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Key points
- ADHD is under-identified and under-treated in girls and women.
- Recent reviews indicate that ADHD is equally prevalent among males and females, and equally impairing.
- Women with ADHD may also experience anxiety or depression, which are more likely to be identified and treated.
- Existing treatments for ADHD can be helpful when adapted to the needs of women.
There have been longstanding observations of the disparities in the diagnosis of ADHD in clinic-referred children, teens, and adults. In some cases, the male-to-female ratios of children diagnosed with ADHD were on the order of 10:1 but are now seen as closer to 2:1 or 2.5:1 for children and teens.
For adults, this number has progressively declined from a 3:1 ratio. It is generally now closer to 1.5:1, though no compelling sex-based (the categorical biological definition used in previous research) reason for any prevalence differences, leaving the main culprit missing the diagnosis in females.
However, despite these narrowing ratios, much of the past understanding of ADHD—both in research and in clinical practice—has been based on predominantly male populations. However, there has been improvement, although more work needs to be done. (See Hinshaw et al., 2022, for a thorough review of the research and its implications.)
Why ADHD in Girls and Women Is Often Missed
One of the reasons for missing the diagnosis of ADHD in girls and women with ADHD is the difference in the presentation of symptoms. An all-too-neat but helpful synopsis of the problem in children is that ADHD in boys appears in the classroom, whereas for girls, it is more likely to show up on the playground.
Boys are more likely to manifest observable hyperactive behaviors that catch teachers’ eyes; girls, on the other hand, might be inattentive in class, staring at the teacher or out the window, which may be reflected in lower-than-expected grades.
Girls with ADHD generally have fewer behavioral or academic problems in the classroom. Problem areas may show up in peer relationships in the form of missed social norms and rejection, perhaps related to verbal impulsivity.
Many of these difficulties may stem from impulsivity in those settings, as well as the reality that emotional dysregulation is a core feature of ADHD but not one listed in the official diagnostic criteria and therefore often missed. However, reviews of existing studies indicate that the difficulties faced by boys and girls with ADHD are equivalent and significant.
What ADHD in Women Looks Like
The inattentive symptoms, in general, are the most persistent domain of ADHD into adulthood, though developmentally modified definitions of hyperactivity and impulsivity to account for adult presentations often indicate greater persistence than previously thought.
ADHD is also associated with high rates of comorbidity, with anxiety and depression spectrum issues ranking first and second place. Living with ADHD, particularly if it is undiagnosed, is very challenging.
The contemporary understanding of ADHD is that it is a neurodevelopmental syndrome of impaired self-regulation: How efficiently you can do what you set out to do.
The resultant consistent inconsistency is associated with the many potential impairments associated with a lifetime diagnosis of ADHD, which likely contributes to anxiety and mood issues.
These emotional matters are more likely to be picked up on by well-meaning mental health professionals better trained to identify and treat those issues than they are for ADHD. Yes, mood and anxiety issues in cases of ADHD deserve attention. Targeting the defining self-dysregulation in ADHD, including emotional dyscontrol, in fact, usually results in a reduction in worry and improved mood as well as overall functioning and well-being.
Unique Issues Faced by Women with ADHD
There are a host of other factors for better understanding women with ADHD, including differences between those with predominantly inattentive and combined presentation. Among these issues are risk for self-injury behavior (both non-suicidal and that for which there is suicide risk), disordered eating, social functioning and relationships, effects of the menstrual cycle, pregnancy, and/or perimenopause and menopause on symptoms as well as treatments, i.e., use and adjustment of medication regimens, not to mention cultural differences in views of women and ADHD, to name only a few.
What's Being Done for Women with ADHD
There is already a movement toward a better identification of ADHD in girls and women. By all accounts, the existing evidence-supported psychosocial and medical treatments for ADHD are equally effective, the issue being personalizing them to the difficulties faced by women with ADHD and helping empower and actualize their many strengths.
If you are a woman who has ever wondered if her struggles might be the result of ADHD, it is a good time to reach out for help.
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References
Hinshaw, S. P., et al. (2022). Annual research review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal process, and key directions. Journal of Child Psychology and Psychiatry, 63(4). 484-496. doi: 10.111/jcpp.13480
