The Mental Health Issue That’s Hard to Spot in Women

Attention Deficit Hyperactivity Disorder, or ADHD, is a neurodevelopmental disorder that typically manifests in childhood in both males and females. However, there is a significant imbalance in the recognition, diagnosis, and treatment of ADHD between males and females, with the odds greatly skewed towards males. According to the Centers for Disease Control (CDC), boys are much more likely to be diagnosed with ADHD (12.9%) versus girls (5.6%). This appears to continue into adulthood, as the percentage of men being diagnosed with ADHD (5.4%) is almost twice as high as women (3.2%). 

However, research has shown that this imbalance is not because males are more likely to have ADHD, but rather, that the condition is consistently overlooked and underdiagnosed in women. 

And perhaps promisingly, research has found that from 2003 to 2015, the proportion of reproductive-age, privately insured women in the US treated for ADHD with medication increased significantly. Further analysis on 4.6 million women between 15 and 44 years of age found that the proportion treated with ADHD medication markedly increased by 344% during that time.

Why it’s more challenging to diagnose ADHD in female

ADHD typically manifests in two major categories: inattentiveness or hyperactivity/impulsivity. People may also experience a combination of the two. However, the symptoms that people usually recognize and associate with ADHD are externally manifesting symptoms like hyperactivity, which is often seen more in boys and men. So, ADHD is commonly preconceived as a “male” disorder and is typically underdiagnosed and undertreated in females.

According to a 2015 study involving 2,332 twins and siblings, there is a sex difference in diagnosis which can be credited to the severity of symptoms, particularly that boys tend to exhibit a broader distribution of symptoms and more severe symptoms versus girls. While diagnoses of ADHD in boys significantly outweigh diagnoses in girls, a 2018 study found that the scale slightly balances out when considering those who meet the ADHD criteria, including less obvious symptoms like mind wandering.

Research indicates that ADHD is only recognized in females when they exhibit symptoms that are more visible and severe than males. A 2019 study conducted on children aged seven to 12 found that parents, by their ratings, appear to downplay girls’ hyperactivity while they emphasize those of boys. Additionally, the girls who met ADHD criteria were likely to have more behavioral or emotional issues than girls who did not meet ADHD criteria. 

Due to the incorrect profiling of ADHD in females, it’s often discounted or mistaken for other disorders. Girls usually get diagnosed or treated more for symptoms of anxiety. Females tend to internalize more and experience higher levels of anxiety and depression.

Symptoms of ADHD in girls and women

There are several indicators in the criteria to be diagnosed with ADHD, manifesting in symptoms of inattentiveness, hyperactivity or impulsiveness, or a combination of all. Girls are more likely to internalize and typically exhibit symptoms of inattentiveness, such as forgetfulness, having difficulty paying attention, and disorganization. 

Some commonly dismissible ADHD symptoms in girls include:

• Frequent daydreaming, looking out the window, and picking at nail cuticles
• Feeling sad and anxious (but not meeting the criteria for a depressive or anxiety disorder)
• Either seeming shy and reserved (inattentive type) or being overly talkative or restless (hyperactive type)
• Having difficulty maintaining strong relationships
• Requiring extra effort to focus and compensate for the inattentiveness, and consequently feeling self-critical or anxious

ADHD symptoms can impact a woman’s life in various ways:

• Relationships with others: Women may struggle to do things that are socially expected such as arriving on time, remembering dates of special events, etc. 
• Social life: Due to hyperactivity, girls with ADHD might have difficulty maintaining friendships and social rules may be challenging to navigate. They may be considered too talkative, but despite this, may not necessarily like attending social gatherings due to feeling overwhelmed. If their ADHD involves inattentiveness, their mind may drift off in conversations. 
• Work: Noise, people, and other activities might make it difficult to work in an office. As such, they may opt to come in early or stay late, or work when there are fewer people around. Their desks may be cluttered with paperwork, despite great effort to tidy and clear it. 
• School: While girls with ADHD are likely to struggle with inattentiveness, they may also hyperfocus on their interests and strengths. This contributes to the possibility of having the condition be overlooked by parents or teachers. When they develop into adults, they may be frustrated that their peers “achieve more” than them, despite knowing they are equally intelligent. 
• Everyday life: Daily challenges may include general disorganization, overspending, paper clutter, indecision, and difficulty relaxing. 

Girls and women may experience other conditions alongside their ADHD. Common conditions experienced by women in addition to ADHD include:

• Substance use disorder (addiction)
• Anxiety disorders (OCD, social anxiety)
• Sleep disorders
• Eating disorders (bulimia, anorexia)
• Mood disorders (bipolar disorder, depression)

How to talk to your mental healthcare provider about it

For those who think they may have ADHD, talk to your mental healthcare provider about it as they routinely diagnose and treat ADHD, or may help refer you to the right health professionals. Keep these steps in mind as you get ready:

• Write down your questions, list any existing medication, and review your family’s medical history.
• Consider bringing a trusted companion if that will help you feel more at ease. They can offer support, help you absorb the information from your provider, and give input on your state and behaviors.
• Remember that you have the right to ask questions about your diagnosis and treatment. Ask for options if you disagree with your provider or are not comfortable with the initial suggestion. There is no “one-size-fits-all” treatment.

Are you struggling with ADHD, fear you have been misdiagnosed, or wonder if you have undiagnosed ADHD? Cerebral is here to help you manage your ADHD and co-occurring disorders. Cerebral is a mental health subscription that offers access to long-term online care and medication management. 

To get started on Cerebral, take our free emotional assessment so we can get to know you more.

Reviewed by: Dr. Aneel Ursani, MD