Is ADHD in adult women underdiagnosed?

With the condition often typified as a male disorder, many girls with ADHD remain undiagnosed. In the UK, ADHD is thought to affect 5% of school-aged children, with a male-to-female ratio of 4:1. However, the actual gender balance may be much more even. Since the condition often presents differently in girls, many girls and women struggle on by themselves, without seeking help.

For reference, there are three subtypes of ADHD - hyperactive-impulsive, inattentive, and combined, each of which has slightly different symptoms. Those with the hyperactive-impulsive subtype are most likely to fit the stereotype of ADHD (they might move around a lot, interrupt others or struggle with self-control). Those with the inattentive subtype often make careless mistakes, and struggle with concentration and organisation. People with combined-type ADHD have characteristics of both.

As Dr Samuele Cortese of the Royal College of Psychiatrists explains, girls with ADHD usually struggle with inattentiveness rather than hyperactivity or impulsivity.

"As girls tend to present in particular with the inattentive presentation, there is a delay in diagnosis as they are thought to be shy or passive rather than having ADHD," he says. "Usually they do not get a diagnosis or, if they do, they are labelled as depressed or anxious."

The problem is compounded by the fact that the bulk of ADHD research has been conducted on boys and men. Generally speaking, boys will show symptoms very early in life, and see a decrease in symptoms at puberty. The opposite is true for girls, whose symptoms may be exacerbated by increasing levels of oestrogen. This means they are less likely to meet the classic diagnostic criteria (which used to specify that symptoms were present by age seven).

"A delay in the diagnosis of ADHD is unfortunate as the earlier you diagnose, the better you can prevent the consequences of ADHD in terms of increased risk of substance use disorder, antisocial behaviour, and mood/anxiety disorders," says Cortese.

Sharyn's story

Sharyn Travers is one of many women with ADHD who wasn't diagnosed until adulthood. In her case, she didn't receive a formal diagnosis until the age of 44, when she applied to study at university and underwent an educational assessment. Her symptoms, however, had been present for many years.

"My foster parents nicknamed me Dilly Daydream at a very young age," she recalls. "School teachers used the term 'inattentive' and described me as being needy - requiring constant support in order to keep me on task. I was later referred to as being overly emotional - excitable and silly in one moment, and then angry and frustrated in the next."

She was also regularly late to school, and arrived without the necessary equipment, as well as gaining a reputation for being argumentative and challenging towards staff.

"I was considered by most as an underachiever who was apparently capable of much more," she says. "I believe my symptoms of ADHD were largely overlooked due to the fact that I was a woman and also a child under local authority care. Teachers would often say that I needed to grow up, to focus more and learn to better apply myself. I was never once assessed [for ADHD], either by health or education professionals."

Since receiving her diagnosis, she says she has finally learnt to embrace a part of herself that she once worked hard to suppress.

"Medication has enabled me to get back in touch with the girl I lost and it has helped me to better understand her," she says. "For the first time ever, I feel as though I finally have a voice that now speaks a language that people easily recognise and actually want to hear. This, in turn, has provided me with a new level of confidence and a sense of achievement that I have never ever known."

The self-esteem impacts

Terry Matlen, a psychotherapist and author specialising in women with ADHD, runs an online resource for adults with the condition. She also has ADHD herself, having received her diagnosis in her 40s. At the time, she says, she had two young children and 'hit the wall'.

"My self-esteem hit an all-time low because I saw how other mums could keep it together and work full-time. What was wrong with me?" she says.

As a child, she had suffered with a lot of anxiety, and struggled to take in information when the teacher spoke to the class. She had problems keeping up with her homework, tidying her bedroom and finishing the projects she started.

"Most girls with ADHD do not have behavioural problems so they don't jump out at the teachers like boys with ADHD typically do," she says. "Girls with ADHD tend to internalise their symptoms: they are the daydreamers looking out the window, twirling their hair, doodling on the margins of their notebooks, and simply being distracted and pulled into a rich inner world."

Over time, though, the strain of dealing with ADHD takes its toll and many girls and women end up suffering with low self-esteem. There can be knock-on effects at work, in relationships and with family life. For some, the condition manifests through impulsive behaviours (like gambling and substance abuse) while others develop eating disorders.

"If women can't 'get their act together', and begin comparing themselves with their peers and seeing how they fall short, depression can easily set in," says Matlen. "For these women, both the ADHD and depression need to be treated."

Finding a way forward

Travers adds that one of the biggest challenges faced by women with ADHD is an overwhelming sense of failure, caused by the inability to meet social expectations.

"The expectations that are placed upon females - to conform, to hold it all together, to do well, to be calm, consistent, reliable and dependent - are aspects that are often unattainable and/or impossible to maintain with ADHD in the mix," she says.

She says that, while doctors have tended to be very quick to prescribe her antidepressant medication, many missed her ADHD. As a result, her advice to other women who think they may have the condition is to research ADHD as it relates to gender. Then, seek out a professional evaluation.

"As a woman with ADHD, connecting with others with the condition has proved to be an awe-inspiring experience that has empowered me no end. My advice is therefore to seek out your very own ADHD tribe and go find yourself," she says.

"A good therapist can help you get you back on your feet by re-framing your now recognised ADHD as a neurobiological disorder rather than a character flaw; you will have the energy to move forward to lead a much happier and more fulfilling life," adds Matlen.