Suffering Silently: ADHD in Women
By Sadira Sittampalam
ADHD is one of the most common neurodevelopmental disorders of childhood, usually being diagnosed in childhood and often lasting into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviours or be overly active. There are three categories or ‘types’ of ADHD, of which one can be diagnosed; predominantly inattentive, predominantly hyperactive-impulsive and a combination of both. However, the hyperactive type is the one that is often associated with ADHD, and the one under which most boys present. This is why, the inattentive presentation, under which most girls are diagnosed, is often severely underdiagnosed. Oftentimes, undiagnosed ADHD girls grow up hearing themselves mislabelled as ‘spacey’ or ‘disorganised’ when in fact they are suffering from this disorder. Even into adulthood, many women are incorrectly diagnosed with other things like anxiety or bipolar disorder rather than ADHD.
Symptoms of ADHD
Moving on to the main symptoms of ADHD, this mental health disorder affects the ability to do some or all of these tasks:
- Pay attention, focus, or concentrate for prolonged periods
- Notice some details
- Break activities and goals into steps or stages
- Stay organised
- Manage schedules
- Remember things
- Sit still
- Manage impulses
To receive an ADHD diagnosis in the US, an individual must have at least six of nine major symptoms listed. These symptoms must be present and disruptive to everyday life for at least 6 months and must be present in more than just one setting - at home and school for example.
Boys vs Girls
Looking at the statistics, boys are still diagnosed with ADHD much more than girls - 12.9 per cent compared with 5.6 per cent in girls (these are statistics from the US, but this trend can be seen worldwide). While many took this as a sign that boys simply have ADHD more often than girls do, we are actually learning that it is a lot more complex than that. One of the biggest reasons that boys are more likely to be diagnosed than girls are because until recently, most studies on ADHD have been focused on boys. Thus, more is known about how boys present ADHD, how they experience it and how their lives are shaped by it. However, ADHD presents differently in different people; sex, gender, and hormones may influence which symptoms are dominant.
Many people have noticed how gender norms may have forced girls to mask and hide their symptoms of ADHD with stereotypes of neatness, organisation, cooperation, and compliance. Moreover, because symptoms can be a lot more subtle in girls, healthcare practitioners may be less likely to diagnose girls with ADHD unless they also show symptoms of emotional disorders, often ending up treating things like anxiety and depression in girls without recognising the coexisting ADHD.
Instead, the hyperactive presentation is the one that gets the most attention, as it is often loud and disruptive in many settings, which means it is easier to capture the attention of parents or teachers. Moreover, people with ADHD aren’t in any way less intelligent than the rest of the population, they simply have a harder time concentrating on tasks at hand, while also having a skewed view of their priorities. Thus, many parents of ADHD girls will know that their children are intelligent and capable and may end up feeling very frustrated with their kids as they slowly fall behind academically. The transition to adulthood is also very challenging for people with undiagnosed ADHD as many struggles due to increased responsibilities and different roles.
How ADHD affects women
Hormone change is also something that affects the effect of ADHD and thus in women, who have a hormone cycle every month; there are some very unfortunate effects. According to a national Norwegian study in 2018 about female ADHD, inattention often increases after the ovulation phase of the menstrual cycle and changes in estrogen levels across your cycle can increase ADHD symptoms, leading to more impulsivity. Changing hormone levels in pregnancy and menopause can also increase symptoms.
Multiple studies of girls with ADHD done by the Prim Care Companion CNS Disorders and PLOS One have also found that their self-esteem is often lower than boys with ADHD, even well into adulthood. This research that compares girls with ADHD with girls who do not have ADHD suggests those with ADHD often have more conflict in their social relationships than those without ADHD. They are also at a higher risk of experiencing symptoms consistent with diagnoses of disorders such as depression, anxiety and eating disorders.
Additionally, a borderline personality disorder is more likely to be reported among women previously or concurrently diagnosed with ADHD with the hyperactive/ impulsive type. With ADHD in women, there is a high likelihood of issues like feeling very disorganised, having uneasy feelings that you have unpaid bills or forgotten projects all over the place. They would also tend to overspend quite a bit, do a lot of things to try and be more organised but never having it work out and being very indecisive. Other conditions can also be present along with ADHD, such as substance abuse such as an addiction to alcohol or drugs, anxiety disorder such as social anxiety disorder or obsessive-compulsive disorder, sleep disorders, eating disorders such as anorexia or bulimia, mood disorders like depression or bipolar disorder. Oftentimes, women with ADHD feel shame at the ways they live their lives and blame themselves for things that they cannot control. Thus, they often seek stimulation that can negatively affect them or try to find coping mechanisms that do more harm than good.
Treatment for women
When children and teens have diagnosed with ADHD, doctors often prescribe stimulant or nonstimulant medications to manage symptoms and improve functioning, and research has shown that doctors routinely prescribe less medication to treat females with ADHD than they do males. This difference in prescription rates is often surprising since studies have shown that both these types of medication improve most symptoms in girls as much as they do in boys.
Again, many of these differences may be attributed to behavioural differences, which lead to boys receiving more attention and treatment than girls. Meanwhile, in adults prescription rates are a little more equal between genders - men still receive more, but the difference is not as dramatic. However, as usual, more research needs to be done to understand the differences in how male and female bodies process ADHD medications, as well as how rising and falling hormones during the menstrual cycle alter the effectiveness of the medication. For example, various studies reviewed by PLOS One in 2020, have shown that stimulant medications tend to ‘wear off’ earlier in the day for girls.
Understanding these key differences may help doctor’s better treat females with ADHD and will help them tailor their treatment plans specifically to what each woman needs. Moreover, medications aren’t the only treatment for ADHD as psychotherapy, cognitive behavioural therapy and social skills training can also help. In Sri Lanka, there aren’t many places to receive proper treatment for ADHD, especially as an adult. The Child Adolescent and Family Services (CAFS) in Sri Lanka, offers help with ADHD in children and are capable of properly treating both boys and girls, but are not entirely experienced with handling adult cases.