What to Know About ADHD in Women

HealthCentral - What to Know About ADHD in Women

“Could it be ADHD?” Maybe you’re wondering about your daughter. Your wife. A woman at work. You might even be thinking of yourself.

The very fact that you—or your healthcare provider—are considering the possibility of ADHD in a woman or girl is no small deal. Twenty years ago, the idea might never have come to mind. “We basically thought ADHD was a male-dominated condition,” says Texas-based Dilip Karnik, M.D., a pediatric neurologist at Child Neurology Consultants of Austin.

Many still hold onto the ADHD (also written as AD/HD) stereotype of an 8-year-old boy, tearing around the house and wreaking havoc in the classroom. But as ADHD research has grown, so has our understanding of what this common neurological condition is—and isn’t.

“It is now recognized that ADHD is not just a boy problem but a girl problem, too. Girls and women just have different, less disruptive symptoms. That’s part of the reason they’ve been and still tend to be misdiagnosed and underdiagnosed,” says Karnik.

The reality: Boys are still diagnosed with ADHD at about twice the rate of girls (a far cry, though, from the five to one ratio of decades ago). “Females may have some protection genetically,” says Marcy Caldwell, Psy.D, director of Rittenhouse Psychological Services in Philadelphia and founder of ADDept.org. “But we still have a lot to learn about what ADHD looks like in girls and women. The more we understand, the more likely we’ll be to spot ADHD early and treat it effectively.”

What’s the Deal With ADHD Again?

Attention deficit hyperactivity disorder is a common neuro-developmental condition. Typically diagnosed during childhood, it affects about 8.8% of kids under 18 in the United States, and of those, about 60% experience symptoms that persist into adulthood. There are three basic types of ADHD:

  • Predominantly inattentive: It’s a struggle to focus, finish tasks, stay organized, and pay attention to details. Following conversations and instructions is also a bear. These kids and adults might be chalked up as “spacey,” “flakey,” or “one hot mess.”
  • Predominantly hyperactive-impulsive: This person fidgets constantly, runs up the down escalator, and takes other impulsive risks. Socially, they might grab at people, not wait their turn in conversations, not listen, and blurt out inappropriate comments.
  • Combined presentation: This person has symptoms of both types of ADHD mentioned above.

Why Girls Go Under the Radar

A significant proportion of females discover they have ADHD when they are adults. “This isn’t because their ADHD is something new, but because their symptoms have gone undiagnosed,” likely since childhood, says Caldwell.

Research suggests this happens, at least in part, because girls are more likely to have the inattentive type of ADHD, while boys tend toward the hyperactive and combined types. The typical outcome? A girl daydreaming about sea turtles during math class is far less likely to be called out than a hyperactive boy chucking pencils across the room. “Teachers complain about disruptive boys to parents. Parents then take them to the pediatrician and get an assessment. The girls with ADHD may not get that attention,” says Karnik.

This isn’t to say that girls don’t get the hyperactive type of ADHD. A good number of them do. But symptoms may not be as obvious or intrusive. “Hyperactivity in a girl can be hyperactivity in her mind, which may race with thoughts and distract her from what’s going on,” says Billy Roberts, LISW-S, founder of Focused Mind ADHD Counseling in Columbus, OH.

Physically, a hyperactive girl may not flip over desks or push kids on the playground. But she may well pick at her skin and cuticles, tap her leg under the dinner table, or flit from one desk to another in class. “She might just get written off as too chatty,” Roberts says.

Other symptoms in girls with ADHD include:

  • Struggling to complete tasks and getting easily overwhelmed
  • Seeming unmotivated or uninterested in applying herself
  • Being disorganized, distracted, and unable to keep track of her belongings
  • Extreme emotional sensitivity; tendency toward crying jags and deep funks
  • Silliness or flakiness
  • Difficulty making and keeping friendships
  • Anxiety over messing up and fixation on “getting things perfect”

A girl with ADHD might not participate in class to avoid interrupting or saying something inappropriate. Or she may obsessively check her backpack to make sure she hasn’t lost her house key. “This is where, for a lot of girls, perfectionism comes in. They feel shame about their struggles and think, ‘If I put 100% into every part of my life, people won’t notice my mistakes.‘ The irony is, they are often not messing up as much as they think they are,” says Roberts.

The Emotional Impact of ADHD on Girls

As years go on, struggling with ADHD symptoms can take a heavy emotional and social toll on girls. Self-esteem and self-image suffer as they face ongoing challenges in school and the relentless grind of masking their symptoms.

The heartbreaking result? Girls with ADHD are at increased risk of anxiety disorders, eating disorders, and depression. Compared to girls without ADHD, girls with ADHD (especially those who go untreated), are less likely to finish college and are at higher risk of having an unplanned pregnancy. Girls with ADHD are also at increased risk of self-harm, including cutting and suicide attempts.

“These comorbid issues tend to come up in large part because girls are often unable to understand why they feel different or why they are having different struggles than other people. They internalize their pain and that results in other problems,” says Caldwell.

Even when parents suspect their daughter might have an issue, a healthcare provider may simply diagnosis the problem as anxiety or depression without considering ADHD as the possible root problem. “That’s why it’s so important to see someone who can put all the pieces together and not make a snap diagnosis,” says Roberts.

Identifying ADHD in Women

As adults, women who suspect they have ADHD may present the possibility to their healthcare provider. “They may have been feeling something’s been up for a long time. But it takes some reflection and assertiveness to make sense of those feelings and allow them to be seen,” says Caldwell. Sometimes, a mom might have a child who is being assessed for ADHD and see mirror symptoms to their own lives, Caldwell adds.

It’s common, too, for women to hit a wall as life gets bigger and more complicated. Work may take a hit. Bills might not get paid. Kids may languish at soccer practice when no one shows for pickup. “The truth is, men don’t take on as much of the childcare and the household and are not playing as many roles on average,” says Caldwell.

ADHD Symptoms in Women

While the actual condition doesn’t change as girls become women, the way symptoms manifest themselves might, says Caldwell. For example, a young girl with ADHD may have had trouble maintaining friendships; as a young woman, she may now have difficulty sustaining a romantic relationship. And a girl who couldn’t finish tasks in school may find in adulthood, she quickly loses interest in jobs and moves from one gig to another.

Other common signs and symptoms of ADHD in women include:

  • Difficulty managing money
  • Trouble with time management
  • Feeling consistently overwhelmed
  • Problems with organization
  • Difficulty with planning and scheduling
  • Impulsiveness, including impulse spending
  • Problems prioritizing
  • Trouble focusing on and completing tasks
  • Difficulty sleeping
  • Engaging in risky sexual behaviors
  • Forgetfulness
  • Tendency to lose and misplace things
  • Aversion to tasks that require stretches of intense focus, such as preparing reports and filling out tax forms
  • Being overly chatting and having difficulty listening to others

How Hormones Affect ADHD

Then, of course, there are hormones. Their fluctuations over the month and over a woman’s lifespan impact just about everything—including ADHD. “In the latter two weeks of a menstrual cycle, as progesterone levels increase, ADHD symptoms get worse,” says Caldwell.

Same holds true for other times when hormone levels fluctuate. Think puberty, pregnancy, postpartum, perimenopause, and menopause.

The good news? There is no age limit for getting help. “I talk to a lot of women who are getting diagnosed in their 40s because the drop in estrogen during perimenopause is making their symptoms much more noticeable. I think this applies across the board for a lot of women when hormones change. Even those who are diagnosed and getting treatment may need more support at these times,” says Meredith Carder, an ADHD coach and mom living with ADHD in Phoenix, AZ.

Treating ADHD in Women and Girls

ADHD treatment options for women are virtually the same as what’s recommended for men. What may be different is how these therapies are applied and prescribed, at least in part because fluctuating hormone levels can impact symptoms and blunt the effectiveness of certain medications.

The most effective treatment for ADHD is “multimodal,” meaning it attacks symptoms from a number of angles and disciplines. Some options your doctor might discuss with you include:

Medication for ADHD

There are several recent innovations in prescription drugs for this condition, as well as some that have been on the market a while.

  • Fast-acting stimulants. Drugs such as Adderall are the go-to treatment for adults and children with ADHD, alleviating symptoms for 70% to 80% of those who take them. Changing hormone levels means medications may require some pharmaceutical fine-tuning. “Stimulant medication is less effective during the latter two weeks of the menstrual cycle,” says Caldwell.
  • Non-stimulants. Meds like Strattera may be prescribed if stimulants aren’t effective or tolerated.
  • Psychotropic medications. Women often present with emotional issues like depression and anxiety, secondary to their ADHD. So, says Karnik, they may often need a combination of ADHD medication and an SSRI or other antidepressant.

Mental Health Therapy for ADHD

Nonpharmaceutical intervention can be an effective way to combat symptoms for some women with ADHD.

  • Talk therapy. Since girls and teens with ADHD tend to struggle with low self-esteem, anxiety, depression, and other emotional issues, speaking with a therapist—especially one trained in the condition—can be enormously helpful.
  • Cognitive behavioral therapy. Women may benefit from this type of talk therapy that helps patients address negative thinking and approach challenges in an effective way. There is a form of CBT specifically developed for adults with ADHD.

Behavior Management for ADHD

Sometimes more useful for girls at younger ages, learning to spot and manage ADHD-related behavior can keep kids from feeling ostracized by their peers.

For young children, behavior management is often more about training parents than it is about training kids. A number of programs teach parents to help their kids develop essential coping and practical skills.

Cognitive behavioral therapy can help women address and deal with daily struggles, including time management, procrastination, and disorganization. ADHD coaches can also help with practical skills development.

The Future of ADHD in Women

Between 2003 and 2015, prescription rates for ADHD drugs increased across all age and gender groups. But the rise was sharpest among young adult women—a whopping 700% for women ages 25 to 29 and 560% among women 30 to 34.

Is it because we’ve made so much progress in identifying the condition in women? Or is ADHD getting too much hype? “Whenever we have a course correction, which is happening with ADHD in girls and women, there is a little bit of a pendulum swing for sure,” says Caldwell. “But if you look at large scale numbers, we are nowhere near an overdiagnosis issue now.”

Increased awareness, assessment, diagnosis, and treatment of ADHD is a step forward for women, experts believe. “After diagnosis and appropriate management, I’ve seen girls who had been silently suffering and struggling for years become highly successful students and go off to medical and law school. Their anxiety and depression often go away completely. Treatment, without question, can change your life,” says Dr. Karnik.

By Peg Rosen