Why ADHD Gets Missed in Women
ADHD, or Attention-Deficit/Hyperactivity Disorder, is largely characterized in the public imagination as being a disorder of not being able to focus or pay attention, and not being able to sit still. Both men and women can and do live with ADHD but it can look very different person-to-person. ADHD is a spectrum disorder which means each ADHD trait is experienced on a spectrum, making a unique constellation of signs and symptoms for each person.
While this is true for everyone with ADHD, there are very distinct gender differences in how this constellation of symptoms is expressed.
More recent research has revised the ADHD model to define it by impulsive symptoms, difficulty managing emotions and actions, and poor reward sensitivity. In this blog, we look at how ADHD gets missed or diagnosed late in adult women, why this happens, and what women seeking evaluation and treatment can do to move past these barriers.
How Does ADHD Look Different in Women?
Research shows that ADHD symptoms in girls and women are often misunderstood or overlooked. The diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders (DSM), as well as the pathways to a referral (caregivers and schools), have historically favored boys who show more disruptive and externally obvious behavior. In turn, this leads to a higher diagnosis rate in boys during childhood. According to Holthe and Langvik (2017), the male-to-female ratio in childhood is about 3:1. Meanwhile, in adults, the ratio levels out closer to 1:1.
This evidence shows that there is a tremendous gap in our collective understanding of what ADHD looks like in men and boys, compared to what it looks like in women and girls. It also highlights that by the time women recognize it in themselves, the systems in place to manage what is largely treated as a childhood disorder by clinicians are that much farther out of reach.
Why ADHD in Women Is Often Misdiagnosed
There’s a critical factor that leads to this split, the presence of, or lack of, disruption. ADHD, like similar (and often comorbid) neurological disorders (autism, for instance), is a disorder where the squeaky wheel gets the grease. In boys, ADHD presents as a behavioral issue: hyperactivity, disruption, and an obvious inability to settle. In short, ADHD in boys externalizes.
In girls, the symptoms often take on an emotional and internalizing theme. Inattention, mood, and anxiety disorders are the more obvious symptoms in girls. A young girl with inattentive ADHD is more often seen as a dreamer than a disruption, and thus left to her own devices. With clinicians and the general community only recently catching on to the inherent gender bias coming from the different presentations, is it any wonder that ADHD is underdiagnosed in women and girls?
Hyperactive vs. Inattentive
While women and girls can present with both inattentive and hyperactive symptoms, the general trend is toward internalizing inattentive traits. According to Young, et al. (2020), as published in BMC Psychiatry, inattention in women and girls can present in several ways:
Being easily distracted
Difficulty with organization
Getting overwhelmed easily
Having difficulty finding motivation
Since these symptoms are far less disruptive than the stereotypical hyperactive presentation seen in men and boys, caregivers and institutions are much less likely to identify ADHD in girls.
In addition, women and girls are often socialized to hide, or “mask” their ADHD symptoms. If a girl grows up in an environment where hyperactivity is tolerated in boys, but girls are expected to be quiet and well-behaved, any hyperactive symptoms may be actively hidden by a girl with ADHD. Unfortunately, the behavior meant to fit more easily into societal expectations means that referral becomes even less likely. It’s quite common for ADHD to go unnoticed in women until their mid-thirties, when seeing symptoms in their own children and connecting the dots to their own circumstances.
The Impacts of Underdiagnosed ADHD
According to Attoe and Climie’s 2020 study of adult women with adult ADHD, the main themes of the research available on adult ADHD in women and girls focus on three categories: social-emotional well-being, difficult relationships, and a lack of control.
A review of the studies looking into adult ADHD in women found that difficulties in social relations, emotional control, and identity formation were a common thread among the women interviewed. Low self-esteem and low self-worth followed issues stemming from inattention, and many reported feeling that they had missed many opportunities in their lives.
Many of the women with ADHD across the studies reviewed experienced a sense of alienation from their peers and had difficulties in picking up social cues. As a result, these women often experienced bullying and peer rejection. Anger issues and a keen sense of limited self-control often followed, persisting into adulthood. This social anxiety may be in large part why ADHD symptoms in women and girls are misdiagnosed as anxiety or depression by clinicians. Young et al (2020) also found that the social impairments coming from this made women with ADHD more vulnerable to bullying, risky decision-making, and burnout.
What Women Can Do To Get Mental Health Evaluation and Treatment
If you’re seeking a referral for ADHD evaluation as an adult woman, remember that masking and coping strategies developed over time may obscure your symptoms. This makes it harder for a clinician who is unfamiliar with your specific situation to identify your difficulties enough to meet the threshold required for a diagnosis. If you have a first-degree relative with ADHD, this can get you to a referral faster. According to CAMH (Canadian Association of Mental Health), the following criteria can fast-track a clinician to the referral stage of getting a diagnosis:
You have a first-degree family member diagnosed with ADHD (i.e. a child, parent, or sibling).
You experience a calming, focused sensation from energy drinks, coffee, cannabis, or other stimulants (this speaks to the effect of common stimulant medication used as treatment options for ADHD patients)
You were tested as a child or adolescent for a learning disability, particularly a problem with working memory.
You have a current diagnosis of depression or anxiety.
Having a clear, specific list of the problems you face as a result of inattentive ADHD and how they impact your life ready for a clinician is also important for circumventing any masking behavior you may do automatically. It’s not unusual for a diagnosis to be denied because the clinician assumes that the coping strategies developed to function as an adult with ADHD are sufficient to not need a diagnosis. If you have people in your life who recognize and can specifically identify your symptoms for an assessment, this will also go a long way to getting the support necessary.
ADHD Treatment Options
According to Holthe and Langvik (2017), nearly all interviewed regarding their ADHD diagnosis end up taking stimulant medications. Ritalin and Adderall are the better-known brands, while Concerta, Vyvanse are metabolized through the liver and release a steady dosage at a constant rate into the bloodstream. Some of these ADHD medications have a side effect of increasing anxiety in patients, but they generally are reported to improve focus and the ability to articulate thoughts into actions, cutting the tendency to get stuck in rumination over doing so.
Healthcare practitioners have also been working to balance medication approaches to treat ADHD with psychotherapy-based strategies within the slate of available treatment options. Cognitive behavioral therapy, where patients learn to identify and moderate troubling thoughts, is one of the primary therapy-based methods used.
More specifically, therapists are using a type of cognitive behavioral therapy known as dialectical behavioral therapy. Holthe and Langvik (2017) found that this type of therapy focuses on managing emotions, and studies have shown it to significantly reduce ADHD symptoms in patients regardless of whether they were receiving medication at the time.
Beyond therapy, ADHD patients often also reach out for coaching in order to get support in managing the more practical difficulties associated with the condition. While therapy can help introduce coping strategies and address emotional dysregulation, coaching can help a person with ADHD with issues such as:
anxiety
interpersonal interactions
planning and organization
assertiveness
self-efficacy
motivation
time management and setting routines
Both coaching and general support from friends, family members, and people in the community who also have ADHD can take a great deal of the pressure off, and provide support while the patient puts the structures in place to make life easier on the whole. Regular exercise, for instance, can improve quality of life by improving sleep quality and concentration, and a general increase of well-being.
Adult women seeking an ADHD diagnosis and treatment often find themselves fighting an uphill battle for support, but the field is getting better at identifying cases and providing support. With support and a bit of guidance, there are plenty of resources out there to help manage the symptoms of ADHD, and lead a more balanced life.
Learn more
Cassie Uribe (she/her/ella), Owner of Blue Agave Therapy and Wellness Services is a licensed social worker who provides counseling for women with ADHD, anxiety, and depression. Cassie specializes in helping adult women manage ADHD symptoms. She understands your struggles, because she’s experienced them too. Cassie offers a free 15-minute consultation for new clients.
Did you know imposter syndrome and ADHD often go together? Click here to download a free copy of Cassie’s Imposter Syndrome Journal (title/link).
Journals:
https://journals.sagepub.com/doi/full/10.1177/10870547231161533
Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders, 27(7), 645–657. https://doi.org/10.1177/10870547231161533 (RECENT lit review)
According to a literature review of the available research by Attoe and Climie (2023)...
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Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjonsson, G., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., Tierney, K., … Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry, 20(1), 404. https://doi.org/10.1186/s12888-020-02707-9
Young, et al. 2020 in BMC Psychiatry
The Strives, Struggles, and Successes of Women Diagnosed With ADHD as Adults Mira Elise Glaser Holthe1 and Eva Langvik1, SAGE Open January-March 2017: 1–12 © The Author(s) 2017 DOI: 10.1177/2158244017701799 journals.sagepub.com/home/sgo https://journals.sagepub.com/doi/pdf/10.1177/2158244017701799