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Friday, December 3, 2021

What does ADHD look like in girls and women and why does it often go unnoticed?

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Attention deficit hyperactivity disorder (ADHD) is often associated with energetic, sometimes ‘disruptive’ children – mainly boys. However, an estimated 2.5% of the adult population also experience ADHD. 

Women are particularly under-diagnosed when it comes to ADHD. This is mainly due to the fact that it presents in a different way in women and girls than it does among their male counterparts.

Girls are more likely to go undiagnosed seeing as their symptoms often do not look similar to those typical in boys in that they are not usually hyperactive, nor do they typically struggle academically. 

The recent era of social media influencers and content sharing on Instagram and TikTok has helped play a role in educating the public on ADHD symptoms and in raising awareness.

This has also helped de-stigmatise it in the process.

As such, many more women are realising that the challenges they are facing with organisation, focus, productivity, forgetfulness and self-doubt come not as a result of personality flaws or laziness, but an actual medical diagnosis. This, in most cases, can be a huge relief, as it presents the first step toward receiving the appropriate treatment.

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Given the current era of growing awareness on social inequities and wage gaps, more and more researchers are looking into issues of health disparities such as why boys are still currently being diagnosed with ADHD so much more than girls (12.9% compared with 5.6%).

It was previously thought that this is simply because ADHD is more common in boys than in girls. However, as of late, researchers have come to the conclusion that it could be much more complex than that.

What is ADHD and how is it diagnosed?

ADHD is a neurodevelopmental disorder by, definition.

It develops in childhood or, at times, during adolescence. The condition tends to be first diagnosed in childhood, but most people don’t grow out of it.

Individuals with ADHD typically show a persistent pattern of issues with attention and/or hyperactivity/impulsivity. These issues tend to be severe enough to the point that they interfere with the affected persons’ daily life and functioning.

ADHD also tends to run in families, and it is believed that the genes one inherits from their parents can be a significant contributing factor when it comes to the risk of developing the condition.

There are no exact rules for what a person with ADHD looks like and behaviours range from one person to another. What is extremely important to understand is that having ADHD does not mean the affected individual lacks the intelligence, skill set, desire, or determination to succeed.

In fact, many people with ADHD will often start their day or their tasks with a determination to be productive and organised but end up feeling defeated. Therefore, getting an accurate diagnosis is absolutely crucial.

ADHD can be categorised into three types depending on the presenting symptoms: the inattentive type, hyperactive-impulsive type, or the combined type.

According to the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) to be diagnosed with any of these types, the affected person must have experienced at least five inattentive and/or hyperactive-impulse symptoms before the age of 12.

However, recently, the field of psychiatry is starting to criticise this approach as the current symptoms described by the DSM may be incomplete and so may not adequately portray the true picture of how ADHD presents in adults (given that the guidelines were originally created for diagnosis in children). 

Why are girls and women under-diagnosed?

The reasons behind boys being more likely to be diagnosed with ADHD than girls are quite complex.

Firstly, until very recently, most of the studies conducted on ADHD have focused on boys. Therefore, we know more about how ADHD manifests in boys, how boys experience ADHD, and how their lives are affected and shaped by it.

We also know that ADHD presents differently across different populations, meaning sex and hormones can have a significant influence on which symptoms are dominant in males and which are dominant in females.

In addition, gender norms can also have an influence over the presentation of ADHD in girls. Girls are more likely to hide or mask their symptoms to “fit” the stereotypes around organisation, neatness, and compliance. Social behaviours may also be the reason behind girls and women denying or compensating for ADHD symptoms in classroom environments or in family structures. 

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Because social norms make symptoms less obvious in girls, this stops or delays teachers from picking up on the associated symptoms and this, in turn, makes healthcare practitioners also less likely to diagnose girls with ADHD. 

Some researchers also believe that females remain under-diagnosed because their symptoms are often more inattentive rather than hyperactive.

Hyperactive/impulsive symptoms of ADHD can be louder and more disruptive when compared to the quietness of the inattentive ADHD symptoms – making them naturally easier to detect.

As such, these inattentive symptoms often pass without capturing the attention of parents, teachers and healthcare providers nearly as much as the hyperactive/impulsive symptoms.

What role do hormones play in ADHD?

In both sexes, hormones and their levels can influence the presence and intensity of ADHD symptoms. However, regardless of gender, individuals can experience shifts in symptoms around the time of puberty seeing as sex hormones influence both physical symptoms as well as behaviour. 

Other ways in which hormones can affect symptoms include:

  • Changes in the levels of hormones in women during pregnancy and menopause often cause an increase symptoms.
  • During the ovulation phase of the menstrual cycle, inattention can increase.
  • Fluctuation in estrogen levels during the menstrual cycle can lead to an increase in ADHD symptoms. This is particularly the case for women with ADHD that tend to experience more impulsivity. 

How does ADHD affect women and girls differently than boys and men?

Multiple studies that examine ADHD in girls have shown that girls often report lower self-esteem than boys with ADHD, and this tends to continue well into adulthood.

In addition, research studies that have compared girls with ADHD to girls without suggest that girls with ADHD experience more conflict in their social relationships than their counterparts.

Women and girls diagnosed with ADHD are also more likely to experience symptoms of other mental health conditions such as depression, anxiety, and eating disorders.

In addition, borderline personality disorder, a condition which is characterised by a difficulty in regulating emotions, is more likely to be reported among women diagnosed with hyperactive/impulsive ADHD either in the past or concurrently. 

Why is an accurate and timely diagnosis crucial?

A delay in a clear diagnosis and treatment can lead to worse outcomes over the course of a lifetime for those affected. Such outcomes include less academic and career achievements, experiences of anxiety and depression, increased conflicts in social relationships, lower self-esteem, sleep problems and higher healthcare costs.

Physical symptoms can also occur as a result, such as headaches and abdominal distress. 

Therefore, getting the correct treatment can help not only with symptoms, but can also help you improve your overall quality of life, and build your potential for future sustained growth and development.

As such, if you feel that you could be experiencing symptoms of ADHD, it is extremely important to seek professional medical help.

Maha El Akoum, MPH, is a public health professional currently working as Head of Content at World Innovation Summit for Health [WISH]. 


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