ADHD in Women: How to Not Miss the Diagnosis

The ratio of boys to girls diagnosed with attention-deficit/hyperactivity disorder (ADHD) is around 3:1. Yet for adults, the ratio is closer to 1:1.

In the past, girls and women often went undiagnosed for ADHD because a “one size fits all” presentation of ADHD was presumed that emphasized only two of the three ADHD subtypes. Now, clinicians are beginning to better understand the nuances of the third type — predominantly inattentive type — that is much more common in girls and women. When ADHD is not recognized in childhood, it can become more difficult to sort through in adulthood.

Women who lived with undiagnosed ADHD for years want to make it clear that hyperactivity is not the only symptom to look out for. Our understanding of ADHD symptom presentation and conceptualization are evolving as more women’s stories are being heard and more research is being conducted.

ADHD: How we thought about it then is not how we think about it now.

ADHD was originally referred to as “hyperkinetic reaction of childhood,” and it was not until around the 1960’s that the American Psychiatric Association (APA) recognized ADHD as a mental health condition. In the 1980s, “attention-deficit disorder with or without hyperactivity,” was coined.

In 1987, the APA decided to merge ADD (attention deficit disorder) and ADHD into solely ADHD with the following subtypes:

• Predominantly inattentive type (used to be referred to as “ADD”)
• Combined type (includes clinically significant difficulties with inattention and hyperactivity)
• Predominantly hyperactive-impulsive type

Currently, the most common subtype of ADHD is the combined type and least common is the hyperactive-impulsive type.

The predominantly inattentive type is the most common diagnoses in adults. As brains fully mature, around the ages of mid-to-late 20’s, there is usually a trend towards less hyperactivity and externalizing behaviors.

Women are more likely than biological males to have the predominantly inattentive form of ADHD, which often does not display as external or disruptive behaviors. This leads to symptoms being unnoticed or not as commonly associated with more traditional views of ADHD.

Diagnosing ADHD across the lifespan

Currently, in the United States, around 1 in 9 children, ages three through seventeen, have been diagnosed with ADHD.

The average age of onset for ADHD symptoms in children is age six. ADHD is often thought of as a disorder of childhood; however, up to 90% of children with ADHD continue to have symptoms when they are an adult. However, only 10-25% of adults with ADHD receive the correct diagnosis and intervention.

The current understanding is that there are both environmental and genetic components related to ADHD. The frontal lobe of the brain, which is where higher-level cognitive abilities are housed (e.g., inhibition, attention, self-monitoring, planning, etc.), is most affected by ADHD.

ADHD research has historically focused more on males than females.

ADHD research has traditionally more heavily focused on biological males, which undoubtedly has led to delays in diagnosis and referral bias for biological females. 

One reason for the increase in women being diagnosed with ADHD could be due to a trend of deeper understanding of women’s experiences both by women themselves and by healthcare providers. Hopefully, the trend continues to not jump to a mood disorder diagnosis for women with ADHD but will lead professionals to assess for the potential of chronic, underlying executive functioning challenges.

Women’s symptoms of ADHD are often less externally obvious and disruptive in their environments. Assessors are no longer only looking for externalizing behaviors and specific decline in academic performance. Individuals who may be high achieving academic students can also struggle with focus and attention, especially as related to their peers. These difficulties can be internalized or hidden, especially in women. Unfortunately, there is less historical research on ADHD in women than in men, so less is known about how it affects them.

Common symptoms of ADHD in women:

• Difficulty with sustained focus, namely on non-preferred activities
• Indecisiveness
• Overspending
• Forgetfulness
• Losing or misplacing items
• Restlessness or fidgetiness
• Trouble with multitasking
• Procrastinating
• Trouble organizing environments
• Lack of full task completion
• Hyper-focus on areas of interest
• Conversational impulsivity
• Emotional dysregulation
• Trouble with time management
• Daydreaming, etc.

Women with ADHD also report a tendency to be overloaded by sensory input, like sounds, touches, lights, etc. They may also experience somatic difficulties, like headaches or gastrointestinal problems, and they also may have increased sleep difficulties.

Common co-occurring mental health diagnoses for women with ADHD include:

• Anxiety
• Depression
• Personality disorders

Hormones and gender role expectations impact executive functioning

Executive dysfunction can worsen depending on hormone changes, such as during menstrual cycles, puberty changes, pregnancy, perimenopause, or menopause.

The combination of low estrogen and high progesterone can lead to symptom worsening.

Estrogen impacts the brain in several ways, specifically with its impact on serotonin and dopamine. These brain chemicals impact executive functioning and general mood. When estrogen levels drop, the ability for the brain to release these chemicals also decreases.

After pregnancy, especially with the co-current sleep deprivation, hormonal shifts and adjustments to parenthood, executive dysfunction can be further impaired.

Individuals who have not been officially diagnosed with ADHD, yet have had symptoms over the years, may be more likely to have symptom difficulty, leading to formal diagnosis. What this shows is that living with undiagnosed ADHD can impact the experience of becoming a new mother. Individuals can only compensate for so long. We also know that living with undiagnosed ADHD leads mothers to be at a higher risk for perinatal anxiety and mood disorders.

Women with ADHD may be better at masking their symptoms.

Women may mask symptoms by appearing to be perfectionistic or diligent, or falling into other gender role expectations. They may also be prone to internalize their difficulties as compared to male counterparts.

Common stereotypes of women with ADHD

It is often heard that women did not know they had ADHD growing up, and the possibility was often not even offered to them. They have frequently had to educate and research ADHD themselves. Anecdotally, women often share a similar sentiment, that their male peers’ behaviors were laughed at or joked about whereas their struggles were punished, invalidated or downplayed.

Common stereotypes include:

• ADHD traits, especially for women, can be judged as character flaws rather than understood as a mental health condition. 
• Women are not hyperactive so cannot have ADHD.
• High performers cannot have ADHD… “Oh, she’s getting straight A’s in school, so there’s no way that she has ADHD.”

Accurately diagnosing ADHD in women can take time.

A comprehensive evaluation with a clinical psychologist is highly recommended. This allows for an extensive clinical interview, collateral interview, review of developmental and historical information, performance-based testing, record review, and self and collateral report forms.

It is important to gather environmental and collateral data, as this helps provide a better context for the individual and leads to more confidence in the current diagnostic impressions.

It is now understood that there are overlaps in symptom presentation between ADHD and other mental health disorders, such as anxiety. So it is not as simple as assessing for ADHD; general diagnostic clarification needs to be taken into consideration as well.

Clinical psychologists base their diagnostic impressions upon symptom criteria in the Diagnostic and Statistical Manual- 5th Edition-TR (DSM-5-TR). Now, the suggestion for diagnosis is that adults have around five out of nine symptoms of inattention and/or hyperactivity, and, for children, six out of nine.

To be diagnosed with ADHD as an adult, an individual must have had symptoms in childhood. Most typically, symptoms begin before the age of twelve. Symptoms can change over time and be quite varied in presentation.

Therapists, psychiatrists or primary care providers often place referrals to clinical psychologists, who specialize in assessment and diagnosis, like what is offered at Pine Rest’s Psychological Consultation Center. After a comprehensive psychological assessment, a report is completed and reviewed with the client. Clinical psychologists aim to differentiate between psychological diagnoses and to, most importantly, suggest recommendations for treatment.

It takes time to sort through underlying and overlapping symptoms. This assessment process should not be rushed and should be a collaborative discussion between the client and examiner.

What women can do after being diagnosed with ADHD

In childhood, recommendations to follow up with school interventions, like a Section 504 or Individualized Education Plan, are often suggested. Because children spend so much time in school, accommodations like a quiet space or extra time can be game changers.

• Checking in with an outpatient therapist to work on behavioral support for executive functioning concerns is highly recommended for individuals of all ages.
• ADHD medications that are prescribed for children with ADHD are often explored for adults with ADHD, as well.
• Collaboration across care providers is of utmost importance.

Psychiatrists who prescribe medication treatment for ADHD should make sure that their client is also actively engaged in therapy, as research suggests that the combination of therapy and medication are highly supportive of ADHD symptoms.

Psychoeducation and links to websites, podcasts, and books are common recommendations also given by providers. Support groups and networking with other individuals diagnosed with ADHD can also be beneficial. Improved functioning in daily life is the goal, and individuals have found support in collaborating with an ADHD coach to help with certain symptoms.

Overall, it is important to:

• Include psychoeducation to the individual and/or their family
• Reframe individuals’ strengths
• Review options for medication intervention, resources for therapeutic intervention, ideas for environmental reorganization, and possibilities for community and support groups

It is time that women have their ADHD symptoms heard, validated and diagnosed.