame.

[Click to Read: How to Make Friends as a Woman with ADHD]

ADHD in Women: Hypersensitivities

Women with ADHD tend to experience more central nervous system hypersensitivities compared to men with ADHD. They often report more of the following:

• tactile defensiveness and sensory overload (to being touched, and to common items like clothing material, tags, loud music, light, smells, etc.)
• somatic complaints, including headaches, migraines, stomach aches, and nausea
• sleep difficulties

ADHD in Women: Comorbidities

By adulthood, most women with ADHD have at least one comorbid disorder that can complicate the ADHD symptom picture, including:

• anxiety (25-40% of people with ADHD have an anxiety disorder)
• mood disorders
• dysregulated eating (bulimia is most common)
• externalizing disorders, like oppositional defiant disorder (ODD) or conduct disorder (mostly found in women with impulsive-type ADHD)
• personality disorders, like borderline personality disorder (BPD)

ADHD in Women: Impulsivity

Symptoms of impulsivity further influence how ADHD presents in women. Impulsivity is associated with

• gender atypical behaviors, including behaviors perceived as controlling, demanding, easily irritated, etc.
• high-risk behaviors, like speeding and extreme sports
• addictive behaviors, including substance use and gambling
• a significantly increased likelihood of acting on negative feelings, including self-harm (picking skin, cutting, etc.)

ADHD Symptoms in Women: Diagnostic Considerations and Challenges

Clinicians use DSM-5 guidelines to diagnose ADHD, as well as rating scales, interviews, and other practices. Research indicates that girls and women, compared to boys and men, are consistently under-identified and underdiagnosed for ADHD using these diagnostic criteria². Reasons for this disparity include the following.

1. ADHD in Women: Inattentive Symptom Presentation

• A subtle symptom presentation with a greater likelihood of inattentiveness marks the ADHD experience for many women and girls, who are not outwardly disruptive to others. Many clinicians, however, are most familiar with the hyperactive, disruptive presentations of ADHD that are more common in men and boys. Studies indicate that hyperactivity and impulsivity, along with other externalizing symptoms (like conduct problems) are strong predictors of diagnosis compared to other ADHD presentations.³
• Camouflaging symptoms: Research shows that women are highly motivated to hide their ADHD symptoms and compensate for them. The symptoms that are observable are often anxiety or mood-related, which can lead to misdiagnosis.

2. ADHD in Women: Gender Bias

Gender bias is rarely intentional, but it is insidious and pervasive. It influences how clinicians see and label women.

• Referrals: Inattentive, non-disruptive symptoms rarely arouse concern, which is why few girls and teens with these symptoms are referred for diagnosis or consultation.
• Rating scales for ADHD are still skewed toward male behavior symptoms. Internalized symptoms and impairments are often unaddressed, and many instruments are not normed for women’s values.

3. ADHD in Women: Hormonal Impact

Ovarian hormones interact with almost every system in the body, and are essential components in physical, social, and emotional health for all women. The brain is a target organ for estrogen, as it protects the brain by enhancing neurotransmitter activity, which then impacts executive functioning, attention, motivation, verbal memory, sleep, and concentration.

Estrogen levels, which fluctuate throughout the month as well as across the lifespan, impact the expression of ADHD symptoms in women. ADHD is largely thought of as a condition with stable symptoms across time, but this is not the case for women and their bodies. The truth is:

• ADHD symptoms vary with hormone fluctuations. ADHD symptoms increase as estrogen decreases. Estrogen decreases after ovulation, in the middle of the cycle, and even further near the start of menstruation. This combination of low estrogen and high progesterone exacerbates symptoms tremendously. It also means symptoms can vary day-to-day. Some women may be even more sensitive to these micro-fluctuations.
• Estrogen kicks in during puberty, around the time when ADHD symptoms become more prominent in girls. These hormonal changes are often expressed as anxiety and emotional volatility, however, may also be high in this time, which could lead to being misdiagnosed with anxiety or a mood disorder, and treated improperly or insufficiently.

ADHD in Women: Treatment Considerations

ADHD can be treated with therapy, medication, lifestyle changes, and accommodations. Women with ADHD should consider the following treatment options:

• A clinician and/or therapist experienced with ADHD in women and girls. Finding this professional is perhaps the most important and most difficult thing to do. Be sure to ask about their experience treating ADHD in women.
• Family psychoeducation: It’s important for your support network to understand ADHD as well.
• Reframing: Therapists can help you validate your experience, question the impact of societal expectations on your outlook and teach you to practice self-advocacy.
• Medication: It’s important to find a doctor who understands the impact of hormones on ADHD, and the interplay with medication. Stimulants, for example, may be less effective in the second half of the menstrual cycle. Hormone replacement therapy greatly improves ADHD symptoms in postmenopausal women, as it increases available estrogen and progesterone. SSRIs are commonly prescribed for anxiety and mood disorders, so it’s crucial for clinicians to understand how stimulants interact with SSRIs and impact symptoms all around.
• Environment restructuring: Therapists and other professionals can help you learn to restructure your surroundings to better suit your needs.and thoughts to suit your life.
• Coaching and support groups: ADHD coaches can help you meet goals, and support groups do wonders in normalizing the ADHD experience and reducing isolation, anxiety, and distress.

The content for this article was derived from the ADDitude Expert Webinar “Why ADHD is Different for Women: Gender Specific Symptoms & Treatments” (ADDitude ADHD Experts Podcast episode #337) by Ellen Littman, Ph.D., which was broadcast live on December 15, 2020.

ADHD Symptoms in Women: Next Steps

• Self-Test: ADHD Symptoms in Women
• Read: Women with ADHD – No More Suffering in Silence
• Read: Why Women with ADHD Feel Disempowered — And What We Can Do About It
• Find: ADHD Specialists or Clinics Near You

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