ADHD in women and girls - your guide to signs, support and solutions*

ADHD in women is misunderstood and underdiagnosed. Here we explore some of the signs, symptoms*, and solutions* for adult ADHD and steps to ADHD diagnosis for women.*

What is ADHD?

ADHD - Attention deficit hyperactivity disorder, sometimes called ADD (Attention Deficit Disorder in the USA in the past) - is a common brain-based difference or in more medical terms, a neurodevelopmental disorder. The ADHD symptoms vary - but I prefer to use the word traits, as although ADHD is a recognised as significant disability, many community members dislike the ‘deficit’ or negative language used. I think it may be the most inaccurately labelled neurodevelopmental difference in current medicine.

Attention Deficit Hyperactivity Disorder (ADHD) is characterized by challenges with focus, hyperactivity, and impulsiveness. More commonly diagnosed in children, it obviously affects adults. In fact, according to the National Institute of Mental Health, about 4% of adults in the United States have ADHD. An estimated 4.4% of adults in the U.S. have ADHD, according to a 2006 University of Michigan survey of 3,199 adults ages 18 to 44. UK and EU data shows similar results.

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Undiagnosed ADHD

Most of the 8 to 9 million adults are either undiagnosed or untreated. One of the biggest challenges is the tests used miss a large number of girls and adult women - a ratio of 3 boys to 1 girl receiving a diagnosis means they may be missed until they reach their teens and adulthood when ADHD leads to burn out, misdiagnosis with anxiety disorders, depression, or even Bipolar.

A recent study published in Nature found that ADHD adults are more likely to be diagnosed with anxiety disorders than autistic adults - both groups internalise problems, have co-occuring conditions such as low self-esteem and other mental health conditions including rumination, which is a very common trait in ADHD adult women.

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Types of ADHD symptoms in women - not just a 'male disorder'.

There are three presentations of ADHD: 

1. inattentive (20-30%), 

2. hyperactive-impulsive (15%), and

3. combined (50-75%).

   
   Women are more likely to be diagnosed with the inattentive/combined BUT gender differences and socialisation mean that inattentive ADHD men and boys are still more likely to be treated while girls tend to be missed.

Inattentive ADHD is still missed for many reasons

"ADHD" conjures a picture of young boys showing hyperactive impulsive ADHD symptoms - because inattentive symptoms are much easier for parents and teachers - and clinicians - to miss until the social roles and academic demands reach a point where their "executive function" challenges become disabling or lead to symptoms of a mood disorder.

Common Signs or Symptoms of ADHD in women

• Trouble paying attention to details or making careless mistakes

• Difficulty completing tasks or projects

• Disorganization

• Procrastination

• Restlessness or feeling easily bored

• Difficulty staying on track during conversations

• Missing social cues & anticipating rejection

• Trouble following through with instructions

but more damaging disruptive behaviour & symptoms later in adult ADHD life -

• impaired quality of life (housing inequality, health problems, social isolation)

• impaired relationships;

• reduced employment;

• vulnerability to addiction;

• vulnerability to depression and anxiety;

• impaired driving safety;

• premature death from accidents;

• suicide.

Other signs may include impulsivity, mood swings, difficulty controlling emotions, and relationship problems. Conduct disorder is more commonly seen in males as boys tend to a more hyperactive impulsive presentation - but this isn't always the case.

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Women with ADHD - different symptoms throughout life

Females with ADHD experience a greater risk of problems in close relationships and engagement in self-harm compared to women without this brain-based difference (sometimes called a neurodevelopmental disorder) -

such as

• eating disorders

• substance abuse

• unplanned pregnancy

• losing jobs or dropping out of higher education

• violence within relationships. (They are more vulnerable to gaslighting - women with ADHD can be attractive to partners who abuse their self-doubt and executive function challenges.)

One study found rates of teenage motherhood to be 15 percent in girls with ADHD compared to 3 percent in those without it - while another showed that 43 percent of the women diagnosed with ADHD experienced an unplanned pregnancy, compared to 11 percent in women without ADHD. A review of studies can be found here.

ADHD diagnosis - women are under diagnosed, not 'faking it because of Tiktok'

Symptoms differ & become more obvious as hormone fluctuations increase during puberty - a time when self esteem faces challenges and young women tend to be moving on from childhood symptoms e.g. young girls with stomach aches before a test to developing mood disorders - studies show major depression is a significant risk, especially when diagnosed ADHD is paired with ODD (oppositional defiant disorder).

The same study showed ADHD alone was enough to increase symptoms of conduct disorder and Bipolar disorder - although this could also be because a lack of coping skills in women who have not been diagnosed with ADHD earlier can be misdiagnosed or misunderstood as a psychiatric condition - not ADHD.

External, observable ADHD disruptive symptoms (for example clinic referred children for assessment) means in boys receive earlier, faster, more conclusive ADHD diagnoses and are more commonly prescribed treatment with stimulant medications - while girls are more likely to be diagnosed with a mental health condition or have symptoms described as personality traits.

ADHD and Hormonal fluctuations - Menstrual cycle - Menopause

If women are not diagnosed with ADHD in childhood, the average age of final diagnosis is commonly mid-30s. For millions of women, it can be much later. We know that diagnostic criteria for ADHD tend to be more focused on 'hyperactive' (and more commonly male) ADHD traits, but could female presentations of ADHD be influenced by something more than doctor's understanding of symptoms and ADHD?

Having a mood or anxiety disorder treated might not resolve the problems - and for many women this failure of treatment is often seen as a failure of their own coping skills to manage their symptoms, more proof of their inadequacy, rather than a missed opportunity for an accurate diagnosis.

As oestrogen and progesterone begin their decades long cycle through our bodies, women find it is harder to manage symptoms like overwhelm. Broken down overwhelm can include: forgetting a task, not noticing a request or comment and being criticised for that failure, leading to a cycle of avoidance, procrastination, low self-esteem and feelings of inadequacy).

As adult life continues, these demands increase - and burn out increases when 'academically able' young women are told they are not reaching potential or engage in risky, impulsive behavior.

Just as puberty begins to make changes to our brains and bodies, young girls are moving to secondary school (or junior high): they must juggle multiple rooms, different teachers, many books and varied, unclear expectations at the same time as social demands are changing rapidly. It is common for ADHD girls to experience an increase in their distractibility, inability to focus or sustain attention - but there are very few executive function classes or supports in most schools.

Dropping out of school, college or university, losing jobs and finding parenthood unmanageable make this negative self-view more stubborn - these women know they are intelligent yet their ADHD symptoms prevent reaching their potential and they find the 'daily scut work' (a phrase of Dr Russell Barclay) more difficult than their non ADHD peers.

In our 40s, perimenopause appears and ADHD changes again - if things were barely manageable before, the reduction in oestrogen which has a protective effect on emotional disregulation as well as the release of serotonin and dopamine which help us feel good, can cause serious mood and memory problems.

Most women experience menopause around age 51 - even without ADHD, it is normal to have a brain that feels fuzzier and slower as our hormone levels adjust - we lose 65% of oestrogen as we enter a time of life when demands on working memory change (managing older children, different working roles, less support from partners).

Is there a connection between ADHD, ASD and PMDD

More serious hormonal problems are reflected in the rates of ADHD women who experience PMDD - pre-menstrual dysphoric disorder. It's not PMS - premenstrual syndrome - and the connection between ADHD, ASC/D (autism) and PMDD is not fully understood. Even serious PMS is more common in the ADHD community.

To have a diagnosis of PMDD, sufferers must have at least five of the following symptoms with at least one from each category. The symptoms must cause distress or interfere with activities of daily living during most menstrual cycles over the preceding year:

• Category A:

• Unstable and easily influenced mood

• Irritability

• Depressive or hopeless mood

• Anxiety or tension

•  Category B:

• Decreased interest in usual activities

• Difficulty concentrating

• Fatigue

• Appetite changes

• Sleep difficulties, either insomnia or hypersomnia

• Feeling of overwhelm

• Physical symptoms: breast tenderness, joint or muscle pain, a sensation of bloating, or weight gain

PMDD disproportionately affects people with ADHD and autism, with up to 92% of autistic women and 46% of women diagnosed with ADHD experiencing PMDD, though estimates vary. 

There is a significant cross-over of symptoms of ADHD and Autism in women. Some clinicians and researchers suggesting that there will be a change in diagnostic criteria in the next few years. For now, we know ADHD presents a significant challenge to physicians whose patients experience disabling hormonal changes.

What are the Social Deficits or problems faced by ADHD Women?

The executive function impact on ADHD in women is often overlooked in social terms - we know that women with ADHD feel more isolated, more misunderstood and more inadequate than their neurotypical peers. Why is that, if we think of 'attention deficit hyperactivity disorder' as a behaviour set of symptoms?

Executive functions determine a lot of our interaction with other humans

• working memory: remembering we offered to call or check in with a friend

• action: not leaving on time to meet or collect others because we procrastinated or were distracted

• processing - we may process information verbally and some people will think we are just dominating the conversation

• sustaining attention - drifting off because a conversation is important but not very interesting

• alertness - missing a conversation point and sounding as though we do not care

• emotional regulation - perhaps the most topical executive function is managing or regulating our emotions.

RSD and ADHD in women

Dr Dodson described 'rejection sensitivity dysphoria' in his patients, a potential treatment and the ADHD community felt recognised - with the result that it has become a hot topic for ADHD coach support, education and many articles.

ADHD leads to more problems 'regulating' our emotions - we react quickly in ways that other adults or children might not expect or accept. Our inner 'gatekeeper' is not as strong as neurotypical brains at managing how we experience other people's comments, behaviours and we also have a long history of being told we are wrong, 'too much' or just not fitting in. We expect to be rejected more often than those without our lifelong experiences.

The severe emotional pain people describe is so significant it may be part of the reason for the common misdiagnosis of BPD (bipolar personality disorder).

Other common traits of RSD include -

• Feeling easily embarrassed or self-conscious.

• Having very low self-worth, unable to believe in themselves.

• Find they cannot contain their emotions if they feel rejected. Children and teenagers react with sudden shows of anger or rage, while others may burst into tears - this leads to social rejection and further damages their self-esteem.

• The inward looking people with RSD may feel a sudden onset of severe depression, and sometimes, it’s mistaken for sudden emotional shifts like BPD or other illnesses. (This is also felt in PMDD, see above).

• RSD sufferers are “people pleasers” and will do anything to avoid the disapproval of others.

• Their low opinion of self and lack of positive belief leads to procrastination - if there’s a chance of failure.

• This leads into perfectionism - having high expectations can mean they ignore self care or avoiding trying new things, both being essential to all of us but especially with ADHD.

There is no 'test' or assessment for RSD - and the only treatment is one proposed by Dr Dodson. Other researchers and specialists are not yet confident that separating this group of genuine symptoms from the overall picture of ADHD is helpful for their patients.

At the moment, however, it is a way for those whose lives are impacted by these symptoms to be recognised and 'seen' by others who do not experience their struggles. ADHD in women seems to particularly predispose them to 'RSD' - however it is defined in future.

Dr Russell Barkley has proposed the wider and more inclusive term DESR - ‘Deficient Emotional Self Regulation’ which avoids any disempowerment of the person experiencing the emotional pain and upset, as well as including those who don’t feel ‘rejected’ but do have the explosive anger or other emotional flashes common in ADHD. Although there are questions about how to support ADHDers develop their own belief in our ability to feel less controlled by our emotions from BOTH of these terms, I think it is more useful overall.

I have a lot of useful material and strategies in development for this aspect of ADHD and will use the Dr Barkley term in preference to RSD for exactly that reason.

How is ADHD Diagnosed in Women?

The first step toward diagnosis for many girls and women is through a general healthcare professional such as a GP - often after recognising ADHD symptoms on a social media platform such as TikTok or Youtube.

An assessment by a psychiatrist to exclude other personality disorders, using objective and subjective measures - this uses information from childhood as well as adult life.

Each country has a different process. In the UK, there is an urgent need for a change in the diagnostic pathway. Some ADHDers report waiting lists in their local NHS being closed or taking 3-4 years for an assessment. In that time their mental health and life circumstances continue to be affected by ADHD.

Prolonged periods of stress for women can lead to complex symptoms that can confuse general doctors and co occurring conditions can make a definitive diagnosis challenging - the importance of professional and reliable assessments can't be underestimated.

Adult Women with ADHD - You Don't Have to Struggle or feel alone

The good news is that ADHD has a really strong collection of possible treatments which have been studied & are effective. 

There are many effective treatment options available. including medication, therapy, coaching, and skill-building.

Effective Treatments for ADHD in Women

The first line is medication: stimulant medications - are highly effective in reducing the focus & attention problems most ADHD women report.

• Stimulant & non stimulant medications

In the UK, only a registered psychiatrist can prescribe medication for ADHD and the options are for stimulant or non-stimulant based treatments.

Some have serious side effects and for 20% of the ADHD community, medication appears to have no impact on the negative traits at all - including Dr Ed Hallowell, author of "Driven to Distraction' and 'ADHD 2.0' (see LINKS PAGE for reading lists).

• Psychological counseling, psychotherapy and talking treatments

Living with ADHD in a neurotypical world where the strengths and positives of ADHD are either overlooked or sometimes punished creates a great need for therapy, counselling and help.

Finding an informed, supportive therapist is challenging - the group ANDT in the UK is a community with the combination of lived experience AND professional training and ethics.

If there are no suitably trained therapists or counsellors nearby, many now work online (see resources).

ADHD coaching - how it works, results and the importance of training & ethics

A well-trained and qualified ADHD coach can be a support for those who are either not in need of therapy or who are having therapy but would like extra support for different needs. What can that look like?

Individual and personalised one to one appointments can uncover:

• your strengths

• how you learn best

• your personal values, needs and boundaries

• beliefs that are damaging

• challenging & replacing negative patterns

• building strategies for unique circumstances

• time to talk about ADHD and your life

• skills for executive function challenges

• creating a positive vision for your future life

There are different types of coaching and you can take steps to make sure you find the right one for you by

• asking for references from previous clients 

• having a sample coaching session

• checking their training

• asking about their ethical guidelines.

Coaching is an unregulated industry - there are no requirements before setting up as a life coach. In the ADHD community, this is a risk - especially if a general life coach decides they feel they understand enough - given the trauma and challenges ADHDers have already experienced.

I chose to study and train with ADDCA, the world leaders in ADHD coach training. I have 320 hours of specific ADHD coach training for individuals and families, with more than 20 hours (and ongoing support) from a master certified coaching mentor and am awaiting official certification from ICF and PAAC, whose ethical guidelines can be read here and here. I am fully insured and regularly submit recordings to my supervisor to ensure the standard of coaching for clients safety.

You can read an in depth, step by step guide to finding a professional ADHD coach HERE.

What are specific strategies that may help women with ADHD?

Creating systems to help with organization and time management - these must be ADHD friendly - see the growing RESOURCES and LINKS pages for suggestions

• Get help to simplify your schedule and setting priorities (most ADHDers are trying to do everything because everything is interesting and we experience time differently)

• Try breaking down tasks into much smaller steps, using your preferred processing style (see RESOURCES library for sites where you can check this yourself).

• Asking for help when needed, even if it feels difficult at first.

• Try new activities such as self-compassion or mindfulness

In addition to these specific strategies, there are various support networks available for women with ADHD. These networks can provide valuable information, resources, support groups and even support groups.

*Throughout this article I use the word traits or symptoms interchangeably - ADHD is a disability recognised by the legislation protecting individual rights in most countries. I use the term 'women'/'girls' to identify the female sex, not gender stereotypes or roles.

If you would like to find out more about ADHD coaching you can contact me.

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