
In this blog, I will discuss ADHD in women. For the purpose of this blog, I use the term "woman/women" to mean people with female sex hormones.
What is ADHD (Attention-Deficit/Hyperactivity Disorder)?
ADHD, or Attention-Deficit/Hyperactivity Disorder, is a neurodevelopmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity. There are three subtypes of ADHD: hyperactive, inattentive, and combined presentation. ADHD is considered a neurodevelopmental disorder because ADHD (Attention-Deficit/Hyperactivity Disorder) influences several key neurotransmitters in the brain. Dopamine, a neurotransmitter responsible for regulating motivation, reward, and pleasure, plays a crucial role in ADHD. Individuals with ADHD often have lower levels of dopamine, which can affect their ability to focus and regulate their impulses. Norepinephrine, another neurotransmitter involved in attention and arousal, is also impacted in ADHD. It helps maintain alertness and regulate attention, both of which can be impaired in individuals with this disorder. Understanding these neurotransmitter imbalances is essential for developing effective treatments that can help manage the symptoms of ADHD and improve overall quality of life.
TL;DR: People with ADHD have a dopamine deficit which leads to difficulties with focusing and regulating impulses. Because people with ADHD have less dopamine, their brains are always looking for dopamine which is why it can be difficult to focus on tasks that are not immediately rewarding and why it can be hard to not engage in behaviors that are instantly gratifying (see: hyperfocus). Norepinephrine is also affected by ADHD which leads to difficulties with attention and arousal.
Why is ADHD underdiagnosed in girls and women?
There are a few key reasons why women and girls' symptoms of ADHD are overlooked including differing presentation from most men, the intersection of female sex hormones, higher rates of comorbidities of other mental health concerns, the tendency to internalize struggles rather than externalize, a lack of sound research about ADHD in women and societal expectations of women.
The impact of female sex hormones on ADHD
The impact of women's sex hormones on ADHD symptoms reveals a complex interplay that often leads to underdiagnosis in women. Research indicates that fluctuations in hormones like estradiol (E2), progesterone (P4), and testosterone (T) significantly influence neurotransmitter systems in the brain, particularly those involved in cognitive and emotional regulation. Studies have shown that lower levels of estradiol combined with higher levels of progesterone or testosterone are associated with increased ADHD symptoms, especially in women with high trait impulsivity. These symptoms fluctuate across the menstrual cycle, peaking during the early follicular and early luteal (post-ovulatory) phases. Additionally, menopausal women and those with conditions like polycystic ovarian syndrome (PCOS) often experience symptoms resembling ADHD, underscoring the role of hormonal imbalances in exacerbating ADHD-related difficulties. The overlap with hormone-related mood disorders such as premenstrual dysphoric disorder (PMDD) and postpartum depression, both of which are more common in women with ADHD compared to the general population, further complicates diagnosis and treatment, and highlight the intersection of hormones and ADHD.
TL;DR: There are a few sex hormones that influence neurotransmitters in the brain. This causes changes in cognitive and emotional regulation. Throughout the menstrual cycle, hormone levels change and therefore can exacerbate ADHD symptoms. Women with ADHD are also more likely to have hormone-related mood disorders including PMDD and postpartum depression, which demonstrates the clear relationship between hormones and ADHD. Due to the changes in symptoms throughout the menstrual cycle, providers often misjudge symptoms because ADHD is seen as a "consistent presentation of symptoms".
Comorbidities and Internalization
Women are more likely to present with comorbid mental health disorders such as anxiety and depression during adolescence, which can overshadow ADHD symptoms and complicate diagnosis because clinicians tend to be more knowledgeable in diagnosing mood disorders in this population. Unlike their male counterparts who may exhibit more externalized behaviors like hyperactivity and impulsivity, women tend to internalize their difficulties, leading to less obvious signs of ADHD. If a young boy is yelling at his parents, and teachers, and bouncing off the walls in a classroom he is going to be evaluated for ADHD. However, a young girl who keeps her difficulties to herself, cries in bed at night alone due to stress about homework and sits quietly when she is unable to pay attention to the teacher, is often going to be overlooked. Women's tendency to internalize means they are less likely to draw attention to their struggles. Moreover, societal expectations often pressure women to mask their ADHD symptoms, attributing their distractibility or disorganization to personal failings rather than a neurological condition. This societal norm of coping silently and appearing to manage multiple tasks simultaneously can further obscure the underlying ADHD, as it may be perceived as typical female behavior rather than a symptom requiring medical intervention. As a result, many women with ADHD endure prolonged periods without diagnosis or treatment, impacting their academic, professional, and personal lives.
TL;DR: Women are more likely to keep their struggles to themselves which leads to them being overlooked by teachers, parents, and therapists who may otherwise see signs of ADHD. Women and girls are also more likely to present with distractability and disorganization which others (and themselves) can interpret more as personal failings rather than a neurological condition Women are also expected to multitask and play many different roles, so that can cloud symptoms of ADHD.
Lack of sound research
The understanding of ADHD in women is hindered by a significant gap in research focused on female-specific manifestations of the disorder. Traditionally, menstrual cycles have been treated as statistical nuisances in ADHD studies or controlled for by predominantly testing male samples, resulting in a lack of robust data on how ADHD uniquely presents in women. Women being excluded in studies means that women are not being studied. This approach overlooks the potential impact of hormonal fluctuations on ADHD symptoms, which are known to vary across different phases of the menstrual cycle. As a consequence, important factors such as the fluctuating nature of symptoms and the influence of hormonal changes on cognitive and emotional regulation in women with ADHD remain poorly understood. Addressing this gap is essential for developing effective diagnostic criteria and tailored treatments that account for the distinct experiences of women with ADHD, ultimately improving outcomes and quality of life for this underserved population.
TL;DR: Studies try to control as many variables as possible so they can see which variables are responsible for certain outcomes. There is a history of most medical research using men as study participants which makes the research less applicable to women. A major reason why we do not know much about ADHD in women, particularly how hormones play a role in ADHD presentation, is because menstrual cycles are seen as a "complicated" variable that doesn't fit the mold of what researchers hope to do in a controlled research study. This means women have been excluded from research and that is why we do not know as much about ADHD in women.
The Takeaway
Understanding ADHD in women requires moving beyond the standardized diagnostic criteria outlined in the DSM and exploring how symptoms manifest in real-life contexts for girls and women. This approach is crucial because ADHD symptoms often present differently in females compared to males, with less overt hyperactivity and more internalized struggles such as disorganization, distractibility, and difficulty sustaining attention. By delving deeper into these nuanced presentations and considering how societal expectations and gender norms may influence symptom expression, clinicians can avoid prematurely attributing symptoms to anxiety or depression. Instead, a thorough assessment that considers both current and developmental history, behavioral patterns, and functional impairments is essential to accurately diagnose ADHD in women and tailor approaches to address ADHD in women across different hormonal contexts. This understanding not only ensures appropriate treatment but also validates the experiences of women whose ADHD may have been overlooked or misinterpreted in the past.
TL;DR: Women tend to internalize their struggles and have different societal expectations that lead to being overlooked for ADHD. There is a lack of research on how ADHD presents in women, particularly how ADHD symptoms change throughout the menstrual cycle. We now know that there is a link between female sex hormones and ADHD but we need to have a better understanding of this link to effectively diagnose and treat women with ADHD. Treating ADHD is essential to quality of life and women deserve the same medical care that men get.
If you suspect you have ADHD or you know you have ADHD and would like support working with a therapist who understands ADHD in the context of being a woman, please reach out for a free consultation.
References:
Cognitive functions of regularly cycling women may differ throughout the month, depending on sex hormone status; a possible explanation to conflicting results of studies of ADHD in females
R. Haimov‐Kochman, Itai Berger
Frontiers in Human Neuroscience
Reproductive steroids and ADHD symptoms across the menstrual cycle
Bethan A Roberts, T. Eisenlohr-Moul, Michelle M. Martel
Psychoneuroendocrinology
ADHD in women - a review
A. Brzezińska, Monika Borowiecka, Marlena Zając, Konrad Warchoł, Wiktor Michniak
Journal of Education, Health and Sport
Review of the Psychosocial Consequences of Attention Deficit Hyperactivity Disorder (ADHD) in Females
Clive Kelly, Carolyn Kelly, Rachael Taylor
European Journal of Medical and Health Sciences
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