An ADHD Specialist Explains Why Female Symptoms Are Often Ignored By Professionals Until Later In Life
Myth meets reality.
Roman Samborskyi / Shutterstock Historically, ADHD was been considered a condition for rambunctious little boys who don't listen to their teachers.
However, that stereotype is based mostly upon myth. Plenty of boys with ADHD don't disrupt class, and little girls can also have ADHD — as can adults.
This stereotype isn't the only reason little girls often grow into adult women without being diagnosed with ADHD, even when their clinical symptoms should have been clear.
What Does it Look Like When Girls and Women Have ADHD?
Ashlee, age 46, has been called into her boss’ office. He’s concerned about how she’s been turning in projects late, appearing disorganized in meetings, and forgetting important details that he’s conveyed to her.
He notices that she's falling behind and seems stressed. Ashlee, herself, is confused about these issues which have been around for years but seem to have worsened since she became a manager six months ago and started skipping her periods.
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She wants to do well at this job but notices that she’s falling behind. She has a history of anxiety and depression and takes an antidepressant which takes the edge off things. But she has always wrestled with time management and feeling overwhelmed.
Now things seem to be intensifying as her doctor recently confirmed that she’s in early peri-menopause.
Meanwhile, it’s 1:30 pm and Tasha’s fourth-grade teacher is talking about the new aquatics project they're beginning in science.
Tasha, age 10, does fairly well academically but wants to do better. She's trying to listen but her mind keeps wandering. First she looks at the sparkly shoes her neighbor is wearing, then she hears the wind outside and glances at the window.
She sees a bird fly by, wonders if it has a nest, what that nest might look like and then thinks of her favorite tree in the park across the street from her house.
Suddenly, everybody in class is laughing and Tasha realizes that she has missed something important. She puts a smile on her face and acts as if she knows what is amusing, worried that the other kids will make fun of her or the teacher will call on her if she doesn’t.
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Why Women Are More Likely To Be Diagnosed With ADHD Later On In Life
What do Tasha and Ashlee have in common? They are both examples of how ADHD can look in girls and women and why it is both misunderstood and misdiagnosed.
Tasha hides her distractibility, pretends that she knows what's going on, and gets by academically. Ashlee has struggled with some executive functioning issues but thought it was due to her anxiety and the demands of her new job.
Attention deficit hyperactivity disorder (ADHD) is defined as a chronic condition marked by persistent inattention, hyperactivity, and, sometimes, impulsivity that's more frequent and severe than in people of the same age and negatively affects academic, work, and social performance.
Due to differences in the connectivity of the prefrontal cortex to the rest of the brain and the development of executive functioning skills, there can be a lag of up to three years in brain maturity for those with ADHD, coalescing in the late 20s.
Most of the research about ADHD has long been centered on males and the externalizing symptoms of ADHD.
Those symptoms include being hyperactive, impulsive, aggressive, fidgeting, excessive movement, visible restlessness, disorganization, loudness, trouble waiting, interrupting, and overtalking.
These behaviors draw attention to boys in the classroom, usually prompting referrals in elementary school. In fact, boys are more likely to be diagnosed with ADHD than girls (12.9% compared to 5.6%).
But ADHD manifests differently in girls and often doesn’t emerge until puberty or during the post-high school or college transition years.
Girls are far more likely to experience these internalizing symptoms of ADHD:
- Excessive talking
- Tardiness
- Disorganization
- Inner restlessness
- Distractedness
- Overwhelm
- Perfectionism
- Acts of self-harm
- Social awkwardness
- Dreaminess
- Early sexual activity
These traits are less disruptive in a classroom so girls are less likely to be referred by educators for an evaluation. In addition, many girls develop strategies to overcompensate for their struggles with inattention and mask their academic and/or social difficulties.
As they enter secondary school or college and the demands on their executive functioning skills intensify, their methods become less effective: they become overwhelmed, anxious or depressed.
Frequently, girls are referred for these mood conditions or self-harming behaviors and their attention issues are overlooked.
Socially, girls with ADHD regularly suffer from exclusion and rejection as well as difficulty making and maintaining friendships. They may miss key social cues because they’ve "zoned out" or they don’t notice that they've been talking too long and peers have stopped listening.
Girls with hyperactive/impulsive or combination type ADHD can be stigmatized as being "too much," nosy, or aggressive–traits that don’t gel with stereotypical female behavior.
Many of these challenges persist into adulthood, with women feeling like outsiders who know something is "wrong" or deficient about them and straining to feel comfortable instead of awkward in conversations, meetings, or public events.
With the shift to emerging adulthood, many young women who wrestle with issues related to focus, prioritizing, and working memory are left to manage their own schedules, balance socializing with work, and find time for chores such as laundry and tidying up.
In addition, hormonal shifts in the menstrual cycle affect the symptoms of ADHD, increasing distractibility, mood changes and forgetfulness.
The onset of peri-menopause and full menopause can lead to extreme mood and cognitive shifts related to the declining levels of estrogen and progesterone.
Women who may have experienced mild symptoms of ADHD (known or unknown) may suddenly experience issues that seem "new" and distressing to them, including decreased working memory and time management abilities and increased impulsivity, reactivity, disorganization and overwhelm.
They may neither understand that they might have ADHD nor do they have a medical provider who validates their concerns. In some cases, a diagnosis brings relief and a context to behaviors that have long been puzzling.
For other women, there's grief about the years they've lost feeling misunderstood. Finding someone to work with you who really knows about ADHD in women and the tendency for late diagnosis is essential to receiving the help you need.
The most important part of diagnosing ADHD in girls and women is accepting that the symptoms look different than they do in boys and men.
Social challenges, lack of focus, feeling driven to excel in all areas (perfectionism), procrastination, frequent apologies, spending excessive amounts of time on homework or work projects, difficulty with transitions, forgetfulness, and emotional lability can all be signs of ADHD.
This is why an accurate assessment that includes ruling out other medical conditions (including trauma and substance abuse) and taking a thorough history in combination with rating scales and sometimes psychological evaluations is so important.
Working with a knowledgeable coach or therapist can assist you to improve executive functioning and social-emotional skills.
Cognitive-behavioral therapy in combination with insight-oriented work and mindfulness will build the tools you need while helping foster better self-esteem and compassionate self-acceptance.
Lifestyle changes — getting more exercise, establishing good sleep hygiene, eating healthier, and reducing stress — will improve your well-being and thinking too.
If you're struggling with work, home, or social challenges related to adult ADHD, try these tips to improve the quality of your daily life:
- Assess your strengths and your challenges without recriminations. You are who you are: we all have warts after all.
- Delegate what you can as often as you can and stop feeling guilty about it.
- Reduce overwhelm by learning when to say "no" and how to say it gracefully.
- Write things down: lists are your friends and keep them electronic so you don’t lose them.
- Break things down into smaller chunks and work for timed periods with timed breaks. Make notes of what you are thinking before you stop something so you can return to it later.
- Prioritize your tasks based on urgency (due dates and deadlines) and importance (value of the project).
- Ask your boss to put as many requests as possible in written form. Or, plan to take notes on what they are asking you to do as they are saying it.
- Get help setting up systems at home or at work for organization so that everything has a place to live.
Be the friend you wish to have: say hello to one person per day, ask people questions about themselves, listen and reflect back on what you hear, and stop thinking you know what they are thinking about you. You don’t. Just be more present and less in your head.
Aim for good enough instead of perfection. Make your goal about steadiness. Try something, see what happens, pivot if necessary, and try again. Live a growth mindset.
Sharon Saline, Psy.D., is an international lecturer and workshop facilitator and has focused her work on ADHD, anxiety, learning differences and mental health challenges and their impact on school and family dynamics for over 30 years. For more information, visit her website.