ADHD Is Underdiagnosed, But Still Serious in Women

If you asked most people to think about someone with attention deficit hyperactivity disorder (ADHD), they'd likely conjure up images of a hyperactive young boy who has trouble paying attention in class at school.

They wouldn't be entirely wrong. ADHD, a chronic condition, makes it difficult to sustain attention and can sometimes lead to hyperactivity and impulsive behavior. The symptoms first manifest during childhood and often lessen with age, though many struggle with symptoms well into adulthood.

It's also true attention deficit hyperactivity disorder is mostly diagnosed in young and teenage boys. However, note the operative word in that sentence: "diagnosed." Statistically, girls aren't diagnosed with ADHD as often as boys are—but does that mean they don't have it?

Research indicates males are much more likely to get an ADHD diagnosis than females, with a male-to-female diagnosis ratio of 4 to 1 found in a large community-based sample. However, some experts are beginning to believe these numbers simply indicate how common it is for girls and women with ADHD to go undiagnosed or misdiagnosed.

"Particularly women get missed all the time or misdiagnosed with anxiety," said R. Derek Brugman, a pediatric doctor and ADHD specialist at Carolina Attention Specialists. "Traditionally, people think ADHD means you run around the room, you have behavior issues and that you do badly in school. And it's just not true for quite a lot of the people who have ADHD."

To understand what ADHD symptoms can look like, it's important to know there are three main types of attention deficit hyperactivity disorder—inattentive type, hyperactive/impulsive type and combined type.

"For people with the inattentive type of ADHD, the running around happens in their head," Brugman said. "So if you have inattentive type, you're not necessarily jumping out of your seat or drawing attention to yourself. I myself have ADHD, and in school, I learned to look at the teacher during class, but I'd hear one word that made me think of something else and my brain would go off on a tangent and I was gone. So for those 20 minutes, I'm looking at her and smiling and nodding so the teacher isn't aware that I can't focus and am totally distracted. That's a way of masking the symptoms, and a lot of people experience that where they learn to compensate for it [so] others don't notice."

Brugman said about 10 percent of people with attention deficit hyperactivity disorder have inattentive type, which can be the hardest to detect due to how symptoms manifest. The least common type of ADHD is found in those whose symptoms are mostly related to hyperactivity and impulsivity, whereas combined type ADHD is most common and involves a mixture of all the different symptom classes.

"When it comes to undetected ADHD in girls, it's often because, in some cases, they may have less obvious symptoms or, in other cases, because they are better at masking and compensating for their symptoms due to gendered social expectations," Brugman said.

"I hate to admit it, but society often just expects girls and women to try harder at things like school and to be better behaved, whereas society accepts that guys often think, 'This is the way I am, and if you don't like it then that's your problem,'" he continued. "So girls have that extra pressure to try to fit in and live up to expectations, so they can often hide their struggles very well."

"It's not uncommon for other mental health issues, such as anxiety or depression, to be present in individuals with ADHD," said Perry Roy, a board-certified internal medicine and pediatrics doctor who also specializes in diagnosing and treating attention deficit hyperactivity disorder at the Carolina Attention Specialists.

"Many times, persons will present with ADHD, but it may look like anxiety or depression," Roy explained. "The root cause is the ADHD. Self-esteem issues due to ADHD are common, particularly in females. A lot of times, boys will come in with oppositional type behaviors, like, 'I'm not doing well in school and I don't care.' Whereas a lot of times females will come in and they're silently suffering and they're sitting there in their brain beating themselves up and their self-esteem is taking a hit. They don't feel worthy. They don't feel smart enough. And they kind of sometimes fly under the radar."

As another barrier to diagnosis, hyperactivity in boys and girls can look different, Roy added.

"There's a thought out there that all little boys are hyperactive," he said. "But that's not the case. Boys, according to studies, are more active than girls. I have two little boys—they're very active. And they do not have ADHD. So the hyper activities will look different, and boys are going to be the ones getting up out of the seat and moving around all the time and in school, whereas little girls often will sit there and they'll doodle or they'll play with their hair. You know, they're not bothering anybody, but they're still just kind of fidgeting around and maybe drifting off to la-la-land. So when you're looking for symptoms, you have to be aware of those differences."

The pressure to live up to these gendered societal standards can be particularly taxing for girls and women with ADHD, who often have to work much harder to pay attention, remember to complete tasks, and turn in homework or meet work deadlines.

"When it goes undiagnosed, often they just internalize it and blame themselves and begin to develop poor self-esteem," Brugman said. "So a lot of times they end up struggling with depression or anxiety. And when it comes to treatment, maybe it's only the anxiety that's diagnosed but not the deeper root of where these feelings are coming from, which is often from trying to navigate life and responsibilities and expectations but constantly struggling due to ADHD."

Both undiagnosed or late-diagnosed ADHD can have a significant impact on an individual's life.

"I've seen very many women that we diagnose later, after many years of living with ADHD, and sometimes they may say that they wanted to be a doctor or go into a certain profession, but since they could never remember to get their homework done in time, their grades were never good enough, so they didn't go down that pathway," Brugman said. "A lot of times there's secondary anxiety and self-esteem issues because they're constantly thinking, 'What am I going to forget today? I'm trying so hard. I can't get this right. Why is everybody else doing better than me?'"

Keeping an eye out for the signs and symptoms of ADHD, especially the ones not so obvious to others, is an important step in detecting ADHD in girls early on. It's also important to remember that not everyone with ADHD is hyperactive or impulsive.

The extra stressors that may arise in the lives of people with undiagnosed ADHD can negatively affect their quality of life, ability to hold down a job or do well in school, and even to maintain healthy romantic relationships as they grow up.

Even when treated, attention deficit hyperactivity disorder can sometimes lead to an erratic sex drive or trouble focusing on and enjoying intimacy in relationships. However, there are strategies that can greatly help with these issues.

Treatment for ADHD typically involves stimulant medications designed to balance brain chemicals and thus improve issues of inattentiveness and hyperactivity, according to the Mayo Clinic. Medications are sometimes used in combination with behavior therapy or counseling to educate individuals about their condition and better help them develop strategies to cope with symptoms in daily life.

If you are experiencing symptoms and think you might have attention deficit hyperactivity disorder, don't hesitate to reach out to a medical professional for help.