Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders diagnosed in the United States with almost 6 million children and 8.7 million adults affected. Despite these numbers, there is growing concern that a significant part of the population is being overlooked and underdiagnosed: adult women. Why are adult women often left out of the equation? The reasons are multifaceted and include differences in behavior presentations across ages and gender, the presence of other mood disorders, and masking due to social gender norms.
ADHD diagnosis in children vs adults
Up until recently much of the attention paid to ADHD highlighted its prevalence in children (5-7% of the population worldwide) and more specifically male children, with most diagnoses occurring during childhood and adolescent years. This is likely because the classic external symptoms of ADHD (impulsivity, hyperactive behavior, inability to sit still, difficulty with sustained attention) become much more apparent when kids enter the school system. And now that more and more teachers and caregivers are aware of the behaviors involved with ADHD, they are more quickly able to notify families in hopes of providing that child with more support.
The adult prevalence of ADHD is lower than children and teens at 3-5%. However, there is far less conclusive research on adult ADHD, so it is difficult to decipher whether adults actually experience lower rates of ADHD or if they are simply being underdiagnosed and are not represented in the data. Indeed, it is estimated that only 20% of adults with ADHD have received a diagnosis and/or are being treated for the condition. Does this mean that adults with ADHD have less disruptive symptoms? Unfortunately, no. Not only do many adults still struggle with the same ADHD symptoms common in children, but their symptoms are also often compounded by comorbidities such as depression, substance use disorder, bipolar disorder, and anxiety. These issues can have a substantial negative impact on a person’s quality of life, so it is vital that adults with ADHD are accurately diagnosed and treated. Effective treatment of ADHD can often improve emotional stability, work performance, and relationship health.
When most people think of ADHD, they think of the qualities associated with the hyperactive subtype of ADHD. This subtype centers around external behaviors associated with hyperactivity and impulsivity such as excessive fidgeting, talking excessively, interrupting others, being constantly on the go, issues with impulse control, etc. In contrast, people who have a lesser-known subtype called “inattentive ADHD”, experience their symptoms internally. They often struggle with sustained attention, organizing activities, procrastination, initiating tasks, following through with projects, and distraction/forgetfulness. Combined ADHD is a third subtype of ADHD that has a mix of features from both the hyperactive and inattentive subtypes.
People with the inattentive form of ADHD are less likely to receive a diagnosis as this subtype can be harder to identify, especially during childhood. Whereas it is easier to identify hyperactive ADHD in a child who is constantly interrupting teachers or is unable to sit still, a child with inattentive ADHD is often staring out the window or lost in their thoughts. These latter behaviors are often chalked up to poor academic skills which can unfortunately lead to a lifetime of school frustration and apathy if that child does not get accurately diagnosed and helped. In adults, diagnosis of this subtype is compromised by co-occurring mood disorders such as anxiety and depression, and symptoms stemming from inattentive ADHD are often incorrectly correlated with the mood disorder rather than identified as ADHD.
Even though the behaviors between the subtypes can differ, their effects on executive functioning in the brain and on overall quality of life are the same. For this reason, it is vital that people with inattentive ADHD do not get overlooked and are able to receive the help they need.
How does gender play a role?
In clinical settings, males are diagnosed at a rate of five times that of females. Does this mean that boys and men or more prone to ADHD? Likely, no, or at least not at such a high rate. Similar to adult ADHD flying under the radar, there is evidence that suggests girls and women are also less likely to be identified as having ADHD despite meeting the same standards of diagnosis. This is partly because girls and women are more likely to have the routinely underdiagnosed inattentive subtype of ADHD. Additionally, studies have suggested that gender norms play a role. Culturally, girls are encouraged to be more conscientious in social settings and so are more likely to complete school tasks and follow instruction despite having issues with inattention and task initiation.
The mean age of women newly diagnosed with ADHD in adulthood is as late as 36 to 38 years old, likely due to comorbidities such as anxiety and depression masking their symptoms. These women often receive treatment for mood disorders that fail to make a notable difference in their ADHD symptoms, because the root of their problem was not accurately identified.
How do hormones play a role in ADHD in women?
Before understanding how hormones can affect ADHD, it is important to understand the role of dopamine in people with ADHD. Dopamine is a neurotransmitter in the brain that acts as the brain’s reward center. Dopamine interacts with other neurotransmitters and chemicals to influence mood and helps elicit feelings of pleasure, satisfaction, and motivation. It has been posited that people with ADHD have a dysfunctional dopamine system that ultimately results in low levels of dopamine. This can lead to feelings of depression, poor focus, and encourage pleasure-seeking behaviors to increase depressed dopamine such as drug addiction.
Estrogen increases the production of dopamine in the brain while also decreasing its rate of breakdown, helping to raise overall dopamine levels. The role of estrogen on dopamine synthesis therefore can mitigate the severity of symptoms in women with ADHD when present in adequate amounts. Progesterone has a more complicated relationship with dopamine. In the striatum and preoptic areas of the brain, progesterone can stimulate the release of dopamine following a pre-exposure to estrogen. In the prefrontal cortex, however, progesterone can inhibit dopamine release.
ADHD in Cycling Women
Because dopamine is partially influenced by the level of estrogen in the body, women may notice changes in their ADHD symptoms throughout their monthly cycles as estrogen levels fluctuate. In cycling women of reproductive age with ADHD, the first half of the menstrual cycle (the follicular phase) is often less symptomatic than the last half (the luteal phase). This is because estrogen is present at higher amounts during the follicular phase, while progesterone is at lower amounts. During the luteal phase, elevated progesterone can decrease the beneficial effects of estrogen on the brain resulting in lower overall dopamine levels and thus exacerbating ADHD symptoms.
ADHD in Perimenopause and Menopause
During perimenopause, levels of estrogen and progesterone start to decline. This period can last from a few months to up to 10 years as estrogen and progesterone levels fluctuate dramatically with an overall downward trend. Once a woman reaches menopause, her estrogen levels have dropped significantly as ovarian production of these hormones ceases. For women struggling with ADHD, this can be a time when they experience a noticeable exacerbation of their symptoms. Low estrogen levels mean less synthesis of dopamine, which causes a worsening of ADHD. Compounding this issue is estrogen’s role in serotonin production. Low levels of serotonin are linked to depression and so the drop in estrogen not only can exacerbate ADHD, it can also trigger or worsen depressive symptoms. As discussed earlier, comorbid mood disorders often make it more difficult for ADHD to be accurately identified in adult women as their symptoms are chalked up to anxiety and/or depression rather than ADHD.
Why an Integrative Approach Matters
We know that ADHD can have a direct and powerful impact on a person’s quality of life and their ability to function within relationships, social networks, and at work. Accurate identification of ADHD is vital so that women can get the support and help they need. For women, this necessitates an integrative diagnostic approach that digs further than the presenting symptoms to uncover how hormones, neurotransmitter health, societal expectations, and stress are playing a role. When the root cause remains buried, so does effective treatment.
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Ginsberg, Y., Quintero, J., Anand, E., Casillas, M., & Upadhyaya, H. P. (2014). Underdiagnosis of attention-deficit/hyperactivity disorder in adult patients: a review of the literature. The primary care companion for CNS disorders, 16(3), PCC.13r01600. https://doi.org/10.4088/PCC.13r01600
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