Why ADHD Is Missed in Women

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It’s 10 am, and Tonya, age 45, has been asked to meet with her supervisor. He’s worried that she seems to turn in projects late, forgets details in instructions that he tells her, and appears scattered in meetings. She seems increasingly stressed and disorganized.

• Tonya feels increasingly overwhelmed and confused as to what is going on, even though some of these issues have been around since she was in middle school. She’s unsure if the additional responsibilities of being a manager are too much for her or if it’s related to the erratic menstrual cycles she’s been having. She wants to do well at this job but notices that she’s falling behind. She’s been anxious and depressed off and on for several years and takes an antidepressant which lowers the edge off things. But it’s still hard for her to manage her time, and she’s usually 10 minutes late for everything, which feels bad. Yesterday, she saw her doctor, who diagnosed her with early perimenopause. It’s all just overwhelming.
• Aliyah, age 24, is finishing her last semester of college. After starting and stopping her studies at three different schools, she’s finally made progress toward her degree. Aliyah does fairly well academically but wants to do better. She struggles with listening in class and taking notes simultaneously, so now she has a note-taker assigned to her. She meets with a tutor on Mondays to map out her study plan for the week. Aliyah tries to follow this, but sometimes it gets boring, and she’ll find herself watching YouTube videos instead of studying biology. The worst thing is when she spaces out in class, and the professor asks her a question. She can hear people snickering as she puts a smile on her face and tries to remember what was just said. It’s embarrassing: She starts sweating, and everybody can see.

What do Aliyah and Tonya have in common? They are both examples of how ADHD can look in girls and women (assigned female at birth) and why it is both misunderstood and misdiagnosed. Aliyah hides her distractibility, pretends that she knows what is going on, and gets by academically. Tonya 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 a chronic condition marked by persistent inattention, hyperactivity, and sometimes impulsivity that is 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 twenties.

Most research about ADHD has centered on males (assigned male at birth) and the externalizing symptoms of ADHD: hyperactivity, impulsiveness, aggression, 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. Boys are more likely to be diagnosed with ADHD than girls (12.9 percent compared to 5.6 percent). But ADHD manifests differently in girls and often doesn’t emerge until puberty or post-high school or college transition years.

Women and girls are far more likely to experience these internalizing symptoms of ADHD: excessive talking, tardiness, disorganization, inner restlessness, distractedness, overwhelm, perfectionism, self-harm, social awkwardness, dreaminess, or early sexual activity. These traits are less disruptive in a classroom, so girls are less likely to be referred by educators for an evaluation.

Many girls and women develop strategies to overcompensate for inattention and mask their academic and/or social difficulties. As they enter secondary school or college and demands on their executive functioning skills intensify, their methods become less effective: They become overwhelmed, anxious, or depressed. Frequently, girls and women are referred for these mood conditions or self-harming behaviors, and their attention issues are overlooked.

These differences explain why many women are delayed in receiving a diagnosis. Socially, throughout school years and beyond, females with ADHD regularly suffer from exclusion, rejection, and difficulty making and maintaining friendships. They may miss key social cues because they’ve "zoned out," or they don’t notice that they have been talking too long and peers have stopped listening.

For women or girls with hyperactive/impulsive or combination-type ADHD, they 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 in conversations, meetings, or public events.

One study found that 74 percent of girls diagnosed with ADHD in childhood persisted into adulthood. With the shift to adulthood and the disappearance of the structure and routine of school, many young women who wrestle with focus, prioritizing, and working memory are left to manage schedules, balance socializing with work and find time for chores.

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Maya, age 23, told me: “I can do work, or I can see my friends or I can keep things off my bedroom floor, but I can’t seem to do all of these things at the same time.” We discussed the shame related to her sense of inadequacy and then made a step-by-step plan to clean her room. This is true for older women too.

In addition, hormonal shifts in the menstrual cycle affect the symptoms of ADHD, increasing distractibility, mood changes, and forgetfulness. The onset of perimenopause and menopause can lead to extreme mood and cognitive shifts related to declining levels of estrogen and progesterone. Women who may have experienced mild symptoms of ADHD (known or unknown to them as ADHD) may suddenly experience issues that seem "new" and distressing. These can include decreases in working memory and time management abilities and increases in impulsivity, reactivity, and disorganization. Social challenges, lack of focus, drive 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 be signs of ADHD as well.

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Many women have been diagnosing themselves after viewing videos on social media Platforms. In a recent study by Anthony Yeung et al., though, the authors reviewed 100 such videos and found that 52 percent were misleading and 71 percent misattributed symptoms to be specific only to ADHD.

For all of these reasons, it is essential to discuss the symptoms and patterns of what looks like ADHD with a licensed mental health provider trained in this area, whether or not you decide to pursue medication. Pursuing a psychoeducational evaluation can be useful in understanding how your brain works and learning about its cognitive strengths and challenges.

A trained mental health professional can talk with you about your social, emotional, academic, and family history, use validated rating scales to assess your executive functioning skills, and examine your daily challenges. An accurate assessment includes ruling out other medical or mental health conditions (including trauma and substance abuse). It's critical to find someone who knows about ADHD in women and the tendency for late diagnosis. After diagnosis, many women feel relieved and see a context to behaviors that have long been puzzling. For others, there is grief about losing years and feeling misunderstood.

Working with a knowledgeable therapist or coach is your next step in accepting your ADHD brain and creating a rich, satisfying life. They will assist you in improving executive functioning and social-emotional skills. They will help you examine and change unhelpful patterns and negative thinking. Cognitive-behavioral therapy, in combination with insight-oriented work, mindfulness, and medication (if you choose), will build the tools you need while helping foster better self-esteem and compassionate self-acceptance. Lifestyle changes such as exercising more, establishing good sleep hygiene, eating healthier, and reducing stress will also improve your well-being and thinking.

If you struggle with work, school, home, or social challenges and think you might have ADHD, or you already have a diagnosis, consider these 10 tips for improving your work, home, and daily struggles.

1. Accept your brain. We all have strengths and challenges; that's part of being human.
2. Live with a growth mindset. Try something, see what happens, pivot if necessary, and try again. Aim for steadiness instead of perfection.
3. Delegate what you can as often as possible and stop feeling guilty about it.
4. Reduce overwhelm by learning when to say no and how to say it gracefully.
5. Write things down. Lists are your friends; keep them electronic so you don’t lose them.
6. Break tasks down into chunks and work for timed periods with timed breaks. Make notes of what you think before you stop something so you can return to it later.
7. Improve social interactions with conversational tools such as reflecting, listening, and concentrating on the subject.
8. Ask your boss to submit as many requests as possible in written form. Or, plan to take notes on what they are asking you to do something as they are saying it.
9. Get help setting up systems at home or at work for where to put your stuff. When everything has a place, it’s easier to find it.
10. Seek out and connect with other women who have ADHD. There are wonderful peer groups online and in person through organizations. You are not alone.

To find a therapist, visit the Psychology Today Therapy Directory.