Women with ADHD oftentimes go misdiagnosed due to the unique presentation of symptoms

What do you think of when you think of Attention-Deficit/Hyperactivity Disorder (ADHD)?

Chances are ADHD brings to mind the image of a restless boy. The one who would yell during class, somehow always finding a way to be the center of attention. It’s the kid who runs around, or can’t sit still, or fidgets restlessly.

No matter what specific image comes to mind, chances are ADHD brings to mind a boy.

Defined by its modern terminology in 1987, The National Institute of Mental Health says ADHD is “marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.” This includes symptoms of careless mistakes, difficulty with organization, being easily distracted of forgetful, fidgeting, excessive talking, interrupting others, and difficulty sitting still. Much of the diagnosis criteria is structured around actions in a classroom setting, and to receive a diagnosis by standard psychological measures, 4-5 symptoms must be present before the age of 12. Additionally, these impulses must lead to issues such as academic difficulties and behavioral issues.  

The studies that designed the diagnostic criteria for ADHD were performed on white boys in the 1970s and 1980s, examining the physical hyperactivity symptoms that have come to define the disease. Boys are almost 3 times as likely to receive a formal ADHD diagnosis than their female counterparts. However, a difference in gender biology may not be to blame, but instead a failure of the diagnosis criteria to include the presentation of symptoms seen in women.

There are three subtypes of ADHD: predominantly hyperactive-impulsive, predominantly inattentive, and combined. In women, ADHD is much more likely to manifest with the “hidden” and the harder to identify subtype of predominantly inattentive. 

Girls tend to struggle with the invisible symptoms of the disorder, marked by distraction, difficulty paying attention to detail, and forgetfulness. Due to the mental nature of these symptoms, they are usually held responsible for any lapses caused by the disorder, thus held to standards that force the development of coping mechanisms throughout much of their school age years. These coping mechanisms work to further cover the expression of ADHD as many girls are able to work harder to meet up for their disorder during middle and high school education.

This contrasts directly with the highly visible and physical symptoms of predominantly hyperactive-impulsive seen in males. Male symptoms of ADHD are typically very visible to the caretakers, teachers, and other guardians of young boys as they interfere with learning environments and peers. For this reason, young boys are referred for official diagnosis at higher rates, thus they receive proper treatment for the disorder early on. 

According to Quinn, the original ability to meet lapses in performance during middle and high school education begins to decline once women reach college and graduate levels of education, as well as face the demands of a career. Once unavoidable symptoms emerge at this age, receiving a formal diagnosis becomes near impossible as there are age restrictions in place. 

Furthermore, coping mechanisms developed during childhood and adolescence can result in the development of further disorders due to the internalization of issues associated with ADHD symptoms. Research by Quinn and Madhoo has found that internalization in girls leads to the development of disorders such as anxiety and depression in later adolescent years. These disorders are much more widely recognizable, and their symptoms tend to cover up the expression of ADHD symptoms. For this reason, many girls with ADHD will receive a diagnosis and subsequent treatment of depression or anxiety as the primary cause of any learning or emotional difficulties they experience. 

Due to the misdiagnosis and mistreatment of ADHD, women with ADHD tend to experience higher rates of negative consequences associated with the disorder later in life. According to research on North American women by Fuller-Thomson, women who go undiagnosed experience higher rates of substance abuse, mood disorders, sleep disorders, chronic pain, and lower socioeconomic status. Additionally, research by Owens and Hinshaw reveals that women who have a history of childhood misconduct issues related to the disorder are more likely to experience issues with work and social relationships, as well as higher instances of drug abuse, incarceration, and mental instability once they reach adulthood.

These issues seen later in life are all associated with the under-diagnosis seen in women. Since there is not proper intervention and treatment, the disorder expands into other aspects of daily life. The development of poor coping mechanisms and subsequent physical and mental disorders become life long consequences, and are much harder to treat as a whole than the causative ADHD. 

These negative effects are manageable if ADHD is caught and treated in time. However, in order to do that we need to rethink how we define the disease. We need to be more aware of gender differences, emotional expression, and hormonal fluctuations seen in the disorder. To truly help, we need to consider everyone in the criteria. By restructuring studies and redefining the ways in which we view ADHD, we can attempt to minimize these harmful consequences.

So next time you think of ADHD, think of the underrepresentation, the consequences, and the millions left out by the gender biased definition of the disorder. With awareness and effort, we can bring attention to the deficit in attention deficit/hyperactivity disorder.

By: M. Almy

References:

Attention-Deficit/Hyperactivity Disorder. (2019, September). Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml

Data and Statistics About ADHD. (2019, October 15). Retrieved from https://www.cdc.gov/ncbddd/adhd/data.html

Fuller-Thomson, E., Lewis, D. A., & Agbeyaka, S. K. (2016). Attention-deficit/hyperactivity disorder casts a long shadow: Findings from a population-based study of adult women with self-reported ADHD: ADHD and women. Child: Care, Health and Development, 42(6), 918-927. doi:10.1111/cch.12380    

Owens, E. B., & Hinshaw, S. P. (2016). Childhood conduct problems and young adult outcomes among women with childhood attention-deficit/hyperactivity disorder (ADHD). Journal of Abnormal Psychology, 125(2), 220–232. https://doi.org/10.1037/abn0000084

Quinn, P. O. (2005). Treating adolescent girls and women with ADHD: Gender‐Specific issues. Journal of Clinical Psychology, 61(5), 579-587. doi:10.1002/jclp.20121

Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: Uncovering this hidden diagnosis. Primary Care Companion to the Journal of Clinical Psychiatry, 16(3) doi:10.4088/PCC.13r01596

Image Credits:

Houghton, Pam, ADHD in Women Often Misdiagnosed, https://www.hourdetroit.com/health/adhd-in-women-often-misdiagnosed/