Diagnosing ADHD in Girls and Women
It used to be that when we thought of ADHD, we pictured school-aged boys, unable to sit still, unfocused, and
disruptive in class. Over time, we’ve learned more about how this neurotype presents in girls and women, which has expanded our understanding of this neurotype. Let’s take a look at some of the differences observed.
Girls and women with ADHD are more likely to struggle with inattention versus hyperactivity and impulsivity. When girls and women do present with these features, they are likely to be less obvious than in boys and men, appearing instead as internal restlessness, racing thoughts, or excessive talking. Essentially, female populations don’t present with this neurotype as “loudly” as their male counterparts. As a result, their difficulties often go unnoticed. Additionally, girls and women are more likely to conceal their symptoms, as obvious ADHD-related behavior isn’t as acceptable for them; we expect girls and women to be quieter, better behaved, and more responsible than boys and men. Because of these cultural expectations, girls often put forth considerable effort to mask symptoms, starting from a young age, in order to garner acceptance and praise from others.
As a result of these phenomena, boys are significantly more likely to be diagnosed with ADHD during childhood. Studies show that teachers, who play an important part of ADHD diagnoses, are more likely to endorse ADHD symptoms in boys than girls. And it’s also true that we tend to look for pronounced and specific indicators of ADHD when the neurotype often manifests in a broader symptom set. ADHD in girls and women might show up in difficulties maintaining friendships and regulating emotions. Girls are often diagnosed with anxiety or depression when, in reality, their emotional dysregulation is a feature of their neurodivergence. One systematic review found that female gender was identified as a barrier to timely ADHD diagnosis and care. But women close the diagnostic gap in adulthood. Many women are diagnosed in their 20s, 30s, and beyond. As adults, they finally have the power to self-refer for treatment, as opposed to relying on parents or teachers to identify them.
The Problem with a Late Diagnosis
Not all diagnostic timelines are created equally. When someone is struggling with symptoms of ADHD but undiagnosed, this can have a sizable impact on their sense of self. Women might have grown up working overtime to mask their symptoms. They might have difficulties that they never understood. They might describe themselves as characterologically disorganized, forgetful, emotionally unstable, or lazy, when really, ADHD is responsible for their struggles. And because they blamed themselves for any shortcomings or failures, rather than understanding their specific neurotype, they are more likely to suffer from self-esteem and other mental health issues than those who are diagnosed, treated, and accommodated earlier on.
The Role of Hormones
At Gatewell, we see many women who report increased struggles associated with ADHD around times of significant hormonal changes – during the premenstrual, postpartum, or perimenopausal/menopausal phases. People with ADHD have lower dopamine levels than those with neurotypical brains. Estrogen, a primary female sex hormone, has been shown to stimulate production and reduce the re-uptake of dopamine. When estrogen drops and its related dopamine boost becomes unavailable, executive functioning can be compromised. As a result, we may see deficits in focus, planning, memory, and emotional regulation during periods of hormonal change. In fact, it’s not uncommon for women to wonder about ADHD for the first time during these hormonal transitions, as symptoms that they’ve long controlled or compensated for become unmanageable. The strategies they’ve relied on for years just don’t cut it anymore. The menopausal transition can make difficulties particularly pronounced. With ongoing decreases in estrogen over the course of years, women may experience a striking uptick in ADHD symptoms, complaining of memory challenges, brain fog, and more. They might fear that they have a mood disorder, dementia, or some other condition when, in fact, ADHD is responsible for the cognitive and emotional changes they’re experiencing.
If You Are a Woman Currently Struggling with ADHD Symptoms
If you’re struggling with some of the symptoms described above, please know that you’re not alone. It’s important, though, to understand the root of your difficulties, because that can impact the interventions selected. When we diagnose ADHD, we first need to rule out other possibilities. If your ADHD symptoms are actually a function of anxiety, depression, PTSD, PMDD, an eating disorder, a substance use disorder, stress, burnout, insufficient sleep, or anything else, we need to treat these issues first. Of course, it’s possible to meet criteria for ADHD and an additional condition or diagnosis. In fact, many women who live with undiagnosed ADHD often develop other difficulties as a result of this.
Treatment of ADHD in Women
ADHD interventions don’t generally differ by gender. Stimulant medication is the “gold standard” approach, though other classes of medications are also available. Cognitive and behavioral therapies have been shown to be effective, and combining therapy and medication tends to yield the most promising results. Exercise, too, is a well-studied intervention. Because physical activity increases dopamine and other neurotransmitters, those who engage in exercise demonstrate improved mood, focus, and impulse control after the fact.
Looking at this neurotype through a disability lens (where the focus is on accommodating versus pathologizing), it’s important to explore how you might accommodate your symptoms. Do what works. If you’re working or at school, it could be helpful to explore specific accommodations (e.g., working in a private office) that might help reduce your difficulties. When working to address difficulties with focus, time management, motivation, or organization, it can be helpful to explore different executive functioning strategies, conducting experiments as you go. For instance, if concentration while you study is a struggle, are there times of the day that concentration is better than worse? Are there certain environments that make things easier or more difficult? Can you experiment with shorter work blocks with breaks (e.g., using the Pomodoro method ) rather than demanding long periods of effort? What makes things easier? Worse? Every strategy you try is part of the data collection process, geared toward learning what works for you.
With regards to the emotion regulation part of ADHD, we see a significant benefit associated with interventions that directly target this variable. In fact, many of the DBT skills we teach in our practice are effective ways of approaching the emotional sequelae of this neurotype. It’s important to note too, that women often juggle multiple responsibilities, already taxing but even more so with ADHD. Giving yourself grace is important here. Just because other people do it, doesn’t mean it works for you; alternate strategies, if available, might be useful to employ. And leaning into an ADHD diagnosis can help reduce self-judgments and potentially increase self-compassion around your struggles. As you can imagine, judging yourself for struggling cognitively or emotionally doesn’t help. Understanding how ADHD impacts you – and what to do about it – can go a long way toward improving your overall functioning and well-being.