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

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

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

“My autism is extremely invisible,” Lehmann says. “Society has more tolerance for a child having a meltdown but when an adult male who doesn’t look disabled does it, it comes across as very threatening.”

Recently on a work trip, Lehmann’s flight was delayed, causing his “Jenga tower of functioning” to come tumbling down. He kicked a trash can in frustration, attracting the attention of a heavily-armed police officer. Lehmann’s mother stepped in, explaining, “My son has autism. I’ve got this.” The officer took a step back, ready but waiting, as Lehmann calmed down.

Lehmann has had enough negative encounters with law enforcement — cornering him, cursing at him, shaming him — to know this was a best-case scenario. He’s terrified about what could have happened if he hadn’t had a traveling companion, or if the officer was more forceful. He wonders what the outcome might have been if he’d been Black.

The duty of law enforcement is to protect and serve, but when they encounter people with disabilities, too often the result is harm instead of help. Adults and teens with autism, ADHD, and other neurodevelopmental disorders appear to be at a heightened risk for negative outcomes every step of the way in the criminal justice system, from first police contact to questioning and detainment, to jail, trial, and beyond. Mishandled interactions can result in everything from distress and humiliation to jail time, or even death.

[Read: What the Americans with Disabilities Act Means For You]

While no comprehensive data exists on the collective outcomes when people with disabilities encounter police, we do know that neurodivergent individuals are over-represented in the carceral system. Rates of ADHD are six times higher among inmates than in the general public,¹  and rates of intellectual and developmental disabilities (including autism) are four times higher.²

Law Enforcement and the Neurodivergent: Unique Risks

Neurodivergent people face challenges with law enforcement as victims, witnesses, and especially as suspects. For individuals with autism, common behaviors like stimming, avoiding contact, or meltdowns arouse suspicion, which can lead officers to shout commands or make physical contact. This, in turn, intensifies sensory overwhelm and anxiety, making compliance less likely, not more.

Similarly, people with ADHD may have trouble following commands, because of impulsivity or distractibility, and this behavior can be viewed by police as uncooperative or disrespectful. An individual’s hyperactivity and restlessness, exacerbated by confinement to a chair in a small room, might be perceived as a sign of guilt. Working memory problems, time blindness, and memory distrust syndrome may cause a person with ADHD to have difficulty accurately answering questions or to reply, “I don’t know” to even simple questions such as: “Is this the road you live on?” Police may misinterpret this as evasiveness, another possible sign of guilt.

[Read About the Mom Spearheading Police Training on Autism]

In all these cases, what might have begun as a harmless situation can escalate quickly. “Officers that can’t identify the signs of disability may over-utilize force, may make an arrest for a situation that doesn’t call for one,” explains Texas Police Sergeant James Turner, who spent nearly a decade heading the Crisis Intervention Team (CIT) training in Austin, Texas.

Heightened Threats for People of Color

For neurodivergent people of color, the perils of an interaction with police are even greater. Black Americans are killed by police at twice the rate of White Americans, according to the Fatal Force Database, which has been tracking deadly police shootings since 2015.

Stephon Watts, a Black 15-year-old with autism in Illinois, was one of these victims. Watts’ parents called 911 to help respond to their son’s meltdown, but the arrival of the police only escalated Watts’ distress. Police fired two shots, killing Watts in his own home. In 2021, Illinois passed the Stephon Watts Act, also called the Community Emergency Services and Support Act (CESSA), which requires emergency responders to send mental health professionals to respond to mental or behavioral health calls.

Devastating stories like these keep Evelyn Polk Green, M.S., Ed., up at night. Past president of ADDA (Attention Deficit Disorder Association) and CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), Green says that as a mother to Black sons with ADHD, she worries about all the things that any mother of a person with ADHD worries about in a police encounter. “It’s just multiplied exponentially by all the other things that we already have to worry about on top of it,” she explains. “Unfortunately, so often law enforcement is ready to jump to the absolute worst conclusion and with Black and brown kids, it’s even worse, because they often automatically assume they’re up to something.”

Disability Awareness Training on De-escalation Techniques

Experts agree: training is the essential first step in ensuring better outcomes. “Most people call 911 when they don’t know what to do. We have to be properly equipped in that moment to handle that crisis,” says Sergeant Turner. “We are problem solvers but we have to have the tools.”

Those tools are exactly what David Whalen, project director for Niagara University First Responder Disability Awareness Training (DAT), aims to provide. The DAT is an eight-hour comprehensive training that covers victimization, Americans with Disabilities Act (ADA) compliance, interface with CIT, interaction skills, proper language and specific information on identifying and understanding a dozen disabilities including ADHD, autism, Tourette’s syndrome, dementia, and epilepsy.

Sergeant Turner’s disability awareness training was received during a 40-hour CIT training, required for all cadets in Texas. CIT training addresses how to support people experiencing a mental health crisis, and Turner hastens to clarify: “People with disabilities are not mentally ill, though they can have that issue as well.” Because some of the techniques (including de-escalation) overlap, disability awareness is often folded into CIT training.

Key topics include:

• Recognition of Disability: Officers learn common signs and symptoms of disabilities. Not all individuals can self-identify, and some choose not to. Proper identification of disability prevents officers from jumping to erroneous conclusions, including that the person is intoxicated, and allows for ADA accommodations.
• De-escalation Techniques, including:
  • Giving the individual space and time to respond. Many encounters with disabled individuals take a tragic turn simply because of the speed at which they unfold, creating unmanageable (and often unnecessary) distress. “You don’t always need to rush up on them,” says Turner. “You need to ask yourself, what are the risks vs. benefits of delaying action?”
  • Appropriate communication is essential. If someone with autism is distressed or experiencing sensory overwhelm, for example, a loud, commanding voice may cause further overwhelm. Adjusting tone and pace of speech, or using a pad and pen or hand signals, might be appropriate. Sometimes, Turner says, the key might be to call a family member to ask for specific guidance about support.
  • When force is unavoidable, using less lethal tools like tasers and pepper spray can save lives.
• Connect with Community Resources: Often, Whalen says, it is invaluable for officers to help individuals pursue longer-term support. Turner agrees: “We are not the experts. We just need to know who the experts are.”

“Fighting for Crumbs of Funding”

It’s clear that training works to improve outcomes. Yet there’s enormous variability in how much, if any, disability awareness training police officers receive, since it’s largely determined on a local level.  Too often, Whalen says, training only happens as a term of a settlement after a person with disability, or their family, sues the police for wrongdoing.

This was the case in Maryland; the bill that now requires disability awareness training for all police officers — through the Ethan Saylor Alliance — was created only after a 26-year-old man with Down Syndrome was killed when sheriff deputies tried to forcibly eject him from a movie theater where he neglected to buy a ticket.

“It would be beneficial to have something mandated at the national level but you have got to have the funding to support implementation,” says Leigh Anne McKingsley, senior director of Criminal Justice Initiatives at The Arc. “This issue of disability justice has been bumped down the priority list, and we’re fighting for crumbs of funding to bring about the exposure and education we need.”

Beyond Training: Community Resources

Training is crucial, but McKingsley says: “You can’t just expect training to take care of everything,” This is why, as part of its training, The Arc’s Pathway to Justice program assembles Disability Response Teams (DRT). These are multidisciplinary planning teams that bring together law enforcement, people with disabilities, attorneys, victim advocates, and disability advocates to collaborate in an open dialogue.

“The mandate is, on the day of training, the DRT starts making a plan of action moving forward,” McKingsley says. That includes brainstorming how to address the most glaring gaps in support and services both short and long term, and figuring out how to expand disability training in the community.

Sergeant Turner, who served on a DRT in 2019, agrees that bringing together police officers and people with disabilities leads to better policing. “Anytime someone calls 911, well, it’s probably not the best day of that person’s life,” Turner says. “Showing what a person with a disability looks like when they’re not in crisis is important.” Lehmann agrees: “Get-togethers with fun activities allow police officers to see the human side of disability, and they give that context.”

On the flip side, Lehmann points out, these community events help people with disabilities familiarize themselves with police officers in a calm environment, alleviating anxiety and setting the stage for better outcomes.

To truly tackle the problem though, McKingsley says, we have to understand its contours more fully, and this requires research, which is currently scarce. “Data would help us better evaluate the training, to know what strategies work and why,” he says. “The more we can show how often these encounters are happening, the more we can bolster our ability to go to local and state entities for action.”

Detained by Police? Keep This in Mind

If law enforcement stops you with questions, remember these three key pieces of advice from Rosemary Hollinger, J.D., founder of Partner Up, LLC:

1. First, pause. It’s important to not say the first thought that goes through your mind.
2. Tell the officer you have ADHD. Under the ADA, you’re entitled to reasonable accommodations, including modified questioning, fidgets, frequent breaks, and access to your medication.
3. Before you answer questions, make sure to have someone you trust, such as a lawyer or family member, with you to figure out exactly what happened. You must be truthful and accurate with police, so if you are forgetful and have time blindness, it’s essential to have a lawyer or trusted person with you to support you.

ADHD and the Risk of False Confession

Susan Young, Ph.D., a clinical psychologist in London, has conducted extensive research about people with ADHD in the criminal justice system. One study in which she was involved found that people with ADHD were at an increased risk of making a false confession, and the more severe the person’s ADHD, the greater the risk.³

If police don’t recognize that an individual’s difficulty following commands, sitting still, and answering questions is a result of ADHD, they may misinterpret these behaviors as evasive and guilty, explains Young. This may cause police to detain the person for even longer, which in turn exacerbates symptoms — particularly if the person’s ADHD medication has worn off. It’s a vicious, dangerous cycle which creates desperation.

“There’s all this anxiety; they want to get out,” says Young, who adds that sometimes, people with ADHD will choose to proceed without an attorney present, because they can’t bear to extend the process at all.

“They just want to leave,” Young concludes. “And they’ll say anything.”

The study concluded that safeguards for people with ADHD must be “put in place to prevent miscarriages of justice.”

Law Enforcement and Neurodivergent Justice: Next Steps

• Read: Crime, Punishment, and Redemption for My Son with ADHD
• Q&A: Recently Diagnosed, ADA Information
• Read: ADHD Clinicians Must Consider Racial Bias in Evaluation and Treatment of Black Children
• Upcoming Webinar: AuDHD Guidance – Why Autism Is So Difficult to Diagnose in Women and Girls with ADHD

SUPPORT ADDITUDE
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.

Sources

¹ Young S, Moss D, Sedgwick O, Fridman M, Hodgkins P. A meta-analysis of the prevalence of attention deficit hyperactivity disorder in incarcerated populations. Psychol Med. 2015 Jan;45(2):247–58. https://doi.org/10.1017/S0033291714000762

²   Bureau of Justice Statistics, Disabilities Among Prison and Jail Inmates, 2011-2012 (U.S. Department of Justice, 2015), tables 4 and 5, http://www.bjs.gov/content/pub/pdf/dpji1112.pdf.

³ Gudjonsson, G. H., Gonzalez, R. A., & Young, S. (2021). The Risk of Making False Confessions: The Role of Developmental Disorders, Conduct Disorder, Psychiatric Symptoms, and Compliance. Journal of Attention Disorders, 25(5), 715-723. https://doi.org/10.1177/1087054719833169

Officer Yancey offers her perspective, as a mother and a police officer, on ensuring the safety of community members with autism and other invisible disabilities.

Q: What worries you most when you think about your son with autism, or others with disabilities or mental health concerns, encountering the police?

Nationwide, many people, particularly African Americans, have been injured or killed by police officers because of misunderstandings about autism, mental illness, or other conditions. Officers are too quick to get physical, from giving a command to drawing a gun. Where is the in-between?

When my son hears sirens or loud noises, he shuts down and grabs his ears. Sometimes he’s in so much pain, he says that he can’t even hear you speaking. What if an officer is talking to him and he shuts them out, and they misconstrue that as being rude or non-compliant? What if he starts flapping his arms, and they think he is violent?

[Self-Test: Signs of Autism Spectrum Disorder in Children]

Q: How have you benefited from disability awareness training?

I received training to learn how to understand and respond to people with autism. They gave us a lot of insight: statistics, what to look for, and better ways to approach someone when we’re called to a scene.

I learned that people with autism tend to gravitate toward bodies of water, and this can lead to drownings. In Sleepy Hollow, we’re on the Hudson River, so that opened my eyes.

Q: Tell us about the H.E.A.R.T.S. registry you developed.

H.E.A.R.T.S. is a voluntary registration program for people in the community with autism, dementia, and other conditions. You register your loved one by filling out a questionnaire, giving us (first responders) information, so we can make things better when we respond to a call. The questionnaire asks for the person’s address, school, emergency contact, and about fears, favorite things or places, and actions or words to avoid. A parent might write, “My son has an infatuation with trains.”

[Download: The ADHD-Autism Link in Children]

Q: How does a registry help first responders support people with autism?

When we get a call from a mom who says that her son is a little out-of-control, we can check to see if they’re on the registry. If so, the desk officer can tell the dispatched officer, “No lights, no sirens,” so we know not to spook the kid. The responding officer can call the desk and get more information.

If a person is missing, it helps us locate them. A little girl who had autism and was nonverbal was signed up. One day, someone called in and said they saw a child in pajamas in the middle of winter on a busy roadway. Because her picture was in the registry, the officer identified her right away and reunited her with her family.

Autism Awareness: Next Steps

• Upcoming Webinar: AuDHD Guidance: Why Autism Is So Difficult to Diagnose in Women and Girls with ADHD
• Free Download: Free Autism Evaluation Checklist
• Read: ADHD, Anxiety, and Autism — Your AAA Guidebook
• Read: Autism vs. ADHD — A Parent’s Guide to Tricky Diagnoses

SUPPORT ADDITUDE
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.

New research proposes that ADHD may increase the risk of gaming disorder (GD) in college students, hindering academic success and sleep. ¹

The study, published in the journal PLOS ONE, reported that 35.7% of college students with GD display ADHD symptoms compared to 23.3% of students without gaming disorder.

Gaming disorder is a mental health condition marked by excessive and compulsive engagement in Internet games, which can significantly disrupt relationships, school, and work. The behavior must be present for at least 12 months (or shorter in severe cases) to receive a GD diagnosis.

After surveying 383 university students in Lebanon, the researchers determined that ADHD symptoms directly affect academic performance and indirectly increase the risk of GD. Among students classified as high academic performers with GPAs of 3.2 and above, only one met the criteria for symptoms of GD or ADHD.

“The absence of GD and ADHD symptoms among high academic performers suggests that academic engagement and success may be protective factors against these conditions,” the study’s authors wrote. “Alternatively, it may be that the symptoms of these disorders disrupt academic performance, which would be consistent with the negative correlation observed between disorder prevalence and academic excellence.”

Gaming behaviors may distract college students from academics as they prioritize playing video games over studying. The study reported that students with a gaming disorder spend more time gaming on weekdays and weekends than do those without the disorder. “The correlation between GD and gaming hours, particularly on non-school days, suggests that free time may exacerbate gaming behaviors, potentially leading to disorder,” the study’s authors wrote. “This finding has practical implications for the management of GD, as it highlights the importance of structured time and alternative leisure activities as part of the therapeutic approach.” ²

Gaming Disorder Affects College Students’ Sleep Habits

According to the researchers, GD also impacts students’ sleep quality and duration. On average, students with GD sleep 6.1 hours; 64.3% wake up in the middle of the night to game. In comparison, those without GD sleep between 6.8 to 7.2 hours, with negligible nocturnal awakenings for males and none for females.

“The high incidence of nocturnal awakenings in the disordered gaming group (DGG) to continue gaming is a concerning trend that warrants attention due to the critical role of sleep in cognitive function, emotional regulation, and overall health,” the study’s authors wrote. ³

Findings also indicate that ADHD is more predictive of GD in females than in males, though other factors beyond ADHD may contribute to the development of GD, especially in females. These results echo a study published in June 2023 in the Journal of Attention Disorders. That study found a staggering 82% of individuals with GD had ADHD; more than half of the participants with ADHD (57%) had GD. ⁴

Why Gaming Appeals to College Students with ADHD

Why are students with ADHD symptoms more susceptible to gaming and, consequently, gaming disorder?

“From escapism and socialization to competition, video games are highly engaging, reinforcing, and stimulating by design,” said Jeremy Edge, LPC, IGDC, during the 2023 ADDitude webinar, “Addictive Technology and Its Impact on Teen Brains.” “Prolonged, excessive exposure to immediate rewards and dopamine hits in gaming may diminish the number of dopamine receptors in the brain over time, which can lead to tolerance and further stimulation seeking. ⁵ Gamers who are motivated by both escapism and achievement and who consider gaming part of their identity, are most at risk for problematic or disordered gaming.”

While the PLOS ONE study suggests a strong link between ADHD symptoms and GD, the study’s design does not establish causality and relies on self-reported data, which may introduce bias. In addition, the prevalence of ADHD in the sample is also higher than typical epidemiological estimates.

“More longitudinal studies are needed to clarify the causal relationships between ADHD and GD and to track how these relationships evolve,” the study’s authors wrote.

Edge emphasized that anyone showing signs of gaming disorder should talk to a doctor or mental health professional. “While still a growing field, help for technology addiction is available and ranges from psychotherapy and inpatient treatment clinics to recovery programs, support groups, and even medication,” he said.

Sources

¹ Hawai, N., Samaha, M. (2024). Relationships of Gaming Disorder, ADHD, and Academic Performance in University Students: A Mediation Analysis. PLOS ONE. https://doi.org/10.1371/journal.pone.0300680

² Buono, F.D., et al. (2020). Gaming and Gaming Disorder: A Mediation Model Gender, Salience, Age of Gaming Onset, and Time Spent Gaming. Cyberpsychology, Behavior, and Social Networking, 23(9): p. 647–651. https://doi.org/10.1089/cyber.2019.0445

³ Bourchtein, E., Langberg, J.M., Cusick, C.N., Breaux, R.P., Smith, Z.R., Becker, S.P. (2019). Technology Use and Sleep in Adolescents With and Without Attention-Deficit/Hyperactivity Disorder. J Pediatr Psychol. https://doi.org/10.1093/jpepsy/jsy101

⁴ Hong, J. S., Bae, S., Starcervic, V., & Han, D. H. (2023). Correlation Between Attention Deficit Hyperactivity Disorder, Internet Gaming Disorder or Gaming Disorder. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231176861

⁵ Sussman, C. J., Harper, J. M., Stahl, J. L., & Weigle, P. (2018). Internet and Video Game Addictions: Diagnosis, Epidemiology, and Neurobiology. Child and Adolescent Psychiatric Clinics of North America,27(2), 307–326. https://doi.org/10.1016/j.chc.2017.11.015

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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.

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When administered at carefully selected dosages in clinical settings, and combined with therapy before and after treatment, psychedelics have been found to provide rapid relief from some of the most painful and difficult-to-treat mental health conditions. Ketamine is being used for depression and suicidality in clinical trials. MDMA is treating severe post-traumatic stress disorder (PTSD), and psilocybin is being used for treatment-resistant depression, alcohol use disorder, and more.

However, important questions remain about the long-term efficacy and safety of psychedelics, as well as patient suitability. Several large-scale studies are now under way to address these concerns, including the first-ever phase 3 clinical trial on psilocybin-assisted therapy — the largest randomized, controlled, double-blind study on the drug, with more than 800 participants. Initial results are expected this summer.

How Do Psychedelics Work?

Research shows that psychedelics improve many neuropsychiatric disorders, but the way they work is less clear. Functional MRIs and laboratory studies offer possible explanations:

• Ketamine binds to NMDA receptors in the brain, increasing levels of a mood-regulating neurotransmitter called glutamate.¹
• MDMA increases oxytocin, dopamine, and other chemical messengers related to positive emotions.²
• Psilocybin stimulates the brain’s serotonin 2A receptors, appearing to decrease activity across the default mode network.³

But these biochemical explanations don’t tell the full story, says Gül Dölen, M.D., Ph.D., professor of psychology and researcher at University of California Berkeley’s Center for the Science of Psychedelics. Psychedelics only reliably improve psychiatric conditions when administered with therapy. “Therapy is the context to get the cure,” Dölen explains. “You can’t take MDMA and go to a rave and expect it to cure your PTSD.”

Indeed, when taken on their own, psychedelics aren’t hugely effective, according to studies; therapy unlocks the drugs’ enduring benefits. Also, there are serious risks to taking the drugs without medical supervision.

[Read: The Truth About Lion’s Mane, Psychedelics & Caffeine]

A Brand-New Framework

Most psychiatric medications must be taken daily, often for a lifetime. By contrast, a single dose of certain psychedelics paired with therapy can result in full-blown remission. This claim appears too good to be true when viewed through the traditional “biochemical imbalance” model of neuropsychological disease that has dominated the field for the past 50 years. “The idea is that depression, for example, is a biochemical imbalance in serotonin,” Dölen says. “So, we’ll restore serotonin levels with a pill, and you’ll get better.”

But what if there were an approach that treated depression by restoring the fundamental ability to learn (and unlearn) behaviors and ways of thinking, and not by raising serotonin levels? It’s an entirely different framework for understanding neuropsychiatric disorders — the learning model — and Dölen says it’s the best way to comprehend how psychedelics work.

Psychedelics act like master keys unlocking what scientists call “critical periods” of learning—specific times when individuals have a heightened ability to soak in new information. During brain development, these are the critical windows in which we acquire vision, language, motor development, and more. And after these critical windows close, they remain locked.

Or so we thought.

Psychedelics Restore Child-Like Learning

In a study that involved giving mice MDMA, Dölen found that the drug unlocks a critical period for social reward learning, restoring adult mice to child-like levels of openness for social development.⁴ Dölen’s next study uncovered the potential of all psychedelics—including LSD, psilocybin, ketamine, and ibogaine—to open these critical periods.⁵

[Watch: “Psychedelic Therapy for Mood Disorders: Research & Potential”]

“This is a big deal,” says Dölen. “And if it’s true, it’s going to revolutionize things, but only if we understand what a critical period is. It’s not that you take a pill and you speak Japanese. It’s that you take a pill and you restore the ability to learn Japanese.”

The drugs open the mind to learning. The therapy provides the learning itself.

“Patients talk about how they had an epiphany, how the trip enabled them to see how they’d built their lives around a foundational myth that wasn’t true, whether about their relationship to other people, their personality, their deserving to be in the world,” Dölen says. The post-trip therapy, in turn, allowed them to identify how that myth led to maladaptive ways of interacting with the world, and understand how to integrate that knowledge into their daily lives.

The potential of psychedelics to re-open critical periods has far-reaching implications. Dölen’s lab is exploring the possibilities of treating conditions like stroke and blindness with psychedelics through a project called PHATHOM (Psychedelic Healing: Adjunct Therapy Harnessing Opened Malleability).

“Psychedelics are not going to be the magic bullet that fixes everything, but we’re excited about the possibilities,” Dölen says. “Being able to restore child-like learning is a major therapeutic opportunity.”

Psychedelics Therapy and Mental Health: Next Steps

• Self-Test: Symptoms of Depression in Adults
• Free Download: Signs of Depression That May Surprise You
• Read: Real Stories of Using Ketamine for Depression, Anxiety, PTSD

Nicole C. Kear is Consumer Health Editor at ADDitude.

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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.

Sources

¹ Matveychuk D, Thomas RK, Swainson J, Khullar A, MacKay MA, Baker GB, Dursun SM. Ketamine as an antidepressant: overview of its mechanisms of action and potential predictive biomarkers. Ther Adv Psychopharmacol. 2020 May 11;10:2045125320916657. doi: 10.1177/2045125320916657. PMID: 32440333; PMCID: PMC7225830.

² Mitchell, J.M., Bogenschutz, M., Lilienstein, A. et al. MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nat Med 27, 1025–1033 (2021). https://doi.org/10.1038/s41591-021-01336-

³ Smausz R, Neill J, Gigg J. Neural mechanisms underlying psilocybin’s therapeutic potential – the need for preclinical in vivo electrophysiology. J Psychopharmacol. 2022 Jul;36(7):781-793. doi: 10.1177/02698811221092508. Epub 2022 May 30. PMID: 35638159; PMCID: PMC9247433.

⁴ Nardou, R., Lewis, E.M., Rothhaas, R. et al. Oxytocin-dependent reopening of a social reward learning critical period with MDMA. Nature 569, 116–120 (2019). https://doi.org/10.1038/s41586-019-1075-9

⁵ Nardou, R., Sawyer, E., Song, Y.J. et al. Psychedelics reopen the social reward learning critical period. Nature 618, 790–798 (2023). https://doi.org/10.1038/s41586-023-06204-3

Nearly two-thirds of ADDitude readers ages 18 to 29 report feeling lonely “always” or “often,” according to a new survey of 4,170 adults with ADHD. Living or working with others made little difference; 89 percent of these young adults say they feel lonely even then. Only 19 percent say social media makes them feel more connected. In contrast, 46 percent of people ages 68 to 77—the demographic traditionally associated with social isolation — reported the same levels of loneliness.

“My ADHD makes it hard to remember to reach out or respond,” wrote one 28-year-old woman with inattentive ADHD, “but rejection sensitive dysphoria hits hard when I’m not reached out to or responded to, even though I acknowledge that hypocrisy. ADHD also makes it hard to leave the apartment (time management, overwhelm at what it takes to leave, energy to be social, executive function difficulties, etc.), so even if I’m invited, I find reasons to cancel.”

“For me, ADHD and loneliness impact one another,” wrote one survey respondent. “Now I neither want relationships nor do I have the energy to keep up the masking necessary to navigate relationships. It requires too much effort.”

When ADHD Symptoms Lead to Loneliness

The stories of social isolation shared by ADDitude readers were reflected in the findings of a recent meta-analysis of studies investigating whether young people with ADHD experienced greater loneliness than their neurotypical peers. The review of 20 studies, involving about 6,300 participants, concluded that people with ADHD who were younger than 25 had significantly elevated levels of loneliness due, in part, to mental health struggles, including anxiety and depression, and to “feeling different” because of their ADHD. Researchers called this an “important problem” of which clinicians should be aware for early identification and intervention, according to the study published in February in the Journal of Attention Disorders.¹

“I feel too quirky and awkward,” wrote one survey respondent. “I’m fun at first, but quickly become too much for others. I want there to be less of me.”

[Read: “Why Don’t I Have Any Friends?”]

For more than three-quarters of ADDitude survey respondents, feelings of loneliness are tied directly to ADHD symptoms, manifestations, and repercussions. According to the survey, the most common ADHD-related roots of loneliness include:

• low self-esteem: 67%
• rejection sensitive dysphoria (RSD): 65%
• social anxiety: 64%
• poor working memory: 63%
• “masking” who they really are: 59%
• executive dysfunction and disorganization: 57%

The Painful Toll of Loneliness

Loneliness correlates to mental health problems for 78 percent of adults with ADHD, who also report high levels of anxiety (65%) and depression (61%), among other comorbid conditions. For two-thirds of survey respondents, loneliness has led to toxic relationships, substance abuse, self-harm, binge eating, excessive spending, and porn addiction.

Among ADDitude readers who say they “always” or “often” feel lonely, only 26 percent live alone. Retirement, lonely marriages, physically limiting health conditions, and strenuous caregiving responsibilities were often cited by older survey respondents, who say that late ADHD diagnoses contributed to their loneliness as well.

“Grieving the loss of what I perceived as a ‘good’ life after my ADHD diagnosis made me feel like a failure,” wrote one older adult. “I cannot undo the damage or ill feelings caused by my past actions, and this recognition has caused me even more pain.”

[Read: The Science of Loneliness]

“When I feel lonely,” said one survey respondent, “I want to reach out, but I usually don’t because:

1.  ‘Out of sight out of mind’ has left too much time between interactions, and I feel shame over this.
2. When no one reaches out to me, or if I reach out and get no immediate response, RSD kicks in and I’m immediately overwhelmed with self-loathing.
3. I dwell on each previous interaction and why this person may be harboring ill feelings toward me.
4. Depression asks, ‘What’s the point of interaction? It’ll just exhaust you.’”

Causes of Loneliness For People with ADHD

More than half of the adults surveyed say they have trouble making and keeping friends for the following reasons:

• feeling overwhelmed
• fearing rejection
• experiencing social anxiety
• receiving few social invitations

“It’s a cruel loop,” one survey respondent said. “I feel safe when alone, so, much of the time, it’s a relief. But then, the loneliness is crushing.”

Coping with Loneliness

A spate of startups like the United Kingdom’s Timeleft and Friender are joining the veteran app Meetup in efforts to facilitate online connections that lead to real-life interactions. Some apps invite groups of strangers to meet for dinner at a specific time and place. Others work more like platonic dating apps where users scroll profiles before making plans. And some draw people together over common interests.

More than two-thirds of people say they feel less lonely when they reach out and connect with others in person, or via text or phone call. They also successfully alleviate loneliness through the following:

• physical touch: 62%
• engaging in a hobby: 58%
• spending time with their pet: 56%
• working with a therapist: 52%

“Letting the Mask Slip“ in Neurodivergent Friendships

More than half of adults surveyed say they relate better to, and feel less lonely around, other neurodivergent adults.

“Being with other neurodivergent folks validates my experience of living with ADHD,” wrote one survey respondent. “There’s less judgment.”

Said another adult with ADHD: “In a neurodivergent group, I don’t feel weird, and I can let my mask slip. It is less taxing and there is less of a chance of me freaking out later over social mistakes I might have made.”

Loneliness and ADHD: Next Steps

• Read: Birds of a Feather: The Joy of Neurodivergent Friendships
• Read: “How Do You Keep From Being Socially Isolated as an ADHD Adult?”
• Read: “Why Don’t I Have Any Friends?”

Sources

¹Jong A, Odoi CM, Lau J, J Hollocks M. Loneliness in Young People with ADHD: A Systematic Review and Meta-Analysis. J Atten Disord. 2024 May;28(7):1063-1081. doi: 10.1177/10870547241229096. Epub 2024 Feb 23. PMID: 38400533; PMCID: PMC11016212.

SUPPORT ADDITUDE

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.

“Social interactions rely on a complex orchestration of brain functions, from understanding another person’s point of view, recognizing their emotional state, feeling their emotional pain, and so on. Difficulties with any of these can affect our ability to connect to others,” says Ellen Lee, M.D., associate professor of psychiatry at the University of California San Diego. “The emotional pain and stress of loneliness can also take a toll on our brains.”

Lee was the corresponding author of a systemic review of 41 studies, involving 16,771 adult participants, examining the neurobiology of loneliness. Researchers in those studies used brain imaging and other scans to identify the differences in the brain structure and function of lonely people. The findings showed that some people were hard-wired for loneliness in the same way that some are hard-wired for anxiety.

Loneliness is defined as the emotional discomfort one feels when their need for intimacy and social connection goes unmet.

In the lonely participants, abnormal structure and/or activity was discovered in the prefrontal cortex, which mediates emotional regulation and inhibitory control; the insula, which plays a role in emotional pain and self-awareness; and in other parts of the brain. The review was published in the journal Neuropsychopharmacology in 2021.¹

[Test Yourself: How Severe Is Your Loneliness? Take This Quiz]

Lee says it’s possible that brain changes associated with ADHD, depression, and anxiety can lead to feelings of prolonged loneliness because people tend to withdraw from social interactions when they have low mood or other symptoms.

“Researchers are starting to study these links to understand if improving loneliness could be a way to improve these symptoms,” she says.

Lonely Brains Process the World Differently

In a study published in the journal Psychological Science in 2023, researchers discovered that lonely people viewed the world differently from each other and from nonlonely people. Using fMRI scans to examine neural responses to stimuli (videos) and other methods, the researchers also administered a loneliness scale and survey to evaluate the 66 study participants.²

They found that loneliness was associated with structural and functional differences in regions of the brain, and the researchers said their results remained significant even after controlling for individuals’ reported numbers of friends.

“Lonely people process the world idiosyncratically, which may contribute to the reduced sense of being understood that often accompanies loneliness,” the researchers said in the study. “In other words, we found that nonlonely individuals were very similar to each other in their neural responses, whereas lonely individuals were remarkably dissimilar to each other and to their nonlonely peers.”

The researchers said the findings “raise the possibility that being surrounded predominantly by people who view the world differently from oneself may be a risk factor for loneliness (even if one socializes regularly with them).”

Those findings echo the lived experience of many adults with ADHD who report feeling a sense of isolation due to their perceived difference. “I mostly feel like a dolphin in a sea of stingrays,” an ADDitude reader says. “I never meet people with whom I have anything significant in common, and with whom I can forge solid, lasting friendships.”

[Read: How to Make Friends As an Adult With ADHD]

The Evolutionary Function of Loneliness

Stephanie Cacioppo, Ph.D., a behavioral neuroscientist whose research seeks to understand how people experience different emotions, says evolution has sculpted the human brain to respond to biological mechanisms like hunger and thirst. Hunger, she says, is triggered by low blood sugar and motivates us to eat. Thirst helps us find water before we become dehydrated. Pain encourages us to take care of our body.

“Loneliness alerts us to potential threats, and damage to our social body, and in doing so, increases our motivation to bond with others,” says Cacioppo, author of Wired for Love. “It’s the brain’s way of telling you: You’re in social danger, you’re on the periphery of the group, you feel left out, misunderstood, you need protection, inclusion, support, and love. One of the most important things that love can do, it turns out, is shield us from the ravages of chronic loneliness.”

Cacioppo says it’s not uncommon for people to mask in the company of others when they don’t feel a sense of connection.

“Masking is totally understandable from a neuroscientific perspective,” she says. “The best solution is to stay authentic. Authenticity is the key to connectivity. Building connections with people while staying true to yourself can be a buffer against loneliness.”

How to Deal with Loneliness

Cacioppo offers several strategies to address chronic loneliness, encapsulated by the acronym G.R.A.C.E.:

Gratitude: Every day, write down five things you truly appreciate. Science shows that expressing gratitude improves emotional wellbeing.

Reciprocity: If you know someone who feels lonely, ask them for help or for advice. Showing respect can give a lonely person a sense of worth and belonging that decreases feelings of isolation.

Altruism: Helping others, and sharing your knowledge, will give you a feeling of self-expansion that is similar to what people experience when they are in a love relationship.

Choice: The tricky thing about loneliness is that, to some extent, it’s self-fulfilling. The more you think you are lonely, the more you are. To break the spiral, shift your mindset and choose to be curious about how you can make meaningful connections.

Enjoy: Smiling and sharing good times (or good news) with people helps reduce loneliness and increase happiness.

How to Deal with Loneliness: Next Steps

• Read: The Big Heart Approach to ADHD Acceptance & Self-Love
• Read: Are You Feeling Lonely?
• Read: Feeling Antisocial? Alone? Both? 3 Common ADHD Friendship Challenges
• Read: 13 Tips for Feeling Connected

Sources

¹ Lam JA, Murray ER, Yu KE, Ramsey M, Nguyen TT, Mishra J, Martis B, Thomas ML, Lee EE. Neurobiology of loneliness: a systematic review. Neuropsychopharmacology. 2021 Oct;46(11):1873-1887. doi: 10.1038/s41386-021-01058-7. Epub 2021 Jul 6. PMID: 34230607; PMCID: PMC8258736.
² Baek, E. C., Hyon, R., López, K., Du, M., Porter, M. A., & Parkinson, C. (2023). Lonely Individuals Process the World in Idiosyncratic Ways. Psychological Science, 34(6), 683-695. https://doi.org/10.1177/09567976221145316

SUPPORT ADDITUDE
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.

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

Related Reading

• “What Years of Debilitating Migraines Taught Me About ADHD in Women”
• What’s Behind the “Depression Gap” Impacting Women?
• Why ADHD in Women is Routinely Dismissed, Misdiagnosed, and Treated Inadequately
• “Could I Be Autistic, Too?” Signs of Autism in Women with ADHD
• Too Few Doctors Screen Women for ADHD — and We Deserve Better

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

Intro: Top 10 Research Priorities

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

Sources

¹ Andersson, 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

² MGH 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/

³ Biederman, 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

⁴ Biederman, 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

⁵ Obaydi, 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

⁶ Andersson, 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

⁷ Hinshaw, 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

⁸ Ahlberg, 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

⁹ Attoe, 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

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Despite highly esteemed and plentiful literature on the use of stimulant and nonstimulant medication to treat ADHD, relatively little information is available on the treatment of complex ADHD — that is, attention deficit disorder plus at least one comorbid condition like anxiety, depression, or an eating disorder. Few studies address the treatment of comorbid conditions, the order of treatment, or the treatment of cognitive deficits and/or hard-to-treat ADHD symptoms.

This presentation will integrate data from controlled and open trials to highlight strategies for illustrative cases of complex ADHD. Participants will learn:

• About new medications approved for ADHD and their use for complex and hard-to-treat ADHD
• About strategies to manage ADHD comorbidities
• About approaches for treating cognitive executive function deficits in ADHD

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

Timothy E. Wilens, M.D., is the Chief of Child and Adolescent Psychiatry, and (Co) Director of the Center for Addiction Medicine at the Massachusetts General Hospital. He is a Professor of Psychiatry at Harvard Medical School. Dr. Wilens specializes in the diagnosis and treatment of ADHD, substance use disorders, and bipolar disorder. Widely published, Dr. Wilens has more than 350 original articles, reviews, chapters, books and editorials to his credit. Dr. Wilens is a consultant to the National Football League, Major/Minor League Baseball, Bay Cove Human Services and Phoenix/Gavin House and is consistently named one of the Best Doctors in Boston and in America for psychiatry.

Treating Complex ADHD: More Resources

• Download: 2024 Scorecard of ADHD Treatments
• Sign Up: The Clinicians’ Guide to Treating Complex ADHD
• Read: Treatment Troubleshooting Guide for Patients
• Replay: Substance Use Disorder and ADHD: Safe, Effective Treatment Options with Dr. Timothy Wilens

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

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

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

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

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

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

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

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

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

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

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

What We Don’t Know

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

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

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

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

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

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

Why It Matters

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

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

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

A Related Consideration

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

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

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

What ADDitude Readers Tell Us

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

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

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

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

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

What ADHD Experts Say

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

Next Steps

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

Related Reading

• Postpartum Care for Mothers with ADHD: A Guide for Clinicians
• Treating for Two: ADHD Meds in Pregnancy
• Study: Prenatal Exposure to ADHD Medication Does Not Impact Neurodevelopment
• Study: Discontinuing Stimulant Medication Negatively Impacts Pregnant Women with ADHD

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

Intro: Top 10 Research Priorities

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

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

Sources

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

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

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

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

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

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

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

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

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

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

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

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

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

What We Don’t Know

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

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

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

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

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

Why It Matters

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

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

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

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

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

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

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

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

What ADDitude Readers Tell Us About PMDD

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

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

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

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

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

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

What ADDitude Readers Tell Us About PPD

Support for postpartum women with ADHD is inadequate.

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

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

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

What ADHD Experts Say

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

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

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

Next Steps

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

Related Reading

• Study: PMDD, Menopause, Postpartum Depression May Be More Severe in Women with ADHD
• Study: ADHD Increases Risk for Postpartum Depression, Anxiety
• Hormonal Changes & ADHD: A Lifelong Tug-of-War
• PMDD Has Affected My Whole Life
• PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms

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

Intro: Top 10 Research Priorities

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

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

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

²Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, J. J. S. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of psychiatric research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

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

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

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

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

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

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

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

• Menopause, Hormones & ADHD: What We Know, What Research is Needed
• ADHD Impairment Peaks in Menopause, According to ADDitude Reader Survey
• Perimenopause Problems: How Changing Hormones Exacerbate ADHD Symptoms

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

Intro: Top 10 Research Priorities

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

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

¹ Weber, 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

² Weber, 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

³ Dorani 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

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

Body-focused repetitive behaviors (BFRBs), a common ADHD comorbidity, are chronic, functional behaviors that often result in physical damage. A wide range of emotional states can precede and follow a BFRB episode; individuals may feel pleasure, relief, shame, or pain, which may drive another episode.

Certain thought processes or beliefs, boredom, anxiety, or the need to relieve an uncomfortable bodily sensation can trigger the behavior. Some people mindlessly partake in the behavior, or it is a compulsion they can’t stop. Many people enjoy engaging in BFRBs, though they hate the outcome of their pulling or picking.

In this download, you will learn…

• Traits of trichotillomania (hair-pulling disorder)
• Signs of excoriation or dermatillomania (skin-picking disorder)
• The difference between nail biting and onychophagia (nail-biting disorder)
• Descriptions of BFRB treatments and interventions, such as habit reversal training (HRT), Comprehensive Behavioral Treatment (ComB), and others.
• And much more!

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

• Women, Hormones, and ADHD
• Hormonal Changes & ADHD: A Lifelong Tug-of-War
• PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms
• Menstrual Cycle Phases and ADHD: Why Cycle Syncing Is Essential
• High and Low Estrogen Exacerbate ADHD Symptoms in Females: New Theory

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

Intro: Top 10 Research Priorities

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

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

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.