Undiagnosed ADHD in Adult Women: The Silent Struggle and Its Implications

 

Historically, ADHD was thought to affect boys far more frequently than girls, with a childhood diagnosis ratio of about 3:1. However, in adulthood, this ratio narrows significantly to almost 1:1, suggesting a glaring underdiagnosis of ADHD in girls (Da Silva et al., 2020). According to the American Psychiatric Association (APA, 2013), ADHD is one of the most common psychiatric disorders in childhood, causing cognitive difficulties and functional impairments. Yet, many women grow up without an ADHD diagnosis, spending their lives feeling “different,” “stupid,” or “lazy,” and blaming themselves for their underachievement (Lynn, 2019).

 

 

For women, receiving an ADHD diagnosis can be a transformative experience. It often serves as a "lightbulb moment," providing an external explanation for their lifelong struggles and enabling them to accept themselves more fully (Stenner et al., 2019). Early detection and treatment of ADHD can dramatically alter outcomes, reducing academic and professional underachievement, relationship difficulties, and psychiatric comorbidities (Quinn, 2004; Sassi, 2010).

 

 

ADHD is described as a developmental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity that are developmentally inappropriate and impairing (APA, 2013). There are three main presentations of ADHD: inattentive, hyperactive-impulsive, and a combination of both. The disorder affects 5% to 10% of school-aged children and persists into adulthood, impacting 2% to 6% of the global population (Song et al., 2021).

 

 

Societal norms play a crucial role in how ADHD is perceived and diagnosed. Girls are often encouraged to display “feminine” behaviors such as empathy, organization, and obedience (Holthe, 2013). Consequently, when girls exhibit ADHD symptoms like impulsivity and disorganization, they face higher risks of social judgment for violating these norms (Holthe, 2013). Many girls with ADHD exert considerable effort to mask their symptoms to avoid social sanctions (Waite, 2010).

 

Differences in Symptom Presentation: Girls are more likely to be diagnosed with ADHD-Inattentive (ADHD-I), presenting symptoms such as distraction and forgetfulness (Nussbaum, 2012), whereas boys more frequently present with ADHD-Hyperactive/Impulsive (ADHD-HI), showing greater levels of hyperactivity and aggression (Waite, 2010). These disruptive behaviors in boys often lead to higher referral rates for ADHD assessment compared to girls (Waite, 2010).

 

 

Mowlem et al. (2018) found that clinical diagnosis of ADHD was more common in boys. Their study revealed that 72% of diagnosed children were boys, while 12.9% who met the symptom criteria for ADHD did not have a formal diagnosis. Of these undiagnosed participants, 36% were girls, indicating significant gender differences in diagnosis rates.

 

Externalizing vs. Internalizing Behaviors: Externalizing behaviors are a stronger predictor of ADHD diagnosis in girls than boys. Girls displaying significant externalizing behaviors are more likely to receive a diagnosis compared to those with internalizing symptoms alone (Mowlem et al., 2018). This suggests a bias in current diagnostic criteria and clinical practices, which are more attuned to the male presentation of ADHD.

 

 

Physicians may lack awareness of gender differences in ADHD, leading to overlooked diagnoses in women and girls (Quinn, 2008). Females with ADHD often seek treatment for mood and emotional problems, which can mask ADHD symptoms and complicate diagnosis. Higher rates of comorbidities such as depression and eating disorders further cloud the diagnosis (Quinn, 2008).

 

 

Klefsjö et al. (2021) found that girls had more psychiatric care visits before receiving an ADHD diagnosis and were prescribed non-ADHD medications at higher rates compared to boys. Girls were also older at the time of referral and diagnosis, indicating a higher threshold for symptom severity before recognition. This delay can lead to significant impairment before girls are referred for assessment.

 

 

Gender bias also exists in the perceptions of parents and teachers, impacting referral rates. Ohan and Visser (2009) conducted a study where participants read vignettes describing a child with ADHD symptoms, differing only in the child's gender. Both parents and teachers were less likely to seek or recommend services for girls than boys.

 

 

Hartung and Widiger (1998) reviewed studies published in the Journal of Abnormal Child Psychology and found a significant gender bias in participant selection. Of the studies examined, 81% of participants were male, and only 19% were female. This bias in research further skews the diagnostic criteria, making it less representative of females with ADHD.

 

 

Living undiagnosed until adulthood can have lasting effects on social-emotional wellbeing, relationships, and feelings of control. Women with undiagnosed ADHD often struggle with low self-esteem, increased anxiety, and significant social stigma (Young et al., 2020). They are also at higher risk for risky sexual behavior, unplanned pregnancies, and being coerced into sex, which can limit occupational opportunities and increase vulnerability to exploitation and abusive relationships.

 

Household and Parental Duties: Societal expectations often place more household and parental responsibilities on women. These increased demands can exacerbate impairment and anxiety in women with ADHD, leading to dysfunctional beliefs such as perceived failure and guilt (Young et al., 2020).

 

 

For many women, the journey to an ADHD diagnosis is complex and challenging. Some begin seeking a diagnosis after their child is diagnosed, while others start by seeking treatment for comorbid conditions like depression or anxiety (Stenner et al., 2019). Self-diagnosis is also common, as women identify with ADHD symptoms and seek professional confirmation. However, many feel the need to prove their symptoms for physicians to take them seriously (Stenner et al., 2019).

 

 

Findings from the current review highlight the need for more research into adult ADHD diagnosis in women. Undiagnosed ADHD in childhood can have lasting negative consequences into adulthood. Accurate and timely diagnosis can profoundly improve the lives of women and girls with ADHD, allowing them to stop self-blaming and lead more fulfilling lives.

 

Undiagnosed ADHD in women is a significant issue that requires greater awareness and understanding. Gender bias in diagnostic criteria, societal norms, and clinical practices contribute to the underdiagnosis of ADHD in girls and women. Addressing these biases and improving diagnostic practices can lead to timely interventions, reducing the long-term impacts of ADHD on women's lives.

 

It is imperative that educational institutions, mental health practitioners, and society at large recognize and address the unique challenges faced by women with ADHD. By doing so, we can ensure that these women are not left out of the ADHD narrative and receive the support they need to thrive.