Gender Differences In ADHD: Why ADHD In Women Is Often Overlooked
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. It affects both adults and children of all genders. Although the prevalence rates of ADHD are similar across genders, men are 69% more likely to be diagnosed with ADHD than women in the U.S. Indeed, doctors, teachers, and mental health professionals have historically overlooked ADHD in women and girls. If women are just as likely to have ADHD as men, why do we see this disparity? Research illustrates that ADHD looks different in women – the presentation of symptoms are impacted by many factors including biology, neurology, societal biases, and gender expectations.
Despite an increasing awareness of ADHD, women’s symptoms continue to fly under the radar of professionals, friends, and family members. Consequently, their ADHD is regularly missed or misdiagnosed. Receiving an accurate diagnosis can be a life-affirming experience, and it is an important first step to managing symptoms. As such, it is crucial that individuals understand the gender differences in ADHD and learn the signs and symptoms to look for in women and girls.
How Does ADHD Impact Women Differently?
Inattentive vs. Hyperactive Symptoms
Firstly, women tend to differ in terms of ADHD type. According to the DSM-5, there are three distinct types of ADHD: inattentive type, hyperactive-impulsive type, and combined type. With inattentive type, symptoms include distractibility, difficulty paying close attention to details, frequent failure to follow through on tasks, difficulty sustaining attention, and challenges with organization and time management. On the other hand, hyperactive and impulsive symptoms include fidgeting or squirming, difficulty waiting one’s turn, frequently leaving one’s seat, and excessively talking or interrupting others. A combined type involves the presence of both inattentive and hyperactive-impulsive symptoms.
Growing research on ADHD and gender illustrates that women and girls are much more likely to have an inattentive symptom presentation than a hyperactive-impulsive presentation. In men and boys, however, ADHD is typically defined by symptoms of hyperactivity, impulsivity, or aggression. Unlike boys with ADHD, who tend to be noticeably energetic and disruptive in class, girls with ADHD are often the students doodling or staring out the window. When girls do display hyperactive symptoms, they are usually subtler than in boys. For example, girls with ADHD may twirl their hair or bite their nails, whereas boys are more likely to jump out of their seats or interrupt their teachers and peers.
Because ADHD symptoms in girls don’t cause overt problems in the classroom, teachers, school counselors, and clinicians often miss them. For many girls with ADHD, academic issues related to attention deficits get misinterpreted as moral failures – these girls are often viewed as lazy, irresponsible, or blind to their own potential. Consequently, women are less likely to be diagnosed with ADHD as children, and many women come to a diagnosis much later in life. In fact, according Dr. Patricia Quinn, author of Understanding Women with ADHD, “the average diagnosis of women with ADHD, who weren’t diagnosed as children, is 36 to 38 years old.”
Internalization vs. Externalization of Problems
In addition to experiencing less overt ADHD symptoms, women tend to internalize failures and criticisms more than their male counterparts. Neurodivergent or not, men are more likely to respond externally to problems in their environment. When criticized, for example, men may react with anger and defensiveness or try to project blame onto others. However, women often direct their emotional reactions inward towards themselves. When faced with conflict, women internalize anxious or angry feelings, which can transform into shame or self-blame. As living with ADHD can lead to many conflicts and failures in life, this poses a major problem for women with the disorder.
Having gradually internalized years of negative messaging and criticism, many women with ADHD develop low-self esteem and symptoms of anxiety and depression. Fearing rejection, they may begin to avoid social settings and withdraw from interpersonal relationships. Anticipating failure, they may stop engaging in new experiences and refrain from taking risks. Although these symptoms are bound to ADHD, clinicians often fail to recognize the connection. Consequently, women are frequently misdiagnosed with anxiety or mood disorders while their primary diagnosis is actually ADHD. This explains why women with undiagnosed ADHD often do not see long-term gains in therapy. Misdiagnosis leads clinicians to treat the symptoms of ADHD (anxiety and depression), rather than the genuine cause (ADHD itself).
Gender Role Expectations
ADHD in women is also complicated by socially imposed gender expectations. In the United States, women have historically been tasked with managing not only their personal lives, but also the home and the family. Although women today are reaching new professional heights, they are still expected to perform the additional labor of housework and childcare duties; one must not just be a woman, one must become Superwoman. Juggling these responsibilities is tiring and burdensome, but it is especially difficult for women with ADHD. Indeed, balancing one’s professional and home lives requires consistent coordination of executive functions – a primary deficit for people with ADHD. Difficulties with planning, time management, working memory, and task completion in ADHD can make it impossible to satisfy all of the expectations placed on women.
Although women with ADHD are not wired for these societally imposed demands, it does not stop women from trying to meet them. Seeking social acceptance, women with ADHD often work in overdrive in order to conform to gender expectations. Moreover, many women with ADHD will try to camouflage or mask their symptoms out of fear that they will be judged or ostracized. They worry that if they admit they are struggling, they will be viewed as inadequate and unequipped to handle life’s challenges – the Superwoman façade will come crashing down. The consequence is that many of these women never reach out for help, instead employing harmful coping mechanisms such as perfectionism and people pleasing to stay afloat.
Hormonal Differences
Another factor rarely considered by clinicians is the impact of hormonal changes on women’s ADHD symptoms. Fluctuations in estrogen and progesterone levels that occur throughout the menstrual cycle have been shown to affect the expression and severity of ADHD symptoms in women. In the first two weeks of the 28-day menstrual cycle, estrogen levels steadily rise. Increasing estrogen in turn promotes the release of “feel-good” neurotransmitters such as serotonin and dopamine. Unsurprisingly, women with ADHD tend to feel the best during this time and often present with milder symptoms.
However, in the third and fourth weeks of the cycle, estrogen levels decrease and progesterone levels begin to spike. The combination of low estrogen and increased progesterone has been found to rapidly exacerbate ADHD symptoms – many women with ADHD report feeling more emotionally volatile and suddenly unable to get things done. Additionally, research has found that higher levels of progesterone can cause women to metabolize their ADHD medications more quickly, which reduces their effectiveness. The impact of hormones on ADHD is especially pronounced in adolescence, as hormones fluctuate the most during this developmental period. Many adolescent girls with ADHD greatly struggle to keep up academically and may engage in more impulsive and risky behaviors throughout puberty. These rapid fluctuations in symptoms can lead clinicians to misdiagnosis ADHD as mood disorders such as bipolar disorder or Premenstrual Dysphoric Disorder (PMDD).
How Can Women With ADHD Live Better?
If you suspect you have ADHD, the first step in the healing process is receiving an accurate diagnosis. Once a diagnosis is made, try these strategies and suggestions:
1. Challenge and reframe negative thoughts. Although women are more prone to internalizing negative feedback, it’s important to remember that we are ultimately in control of our thoughts and interpretations. When you receive criticism, try disputing the automatic thought that arises rather than taking the thought at face value. Some helpful questions to ask yourself include: Is there substantial evidence for my thought?; Is there evidence that is contrary to my thought?; What is another way this situation could be interpreted from an outside observer? Remember that thoughts are like fuel to the fire for subsequent feelings and behaviors. Thus, learning to challenge and reframe automatic negative thoughts can be a powerful catalyst for a more balanced and fulfilled lifestyle.
2. Practice saying no. Women with ADHD often try to become superwomen, overcommitting themselves as they try to balance family, career, and other responsibilities. Placing unrealistic expectations on oneself can be draining and lead to burnout. As such, it’s important to practice boundary setting. Before you automatically agree to something, take some time to think about the decision. Give yourself permission to say: “I need some time to think about that” or “I’m sorry that doesn’t work for me right now.” By learning to say no, you allow yourself the space to pursue things that provide you with genuine fulfillment, rather than endlessly trying to placate others.
3. Find the right medications and dosages. If you take medication for ADHD, it’s important to find a doctor that understands the impact of hormones on ADHD symptoms. Changing the dosage of ADHD medication or adding a low-dose antidepressant at the end of the menstrual cycle has been shown to help many women manage their symptoms. Hormone therapy or regular supplements such as fish oil have also been beneficial to some women. Work with your doctor to find a treatment regimen that is right for you.
4. Schedule an appointment with an ADHD-focused therapist. Although there are plenty of strategies you can try on your own, an ADHD-focused therapist can provide you with a more individualized treatment approach. ADHD-focused therapists are trained to help you re-evaluate the negative beliefs you hold about yourself and your abilities. They will work with you to identify and challenge unhelpful thoughts and also teach you skills to manage your ADHD symptoms. More generally, they can help you move from a place of self-criticism towards a place of self-acceptance.
In Conclusion…
ADHD symptoms present differently in women than in men. Not only are women less likely to experience hyperactive symptoms, but also social and hormonal factors can distort the full picture of the disorder. Taken together, these factors often lead clinicians to either miss or misdiagnosis ADHD in women. Although there is still much to learn regarding gender differences in ADHD, educating the public on current research is vital to improving ADHD treatment in women
Our team at the ATTN CENTER is happy to offer a variety of services to support women with ADHD. This includes therapy for ADHD-related anxiety and depression, group therapy, ADHD-focused therapy, testing, and neurofeedback options. At the ATTN Center of NYC, we treat ADHD without the use of medication, but we understand in some severe cases additional measures may be needed. As a result, we also maintain close relationships with many of NYC’s best psychiatrists we can refer you to. Feel free to learn more by visiting our blog or FAQ page today.