Written by: Savanna Paynes
Edited by: Christine Huang
What is ADHD?
Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders diagnosed in children. While symptoms can vary with age and individual presentation, the signs of ADHD have been stereotyped as an inability to focus, excess and inappropriate movement, and impulsive behavior (Philipsen et al., 2008). This particular presentation of symptoms tends to be seen more strongly in young males, and for several decades has thought to be a disorder that was “male dominant” (Waite, 2010). However, as research on psychiatric disorders and social behavior grows, this typical spectrum of symptoms is likely only a portion of the phenotypes that can be expressed. Women in particular tend to be overlooked and underdiagnosed for ADHD in both childhood and adulthood. While research may help expand diagnosis criteria to include more diverse presentations, the concerns surrounding of ADHD diagnosis in women may not be such a simple fix. Understanding how ADHD is expressed in women and analyzing why low ADHD diagnosis occurs is critical before any progressive steps can be taken to changing the statistic.
ADHD Symptomatology in Females
Unlike the common symptoms that can be seen in males, females with ADHD are less likely to exhibit prominent external behaviors, like large outbursts. ADHD symptoms in females tend to be “internal” –and therefore, more subtle–which can be seen by the increase in the display of inattentive symptoms rather than hyperactive or “external” symptoms (Williamson & Johnston, 2015). Rather than the standard signs of ADHD like loud and disruptive behavior, young females may express forgetfulness, constant daydreaming, and difficulties in making relationships with their peer. Although these differences in behaviors could be passed off as simple biological differences between sexes, the impact of societal norms likely plays a more significant role. An individuals’ behavior can be greatly affected by the expectations of society, especially in the case of gender roles. While males are encouraged to be independent and assertive in their thoughts and actions, “feminine” behaviors are associated with establishing emotional connection and exhibiting virtue and obedience. More often than not, women are scrutinized for abrasive and over-external behaviors to a greater extent than their male counterparts. As a result, social pressures cause young females with ADHD to be more likely to “mask” or hide their more hyperactive symptoms to avoid social judgement, and also causes professionals to overlook the severity of their condition. (Quinn & Madhoo, 2014). Not only does this pose consequences of an unnoticed ADHD diagnosis, but it can also cascade into massive negative implications regarding the individual’s mental and physical health in the future.
Consequences of Misdiagnosis in Women with ADHD
The pressures of existing societal expectations can already be a challenge to navigate in modern society. For women, the added strain of an undiagnosed neurodevelopmental disorder, like ADHD, can significantly impact their mental and physical health. These difficulties can often start in educational settings in childhood, where struggles with social connection and academic demands can greatly intensify these challenges. For young girls with ADHD, the struggles to meet engagement expectations in school can make it harder to build and maintain peer connections, leading to higher rates of self-criticism, anxiety, and depression compared to their neurotypical peers (Young et al., 2020). When ADHD remains undiagnosed, many of these girls may adopt maladaptive coping strategies in adulthood, including substance abuse and risky sexual behaviors. In fact, researchers have found that women with ADHD are twice as likely to experience substance abuse, depressive disorders, severe poverty, and three times as likely to suffer from insomnia, chronic pain, suicidal ideation and generalized anxiety disorder (Fuller-Thompson et al., 2016). Changing the narrative surrounding how professionals and the public perceive ADHD is crucial to addressing these disparities and will help contribute to the first steps to reducing these concerning statistics.
Next Steps
Education of the diversity of ADHD presentations is essential to promoting a more inclusive and holistic approach to diagnosis, as well as adopting more effective research and treatment methods. Historically, studies have often excluded a variety of minority groups—such as women, nonconforming genders, older adults, and individuals of non-European descent—due to an emphasis on a "typical" ADHD presentation commonly associated with young males of European descent. Although certain demographic patterns may be more prevalent in ADHD, maintaining an open and adaptable perspective when approaching a diagnosis is crucial for enhancing not only how ADHD is treated, but also how ADHD is perceived as a whole. The way ADHD is perceived is shaped not only by the assessments of psychiatric professionals, but also by the experiences and feelings of the patients themselves. This dynamic relationship between individuals greatly impacts how symptoms are identified, understood and treated. Overall, it is the collective effort of society that allows professionals to grow in their understanding and for patients to receive the unique care they need.
References
Fuller-Thomson, E., Lewis, D. A., & Agbeyaka, S. K. (2016). Attention-deficit/hyperactivity disorder casts a long shadow: findings from a population-based study of adult women with self-reported ADHD. Child: Care, Health and Development, 42(6), 918–927. https://doi.org/10.1111/cch.12380
Philipsen, A., Heßlinger, B., & Elst, L. T. van. (2008). Attention Deficit and Hyperactivity Disorder in Adulthood. Deutsches Aerzteblatt Online. https://doi.org/10.3238/arztebl.2008.0311
Waite, R. (2010). Women With ADHD: It Is an Explanation, Not the Excuse Du Jour. Perspectives in Psychiatric Care, 46(3), 182–196. https://doi.org/10.1111/j.1744-6163.2010.00254.x
Williamson, D., & Johnston, C. (2015). Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review. Clinical Psychology Review, 40(40), 15–27. https://doi.org/10.1016/j.cpr.2015.05.005
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. (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
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