Written by Tasneem Abrahams, Occupational Therapist
Tasneem Abrahams, is an Occupational therapist in private practice providing support, therapy and/or coaching for adults and teenagers who struggle with executive functioning and emotional and sensory regulation affecting their daily functioning.
Although ADHD is a well-known diagnosis and has received increased awareness and attention on social media, for many girls and women, it goes unrecognized, misdiagnosed, or is not diagnosed until adulthood. As a result, girls with ADHD continue to suffer for years, often in silence, without getting the help they need. In this article, we explore why ADHD is often overlooked in girls and women.
Disclaimer: Studies are "typical" of biological differences and do not reflect all girls/boys or the entire gender spectrum
What is ADHD?
Attention-Deficit/Hyperactivity Disorder (ADHD) is the current term for a specific developmental disorder that involves problems with impulse control, sustained attention, and perseverance in completing tasks. ¹
It affects people of all ages and impacts daily life, school performance, social interactions, and general quality of life. An estimated 5% of all children and adolescents worldwide are affected by ADHD. ²
Diagnosis
There is no single medical test for ADHD. It also cannot be definitively diagnosed by just completing a self-report rating scale. It can only be diagnosed by a trained health professional through a comprehensive assessment that accurately captures the symptoms of ADHD across multiple settings, their persistence over time, and associated functional impairments.
This is because the core symptoms of ADHD are related to the executive functions of the brain, and executive functioning can be negatively affected by many other conditions, such as burnout, depression, anxiety, grief, physical illness, etc. It is, therefore, critical that the diagnostician takes a full background history to first rule out the possibility of other causes of dysfunction.
According to the Diagnostic and Statistical Manual 5 (DSM5), symptoms and/behaviours needs to have persisted for 6 months or more, in 2 or more settings, and must have negatively impacted functioning. ³
There are 19 symptoms listed in DSM5 – 8 symptoms of inattentiveness, and 9 symptoms of hyperactivity or impulsivity. In order to meet the criteria for a diagnosis, the presence of 6 or more symptoms must be present in children under the age of 17, and 5 or more in adults.
There are therefore 3 presentations of ADHD, depending on what combination of symptoms are present:
Inattentive presentation
Impulsive/hyperactive presentation
Combined presentation
Self-rating scales are typically used to screen for the presence of these symptoms, but should never be used as the only tool for diagnosis, as it relies solely on the self-awareness of one’s own struggles, which happens to also be one of the challenges faced by individuals with ADHD. Given that the diagnostic criteria require there to be a marked functional impact on the individual’s daily life, it is surprising that occupational therapists are not included in the assessment process by default, as this is the area of expertise of occupational therapists.
Impact of ADHD on daily functioning
It is important to recognize and understand the wide-ranging functional impact to develop effective interventions and support systems that address the unique challenges faced by individuals with ADHD. ADHD impacts functioning in 2 or more of the following settings:
Academic performance
Difficulty paying attention in the classroom therefore often missing important information or instructions
Poor organizational skills and forgetfulness leads to often losing personal belongings, or forgetting to hand in homework or assignments
Impaired working memory affecting information retention and an inability to listen to the teacher and take notes, or difficulty articulating answers even if they know the work
Struggles with following instructions and completing tasks
Perceived as disruptive in class due to being overly talkative, unable to wait a turn to speak, blurting out answers, constantly rocking chairs, etc.
Work and productivity
Not meeting deadlines or forgetting to do tasks as and when expected
Often leaving work to the last-minute leading to high levels of stress and can lead to burnout
Inconsistent work performance and productivity
Challenges following multi-step instructions or complex procedures
Struggles with organizing tasks and attention to detail
Perceived as disruptive or abrupt in meetings due to arriving late, missing meetings altogether, or speaking over others
Inefficient communication management such as not responding to emails or other messaging timeously, missing important email communication due to poor email inbox management, etc.
Activities of daily living
Difficulties with organizing and initiating self-care routines, leading to difficulties in maintaining consistent personal hygiene practices
Challenges in organization, prioritization, and task initiation can impact housekeeping routines and home maintenance tasks, resulting in cluttered or disorganized living spaces
Impulsivity and inattention can affect mealtime behaviours, such as difficulty sitting still, rushing through meals, or being easily distracted during eating. It is very common for ADHDers to completely forget to eat entirely!
They may also struggle with planning and organizing meals, following recipes, and managing time effectively in the kitchen.
Inattention and impulsivity can influence financial decision-making, leading to impulsive purchases, difficulties budgeting, and challenges in managing finances effectively. Planning and executing shopping trips can also be affected by difficulties with organization and sustained attention.
Struggle with consistently adhering to medication schedules, organizing medications, and remembering to take prescribed doses. This can impact the effectiveness of treatment and overall health management.
Social and emotional wellbeing
Difficulties in controlling their behavior and inhibiting inappropriate responses. This can result in interrupting others, speaking out of turn, or engaging in impulsive actions, which can strain social relationships and lead to misunderstandings.
Inattention and distractibility can make it difficult for individuals with ADHD to pick up on social cues, leading to misunderstandings in conversations, difficulties maintaining eye contact, or missing nonverbal signals from others.
Difficulties with sustained attention and impulse control can lead to increased frustration when tasks become challenging or require extended effort.
Heightened emotional reactivity, leading to outbursts of anger, irritability, or mood swings.
These challenges can lead to social rejection, teasing, or feelings of exclusion. This can contribute to a sense of isolation and impact overall self-esteem and well-being.
The demands of managing ADHD symptoms, such as forgetfulness, disorganization, and difficulties with time management, can create chronic stress and anxiety. ADHDers may constantly worry about forgetting important tasks, being late, or making mistakes, which can impact their overall emotional well-being.
Negative experiences related to ADHD symptoms, such as academic underachievement, social difficulties, or feelings of being different, can contribute to lowered self-esteem and self-worth. Individuals with ADHD may develop negative beliefs about their abilities, leading to diminished confidence and a negative self-image.
ADHD in girls and women
In a 2021 research review of ADHD in girls and women, it was found that girls meet diagnostic criteria for ADHD at just under half the rates of boys, a ratio that becomes much closer to equal by adulthood. ⁴
Given that ADHD is not developed in adulthood, it suggests that girls are often missed for a diagnosis of ADHD in childhood, often diagnosed only later in adulthood. There are a number of reasons this occurs. These include differences in symptom presentation, gender biases due to stereotypical social expectations from girls compared to boys, or factors that mask or overshadow the functional impact of ADHD symptoms in girls.
Symptom presentation and gender bias
Research suggests that the symptom presentation in girls is different to boys. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. However, girls and women tend to exhibit more internalised behaviour which is less disruptive to others, making them less likely to be referred for assessment. ⁵
Hyperactivity in girls might manifest as fidgeting, excessive talking, or a restless inner energy that goes unnoticed. Societal gender stereotypes also influence how symptoms in girls are interpreted by others. Impulsivity in girls may sometimes be perceived as part of an overemotional or pushy personality, while girls expressing inattentive symptoms are often described as “ditzy”, “scatterbrained” or introverted. Inattentiveness in children also isn’t disruptive to others in a class or home environment, which makes it easier to overlook. As the child grows older and is required to be more independent in managing themselves, the symptoms of ADHD have an increasingly negative impact on day-to-day functioning. This is why girls are often only referred in high school, college, when they start working, or are required to manage a household.
Thresholds for symptom severity
One study suggests that females appear have a slightly higher threshold for symptom severity. ⁶ This may be attributed to masking behaviours. Masking is when a person consciously or unconsciously suppresses or hides their feelings, thoughts or struggles to comply with social expectations or to protect themselves. This often results in the internal experience not being outwardly expressed. Girls with ADHD have been found to develop coping mechanisms like excessive rule-following or people-pleasing, to mask their struggles and fit in. This "masking" can make it even harder to identify the underlying ADHD.
Gender bias in research and diagnosis
Historically ADHD research has been predominantly centred around boys, as ADHD was thought to be mainly male child disorder. As a result, rating scales used in diagnosis may be based on male norms. The resulting misconceptions held by health professionals with outdated knowledge about ADHD can lead to bias in diagnosis, in that they might be less likely to consider ADHD in girls who don’t display typical hyperactive symptoms.
Consequences of missed diagnosis
When ADHD is identified at a young age, effective early intervention may result in a reduction in later impairment as the child is assisted to develop executive functioning skills, and strategies to compensate for lagging skills and abilities, or to optimize the strengths often associated with neurodivergence. Undiagnosed ADHD in girls and women means they may struggle academically, socially, and professionally without any support or understanding about why they are struggling. Over time, this can lead to chronic stress, anxiety, a negative self-image, and depression. One study found that one third of women with ADHD have anxiety disorders. ⁷ Although all humans use masking to some degree to “fit in”, for people with undiagnosed ADHD, constantly concealing their true selves can lead to feelings of guilt and shame for being different without the understanding and awareness of their brain difference.
Moving forward: Early identification and support
Fortunately, there is growing awareness about ADHD in girls and women. By recognizing the unique presentation of ADHD in girls and women, we can ensure they receive the proper diagnosis and support they need to thrive. There needs to be more research focussed on ADHD in girls and women.
The education of healthcare professionals, parents and educators about the different presentations of ADHD in girls and women is paramount. The use of gender-neutral diagnostic tools and assessments can take into account a broader range of symptoms. The assessment process should be comprehensive, with an emphasis on understanding functional impact beyond the presence of outwardly expressed symptoms. Involving occupational therapists in the diagnostic and intervention process can be hugely beneficial.
In the management of ADHD, a comprehensive and multidisciplinary approach is essential to address the diverse needs of individuals with ADHD. Interventions for ADHD are mainly focused on how symptom reduction can be achieved with either medication or talk therapy Interventions. Although useful, these don't provide guidance on how interventions can be structured to deliver ‘real life’ benefits beyond symptom reduction, or increase participation, bearing in mind that symptom reduction alone does not always produce improvement in daily functioning.
Occupational Therapy (OT) interventions can enhance the effectiveness of ADHD medication by addressing functional challenges and promoting the development of skills and strategies that complement the medication treatment. Through structured activities and therapeutic exercises, OTs help individuals develop strategies, practice skills, and build confidence in their abilities. We may utilize various therapeutic modalities, such as role-play, simulations, visual aids, and technology-based tools, to facilitate skill development. We also collaborate with educational professionals, parents, and caregivers to ensure consistency and support across different settings (e.g., home, school, community), and provide recommendations and support for modifying environments, adapting tasks, and implementing strategies to promote success and functional independence.
I conclude with this quote from successful and celebrated journalist, Lisa Ling, who was diagnosed at age 40, after relating so much to the families she was interviewing for a story on American families battling ADHD:
“My head is kind of spinning, but I feel a little bit of relief because, for so long, I’ve been fighting it and I’ve been so frustrated with this inability to focus.”
Tasneem Abrahams, Occupational Therapist
Tasneem Abrahams, is an Occupational therapist in private practice providing support, therapy and/or coaching for adults and teenagers who struggle with executive functioning and emotional and sensory regulation affecting their daily functioning. She uses a client-centered, evidence-based, and neurodiversity-affirming approach. Tasneem is also the founder of the Private Practice Growth Club, developing the mindset and business skills of health professionals, and other coaches in the wellness space through content creation, knowledge-based products and coaching.
References:
[1] Russell A. Barkley. (2013). Attention deficit hyperactivity disorder (ADHD) facts. Retrieved from Russell Barkley
[3] DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th edition; ADHD: attention deficit hyperactivity disorder
[4] Hinshaw, S. P., Nguyen, P. T., O'Grady, S. M., & Rosenthal, E. A. ("Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions." Journal of Child Psychology and Psychiatry (2021)).
[5] Berry CA, Shaywitz JE, Shaywitz B. Girls with attention deficit disorder: a silent minority? A report on behavioral and cognitive characterisitics. Pediatrics. 1985;76:801–809.
[6] Mowlem F. D., Rosenqvist M. A., Martin J., Lichtenstein P., Asherson P., Larsson H. (2018). Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. European Child & Adolescent Psychiatry, 28, 481–489. 10.1007/s00787-018-1211-3
[7] E. Fuller-Thomson, D. A. Lewis, S. K. Agbeyaka. Attention-deficit/hyperactivity disorder casts a long shadow: findings from a population-based study of adult women with self-reported ADHD. Child: Care, Health and Development, 2016; DOI: 10.1111/cch.12380
