Chatty, Clumsy, Messy, Lazy, Shy, Ditzy—ADHD in Girls and Women
By: Julia Daley
For too many girls and women, these adjectives will sound familiar—yet they may not be signs of personal character flaws, but instead can be signs of unrecognized Attention Deficit/Hyperactivity Disorder (ADHD). It was believed for a long time that it only affected boys, the disorder in girls and women (and adult men) has been woefully under-studied by researchers, is often misdiagnosed by doctors, and is very much misunderstood by most people. Major research on the disorder in women goes back barely 20 years! The DSM-5, the current diagnostic manual used by the American Psychiatric Association, is still, broadly speaking, centered on the presentation of ADHD in young boys in its criteria for guiding doctors in making a diagnosis. If that sounds frustrating to you, you’re not alone—the more research I’ve done into this topic, the more infuriated I’ve become at the current state of ADHD research for those of us with two X chromosomes. Let’s take a closer look at what ADHD is, the neurological components behind the disorder, and the disparate impacts it has on the lives of girls and women with the condition.
Just What Is ADHD Exactly?
Attention Deficit/Hyperactivity Disorder, or ADHD, is a surprisingly misnamed disorder [1] that has more to do with executive dysfunction and low levels of norepinephrine and dopamine transmitters than a lack of attention or a surplus of physical energy. Individuals with ADHD can pay attention to things, sometimes too much so in the case of hyperfocus, but their ability to control or regulate their attention is impaired. A neurotypical person is able to decide what they will focus on, adjust how much they will focus on it, and can shift their focus to a new task with relative ease. All of this, however, is difficult for someone with ADHD—they can struggle to focus on things they’re uninterested in, or conversely focus too deeply on something to a degree that it can negatively impact their daily lives. At its core, this struggle to regulate attention originates in the ADHD brain.
[1] There’s a push to rename ADHD as VAST—Variable Attention Stimulus Trait—both to better describe the behaviors associated with the “trait” but also to help to destigmatize it.
There are a few key areas of the brain’s structure and neurochemistry, in particular, that seem to be behave differently in individuals with ADHD:
- Smaller prefrontal cortex (PFC). This part of the brain is the core of our executive functions, and is responsible for our ability to make decisions, be self-aware, empathize, and regulate emotions and behaviors; people with ADHD can struggle with all of the above abilities.
- Reduced volume in the posterior inferior vermis of the cerebellum. This part of the brain coordinates body movement, balance, and control. Those with ADHD often have delayed development in fine motor control and can be clumsier than others.
- Less gray matter in the caudate nucleus. This area is part of the basal ganglia and is believed to be important for motivation. Self-motivation can be a real struggle for those with ADHD.
- Hippocampus is larger than typical. This brain structure is believed to be our memory repository, housing both long-term and working memory. It’s hypothesized that the larger size is part of how the ADHD brain compensates for its other deficiencies.
- Failure to engage the anterior cingulate cortex during tasks. This part of the brain handles attention and where, when, and how long to focus on something. ADHD brains compensate by activating other regions, but these areas are not able to regulate attention as well.
- Default Mode Network (DMN) remains active during tasks. This is the “daydreaming” part of the brain that in neurotypical individuals only turns on when we aren’t actively doing anything. This may be part of the reason that people with ADHD have difficulty focusing.
- Deficiency in the amount of the neurotransmitters norepinephrine and dopamine. Neurotransmitters connect different neurons together—they are the messengers of the brain. Dopamine is used by the brain to make more norepinephrine. Both neurotransmitters are associated with the reward circuitry in the brain. This deficit may be why ADHD brains struggle with long-term motivation, focusing instead on short-term rewards.
The research on all of the differences in an ADHD brain vs a neurotypical brain is still very much in its infancy, but even this relatively short list of the major impacts should make it very clear that ADHD is a complex condition. There is now evidence to suggest that ADHD may be part of our DNA. That’s right—there may be genes involved in the development of ADHD, and it can run in families. It’s not at all uncommon for a parent to get their own ADHD diagnosis after their child receives one.
Diagnosing ADHD: The Gender Gap
As of yet, we cannot diagnose ADHD from a brain scan, so doctors and psychiatrists look instead to behaviors to determine if someone has the disorder. ADHD comes in three “flavors,” or presentations: hyperactive/impulsive type, inattentive type, and combined type (a mix of both inattentive and hyperactive/impulsive). For teachers, parents, and doctors, the behaviors of hyperactive/impulsive and combined types of ADHD are usually much more readily apparent in children, especially in boys, than in adults. Hyperactive behaviors include things such as fidgeting or squirming; an inability to sit still; talking loudly and often; and interrupting others’ sentences, questions, or conversations. Hyperactive/impulsive-type ADHD is noticeable as the behaviors associated with it can be disruptive in the classroom—these are the students who get referred for psychiatric analysis.
But what about the quiet daydreamer, sitting in the back of the room, completely lost in their own world? That inattentive student can be having just as much of a problem focusing on a lesson as a hyperactive one, but because they are not actively disrupting the classroom, their subtler form of ADHD is much less obvious. Other behaviors associated with inattentive-type ADHD include: disorganization, like a messy room or backpack; difficulty in completing longer, less-interesting tasks, like homework; seeming to “zone out” or not listen during conversations; regularly forgetting important things, like school materials, homework, keys, wallets, etc.; or work and homework that may be full of careless mistakes.
Although it’s now believed that males and females have the same chances of developing ADHD, the rates of diagnosis reveal a startling gender gap: boys are 2.5 times as likely to be diagnosed with ADHD as girls, whereas men and women are diagnosed at about the same rate. This means that ADHD goes undiagnosed in many women during childhood and is only identified later in their lives. If ADHD is a life-long neurobiological disorder[2], what then can explain this diagnostic gap between girls and boys? It comes back to the behaviors and how the different genders[3] present them.
Boys tend to be diagnosed most often with either hyperactive/impulsive-type or combined-type ADHD, and girls are more frequently found to have the nattentive type. As discussed earlier, the behaviors associated with hyperactive/impulsive and combined forms of ADHD are recognized more easily, meaning boys get referrals for their suspected ADHD more often than girls—this is known as referral bias.
Generally speaking, boys and men tend to externalize their ADHD symptoms, and these outward-focused behaviors are easier to detect. Girls and women, on the other hand, are likely to internalize their ADHD symptoms, which when paired with masking or coping strategies can make the signs harder to notice for parents, teachers, and doctors. Complicating things further, girls with undiagnosed ADHD often develop other psychological conditions like anxiety or depression, which can make it harder to spot the ADHD that is likely the root of their problems. Girls are most likely to be diagnosed first with depression or anxiety (or both) before ever receiving recognition of their ADHD.
[2] The possibility of adult-onset ADHD is considered controversial among researchers. For now, most researchers believe it to be a matter of late diagnosis in adults, rather than a newly developed condition.
[3] Most research on ADHD has been done on boys and, while more is now being done on girls, women, and men, the research on them is still limited. At this time, there is no research whatsoever on how ADHD can affect non-binary or transgender people.
ADHD in Girls and Women
At the end of the day, the diagnostic gap may well come down to the fact that ADHD can just look different in girls and women than it does in boys and men. There are some behaviors that tend to be more pronounced in, or even unique to, girls with ADHD that are not fully accounted for in the DSM-5, meaning that doctors are more likely to overlook them. For example, females with ADHD often have somatic, or physical, symptoms like stomachaches and headaches. Instead of running around the room, hyperactivity behaviors in girls might present instead as talking fast, twirling hair, picking cuticles (and other body-focused repetitive behaviors), having racing thoughts (which can lead to insomnia as well), or even hypersexuality (which can lead to risky sexual behaviors). For more on how ADHD presents in girls, I recommend watching this video; for more on what ADHD looks like in women, I’d recommend starting with this video.[4]
[4] I cannot recommend enough the “How to ADHD” channel on YouTube by Jessica McCabe for informative and brainy videos on different aspects of living with ADHD. Her TEDx Talk is also phenomenal!
Many girls and women with ADHD mask their symptoms, often due to societal pressure to appear as “normal” as possible. These compensatory behaviors can do a good job of hiding ADHD in girlhood and even into young adulthood and are likely part of the reason so many girls’ ADHD goes unrecognized. Masking, however, takes its own cognitive toll. It takes a lot of sustained effort and concentration to maintain a mask during the day; and these are already two areas of cognition that people with ADHD brains struggle with. Keeping the mask up can be exhausting and stressful and further exacerbate symptoms of ADHD.
There is still so much that we don’t know about how hormones impact ADHD in both men and women. Research is only just starting to tease out how fluctuating estrogen and progesterone levels throughout the month and also through a woman’s lifetime can have profound effects on ADHD symptoms. Estrogen encourages the body to release more serotonin, dopamine, and glutamate—all neurotransmitters that we associate with feeling good, motivated, and excited—and decreases production of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits neural activity, helping you to feel calmer. Taken together, higher estrogen levels are associated with improved learning outcomes and better attentional focus. Progesterone, on the other hand, is associated with lower glutamate, dopamine, and norepinephrine levels—the neurochemicals that are already lower-than-typical in people with ADHD.
Pre-pubescent girls have low levels of both estrogen and progesterone. This means that, for girls in this age group who are diagnosed with ADHD, treatment with stimulant medication can be easier as the steady hormone levels means there’s not too much fluctuation in neurotransmitter levels.
Things become more complicated during puberty, not only because of the rush of hormones that that life stage entails, but also because for many girls it means the beginning of menstruation. During the typical 28-day menstrual cycle, estrogen and progesterone levels can change drastically. During the first two weeks, or the Follicular Phase, estrogen levels go up and progesterone levels go down; more estrogen means more dopamine and norepinephrine, which means that women will have less noticeable ADHD symptoms during this phase. However, in the latter two weeks of the cycle—the Luteal Phase—estrogen levels drop, and progesterone levels rise; not only does this phase mean a worsening in ADHD symptoms, but it can also reduce the effectiveness of the stimulant medication used for treating ADHD. This monthly fluctuation in hormones means that medication dosage may need to be adjusted throughout the month to help girls and women better manage their ADHD.
Pregnancy, childbirth, perimenopause, and menopause also have large impacts on a woman’s hormones and ADHD. These can cause changes in their symptoms, and even lead to the development of new ones, like memory or sleep problems. ADHD that might have been manageable beforehand can suddenly seem overwhelming. Women can feel as if their lives are falling apart. Only then do many start to seek outside help for what, in many cases, turns out to be undiagnosed ADHD.
The Harms of Un-Diagnosed and Undertreated ADHD
Much of what we know about the long-term effects of ADHD on girls and women comes from the research by Dr. Stephen Hinshaw. His ongoing longitudinal study of the 228 “B-GALS” has already yielded some disturbing results that have helped to trigger calls for more research into women’s and girls’ ADHD. I recommend watching the video below to hear Dr. Hinshaw describe some of the latest research on some of the risks of female ADHD:
However, I’ll also summarize his research, from my understanding of it. As of this writing, the female participants have been studied four times: first in childhood (ages 6-12), then in adolescence (ages 11-17), followed by early adulthood (ages 17-24) and most recently in rising adulthood (ages 21-29). The participants were divided into two groups: neurotypical girls, and girls with ADHD. In the first observation, Hinshaw and his team found that the girls with ADHD were far more impaired in their executive functions when compared with the control group, and they were about as impaired as boys with ADHD. In adolescence, while the obvious behaviors of the girls with ADHD seemed to have improved (perhaps because of masking, or growing maturity, or both), all areas of their lives still showed significant impairments versus the neurotypical girls. It’s in these later observations, in early and rising adulthood, that the results became alarming: by large margins, the girls with ADHD were more likely than their neurotypical peers to have engaged in self-harming behaviors, to have attempted suicide, to be in abusive relationships, and to have unplanned pregnancies. In addition, the young women (ages 21 – 29) with ADHD were less likely to have completed college and were having lots of problems getting and keeping jobs.
Building on Dr. Hinshaw’s work, more researchers are finding similarly negative outcomes across a wide range of areas for women with ADHD. They are twice as likely to experience major depressive episodes, they tend to have fewer friends, and they are at higher risk of being victims of domestic violence than their neurotypical peers. Girls with ADHD are more likely to experience social isolation and bullying as navigating social situations is more challenging for them. They may take this social rejection harder than neurotypical girls, as ADHD often comes with Rejection Sensitive Dysphoria (RSD), which means that criticism can lead to feelings of intense, even extreme, emotional and physical pain. This strong reaction to negative feedback may be partly due to the difficulties people with ADHD have with regulating their emotions. Behaviors associated with RSD include obsessing over previous “failures,” incorrectly interpreting feedback as rejection, acting as if even a small mistake is a catastrophe, perfectionism or people-pleasing, and avoiding behaviors or situations due to the perceived risk of failure.
Remember, girls and women have a tendency to internalize their ADHD symptoms. That means they are more likely to blame themselves when things in their life go wrong, self-assigning to themselves character flaws that can become self-fulfilling prophecies. This terrible self-image can be very hard to change once it becomes fixed.
Yet many, if not most, of these harms can be avoided if only girls’ ADHD was recognized and treated as early as possible. Fortunately, research has shown that stimulant treatment is just as effective for girls as it is for boys (though it requires adjustment throughout their lifespans as hormones fluctuate). Medication alone isn’t the magic cure, of course—best practice is to pair stimulant medicines with things like Cognitive Behavioral Therapy or peer support groups. The medicines help to ease ADHD symptoms, and the therapy can teach girls and women strategies for better managing their ADHD brains. All of this, however, depends on girls’ ADHD being recognized promptly.
What This Means for Teachers
And that’s where teachers can come in. Children’s ADHD symptoms are often recognized first by teachers, as the demands and structure of school can make the behaviors associated with executive dysfunction most apparent. It’s not our job to diagnose ADHD—of course!—yet we can help parents and doctors find supporting evidence for a students’ possible ADHD based on our observations in our classroom. As teachers, we need to throw away our outdated stereotypes of what ADHD looks like—loud, rambunctious, disruptive boys—and recognize that it can come in many forms. We should do our best to notice the subtler signs and behaviors of ADHD in our students, both girls and boys. No matter the presentation—hyperactive/impulsive, inattentive, or combined—students with ADHD can face significant impairments that, if not recognized and treated early enough, can have tragically cascading impacts on their futures. At the end of the day, we all want our students, neurotypical and neurodivergent alike, to have successful lives.
Julia Daley is a senior lecturer at Hiroshima Bunkyo University and received her Masters in TESOL from Northern Arizona University. She’s taught English writing and conversation in many classrooms in the US and Japan. She learned only two years ago that her brain has less norepinephrine receptors than typical.