Is ADHD Different for Women and Girls?
ADHD, aka Attention Deficit Hyperactivity Disorder, has long been the domain of school age boys who seem to come with a built-in jet pack. What’s slowly emerging is that girls and women suffer too, but with slightly different symptoms that often get overlooked. This week, Savvy Psychologist Dr. Ellen Hendriksen examines how ADHD often manifests in girls and women.
Pop quiz: what’s the first thing that comes to mind when I say “ADHD”?
a. Getting distracted
b. Ants-in-pants
c. Elementary school boys
d. Women and girls
Most likely, you didn’t pick D.
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If that’s the case, you’re not alone. For most people, ADHD conjures a mental image of school-aged boys squirming at desks or bouncing off walls, not a picture of adults, girls, or especially adult women. Both scientists and society have long pinned ADHD on males, even though girls and women may be just as likely to suffer from this neurodevelopmental disorder.
Back in 1987, the American Psychiatric Association stated that the male to female ratio for ADHD was 9 to 1. Twenty years later, however, an epidemiological study of almost 4,000 kids found the ratio was more like 1 to 1—half girls, half boys.
In both sexes, core symptoms are the same: difficulties with paying attention, getting and staying organized, planning ahead, and time management. There’s also the phenomena I call “The Laser Beam” and “The Disco Ball,” where attention is either hyperfocused or unfocused with not much in between, and toggling in and out of either is difficult.
How Does ADHD Manifest in Women? Low Self-Esteem
ADHD is a bit of a misnomer—because it can exist with or without the “H.” And while girls can certainly be hyperactive, they more often fall into the category without the H, called ADHD Inattentive Type.
For these girls, ADHD looks more like dreaminess, spaciness, or messiness than like Honey Boo Boo after a dose of go-go juice. They get written off as ditzy or dumb, and because they’re not disruptive like individuals with the hyperactive subtype, they fly under the radar. In other words, because they’re generally well-behaved, girls often miss out on diagnosis that could get them treatment and valuable academic accommodations.
Of course, there are boys who appear spacey and dreamy and girls who are hyperactive, but even for a girl with hyperactivity, the “H” doesn’t necessarily look like bouncing off the walls. Instead, hyperactivity could manifest as talkativeness, being “dramatic” (aka overly emotional and reactive), or she might simply be labeled a tomboy. Again, because it’s not necessarily disruptive, and because many girls try to compensate by people-pleasing, all of this frequently gets missed.
For adult women, ADHD often manifests as feeling constantly overwhelmed. Moms in particular are expected to multi-task, be in charge of the family’s social life, keep track of kids’ activities, and generally keep the million little pieces of a family running smoothly. Problems getting organized or planning ahead can have publicly humiliating consequences, like when your kid is the only one without a permission slip for the field trip, or you forget to pick him up after Little League … again.
Tedious, repetitive tasks, like folding laundry, writing thank you notes, balancing a checkbook, or sorting the mail, are kryptonite to folks with ADHD. But many women feel like they “should” be able to do these things because so many other women seem to without a second thought.
All this leads to the most common symptom of ADHD you’ve never heard of: low self-esteem. So many bright, capable women with ADHD think they’re stupid, incompetent, lazy, or defective. They perpetually feel like they’re not good enough, not smart enough, not together enough. As if that’s not enough, up to 75% of individuals with ADHD have another disorder, most commonly anxiety, a learning disability, or, especially in women, depression. Oftentimes, women suffer for decades, and only begin to suspect they might have ADHD when their child is diagnosed.
Why Do Symptoms Differ Based on Gender?
Part of the problem is historical: knowledge about the disorder was based on initial research on boys; it was assumed that the symptoms of the boys were the symptoms of the disorder. The diagnostic criteria are therefore based on the symptoms of these early subjects.
Next, it’s not just the diagnostic criteria that are the problem—it’s the diagnosers. Societal perceptions about ADHD blind those who might otherwise detect the disorder in girls and women. A parent or teacher might recognize the hyperactivity of a male student as ADHD and refer him to a mental health professional—but he or she might not detect the more understated symptoms of a female student, leaving her to endure untreated.
Part of the problem may also be biological, but for now that’s beyond the current research (though scientists are working on it). Part of the problem is that because ADHD has historically been thought of as a boys’ issue, most of the people studied have been, well, boys. As recently as 2007, a meta-analysis of ADHD brain imaging studies noted that the participants in fully half of the studies were 100% male and and across all the studies analyzed, the samples were less than 20% female.
A final part of the problem may be more complicated than a mere inability to detect the disorder in girls. According to a 2009 study, even when girls’ and boys’ ADHD symptoms were perceived by participants as equally severe, parents and teachers were still more likely to refer boys for services than girls. Why? Researchers speculated that the boys were expected to benefit more from these services. And unfortunately, these expectations may reflect a gender gap in the value of academics. Indeed, if we value education for boys over girls, adults may consciously or unconsciously feel a greater urgency to help them overcome any impediments to their academic success.
What Can Be Done?
First, change can come from the grassroots. It’s extremely important that girls and women get referred for diagnosis and treatment. Untreated girls may be prone to all sorts of negative life outcomes from academic underachievement to divorce to financial crises to substance abuse and more. More frightening, folks with ADHD are also more likely to consider and attempt suicide.
So referral to treatment is key. And while treatment isn’t perfect, it can help dramatically. Usually, it’s a combination of medication and tightly focused, goal-oriented behavior therapy with an additional emphasis on working through a longstanding sense of guilt and shame and building up long-eroded self-worth.
Second, change can come top-down: A 2006 study in the prestigious Journal of Consulting and Clinical Psychology found a group of girls who didn’t meet current diagnostic criteria for ADHD, but when sex-specific criteria were used, registered as distressed and impaired, the very definition of a disorder. This indicates that if diagnostic criteria were revised to account for sex-specific differences, more girls and women might be diagnosed and treated. And as more people become aware and talk about it, stigma could also decrease. Then it wouldn’t be as surprising to pick multiple choice option D.
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About the Author
Dr. Ellen Hendriksen was the host of the Savvy Psychologist podcast from 2014 to 2019. She is a clinical psychologist at Boston University’s Center for Anxiety and Related Disorders (CARD). She earned her Ph.D. at UCLA and completed her training at Harvard Medical School. Her scientifically-based, zero-judgment approach is regularly featured in Psychology Today, Scientific American, The Huffington Post, and many other media outlets. Her debut book, HOW TO BE YOURSELF: Quiet Your Inner Critic and Rise Above Social Anxiety, was published in March 2018.
