ADHD Symptoms in Women Aren’t ‘Hidden.’ They Are Misinterpreted.

ADHD symptoms in women and girls aren’t “hidden” or “easy to miss.” They are obvious, persistent, and often quite serious. Why, then, do we continue to disregard or misdiagnose ADHD in girls and women? And why do we more accurately diagnose boys, who get a head start of about four years on treatment?¹

The reason: ADHD is still viewed from a largely male-centric point of view. This bias toward recognizing externalizing symptoms and disruptive behaviors means that female manifestations of ADHD — including the critical role of hormonal fluctuations on symptoms and functioning — are all but disregarded. Clinicians readily misattribute the downstream consequences of undiagnosed ADHD in women, and this is why, in a bizarre twist, girls and women often show up everywhere in the health care system before they’re identified with ADHD.¹

ADHD in Girls and Women: Under Our Noses, Off Our Radars

Emotional Dysregulation: A Major Clue for Female ADHD

Emotional dysregulation — a core feature of ADHD — and distressing social-emotional outcomes impact girls and women with ADHD in the following ways:

• Masking and overcompensating. Girls realize earlier than boys what’s expected of them in social settings, so they try their best to hide their symptoms and challenges — an exhausting feat.²
• Social difficulties and bullying. Girls with ADHD are more likely than girls without ADHD to experience peer rejection and victimization, and to face challenges with social skills, among other social difficulties.³
• Tantrums and meltdowns. While girls and women keep it together in the world, they lower their guards at home and other safe places. Emotional dysregulation shows through here as big emotions damage interpersonal relationships and further harm self-concept.
• Low self-esteem and negative self-talk. Without answers or explanations for their challenges, girls and women with ADHD assume that something is terribly wrong with them.

Over time, teen girls and young women with undiagnosed and untreated ADHD become increasingly impaired by emotional dysregulation, and they begin to show up in the healthcare system seeking help for depression, anxiety, eating disorders, self-harm, and other related conditions.¹ They also seek social services for trauma or victimization.¹ Over and over again, we miss identifying ADHD in these girls and women, despite the signs. We get the causality backwards; we blame their struggles on trauma, depression, or social failure instead of considering that ADHD is at the core.

[Read: ADHD in Women and Girls — Why Female Symptoms Slip Through Diagnostic Cracks]

Hormonal Fluctuations Matter

Complicating the picture are hormonal fluctuations during the menstrual cycle (and across the entire lifespan). Given that sex hormones influence neurotransmitters like serotonin and dopamine — which is heavily implicated in ADHD — it’s plausible that fluctuating hormonal levels through the monthly cycle impact symptom severity, mood, functioning, and even medication efficacy. That the medical community at large overlooks this relationship is astonishing, especially when we consider that hormone-related mood disorders like premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome (PMS), disproportionately impacts women with ADHD.⁴

Most of our approaches, unfortunately, are based on studies done on males with ADHD, who do not experience monthly fluctuations of estrogen and progesterone once they hit puberty.

Girls and Women with ADHD Deserve Better: Steps for Clinicians

Girls and women with ADHD continue to fly under the radar because our tracking systems are calibrated to signs of male ADHD only. The result is that girls and women with ADHD feel abandoned by healthcare and left to ‘fix’ life with an incomplete toolbox of strategies and treatments.

Consider the following insights, approaches, and steps to recalibrate how you evaluate, diagnose, and treat female patients.

[Read: Protecting the Emotional Health of Girls with ADHD]

1. Understand that female ADHD isn’t male ADHD-lite. (If anything, research indicates that ADHD may be even more impairing for women than it is for men.) Lead with the understanding that you will need to adopt a differentiated view when looking at your female patients with ADHD and their challenges.

2. Look for signs of emotional distress and educate yourself on how ADHD may appear in girls and women, from perfectionism to low self-esteem. Understand that masking and mimicking are coping mechanisms that may, alongside shame, impair your patient’s ability to fully report their symptoms and symptom severity. Overwhelm, in my experience, is a major theme of discussion among undiagnosed girls and women with ADHD. Be curious, clever, and receptive when you evaluate your patients.

3. Disentangle emotional dysregulation. Consider the full picture to separate ADHD emotional dysregulation from distinct and overlapping comorbidities like bipolar disorder, borderline personality disorder, anxiety, and depression. The presence of these conditions, of course, will require different treatment approaches. Given that 85% of adult patients with ADHD also have at least one comorbid condition, it’s your duty to screen your female patients thoroughly.

4. Consider hormones and how a naturally cycling patient’s symptoms, ADHD medication efficacy, and overall functioning may change with monthly fluctuations in estrogen and progesterone. High-estrogen states may improve mood, symptoms, and functioning in some patients, while low-estrogen states may exacerbate symptoms and render ADHD medications ineffective. For patients who struggle with impulsivity, high-estrogen states may trigger greater levels of dopamine and increase the likelihood of engaging in risky behaviors due to a surge in positive emotions.^{5 6}

• Encourage menstruating patients to track their cycles. They should log objective data on changes to their mood, ADHD symptoms, and functioning through their cycles to improve shared medical decision-making and treatment.
• Consider cyclic dosing by fine-tuning a patient’s ADHD medication dosages based on hormonal status and functioning. A 2023 study found that increasing premenstrual psychostimulant dosage in women with ADHD resulted in improvements in ADHD symptoms, mood stabilization, emotional control, and productivity, with minimal side-effects.⁷

5. Bolster your patient’s care toolbox. Some patients abandon medication because of inconsistent results (perhaps due to hormonal fluctuations that weren’t factored into care), and feel that self-care, emotional regulation, and skills training are their only options. Help patients understand that the most effective treatment takes a multimodal approach including pharmacological treatment and coping/life skill strategies.

ADHD Symptoms in Women: Next Steps

• Self-Test: ADHD Symptoms in Women
• Free Workbook: Track Your ADHD Symptoms During Your Menstrual Cycle
• Read: Women with ADHD – No More Suffering in Silence
• Read: Why Women with ADHD Feel Disempowered — And What We Can Do About It
• Find: ADHD Specialists or Clinics Near You

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “The Emotional Lives of Girls with ADHD” [Video Replay & Podcast #488] with Lotta Borg Skoglund, M.D., Ph.D., which was broadcast on January 23, 2024.

ADDitude readers: Sign up to access LetterLife, an app co-founded by Dr. Lotta Borg Skoglund that provides users with personalized insights — on hormonal cycles, ADHD symptoms, and lifestyle factors — to better manage ADHD.

Use the discount code ADDWEB20 to get 20% off Dr. Skoglund’s book, ADHD Girls to Women, when purchased via uk.jkp.com.

---

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹ Skoglund, C., Sundström Poromaa, I., Leksell, D., Ekholm Selling, K., Cars, T., Giacobini, M., Young, S., & Kopp Kallner, H. (2023). Time after time: failure to identify and support females with ADHD – a Swedish population register study. Journal of child psychology and psychiatry, and allied disciplines, 10.1111/jcpp.13920. Advance online publication. https://doi.org/10.1111/jcpp.13920

² Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3), PCC.13r01596. https://doi.org/10.4088/PCC.13r01596

³ Kok, F. M., Groen, Y., Fuermaier, A. B., & Tucha, O. (2016). Problematic Peer Functioning in Girls with ADHD: A Systematic Literature Review. PloS one, 11(11), e0165119. https://doi.org/10.1371/journal.pone.0165119

⁴ Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, J. J. S. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of psychiatric research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

⁵ Roberts, B., Eisenlohr-Moul, T., & Martel, M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

⁶ Eng, A. G., Nirjar, U., Elkins, A. R., Sizemore, Y. J., Monticello, K. N., Petersen, M. K., Miller, S. A., Barone, J., Eisenlohr-Moul, T. A., & Martel, M. M. (2024). Attention-deficit/hyperactivity disorder and the menstrual cycle: Theory and evidence. Hormones and behavior, 158, 105466. https://doi.org/10.1016/j.yhbeh.2023.105466

⁷ de Jong, M., Wynchank, D. S. M. R., van Andel, E., Beekman, A. T. F., & Kooij, J. J. S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in psychiatry, 14, 1306194. https://doi.org/10.3389/fpsyt.2023.1306194

Removed