ADHD among Girls and Women

Attention deficit hyperactivity disorder (ADHD), is one of the most commonly diagnosed behavioral disorders in children, affecting an estimated 3% to 9% of U.S. children. According to the ​American Psychiatric Association, about half of those children will carry symptoms into adulthood.

Males are generally more likely to be diagnosed with ADHD than females, with a male to female ratio of approximately 4:1 in community samples. However, women are as likely as men to have ADHD – with the latest research suggesting that the disorder exacts a greater toll on women than it does on men.

“ADHD is still presumed to be a male disorder,” says Fred Reimherr, M.D., director of the University of Utah Mood Disorders Clinic and the lead author of a recent study that found that ADHD has a disproportionate impact on women, and that underdiagnosis of ADHD in women has its roots in childhood. 

“Historically, research on ADHD has focused almost exclusively on hyperactive little boys, and only in the past six or seven years has any research focused on adult ADHD,” says Dr. Kathleen Nadeau, an expert on the disorder in women and director of Chesapeake Psychological Services of Maryland in Silver Spring. “And the recognition of females [with the disorder] has lagged even further behind.”

Most mainstream research on ADHD tells us that there are no significant differences in how the disorder presents in men versus women. That is, on most measures, data suggests that the sexes experience the same type, number, and severity of symptoms – as well as the same academic struggles, number of comorbid disorders, and efficacy of medication.

But the lived experiences of real women make it clear that this isn’t the whole story. Women with ADHD face many of the same symptoms as their male counterparts, it’s true — but they also labor under the added burden of gender roles, fluctuating hormones, and a greater tendency towards self-doubt and self-harm. Emerging research reveals that while daily symptoms may mirror each other, in the long-term, men and women with ADHD face dramatically different outcomes.

Right out of the gate, girls with ADHD face an uphill battle, with an estimated 50% to 75% of cases of ADHD in girls being missed.  

According to Nadeau, this lagging recognition of girls and women is due to current diagnostic criteria – which remain more appropriate for males than females – and to parent and teacher referral patterns, spurred by the more obvious and more problematic male ADHD behaviors “Girls experience significant struggles that are often overlooked because their ADHD symptoms bear little resemblance to those of boys,” says Nadeau. Researcher and educational therapist Jane Adelizzi, PhD, theorizes that’s because girls are more likely than boys to suffer from attention deficit disorder (ADD), the inattentive type of ADHD.

Boys with ADHD tend to display externalized symptoms (such as running, impulsivity, physical aggression), while girls with ADHD display internalized symptoms (like being withdrawn, frequent daydreaming and verbal aggression).   

“In a classroom setting, a boy might continually blurt out answers or repeatedly tap his foot, where a girl might demonstrate hyperactivity by talking incessantly,” explains Patricia Quinn, M.D., director of the National Center for Gender Issues and ADHD in Washington, D.C. “A girl who talks all the time is often viewed by the teacher as chatty, not hyper or problematic – and thus is less likely to be recommended for an evaluation.”

Simply put, a hyperactive boy who repeatedly bangs on his desk will be noticed before the inattentive girl who twirls her hair while staring out the window.

Research suggests that undiagnosed ADHD can have a negative impact on self-esteem, since girls with ADHD turn their pain and anger inward (while boys with ADHD externalize their frustration). This puts girls with untreated ADHD at an increased “risk for chronic low self-esteem, underachievement, anxiety, depression, teen pregnancy, early smoking during middle school and high school,” says Nadeau.

As adults, they’re at risk for “divorce, financial crises, single-parenting a child with ADHD, never completing college, underemployment, substance abuse, eating disorders and constant stress due to difficulty in managing the demands of daily life – which overflow into the difficulties of their children, 50% of whom are likely to have ADHD as well,” Nadeau adds.

“Society has a certain set of expectations we place on women and ADHD often makes them harder to accomplish,” Nadeau says, pointing to women’s traditional societal roles. “They are supposed to be the organizer, planner, and primary parent at home. Women are expected to remember birthdays and anniversaries and do laundry and keep track of events. That is all hard for someone with ADHD.”

In “The Secret Lives of Girls with ADHD,” published in the December 2012 issue of Attention, Dr. Ellen Littman investigates the emotional cost of high-IQ girls with ADHD, particularly for those undiagnosed. “It’s this sense of not being able to hold everything together.”

“For a long time, these girls see their trouble prioritizing, organizing, coordinating, and paying attention as character flaws. No one told them it’s neurobiological,” clarifies Sari Solden, therapist and author of Women and Attention Deficit Disorder.

Often, women who are finally diagnosed with ADHD in their 20s or beyond have been anxious or depressed for years. A recent study published in the Journal of Consulting and Clinical Psychology found that girls with ADHD have high rates of self-injury and suicide during their teenage years, bringing attention to the distinct severity of ADHD in females.

There is a growing group of millennial women who are searching for relatable and relevant resources for their experiences.

Adult women with ADHD between the ages of 24 to 36 are the fastest growing population undergoing treatment for ADHD. In the last 5 years the use of ADHD medication by this age group of women increased by 85%. Ideally, an ADHD diagnosis is the first step toward reversing the destructive belief system that builds from being misdiagnosed or undiagnosed – as it offers a neurological explanation for why things are so hard and validation to own one’s successes.

If you suspect that you may have symptoms of ADHD, complete this free female ADHD test from ADDITUDE Magazine and share the results with a health care professional.

Sources:

• BBC. Why is ADHD misses in girls? BBC.com.
• Sigler, Eunice. ADHD Looks Different in Women. Here’s How – and Why. ADDITUDEmag.com. 2019.
• Crawford, Nicole. ADHD: a women’s issue. American Psychological Association. https://www.apa.org/monitor/feb03/adhd
• Gromisch, Elizabeth. Gender Differences in ADHD. PsychCentral. 2018.
• Littman, PH.D., Ellen. Women with ADHD: No More Suffering in Silence. ADDITUDEmag.com. 2018.
• Worth, Tammy. Women and ADHD. Webmd.com. 2013.
• Yagoda, Maria. ADHD is Different for Women. The Atlantic. 2013.