Women with ADHD — Practice Tips

By Elisabeth Baerg Hall, MD, CCFP, FRCPC (biography and disclosures)

Disclosures: Volunteer board member for CADDRA (Canadian ADHD Resource Alliance), no payments received. Mitigating potential bias: Recommendations are consistent with current practice patterns. All available medications for ADHD are discussed or referenced. Generic names are provided.

2021 ADHD article: Elisabeth Baerg Hall. Adult ADHD — Practice Tip. This Changed My Practice. October 27, 2021. View: https://thischangedmypractice.com/adult-adhd/

What I have noticed

Until recently, female presentations of ADHD have been largely overlooked in both clinical and research settings.¹ With increasing awareness and media attention to women and ADHD, adult women are asking if ADHD could explain their longstanding challenges with focus, organization, overwhelm, and achievement.

Data that addresses these issues

The prevalence of ADHD in childhood is approximately 5–7%, while in adults rates are 2.5–4%.¹ The sex ratio of clinically diagnosed ADHD in boys:girls is approximately 2.5:1, while in adults it is 1:1. The sex ratio is closer to equal in community samples suggesting that many girls with ADHD are undiagnosed and untreated.

Males with ADHD commonly present with hyperactive/impulsive symptoms. Inattentive symptoms are present, but hyperactive/impulsive symptoms attract attention and lead to childhood referrals for ADHD assessment. Females with ADHD commonly experience a combination of inattentive symptoms and hyperactive/impulsive symptoms.

Inattentive symptoms can be challenging to identify in childhood. Girls with ADHD are noted to have better coping skills than boys and they appear to be functioning better, even when that is not the case.  ADHD symptoms are masked and still play a role in dysfunction. The process of masking/compensating for inattentive symptoms by maintaining organization, time awareness, and order, adds an exhausting cognitive burden. Chronic exhaustion depletes capacity to manage stress burden, resulting in less energy for enjoyable activities, socializing, managing family, or pursuing major life goals such as work and studies.

Hyperactive/impulsive symptoms can look different in females. Females have better inhibition of physically impulsive responses e.g., girls are less likely to hit others in the playground when provoked. The hyperactivity/impulsivity trajectory in females can take many forms. A woman might be verbally impulsive, talk too much, not notice cues to stop, say inappropriate things, gossip, or blurt things out, leading to a cascade of negative consequences. For example, she might have excessive ruminations about what was said, worry about social rejection, experience interpersonal conflict, job loss, insomnia, depressed mood, and avoid social situations. Hyperactivity/impulsivity can be expressed via sexual activity in both males and females, however, girls are more vulnerable to problematic outcomes. Hyperactivity/impulsivity might include engaging in unplanned sexual activity, unwanted sexual encounters, STIs, near misses with contraception, unwanted pregnancies, or in gender non-specific behaviours such as tobacco use, substance use, poor driving, dropping out of school, frequent loss/quitting or change of jobs.

When females are diagnosed at a young age, there are often neurodevelopmental comorbidities like intellectual impairment. Collateral ratings by teachers and parents underreport ADHD symptoms in girls, even when ADHD behavioural descriptions are identical between boys and girls.² Many common ADHD rating scales are normed on men and boys.¹

As adults, females identify functional impairment from childhood, despite it having been overlooked by caregivers. Equal or higher proportions of females:males present for the first time as adults.

Females with mental health issues, typically present with “internalizing” disorders such as anxiety and depression. Non-suicidal self-harm and suicidal ideation in young females is often understood as stemming from mood and anxiety disorders. There can also be underlying conditions at play. An ADHD diagnosis in childhood robustly predicts adolescent depression, and later self-harm and suicide attempts. Female sex is a predictor for these adverse outcomes.³

Adult females may minimize ADHD symptoms based on feelings of guilt, shame, and low self-esteem associated with a lifelong experience of failure. Unrealistic societal expectations about women’s roles, and self-perceptions of how women should manage multiple roles in the home and at work perpetuate these feelings.

In a recent review of psychiatric symptoms across the menstrual cycle in adult women, premenstrual and menstrual phases are most consistently implicated in transdiagnostic occurrence of mental health symptoms.⁴ Space limits a full discussion of biological factors in this article. Stay tuned for part 2 of this series, addressing clinical approaches to biological issues in women with ADHD.

What I recommend

Assessment tips:

• Currently, there is no indication for gender-specific assessments. For an overview of the adult assessment process see 2021 TCMP article on adult ADHD.⁵
• Questionnaires are used to aid the clinical diagnosis. If the history is clear and the questionnaire is less so, consider the possibility of questionnaire bias and focus on the history. Referral may be necessary to support your longitudinal impressions.
• Assess all family members regardless of sex if a parent has ADHD. Note family of origin history of ADHD and assess regardless of gender) if this history is positive.
• Ask about impulsive behaviours typical of females in addition to general impulsivity symptom screen. Some examples:
  • Verbally impulsive, talks too much, says inappropriate things, gossips, verbal fights, no filter on what she discusses.
  • Early sexual activity, unwanted sexual encounters, vulnerability to sexual assault, STIs, near misses with contraception, unwanted pregnancies.
  • Legal problems, poor driving, online gambling, gaming, etc.
• Ask about inattentive behaviours. Some examples:
  • Distractibility because of problems keeping up with multiple tasks. Can’t listen to spouse or kids. Distracted at work due to stress/worries after hearing from school about their child.
  • Disorganization around the house and with the family. Messy. Embarrassed to have visitors.
  • Overwhelmed with managing everyday life. Can’t seem to hold it together.
  • Unable to manage stress, constantly feeling bombarded by the demands of life.
  • Sees self as unmotivated and lazy. Knows what to do but has no idea how to start.
  • Sees self as underperforming compared to peers in all life arenas, as wife, mother, professional, daughter, etc.

• If your patient is struggling during life transitions, consider that ADHD symptoms might play a role in this deterioration. ADHD can be more prominent and identifiable at this time. Use the ASRS to screen (Download). Some examples:
  • Moving out of family home and unable to pay bills, organize groceries, get to work.
  • Change in financial status because of debt/creditors. Impulsive spending on unaffordable items.
  • Becoming sexually active (at any age) and making ill-considered choices with resultant shame and substance use to cope. Susceptible to partner abuse.
  • Post-secondary school, failing first term, partying too much, not learning how to pace, getting depressed, dropping out, avoiding trying again. Or taking on too much and feeling overwhelmed and behind by end of the term.
  • Starting romantic life with a partner, focusing only on them, losing touch with friends, easily bored in the relationship, impulsively having an affair.
  • Pregnancy, feeling overwhelmed, post-partum mood issues, challenges staying connected to community supports.
  • Managing spouse and aging parental health challenges, feeling overwhelmed and unable to cope with added demand in the context of other tasks, anxious, and suicidal.
  • Neurodevelopmental conditions in biological children are overwhelming. Does nothing but address these issues. Has no time for anything else. Burned out, arguing with children and spouse. Challenges organizing appointments. No emotional reserves.

Consider comorbid conditions:

• In girls and women, emotional symptoms like mood reactivity and instability are often the reason they present for care. Consider that ADHD symptoms may be underlying.
• Treat the primary concern but screen for ADHD using the ASRS in adults or the SNAP-IV in children. (Note, both questionnaires use male norms.)
• ADHD is commonly comorbid with depression, anxiety, non-suicidal self-harm, borderline PD (BPD), substance use disorders, and suicide.
• Treated ADHD (e.g. in a patient with BPD) can improve engagement with therapy and capacity to learn skills.
• Consider ADHD especially if conditions remain problematic after psychotherapeutic and psychopharmacological treatment or when other treatments don’t work.

Treatment considerations:

• Medications for ADHD. See 2021 TCMP article on adult ADHD.
• If your patient seems unmotivated to attend psychotherapeutic treatment or doesn’t follow through, consider a comorbid ADHD diagnosis.
• Other health-care providers may see women with ADHD as lazy and unmotivated to engage in treatment.
• Women may feel overwhelmed by adding something else to their busy life, or they too, see themselves as lazy.
• Consider academic and work accommodations. Centre for ADHD Awareness, Canada (CADDAC) has helpful templates. See links below.
• Psychological interventions are an important component of treatment. Note the above areas to consider for impulsivity and inattention which lead to further lack of motivation and underachievement.
• Non-ADHD psychotherapeutic treatments address related challenges, e.g., sexual assault, couples therapy.
• Executive Function Treatment for adults is being piloted through CBTSkills.ca through a Shared Care Project.
• See below for a recent CADDRA Meta-Analysis of Psychosocial Interventions for ADHD. (View)

For further information please consult these recent reviews and consensus statements:

1. Young S, Adamo N, Ásgeirsdóttir BB, et al. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry. 2020;20:404-404. Accessed Oct 17, 2022. (View)
2. Hinshaw SP, Nguyen PT, O’Grady SM, Rosenthal EA. Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. J Child Psychol Psychiatry. 2022;63(4):484-496. doi:10.1111/jcpp.13480 (Request with CPSBC or view with UBC)
3. CADDRA Guidelines working group has just released a meta-analytic review of psychosocial interventions: Tourjman V, Louis-Nascan G, Ahmed G, et al. Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP. Brain sciences. 2022;12:1023. (View) Accessed Oct 17, 2022.

Additional resources

1. Centre for ADHD Awareness, Canada (CADDAC). (View) Accessed Oct 17, 2022.
   1. Workplace accommodations Download PDF
   2. Elementary school classroom accommodations Download PDF
   3. Secondary school classroom accommodations Download PDF
   4. Post-secondary classroom accommodations Download PDF
2. ASRS (Adult Self-Report Rating Scale V 1.1 WHO) Scoring Key is on greyed questionnaire. This form can be used for diagnosis, collateral (e.g. spouse completes) and medication efficacy. Download PDF Accessed Oct 17, 2022.
3. Canadian ADHD Resource Alliance (CADDRA). (View) Accessed Oct 17, 2022.
   1. ADHD Questionnaires https://www.caddra.ca/etoolkit-forms/
   2. SNAP-IV-26 Teacher and Parent Rating Scale (SNAP)
4. BC-based Cognitive Behavioural Therapy (CBT) Skills Groups https://cbtskills.ca/physicians/. Accessed Oct 17, 2022.

*In this article, ‘sex’ denotes biological male or female status (acknowledging that this designation is not a binary) and gender to depict the social and/or cultural roles applied to biological sex or the personal identification with such roles. The presentation of ADHD in transgender and gender non-binary individuals, although important, is outside the scope of this article.

References

1. Young S, Adamo N, Ásgeirsdóttir BB, et al. Females with ADHD: an expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC psychiatry. 2020;20:404-404. doi:10.1186/s12888-020-02707-9. (View)
2. Hinshaw SP, Nguyen PT, O’Grady SM, Rosenthal EA. Annual research review: attention deficit hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. J Child Psychol Psychiatry. 2022;63(4):484-496. doi:10.1111/jcpp.13480 (Request with CPSBC or view with UBC)
3. Chronis-Tuscano A, Molina BSG, Pelham WE, et al. Very early predictors of adolescent depression and suicide attempts in children with attention deficit hyperactivity disorder. Arch Gen Psychiatry. 2010;67(10):1044–1051. doi:10.1001/archgenpsychiatry.2010.127 (View)
4. Camara B, Padoin C, Bolea B. Relationship between sex hormones, reproductive stages and ADHD: a systematic review. Arch Womens Ment Health. 2022;25(1):1-8. doi:10.1007/s00737-021-01181-w (Request with CPSBC or view with UBC)
5. Baerg Hall E. Adult ADHD — practice tips. This Changed My Practice, UBC CPD. October 27, 2021. Accessed Oct 17, 2022. (View)
6. Roberts B, Eisenlohr-Moul T, Martel MM. Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology. 2018;2017;88:105-114. doi:10.1016/j.psyneuen.2017.11.015 (View)
7. Kittel-Schneider S, Quednow BB, Leutritz AL, McNeill RV, Reif A. Parental ADHD in pregnancy and the postpartum period – a systematic review. Neurosci Biobehav Rev. 2021;124:63-77. doi:10.1016/j.neubiorev.2021.01.002 (View with CPSBC or UBC)
8. Owens EB, Hinshaw SP. Adolescent mediators of unplanned pregnancy among women with and without childhood ADHD. J Clin Child Adolesc Psychol. 2020;49(2):229-238. doi:10.1080/15374416.2018.1547970 (View)
9. Dakwar E, Levin FR, Olfson M, Wang S, Kerridge B, Blanco C. First treatment contact for ADHD: predictors of and gender differences in treatment seeking. Psychiatr Serv. 2014;65(12):1465-1473. doi:10.1176/appi.ps.201300298 (View)
10. Kok FM, Groen Y, Fuermaier ABM, Tucha O. The female side of pharmacotherapy for ADHD – a systematic literature review. PLoS One. 2020;15(9):e0239257. Published 2020 Sep 18. doi:10.1371/journal.pone.0239257 (View)
11. Winter H, Moncrieff J, Speed E. “Because you’re worth it”: a discourse analysis of the gendered rhetoric of the ADHD woman. Qual Res Psychol. 2015;12:415-434. doi:10.1080/14780887.2015.1050748 (Request with CPSBC or view with UBC)
12. Nigg JT, Sibley MH, Thapar A, Karalunas SL. Development of ADHD: Etiology, heterogeneity, and early life course. Annu Rev Dev Psychol. 2020 Dec;2(1):559-583. doi:10.1146/annurev-devpsych-060320-093413 (View)
13. Shaw P, Sudre G. Adolescent Adolescent attention deficit hyperactivity disorder: understanding teenage symptom trajectories. Biol Psychiatry. 2021 Jan 15;89(2):152-161. doi:10.1016/j.biopsych.2020.06.004 (View)
14. Callahan BL, Shammi P, Taylor R, Ramakrishnan N, Black SE. Longitudinal cognitive performance of older adults with ADHD presenting to a cognitive neurology clinic: a case series of change up to 21 years. Front Aging Neurosci. 2021;13:726374. Published 2021 Nov 15. doi:10.3389/fnagi.2021.726374 (View)
15. Tourjman V, Louis-Nascan G, Ahmed G, et al. Psychosocial interventions for attention deficit hyperactivity disorder: a systematic review and meta-analysis by the CADRRA guidelines work group. Brain sciences. 2022;12:1023. doi:10.3390/brainsci12081023 (View)
16. Handy AB, Greenfield SF, Yonkers KA, Payne LA. Psychiatric symptoms across the menstrual cycle in adult women: a comprehensive review. Harv Rev Psychiatry. 2022;30(2):100-117. doi:10.1097/HRP.0000000000000329 (View)

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