To date, there have been few and limited studies conducted on the manifestation of ADHD in women. Consequently, the mainstream ADHD model skews toward symptoms presenting in the male population but women’s lived experiences and the clinical observations of health care professionals are increasingly showing that there can be significant differences in the manifestation of consequences of ADHD symptoms between the sexes. By Tess de Klerk

ADHD was first defined based on the behaviours of hyperactive boys, and ADHD in girls is often overlooked. The condition can be divided into three subtypes: hyperactive/impulsive, inattentive and a combination of the two. Although the severity of ADHD symptoms can settle down as people age and learn to manage the symptoms, the root manifestations remain the same.

Male and female symptoms may mirror each other but males tend toward the hyperactive/impulsive, which can present as ‘always on the go’, making quick decisions without thinking of the consequences, general impatience (especially when required to queue anywhere), speaking over people and excessive movement. Females often tend more toward the more subtle inattentive subgroup which only became recognised as a subtype in 1994. The commonly assigned manifestations of inattentiveness are forgetfulness, tardiness, poor organisational skills, jumping from task to task and anxiety but ADHD in women is rarely that straightforward.

On top of the above symptoms, women often labour under the added burden of fluctuating hormones, restrictive gender roles and a greater tendency to self-doubt. Subtle ADHD presentations can easily be misinterpreted and disguised as girls mask their behaviour to conform to gender role expectations to find acceptance. Later on in life, these women struggle with an internalised sense of impairment and despair that affects their self-confidence and levels of achievement.

A woman dealing with ADHD may blame herself for feeling overwhelmed, disorganised or unmotivated at work instead of recognising that she is living with a disorder. She may censor her overwhelming emotions rather than risk inappropriate responses but when she is less guarded frustrations bubble over as she lashes out at partners or children. Such unintended outbursts can leave her feeling demoralised and overwhelmed with regret. Without a neurobiological explanation, she may blame herself and her ‘flawed character’.

Consequently, anxiety and depression are frequently diagnosed in adult women when ADHD is actually the underlying cause. Chronic sleep deprivation and dysregulated eating patterns are common and physical manifestations such as nail-biting or fidgeting are a way of attempting to dissipate excess energies. Women with ADHD are more likely to present with compulsive behaviours and substance abuse than their counterparts without the condition. They are also more likely to suffer from conditions related to chronic stress such as fibromyalgia and hypertension.

Interestingly, girls with ADHD may develop into highly-strung perfect-ionists. Many girls partly develop their self-esteem through early academic achievements and continue to rely on their intellect to compensate for their ‘flawed character’ into adulthood but their struggles in maintaining attention and focus cause them to doubt their intellectual abilities. Since they are less likely than boys to have been diagnosed with ADHD, less likely to have received help and acceptance and less likely to understand their own neurological needs, they tend to compare themselves unfavourably to colleagues who appear to achieve effortlessly. They judge themselves harshly and are determined to mask their struggles by projecting a flawless facade but this relentless self-monitoring is fueled by exhausting anxiety. For example, she might spend most of her free time working, preparing obsessively to ensure that her work is to the highest standard but when something falls through the cracks she is left feeling utterly worthless and depressed.

Hormone fluctuations throughout the female lifetime also play a major role in the manifestation of ADHD symptoms. Monthly fluctuations of estrogen, progesterone and testosterone impact symptoms, with a drop in premenstrual hormone levels exacerbating ADHD symptoms. Low estrogen triggers greater irritability and disruptions of mood, sleep, and concentration.

As estrogen levels drop throughout menopause, ADHD symptoms can intensify but according to researchers Ronit Haimov-Kochman, MD, and Itai Berger, MD, most studies have considered monthly changes in sex hormones a nuisance to be controlled, or have ignored it completely by focusing exclusively on male subjects.

Google successful people with ADHD and Bill Gates, Richard Branson, Einstein and many other famous names pop up but the lack of females is glaringly obvious. We know that this is not because "girls can't really have ADHD". No, it is because the traditional parameters of diagnosis have been based on the symptoms of hyperactive boys. Thankfully, this is changing as it  is essential that the neurodivergence of ADHD in women and girls is recognised since learning how to channel symptoms can turn them into superpowers! When people with ADHD harness their inherent hyperfocus, creativity, problem-solving skills and phenomenal multitasking abilities, to name but a few, they can accomplish much more, much faster than many without this condition.

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