Adult women can have ADHD, too - but why are they not getting diagnosed?

Why are women diagnosed with ADHD later in life?

In 2016, the Centers for Disease Control and Prevention (CDC) shared results of a parent survey indicating that the total number of children between the ages of 2–17 years old with attention deficit hyperactivity disorder (ADHD) was 6.1 million (or 9.4% of US children). Within this group, boys accounted for the majority of cases: 12.9% males versus 5.6% females.¹

A review article about ADHD in the scientific journal Nature also noted that boys are diagnosed more frequently than girls at a ratio of 3:1. 

Furthermore, there is a significant difference between when they receive their diagnoses. The average age of ADHD diagnosis among girls is around 12 years old. Whereas in boys, the average age for ADHD diagnosis is seven years old.²

Interestingly, by the time females receive their diagnosis, the gender gap starts to close. For diagnosis of ADHD in adults, men and women are equally affected.³

This has prompted experts to wonder why girls are slipping through the cracks when it comes to identifying and treating ADHD. 

The main reason is that ADHD symptoms in girls are going unnoticed, and this is caused by two reasons. Firstly, there is a cultural tendency to label boys as “more energetic” than girls. So many in their social circle (parents, teachers, or family doctors) may attribute ADHD symptoms to other problems. 

Another issue relates to the way symptoms of ADHD are understood. Common knowledge of ADHD usually entails more awareness of its associated hyperactivity rather than attention deficit (inattentive-type) symptoms. 

Girls can present with either set of hyperactivity or attention deficit symptoms, or a combination of the two. However, females appear to be more likely to have the inattentive form of ADHD. 

Such symptoms and behavior can appear more internalized and harder to identify (such as being easily distracted), so this frequently results in diagnostic delays. 

However, lack of symptom identification is just one of the barriers for females with ADHD.

Keep reading to learn more about the many reasons why women tend to be diagnosed with ADHD later in life. 

ADHD: Why women aren’t getting diagnosed or treated early

When we think about ADHD, the general public often still imagines a stereotypical picture of active boys with boundless energy who just can't sit still.

However, the reality is that ADHD symptoms vary significantly between individuals, and understanding the differences is key to closing the diagnosis gender gap. 

If we look closely at the diagnostic criteria for ADHD in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), ADHD has two main clusters of symptoms that present before the age of 12:⁴

  1. Inattention

  2. Hyperactivity and impulsivity

Hyperactivity and impulsivity symptoms can present as:

  • Fidgeting or restlessness

  • Trouble staying seated 

  • Talking more than average

  • Interrupting the other speaker in conversations

  • Difficulty waiting your turn

  • Climbing, being overly active in inappropriate places or situations 

Inattentive symptoms might appear as:

  • Problems focusing on tasks

  • Daydreaming

  • Distractibility

  • Frequently failing to complete tasks

  • Careless mistakes at school or work

  • Forgetfulness

Identifying the ADHD type

When diagnosing ADHD, clinicians also identify whether the child's symptoms fit into one of these three types:

  • Both inattention and hyperactivity/impulsivity

  • Predominantly inattention

  • Predominantly hyperactivity and impulsivity

Understanding these ADHD types play a role in why it's being overlooked in girls. 

If you are concerned that you or your child may have symptoms in keeping with ADHD, it's important to see your family doctor. They may then refer you to a child or adult psychiatrist for further workup.

More girls have inattentive-type ADHD, and it's going unnoticed

A predominantly inattentive profile is more likely to be seen in girls than boys.⁵ And because these symptoms are often more internal, they're also easier to miss. For example, a child could be staring straight at a teacher, but actually have no idea what's going on in the class (for a lack of focus). 

Practically speaking, it’s much easier to overlook distractedness or daydreaming than a child who is constantly getting out of their seat in class or frequently interrupting the teacher. 

Even when teachers or parents suspect something may be wrong, they may simply cast inattentive-ADHD symptoms as “dreaminess,” or underachievement without recognizing the hallmarks of the disorder.⁶ 

Many women go undiagnosed with ADHD until their 30s or 40s. Sometimes the diagnosis is made only after their own child is diagnosed with ADHD, bringing long-standing issues with time management or organization into context.⁷

Why symptomatic presentation of ADHD in girls is frequently different from boys is still poorly understood. 

But current research suggests that there might be different genetic and hormonal factors at play. For example, twin studies suggest that girls naturally have more "protection" against developing ADHD, and need a greater combination of risk factors to develop symptoms.⁸

In females, ADHD gets confused with other disorders

Another diagnostic issue and barrier that females with ADHD face is that they're more likely than males with ADHD to have other conditions as well (comorbidities, in medical terminology). 

Common conditions may include eating disorders, anxiety, autism spectrum disorder, schizophrenia, oppositional defiant disorder, intellectual disability, personality disorders, substance use disorders, or suicidal behavior. ⁹ ¹⁰

A Norwegian study found that 53.5% of women with ADHD had one or more of six psychiatric disorders (notably depression and anxiety) compared to only 48.5% of men.¹¹

Symptoms of these conditions can overlap, leading to misdiagnosis while ADHD goes unidentified for years. 

As a result, girls may be treated for the wrong disorder. For example, an inability to focus at school can create frustration and defiance which may be mistaken for oppositional defiant disorder.¹²

Even certain medical conditions like thyroid dysfunction (which is more common in women) can mimic ADHD symptoms.¹³ ¹⁴

As such, it may take especially astute healthcare professionals to tease apart the true nature of ADHD-like symptoms. 

Females and societal pressure to mask ADHD

Compared to boys, girls face a greater number of gender stereotypes which make it less socially acceptable to receive an ADHD diagnosis. This social stigma frequently leads to masking (compensating for symptoms) to maintain the image of a "neat and organized girl" to avoid social repercussions. This may include silently pushing themselves to work harder even though they're extremely overwhelmed and stressed.  

This theory has been substantiated by a study that found that parents and teachers had significantly more negative ratings for girls with ADHD compared to girls without ADHD. This difference was a lot less pronounced when they rated boys with ADHD versus boys without ADHD.¹⁵ ¹⁶ Another study found that parents are more likely to underrate the level of impairment that ADHD had on daughters, and overrate impairment for sons.¹⁷

On the surface, many girls and women with ADHD may also appear to be socially well-adjusted, have good grades, or have successful careers. This makes them seem like they have no issues with daily functioning, and some doctors have incorrectly ruled out ADHD in women because they were A-students.¹⁸ 

Experts also suggest that these gender gaps lead more women to blame themselves for their symptoms, which may be part of the reason why rates of depression and anxiety can be higher in females with ADHD. ¹⁹ ²⁰ ²¹ ²²

Late-onset ADHD may occur more frequently in women

In recent years, experts have also questioned whether females may generally develop ADHD symptoms later in life (in their adolescent or adult years) compared to males. Since the disorder is currently labeled as a developmental disorder that emerges in childhood, these late-onset cases are being missed. 

One UK study that tracked children from birth to 18 years of age found that 5.5% of participants had ADHD symptoms in adulthood but not childhood. Within this group, females were more likely than males to be diagnosed with adulthood ADHD — even though males were more likely than females to have ADHD in childhood.²³

However, the general idea of late-onset ADHD is still controversial because the condition is classified as a childhood disorder that emerges before 12 years of age. 

Most experts at this point agree the more likely scenario is that late-onset symptoms can be accounted for by early misdiagnosis in childhood or other psychiatric disorders with overlapping symptoms in adulthood (e.g. substance use).²⁴

Even though late-onset ADHD might not be widely recognized in the psychiatric community yet, girls may still face a slight delay in the emergence of inattentiveness symptoms. This is because it may only become pronounced later in primary school when organizational and planning demands start to increase significantly.²⁵

Boys can have a missed or late diagnosis too 

While girls are generally at a disadvantage when it comes to being identified for ADHD, boys with ADHD can be overlooked too. For example, hyperactivity symptoms may be cast as “boys just being boys” instead of recognized as a neurodevelopmental condition. 

Additionally, boys can also have inattentive-type ADHD. It is important for individuals to be treated based on presenting symptoms rather than biased perceptions of gender.²⁶

Gender biases may influence ADHD treatment too

Even after a girl is diagnosed with ADHD, she faces further barriers  — getting the appropriate access and correct treatment to manage her symptoms. Unfortunately, females face yet another bias in this area. 

Treating ADHD

The general treatment protocol for ADHD is largely similar for both males and females, and it usually involves a combination of: ²⁷ ²⁸ ²⁹

  • Stimulant and non-stimulant medication (for example Ritalin, Adderall, and Strattera)

  • Psychological therapy to assist in developing coping strategies like

    • Reducing feelings of self-blame

    • Setting up the environment for success — clearing work area from distractions

    • Learning organizational skills

    • Developing a daily routine

    • Breaking tasks into manageable steps to maximize attention span

  • Parenting training

  • Social skills training

  • Education about living with ADHD 

Girls are prescribed ADHD medication less often than boys

ADHD medication is one of the key factors in reducing symptoms. But unfortunately, this is where the greatest disparity is seen between the genders in the area of treatment.

A 2020 review examined seven different studies on ADHD prescription rates. All of the studies reported that females under 18 years old were significantly less likely to receive medication compared to males. Interestingly, this gender difference becomes less apparent in adulthood.³⁰

Not being provided with the right medication for ADHD can be detrimental to functioning in many areas including self-esteem, academic and professional success, relationships, sleep, and more.³¹

A review has shown that the vast majority of studies demonstrate poorer outcomes in untreated ADHD patients regardless of gender.

On the flip side, stimulants have been highly effective with 70-80% of children showing improved symptoms when taking this type of medication.³¹ ³²

However, experts also caution that simply administering any type of ADHD medication may not be the right solution for girls with ADHD either. As most research studies have centered around boys, there is a lack of clinical data detailing how girls react to them.  

In more recent years, some experts have also suggested that hormonal differences between the sexes may lead to ADHD medication being less effective for girls. Therefore, more long-term studies that focus on the unique biological and pharmacological needs of female ADHD patients are needed.³³

ADHD research in the female population needs more attention

Over the years, multiple studies have uncovered the subtle variations in how ADHD appears among males and females. The more "silent" types of ADHD, which frequently occur in females, need more attention. 

There have even been calls to include more gender-specific symptoms in the diagnostic criteria. For example, internal restlessness in females could be a form of hyperactivity. 

Frequent blank stares from a female student should raise just as many flags as the boy who wanders around the classroom. Researchers must begin to explore the links between ADHD and gender to address the gaps and barriers to treatment. Meanwhile, clinicians and society should be aware of these potential barriers and struggles that girls and women with ADHD face.

If you think you might have ADHD, speak with a healthcare professional. Receiving a diagnosis could lead to alleviating your symptoms and improving your quality of life. Share your symptoms with a mental health professional or your doctor so they can carefully evaluate your concerns.

Sources:
  1. Data and statistics about ADHD | Centers for Disease Control and Prevention

  2. 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 (2020)

  3. ADHD (2015)

  4. Attention-deficit/hyperactivity disorder (ADHD) | Pearson

  5. Gender differences in attention-deficit/hyperactivity disorder (2010)

  6. Gender differences in objective and subjective measures of ADHD among clinic-referred children [2019]

  7. ADHD: a women's issue (2003)

  8. Is there a female protective effect against attention-deficit/hyperactivity disorder? Evidence from two representative twin samples [2016]

  9. Study: Comorbid conditions more prevalent in women with ADHD | Additude

  10. Sex differences in comorbidity patterns of attention-deficit/hyperactivity disorder (2019)

  11. Gender differences in psychiatric comorbidity: a population‐based study of 40 000 adults with attention deficit hyperactivity disorder (2018)

  12. ADHD in women (2021)

  13. Diagnosis and management of attention deficit hyperactivity disorder (ADHD) (2019)

  14. Are women more prone to thyroid issues? (2020)

  15. Stigma in attention deficit hyperactivity disorder (2012)

  16. Perceptions of Academic Skills of Children Diagnosed With ADHD [2007]

  17. Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms [2019]

  18. Perceptions of Academic Skills of Children Diagnosed With ADHD [2007]

  19. Privilege plays a huge role in getting an ADHD diagnosis [2021]

  20. Why ADHD is underdiagnosed in women and what we can do about it [2021]

  21. How Girls With ADHD Are Different

  22. ADHD in Women [2021]

  23. Evaluation of the Persistence, Remission, and Emergence of Attention-Deficit/Hyperactivity Disorder in Young Adulthood [2016]

  24. Little Evidence for Late-onset ADHD in a Longitudinal Sample of Women [2020]

  25. Attention-Deficit/Hyperactivity Disorder [2017]

  26. Gender differences in ADHD symptoms

  27. How to Help Girls With ADHD

  28. ADHD and Brain Structure and Function [2019]

  29. The female side of pharmacotherapy for ADHD—A systematic literature review [2020]

  30. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment [2012]

  31. Attention-Deficit / Hyperactivity Disorder (ADHD)

  32. The female side of pharmacotherapy for ADHD—A systematic literature review [2020]

The author, Dawn Teh, is a health writer and former psychologist who enjoys exploring topics about the mind, body, and what helps humans thrive. 

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