ADHD in Children: Symptoms, Tests, Treatment

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

Live Webinar on June 27: AuDHD Guidance: Why Autism Is So Difficult to Diagnose in Women and Girls with ADHD

Carly Broadway — Thu, 23 May 2024 15:11:21 +0000

Register to reserve your spot for this free webinar and webinar replay ►

Not available June 27? Don’t worry. Register now and we’ll send you the replay link to watch at your convenience.

ADHD and autism share many symptoms. Yet the Diagnostic and Statistical Manual of Mental Disorders (DSM) allowed for ADHD and autism to be diagnosed in the same person only 11 years ago. Before 2013, the DSM did not recognize or allow for a dual diagnosis. Since then, research and clinical understanding of AuDHD have evolved.

However, we still don’t have an evidence-based, standardized approach to diagnosing and supporting adults, women, and gender-diverse individuals with AuDHD. Clinical consensus, stakeholder perspective, and increasing empirical research suggest that ADHD and autism are spectrum conditions that present differently across development and genders, making accurate diagnoses and treatment both challenging and vital.

This presentation will explain the ways in which ADHD and autism overlap and how they can present differently in children and adults — and across genders. In this webinar, you will also learn:

About how AuDHD is diagnosed in children and adults
How autism can look different from childhood to adulthood and across genders
About the association between autism and gender diversity
Why autism is so easily missed and misdiagnosed, especially in girls and women, and the consequences of that
About the myths and misinformation about autism in adults and girls and women
About what your medical and mental health providers need to know and how you can help them make an accurate diagnosis
Future directions in diagnosis and treatment

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meet the Expert Speaker

Dr. Karen Saporito is a licensed clinical psychologist who has been in private practice for over 20 years. She provides care to a wide range of clients with varying issues, but has a particular interest and specialty in diagnosing and supporting children and adults with ADHD and autism spectrum disorder. She is passionate about educating medical and mental health providers, as well as clients, about the different presentation of girls and women with neurodevelopmental disorders. Karen has been a member of APSARD for several years and serves on the APSARD Adult ADHD Guidelines Committee and the Diversity Committee.

ADHD & Autism: More Resources

Sign Up: The Clinicians’ Guide to Differential Diagnosis of ADHD
Self-Test Video: What Does Autism Look Like in Adults?
Read: Signs of Autism in Women with ADHD
Read: An Open Conversation with Temple Grandin, Autism Advocate

Certificate of Attendance: For information on how to purchase the certificate of attendance option (cost $10), register for the webinar, then look for instructions in the email you’ll receive one hour after it ends. The certificate of attendance link will also be available here, on the webinar replay page, several hours after the live webinar. ADDitude does not offer CEU credits.

Closed captions available.

“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.

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Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

We Demand Attention on Self-Harm, Intimate Partner Violence, and Substance Abuse Among Women with ADHD

Nicole Kear — Thu, 09 May 2024 14:20:44 +0000

What We Know

The lives of girls and women with ADHD are jeopardized by exponentially higher rates of self-harm, suicidality, and intimate partner violence, as compared with their neurotypical counterparts or with neurodivergent boys and men.

“ADHD in girls portends continuing problems through early adulthood that are of substantial magnitude across multiple domains of symptomatology and functional impairment,” write the authors of the Berkeley Girls ADHD Longitudinal Study (BGALS) follow-up study.¹ “The sheer range of negative outcomes is noteworthy; the most striking include the high occurrences of suicide attempts and self-injury in the ADHD sample, confined to the childhood-diagnosed combined type.”

What We Know About Self-Harm

“Girls with combined-type ADHD are 2.5 times more likely to engage in non-suicidal self-injuring behavior than are their neurotypical peers, and 3 to 4 times more likely to attempt suicide,” said Stephen Hinshaw, Ph.D., lead author of the BGALS study, in an ADDitude webinar titled, “Girls and Women with ADHD.” It’s important to note, Hinshaw says, that self-harm is a “potent indicator” of future suicide attempts.

This is an arresting statistic, particularly considering how self-harm and suicidality have spiked in adolescent girls in general. The most recent CDC Youth Risk Behavior Survey (YRBS) report found that 1 in 10 girls has attempted suicide, and 1 in 3 of girls seriously considered suicide during the past year, which is an increase of nearly 60% from a decade ago.

Research suggests that neurodivergent girls face a significantly higher risk for self-harm than do neurodivergent boys, or neurotypical people of any gender. A 2020 study in European Child & Adolescent Psychiatry found that the rate of self-harm was four times greater in females than it was in males (8.7% vs 2.2%).²A 2022 ADDitude survey found reports of self-harm among 18% of girls with ADHD versus 9% of boys with ADHD.

The correlation between teen girls with ADHD and self-harm is so strong that a 2021 study published in Child and Adolescent Mental Health proposed that all teen girls treated for self-harming behavior should be screened for ADHD:³ A full 83% of teen patients admitted to the hospital for self-harm were girls, the study found.

Indeed, early diagnosis and treatment of ADHD is critical to mitigating the risk of self-harm. “Girls and women with untreated ADHD are at double the risk for engaging in self-harm and significantly more likely to attempt suicide,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD.

What We Know About Intimate Partner Violence

Low self-esteem, high rejection sensitive dysphoria (RSD), and social skill deficits put women and girls with ADHD at heightened risk for intimate partner violence (IPV). A study published in the Journal of Abnormal Child Psychology found that: ⁴

Girls with ADHD were five times more likely to be victims of physical intimate partner violence than non-ADHD girls (30% vs. 6%)
Greater ADHD symptom severity in childhood was associated with increased risk for physical victimization

“Findings indicate that in young women, childhood ADHD is a specific and important predictor of physically violent victimization in their intimate relationships,” write the authors of the study. “Given the devastating impact of intimate partner violence, additional research on how to empower females with ADHD in their social and romantic relationships is greatly needed.”

What We Know About Substance Use

The connection between SUD and ADHD has been well-established through research. We know that:

People with ADHD are three times more likely to develop an SUD then those without⁵
25% of adults with SUD have ADHD⁶
SUD is often more severe in individuals with ADHD⁷

Among the general population, we know that teen girls are more likely to use substances than are teen boys. According to the CDC’s YRBS:

Alcohol: 27% of teen girls reported drinking in the last month vs 19% of boys
Vaping: 21% of girls reported vaping in the last month vs 15% of boys
Illicit drugs: 15% of girls reported ever using illicit drugs vs 12% of boys
Misuse of prescription opioids: 15% of girls reported ever misusing opioids vs 10% of boys

That said, studies on the prevalence of SUD among girls and women with ADHD have resulted in mixed findings. An elevated risk of substance use was found in a large-scale study led by Joseph Biederman, M.D.,⁸however no such association was found in the BGALS follow-up.

Most recently, researched at the University of Minnesota conducted a study investigating how ADHD symptoms may influence substance use in women and men, and it found a stronger association between alcohol use and ADHD for young adult women than for young adult men.⁹

“The current study confirms that ADHD-associated risk for adult substance problems is consistently greater in magnitude for women,” the authors of the study write. “The presence of adult ADHD increases risk for substance problems in women more than men.”

What We Don’t Know

No research exists on the relative efficacy of interventions that may reduce the risks for self-harm, suicidality, intimate partner violence, and substance use among girls and women with ADHD. Without fully understanding where these threats begin and how they escalate, we cannot devise and adjust solutions.

The BGALS follow-up study found elevated risks of self-harm and suicidality only among girls with combined-type ADHD, and not among those with inattentive symptoms alone, which leads researchers to speculate that impulsivity is associated with higher risk. Researchers also posit that psychosocial factors, such as the teen’s environment, contribute to the likelihood of self-harm. Longitudinal research is needed, however, to confirm this.

“What are the transition points — psychologically, family or school-related, community-wide — that predict impairment vs. resilience for girls with ADHD as they transition through adolescence to adulthood?” asks Hinshaw. “What are the strategies and supports that teen girls and women with ADHD find most helpful in self-advocacy and thriving?”

In the British Journal of Psychiatry,¹⁰ Hinshaw and doctoral student Sinclaire O’Grady call for longitudinal research on long-term correlated outcomes, such as the development of borderline personality disorder, as well as research into the intergenerational transmission of risk for negative outcomes in the children of women with ADHD.

Further research is needed to answer the following questions:

What are the specific predictors and mediators of the high risk for self-harm in girls and women with ADHD?
Does screening self-harming teens for ADHD reduce the occurrence of self-harm?
What, exactly, makes early adulthood a time of heightened risk for substance use issues, specifically for women with ADHD?
What are the impacts of ADHD treatment on intimate partner violence victimization?
What psychosocial interventions, specific to girls and women with ADHD, may mitigate risk of intimate partner violence victimization?

Why It Matters

Researching suicidality, self-harm, intimate partner violence, and substance abuse among women with ADHD will, quite literally, save lives.

A study led by Russell Barkley, Ph.D., published in the Journal of Attention Disorders, found that life expectancy was 13 years lower for patients with combined-type ADHD diagnosed in childhood and with persistent symptoms, relative to control children.¹¹

However, because of the severely limited number of females in the study, the findings are largely not relevant. No major study has investigated the impact of ADHD on life expectancy specifically in women.

With dramatically higher rates of self-harm and suicidality, as well as intimate partner violence, this research is desperately needed to protect women from bodily harm, as well as devastating emotional consequences.

What ADDitude Readers Tell Us

Feelings of loneliness, RSD, emotional dysregulation, anxiety, and low self-worth exert a crushing emotional burden — and prompt some readers to harm themselves, to abuse substances, and to maintain toxic relationships.

“I made poor choices that led to abuse,” says Debs, an ADDitude reader in the United Kingdom. “I’ve taken substances to make the pain less, and I have self-harmed to try to take away the pain.”

“The inner turmoil just seems to get louder and louder and more difficult to turn down, which leads to unhealthy ways of coping like self-harm to help manage the stress,” shares Laura, an ADDitude reader in Texas.

“I abuse cannabis,” explains ADDitude reader Elizabeth, in the United Kingdom.

“Sometimes I feel worthless and want to self-harm because of RSD, assuming I’m not loved by my loved ones.”

“I get myself in relationships that aren’t good for me as I’m just happy that somebody finally loves me despite my flaws,” explains ADDitude reader Annika in Germany. “Self-harm comes into play when I feel like a failure because the relationship is rocky, and I get invalidated or criticized.”

“I constantly feel like I’m failing, which makes the thoughts about self-harm pop up often, although I haven’t given in to those for a while now,” says Lizzy in the Netherlands.

“I drink a lot right now,” says Nicole, an ADDitude reader in Washington. “I know it is unhealthy, but it is the only way for me to cope.”

“I have a history of self-harm, which was sometimes brought on my intense feelings of worthlessness and loneliness,” shares an anonymous ADDitude reader.

What ADHD Experts Say

The long-term ravages of underdiagnosed and undertreated ADHD in women are dire — a matter of life and death in some cases. To develop effective interventions, research is essential.

“There is a critical need for studies into how increasing degrees of isolation, shame, and despair lead to self-harm and earlier mortality, exploring the relationships to early chronic trauma, impulsivity, poor self-care,” says Ellen Littman, Ph.D. “Research must respond to outcomes signaling such a significant public health crisis.”

“Too little is known about later-adult outcomes of females with ADHD,” write Hinshaw and O’Grady. “Overall, we contend that the extraordinarily high risk for self-harm incurred by girls with ADHD as they mature requires a shift in clinical perspective.”

“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,” says Schechter. “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.”

Self Harm & Intimate Partner Violence: Related Resources

Suicide &Crisis Lifeline: Call or Text 988
988lifeline.org
National Sexual Assault Helpline: 1-800-656-HOPE
National Substance Abuse Helpline: 1-800-662-HELP
Stop Bullying

Related Reading

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

Intro: Top 10 Research Priorities

Sources

¹SP, Owens EB, Zalecki C, Huggins SP, Montenegro-Nevado AJ, Schrodek E, Swanson EN. 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. 2012 Dec;80(6):1041-1051. doi: 10.1037/a0029451. Epub 2012 Aug 13. PMID: 22889337; PMCID: PMC3543865.

²Ohlis, A., Bjureberg, J., Lichtenstein, P. et al. Comparison of suicide risk and other outcomes among boys and girls who self-harm. Eur Child Adolesc Psychiatry 29, 1741–1746 (2020). https://doi.org/10.1007/s00787-020-01490-y

³ Ward JH, Curran S. Self-harm as the first presentation of attention deficit hyperactivity disorder in adolescents. Child Adolesc Ment Health. 2021 Nov;26(4):303-309. doi: 10.1111/camh.12471. Epub 2021 May 3. PMID: 33939246.

⁴ Guendelman MD, Ahmad S, Meza JI, Owens EB, Hinshaw SP. Childhood Attention-Deficit/Hyperactivity Disorder Predicts Intimate Partner Victimization in Young Women. J Abnorm Child Psychol. 2016 Jan;44(1):155-66. doi: 10.1007/s10802-015-9984-z. PMID: 25663589; PMCID: PMC4531111.

⁵Wilens T. E. (2004). Attention-deficit/hyperactivity disorder and the substance use disorders: the nature of the relationship, subtypes at risk, and treatment issues. The Psychiatric clinics of North America, 27(2), 283–301. https://doi.org/10.1016/S0193-953X(03)00113-8

⁶Charach, A., Yeung, E., Climans, T., & Lillie, E. (2011). Childhood attention-deficit/hyperactivity disorder and future substance use disorders: comparative meta-analyses. Journal of the American Academy of Child and Adolescent Psychiatry, 50(1), 9–21. https://doi.org/10.1016/j.jaac.2010.09.019

⁷Wilens, T. E., & Morrison, N. R. (2011). The intersection of attention-deficit/hyperactivity disorder and substance abuse. Current opinion in psychiatry, 24(4), 280–285. https://doi.org/10.1097/YCO.0b013e328345c956

⁸Biederman J, Monuteaux MC, Mick E, Spencer T, Wilens TE, Klein KL, Price JE, Faraone SV. Psychopathology in females with attention-deficit/hyperactivity disorder: a controlled, five-year prospective study. Biol Psychiatry. 2006 Nov 15;60(10):1098-105. doi: 10.1016/j.biopsych.2006.02.031. Epub 2006 May 19. PMID: 16712802.

⁹Elkins IJ, Saunders GRB, Malone SM, Wilson S, McGue M, Iacono WG. Differential implications of persistent, remitted, and late-onset ADHD symptoms for substance abuse in women and men: A twin study from ages 11 to 24. Drug Alcohol Depend. 2020 Jul 1;212:107947. doi: 10.1016/j.drugalcdep.2020.107947. Epub 2020 Feb 27. PMID: 32444170; PMCID: PMC7293951.

¹⁰O’Grady SM, Hinshaw SP. Long-term outcomes of females with attention-deficit hyperactivity disorder: increased risk for self-harm. Br J Psychiatry. 2021 Jan;218(1):4-6. doi: 10.1192/bjp.2020.153. PMID: 33019955; PMCID: PMC7867565.

¹¹ Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907-923. https://doi.org/10.1177/1087054718816164

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

19 Authoritative Parenting Tips for Raising Neurodivergent Children

Shreya Rane — Mon, 06 May 2024 07:12:47 +0000

Use this checklist of parenting tips and strategies to set clear limits and expectations, establish consequences, build self-esteem, and grow desired behaviors for neurodivergent children.

“Women with ADHD Are Caught In an Endless Cycle”

Nathaly Pesantez — Sun, 05 May 2024 08:09:13 +0000

The following is a personal essay reflecting the opinions of the authors.

May 5, 2024

Every ADHD expert that we know believes that girls and women with ADHD are underdiagnosed and misdiagnosed.

In 1994, a meeting of ADHD experts was convened at the National Institute of Mental Health (NIMH) to make recommendations about ways to better meet the needs of girls. This committee strongly recommended the creation of diagnostic criteria designed to better identify girls with ADHD. More than a generation later, this recommendation remains largely ignored, despite the clear and compelling need for such a change.

It is well documented that untreated ADHD in women leads to potentially disastrous consequences starting in adolescence with anxiety, depression, low self-esteem, and unplanned pregnancies followed by academic failure, psychiatric hospitalization, and suicide. Women with ADHD are more likely to face divorce, to become single parents who raise challenging children with ADHD, to experience domestic violence, and to struggle with income insufficiency — which, in combination, trigger the destructive spiral of intergenerational ADHD challenges.

[Read: Wanted — ADHD Research on Women & Girls]

Better identification and treatment of women will have a positive cascading effect, benefitting women by increasing self-esteem, improving employment, and building stronger parenting skills that, in turn, benefit their children.

Today, as APSARD (The American Professional Society for Attention and Related Disorders) is undertaking worthy effort to develop the first U.S. adult ADHD guidelines, we urge its leaders not to overlook the longstanding need for better identification of ADHD in women. We are calling on all women with ADHD, those who care about them, and those who provide care for them to sign our petition to develop gender-equitable ADHD diagnostic criteria. Gender-equitable criteria will allow us to better identify women with ADHD and help them to receive the treatment they need.

The effort to create more gender-equitable ADHD criteria has been thwarted by “lack of research evidence” to support such changes. We are caught in an endless cycle: there is minimal investment in research on gender differences in ADHD, resulting in limited evidence-based knowledge about gender differences.

Now, as APSARD works to recommend new adult ADHD diagnostic guidelines, we urge them to consider the long-overdue need to develop guidelines that are better suited to correctly identify females with ADHD. This guideline process can massively advance gender-equity if APSARD leaders are forward-thinking enough to take the needed steps. Alternatively, if gender is ignored, the guidelines could calcify historically male-biased approaches to describing and diagnosing ADHD.

[Read: ADHD Symptoms in Women Aren’t ‘Hidden.’ They Are Misinterpreted.]

We urge APSARD, as part of its adult ADHD guidelines, to acknowledge that current diagnostic approaches are not fully gender-equitable, and to propose more gender-equitable criteria for further study. Once such recommendations are made by a well-respected organization, it becomes more likely that research dollars, including funding from President Biden’s Executive Order on Women’s Health, will be allocated to research studying these proposed criteria.

We call on APSARD to take the first step in this long-overdue process by identifying gender-equity as a priority and by proposing more gender-equitable diagnostic criteria. Once this exciting first step is undertaken, the criteria can be tested and improved through a process that makes them evidence-based. Please sign our petition and share it widely through your networks.

Petition to APSARD: Improve Gender-Equity in the Diagnosis of Adult ADHD

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

Intro: Top 10 Research Priorities

Michael Morse, M.D., is the director of psychiatric education and training at The Chesapeake Center — ADHD, Learning and Behavioral Health in Bethesda, Maryland. Kathleen Nadeau, Ph.D., is founder and director of The Chesapeake Center.

We Demand Attention on How Medication Adjustments During the Monthly Menstrual Cycle and Menopause Could Improve Treatment Outcomes for Women

Anni Layne Rodgers — Fri, 03 May 2024 22:20:56 +0000

What We Know

A small study suggests that menstruating people with ADHD may achieve more effective and consistent symptom control by increasing the dosage of their prescribed stimulant medication in the luteal phase, when estrogen levels hit their lowest point.

There is a dearth of research examining the changes in ADHD symptoms and medication efficacy during all phases of the menstrual cycle, and during other times of hormonal change.

However, one 2023 study published in Front Psychiatry found that increasing a patient’s dosage of stimulant medication during the week prior to menstruation can significantly improve cognitive and emotional symptoms of ADHD during this notoriously difficult phase in the menstrual cycle.¹ The study was the first of its kind to examine the impact of adjusting stimulant medication dosages during the menstrual cycle for women with ADHD and co-occurring depression and premenstrual dysphoric disorder (PMDD) – a severe form of PMS.

Prior to the study, these women experienced “diminished response to amphetamines in the late luteal phase” and an “exacerbation of their ADHD and depressive symptoms in the premenstrual week” that was not helped by their regular ADHD medication. This experience was echoed in ADDitude’s 2023 survey of nearly 2,000 women with ADHD, two-thirds of whom said they experienced intense symptoms of premenstrual syndrome (PMS) or PMDD, beginning, on average, at age 14 and lasting for up to 40 years. The most common luteal-phase symptoms reported were:

Irritability (80%)
Mood swings (79%)
Cramps or discomfort (78%)
Tension/anxiety (68%)
Lack of focus/concentration (66%)

“In ADHD, we know there is low prefrontal dopamine. If you have low estrogen as well in the third and fourth week of the cycle, you have doubly low levels of the neurotransmitters and hormones that help you focus and control your mood,” said Sandra Kooij, M.D., one author of the 2023 study, titled, “Female-Specific Pharmacotherapy in ADHD.” “This may help to explain why women with ADHD have much more severe symptoms during that week.”

When Kooij and her colleagues administered higher doses of prescribed stimulant medication to subjects with ADHD during the luteal phase, “all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy.”

No similar studies on ADHD symptoms in menopausal women exist. As stated in Part Four of this We Demand Attention package, research tells us only that ADHD medications may help women without ADHD manage typical executive function difficulties associated with the onset of menopause.

What We Don’t Know

Women with varying ADHD subtypes may respond differently to cycle dosing of stimulant medications, however, we don’t understand the implications of modulating methylphenidate vs. amphetamine during hormonal fluctuations due to a lack of research.

At a very basic level, we need research validating the presumption that hormonal fluctuations during the menstrual cycle, and hormonal changes during perimenopause and menopause, influence ADHD symptoms, ADHD medication effectiveness, and overall functioning. As stated in Part Three of this We Demand Attention package, understanding the relationship between hormonal fluctuations and ADHD symptom characteristics and severity across the lifespan is a critical first step.

Tailoring medication dosages to hormonal status — known as cycle dosing — could optimize ADHD treatment and improve mood disorders in women who experience premenstrual symptoms.²Kooij’s 2023 study strongly suggests this, though it followed only nine women with ADHD. A larger, longitudinal study is needed to understand the long- and short-term implications of adjusting ADHD medication according to hormonal fluctuations. Similar studies are also needed to understand the risks and rewards associated with ADHD medication adjustments during perimenopause, when estrogen and progesterone levels begin a steady decline, and during menopause, when they bottom out and stay low. Longitudinal studies of menstruating, perimenopausal, and menopausal women with ADHD can help answer pivotal questions, such as:

Do symptoms of PMS and PMDD impact women with inattentive-type ADHD and combined-type ADHD similarly? Or do symptoms differ according to subtype?
During the luteal phase, do patients respond differently to higher doses of methylphenidate vs. amphetamine? If so, what are the significant differences?
Could some patients benefit from lower doses of stimulant medication during the high-estrogen follicular phase, when estrogen and dopamine potentiate each other and may encourage risky behaviors in some women?
Could cycle dosing with ADHD medication also improve symptoms of depression and/or anxiety in women with those comorbidities? Could the converse also be true?
Is cycle dosing of ADHD medication associated with any short- or long-term health risks?
How might use of hormonal birth control complicate cycle dosing for women with ADHD?
Could women with PMDD experience PMDD improvement of those symptoms with cycle dosing of ADHD medication? If so, would they require even higher doses than average to achieve significant results?

Why It Matters

Unlocking the power of cycle dosing for women who suffer extreme symptoms of ADHD and its comorbidities during each luteal phase could save them from more than 3,000 days of agony over a lifetime.

In a survey of 703 ADDitude readers, 36% said their lives could be significantly impacted by research exploring “how adjusting ADHD medication during the menstrual cycle could improve symptom control.” In a separate survey, we learned that two-thirds of ADDitude readers who menstruate experience significant symptoms of PMS and/or PMDD. In other words, the majority of women with ADHD are suffering each month from debilitating symptoms of comorbid conditions that may be addressed, at least in part, with simple medication dosage adjustments. That seems like a no-brainer.

Though some psychiatrists are collaborating with patients on cycle dosing now, widespread adoption of this potentially life-changing practice will hinge on the availability of reliable research data from longitudinal studies on women with ADHD and comorbid conditions. Initial studies demonstrate universal benefit to women who are suffering; we just need larger studies and more of them to unlock this treatment for tens of millions of menstruating girls and women.

Similar research on perimenopausal and menopausal women with ADHD could help to provide relief during the phase of life when ADDitude readers tell us their ADHD symptoms are at their worst due to falling estrogen and progesterone.

What ADDitude Readers Say

According to an ADDitude survey of nearly 1,700 women with ADHD, symptoms experienced during the luteal phase range from migraines and memory loss to self-harm and suicidality. Very few have tried cycle dosing because very few clinicians recommend it.

“My ADHD medication doesn’t work during the luteal phase,” wrote one 36-year-old ADDitude survey respondent in Canada. “I had extreme emotional dysregulation.”

“My ADHD meds are significantly less efficacious for about 10 days per month; two days before the bleed I am a barely functional zombie,” wrote another reader.

“The week leading up to my cycle, I might as well not even take my ADHD meds,” wrote a woman in Wisconsin. “It’s like my body overrides them.”

“I’d like to see research into a device similar to that for people with diabetes that monitors hormone levels and micro-doses medication for great ADHD medication efficiency,” wrote a woman from Ireland in her 60s.

As covered in Part Four of this We Demand Attention Package, ADDitude readers almost unanimously report that their ADHD symptoms were most debilitating and life-altering during perimenopause and menopause.

“Please, for the love of God, do something on the changes in ADHD medication dosing that perimenopausal and menopausal women need,” wrote a woman with ADHD and anxiety in her 50s. “The effectiveness of ADHD meds has changed drastically for the worse for me. I used to be really sharp when I could focus, and the brain fog is significantly disabling now.”

“The DEA’s strict limits on stimulants leaves doctors unwilling to adjust ADHD meds for women in their 40s and 50s,” she said. “If your blood pressure medication stopped being as effective in perimenopause, would your doctors shrug and say, ‘Well, you’ll just have to work with the dose you’ve got?’ No, they would not.”

What ADHD Experts Tell Us

Hormonal status matters. Cycle dosing is a reasonable and effective response to elevated symptoms of ADHD and comorbidities during the menstrual cycle, but few healthcare providers understand the efficacy of this strategy due to a lack of research.

“Is it possible that women could require different medications and/or dosages at different times in their cycle? Absolutely, unequivocally, without doubt,” said Jeanette Wasserstein, Ph.D., in the ADDitude webinar titled “Hormonal Fluctuations and ADHD.” “The problem is that psychiatrists don’t know this, or very few psychiatrists know this.”

“Research should assess the degree to which girls and women with ADHD require additional or unique treatment approaches,” said Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD. “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.”

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’
Join the Head Heart Hormones network co-founded by Sandra Kooij, M.D., to address questions of ADHD, among other conditions, in menopause.

Menstrual Cycle and Menopause: Related Reading

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

¹de Jong M, Wynchank DSMR, van Andel E, Beekman ATF, Kooij JJS. Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Front Psychiatry. 2023 Dec 13;14:1306194. doi: 10.3389/fpsyt.2023.1306194. PMID: 38152361; PMCID: PMC10751335.

²Roberts, B., Eisenlohr-Moul, T., & Martel, M. M. (2018). Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology, 88, 105–114. https://doi.org/10.1016/j.psyneuen.2017.11.015

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 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.

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.

We Demand Attention on Sex Differences in ADHD

Anni Layne Rodgers — Fri, 19 Apr 2024 15:43:11 +0000

What We Know

Research tells us that women experience distinct and distinctly impairing symptoms of ADHD, which they are more likely to mask and hide due to shame.

Though clinical and research bias has historically overemphasized young male presentations of ADHD, Patricia O. Quinn, M.D., and Manisha Madhoo, M.D., emphasize in a 2014 review that, “several characteristics are unique to the expression of ADHD in women and girls.”¹ A review of 41 articles and studies led Quinn and Madhoo to conclude that women are more likely than men to have inattentive ADHD and…

to experience internalizing symptoms
to suffer coexisting anxiety and affective disorders
to develop eating disorders and engage in self-harm
to develop coping strategies that mask symptoms
and to report low self-esteem and relationship problems.

These findings were echoed in a 2021 report by 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.² That report concluded that “Females with ADHD experience, on average, serious impairments, with a particularly heightened risk for problems in close relationships and engagement in self-harm.” He notes that clinicians may overlook symptoms and impairments in females because of less overt — but nonetheless impairing — symptom manifestations that girls and women frequently mask.

Several experts posit that gender norms and expectations may explain why girls and women with ADHD mask their symptoms. “There’s no room for ADHD when society expects girls and women to be perfect — nurturing, competitive, and sexualized — a pernicious triple bind accentuated during adolescence,” reads an ADDitude article co-authored by Hinshaw.

What We Don’t Know

We don’t definitively know all the distinct ways ADHD manifests in women or how to better recognize female-specific symptoms and impairments across the lifespan.

The BGALS study of 140 girls, beginning around age 9, demonstrates how ADHD manifestations and outcomes change during childhood, adolescence, and early adulthood. However, we’re lacking any longitudinal studies that show how symptoms and challenges manifest and change across a woman’s lifetime. We have no definitive comparison of symptoms in women vs. men from childhood through adulthood. We suspect that symptom severity and distress are higher in women than in men, but we don’t know this with certainty because we lack severity rating scales based on gender. (Current diagnostic tools also favor male presentations of ADHD.) We also don’t know when, exactly, women face the greatest risk for adverse health outcomes due to undiagnosed or untreated ADHD.

“There is such a gap between DSM ‘symptoms’ and ‘daily life challenges’ for women,” says Kathleen Nadeau, Ph.D., co-author of Understanding Girls with ADHD among other books. “I support conducting a large-scale survey of high school girls, female college students, and adult women identified with ADHD to tell us what their areas of biggest struggle are so that, at the very least, we can have the next DSM list accompanying features for females.”

DSM stands for Diagnostic and Statistical Manual of Mental Disorders, a guidebook used by health care professionals to diagnose ADHD, among other mental health conditions.

The accurate diagnosis of ADHD in girls and women hinges on researchers’ ability to establish a history of ADHD symptoms and behaviors commonly seen in females — inattention, emotional reactivity, decreased self-esteem, academic difficulties, and risky behavior. Quinn and Madhoo urge clinicians to identify behaviors suggestive of comorbid anxiety and depression, and to consider not just functioning but distress at home, with peers, in school, and in the workplace.

Why It Matters

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.

With greater understanding of female symptom profiles and relative symptom severity, we may do the following:

determine if the female symptom profile is unique enough to merit a distinct set of ADHD diagnostic criteria
understand whether the current DSM criteria should be adjusted to allow for an ADHD diagnosis with fewer or different symptoms
decrease the likelihood of misdiagnosis with internalizing disorders or personality disorders, which often delay proper diagnosis and appropriate treatment
know why and when ADHD symptoms cause the most impairment to women, and how to adjust treatments and supports to improve health outcomes and quality of life.

“What are the transition points — psychologically, family or school-related, community-wide — that predict impairment vs. resilience for girls with ADHD as they transition through adolescence to adulthood?” asks Hinshaw, architect of the pivotal BGALS study, in response to ADDitude’s call for research priorities.

What ADDitude Readers Tell Us

ADDitude survey results suggests a chasm between ADHD symptoms in men vs. women that grows with age.

In a 2023 survey of adults with ADHD, 78% of women and 75% of men said their ADHD symptoms manifested as procrastination and time-management problems in puberty. While 61% of men cited academic performance issues in puberty, only 49% of women said the same. Women were more likely to recall feelings of sadness or depression, feelings of overwhelm, and rejection sensitive dysphoria as their hallmark symptoms of ADHD in adolescence.

The chasm between ADHD symptoms in men vs. women grew with age, according to the ADDitude survey. In their 40s and 50s…

83% of women with ADHD reported debilitating feelings of overwhelm, but only 59% of men said the same.
working memory problems impacted 80% of women but only 65% of men.
heightened emotional dysregulation, including anger or hostile behavior, impacted 59% of women but only 44% of men.

The disparities in symptom prevalence and severity between the sexes certainly seem worthy of further investigation.

“The most valuable research, in my opinion, would identify the different presentation of ADHD compared to the typical stereotype,” says an ADDitude reader with ADHD, anxiety, and a learning difference. “Most women are diagnosed too late because biased medical research is geared toward men. Identifying ADHD earlier in women would make the biggest difference. Second, I would like to see research into how women with ADHD receive more negative feedback regarding the exact same symptoms that men exhibit, and how that affects us. For example, if a man with ADHD talks too much or has excessive energy, he’s just an energetic guy, but if a woman acts exactly the same she is domineering and is self-centered.”

What ADHD Experts Say

“The greatest disparities in research on ADHD in women vs. men that I see raise the following questions,” says Maggie Sibley, Ph.D., Associate Professor of Psychiatry & Behavioral Sciences at the University of Washington School of Medicine and a researcher and psychologist at Seattle Children’s Hospital.

“What role do hormones play in the expression of ADHD in biological females across the lifespan and across the menstrual cycle?”
“What are the core symptoms of ADHD in girls and women across the lifespan (in terms of both sensitivity and specificity)?”
“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 of their life and domains of impairment)?”

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.

ADHD in Women: Related Reading

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

Intro: Top 10 Research Priorities

Sources

¹Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3), PCC.13r01596. https://doi.org/10.4088/PCC.13r01596

²Hinshaw, S. P., Nguyen, P. T., O’Grady, S. M., & Rosenthal, E. A. (2022). Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions. Journal of child psychology and psychiatry, and allied disciplines, 63(4), 484–496. https://doi.org/10.1111/jcpp.13480

Fraticelli, S., Caratelli, G., De Berardis, D., Ducci, G., Pettorruso, M., Martinotti, G., Di Cesare, G., & di Giannantonio, M. (2022). Gender differences in attention deficit hyperactivity disorder: an update of the current evidence. Rivista di psichiatria, 57(4), 159–164. https://doi.org/10.1708/3855.38380

We Demand Attention! A Call for Greater Research on Women with ADHD

Anni Layne Rodgers — Thu, 18 Apr 2024 17:46:29 +0000

May 1, 2024

“Female ADHD isn’t male ADHD-lite. If anything, research indicates that ADHD may be even more impairing for women than it is for men.” — Lotta Borg Skoglund, M.D., Ph.D.

Most of what we know about ADHD stems from research done on men and boys. We know relatively little about ADHD in women, but the research that exists is sobering.

Women* with ADHD experience more psychological distress, anxiety, depression, insomnia, and eating disorders than their male counterparts.
They are more likely than men with ADHD to suffer with low self-esteem, self-harming behaviors, poor social relationships, and emotional dysregulation.
For many women, ADHD symptoms become debilitating as hormonal levels shift dramatically each month. Women with ADHD also are at elevated risk for unwanted pregnancy and sexual violence.

Arguably, women face more impairing ADHD symptoms and more devastating consequences than do men with the condition. Yet, due to gender-based societal expectations and medical bias, they are also more likely to mask or hide their symptoms. Many women avoid seeking help due to overwhelming shame about real and perceived failures. If they do pursue an evaluation, women “often feel they need to prove symptoms for a physician to take them seriously and consider a diagnosis of ADHD.”¹

And so the consequences of untreated ADHD pile up. Research conducted in 2021 found that girls had more visits to a psychiatric care facility prior to ADHD diagnosis, were prescribed non-ADHD medications (e.g., anti-depressants) before and after diagnosis at a higher rate, and they were older than boys at time of referral and at age of diagnosis.² In other words, they remained undiagnosed and untreated for longer than their male counterparts, who are referred for evaluation and diagnosed at significantly higher rates.

Why the gender disparity? Lopsided medical research, in part, perpetuates gender stereotypes and ignores fundamental truths about ADHD in women that could unlock superior care.

“Untreated or inadequately managed ADHD in women can lead to adverse long-term outcomes, including academic underachievement, unemployment, relationship difficulties, inappropriate treatment, and increased risk of substance abuse and mental health disorders,” says Dawn K. Brown, M.D. “Further research regarding these topics is indeed crucial. 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.”

Addressing Inequities in Health Research

This Women’s Health Month, ADDitude is joining the chorus of medical experts, healthcare advocates, and government agencies calling for gender equality in medical research. Regarding ADHD, we know that roughly 80% of subjects in pivotal early research were boys, and 29% of research studied boys exclusively.¹ As a result, the symptom criteria in the DSM-5 excludes many key characteristics specific to the expression of ADHD in women, such as “decreased self-esteem, more difficulty in peer relationships, increased likelihood of anxiety and other affective disorders,” and more.¹ As Andrea Chronis-Tuscano, Ph.D., notes in a 2022 review, “Our theories and clinical approach to ADHD were largely guided by studies on elementary school-aged boys.”³

The diagnostic criteria fail to reflect the lived experiences of women with ADHD because they have largely been absent from research studies. So those patients are not properly diagnosed and instead left to believe that something is fundamentally wrong with them that can’t be explained or treated.

“For decades, girls and women with ADHD have missed out on critical interventions to help manage their ADHD symptoms,” says Julia Schechter, Ph.D., of the Duke Center for Girls and Women with ADHD. “A primary reason for missing or misidentifying girls and women with ADHD is that they have largely been left out of ADHD research studies. As a result, researchers have conceptualized ADHD mainly based on the male presentation, which has led to many clinicians who assess and treat ADHD being unaware of the different symptom presentations that girls and women may express.”

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,” Schechter says. They are at double the risk for engaging in self-harm and significantly more likely to attempt suicide.

“Research specifically devoted to girls and women with ADHD is not only an issue of equity,” Schechter adds, “but a life-or-death matter for some girls and women.”

The U.S. Government Prioritizes Research Equity

More broadly, government and research agencies are beginning to recognize the serious consequences of gender bias in health research. In late 2023, First Lady Jill Biden, Ed.D., established the White House Initiative on Women’s Health Research and promptly announced $100 million in funding for women’s health research to be conducted by the Advanced Research Projects Agency for Health (ARPA-H).

“Research on women’s health has always been underfunded, many medical studies have focused on men and left women out, many of the medicine dosages, treatments, medical school textbooks, are based on men and their bodies — and that information doesn’t always apply to women,” Biden said in announcing the funding. “There are big gaps in research on diseases and conditions that only affect women, that disproportionately affect women, or that affect women and men differently.”

The White House Initiative is chaired by Carolyn Mazure, Ph.D., the Norma Weinberg Spungen and Joan Lebson Bildner Professor in Women’s Health Research at Yale University, who will coordinate the Initiative on behalf of the Office of the First Lady and the Gender Policy Council.

The Most Vital Research on Women with ADHD

We know that gaping holes in research have led to real-life risks and impediments for countless women with ADHD. More gender-based studies are clearly needed, but narrowing down the list of research priorities to those with the greatest potential benefit to patients is challenging. From puberty to menopause, and PMDD to age-related cognitive decline, the research need is vast.

“What we need are studies that follow a significant body of women through the lifespan… and that have women self-report on any symptoms or other experiences at the time they are having them, not retrospectively, which is always subject to biased memory and recall,” says Mary V. Solanto, Ph.D., Director of the ADHD Center in the Division of Child and Adolescent Psychiatry at Mount Sinai School of Medicine in New York City.

Solanto was among more than a dozen leading experts that ADDitude consulted in devising the following list of health research priorities for women with ADHD. In addition, ADDitude surveyed 703 readers and asked, “What areas of research would most significantly impact your life as a woman with ADHD?” Their answers helped to inform the following list, which ADDitude will bring to the White House Initiative on Women’s Health Research for consideration.

Check back often for links to detailed information about each of the following research priorities as we release them.

#1: Longitudinal Studies of Sex Differences in ADHD

How and why do ADHD symptoms manifest differently and more intensely in women vs. men?

#2: Studies on the Mental and Physical Health Consequences of Delayed ADHD Diagnoses on Women

What are the long-term health implications of delayed ADHD diagnosis and/or misdiagnosis for women?

#3: Studies Investigating How Hormonal Changes Across the Lifespan Impact ADHD Symptoms in Women

How do fluctuations in estrogen, progesterone, and other hormones from adolescence to post-menopause impact neurotransmitters like dopamine and norepinephrine, which play a crucial role in focus, attention, and mood?

#4: Studies Investigating How Perimenopause and Menopause Impact ADHD Symptoms, and Vice Versa

How do the hormonal changes of perimenopause and menopause uniquely impact women with ADHD, and how can the often-overlapping symptoms of each condition be teased apart for proper diagnosis and effective treatment?

#5: Studies Investigating Why Women with ADHD Experience PMS, PMDD, and PPD at Significantly Elevated Rates

Is there an inherent component of ADHD, or of the interplay between dopamine and estrogen, that makes women with ADHD experience premenstrual syndrome, premenstrual dysphoric disorder, and postpartum depression with greater likelihood and severity than other women?

#6: Studies Exploring Whether ADHD Medication Use is Safe and Protective to Parents During Pregnancy and While Nursing

Do the benefits of ADHD medication use to expectant and new parents outweigh the potential risks to babies who may be exposed to stimulant medications in utero or through breastmilk?

#7: Studies Exploring How ADHD Medication Adjustments During the Monthly Menstrual Cycle Could Improve Outcomes for Women

Could adjusting dosages during menstrual cycle phases – especially increasing an ADHD medication’s dosage during low-estrogen phases – provide more consistent symptom management for ovulating individuals?

#8: Studies on the Long- and Short-Term Implications of Hormonal Birth Control and Hormone-Replacement Therapy Use Among Women with ADHD

Can hormonal birth control be used to safely mitigate the effects of monthly hormonal fluctuations on ADHD symptoms? Can hormone-replacement therapy be used to safely counteract the effects of reduced estrogen on ADHD symptoms in menopause?

#9: Studies Investigating How and Why Comorbid Conditions Like Anxiety, Depression, and Eating Disorders Impact Females with ADHD

Beyond late diagnosis, what other factors contribute to the high prevalence of anxiety, depression, and other comorbid conditions among women with ADHD?

#10: Studies to Identify Early Indicators of Self-Harm, Partner Violence, Substance Abuse, and Other Adverse Outcomes Common Among Women with ADHD

How can we better protect girls and women with ADHD against the unique risks and adverse outcomes that pose a serious threat to their health and wellbeing?

Additional ADHD Research Priorities:

#11: Studies Investigating the Intersections of Race, Ethnicity, and ADHD for Women of Color

#12: Studies to Establish the Differentiating Characteristics Between Age-Related Cognitive Impairment and ADHD in Older Women

#13: Studies Investigating the Ways That Gender Roles and Stigma Contribute to Delayed Diagnoses, Missed Diagnoses, and Misdiagnoses Among Women with ADHD, and Women of Color with ADHD, in Particular

#14: Research Into Long-Term Educational and Professional Outcomes for Women with ADHD, Relative to Men with ADHD and to Neurotypical Women

*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

¹Attoe, 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

²Klefsjö, U., Kantzer, A. K., Gillberg, C., & Billstedt, E. (2021). The road to diagnosis and treatment in girls and boys with ADHD – gender differences in the diagnostic process. Nordic journal of psychiatry, 75(4), 301–305. https://doi.org/10.1080/08039488.2020.1850859

³Chronis-Tuscano A. (2022). ADHD in girls and women: a call to action – reflections on Hinshaw et al. (2021). Journal of child psychology and psychiatry, and allied disciplines, 63(4), 497–499. https://doi.org/10.1111/jcpp.13574