Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental condition associated with deficits in attention, impulsivity, and hyperactivity.
While it is common for everyone to experience difficulties with attention or controlling impulses to some degree, for those with ADHD, these problems are so pervasive to the point where it interferes with every aspect of their lives.
In This Article
Gender Differences
ADHD is a condition that is more commonly diagnosed in males than females, typically three times as many males are diagnosed.
This may have led to some stereotypes that ADHD is a condition associated with boys who cannot keep still and are disruptive.
However, there are likely many girls and women who are not diagnosed because their symptoms of ADHD are being missed.
The discrepancy that males are diagnosed more than girls on a ratio of 3:1 highlights that many girls with ADHD are likely to remain unidentified and untreated.
This leads to implications that without a diagnosis, girls are likely to suffer more long-term social, educational, and mental health outcomes.
Girls often tend to display less severe symptoms of ADHD than boys, especially when it comes to hyperactivity and impulsivity. More girls with ADHD may fall more into the predominantly inattentive presentation of ADHD.
The inattention symptoms may present as being easily distracted, overwhelmed, and lacking effort and motivation.
Girls who struggle with inattentive issues are often overshadowed by hyperactive boys, who are more likely to demonstrate more stereotypical hyperactive ADHD behavior. Girls and women are also more likely to mask their symptoms of ADHD.
A reason for this may be that girls are often expected to be more social than boys, and so they learn to present in ways that are deemed more acceptable, which can make it harder for girls to get a diagnosis.
Types of ADHD
The categorization of ADHD has changed over the years and given several names, one of which is attention deficit disorder (ADD). Although ADD is often still used today, the DSM-5 only uses the term ADHD to describe individuals with this condition, regardless of whether the person displays symptoms of hyperactivity.
The DSM-5 criteria for ADHD now state three separate presentations of the condition.
Each person falls into one of the following categories: predominately inattention presentation, predominantly hyperactive-impulsive presentation, and combined hyperactive-impulsive and inattentive presentation.
Below are the different types of ADHD and the traits associated with each.
Inattentive
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Significant difficulty sustaining attention
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Find themselves easily distracted
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May not appear to be listening in conversations
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Struggle to follow directions or instructions
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Fail to give close attention to details or may make careless mistakes
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Difficulty with organization
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Tend to lose things often, such as their keys or phone
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Can be very forgetful in daily activities
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Often procrastinates on tasks
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Dislikes tasks that require sustained mental effort and may avoid these tasks
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Find difficulty in completing tasks from start to finish
Impulsive and Hyperactive
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Extreme restlessness
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In children – often running about or excessively climbing
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Has difficulty remaining seated
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Fidgets with their hands or feet
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Talks excessively
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Acts as if driven by a motor
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Has difficulty engaging in activities quietly
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Gives or shouts out answers before they have finished being asked
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Difficulty waiting or taking turns
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Interrupts others
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Behaviors can be loud and disruptive
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Excessively high levels of activity, which may be physical and/or verbal
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Tendency to dominate conversations
ADHD combined presentation
The combined presentation is where individuals meet the criteria for both the inattentive and hyperactive-impulsive presentations.
ADHD in women and girls
Not all women and girls with ADHD will exhibit all the following symptoms, but some of the common ones include:
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Appearing withdrawn or shy
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Forgetful
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Difficulty maintaining focus
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Hyper-talkative
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Being disorganized and messy
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Appears to be unmotivated
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Daydreaming often
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Crying easily
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Verbally impulsive such as interrupting others
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Not appearing to be trying
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Highly sensitive to noise, fabrics, and emotions
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Hyperreactivity
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Poor time management
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Looking to be making careless mistakes
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Problems completing tasks
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Shifting focus from one activity to another
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Taking time to process information and directions
Women and girls with ADHD are believed to have more inattentive symptoms rather than hyperactive symptoms. This does not mean that they never experience this symptom, but that it may look different.
Females may present their hyperactive symptoms internally as racing thoughts or outwardly as being very talkative and interrupting conversations.
To compensate for their inattention, females with ADHD may hyperfocus on something they enjoy or are good at. They may put forth so much effort and concentration that their parents or teachers may dismiss the possibility that they have ADHD.
Sometimes this hyperfocus is a coping strategy to keep them entertained when something is boring, while other times, they may not feel as if they have any control over it. Females with ADHD may hyperfocus in working overtime on tasks to succeed well, which can be a type of perfectionism.
Another common symptom of ADHD in females is the social differences they have. They may struggle to make and keep friends, and their social world may be more complicated than that of males.
Girls may feel more pressure to pay close attention to their friend’s feelings, or they may have to pick up on subtle social cues, which can prove hard for them.
Females with ADHD are often more likely to have an internal locus of control than males. For instance, they may be more likely to blame themselves when things go wrong, whereas males may be more likely to blame external factors.
Importance of a diagnosis
Often, girls and women who have undiagnosed ADHD get diagnosed as having a mood disorder.
This may be because their undetected symptoms can lead to complications such as anxiety and depression, which can be flagged up more easily by professionals. A lot of the time, girls and women do not seek help for their ADHD until they have developed comorbid conditions.
Women and girls with ADHD must receive an accurate diagnosis that addresses symptoms and other important issues with functioning and impairment. This can help determine appropriate treatment and strategies for individual women with ADHD. Educating girls about ADHD may help them to avoid:
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Feeling ashamed and blaming themselves for their symptoms.
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Feeling like they have failed in life.
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Seeking stimulation that can negatively affect them.
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Coping strategies that are unhelpful and do more harm than good.
A diagnosis of ADHD can help women and girls have clarity on their behaviors, both past and present, and can reduce feelings of guilt about how their behavior. Before the diagnosis, girls may have been attributed labels such as ‘chatterbox,’ ‘drama queen,’ or ‘tomboy’ due to their symptoms.
Having a diagnosis of ADHD can help free them from these labels, and other people may be more compassionate and accommodating as a result.
When a clear diagnosis is delayed, these individuals can experience worse outcomes over the course of a lifetime, including:
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Less academic and career achievement
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Higher levels of anxiety and depression
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More conflict in relationships
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Lower self-esteem
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Physical symptoms such as headaches and abdominal distress
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Sleep problems
When accurately diagnosed, ADHD can be better managed, leading to increased satisfaction in life and significant improvements in daily functioning.
Many people with ADHD can lead successful and happy lives, but an accurate diagnosis is the first step to effectively managing the disorder.
Impact of ADHD
Academic/occupational
The academic functioning of women and girls with ADHD is thought to be similar to males with ADHD. The impact is that they may complete tasks later than those without ADHD, and they are more likely to repeat years at school, get suspended, drop out, or have specific learning difficulties.
The occupational functioning of females with ADHD is similar to males with ADHD. They may be more likely to have a high turnover of jobs, frequently change the type of work they do, and have lower productivity levels than those without ADHD.
Home life
Women with ADHD may struggle with maintaining an organized home life. Their finances may be chaotic, paperwork and record-keeping are often poorly managed, and they may feel less able to keep up with the daily tasks of meal planning, cleaning, and other aspects of life management.
Some women may manage to hide their struggles and may work on tasks late into the night to get things done.
Relationships
Women and girls with ADHD are more likely to have a high turnover of friendships and experience social isolation, peer rejection, and more bullying than those without ADHD.
They may find that they seek a social network by forming damaging relationships, such as joining a gang or increasing their sexual availability to make relationships; thus, the quality of their relationships may be poorer.
They may also find it difficult to navigate romantic relationships with others, especially if ADHD is undiagnosed and their partner cannot offer understanding.
Even made aware, research suggests that husbands of women with ADHD are less tolerant of their spouse’s ADHD patterns than wives of men with ADHD. As a result, women with ADHD may be more likely to experience breakups or divorce as an impact of their ADHD.
Mental and physical health
Whether a woman’s life is in chaos or they can hide their struggles, they often describe themselves as feeling overwhelmed and exhausted. Compared to women without ADHD, women with ADHD are more likely to suffer depressive symptoms, are more stressed and anxious, and have lower self-esteem and feelings of shame.
Co-existing anxiety may result from procrastination/avoidance and concern about the failure to perform or meet expectations. Over time their self-esteem and self-image are likely to suffer from repeated experiences of failure, alienation, and inadequacy.
Many clinicians are findings significant concerns and other co-existing conditions in women with ADHD, such as compulsive overeating, alcohol abuse, and chronic sleep deprivation. There is also an alarming link between ADHD and non-suicidal self-injury (NSSI) and suicidal behavior.
For NSSI, it is thought that adolescent externalizing behaviors, poor executive function, and peer victimization are mechanisms for this (Hinshaw et al., 2012). For suicidal behavior, early internalizing problems and peer rejection are documented mediators (Meza, Owens, & Hinshaw, 2021).
Chronic stress can also take its toll on women with ADHD, affecting them physically and psychologically. Chronic stress associated with ADHD puts someone at risk for stress-related diseases such as fibromyalgia.
Therefore, it is becoming clear that the lack of appropriate identification and treatment of ADHD in women is a significant public health concern.
Social judgment
Women and girls are often encouraged to exhibit traditional ‘feminine’ qualities such as being empathetic, good with relationships, and nice, as well as traditional ‘masculine’ qualities such as being assertive, academically driven, and career-focused.
So, when they display impulsive, disorganized, or disruptive behaviors, they risk harsh social judgment since these traits violate the norms for female behavior.
ADHD also tends to carry a strong social stigma, the negative effects of which add significantly to the impairments caused by the disorder itself. Some variables which can contribute to the stigma include:
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Public’s uncertainty regarding the validity and reliability of the diagnosis.
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Interpretations of impairments as trivial or caused by a lack of willpower or resistance to conform.
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If ADHD is not perceived as a real disorder, a diagnosis of the disorder is less likely to give rise to empathy and understanding.
In an attempt to avoid social judgment, many women and girls with ADHD may spend excessive amounts of energy trying to hide their problems, which in turn go unrecognized by others.
Parenting
In a lot of families, the primary parent is the mother. The mothers are usually expected to be the household and family manager, roles that require focus, organization, and planning, as well as the ability to juggle multiple responsibilities. ADHD typically interferes with these abilities making the job of a mother with ADHD very difficult.
Women with ADHD are also more likely to have a child with ADHD, which further increases parenting challenges.
Frequently, a woman comes to recognize their own ADHD after one of their children has received a diagnosis. When learning about the child’s diagnosis, the mother may begin to see similar patterns in their own behavior.
Coping with ADHD
The following strategies can be incorporated into life without the guidance of a therapist to reduce the impact of ADHD:
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Letting go of perfectionism – spending too much time on things that don’t have a big impact on life can create unnecessary stress and anxiety.
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Understanding and accepting the challenges of ADHD instead of putting blame and judgment on yourself.
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Identify any unnecessary sources of stress in daily life and systematically make life changes to lower your stress levels.
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Seek structure and support from family and friends.
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Schedule regular times out, especially when things get overwhelming.
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Develop healthy self-care habits such as getting enough sleep and eating well.
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Get organized where possible, such as writing down the top priorities for the day and creating a schedule.
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Identify your strengths and weaknesses, such as looking at what you know you can do quickest, with little trouble, and what can take the most time.
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Allow yourself extra time to complete tasks if needed.
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Use the Pomodoro technique – a time management system that breaks down the work or study day into chunks, separated by regular short breaks. For instance, you can work on a task solely, without any distractions, for 25 minutes, followed by a 5-minute break. This technique encourages people to work with their time and makes the day more manageable.
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Incorporating physical exercise into a daily routine can not only help people with ADHD feel focused and calm but is also good for coexisting mental health conditions.
Treatment
Those girls and women fortunate enough to receive an accurate diagnosis of ADHD often face the challenge of finding a professional who can provide appropriate treatment. There are few clinicians experienced in treating adult ADHD, and even fewer are familiar with the unique issues faced by women with ADHD.
Consequently, most clinicians use standard psychotherapeutic methods. Although these can help provide insight into emotional and interpersonal issues, they may not help a woman with ADHD learn to manage her ADHD daily better or learn strategies to lead a productive and enjoyable life.
Effective treatment for women may involve a multimodal approach that includes medication, psychotherapy, stress management, and group therapy.
Medications
Stimulants are mostly used to manage the symptoms of ADHD. Research shows that 70% of adults and 70-80% of children with ADHD have fewer symptoms while taking these medications (Advokat & Scheithauer, 2013).
Stimulants can help those with ADHD as these individuals and believed to have chronically under-aroused brains. A type of stimulant includes methylphenidate, which is found in Ritalin.
This type of stimulant is known as a dopamine reuptake inhibitor, meaning it stops dopamine from being absorbed back into the neuron which released it, meaning there is more circulating in the brain.
Amphetamines are another type of stimulant found in Adderall and Vyvanse. These stimulate the neurons so that they release more dopamine. Both types of stimulants increase dopamine levels to a more ‘neurotypical’ level so there is less of a need to find stimulation from the environment, making it easier to focus.
All aspects of a woman’s life need to be considered when prescribing medicative treatment, including the treatment of any coexisting conditions. Medication may be further complicated by hormone fluctuation across the menstrual cycle and the lifespan (including puberty and menopause), so these factors need to be considered before starting treatment.
Behavior therapy
For some, behavior therapy can help people with ADHD learn the skills required to control their symptoms and help them manage tasks. Behavior therapy aims to replace negative behaviors with positive ones.
People with ADHD can learn strategies to improve problem areas such as organization, focus, and impulse control, among others. Many find that behavior therapy can help them effectively manage their ADHD symptoms without using medications.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) involves working with a therapist to identify patterns of behavior and unhelpful thought patterns that can make ADHD symptoms worse.
Once identified, these thoughts and behaviors can be challenged and changed to more realistic thinking. New behaviors can be learned to manage stress, obligations, coping, and many aspects of everyday life.
As well as helping with ADHD symptoms, CBT can be helpful for women with ADHD to manage other conditions which can coexist alongside their ADHD, such as depression and anxiety.
Group therapy
As many women with ADHD may feel shame and rejection due to their symptoms, psychotherapy in a group setting designed for women with ADHD may provide a beneficial experience.
This can provide a place where women can feel understood and accepted by other women and provides a safe place to begin their journey towards accepting themselves more and learning to manage their lives better.
Parent management programs
Evidence-based parent management programs are found to be effective in children with ADHD and are also recommended for parents with ADHD. However, these approaches have shown that parent training may be less effective if the mother has high levels of ADHD symptoms.
Therefore, it may be useful to incorporate adult ADHD life management strategies into parent training programs for mothers with ADHD.
Why are females undiagnosed?
The ratio of boys to girls diagnosed with ADHD is around 3:1. Interestingly, by adulthood, the male/female ratio for those with ADHD is closer to 1:1. ADHD symptoms are present in childhood.
Still, these ratios suggest that the disorder goes undiagnosed in girls or that the presentation of ADHD in girls is different from those displayed by boys and persists differently that it gets missed by others.
A significant proportion of women receive their diagnosis in adulthood, or they do not get diagnosed at all.
When ADHD remains unidentified, the prospects of understanding the person’s problems and accessing adequate treatment options are also lost.
Several factors may play a part in explaining why ADHD is often undiagnosed in women and girls. As most of the information on ADHD refers to cisgender males and females and rarely those who are not cisgender, for the purpose of this article, the terms used will refer to cisgender males and females.
Research on ADHD
The diagnostic criteria and general understanding of ADHD today are mainly based on observations of how the disorder manifests in young boys.
Much clinical research on ADHD has studied samples of boys, meaning that rating scales are also based predominantly on male samples, which may disadvantage their use on females. Without sufficient research into girls and women with ADHD, our ideas on how ADHD should present itself will be based on how it manifests in males.
Different presentation
From the research that exists on girls with ADHD, it is now understood that these girls are more likely to present with inattentive symptoms rather than hyperactive symptoms, which are more common among boys (Hinshaw, 2021). Common symptoms of inattention in females include forgetfulness, low arousal, daydreaming, and disorganization.
Females are still believed to have impulsive symptoms of ADHD. However, these may manifest as a tendency to disrupt others, say whatever comes to mind, act on impulses, and suddenly change direction in life.
While these symptoms may also be present in boys, if these are present in girls without obvious hyperactive symptoms, many may misinterpret these as signs of emotional difficulties or disciplinary problems rather than symptoms of ADHD.
Research has found that girls with ADHD predominately have the inattention type of the disorder, alongside associated internalizing problems, while boys with ADHD predominately have the hyperactive-impulsive type with associated externalizing problems.
It is also thought that many ADHD symptoms and externalizing problems only become more salient in girls as they reach puberty, in contrast to boys, whose symptoms and externalizing problems are more noticeable in earlier childhood.
The externalizing problems, hyperactive and interruptive behaviors often seen in boys are most likely to lead to a referral. The combination of mostly inattentive symptoms, alongside fewer externalizing problems, means that the symptoms of these girls can be easily missed by teachers and parents or misunderstood as something else.
Societal expectations
Since boys with ADHD are more likely to receive a referral for a diagnosis, statistics based on clinically referred samples will naturally reflect an image of ADHD as a predominantly male disorder.
As there is often an understanding that ADHD is a condition associated with boys who are ‘disruptive,’ if a girl displays similar symptoms, people may not be as inclined to consider she may have ADHD.
Likewise, hyperactive symptoms are commonly judged to be less socially acceptable in girls than in boys, and their hyperactive symptoms in girls may be misinterpreted as emotional problems.
In many societies, girls are often expected to be polite, quiet, and obedient. It is thought that girls with ADHD will often mask their symptoms to fit in with their peers. If girls are effectively masking their symptoms, it can be harder for others to notice that they have any difficulties, making it less likely that they will be referred for a diagnosis.
Misdiagnosis
Internalizing problems such as depression and anxiety are often more prominent in girls with ADHD. Sometimes, these internalized problems can be more noticeable than the other ADHD symptoms, meaning that they can mask the presence of ADHD and delay a diagnosis.
Moreover, not receiving an earlier diagnosis and missing out on appropriate support may make the internalized problems worse or lead to the development of a co-existing mental health condition, which can mean that ADHD is even less noticeable. Often, it may not be until adulthood that women realize for themselves that they have ADHD.
Further Reading
References
Advokat, C. D., & Scheithauer, M. (2013). Attention-deficit hyperactivity disorder (ADHD) stimulant medications as cognitive enhancers. Frontiers in neuroscience, 7, 82.
Children and Adults with Attention-Deficit/Hyperactivity Disorder. (n.d.). Women and Girls. Retrieved 2022, January 25, from: https://chadd.org/for-adults/women-and-girls/
Chronis‐Tuscano, A. (2022). ADHD in girls and women: a call to action–reflections on Hinshaw et al.(2021). Journal of Child Psychology and Psychiatry .
Gershon, J., & Gershon, J. (2002). A meta-analytic review of gender differences in ADHD. Journal of attention disorders, 5 (3), 143-154.
Gurian, A. (2014). Girls with ADHD: overlooked, underdiagnosed, and underserved. NYU Child Study Center About Our Kids .
Hinshaw, S. P. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices. Journal of consulting and clinical psychology, 70 (5), 1086.
Hinshaw, S. P., Nguyen, P. T., O’Grady, S. M., & Rosenthal, E. A. (2021). Annual Research Review: Attention‐deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. Journal of Child Psychology and Psychiatry.
Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of consulting and clinical psychology, 80 (6), 1041.
Meza, J. I., Owens, E. B., & Hinshaw, S. P. (2021). Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder. Development and psychopathology, 33 (4), 1351-1367.
Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16 (3).
