Women often receive attention deficit hyperactivity disorder (ADHD) diagnoses later in life than men. This is because the symptoms can present differently in women and because research into the condition in women is lacking.

ADHD is a common neurodevelopmental disorder. It often appears in childhood but can last into adulthood. In some cases, people with ADHD do not receive a diagnosis until they are adults.

Doctors usually diagnose ADHD during childhood. In 2019 in the United States, 11.7% of boys received a diagnosis of the condition. This is compared with just 5.7% of girls.

This does not necessarily mean that girls have ADHD at lower rates. Instead, researchers think that this is due to a lack of understanding regarding how the condition presents in girls and women.

Historically, much of the research into ADHD has taken place in boys and men. Therefore, the current diagnostic criteria do not recognize symptoms that may be more common in girls and women.

Research focusing on ADHD in women lags behind that of men. However, some newer studies suggest that other psychological conditions, such as overeating and sleep deprivation, tend to co-exist in women with ADHD.

Read on to learn more about the symptoms, diagnosis, and treatment of ADHD in women.

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Infographic by Diego Sabogal

Although the terms “sex” and “gender” are not interchangeable, much of the research into this topic uses them interchangeably. This article uses the terminology in the studies it cites.

It is also important to note that much more research is needed, particularly into ADHD in transgender and intersex individuals.

ADHD is characterized by inattention and hyperactivity/impulsivity. According to one 2020 review, some symptoms of ADHD are more subtle in females than males. These symptoms include hyperactive and impulsive behaviors.

It is unclear why this is the case. Although neurological differences across sexes may be a cause, social “norms” may also play a role. For example, although boys with ADHD are often identified as “disruptive troublemakers,” girls may be socialized to be quiet, to be reserved, and to follow the rules.

Symptoms

When girls and women have ADHD, they may present with the following symptoms:

  • subtle hyperactivity
  • subtle impulsivity
  • problems with organization
  • problems with distractions
  • feeling overwhelmed
  • a lack of motivation

These symptoms may be more prevalent when the person is going through a significant life transition. For example, going to college or leaving home for the first time can exacerbate symptoms.

Research indicates that changes in hormones during the menstrual cycle, as well as during pregnancy and menopause, may affect ADHD symptoms.

However, the research so far is limited and has produced conflicting results. More research is needed, but it is likely that the hormones associated with menstruation influence ADHD behaviors.

Compensatory behaviors

Women with ADHD may engage in compensatory behaviors. These may be either in an effort to mask their ADHD symptoms or to cope with the emotional discomfort they can cause.

Compensatory behaviors include:

  • drinking alcohol
  • smoking cannabis
  • engaging in high risk activities

Testing for ADHD is the same for everyone.

When a person contacts a doctor about their symptoms, the doctor will refer to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The DSM-5 contains the diagnostic criteria for ADHD. The doctor will determine whether or not a person’s symptoms and behaviors fit the guidelines.

When testing for ADHD, the doctor will look for a pattern of symptoms relating to inattention, hyperactivity, and impulsivity.

They will also ask questions. They might want to know about the person’s medical history, their family history, and how long their symptoms have been occurring.

Before diagnosing ADHD, the doctor also needs to rule out other mental health conditions, such as anxiety and personality disorders.

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Doctors underdiagnose ADHD in girls and women for several reasons. These include gender biases and symptom differences, which can lead to fewer referrals.

Gender biases

The existence of social “norms” means that people have expectations of how people of different genders should behave. This can influence professionals’ judgments, and it may affect who they refer to be tested for ADHD.

One older 2004 study investigated this by using fictional student profiles to see who teachers referred for an ADHD evaluation. Despite the profiles listing identical symptoms, elementary school teachers referred more male children than female children.

Additionally, societal beliefs make many people believe that ADHD is a condition that primarily affects boys. Although symptoms commonly associated with ADHD, such as hyperactivity and impulsivity, are more prevalent in boys and men, they may be less common or less commonly detected in girls and women.

This means that girls and women with ADHD are often underdiagnosed. Instead, doctors frequently diagnose comorbid conditions, such as depression, anxiety, bipolar disorder, and substance use disorders.

Symptom differences

People with ADHD can have both internalized and externalized symptoms. Externalized symptoms may include novelty seeking, risky behaviors, and a lack of agreeableness, while internalized symptoms can include neuroticism, low moods, and harm avoidance.

According to one study, females tend to have lower rates of externalized symptoms and higher rates of internalized symptoms.

Because externalized symptoms are typically more obvious to others, people who exhibit them may be more likely to be referred for an ADHD evaluation. Conversely, people with more internalized symptoms may be more likely to remain undiagnosed.

Experiencing ADHD symptoms without having a formal diagnosis of the condition can be very difficult. Without a diagnosis, the person may be unable to seek treatment or learn coping skills.

For this reason, an individual may feel as though they are incapable of doing well in school, succeeding in a job, or managing their money because of their undiagnosed ADHD.

They may also experience other behavioral or mood disorders. Major depression, anxiety, and dysphoria (unpleasant mood) are prevalent in both men and women with ADHD.

However, according to one study, females tend to have higher rates of psychological distress and negative self-image.

Because many women do not receive a diagnosis during their childhood, they miss the treatment that could help them succeed in school. Without a diagnosis and treatment regimen, their symptoms may continue into adulthood.

These untreated symptoms may contribute to the development of compensatory actions, such as engaging in risky behaviors and using substances, and other poor outcomes.

Pharmacological treatment for ADHD is generally the same for everyone.

Doctors often prescribe stimulants, such as methylphenidate (Ritalin) and amphetamine (Adderall), to treat ADHD. This is because they increase a person’s attention and focus.

However, some people experience unpleasant side effects, such as a loss of appetite. In these cases, a doctor may prescribe a non-stimulant medication. These take longer to work, but they are just as effective at controlling ADHD symptoms.

Although everyone receives the same medications, they may not receive them at the same rates. For example, one 2020 study found that in an analysis of 21 studies, girls received significantly fewer ADHD medication prescriptions than boys. This disparity was not shown in adult females.

Many researchers say that doctors can make some changes that will make treatment better for girls and women with ADHD. Some modifications include:

  • ensuring that ADHD medications do not interact with other co-existing conditions, such as anxiety and depression
  • reviewing a person’s medication during menopause or pregnancy
  • educating people on the risk of self-harm and other risky behaviors
  • paying attention to side effects that affect appetite, as eating disorders seem to be more common in girls and women with ADHD

Doctors may also try therapies that address the psychological components of ADHD that are more prevalent in girls and women. These include low self-esteem, problems with self-image, and self-blame. Talk therapy, cognitive behavioral therapy, and other therapies may be beneficial.

Often, girls and women with ADHD experience co-occurring conditions. These include low mood, anxiety, and depression.

However, these conditions can mask other ADHD symptoms. This means that doctors often treat the resulting symptoms, not the root cause: ADHD.

For example, ADHD in girls and women may manifest as:

  • learning difficulties
  • dyslexia
  • low self-esteem
  • relationship problems
  • eating disorders
  • substance use
  • risky sexual behaviors

Without treatment, these symptoms may persist into adulthood. This can lead to:

A person should contact a doctor if they believe that they are experiencing ADHD symptoms.

Because females present with more internalized symptoms, according to some research, they should pay particular attention to these. Some doctors may focus on externalized symptoms, so girls and women should feel empowered to advocate for themselves and to explain their symptoms thoroughly.

Doctors underdiagnose ADHD in girls and women for several reasons. Some of these include perceptions of ADHD as a condition that only affects boys and men, social norms affecting behaviors, and symptom differences.

Girls and women also tend to experience more co-existing conditions, such as anxiety and depression, which can mask their ADHD symptoms. People with ADHD symptoms should contact a doctor to seek a proper diagnosis.

Research focusing on the presentation of ADHD in girls and women is ongoing, and more research is needed on the condition in transgender and intersex individuals. This will lead to better treatment outcomes and a greater awareness of the condition.