Women and ADHD

Underdiagnoses, misdiagnoses, and way too much shame

In this post, I’m talking about women and ADHD. Specifically, I’m going to be talking about cis women, though I think there’s some relevant info here for anyone who has/has had female-coded hormonal profiles (estrogen, progesterone, menstruation, menopause, etc.) and/or anyone who has been socialized with culturally female gender roles.

Here’s the tl;dr before I dive in:

• Diagnosed ADHD is more common in boys than in girls, but it’s about equal between adult men and women.

• Girls are more likely than boys to have inattentive symptoms of ADHD, like disorganization, distractibility, forgetfulness, and difficulty completing tasks (especially boring ones).

• In an effort to embody female gender roles, girls may exert a great deal of energy into efforts to minimize, hide, or compensate for their symptoms.

• Parents, educators, and clinicians often know very little about how ADHD presents in girls, resulting in missed or inaccurate diagnoses.

• Girls and women with ADHD experience greater psychological distress than boys and men with ADHD, including higher rates of depression and anxiety.

• Hormonal changes during menstruation, pregnancy, postpartum, and menopause likely affect ADHD symptoms.

Do menstrual cycles affect ADHD? Probably! Do we have enough research on this? No!! Photo by Natracare on Unsplash

Diagnosed ADHD is more common in boys than in girls, but it’s about equal between adult men and women

Most scientists agree that ADHD begins in childhood, and while some people no longer experience symptoms as they grow older, ADHD persists in adulthood in 50% or more of cases. 

From ages 2 to 18, boys are diagnosed with ADHD more often than girls, at a ratio of about 2 to 1. However, in adulthood, the disparity between male and female diagnoses narrows, and the ratio gets close to 1:1. 

There are two popular explanations for this discrepancy:

1. Maybe girls are more likely to have ADHD that persists into adulthood, while boys are more likely to grow out of ADHD as they get older.

2. Maybe ADHD is underdiagnosed in girls and more accurately diagnosed in adult women.

Girls are more likely to show inattentive symptoms of ADHD, like disorganization, distractibility, forgetfulness, and difficulty completing tasks (especially boring ones). Boys are more likely to show hyperactive-impulsive symptoms of ADHD, like restlessness and difficulty waiting.

Hyperactive symptoms tend to decrease for everyone as they get older, while inattentive symptoms are more likely to stick around in adulthood. So this could help explain why boys might grow out of ADHD more frequently than girls do.

That said, there are also plenty of reasons why ADHD could be underdiagnosed in girls:

• Adult diagnoses include women’s self-reports of their symptoms. Childhood diagnoses rely on parent and educator reports.

• Girls are more likely than boys to have inattentive ADHD symptoms, which tend to be less obvious to people around them. (Daydreaming is less obvious to a teacher, than, say, getting up and running around the classroom—especially if you’ve got a teaching load of 34 elementary kids or 170 secondary kids.)

• Hyperactive behavior is less socially acceptable in girls than in boys, so girls may express hyperactive symptoms in more subtle ways, like quiet fidgeting, emotional reactivity, or talkativeness. 

• In an effort to embody female gender roles (nice, obedient, organized, cooperative), girls may exert a great deal of energy into efforts to hide or compensate for their symptoms.

• Parents, educators, and clinicians often know very little about how ADHD presents in girls. Thus, they may fail to notice symptoms, or they might misdiagnose the symptoms as depression or anxiety. (

  Liana Hornyak
  writes about this eloquently in her essay on her own late diagnosis.)

We are not doing enough to support girls and women with ADHD

Girls and women with ADHD experience a number of very severe challenges at higher rates than males with ADHD or females without ADHD. 

There is evidence that girls and women with ADHD experience greater psychological distress overall, including poorer self-concept and higher rates of depression, anxiety, eating disorders, and self-harm. This may be exacerbated among women with late-diagnosed ADHD, who may have spent decades shaming themselves for symptoms that were not their fault.

Adolescent girls and women with ADHD are more likely to be victims of violence and abuse in their relationships, and they are more likely to experience unwanted pregnancy. This may be related to the experience of chronic shame and poor self-concept.

For many adult women with ADHD who have children, compensatory behaviors that may have managed ADHD symptoms prior to having children are no longer adequate under the stress of parenting and the high cultural expectations of motherhood. This is particularly a concern in countries like the US with inadequate childcare and parental support. Postpartum and perimenopausal hormone changes may also exacerbate ADHD symptoms during this time period (more on this below). For some women, the breaking point of motherhood is what finally prompts a late ADHD diagnosis.

Overall, the evidence is pretty clear that we are not adequately supporting girls and women with ADHD. We aren’t recognizing or correctly diagnosing their symptoms. Our social structures and cultural obsession with hyper-productivity foster chronic shame and low self-worth. We aren’t adequately preventing partner violence or providing comprehensive reproductive healthcare. We are putting an inordinate amount of stress on parents, especially mothers. And, as I’m going to talk about next, we don’t have enough research on ADHD and women—especially when it comes to female reproductive hormones.

Female reproductive hormones (probably) influence ADHD symptoms

Many researchers speculate that ADHD symptoms are influenced by the hormonal changes of menstrual cycles, pregnancy, postpartum, and menopause. There is evidence that dopamine and the effects of stimulant medications vary during the menstrual cycles of non-ADHD women, and there are a few case studies of women with ADHD who responded well to adjustments in medication around their menstrual cycles. 

Also, while it has not yet been studied, it is highly likely that hormonal changes during pregnancy, postpartum, and menopause exacerbate ADHD symptoms. As I mentioned above, hormonal changes at perimenopause may be a key trigger for women to seek out a mid-life ADHD diagnosis.

There is not enough evidence (yet!) to set forth official medical guidelines for adjusting ADHD treatments based on the female reproductive life cycle. While the early evidence is promising, we need some larger, randomized trials before this can happen. 

However, your healthcare provider may be open to adjusting your medication on an individual basis, monitoring you to see if it helps your symptoms.

Kristen McClure

encourages readers to do just that in a post on her newsletter, Flourish. If you want to share some of the preliminary evidence with your provider, I’d suggest this de Jong et al case study (at the time of writing, this article is open access, no paywall).

And, if you are a person with ADHD entering perimenopause, you might note that these intense hormonal shifts will likely affect your symptoms. It could help to be open to the possibility of adjusting medications or trying different treatments, like coaching or a different therapy modality. (Also, enjoy this hysterical post on perimenopause from

Shelly Mazzanoble

. You’re welcome.)

ADHD women’s self-identified strengths

In one small interview study, researchers asked women with ADHD to describe their personal strengths that they considered to be at least partly related to ADHD. Some of the strengths that women described are:

• Energy

• Creativity

• Determination

• Tenacity

• Excitement about new things

• Adventurousness

• Willingness to take risks

These were individual women’s reflections, not necessarily characteristics that apply to all women with ADHD. (Anecdotally, I know women with ADHD who are feeling pretty burned out and not at all energetic or tenacious right now!) But even though these don’t apply to all ADHD women all the time, I still feel that research findings about self-identified ADHD strengths are important and worthy of our attention.

***

This week’s post was inspired by comments from

Jenny Eden Berk, MSEd

and

Tanya Mozias

in a conversation on the Substack Writers at Work platform. Mentioned in that same thread:

• Therapy and Other Stories
  described plans to write about women with ADHD

• Mikhal
  mentioned a planned post on ADHD and sleep disorders in adult women

• Folks shouted out many fantastic writers on Substack who are sharing about their experiences as women with ADHD, including

  Mika
  ,
  Susan Earlam
  ,
  Liana Hornyak
  ,
  Rebecca Makkai
  , and
  Emily Farris
  .

• To that list, I would add

  Asmita Puri
  ,
  Karen Wesley
  , and
  Rach Idowu
  .

Please share other recommendations for writers and books regarding women and ADHD in the comments!

I’d love to hear what you think of the research collected here. Do any of these findings resonate with, or depart from, your own experience?

Stay curious,

Dr. Taylor Allbright