Why talk about females and ADHD?

I am very interested in this topic, as I have a number of family members with diagnoses of ADHD. Despite having a number of ADHD traits myself this was not considered as a child at all. I was fidgety, a doodler, but not disruptive. I was chatty, enthusiastic, and impulsively volunteered to help with everything. I was anxious and a ruminator and had a ‘busy brain’ that often ended up trying lots of different hobbies because I was curious but gave them up if they bored me. I also seemed to work much harder than others to achieve what others seemed to do with less effort. As a student, I put in endless hours when others were ‘playing’. I look back and think now was that about inefficiency, or uncertainty about being good enough? I have always had ‘imposter syndrome’ and never really believing I was good enough even when I won awards from others… I always thought it was not for me! I never thought that I had ADHD…. till in my 60s… despite diagnosing and recognizing it in others.

Adults talk about feelings of ‘inner restlessness’, and I find this is very real for me. I find it very hard to do one thing only. If I am listening to a lecture, I need to make notes or doodle at the same time. If I am watching TV, I often do something else at the same time like being on my laptop writing something while listening to it in the background. The thought of sitting still doing only one thing is hard for me. I think this is why I prefer to be lecturing as I am the one doing something and can move around.

As the chair of the ADHD Foundation, I feel passionate about raising awareness of ADHD and neurodiversity in all sectors of society but especially in females as so many girls have been completely missed in childhood. Many of us are emerging now at different stages of our lives, and some are looking back and thinking how much easier could it have been if I had known….

What is it all about?

The term neurodiversity recognizes diverse and varying brains and it is becoming associated with both positive traits and characteristics associated in some people with Dyslexia, Dyscalculia, Attention Deficit Hyperactivity Disorder (ADHD), autism spectrum disorder/condition  (ASD/C), Developmental Coordination Disorder/Dyspraxia, and Developmental Language Disorder as well as specific challenges that some people may have.

Increasing awareness of neurodiversity means there are females self-diagnosing one or more conditions in adulthood. But there are many girls and females who still haven’t had their support needs recognized and continue to have challenges in day-to-day life. For some arriving at adulthood, it can mean having years of constant feelings of anxiety and for many being or having been depressed. Cycles of burnout, with challenges with sleep, may have been their norm. Their diagnosis was missed altogether or considered as something else.

Past challenges can result in difficulties progressing in education and socially. It can include a sense of never quite fitting in. I have had many females feel both relieved and at the same time angry at gaining a diagnosis in adulthood. Some are frustrated at not achieving what they see now as their potential. Sadly, some end up with lower-level qualifications despite having wasted talents. Even sadder are some females who end up in the justice system have been both misunderstood and misdiagnosed.

Estimates for childhood ADHD range between 3% and 7%. The pathway to adulthood does not appear to be different in males or females with ADHD. A recent review has shown that about 80% of children continue to experience challenges that can impact on day to day functioning. Importantly, research on gender differences in ADHD increasingly suggests that girls may be consistently under-identified and underdiagnosed. 

This has mostly been explained by some differences in the way challenges and strengths are present in females compared to males. Females (in general) with ADHD have been reported to have fewer hyperactive/impulsive symptoms and more inattentive symptoms when compared with males with ADHD. They are less likely to be disruptive and so fade somewhat into the background and so not necessarily noticed as being a ‘nuisance’ to others. 

If they are disruptive then this may be associated with other factors in their life and ADHD not even considered.

Lack of knowledge by teachers and health professionals about the presentation in females means they can be missed altogether till adulthood. Sciutto, Nolfi, and Bluhm(2004) found that teachers more often refer more boys than girls for treatment for ADHD, even when showing equal levels of impairment.

Overshadowing

A major contributing factor to late or missed diagnoses of ADHD in females appears to be the presence of coexisting symptoms that often cloud or overshadow the diagnostic picture. As many as 75% of children with ADHD are likely to have at least one other mental health condition. In general, boys with ADHD have been found to have more externalizing disorders (noticed by others) than while females tend to show more internalizing disorders( not seen always by others) in comparison to girls without ADHD. Low mood, emotional lability, and anxiety may be especially common in females with ADHD. Substance misuse may be problematic for some people with ADHD. This often means other conditions are diagnosed before ADHD is considered.

Females who get diagnosed with ADHD generally have to be more symptomatic than their male counterparts. This means they need to have a greater impact on day-to-day life before being recognized or considered as potentially having ADHD. Often females get diagnosed because someone else in their family has a diagnosis of ADHD such as their child.

Some ADHD signs and the impacts for females

(Note: not everyone has everything and this list is not exhaustive. Some of these signs may be associated with other conditions too – this is why it is helpful to be professionally diagnosed).

1. Starting something and not finishing it and then feeling bad because of this
2. Working much harder to achieve because not sure of how hard you need to work … burn out cycles
3. Chatty, enthusiastic, overly engaged ( and then not!)
4. Losing your day drifting off down a rabbit hole of interest- seen sometimes as ‘daydreaming’.
5. Distracted by other people’s conversations around you and drifting off when talking to someone – unless the topic is of high interest and then fully engaged.
6. Impulsive ( enthusiastic) decision making – saying yes before saying no and then regretting it because of too many yes’s
7. Not being able to sit still/stay quiet for long/fidgety/toe-tapping/doodling/hair twirling
8. Sleep disturbance, busy brain, and rumination and feelings of disappointment when it hasn’t gone right ( again). Feeling anxious.
9. Losing possessions even though you are sure you put them in one place, disorganised.
10. Loads of information/knowledge… but a brain that has an inconsistent filing system 
11. Poorer concepts of time passing
12. Other people’s perceptions of you – thinking that you are less capable than you really are or overly direct or rude because of interrupting ( I often find it hard to stay quiet for long!).
13. Compensating to camouflage by working even harder to cover up mistakes /driving anxiety and obsessional actions to do so- putting the pressure on yourself
14. Prevarication ends up with you doing the things you like doing and avoiding the tedious things we still all have to do as much as possible even though we know they often won’t take us long in reality.
15. The impact for females may result in having greater social problems in school and it may result in having been more vulnerable to bullying, including physical and social-relational bullying, and cyberbullying.
16. Like males, there is an increased school dropout, academic under-achievement, and more accidents with females. Not surprisingly there is an impact on self-esteem and self-concept.

Living with ADHD 

The challenge for many females who have not been diagnosed is they may have learned a whole range of ( not always positive) compensatory strategies such as using alcohol or cannabis to slow them down. Social interaction may be achieved with higher-risk activities. Coping strategies may be less overtly noticed, such as avoiding specific events, settings, or people, not facing up to problems, spending too much time online, or not seeking out help when needed. 

Women with ADHD may experience challenges in the workplace, such as disorganization, inattention, difficulty accepting constructive criticism and appraisal, and difficulties managing interpersonal relationships with colleagues. Working longer hours ( but often hidden from others) to complete tasks because of time management/focus challenges can also be exhausting. Cycles of burnout may also be more common but may not be recognized or seen as something else. 

We start to see increasing numbers of highly skilled females with ADHD talking about what it is like for them. Some of them are entrepreneurs using their vision of pulling things together, commitment, and passion to be successful. 

It will be interesting to understand more the factors at play that resulted in being more resilient and successful and what differentiates these females so we can help all with ADHD to be their personal best.

We have a lot to learn! What’s your experience if you are a female with ADHD?

Thanks also to this amazing review of the literature ( link below) and all those who contributed to the body of work and especially Suzie Young.

Reference: Young, S., Adamo, N., Ásgeirsdóttir, B.B. et al. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry 20, 404 (2020). https://doi.org/10.1186/s12888-020-02707-9