ADHD and Women: Call for Gender Equity in Health Research

Study: Complex ADHD More Common in Women and Girls, Leading to Later Diagnoses

Nicole Kear — Thu, 30 May 2024 13:20:29 +0000

May 30, 2024

Females are more likely than males to have complex presentations of ADHD, potentially leading to delayed diagnosis and treatment, according to new research published in the Journal of Attention Disorders. The study found that females with ADHD are more likely than males to have inattentive ADHD, are diagnosed at older ages, and have higher rates of anxiety and depression diagnoses both before and after their ADHD diagnoses. ¹

The retrospective observational study was conducted using data from four U.S. health databases. The researchers sought to explore the relationship between sex as well as ADHD subtype and diagnosis timing. They also hoped to assess whether receiving an ADHD diagnosis had an impact on pre-existing diagnoses of depression and anxiety in women and girls, who receive treatment for these comorbidities at higher numbers.

Age of ADHD Diagnosis Rates by Sex and Subtype

The study revealed:

The average age of ADHD diagnosis by gender:
- Females:16 to 29 years
- Males: 11 to 23 years
Across both sexes, the average age of diagnosis by ADHD type:
- Inattentive Type: 17 years to 27 years
- Hyperactive impulsive Type: 10 years to 20 years
Females were substantially more likely than males to be diagnosed with inattentive ADHD

How Mood Disorders Fit Into the Diagnostic Picture

Females were twice as likely as males to have depression or anxiety diagnoses and treatments in the year before their ADHD diagnosis.
Females were more likely than males to receive new diagnoses or treatments for depression or anxiety in the year following an ADHD diagnosis.
The number of females with pre-existing depression or anxiety diagnoses with symptoms that did not continue after their ADHD diagnosis was higher than the number of males. In these cases, ADHD may have been misdiagnosed as anxiety or depression.
Patients with inattentive ADHD were more likely to receive a prior diagnosis of depression or anxiety:
- Inattentive ADHD: 13% to 18% (depression) and 17% to 26% (anxiety)
- Hyperactive impulsive ADHD: 5% to 12% (depression) and 9% to 20% (anxiety)

Repercussions of Delayed Diagnosis

The study’s finding that females are diagnosed five years later than males, on average, together with other key data points lead researchers to conclude that diagnoses in females tend to occur “only once ADHD symptoms become more severe,” and underscores the importance of addressing this gap in health equity.

The consequences of undiagnosed ADHD are dire, especially for women.

“Women who live undiagnosed until adulthood experience significant negative outcomes in the areas of self-esteem, social interaction, and psychosocial wellbeing beginning in childhood and continuing into adulthood,” concluded the authors of a systematic review of research published in March 2023. “Women in these studies engaged in less task-oriented coping and more emotion-oriented coping and often turned to recreational drugs, alcohol, nicotine, and sex to self-medicate for symptoms of undiagnosed ADHD.” ²

A female ADDitude reader explains the lived experience of late diagnosis this way: “I have lived with the misleading belief that I was a loser, lazy, incompetent. What are the long-term impacts of these self-defeating beliefs?”

The Complicating Presence of Mood Disorders

The connection between ADHD and mood disorders, including depression, is well-established. According to a recent study in BMJ Mental Health: ³

People with ADHD are 9% more likely to have MDD
An MDD diagnosis increases the risk for ADHD by 76%

These findings are echoed in the responses to a recent ADDitude survey of 6,810 adults, which found that 72% reported having anxiety and 62% having reported depression.

In addition to the over-representation of mood disorders among individuals with ADHD, previous research has documented that women in general are twice as likely as men to suffer from MDD and General Anxiety Disorder (GAD).

While rates of mood disorders are unequivocally higher among women with ADHD than either men with ADHD or women without the condition, the new study lends credence to what many women have reported anecdotally: They are also more likely than men to have ADHD initially misdiagnosed as depression or anxiety.

“Because of stigma and thoughts related to gender role presentations, when females do present with ADHD symptoms, it can be thought that it’s more likely due to anxiety or depression, because those are presentations that people are used to seeing in females early on,” explained Dave Anderson, Ph.D., in the ADDitude webinar “ADHD Then and Now: How Our Understanding Has Evolved.” “So, people say, ‘She’s distracted because she’s anxious or sad,’ not because she has ADHD. That’s something that we’re actively trying to fight, even in clinician bias.”

The new study, and research like it, helps shed light on the unique toll exacted on women by ADHD. More investigation is desperately needed, explains Dawn K. Brown, M.D., in the ADDitude article, We Demand Attention! A Call for Greater Research on Women with ADHD.

“Further research regarding these topics is indeed crucial,” Brown explains. “By conducting in-depth investigations into the gender-specific nuances of ADHD presentation and impact, healthcare professionals, policymakers, and advocates can promote greater awareness, understanding, and tailored support for women with ADHD.”

Read on to learn about the Top 10 research priorities detailed in ADDitude’s groundbreaking, cross-platform initiative : We Demand Attention! A Call to Action for Greater Research on Women with ADHD.

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

Sources

¹ Siddiqui, U., Conover, M. M., Voss, E. A., Kern, D. M., Litvak, M., & Antunes, J. (2024). Sex Differences in Diagnosis and Treatment Timing of Comorbid Depression/Anxiety and Disease Subtypes in Patients With ADHD: A Database Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547241251738

² Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders, 27(7), 645-657. https://doi.org/10.1177/10870547231161533

³ Meisinger, C. & Freuer, D., (2023) Understanding the Causal Relationships of Attention Deficit/Hyperactivity Disorder with Mental Disorders and Suicide Attempt: A Network Mendelian Randomisation Study. BMJ Mental Health. doi.org/10.1136/bmjment-2022-300642

Duke Project Narrows Top Research Priorities for, and by, Women with ADHD

Anni Layne Rodgers — Fri, 24 May 2024 02:03:42 +0000

May 24, 2024

The most urgent and important areas of medical research on women with ADHD include the following:

Hormonal Influences: Understanding how hormones impact ADHD presentation and treatment in girls and women
Aging and Cognitive Decline: Investigating the connection between aging, cognitive decline, and ADHD in post-menopausal women with ADHD
Misdiagnosis and Late Diagnosis: Exploring the unique harms of misdiagnosis or later-in-life diagnosis of ADHD in women
Executive Function Challenges: Studying how executive functioning challenges (e.g., organization, prioritizing, time management) manifest in girls and women with ADHD

These research priorities emerged from the interim results of a survey conducted by the Duke Center for Girls & Women with ADHD last month. The online survey asked respondents to rank 46 unique health research according to their personal importance, revealing broad consensus among women of various ages and socioeconomic backgrounds. To date, 1,350 people have completed the survey.

For women with ADHD in their 20s, 30s, and 40s, the top research priority was understanding the role of hormones in ADHD symptoms and treatment. Women aged 51 and older prioritized research on the interplay between ADHD, aging, and cognitive decline after menopause.

These findings complement those of ADDitude’s recent survey of 705 women with self-reported ADHD, 69% of whom said their quality of life would be most significantly impacted by research on “how the hormonal changes of perimenopause and menopause affect ADHD symptoms.” The survey respondents also expressed frustration by the historical lack of recognition of ADHD in women and girls.

“Surely I’m not seeing something that the actual scientists can’t,” wrote one ADDitude reader in response to an Instagram post calling for greater research on hormones and ADHD. “We know that dopamine levels are directly correlated with estrogen levels. It seems obvious that the Estrogen Rollercoaster we live on would have a huge impact on our symptoms, no?”

Among post-menopausal women who completed the Duke Center’s survey, their research priorities shifted to also include studies on the psychological, emotional, and long-term health implications of late diagnosis, including:

The impact of ADHD on girls’ and women’s beliefs about themselves
Specific considerations for therapy for women who were diagnosed with ADHD later in life

“I was an older woman (60+) when I realized that ADHD is real and that I have it,” wrote one respondent to ADDitude’s survey on research priorities. “I have lived with the misleading belief that I was a loser, lazy, incompetent… What are the long-term impacts of these self-defeating beliefs? Where does one this old go for help this late in life?”

Another woman lamented clinicians’ failure to understand, diagnose, and treat women for ADHD. “Most people going through menopause have not been allowed to have ADHD according to the DSM,” the woman said in response to an Instagram post calling for greater research on menopause in women with ADHD. “When we were kids, we had to be male and physically hyperactive [to get an ADHD diagnosis]. Born female before the late ‘80s, you had to be a sodding unicorn to be diagnosed. Seeing as we’ve only been in the club for a few years, why would anyone think to have looked?”

Quantifying ADHD Research Needs

Of the 1,350 survey responses included in the Duke Center’s early results, 1,128 came from adult women who self-identified as living with ADHD. The majority of these women were White, lived in mostly urban or suburban regions, and reported that they did not experience significant financial hardship. A third of the sample were of “childbearing age” (i.e., ages 24-40), more than half were in their 40s and 50s, and 37% were 60 and older. A small minority (2%) were “young adult” women (ages 18-23).

The majority (N=429, 38%) of the sample identified as not yet starting menopause, 35% (N=392) were perimenopausal or in menopause, and 285 respondents (25%) identified as being post-menopausal.

Research Priorities for Girls with ADHD

More than 400 survey respondents identified as being a parent of a daughter with ADHD. The Duke Center used their responses as a proxy for the top child-specific research priorities for girls with ADHD, which included the following:

Investigating the reasons why girls with ADHD experience heightened rejection sensitivity
Exploring how teachers’ understanding of ADHD presentation in girls can be different from boys, and how this unique presentation impacts identifying and supporting girls with ADHD in school
Understanding the impact of social development delays in girls with ADHD
Studying the challenges of identifying, supporting, and advocating for girls with ADHD in education settings
Researching effective learning environments, teaching approaches/school accommodation, and strategies for girls with ADHD

Other Notable Findings

Women in their 20s and 30s were the only respondents to rank “unique medication concerns for girls and women with ADHD” as one of their top priorities. They also identified “workplace accommodations and strategies that are most helpful for women with ADHD” as especially important, a theme that was not prioritized as highly by other groups.

Post-menopausal women were in the only group to rank “impact of ADHD on girls’ and women’s beliefs about themselves” as one of their top four priorities.

Given that 90% of the sample of adult women with ADHD identified as White, and 95% identified as non-Hispanic, the researchers were unable to examine whether different races or ethnicities prioritized themes differently. Additional recruitment of more diverse groups is under way.

Research by the Duke Center for Girls & Women with ADHD is supported by a Patient-Centered Outcomes Research Institute (PCORI) Engagement Award (EASCS-26478), which aims to learn from girls and women living with ADHD — as well as from the people who love and support them — about the research areas that are the most important to them. The center’s mission is to advance education about the unique needs of girls and women with ADHD across the lifespan.

ADHD Symptoms in Adult Women: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Top 10 Research Priorities According to ADDitude Experts, Readers

“How I Restarted My Life After a Post-Menopausal ADHD Diagnosis”

Nathaly Pesantez — Wed, 22 May 2024 09:45:30 +0000

The First 50 Years

Why am I like this? Why is everything such a struggle?

These are the questions that would plague me as soon as I’d wake up. There would be an avalanche of tumbling thoughts accompanied by fruitless resolutions to do better today than I did yesterday and most of the days of the past 50 years of my life.

Shoulds and have-tos mounted before I even sat up in bed. Procrastination began immediately. Today, I’d proclaim, I’ll start getting ready as soon as I have my coffee. But… I didn’t. Merely getting into the shower was a battle. By the time I was ready, I was already running behind. Again.

Most of the days in my life looked like this. I’m an adult, I’d tell myself. I’ve been an adult for decades. So why can’t I ever manage to plug my intentions into my motor cortex and just DO things without an epic struggle through resistance?

As Brené Brown told Tim Ferriss: “Midlife… is not a crisis. It’s a slow, brutal unraveling.” For most of my life, cycles of procrastination and panic-induced productivity got me through things — more or less. But when I reached midlife, burnout was increasingly winning these battles. My old constant companion, anxiety, was just sort of there, hanging out like the parasite it was. Cranked up to 11, yes, but what good was it if it could no longer motivate me like it used to?

The Midlife Shift

Today, when I wake up, there’s no wave of anxiety, no dread of getting out of bed. I pour a cup of coffee and sit at my window, watching the birds. I take my time in the morning. My one rule for early mornings is to not engage in screen time right after waking. I sit and sip and let my mind wander.

[Download This Free Guide to Menopause and ADHD]

After journaling and meditating, it’s time for breakfast. I get ready at my own pace. My morning routine takes a long time, but I can afford to take my time. I schedule my days to allow it, because this is what my mind and body want. This sets the tone for the day.

Then comes work. I step gently through my to-do list, taking breaks when I need to. I switch tasks, working for a short block at each. The pacing is enough to prevent boredom and frustration, while still giving each task enough time to make some progress. I’m so much more consistent than I used to be; I make a little progress on each project each day. No more default procrastination, unable to start a task until I’m right up against — or past — an appointment or a deadline, then relying on intense stress to push through.

What changed?

An ADHD Diagnosis After Menopause

I was diagnosed with ADHD at the age of 52. Like many women with ADHD, I was diagnosed after menopause, when a drop in hormones makes symptoms much more apparent. Despite no medical professional ever spotting it before, my ADHD, as my diagnostician put it, “isn’t subtle.” He had to walk me through a meltdown over the phone when I couldn’t get through the questionnaire for my evaluation.

I’ll never forget the sense of gratification and relief I felt as I looked at his report. I read his clinical judgments for the degree of impairment for each symptom: “Severe.” “Severe.” “Severe.” Or sometimes, “Moderate to severe.”

[We Demand Attention: A Call for Research on ADHD and the Menopausal Transition]

After learning what having ADHD really meant — being wired for executive functioning difficulties — I was finally able to be compassionate and accepting toward the way I operated. My struggles and limitations started to make sense.

Starting Over

I tried a thought experiment: What if I start to regard all my supposed flaws and weaknesses — my absentmindedness, my inability to focus, the way I was always running late, how desperately hard it was to start any task — as features I simply have to work with, with no moral condemnation attached to them?

This was a major reversal from the way I had previously moved through my life. This meant starting over with a mindset that I hadn’t had since almost before my earliest memories. And with that, everything shifted.

I started to schedule around my energy levels, instead of what I thought I “should” be able to do. For example, I stopped thinking of 40-hour (or more) work weeks as somehow being optimal. Instead, I asked myself what I could do with part-time hours, so that I could live without constant burnout.

By understanding executive dysfunction and the constant fatigue of working with a very messy high-octane brain, I radically dialed back my demands of myself. I learned to work within my window of tolerance.

I stopped thinking of my energy limits as temporary obstacles, to be dismissed or plowed through. This was my wiring. It’s not going to change. This is what I have to work with.

Midlife ADHD and Menopause: Next Steps

Free Download: Women, Hormones, & ADHD
Read: ADHD Impairment Peaks in Menopause
Read: Hormonal Changes & ADHD — A Lifelong Tug-of-War

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“11 Things I’d Tell My Younger Self”

Nathaly Pesantez — Tue, 14 May 2024 08:02:42 +0000

When I was diagnosed with ADHD in my 40s, I looked back at my life with a new set of eyes. My heart broke for the child I was. Messiness, time blindness, compulsive hyperfocus, emotional dysregulation, and rejection sensitivity were all things I’d internalized as my personal failings and default personality traits rather than what they really were: ADHD symptoms.

For most of my life, I did not have the knowledge I needed to understand myself and counterbalance pervasive negative messaging that made me feel inherently defective and ashamed. Post-diagnosis, it still takes a lot of effort to notice and rectify harmful, anti-neurodivergent messaging from those close to me and from wider society.

I’ve been on a journey to drain my seemingly bottomless pool of shame, and it’s not a linear process. There are days I revert to child-me, hiding in my bathroom, feeling small, powerless, and voiceless. What helps me is to speak to that little girl and tell her all the things I wish I heard growing up — things that would have helped me break the difference = shame equation that crystallized in my young mind.

Dear Younger Self: What All Girls with ADHD Need to Hear

1. You are strong. Strength is not the absence of fear. Strength is having fears and going outside your comfort zone anyway. It takes strength and courage to show your vulnerability. Your differences, challenges, and even your perceived blunders are signs of strength and determination!

2. There’s no singular “right way” of doing things. There are many ways to do things and many paths to get you where you want to go.

[Read: What Are the Consequences of Late-Life ADHD Diagnoses for Women?]

3. Some things are super hard, and you can ask for help if you need it. Asking for help doesn’t mean you are a failure, or that you are weak or a burden to others. I know you want to push through all on your own, because people always tell you to “try harder” or “have more discipline,” which makes you feel guilty. To be honest, that’s bad advice because they don’t know how hard you’re trying. I really need you to not be so hard on yourself, to learn to ask for help – everyone struggles with some things in life and it’s OK. And when you find yourself struggling, remember that you have plenty of other strengths and skills to celebrate!

4. Trust yourself! Your intuition – it is trustworthy. Your feelings – they are valid. Your voice – you don’t need permission to use it, and it’s OK to struggle to express yourself verbally; it’s something that takes practice and you’ll get better at it.

5. Shame tells us to hide. Don’t. Look it in the eye, say no, thank you, and tell it to leave. I know you try hard to be a “good girl” and make your parents proud, but it’s OK to break out of the mold and color outside the lines. You have a right to claim space. You have things to show and teach the world! Let people know the real you!

6. You are not alone in your feelings. If you feel lonely, insecure, or misunderstood, chances are others do, too! Sometimes you can have a lot of feelings, and it can be tough to contain them all. When you share how you feel, it helps you make sense of your emotions. And you give others the chance to help you, and to share their vulnerabilities.

[Read: 42 Raw Confessions from Women with ADHD]

7. It’s a beautiful thing to be a sensitive soul. You feel things deeply, you tune into people’s emotions, and wear your heart on your sleeve. That’s not a bad thing, though it does mean you can feel hurt and rejected when others don’t treat you the way you want to be treated. Just remember people have different levels of sensitivity. Some people struggle to be sensitive, while you have easy access to this quality and the gifts it presents, like being creative and empathetic.

8. Don’t try to be like everyone else. It’s normal to want to fit in with others, especially when you are growing up. But people love you for who you are. They love your light, your creativity, your uniqueness. Continue being your playful self!

9. You don’t need to be perfect to be loved. You are enough. Just the way you are. Enjoy the process rather than focusing on the results. Embrace imperfection — it will teach you to let go of self-criticism. It’s totally OK to be imperfect and to fail, and you will still be loved and accepted for who you are.

10. I am proud of you. Your value is not in what you achieve, but in who you are as a person. Your heart and your spirit. I am proud of who you are. I am proud of you for always trying things even though they may be hard for you.

11. I love you!

Spoiler alert: I still struggle and I don’t have it all figured out. I still need to repeat these nuggets of advice to myself each day. But the imaginary exercise of speaking to my younger self has helped me to understand where my limiting beliefs came from and to choose the words that help change my narratives.

Unlearning ingrained thought patterns is hard work. But repeating these things to myself and being my own advocate has made me kinder to myself and more authentically me. I hope it helps you, too.

I also made a comic about this very topic! You can read it in full here.

Healing Your Inner Child: Next Steps

Read: “Dear 10-Year-Old Me, Just Be You.”
Join ADDitude’s Call! We Demand Attention on Sex Differences in ADHD
Read: Stop the Cycle of Shame for Girls with ADHD
Read: How to Raise a Self-Confident Daughter

Illustrations courtesy of Juliette Yu-Ming Lizeray.

42 Raw Confessions from Women with ADHD

Nathaly Pesantez — Sun, 12 May 2024 08:41:41 +0000

ADDitude asked its readers: What do you wish the world knew about being a girl or woman with ADHD? More than 600 of you responded.

We Demand Attention on Understanding Why Comorbid Conditions Like Anxiety and Depression Uniquely Impact Women with ADHD

Anni Layne Rodgers — Mon, 06 May 2024 23:17:18 +0000

What We Know

Women with ADHD suffer from serious comorbid conditions with more frequency and severity than do men with ADHD or the neurotypical population.

A staggering 93% percent of women with ADHD report at least one related diagnosis, according to a 2023 ADDitude survey. The most common comorbidities among women were:

Anxiety (73%)
Depression (63%)
PTSD or c-PTSD (23%)
Migraines (22%)
Sleep disorder (18%)
Eating disorder (15%)
PMDD or severe PMS (15%)
Obsessive compulsive disorder (11%)
Sensory processing disorder (10%)
Learning disorders (9%)
Autism spectrum disorder (8%)
Substance use disorder (7%)

A separate ADDitude survey of 1,148 women with ADHD found that 57% of those who had given birth suffered from postpartum depression (PPD) with at least two-thirds reporting symptoms of mood swings, crying spells, and feelings of worthlessness, shame, guilt, or inadequacy.

These self-reported comorbidity rates are higher than those found in most other studies. But even those scientific research reports contain shocking findings:

59% of women diagnosed with ADHD have an additional psychiatric disorder compared to only 5% of the women without ADHD¹
Women with ADHD are five times more likely to experience anxiety than are women without ADHD²
Women with ADHD face 2.5 times higher risk for major depression than do their neurotypical counterparts³
Among women with ADHD, depression has an earlier age of onset, lasts longer, presents with more severe symptoms, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization compared to women without ADHD⁴
Up to 46% of women with ADHD experience PMDD⁵
25% of people with ADHD who give birth will suffer from postpartum anxiety — compared to approximately 10% of women without ADHD. In addition, 17% of women with ADHD who give birth will experience PPD — at least a 24% increase over the general population⁶
Girls with combined type ADHD are three to four times more likely to attempt suicide than are their neurotypical peers, and they are more than twice as likely to engage in self-harm⁷

“Our findings of extremely high rates of cutting and other forms of self-injury, along with suicide attempts, show us that the long-term consequences of ADHD in females can be profound,” says Stephen Hinshaw, Ph.D., director of the Berkeley Girls and ADHD Longitudinal Study (BGALS) — the only longitudinal study on females with ADHD conducted to date.

What We Don’t Know

Why are women with ADHD at greater risk for developing comorbid conditions and why do these conditions appear to take a greater toll on this group? What factors — neurological, biological, social, emotional, and others — possibly put women with ADHD at such relatively high risk for comorbid conditions? These questions remain unanswered due to an absence of research.

A 2023 study found that sleep disorders impact a higher percentage of women with ADHD than men with ADHD,⁸ and it implored researchers to investigate the root causes of this gender-specific discrepancy. This pattern is repeated in other conditions as well. We know women with ADHD are more likely than men to suffer from mood disorders, anxiety, eating disorders, borderline personality disorder, and countless other co-existing conditions, but we don’t understand why — or how to best help them — because there is simply no research to guide clinicians.

Longitudinal and double-blind studies are needed to probe questions like the following:

Why do nearly three-quarters of women with ADHD report living with anxiety and more than half with depression? Why are these comorbidity rates so much higher than those seen in men with ADHD?
Are comorbid conditions more often co-occurring or secondary to ADHD in women?
Do years spent undiagnosed and untreated for ADHD cause such emotional turmoil and low self-esteem that secondary anxiety commonly develops? Is secondary depression similarly a common byproduct of a missed ADHD diagnosis? What about eating disorders? Sleep disorders? Substance use disorder?
Do clinicians commonly dismiss or misinterpret signs of ADHD in women and misdiagnose them with internalizing disorders, and vice versa?
Is there a biological, neurological, or genetic connection between ADHD and these comorbid conditions that cause them to co-exist so commonly in women?
Does having a single ADHD comorbidity increase the likelihood that a woman will have others?
Does acute sensitivity to hormonal fluctuations put women with ADHD at higher risk for PMS, PMDD, and PPD? What about migraines?
How can we better screen girls and young women with ADHD for the comorbid conditions we know they experience most frequently and those associated with the worst long-term outcomes?
Why isn’t it standard practice for clinicians to perform ADHD evaluations on the girls and young women who have been referred to them for internalized symptoms of emotional dysregulation, anxiety, and low mood?
Does early, effective treatment for ADHD reduce the likelihood that women will experience symptoms of comorbid conditions as they age?

“At age 12, I was diagnosed with general anxiety disorder, major depression, and OCD,” wrote one ADDitude reader. “When I got my ADHD diagnosis at age 23 and went on medication, almost all my problems with depression and anxiety disappeared. I realized that my untreated ADHD was a likely factor in every other problem I’d faced. Addressing the root cause nearly fixed all the other issues.”

Why It Matters

Clinicians who do not understand the overlap of ADHD and other conditions in women cannot begin to accurately piece apart and diagnose those symptoms or prescribe effective treatments. Until research exists on complex ADHD and its comorbidities, women will continue to suffer inaccurate or incomplete diagnoses with adverse effects touching every aspect of life.

As covered in Part One of this We Demand Attention package, ADHD is missed more than it is diagnosed in girls and young women. Their internalized symptoms are either misinterpreted as signs of another condition, like anxiety or a mood disorder, or they receive only a partial diagnosis. Typically, inappropriate and ineffective treatment follows, which only increases the likelihood for additional or more severe mental health problems.

“ADHD does not happen in a vacuum,” notes Nelson M. Handal, M.D., founder of the Dothan Behavioral Medicine Clinic. “Its effects are far more impairing when the condition goes undiagnosed, untreated, or improperly treated.”

“Many women seeking treatment for mood and emotional problems may have unrecognized ADHD,” states the 2023 research paper “Miss. Diagnosis: A Systematic Review of ADHD in Adult Women.” “Higher rates of comorbidities such as depression and eating disorders in females with ADHD may make diagnosis more difficult. As well, physicians may have more difficulty separating ADHD from its comorbidities, potentially clouding ADHD symptoms and leading to delayed diagnosis in females.”⁹

In an ADDitude survey of 703 readers, 59% said that research on comorbidities like depression and anxiety in girls and women with ADHD would positively impact their lives. Greater study, they argue, would help ensure that more women receive an accurate diagnosis early in life — the effects of which cannot be overstated.

“I was diagnosed with depression first, but I couldn’t stick to treatment because nothing worked. When I finally got my ADHD diagnosis, it was life-saving,” wrote one ADDitude reader. “Maybe I wouldn’t have developed depression if I didn’t have untreated ADHD for decades.”

“I was recently diagnosed with ADHD after years of struggling with anxiety and depression. It turns out that ADHD (with a side of PTSD) has been the underlying problem all along — 38 years in the making,” wrote another survey respondent.

“I initially had generalized anxiety disorder and depression in high school,” wrote an ADDitude reader. “I was shy of 30 when I finally received my ADHD diagnosis. It finally made sense. My anxiety symptoms were ADHD symptoms. I overthink and overreact, not because I am afraid but because I am wired differently. My ADHD diagnosis is a life-changer.”

In addition, it is critical to understand how ADHD affects females with chronic illnesses that require reliable daily medication, timely medical appointments, and consistent self-care.

What ADDitude Readers Tell Us

While research on ADHD comorbidities is needed across the board, ADDitude readers are desperate for studies on autism, trauma, sensory sensitivities, and other comorbid conditions with strong ties to ADHD but very little study to date. Readers also urge greater research into hormonal influences on ADHD and comorbid conditions.

“I would like to see research into AuDHD (autism and ADHD) in girls and women — primarily as it affects racialized minorities/POC!” wrote one ADDitude reader in Canada. “I’m Black and, as a POC, and I struggled for years in higher ed and workplaces due to this absence of medical research supporting our existence as research subjects… With dedicated investment and deep investigation, I’m confident that public and private awareness will organically follow.”

“I have ADHD, anxiety, depression, and PTSD. My symptoms can shift daily or pile on top of each other,” said an ADDitude reader with multiple diagnoses. “Sometimes my ADHD symptoms get challenged. This triggers my PTSD, which then increases my anxiety and causes depression. They all feed off each other, and it never ends.”

“I would like to see more autism research, but also generally anything that might help undo/uncover all the countless misdiagnoses that have been assigned to women/AFAB,” wrote an ADDitude reader in Utah. “With a child, I’m all for investing in the accuracy of future diagnoses, but as a late-diagnosed AuDHD person, I don’t want anybody to be left behind.”

“I’d like to see research on how women’s hormonal changes impact behavior, mental health, physical health, and other aspects of well-being throughout their lifespan,” wrote an ADDitude reader in North Carolina. “This would be critical to understanding how ADHD, autism, depression, and many other conditions affect women and girls differently than men.”

“I’d like to see the treatment options for those with eating disorders and ADHD better understood, particularly when sensory issues and food allergies are present from birth,” wrote an ADDitude reader in California.

What ADHD Experts Say

Experts agree that women with ADHD face a disproportionately large risk for comorbid conditions with adverse outcomes, and that clinicians could do much more to identify and treat these women at a young age.

“Women with ADHD are more likely to have comorbid conditions such as depression, anxiety, and eating disorders,” said Dawn Brown, M.D. “Recognizing and addressing the potential for these concurrent conditions is essential for comprehensive treatment and improved outcomes.”

“Girls and women with untreated or undertreated ADHD — or those who have been misdiagnosed with other conditions — have been put at higher risk for an array of negative outcomes including higher rates of depression and anxiety, intimate partner victimization, and risky sexual behaviors resulting in teen and unplanned pregnancies,” said Julia Schechter, Ph.D. “These girls and women with untreated ADHD are at double the risk for engaging in self-harm and significantly more likely to attempt suicide.”

Next Steps

Watch a free replay of the 2020 ADDitude webinar titled “Why ADHD Is Different in Women: Gender-Specific Symptoms and Treatments” lead by Ellen Littman, Ph.D.
See ADDitude’s full library of free, on-demand webinar replays on ADHD and its comorbid conditions.
Consider joining a research study on women with ADHD and related conditions.
- CHADD offers a database of ADHD-related research studies that is searchable according to region.
- The U.S. Food & Drug Administration maintains a database of clinical trials for women that is searchable by condition and location.
- ResearchMatch is a free and secure tool that helps match willing volunteers with eligible researchers and their studies at institutions across the United States.
- ClinicalTrials.gov is a U.S. government database of clinical trials that is searchable by condition, treatment, or location.Consider joining a research study on women with ADHD and related conditions

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

Sex Difference in ADHD
The Health Consequences of Delayed ADHD Diagnoses on Women
How Hormonal Changes Impact ADHD Symptoms in Women
How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa
The Elevated Risk for PMDD and PPD Among Women with ADHD
The Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing
How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women
The Long-Term and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD
How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Uniquely Impact Women with ADHD
Early Indicators of Self-Harm, Partner Violence, and Substance Abuse Among Girls and Women with ADHD

Sources

¹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

²MGH Center for Women’s Mental Health (2023, October). “ADHD as a Risk Factor for Postpartum Depression and Anxiety.” https://womensmentalhealth.org/posts/adhd-as-a-risk-factor-for-pmad/

³Biederman, J., Ball, S. W., Monuteaux, M. C., Mick, E., Spencer, T. J., McCREARY, M., Cote, M., & Faraone, S. V. (2008). New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of the American Academy of Child and Adolescent Psychiatry, 47(4), 426–434. https://doi.org/10.1097/CHI.0b013e31816429d3

⁴Biederman, J., Ball, S. W., Monuteaux, M. C., Mick, E., Spencer, T. J., McCREARY, M., Cote, M., & Faraone, S. V. (2008). New insights into the comorbidity between ADHD and major depression in adolescent and young adult females. Journal of the American Academy of Child and Adolescent Psychiatry, 47(4), 426–434. https://doi.org/10.1097/CHI.0b013e31816429d3

⁵Obaydi, H., & Puri, B. K. (2008). Prevalence of Premenstrual Syndrome in Autism: A Prospective Observer-Rated Study. The Journal of International Medical Research, 36(2), 268–272. https://doi.org/10.1177/147323000803600208

⁶Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, L., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. J Affect Disord, 325:817-823. https://doi.org/10.1016/j.jad.2023.01.069

⁷Hinshaw, S.P., Owens, E.B., Zalecki, C., Huggins, S.P., Montenegro-Nevado, A.J., Schrodek, E., Swanson, E.N. (2012). Prospective Follow-Up of Girls with Attention-Deficit/Hyperactivity Disorder into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide Attempts and Self-Injury. J Consult Clin Psychol, 80(6):1041-1051. https://doi.org/10.1037/a0029451

⁸Ahlberg, R., Garcia-Argibay, M., Taylor. M., Lichtenstein, P., D’Onofrio, B.M., Butwicka, A., Hill, C., Cortese, S., Larsson, H., Du Rietz, E. (2023) Prevalence of Sleep Disorder Diagnoses and Sleep Medication Prescriptions in Individuals with ADHD Across the Lifespan: A Swedish Nationwide Register-Based Study. BMJ Ment Health. (1):e300809. https://doi.org/10.1136/bmjment-2023-300809

⁹Attoe, D.E., Climie, E.A. (2023) Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. J Atten Disord. (7):645-657. https://doi.org/10.1177/10870547231161533

Wanted: ADHD Research on Women & Girls

Carole Fleck — Wed, 01 May 2024 00:04:21 +0000

It is indefensible how little is known about ADHD in women today. Research is nearly non-existent in the way ADHD symptoms change with the hormonal fluctuations of puberty, pregnancy, menopause, and beyond. And experts who study ADHD are deeply concerned — outraged even — about the persistent lack of research on a population that is chronically underdiagnosed and misdiagnosed.

“For decades, girls and women with ADHD have missed out on critical interventions to help manage their ADHD symptoms, primarily because they have largely been left out of ADHD research studies,” says Julia Schechter, Ph.D., co-director of the Duke Center for Girls and Women with ADHD. “Females with untreated ADHD have been put at higher risk for depression and anxiety, intimate partner victimization, and risky sexual behaviors resulting in teen and unplanned pregnancies. Research devoted to girls and women with ADHD is not only an issue of equity but of life or death for some.”

Here, leading experts weigh in on where research is critically needed to guide accurate diagnosis and effective treatment of ADHD in females.

ADHD Research Priority: Defining Sensitive and Precise Screening Tools

Julia Schechter, Ph.D., co-director of the Duke Center for Girls and Women with ADHD

There are numerous research topics related to girls and women with ADHD that deserve thorough investigation. Three specific areas of research that span the life course include:

1. Developing more sensitive and precise screening tools that can better identify girls and women who may have ADHD and require comprehensive evaluation. Many screening tools — particularly those that are freely available — ask raters to report on overt behaviors that align with DSM-5 criteria. Yet, this approach may not be as effective for girls and women. Females with ADHD often compensate for and “mask” their symptoms, making it difficult for observers to rate how frequently a symptom is occurring or whether it is present at all. Research can also focus on developing additional prompts that could be incorporated into existing tools to help raters consider how symptoms may present differently in girls and women (e.g., more likely to be hyperverbal rather than hyperactive). Once developed, these gender-sensitive tools need to be free to use, easy to implement, provide gender or sex-based norms, and be interpretable by those without specialty mental health backgrounds (e.g., teachers, pediatricians).

2. Investigating the role of hormones in ADHD symptom expression in girls and women. This research should examine hormonal levels across the reproductive lifespan including puberty onset, menstrual cycle, pregnancy, postpartum period, and menopause, and post-menopause.

3. Assessing the degree to which girls and women with ADHD require additional or unique treatment approaches. For example, studies can investigate the efficacy of ADHD medication type and dose for girls and women and whether medication effectiveness might interact with hormone levels. With regard to behavioral treatments, research questions might include whether additional modules of CBT for ADHD or behavioral parent training potentially targeting emotion dysregulation could enhance the effectiveness of these psychosocial interventions. In addition, research can explore whether there are certain treatment delivery formats, such as group therapy (vs. individual therapy), that might be more effective for girls and women with ADHD.

[Join Our Call for Greater Research on Women with ADHD]

ADHD Research Priority: Why ADHD Exacts a Greater Toll on Women

Ellen Littman, Ph.D., clinical psychologist and co-author of Understanding Girls with ADHD

The overarching research question is: Why does ADHD exact a far greater toll on women? Why have researchers refused to explore the dramatic sex/gender differences in outcomes — and how can we compel researchers to care?

Here is the most urgent research needed to improve care for females:

Studies that will increase recognition and understanding of the widest continuum of presentations, complex trajectories, hormonal mediation, cumulative mood-based impairments, and severity of outcomes.
How do cycling hormones impact all aspects of female behavior and impairment —including PMS and PMDD (premenstrual dysphoric disorder), and the postpartum, perinatal, and menopause stages?
To what degree do isolation, shame, and despair lead to self-harm and earlier mortality in females?
How can we identify symptoms earlier in girls?

These findings will provide a basis for revised, inclusive diagnostic criteria and rating scales to assess internalizing symptoms, functional impairments, masking, and symptom proliferation after puberty.

ADHD Research Priority: Understanding the Core Symptoms of ADHD in Women

Maggie Sibley, Ph.D., psychologist, and researcher at the University of Washington School of Medicine

What are the core symptoms of ADHD in girls and women across the lifespan?
What is the typical trajectory of onset for ADHD in girls and women?
What are the key points of intervention for women with ADHD (in terms of times in their lives and domains of impairment)?

[Survey: How Does Your Menstrual Cycle Impact Your ADHD Symptoms?]

ADHD Research Priority: The Impact of Hormonal Fluctuations on Women with ADHD

J.J. Sandra Kooij, M.D., Ph.D., founder, and chair of the European Network Adult ADHD

Why do some women feel better with oral contraceptives and others feel depressed?
How do hormones interact with neurotransmitters, such as dopamine, in women?
What is most helpful for women with PMDD: an antidepressant, increased stimulant dosage in the last week of the cycle, taking birth control pills, or a progesterone antagonist? Same for perimenopausal women with ADHD: Which treatment would be best?
Why do women with ADHD have higher rates of polycystic ovary syndrome, which is associated with fertility problems and hormonal disturbances, and primary ovarian insufficiency, which is associated with early-onset menopause?

ADHD Research Priority: Sexual and Reproductive Health for Females with ADHD

Lotta Borg Skoglund, M.D., Ph.D., author, associate professor at Uppsala University, Department for Women’s and Children’s Health, principal investigator at GODDESS ADHD, and author of ADHD Girls to Women

Are negative sexual and reproductive outcomes and functional somatic symptoms more prevalent in females with ADHD compared to females without ADHD and how are they influenced by age at diagnosis and ADHD treatment?
What daily life challenges do females with ADHD experience, and are negative sexual and reproductive outcomes and functional somatic symptoms related to low daily life functioning?
What barriers do females with ADHD face regarding their sexual and reproductive health?
How are cyclic variations of hormones during the menstrual cycle or the use of hormonal contraceptives related to:
- ADHD symptom levels
- Use of ADHD medication
- Comorbid and functional somatic symptom levels
- The effects of ADHD medication

ADHD Research Priority: Treatment Efficacy for Women with ADHD

Kathleen Nadeau, Ph.D., author of Still Distracted After All These Years

ADHD, mood, and menses: Following adolescent and young adult women through several monthly menstrual cycles to report issues related to mood, focus, memory, and emotional regulation.
Better DSM profile: Conducting a large-scale survey of high school girls, female college students, and adult women with ADHD to tell us their biggest struggles so that, at the very least, the next updated Diagnostic and Statistical Manual of Mental Disorders (DSM) can incorporate these features for females.
Efficacy of treatment: Asking women with ADHD to rate the effectiveness of treatment with stimulant medication, psychotherapy, group therapy, and lifestyle changes—sleep, exercise, and stress-busting activities.

ADHD Research Priority: The Transition Points That Predict Impairment Versus Resilience for Girls

Stephen Hinshaw, Ph.D., distinguished professor of psychology at the University of California, Berkeley, and author of Straight Talk About ADHD in Girls: How to Help Your Daughter Thrive

What are the transition points — psychological, family- or school-related, community-wide — that predict impairment versus resilience for girls with ADHD as they transition through adolescence to adulthood?
What are the pros and cons of social media-related promotion of ADHD information for women, leading to valid diagnosis and treatment?
What are the pros and cons of self-reported screenings, with the potential for receiving mail-order stimulants?
What are the strategies and supports that help teen girls and women with ADHD thrive?

ADHD Research Priority: Gender Differences in ADHD

Dawn K. Brown, M.D., owner/CEO of ADHD Wellness Center and Mental Healthletics

Gender differences between the presentation and coping mechanisms of girls and women with ADHD compared to boys and men.
The adverse long-term outcomes of untreated or inadequately managed ADHD in women, including academic underachievement, unemployment, relationship difficulties, inappropriate treatment, and increased risk of substance abuse and mental health disorders.
How society’s expectations of gender roles e.g., cultural norms around femininity, such as the pressure to be organized and focused, may influence ADHD presentations and exacerbate the challenges faced by women with ADHD
How fluctuations in hormone levels across the menstrual cycle and during pregnancy can impact ADHD symptoms in women.
How the combination of ADHD and hormonal-related conditions (e.g., PMS, PMDD, and PCOS) can lead to an overlooked diagnosis and can complicate treatment in women.
Recognizing and addressing comorbid conditions in women with ADHD, such as depression, anxiety, and eating disorders.
How ADHD can significantly affect academic, professional, and financial success in women.
The interplay between ADHD symptoms, parenting stress, and family dynamics of women with ADHD who are parents of children with ADHD.
How stigma, lack of awareness, and gender bias continuously contribute to delays in diagnosing ADHD in women.

ADHD Research Priority: The Impact of Perimenopause and Menopause on ADHD Symptoms

Jeanette Wasserstein, Ph.D., clinical assistant professor of psychiatry, at the Icahn School of Medicine at Mount Sinai

An ADDitude survey found that an enormous number of women are diagnosed with ADHD during the perimenopausal and menopausal years and that those who were previously diagnosed experienced a worsening of symptoms. These observations correlate with a period of significant underlying hormonal changes. Since ADHD is a neurodevelopmental disorder thought to be typically present during the childhood or teen years, this apparently ‘new onset’ or worsening of ADHD implies an important role for sex hormones in the expression of some ADHD symptoms.

Such observations also imply that there may even be two types of women who are diagnosed with ADHD during this period: Those who were borderline ADHD their whole lives but did not meet criteria until their symptoms worsened and those who are entirely ‘new onset.’ Unfortunately, almost no research exists regarding the role of hormones on ADHD during the climacteric. Since women represent 50% of the world’s population and all will experience menopause if they live into their 60’s the impact of perimenopause and menopause on ADHD symptoms is an enormously unrecognized and important topic in global female health.

ADHD Research Priority: Diagnostic and Treatment Gaps for Women of Color

Sharon Saline, Psy.D., clinical psychologist and author of What Your ADHD Child Wishes You Knew: Working Together to Empower Kids for Success in School and Life

Addressing diagnostic and treatment gaps for women of color, including common cultural issues and difficulties with access to care.
Developing tools for earlier detection of ADHD in girls, teens, and women including more effective options for detecting the internalizing, inattentive symptoms.
Examining the connection between the rise of peri and post-menopausal women and how estrogen and progesterone affect the dopamine and norepinephrine receptors and pathways in the brain.
Exploring how the socialization and gender identity of women affect the increased accounts of perfectionism, imposter syndrome, and low self-esteem.

ADHD Research Priority: Early Identification of ADHD in Girls and Women

Andrea Chronis-Tuscano, Ph.D., professor at the University of Maryland and director of the UMD ADHD Program and UMD SUCCEEDS College ADHD Clinic

How can we raise awareness about ADHD in girls and women among parents, teachers, pediatricians, and other healthcare providers so they can be identified earlier and get the help they need?
How can we support women through the transition to parenthood so that we can help not only them but also their children who are at risk for ADHD?

ADHD Research: Next Steps

Download: Free Menstrual Cycle Workbook for Women with ADHD
Read: Why Research Is Needed on Sex Differences in ADHD
Read: The Fate of Females with ADHD Is Improving Too Slowly

We Demand Attention on the Safety and Efficacy of ADHD Medication Use During Pregnancy and While Nursing

Anni Layne Rodgers — Tue, 30 Apr 2024 14:40:50 +0000

What We Know

New research suggests that continued ADHD medication use during pregnancy carries few maternal or fetal risks, however most women do not treat their ADHD symptoms with medication while pregnant.

Women who continue dexamphetamine use throughout pregnancy experience no elevated risk of adverse neonatal or maternal health outcomes, compared to those who cease ADHD medication use during pregnancy. This groundbreaking conclusion of a March 2024 study¹ including 1,488 pregnant people reinforced the findings of an even larger Swedish study published in 2023.

That research, which followed 898 children exposed to ADHD medication in utero, found that such exposure does not impair a child’s neurodevelopment or physical growth. “These findings provide reassurance for women with ADHD who depend on ADHD medication for daily functioning and who consider continuing medication in pregnancy,” the study concluded.

Still, just 2.45% of ADDitude readers who have been pregnant said they used ADHD medication during pregnancy, according to a survey of 1,180 such women. Many of these survey respondents said they remained unmedicated during pregnancy not due to fears or medical advice, but because they weren’t yet diagnosed with ADHD.

Without ADHD medication to ease symptoms during pregnancy, life felt unbearable for many women. “I wasn’t diagnosed until age 49,” wrote one 53-year-old woman in Australia. “The first trimester of my pregnancy was awful. I could not control my reactions or emotions and it’s fair to say that, in hindsight, it was the worst time for ADHD issues I can recall in my life.”

More than three-quarters of the women surveyed by ADDitude said their ADHD symptoms stayed the same or worsened during pregnancy — and nearly all were unmedicated during this time. Of the 29 survey respondents who continued taking ADHD medication during pregnancy, most reported achieving successful symptom management that improved their quality of life.

“During my first pregnancy, I came off my medications cold turkey after being on them for 24 years. I do NOT recommend this strategy,” wrote a woman diagnosed with ADHD at age 8. “I nearly lost my job during that time. I was more anxious/worried, and I couldn’t complete even the simplest tasks. My symptoms did not change like this during my second and third pregnancies because I was able to continue taking my medication.”

“I consulted my doctor, and we decided the benefits outweighed the risks” of continued medication use during pregnancy, wrote a 33-year-old reader in North Carolina.

According to a November 2022 study of 45,737 pregnant females with ADHD, medication use during pregnancy may be protective against a host of adverse outcomes.² The study found that pregnant individuals with ADHD who were unmedicated were significantly more likely than their non-ADHD counterparts to experience depressive episodes, postpartum depression, hyperemesis gravidarum (extreme, persistent nausea), eclampsia (seizures in pregnant people with preeclampsia), gestational hypertension, and cardiac disease, among 10 other adverse health outcomes. Women with ADHD who took ADHD medication during pregnancy saw those risks fall across the board. Women who took stimulant medication saw the biggest risk reductions in preterm births and anemia, while women taking non-stimulants saw the greatest risk reductions in renal disease, malnutrition, and gestational diabetes.

“Women with moderate-to-severe ADHD should not necessarily be counseled to suspend their ADHD treatment [during pregnancy] based on these findings,” wrote the study authors. “Untreated ADHD can lead to negative outcomes for both mother and infant. Studies have shown that pregnant women with ADHD may have greater difficulty with managing obstetric appointments, which may increase the risk of negative health outcomes of undiagnosed and unmonitored complications such as preeclampsia and gestational diabetes… Given the highly correlative nature of ADHD and other mental health conditions, one must consider comorbidities of untreated ADHD. Left untreated during pregnancy, individuals with ADHD might be at increased risk of depression, feelings of isolation, and familial conflict.”

A 2020 study found that women who discontinued stimulant medication use during pregnancy experienced a significant increase in postnatal depression, despite remaining on their antidepressant medication. They also suffered significant impairment in family functioning.³ Meanwhile, a large Swedish cohort study with sibling analysis recently found that taking acetaminophen (Tylenol) during pregnancy was not associated with the development of autism or ADHD in babies.⁴

What We Don’t Know

Though 99% of women with ADHD report at least one comorbid condition, no research exists on the safety and efficacy of multimodal treatment for ADHD, depression, and/or anxiety during pregnancy, or the relative benefits and risks of each medication class.

We rely largely on anecdotal evidence today to argue that unmedicated ADHD symptoms cause significant psychological and neurocognitive distress during pregnancy, and that these impairments are more severe than those experienced by pregnant women without ADHD. A 2014 study concluded that, “It is possible that women with preexisting ADHD constitute a vulnerable subgroup for neurocognitive worsening during pregnancy,” however, scant research exists to prove or disprove this theory. Are women with ADHD who suspend treatment during pregnancy more likely to experience job loss, relationship problems, and mental health crises? The 2022 study titled “Obstetric Complications in Mothers with ADHD” shows that depression risk is 2 to 3 times higher for this cohort; however, we’re left making educated guesses about most other maternal outcomes.

That 2022 study was among the first to demonstrate the positive outcomes associated with medication use during pregnancy for women with ADHD, and to confirm the low risk of poor fetal outcomes from maternal medication use. However, the study authors acknowledge that they “did not examine many other comorbid conditions, such as depression, anxiety, or substance use, which may have impacted the results.” In a 2022 ADDitude survey of 5,230 women with ADHD, 73% said they had anxiety, 63% said they experienced depression, 23% said they had PTSD or c-PTSD, and 22% said they suffered migraines. Comorbidities are the rule with ADHD, not the exception.

Future research on pregnant people with ADHD must take into consideration comorbid conditions and aim to answer questions such as these:

How do the hormonal changes during each trimester of pregnancy specifically impact symptoms of hyperactive/impulsive vs. inattentive ADHD?
Why do some women experience heightened or aggravated ADHD symptoms during pregnancy, while others experience more mild ADHD symptoms during pregnancy?
Is there a correlation between the dosage of ADHD medication used during pregnancy and maternal or fetal outcomes? If so, what is the relationship?
How do the risks of adverse fetal outcomes differ, if at all, with use of prescribed methylphenidate vs. amphetamine vs. a non-stimulant medication during pregnancy? While nursing?
Are the medications less commonly prescribed for ADHD — such as bupropion, atomoxetine, viloxazine, clonidine, and guanfacine — safe to use during pregnancy?
Is it safe to use ADHD medications in conjunction with antidepressant medications, such as serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), during pregnancy? Similarly, is it safe to treat both ADHD and anxiety during pregnancy?
What are the relative risks and benefits of ADHD medication use vs. antidepressant use or anti-anxiety medication use for pregnant women with these conditions?
What are the long-term mental health outcomes for women with ADHD who are medicated during pregnancy and while nursing, vs. those who are not medicated during those critical periods?

The list of questions could stretch on regarding ADHD symptoms, treatment, and outcomes during and after pregnancy, but answers to the above would significantly impact many women’s lives.

Why It Matters

Without research findings to provide a clear understanding of the benefits and risks associated with ADHD medication use during pregnancy, many women fearful of adverse outcomes will discontinue medication use, only to suffer a range of difficulties that can make day-to-day life nearly intolerable. Research studies to clarify these questions will guide more informed, effective treatment decisions and improve the mental and physical health outcomes for many neurodivergent patients.

The fact is that roughly 97% of women with ADHD receive no ADHD treatment during pregnancy, resulting in serious and sometimes fatal health consequences. Improving our understanding of ADHD medication safety and efficacy during pregnancy stands to reduce risks of everything from depression to preterm birth and gestational diabetes in women with the condition. This can save women’s lives and improve the lives of their family members as well.

The maternal mortality rate in the United States – 32.9 deaths per 100,000 live births overall and 69.9 deaths per 100,000 live births among Black women — has nearly doubled since 2017. The U.S. maternal mortality rate is 10 times that of Norway and four times that of the European Union. Why aren’t we doing everything in our power to keep women safe and healthy during and after pregnancy?

A Related Consideration

Young women with ADHD are about four times more likely than their neurotypical peers to experience an unwanted pregnancy before age 30,⁵ according to research conducted, in part, by Stephen Hinshaw, Ph.D., principal investigator of the ongoing Berkeley Girls with ADHD Longitudinal Study.

“By the time they reached their mid to late 20s, about 43% of the BGALS participants in the ADHD group had one or more unplanned pregnancies compared to about 10% of individuals in the comparison group,” said Hinshaw, who noted that girls and women with ADHD face higher risk for an array of negative outcomes including higher rates of depression and anxiety, intimate partner victimization, and risky sexual behaviors.

What if, armed with significant research regarding the symptoms of ADHD in young women, obstetricians partnered with primary care doctors or neurocognitive specialists to screen patients with unplanned pregnancies for ADHD? We know from the ADDitude survey of 1,180 women with ADHD that few knew they had ADHD when they were pregnant and, therefore, they did not receive the healthcare they needed to avoid the adverse health outcomes common during and after pregnancy. Screening this population of patients for ADHD would significantly improve outcomes for women during a time of heightened symptoms and physical and psychological stress, especially if evaluations were paired with reliable data and medical advice about medication use during pregnancy.

What ADDitude Readers Tell Us

Patients who work closely with their healthcare providers to devise ADHD treatment plans and monitor vital signs while using medication during pregnancy achieve consistently good outcomes, while those who cease medication outright sometimes suffer symptoms that impair their professional and personal lives.

“Working memory issues were obvious throughout pregnancy,” said a 33-year-old health care provider in Wisconsin who stopped taking Adderall while pregnant. “I would forget what I was going to say once it was my turn to talk with my patients. My impulsivity was the worst in the first trimester; I was constantly eating out of boredom.”

“I saw a special OBGYN who frequently monitored my and my baby’s health,” wrote a 35-year-old in Illinois. “I continued to take 5 mg Adderall two times a day as well as a mood stabilizer.”

“I actually feel like the greater purpose of caring for my health because there was another human involved helped me stay committed to better habits that mitigate symptoms,” said a reader. “I was also seen by a special OBGYN so that I could stay on a low dose of my mental health medications, which I’m sure worked better in combination with consistently making positive lifestyle changes.”

“During pregnancy, I was off my medication, so my life was like it was before the diagnosis and starting medication,” said a 50-year-old reader in Maryland. “Thankfully, I was busy working and getting ready for the baby. Being busy always helps me.”

What ADHD Experts Say

“The new demands of caring for their babies during a time of changing hormone levels, infant feedings, and sleep disruption are exceedingly difficult for some women,” wrote Allison S. Baker, M.D., in the ADDitude article “Treating for Two: ADHD Meds in Pregnancy.” “Being an effective mother requires the ability to get and stay focused, modulate attention, control impulsivity, and utilize executive function skills. Women with ADHD struggle in these domains, yet this population and the course of their condition during pregnancy and the postpartum period have received little attention and systematic study.”

Next Steps

Write to the White House Initiative on Women’s Health Research (WomensHealthResearch@who.eop.gov) to request funding for research dedicated to understanding how ADHD treatment during pregnancy may significantly improve both maternal and fetal health outcomes.

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

ADDitude is dedicated to honoring gender diversity and fluidity. For the purposes of this reporting, we use the terms “girls” and “women” to refer to individuals assigned female at birth and/or who identify as female.

Sources

¹Russell, D.J., Wyrwoll, C.S., Preen, D.B. et al. Investigating maternal and neonatal health outcomes associated with continuing or ceasing dexamphetamine treatment for women with attention-deficit hyperactivity disorder during pregnancy: a retrospective cohort study. Arch Womens Ment Health (2024). https://doi.org/10.1007/s00737-024-01450-4

²Walsh, C. J., Rosenberg, S. L., & Hale, E. W. (2022). Obstetric complications in mothers with ADHD. Frontiers in reproductive health, 4, 1040824. https://doi.org/10.3389/frph.2022.1040824

³Baker AS, Wales R, Noe O, Gaccione P, Freeman MP, Cohen LS. The Course of ADHD during Pregnancy. Journal of Attention Disorders. December 2020. doi:10.1177/1087054720975864

⁴Lee BK, et al “Acetaminophen use during pregnancy and children’s risk of autism, ADHD, and intellectual disability” JAMA 2024; DOI: 10.1001/jama.2024.3172.

⁵Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80(6), 1041–1051. https://doi.org/10.1037/a0029451

We Demand Attention on the Elevated Risk for PMDD and PPD Among Women with ADHD

Anni Layne Rodgers — Mon, 29 Apr 2024 16:55:46 +0000

What We Know

ADHD is a significant risk factor for the development of premenstrual dysphoric disorder (PMDD) and postpartum depression (PPD), both of which are debilitating and potentially life-threatening conditions that disproportionately impact women with ADHD.

Premenstrual Dysphoric Disorder (PMDD) is a more serious form of premenstrual syndrome (PMS) that causes clinically significant and impairing depression, anxiety, mood swings, and uncomfortable physical symptoms in the week leading up to the onset of a period. PMDD impacts about 2% of the general population of women (though actual prevalence rates may be higher)¹, often requires medication (typically, hormonal birth control and antidepressants), and is associated with an elevated risk for suicidality and suicide attempts.

Research on PMDD and ADHD is limited. In a 2021 study of 209 women with ADHD, more than 45% reported having symptoms suggestive of PMDD.² A recent ADDitude survey revealed that a staggering 66% of women with ADHD said they have suffered from PMS and/or PMDD beginning, on average, around age 14 — with nearly 60% of respondents reporting symptoms that lasted 20 years or longer.

PMDD is caused by decreasing levels of estrogen and progesterone after ovulation and before menstruation. These hormones also drop markedly following childbirth, contributing to postpartum depression in 10% to 15% of women.³ Among women with ADHD, the risks for postpartum mood disorders are elevated.

A 2023 study found that about 25% of women with ADHD who gave birth were diagnosed with anxiety disorders postpartum compared to 4.6% of women without ADHD. In addition, about 17% of women with ADHD met the criteria for PPD compared to 3.3% of women without ADHD who had given birth.⁴

Another study found that women with ADHD, even those without a history of depression, are 24% more likely to be diagnosed with PPD than are women without ADHD.⁵ A survey of ADDitude readers found an even higher prevalence — 61% of women with ADHD who had given birth reported experiencing symptoms of PPD, at least a fourfold increase over the rate found in the general population of birthing individuals.

ADDitude readers who said they suffered with PMDD reported that symptoms lasted roughly one year, and included the following:

Crying spells: 76%
Feelings of worthlessness, shame, guilt, or inadequacy: 72%
Mood swings: 66%
Irritability: 62%
Lack of concentration: 58%
Sleep problems: 57%

What We Don’t Know

Why do women with ADHD face an outsized risk for PMDD and PPD, and why are the symptoms they experience more severe and longer lasting than those of their neurotypical peers?

Research has not yet explained the disproportionate links between ADHD and both PMDD and postpartum mood disorders. We do not know why women with ADHD appear more sensitive to the hormonal fluctuations of the menstrual cycle and the hormonal changes following childbirth. Research on these associations would help us answer these essential questions:

What is the relationship between ovarian hormones and ADHD?
What is the relationship between hormones and the neurotransmitters involved in ADHD?
Why do women with ADHD experience PMDD and PPD more frequently and more severely than their neurotypical counterparts?
Why are some women with ADHD at greater risk for PMDD and/or PPD than others?
What are the early warning signs of PMDD and PPD in people with ADHD?
How can early diagnosis of and treatment for PMDD and PPD improve long-term outcomes for girls and women with ADHD?
Conversely, what are the greatest risks associated with undiagnosed and untreated PMDD or PPD in women with ADHD?
What treatment modalities most effectively address the symptoms of PMDD and PPD in women with ADHD?
Might women with ADHD face higher risk for other hormonal health conditions?

To that last question, J.J. Sandra Kooij, M.D., Ph.D., adds: “Why do women with ADHD suffer more frequently with polycystic ovarian syndrome (PCOS), associated with fertility problems and hormonal disturbances, and with premature ovarian insufficiency (POI), associated with early menopausal symptoms?”

“These conditions are commonly not recognized or treated, and they can invalidate women severely at an early age,” says Kooij, who has published more than 100 peer-reviewed international papers and more than 20 books or book chapters on ADHD in adults.

Why It Matters

PMDD is a serious risk factor for depression and self-harm. Postpartum depression is also potentially life-threatening. When researchers and medical professionals fail to address the high comorbidity rates between ADHD and these conditions, they put women’s lives at risk unnecessarily.

PMDD often co-occurs with other psychiatric disorders, including major depressive disorder (MDD) and anxiety disorder.⁶ ⁷ Individuals with PMDD are also at greater risk for suicide and suicidal behavior.⁸

Despite the known association between ADHD and PMDD, and the serious health risks associated with PMDD, very few physicians screen girls with ADHD for signs and symptoms of premenstrual dysphoric disorder. Even worse, ADDitude readers regularly tell us that their early complaints of PMDD symptoms were dismissed or ignored by healthcare professionals.

“I have exhibited significant PMDD symptoms since puberty,” wrote one ADDitude reader. “My symptoms were ignored, and I was mistreated more times than I could count. There was always an excuse — whether it came from other women, my family doctor, or other doctors.”

Likewise, women with ADHD are known to face a higher risk for PPD, however routine screenings are rare. In an ADDitude webinar poll, about 70% of respondents said their doctor missed their symptoms of postpartum depression. In a separate poll, about 45% of ADDitude readers said they wouldn’t be able or aren’t sure if they’d be able to identify postpartum depression in themselves or in others. Almost half of ADDitude survey respondents said they were not offered any treatment for their postpartum depression, while 41% were prescribed antidepressants and 20% received therapy.

“The nurses I spoke to did not recognize my postpartum depression and told me it was probably a normal hormonal drop, but things never improved,” said a 36-year-old mother with ADHD in Pennsylvania.

Research into the root causes, key indicators, and effective treatments for hormonal health conditions associated with ADHD would improve the quality of life and healthcare for women with ADHD by…

Educating healthcare professionals regarding the high rates of comorbidity between ADHD and PMDD and PPD
Educating patients about telltale signs of these conditions and reducing stigma around symptoms
Encouraging routine screenings that could significantly reduce patient suffering by identifying PMDD and PPD early
Introducing new treatment protocols based on scientific evidence
Suggesting collaborative treatment strategies for gynecologists and ADHD practitioners

What ADDitude Readers Tell Us About PMDD

PMDD is a serious health condition that impacts daily functioning, relationships, and mental health every month for decades. What’s worse, many women with PMDD report feeling dismissed, ignored, and left to suffer by healthcare practitioners who did not take their concerns seriously and failed to offer treatment options.

“The first two to three days of my cycle were always full of painful cramping and nausea,” wrote one ADDitude reader with PMDD. “I was completely miserable and sometimes doubled over in pain. Then I’d have heavy bleeding for 7 to 10 days… Doctors just scoffed and said, ‘I couldn’t possibly be in that much pain.’”

“Treatment-resistant PMDD has affected my whole life,” said Ray, an ADDitude reader in Canada. “I have struggled with physical symptoms and social stigma. The severity of my symptoms has destroyed my social and work relationships… I have hurt many people, just trying to experience a life worth wanting.”

“Seven to 10 days before my cycle starts, I get irritable and sad. I rage out. I feel like nothing can contain me or calm the storm. I hurt the people around me, the people I love,” said an ADDitude reader with PMDD. “It scares my kids and frustrates my husband. I was finally diagnosed last month and have been taking Zoloft. I was amazed this last pre-cycle time that I could remain calm. I used to think it was me; that I was born ‘bad.’ It’s been a relief to feel my true loving self.”

“For one week a month, I turn into a different person. I have outbursts of laughter, tears, and anger,” said Stacey in Kenya. “I feel like combusting. My sensory issues are heightened. I’m irritated by everything. My stimming gets way worse.”

“I thought it was normal to feel suicidal four to five days leading up to my period,” said Kristy, an ADDitude reader with PMDD in Australia.

What ADDitude Readers Tell Us About PPD

Support for postpartum women with ADHD is inadequate.

“My anxiety level skyrocketed and I felt like I might be losing myself,” wrote an ADDitude reader in California who suffered symptoms of postpartum depression for 7 to 9 months. “There was a lot of time spent in my head wondering if I was going crazy.”

“My postpartum depression continued after the birth of my third child, and I was hospitalized eight times for severe depression,” wrote an Australian reader who had persistent PPD.

“I didn’t want to hold my child and actively sought to hand him off to others in the early weeks,” wrote an ADDitude reader in Washington who also suffered from PPD for 7 to 9 months. “I still feel robbed of that miraculous time if I think on it too much, so I try to focus on the good parts and the happy moments instead. And my son and I are closer now than ever. He’s awesome and gives great hugs. Maybe that makes up for it a little.”

What ADHD Experts Say

Devising better screening protocols and treatment strategies for PMDD and PPD in women with ADHD should be a top medical priority given the high risk of adverse outcomes and the established connections between these conditions.

“We need studies on how cycling hormones impact all aspects of female behavior and impairment, underscoring the importance of new research based on awareness of the hormone/neurotransmitter connection,” says Ellen Littman, Ph.D. “After acceptance of the centrality of hormonal involvement, specific areas of needed research include post-partum, perinatal, climacteric, menopause, PMS, PMDD, and PCOS.”

“We need treatment studies investigating what is most helpful for women with PMDD: an antidepressant (SSRI), increased stimulant dosage in the last week of the cycle, or the pill continuously, or maybe even a progesterone antagonist (Sundstrom),” asks Kooij. “Because not estrogen but progesterone seems related to the negative effect on mood in the last phase of the cycle.”

Next Steps

Watch an on-demand replay of this ADDitude webinar hosted by Jayne Singer, Ph.D., titled, “The Unspoken Truths of Postpartum Depression: Help for Women With and Without ADHD”
Could you be showing signs of PMDD? Take this test and share the results with your doctor for further discussion and analysis.
Could you or someone you love be showing signs of postpartum depression? Take this test and share the results with a medical professional for further discussion and analysis.

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

Sources

¹Reilly, T. J., Patel, S., Unachukwu, I. C., Knox, C. L., Wilson, C. A., Craig, M. C., Schmalenberger, K. M., Eisenlohr-Moul, T. A., & Cullen, A. E. (2024). The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis. Journal of affective disorders, 349, 534–540. https://doi.org/10.1016/j.jad.2024.01.066

²Dorani, 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

³Bauman, B. L., Ko, J. Y., Cox, S., D’Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression – United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2

⁴Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

⁵Bartelt K, Piff A, Vitek G, Barkley E. Maternal ADHD Correlated with Increased Risk of Postpartum Depression. Epic Research. https://epicresearch.org/articles/maternal-adhd-correlated-with-increased-risk-of-postpartum-depression.

⁶Eisenlohr-Moul, T., Divine, M., Schmalenberger, K. et al. (2022). Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder. BMC Psychiatry 22, 199. https://doi.org/10.1186/s12888-022-03851-0

⁷Tiranini, L., & Nappi, R. E. (2022). Recent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome. Faculty reviews, 11, 11. https://doi.org/10.12703/r/11-11

⁸Eisenlohr-Moul, T., Divine, M., Schmalenberger, K. et al. (2022). Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder. BMC Psychiatry 22, 199. https://doi.org/10.1186/s12888-022-03851-0

We Demand Attention on How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa

Anni Layne Rodgers — Sun, 28 Apr 2024 11:22:07 +0000

What We Know

The wild hormonal swings of perimenopause and marked estrogen drop of menopause correlate to more severe and sometimes new symptoms of ADHD in women.

As they enter perimenopause around age 47, women will begin to experience irregular, extreme, and worsening drops in total estrogen and progesterone levels. Levels of follicle-stimulating hormone (FSH), which stimulate the ovaries to produce estrogen; and luteinizing hormone (LH), which triggers ovulation, also vary considerably. These fluctuating estrogen levels help explain the sometimes extreme mood and cognitive problems that many women, ADHD or not, experience in the lead up to menopause.¹ These symptoms also happen to overlap with and mimic the symptoms of ADHD.

By menopause (average age, 51), estrogen levels have dropped about 65%. The loss of estrogen leads to a decrease in serotonin and dopamine levels in the brain. During the menopausal transition, women report moodiness, sadness, irritability, fatigue, fuzzy thinking, and memory lapses. A study published on April 30, 2024 reports that women in perimenopause are 40% more likely to experience depression than are premenopausal women. No research has determined whether menstruating individuals with ADHD are more affected, or differently affected, by the transition, but current evidence — and an abundance of anecdotal reports — suggest that women with ADHD are likely more vulnerable to challenges during perimenopause and after menopause.² ³

Indeed, in an ADDitude survey of nearly 5,000 women with ADHD, 63% of respondents aged 45 and older said ADHD had the greatest impact on their lives during perimenopause and menopause. (In contrast, less than 6% said ADHD had the biggest impact before age 20.)

More than 93% said they noticed a difference in the severity of some ADHD symptoms during perimenopause and/or menopause. More than half of survey respondents said the following symptoms had a “life-altering impact” from ages 40 to 59:

Feelings of overwhelm (73.67%)
Brain fog and memory issues (74.32%)
Procrastination (65.60%)
Time-management difficulties (64.27%)
Inattention/distractibility (61.74%)
Disorganization (60.98%)
Emotional dysregulation (58.82%)

These symptoms are in addition to those more commonly associated with menopause: hot flashes, sleep problems, weight gain, anxiety, and loss of libido to name a few.

Research suggests that ADHD medications may help women without ADHD manage typical executive function difficulties associated with the onset of menopause. A series of studies conducted on healthy women aged 45 to 60 without ADHD found that treatment with ADHD medications improved their executive functions — namely, organization, focus, emotional regulation, and memory.

“These studies showed that some women report mid-life onset of some executive functions similar to ADHD symptoms during menopause and/or in their post-menopausal functioning,” wrote study co-author Thomas E. Brown, Ph.D., “and that those symptoms may respond to treatment with medications approved for treatment of ADHD, specifically atomoxetine and lisdexamphetamine (i.e., Vyvanse).”⁴

What We Don’t Know

Essentially, we know nothing about ADHD and the menopausal transition. Most women who live to 60 will experience perimenopause and menopause, yet no formal medical research exists on climacteric women with ADHD.

“How do the hormonal changes of menopause uniquely affect women who have ADHD? The science, unfortunately, is simply not there,” wrote Jeanette Wasserstein, Ph.D., in the article “Menopause, Hormones, & ADHD.” “Despite increased and hugely warranted interest, there are no studies that specifically examine menopause in females with ADHD. And that is a serious medical problem.”

No research exists on ADHD symptoms in perimenopausal and menopausal women, which means we are lacking answers to all of the following questions (and many more):

Is the timing, symptom profile, and/or severity of menopause different in women with ADHD?
Why do ADHD symptoms grow worse in perimenopause and menopause for so many individuals?
How can menopause mimic ADHD?
Are women with ADHD more likely to develop comorbid conditions like anxiety and depression in menopause?
How many people are diagnosed with ADHD for the first time during perimenopause or menopause?
Is there such a thing as “new onset” ADHD in menopause?
How can diagnosing clinicians effectively evaluate menopausal women for ADHD when so many symptoms overlap?
What pharmacological treatments and non-pharmacologic treatments are most effective for managing ADHD symptoms in menopause?
Is hormone replacement therapy (HRT) safe and effective for women with ADHD in perimenopause and menopause?

Why It Matters

Women with ADHD describe perimenopause and menopause as the most challenging phases of their lives. They are desperate for information and solutions to improve their quality of mid-life, yet a lack of scientific research leaves the medical community unable to provide diagnosis, guidance, or treatment during this pivotal time.

“What areas of research would most significantly impact your life as a woman with ADHD?” In a recent survey of 703 women with ADHD, the most common answer to this question was this: How the hormonal changes of perimenopause and menopause affect ADHD symptoms.

From brain fog to emotionality and poor memory to disorganization, the symptoms of ADHD grow markedly worse and largely unmanageable in perimenopause and menopause. Nearly half of ADDitude readers call this the most challenging time of life for them. Yet no formal research exists on menopause and ADHD, so a significant population of patients is left without answers or solutions in their years of greatest need. They report feeling medically gaslit and abandoned – their bona fide ADHD symptoms often dismissed as regular symptoms of perimenopause – and their long-term health outcomes suffer as a result.

To ignore what women are telling us about the extreme and debilitating nature of ADHD symptoms in their 40s and 50s is medically irresponsible and inexcusable. Dedicated research is needed to help women understand the impact of hormonal changes on their ADHD symptoms, to reveal the early warning signs of undiagnosed ADHD in midlife, to uncover treatment strategies fine-tuned to women experiencing the hormonal fluctuations of perimenopause, to determine the safety and efficacy of HRT in managing ADHD in midlife, and much more.

What ADDitude Readers Tell Us

Women almost unanimously report that their ADHD symptoms were most debilitating and life-altering during perimenopause and menopause, when executive dysfunction and emotional dysregulation grew beyond their capacity to manage them effectively.

“Everything flared up in perimenopause. I feel the worst I have ever felt, and my life is in disarray,” wrote one respondent to ADDitude’s 2022 menopause survey. “I am unemployed, without a fixed address, lonely, anxious, depressed, and can’t think straight. I’ve turned my life, which appeared to be running well enough, into a blazing dumpster fire.”

“I somehow managed to mask and manage my ADHD all my life,” wrote another survey respondent, “but by perimenopause, the hormone changes affected my energy and my physical ability to recover from sport. By exercising less, my energy levels dropped further. My emotions were more dysregulated. My brain fog got really bad, and my anxiety skyrocketed. I had daily heart palpitations and could not stay focused if my life depended on it. It got so bad that I eventually was laid off from my job… The worst part was that I had no idea it was ADHD until my daughter was diagnosed. I went through 10 years of hell before I knew.”

“My procrastination, attention, and distractibility all got markedly worse in perimenopause,” wrote a 53-year-old woman diagnosed with ADHD at age 43. “The worst, by far, though was the emotional stuff. That got way, way worse – and then made the other issues worse because I was either super upset or depressed about why I couldn’t get my work done.”

“In perimenopause, the brain fog and memory, inattention, distractibility, perfectionism, hyperactivity, and restlessness issues become progressively worse,” wrote a 52-year-old woman diagnosed with ADHD at age 50. “I have always had these symptoms, but I was able to manage them with systems that I created for myself. My ability to manage them has declined significantly, and this makes these symptoms seems like they are the worst they have ever been.”

What ADHD Experts Say

Research into menopause and ADHD is imperative — and long overdue.

“Whether it’s ADHD or perimenopause or ADHD and perimenopause, the impact of perimenopause and menopause on presentation of ADHD symptoms is an enormously unrecognized and important topic in global female health,” said Jeanette Wasserstein, Ph.D., during her 2023 ADDitude webinar titled, “Hormonal Fluctuations and ADHD.” “We’re half the world, and this is a significant issue, and it should be recognized and addressed.”

“It’s critical that we examine the connection between the rise of ADHD symptoms and the onset of perimenopause and menopause in women,” said Sharon Saline, Psy.D., “and how estrogen and progesterone affect the dopamine and norepinephrine receptors and pathways in the brain.”

Next Steps

Contribute to research on the impact of perimenopause and menopause on ADHD symptoms by completing ADDitude’s ADHD in Menopause survey.
Download this free resource: ‘Interventions for Treating ADHD During Perimenopause and Menopause’
Read books like The Menopause Brain and Sex Cells

Perimenopause and Menopause Impact ADHD Symptoms: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

Sources

¹Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and mood in perimenopause: a systematic review and meta-analysis. The Journal of steroid biochemistry and molecular biology, 142, 90–98. https://doi.org/10.1016/j.jsbmb.2013.06.001

²Weber, M. T., Maki, P. M., & McDermott, M. P. (2014). Cognition and Mood in Perimenopause: A Systematic Review and Meta-Analysis. The Journal of steroid biochemistry and molecular biology, 142, 90–98. https://doi.org/10.1016/j.jsbmb.2013.06.001

³Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. Published online December 3, 2020. doi:10.1016/j.jpsychires.2020.12.005

⁴https://www.additudemag.com/menopause-memory-loss-women-adhd-medication/

We Demand Attention on How Hormonal Changes Impact ADHD Symptoms in Women

Anni Layne Rodgers — Fri, 26 Apr 2024 06:02:43 +0000

What We Know

Hormonal fluctuations during the menstrual cycle, pregnancy, postpartum, perimenopause, and menopause intensify ADHD symptoms, revealing a direct correlation between estrogen and dopamine levels.

Estrogen is the hormone responsible for the sexual and reproductive development of girls and women. It also manages important neurotransmitters in the brain, including dopamine, which is central to executive functioning; serotonin, which regulates mood; and acetylcholine, which aids memory. Fluctuations in estrogen affect all women but are often felt more acutely in women with ADHD, who are more likely to experience debilitating premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), and postpartum depression (PPD). According to a recent ADDitude survey, nearly two-thirds of women with ADHD experience PMS, PMDD, and/or PPD.

Researchers theorize that the fluctuating intensity and character of ADHD symptoms correlate with hormonal changes during the menstrual cycle.¹ During the follicular phase, rising estrogen levels lead to better mood and executive function but may also cause spikes in impulsivity and hyperactivity. During the luteal phase prior to menstruation, declining estrogen and increasing progesterone may spark emotional dysregulation, working memory problems, and PMS, among other symptoms.

Those findings were confirmed in an ADDitude survey of 685 women with ADHD, 98% of whom said they have experienced changes in cognitive function and/or mood that correspond to hormonal fluctuations. The most common hormone-related changes cited involved focus and attention, energy levels, mood and emotional regulation, and memory.

In general, women with ADHD are more likely to experience hormone-related mood disorders and their symptoms tend to be more severe than those experienced by their neurotypical counterparts, according to a study published in the Journal of Psychiatric Research. ²

We know that estrogen and progesterone plummet following childbirth, putting women with ADHD at elevated risk for postpartum depression. A 2023 study conducted by Massachusetts General Hospital Center for Women’s Mental Health found a fivefold higher risk for PPD (16.8% of all subjects with ADHD) and/or postpartum anxiety (24.92%) among new mothers with ADHD compared to women without ADHD. A 2023 ADDitude survey of 1,829 adults with ADHD found that a staggering 61% of women reported that they experienced symptoms of PPD.

Estrogen and progesterone also drop during perimenopause. Of more than 4,000 women surveyed by ADDitude, 70% said ADHD symptoms had a “life-altering” impact in their 40s and 50s. This suggests that the dopamine-estrogen relationship may grow more severe during perimenopause and menopause.

What We Don’t Know

No longitudinal studies exist that chart the relationship between hormonal fluctuations and ADHD symptom characteristics and severity across the lifespan. No definitive research exists on how hormones affect ADHD in women.

“We need recognition that the relationship between hormones and cognition is an important issue in women’s health… but the literature is so sparse,” said Jeanette Wasserstein, Ph.D., during her 2023 ADDitude webinar titled, “Hormonal Fluctuations and ADHD.” “We need more research regarding the impact of sex hormones on women’s psychology in general, ADHD or not, and during all stages of life.”

General research findings suggest that sex hormones such as estrogen play a role in memory, cognition, emotional regulation, memory consolidation and retrieval, and cognitive processes in general.³ However, no definitive research exists on how hormones affect ADHD in women. We don’t fully understand the ways in which fluctuations in estrogen, progesterone, and other hormones across a woman’s lifetime impact the ADHD brain and its neurotransmitters like dopamine and norepinephrine. We are lacking vital information about hormones and health, including the following:

How the onset of puberty might correspond to heightened ADHD symptoms in individuals who menstruate
How menstrual cycle information should be considered when evaluating and treating girls and women for ADHD
Why menstruating people with ADHD more commonly experience debilitating symptoms of PMS and PMDD, and what treatment strategies might offer relief
How to mitigate the risk for postpartum depression and anxiety among women with ADHD, who are five times more likely to suffer symptoms
How perimenopause and menopause exacerbate ADHD symptoms, and vice versa
The benefits and risks of hormonal birth control for women with ADHD
The benefits and risks of hormone replacement therapy for menopausal women with ADHD

Why It Matters

Greater understanding of how hormonal fluctuations impact ADHD symptoms can significantly improve diagnosis rates and treatment for women, and result in preventative care and treatment for conditions like PMDD and PPD.

In a survey of 1,968 women with ADHD, ADDitude asked: “On a scale of 1 (minor) to 5 (life-altering), please rate the impact of your menstrual cycle on your symptoms of ADHD.” Nearly one in two respondents called the impact of hormonal fluctuations on their ADHD “life-altering” or “severe.”

On a scale of 1 (poor) to 5 (excellent), ADDitude readers also rated the health care they received for hormone-related ADHD problems. On average, it received just a 2.19. And it’s no wonder.

We hear too often from women that their providers dismissed their ADHD symptoms as typical hormonal fluctuations. We also hear from women with ADHD who suffered for years, even decades, with life-altering symptoms of PMDD before a doctor took their complaints seriously.

Women dealing with postpartum depression have suffered the same fate. Almost half of ADDitude survey respondents said they were not offered any treatment for their PPD. Today’s medical establishment appears woefully unwilling or unable to investigate and understand the debilitating impact of hormonal fluctuations on individuals with ADHD.

“The most recent meta-analyses of gender differences in ADHD symptom presentation and associated features were reported over 15 years ago,” in 2005, according to a 2020 expert consensus statement. “More research is also required to elucidate the interaction of hormones, ADHD symptoms, and stimulant medication on functioning during key times of hormonal change (e.g. during the menstrual cycle, pregnancy and the postpartum period, and menopause), to help inform treatment plans.”

What ADDitude Readers Tell Us

Many women with ADHD feel that their careers, relationships, and emotional health are held hostage each month by hormonal fluctuations that cause ADHD symptoms like inattention, impulsivity, and emotional dysregulation to run amok.

“After my period, I wake up and suddenly it feels easier to breathe, I feel lighter,” wrote one ADDitude reader. “Then I have to clean up the mess I created for the past two weeks. Laundry, dishes, the icky floor, the bathroom… then I (try) to stay on top of it for as long as I can, but around a week before my period starts, I feel heavy again, unmotivated, depressed. In this period, hanging up the laundry and doing other household tasks are like climbing a mountain, and 99% of the time, they end with me in tears.”

“My periods have ruined so much in my life… I have lost jobs, boyfriends, friends and ruined events due to just never quite being able to cope with the severity of my ADHD-heightened cycle,” wrote an ADDitude reader in Colorado. “My periods were heavy, long, painful and filled with PMS/PMDD. They were often irregular, too, which means hard to plan around. I cannot deal with anything when I am menstrual. Everything sets me off, and I feel suicidal every single month of my life.”

“I have depression along with having had PMDD, and the decades of my 20s through 40s were harsh,” wrote an ADDitude reader in Maryland. “My cycle took over my life, and I hope that for younger women in similar circumstances, things will change.”

“The day or two before I get my period, I have difficulty regulating my emotions and impulse control,” wrote an ADDitude reader in Minnesota. “This creates situations where I binge eat and struggle to keep my opinions to myself, leading to arguments at home. As an OB-GYN nurse, I can tell you that when progesterone levels are high, dopamine levels drop. So, for women with ADHD, the week leading up to menstruation is an awful time to try and get anything done.”

What ADHD Experts Say

Women in medicine first drew attention to the pivotal relationship between hormonal fluctuations and ADHD in the 1990s; in the ensuing 30 years, remarkably little research has been conducted in this area.

“Fluctuations in hormone levels across the menstrual cycle and during pregnancy can impact ADHD symptoms in women,” says Dawn K. Brown, M.D., owner and CEO of ADHD Wellness Center. “The combination of having ADHD and hormonal-related conditions (such as PMS, PMDD and PCOS) can lead to an overlooked diagnosis AND can often complicate treatment in women. Therefore, understanding these hormonal influences is essential for tailoring treatment approaches and providing appropriate support.”

“We need research investigating the role of hormones in ADHD symptom expression in girls and women,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD. “This research should examine hormonal levels across the reproductive lifespan including puberty onset, menstrual cycle, pregnancy, postpartum period, and menopause, and post-menopause.”

“We should be following adolescent and young adult women through several monthly menstrual cycles, electronically, asking them to complete a very short, simply daily questionnaire to report issues related to mood, focus, memory, and emotional regulation in relation to their menses,” says Kathleen Nadeau, Ph.D., author of Understanding Girls with ADHD among other books.

Next Steps

Contribute to research on the impact of hormones on ADHD symptoms by downloading ADDitude’s Free Menstrual Cycle Workbook for Women with ADHD. After tracking key ADHD symptoms for two cycles, complete this anonymous survey regarding your findings.
Download this ‘Free Guide to Hormones and ADHD in Women

Hormonal Changes Impact ADHD Symptoms: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

Sources

¹Eng, 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). ISSN 0018-506X. https://doi.org/10.1016/j.yhbeh.2023.105466

²Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. Published online December 3, 2020. doi:10.1016/j.jpsychires.2020.12.005

³Ali SA, Begum T, Reza F. Hormonal Influences on Cognitive Function. Malays J Med Sci. 2018 Jul;25(4):31-41. doi: 10.21315/mjms2018.25.4.3. Epub 2018 Aug 30. PMID: 30914845; PMCID: PMC6422548.

Free Women’s Health Month Calendar: 31 Days to Demand Attention!

Melanie Wachsman — Thu, 25 Apr 2024 01:51:28 +0000

There is so much we don’t know about ADHD in women, largely because of non-existent or paltry medical research. Consequently, girls and women with ADHD have missed out on critical interventions to help manage their ADHD symptoms.

This Women’s Health Month, ADDitude’s Women Demand Attention initiative seeks to change this by drawing attention to the research that doesn’t exist or doesn’t fully reflect the lived experiences of ADHD in women. From puberty to menopause and PMDD to age-related cognitive decline, the research need is vast and spans the lifespan.

A better understanding of sex differences in ADHD — a condition linked to devastating health outcomes when untreated — will improve diagnostic and treatment outcomes for women.

Download this free calendar and join the chorus of medical experts, health advocates, and government agencies calling for gender equality in health research. The calendar contains actionable steps to address inequities in health research and insights — one for each day in May 2024 — to enhance your knowledge of ADHD in women.

“Research specifically devoted to girls and women with ADHD is not only an issue of equity but a life-or-death issue for some girls and women.” — Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD

We Demand Attention on the Mental and Physical Health Consequences of Late-Life Diagnoses on Women

Anni Layne Rodgers — Wed, 24 Apr 2024 15:48:55 +0000

What We Know

Research tells us that girls and women with ADHD are diagnosed much later in life than are boys and men due to misunderstood symptom profiles in women ¹, outdated gender stereotypes, strong coping mechanisms among women, poor clinician awareness, and a high prevalence of comorbidities. ²³ ⁴

Studies on gender differences show that ADHD is consistently under-diagnosed, misdiagnosed, or undiagnosed in girls and women for the reasons above — and many more. For one, we know that women and girls are socialized to be organized, generous, empathetic, and obedient. When ADHD makes it difficult to fulfill these ideals, girls and women are more likely to mask their symptoms to avoid judgment and ostracism. Women are also twice as likely as men to experience depression, leading many clinicians to diagnose a mood disorder but miss the ADHD underneath it all. As a result, many women with ADHD come of age feeling there is something fundamentally wrong with them.

The short- and long-term effects of delayed ADHD diagnosis and treatment for women are wide ranging and may include the following: ⁵

Broad academic and social problems during childhood and adolescence ⁶
Lower and more anxiety ⁷
Higher emotional lability including anger-management problems
A higher likelihood of requiring mental health treatment
Difficulties in coping with home life ⁸
Feelings of disorganization
Somatization (including headaches, stomachaches) ⁹
Sleep difficulties ¹⁰
Elevated risk for eating disorders ¹¹
Workplace performance problems
A higher risk of self-medication with drugs and alcohol
Risky sexual behavior and higher rates of unplanned pregnancy
A higher likelihood of unsafe driving and traffic accidents
Elevated rates of intimate partner violence ¹² and sexual violence ¹³

A 2023 analysis of eight articles published in the Journal of Attention Disorders found that living with undiagnosed ADHD in childhood profoundly impacts self-esteem, mental health, well-being, and relationships. A diagnosis, not surprisingly, improves self-acceptance. Prior research has also demonstrated that ADHD treatment improves outcomes for most patients across these domains: driving, obesity, self-esteem, social function, academic outcomes, and drug use or addictive behaviors.

“ADHD is worse than any single other life expectancy risk factor that we are concerned about as a population — diabetes, smoking, obesity, alcohol use, and so on. ADHD is worse than all of them,” says Russell Barkley, Ph.D., in the ADDitude webinar titled, “How ADHD Shortens Life Expectancy: What Parents and Doctors Need to Know to Take Action.”

“Women who live undiagnosed until adulthood experience significant negative outcomes in the areas of self-esteem, social interaction, and psychosocial wellbeing beginning in childhood and continuing into adulthood,” reads a systematic review of research published in March 2023. “Earlier diagnosis and treatment may help to mediate these negative outcomes.”

What We Don’t Know

The full extent of the long-term health implications associated with delayed ADHD diagnosis and/or misdiagnosis for women is unknown.

According to every available metric, undiagnosed individuals with ADHD fare worse than their diagnosed counterparts. More in-depth, first-hand research is needed to understand the ways in which a patient’s mental health and happiness deteriorate as diagnosis is delayed, and whether that degradation worsens exponentially with time and/or hormonal changes in women.

Does a delayed ADHD diagnosis cause enduring emotional and psychological damage to women?
Does it increase the chances of developing a secondary comorbidity like anxiety or depression?
Does it increase the risk of physical health problems, serious accidents, and/or intimate partner violence?
And, if so, what can be done to minimize and mitigate this damage? How would early diagnosis improve overall health outcomes across the lifespan?

“Distracted from their own self-care, women with ADHD postpone checkups and procedures, and function with serious sleep deficits,” says Ellen Littman, Ph.D., clinical psychologist and co-author of the book Understanding Girls with ADHD. (#CommissionsEarned) “Inconsistent eating patterns, shaped by inattention and impulsivity, can result in complications. Chronically stressed, they may depend on prescription medications to manage anxiety, mood disorders, sleep, or pain, or they may self-medicate with alcohol or drugs.”

Why It Matters

Undiagnosed and untreated ADHD may reduce an individual’s life expectancy by 13 years. Understanding the signs of early distress could improve mental health and quality of life — and literally save lives.

Clinicians need to better understand the health consequences of dismissing or failing to recognize the signs of ADHD in women, and the empirical evidence that effective treatment is the key to unlocking better, even life-saving health outcomes. Research like this will illuminate the long-term implications of untreated ADHD and underscore the importance of diagnosis to healthcare providers who may otherwise shrug off reports of emotional dysregulation, impulsivity, or disorganization by female patients. Research unlocks education, which unlocks better healthcare.

This research may also help to identify early warning signs that may suggest to caregivers, clinicians, and educators that an ADHD evaluation may be appropriate.

What ADDitude Readers Tell Us

Women diagnosed with ADHD later in life carry a heavy burden that continues to impact their mental and physical health, relationships, careers, and treatment outcomes even after diagnosis.

“I was an older woman (60+) when I realized that ADHD is real and that I have it,” writes one respondent to ADDitude’s survey of 700 readers regarding research priorities. “I have lived with the misleading belief that I was a loser, lazy, incompetent… What are the long-term impacts of these self-defeating beliefs? Where does one this old go for help this late in life?”

“I believe the forgetfulness of ADHD and my tendency toward rumination and self-doubt kept me with my abuser longer, as it contributed to second-guessing myself, shame, self-blame, and not trusting what I saw or valuing how I felt,” wrote another ADDitude reader diagnosed late in life.

What ADHD Experts Say

Research shows that the long-term outcomes for women with ADHD are worse than they are for men with the condition. We need to understand why, and the critical points at which intervention is essential.

“It is critical that research explore why ADHD exacts a far greater toll on women,” Littman says. “Perhaps the perfect storm of internalized symptoms, hormonal fluctuations, and the pressure of societal expectations combine to create a context of stressors unique to females.”

“What are the strategies and supports that teen girls and women with ADHD find most helpful in self-advocacy and thriving?” asks Stephen Hinshaw, Ph.D., director of the Berkeley Girls and ADHD Longitudinal Study (BGALS).

Next Steps

Consider joining a research study on women with ADHD.

CHADD offers a database of ADHD-related research studies that is searchable according to region.
The U.S. Food & Drug Administration maintains a database of clinical trials for women that is searchable by condition and location.
ResearchMatch is a free and secure tool that helps match willing volunteers with eligible researchers and their studies at institutions across the United States.
ClinicalTrials.gov is a U.S. government database of clinical trials that is searchable by condition, treatment, or location.
Though it is not currently running any studies on adult women with ADHD, the National Institute of Mental Health (NIMH) does maintain a database of related research studies underway now.

Late Diagnosis of ADHD in Women: Related Reading

We Demand Attention: A Call for Greater Research on ADHD in Women

Intro: Top 10 Research Priorities

#CommissionsEarned As an Amazon Associate, ADDitude earns a commission from qualifying purchases made by ADDitude readers on the affiliate links we share. However, all products linked in the ADDitude Store have been independently selected by our editors and/or recommended by our readers. Prices are accurate and items in stock as of time of publication.

Sources

¹Biederman, J., Faraone, S., Mick, E., and Lelon, E. (1995). Psychiatric comorbidity among referred juveniles with major depression: fact or artifact? J. Am. Acad. Child Adolesc. Psychiatry 34, 579–590. doi: 10.1097/00004583-199505000-00010

²Mowlem, F. D., Rosenqvist, M. A., Martin J., Lichtenstein, P., Asherson, P., Larsson, H. (2018). Sex Differences in Predicting ADHD Clinical Diagnosis and Pharmacological Treatment. European Child & Adolescent Psychiatry. 28, 481–489. https://doi.org/10.1007/s00787-018-1211-3

³Quinn, P., Wigal, S. (2004). Perceptions of Girls and ADHD: Results from a National Survey. Medscape General Medicine, 6(2), 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395774/#__ffn_sectitle

⁴Waite, R. (2010). Women with ADHD: It Is An Explanation, Not the Excuse Du Jour. Perspectives in Psychiatric Care. 46(3), 182–196. https://doi.org/10.1111/j.1744-6163.2010.00254

⁵Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders. 27(7), 645–657. https://doi.org/10.1177/10870547231161533

⁶Quinn P, Wigal S. Perceptions of girls and ADHD: results from a national survey. MedGenMed. 2004;6(2):2

⁷Rucklidge JJ, Kaplan BJ. Psychological functioning of women identified in adulthood with attention-deficit/hyperactivity disorder. J Atten Disord. 1997;2(3):167–176.

⁸Fedele DA, Lefler EK, Hartung CM, et al. Sex differences in the manifestation of ADHD in emerging adults. J Atten Disord. 2012;16(2):109–117.

⁹ Graetz BW, Sawyer MG, Baghurst P. Gender differences among children with DSM-IV ADHD in Australia. J Am Acad Child Adolesc Psychiatry. 2005;44(2):159–168.

¹⁰Rasmussen K, Levander S. Untreated ADHD in adults: are there sex differences in symptoms, comorbidity, and impairment? J Atten Disord. 2009;12(4):353–360.

¹¹Fernández-Aranda F, Agüera Z, Castro R, Jiménez-Murcia S, Ramos-Quiroga JA, Bosch R, Fagundo AB, Granero R, Penelo E, Claes L, Sánchez I, Riesco N, Casas M, Menchon JM. ADHD symptomatology in eating disorders: a secondary psychopathological measure of severity? BMC Psychiatry. 2013 Jun 11;13:166. doi: 10.1186/1471-244X-13-166. PMID: 23758944; PMCID: PMC3693886.

¹²Guendelman, M.D., Ahmad, S., Meza, J.I. et al. Childhood Attention-Deficit/Hyperactivity Disorder Predicts Intimate Partner Victimization in Young Women. J Abnorm Child Psychol 44, 155–166 (2016). https://doi.org/10.1007/s10802-015-9984-z

¹³Arrondo G, Osorio A, Magallón S, Lopez-Del Burgo C, Cortese S. Attention-deficit/hyperactivity disorder as a risk factor for being involved in intimate partner violence and sexual violence: a systematic review and meta-analysis. Psychol Med. 2023 Dec;53(16):7883-7892. doi: 10.1017/S0033291723001976. Epub 2023 Jul 24. PMID: 37485948; PMCID: PMC10755239.

Q: “What Causes Postpartum Depression?”

Shreya Rane — Wed, 24 Apr 2024 08:48:40 +0000

Q: “What are the causes of postpartum depression? As an expectant parent with ADHD, what should I know about factors that increase risk for postpartum mood disorders? How can I protect myself after I have my baby?”

The causes of postpartum depression (PPD) and postpartum mood disorders are complex and combine differing sources for different people. These sources are not always fully understood. Genetic and biological factors, including dramatic hormonal fluctuations after birth, are thought to play a major role. However, hormones or biology alone do not fully explain why someone might develop a postpartum mood distress or disorder. While no parent is immune to developing PPD or other postpartum mood disorders, the following psychological and psychosocial factors are known to increase risk for these conditions: ¹ ² ³ ⁴

a history of depression or anxiety
experiencing depressive/anxious/high stress symptoms during pregnancy
a history of trauma
a history of significant mood changes during menstruation
a history of significant reactions to sleep deprivation
an unwanted pregnancy
a lack of social supports, particularly stress in a primary parenting partner relationship
social isolation
a lack of access to basic needs
low socioeconomic status

[Take This Self-Test: Signs of Postpartum Depression]

Black women and individuals of other ethnic and racial groups who have been historically under-resourced and overlooked also face higher risk for postpartum depression, largely because of expressed concerns not being adequately tended to by the helping professions. ⁵ ⁶

The ADHD-Postpartum Depression Link

Recent studies show that ADHD is a risk factor for PPD. A 2023 study found that mothers with ADHD, even those without a history of depression, are 24% more likely to be diagnosed with PPD than are mothers without ADHD.⁷ This link may be partly explained by increasing rates of first-time diagnosis of ADHD among adults, and among women in particular of childbearing age ⁸, which is likely contributing to better identification of individuals with ADHD who have developed postpartum depression.

Another 2023 study of more than 773,000 women who gave birth found that about 25% of women with ADHD were diagnosed with anxiety disorders postpartum compared to 4.6% of women without ADHD. In addition, about 17% of women with ADHD had PPD compared to 3.3% of women without ADHD.⁹ Researchers are still working to understand what underscores the disproportionate link between postpartum depression and ADHD. Both ADHD and postpartum depression and anxiety disorders represent challenges in self-regulation.

Frequent Screenings Are Key for Postpartum Parents

Though about one in eight women or birthing parents — and as many as one in 10 fathers or caregiving partners — develop a postpartum mood disorder, ⁶ ¹⁰these conditions are still largely overlooked. In a live ADDitude webinar poll, about 70% of respondents said their doctor missed their symptoms of postpartum depression. In a separate poll, about 45% of ADDitude readers said they wouldn’t be able or aren’t sure if they’d be able to identify postpartum depression in themselves or in others.

[Free Download: The Facts About Major Depressive Disorder in Women]

Frequent screenings are the most powerful tool for early detection of PPD and other postpartum mood disorders. Early detection is important to curb the development of severe forms of postpartum mood disorders. While postpartum mood disorders typically onset within three weeks of a child’s birth, they can develop through the first postpartum year. Screenings, therefore, should occur all through the first year after childbirth. Like most women and birthing parents, you likely won’t see your OB-GYN after your six-week postpartum appointment. In that case, your primary care provider and pediatrician should screen you.

At the same time, it’s critical that you know the signs of PPD and other postpartum mood disorders. Do not wait to talk to your doctor(s) if you think you show any of the signs. Insist on formal screeners, especially if you have a risk factor for PPD.

Postpartum Depression: Next Steps

Free Download: Hormones & ADHD in Women
Read: Postpartum Care for Mothers with ADHD
Read: Healing Through Parenting — The Key to Postpartum Depression Recovery

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “The Unspoken Truths of Postpartum Depression: Help for Women With and Without ADHD” [Video Replay & Podcast #470] with Jayne Singer, Ph.D., IECMH-E®, which was broadcast on September 7, 2023.

Sources

¹Stewart, D. E., & Vigod, S. N. (2019). Postpartum Depression: Pathophysiology, Treatment, and Emerging Therapeutics. Annual Review of Medicine, 70, 183–196. https://doi.org/10.1146/annurev-med-041217-011106

²Beck C. T. (2002). Revision of the postpartum depression predictors inventory. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN, 31(4), 394–402. https://doi.org/10.1111/j.1552-6909.2002.tb00061.x

³Buttner, M. M., Mott, S. L., Pearlstein, T., Stuart, S., Zlotnick, C., & O’Hara, M. W. (2013). Examination of premenstrual symptoms as a risk factor for depression in postpartum women. Archives of Women’s Mental Health, 16(3), 219–225. https://doi.org/10.1007/s00737-012-0323-x

⁴ Choi, K. W., Houts, R., Arseneault, L., Pariante, C., Sikkema, K. J., & Moffitt, T. E. (2019). Maternal depression in the intergenerational transmission of childhood maltreatment and its sequelae: Testing postpartum effects in a longitudinal birth cohort. Development and psychopathology, 31(1), 143–156. https://doi.org/10.1017/S0954579418000032

⁵Onyewuenyi, T. L., Peterman, K., Zaritsky, E., Ritterman Weintraub, M. L., Pettway, B. L., Quesenberry, C. P., Nance, N., Surmava, A. M., & Avalos, L. A. (2023). Neighborhood Disadvantage, Race and Ethnicity, and Postpartum Depression. JAMA network open, 6(11), e2342398. https://doi.org/10.1001/jamanetworkopen.2023.42398

⁶Bauman, B. L., Ko, J. Y., Cox, S., D’Angelo Mph, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K. C., Harrison, L., & Barfield, W. D. (2020). Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression – United States, 2018. MMWR. Morbidity and mortality weekly report, 69(19), 575–581. https://doi.org/10.15585/mmwr.mm6919a2

⁷Bartelt K, Piff A, Vitek G, Barkley E. Maternal ADHD Correlated with Increased Risk of Postpartum Depression. Epic Research. https://epicresearch.org/articles/maternal-adhd-correlated-with-increased-risk-of-postpartum-depression.

⁸Russell J, Franklin B, Piff A, Allen S, Barkley E. Number of ADHD Patients Rising, Especially Among Women. Epic Research. https://epicresearch.org/articles/number-of-adhd-patients-rising-especially-among-women. Accessed on March 18, 2024.

⁹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

¹⁰Paulson, J. F., & Bazemore, S. D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA, 303(19), 1961–1969. https://doi.org/10.1001/jama.2010.605

Healing Through Parenting: The Key to Postpartum Depression Recovery

Shreya Rane — Tue, 23 Apr 2024 08:34:38 +0000

Postpartum Depression: Key Takeaways

Postpartum depression is characterized by significant emotional challenges that affect the parent-child bond.
Hands-on parenting, not separation, is essential in powering recovery from postpartum depression and in repairing bonds.
Self-care and other coping strategies are an important part of postpartum depression recovery.

The Fourth Trimester: What No One Talks About

The first few months after a baby is born — sometimes called the “fourth trimester” — is a critical time for the emerging parent-infant relationship. You and your newborn are rapidly adjusting to a new way of life, a reality that is often complex and unexpected.

You may feel ambivalent. We’re told that pregnancy and parenthood should be happy and joyous, but experiencing mixed feelings after a baby arrives is common — and normal. You might well not feel the rush of falling in love that you might have expected.
You may have held unrealistic expectations of your baby. There may be a disconnect between the baby you imagined or wished for and the baby in front of you.
You may feel overwhelmed. Like many expectant parents, you might have imagined your new baby smiling and cooing all the time. But newborns more often cry and fuss and sleep as they learn to regulate (and do so with help from parents). The round-the-clock care babies require, which invariably disrupts sleep and daily routines, is a major adjustment for any parent.
You may feel worried about your baby’s health and wellbeing, about your emotions about your baby, and your emerging parenting skills.
You are likely sleep deprived. You are learning to care for a newborn during a period of acute disruption of your sleep.
You may feel discouraged. Especially if your baby is fussy or requires special caregiving needs, you may struggle with feeling successful as a parent and emotionally attached to your baby.
You may feel under pressure to return to work and make childcare decisions and arrangements.
There may be friction in the parenting partnership or lack of partnership if you’re a single parent.

These common factors — combined with dramatic hormonal fluctuations following childbirth — can increase risk for postpartum depression (PPD) during this critical stage.

Characterized by persistent and acute feelings of sadness, guilt, irritability, anxiety, and lethargy — well beyond the baby blues — PPD is a condition that interferes with your wellbeing and how you bond with your baby. It is important for your health and wellbeing – and the healthy development and wellbeing of your baby – for you to seek and accept help. You deserve relief!

PPD is treatable, and a major aspect of recovery happens by virtue of the parent-infant relationship. Getting help from others for the care of your baby is crucial in the newborn period, especially if you are experiencing signs and symptoms of PPD. But it is also very important to spend time with your baby as well, since your relationship with your little one will help you recover from distress. With PPD, this process deserves support.

[Take This Self-Test: Could You Be Experiencing Postpartum Depression?]

Postpartum Depression Treatment: Parenting Is Essential to Healing

PPD and other postpartum mood disorders affect neural pathways responsible for driving parenting and attachment behaviors. This explains, in part, why you may have trouble bonding with your baby.

Too often, parents recovering from PPD believe they must distance themselves from their baby because they’ve been told PPD is “not good” for the child. Such messaging can feel devastating to a new parent, especially if you already struggle to feel close to your baby and have low confidence in your parenting.

While separation may be initially required for parents experiencing severe PPD (especially with postpartum psychosis), reunification should happen as quickly as possible. Parenting should never be separated from the PPD healing process, as active involvement in caregiving has the potential to “reset” the brain.¹Your chances of experiencing positive, successful parenting moments — which are key to repairing bonds with your baby and raising confidence in yourself as a caregiver — can only happen through interaction.

Working with a healthcare provider who specializes in parent-infant or dyadic therapy in PPD is especially helpful. Your provider can facilitate “moments of meeting,” typically through your baby’s behaviors, that bring you closer and rewire the way you see your baby.

[Read: Postpartum Care for Mothers with ADHD — A Guide for Clinicians]

Especially if you’re recovering from acute PPD, you may require extra support for navigating the demands of parenting and of your own healing. Your provider may help you with self-regulation so you can support your baby’s regulation. You may learn how to soothe your baby, so they are available for social engagement, opening the way for those crucial moments of bonding that allow you to feel the joy in parenting to which you — and your baby – are entitled.

Postpartum Depression Treatment: Additional Coping Strategies

Your provider may have prescribed medications and/or therapy as part of your PPD treatment. As you recover from PPD, make sure the following strategies also become part of your healing process:

Find peer support. Connect with at least one other parent who is experiencing or has experienced PPD or a postpartum mood disorder. Reflecting upon and sharing your experience with PPD and how it has affected you can be immensely healing.
Engage in physical activity and movement, focus on nutritious meals, and stay hydrated. These are all cornerstones of the healing process.
Establish routines and rituals to bring structure and order into your family’s life.
Manage stress by engaging in mindfulness practices, breathing/relaxation exercises, and joyful activities, among other healthy habits.
Sleep is vital to prevent symptoms of PPD from worsening. Understandably, sleep is scarce when caring for a baby. Know that your baby can become accustomed to bedtime routines and rituals as soon as they leave the hospital. A soothing bedtime routine can help your child move toward longer stretches of sleep, which can help you avoid sleep deprivation — a critical step in your recovery.

Postpartum Depression and Parenting: Next Steps

Free Download: The Facts About Major Depressive Disorder in Women
Read: Postpartum Mood Disorders — Do You Know the Early Signs?
Research: ADHD Increases Risk for Postpartum Depression, Anxiety
Watch: The Unspoken Truths of Postpartum Depression

Additional Resources

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “The Unspoken Truths of Postpartum Depression: Help for Women With and Without ADHD” [Video Replay & Podcast #470] with Jayne Singer, Ph.D., IECMH-E®, which was broadcast on September 7, 2023.

¹ Pajulo, M., & Kalland, M. (2013). Mentalizing-based intervention with mother-baby dyads. In N. E. Suchman, M. Pajulo, & L. C. Mayes (Eds.), Parenting and substance abuse: Developmental approaches to intervention (pp. 282–302). Oxford University Press. https://doi.org/10.1093/med:psych/9780199743100.003.0014