The Impact Of Underdiagnosed ADHD On Women's Mental Health and Why It's Still Happening In 2024
Please note that this article contains content that may be triggering - please read with caution - themes: mental health disorders, suicide. If you are struggling with your mental health or any of the topics discussed in this post, please reach out for support - https://www.mind.org.uk is a great place to start.
Did you know for every three boys diagnosed with ADHD, only one girl will be diagnosed? However, in adulthood, that ratio is closer to 1:1; however, women are diagnosed way later than men (research by Da Silva et al. 2020). This doesn’t add up, especially now that we know that ADHD is a condition you are born with and runs through families (shown in twin studies).
Whilst doing my ADHD Coaching course this last year, I have been forced to reflect on (and start to process) my own experience as a woman (and girl) with ADHD and how far we’ve come very rapidly in acceptance and reducing the stigma of being neurodivergent; but also how far we still have to go. As we mark ADHD Awareness month as I write this, I want to take this time to highlight this issue and one that is impacting women’s mental health worldwide - the underdiagnosis of ADHD and the medical approach to women’s health.
As a woman diagnosed with ADHD in my 40s (although I was labelled ADHD in my childhood), I’ve experienced the challenges of living undiagnosed for years in a health system that still lacks an understanding of women’s health. Historically, women’s healthcare has been neglected, meaning there’s still not enough research, funding or resources, often leaving us without the right support - you only have to give birth, go through menopause, or experience gyno issues in the UK to see this starkly.
There are many reasons why ADHD is so underdiagnosed in women, from the initial idea that it was a predominantly male disorder, resulting in the majority of the diagnostic criteria surrounding hyperactivity symptoms ('naughty boy' behaviour). A lack of understanding of how it presents in girls is a big factor, and the patriarchal dismissive attitude towards female health issues that we’ve all faced at some point or other. Keep reading as we look at the challenges we face without a diagnosis and the fight many of us have to go through to get one.
In this post, I’ll cover:
UNDERSTANDING ADHD IN WOMEN AND THE CHALLENGES IN DIAGNOSIS
Let’s start by looking at what ADHD is and how it can be present in women specifically. Research has long viewed ADHD as a male disorder, which has led to a lack of understanding of ADHD in women until recent years. Unlike men and boys, ADHD symptoms in women are often less obvious, making it more challenging to get the right diagnosis and support.
Boys typically present as hyperactive, while girls are more likely to show signs of predominantly inattentive type (ADHD-PI), which includes internal restlessness, inattentiveness, distraction, maladaptive daydreaming and slower processing levels with higher rates of emotional dysregulation.
This makes it harder to diagnose and, in many cases, leads to a misdiagnosis of mood or personality disorders, resulting in the wrong medication and often being given antidepressants with no diagnosis at all and sent on your way with little to no support - more on this later.
This delay in recognising and diagnosing ADHD in women, misdiagnosis, wrong medication or no support at all puts a huge strain on so many different areas of our lives. Still, it isn’t just caused by a lack of knowledge surrounding women’s health and ADHD in women; it’s the medical approach, too, and we need to talk about it.
THE MEDICAL APPROACH TO WOMEN IN THE UK AND OUR EXPERIENCE
Many women, including myself and so many friends and family members, have encountered dismissive attitudes from healthcare providers towards neurodivergence. I remember chasing my diagnosis at my GP practice. The doctor said something along the lines of “You’re so lovely; why would you want something like ADHD?” as if it was something I was “choosing” to have. The doctor clearly was not thinking of how much my identity and personality are tied to my ADHD.
Let’s be clear, “I am ADHD” and "ADHD is me". It defines me - it affects how much I sleep, how and when I eat, how much I move and my behaviour and relationships (not least the negative relationship I was brought up to have with myself for being "too much" or "too loud" or "too chaotic" or "a disaster"). I know I’m not the only one who has experienced this either - in a study by Dr William Dobson, he identified that ADHD children experience 20,000 more criticisms by the age of 10 compared to neurotypical children!
The problem with the current medical situation with ADHD is that it holds an “it’s all in your head” undertone, which prevents ADHDers from going through the "relief" phase, which brings self-acceptance and allows you to come to terms with the years of "not knowing", thinking "what's wrong with me", or "I know I am different but I don't know why" and subsequent masking that this drives.
I still think that women’s health across the board is not deemed that important. Most of the ADHD research was done on hyperactivity, completely missing the PI (predominantly inattentive) type of ADHD, which the majority of women and girls have. And then it's common for women to stop asking for help because we just aren’t being listened to; plus, it’s exhausting to get through your GP onto a waiting list to be seen and do the rigorous tests even to get diagnosed. This has resulted in years of women being misdiagnosed and sent away with antidepressants that they are then left on for years (I have one client who has been left on them for nearly 30 years and only recently got a diagnosis at nearly 70!!). This robs women of their time to understand their symptoms and how their ADHD impacts their lives and families, build self-resilience and a closer relationship with themselves.
Hormones also play a massive part, exasperating symptoms during times of change, complicating diagnosis and treatment further. Puberty is a difficult time for ADHDers. During our 20s and 30s, we’re often given contraception, and you just have to look at recent press to know that perimenopause and ADHD are a perfect storm! In my case, the perimenopause rendered me unable to make any decisions or even know what I was supposed to do when I sat down at my desk. My brain fog turned into total memory loss for a couple of years, and I resorted to leaving myself little notes around the house about where I had put things - a little tip I had gleaned from my 90-year-old neighbour across the street who was starting with dementia! Thank God for HRT - that’s all I can say, but not everyone can take it, and the risks of staying on it forever are unknown.
If you think you are perimenopausal and have ADHD, listening to Katie Breathwick’s experiences from the podcast “You’re Wrong About ADHD” has massively resonated with me and helped me normalise my experiences in equal measure.
THE IMPACT THIS IS HAVING ON WOMEN EVERYWHERE
The reality is this: many women are struggling in so many areas of their lives and have truly been let down by a system that’s supposed to support us. The impact of living undiagnosed is detrimental to our mental health on its own - I have heard from many ADHD coaching clients, “Why can't I just..... (do the washing up in one sitting, stay on top of the housework, not live in a mess - fill in your own gaps here). The opportunity for self-criticism is massive when women say to themselves (every hour!), “I don't understand why I can just get the basics right today?”.
Starting a family can be a pressure point for everyone, but if you are an ADHDer and a new mum, the wheels can come off. I remember telling my therapist then, “I just can’t do the weekly shopping.” She completely did not accept that I was telling the truth - she argued that I was being hard on myself or having too high expectations. Assumptions she had made from her Neurotypical standpoint - not being able to do something as simple as the weekly shopping or laundry wasn’t a possibility.
I am pleased to say that online delivery shopping has revolutionised my life; however, I probably messed 1 or 2 shops up, last week 2 bottles of vodka arrived and some cat litter and no food for the kids or me, having not been able to maintain my focus and check out my basket fully after spending 40 minutes filling it (btw, I am not a massive alcoholic; I just had high-priced items into the basket initially to check out quickly and save my slot).
The pressures of giving our all at work while staying on top of the home, raising our children, supporting our partners and showing up for everything and everyone before ourselves with a smile and without complaint (this deserves an article all by itself but you get the idea) on top of managing ADHD (whether diagnosed or not) and the “why can’t I just…” attitude, it’s a cocktail for self-judgement and feelings of inadequacy when we can’t measure up to unrealistic standards (or even to the basic tasks that neurotypical women seem to be able to breeze through).
Even with society’s growing knowledge of ADHD and how executive functioning works, ableism is still rife, not least internalised ableism, where we feel a sense of shame about having the disorder and are in denial about how much it impacts our lives. Internalised ableism is also compounded by neurodivergence being stigmatised. I have found myself having to pull friends up for using the phrase “they are clearly on the spectrum” in a derogatory fashion, so we have a way to go. Although ADHD is a widely known condition, there’s still this idea that people who have ADHD are “too much” “dizzy” or “lazy” and any negative connotations you can attach to not functioning in a way that fits a single narrative.
As more people are being diagnosed later in life, the stigma is shifting in the right direction. However, there’s still an underlying tone of “wanting to be different” and “wanting attention”, which is quite bizarre thinking. Someone recently commented (directly to me) that “ADHD was so trendy right now” (cringe), and I promptly changed the subject. This highlights how far we still have to go in our understanding of ADHD (and other neurodiversities) and the education and acceptance of society as a whole. At least 1 in 6 people are neurodiverse, for goodness sake!!
You may have heard of the term “Masking”, which means neurodiverse people modifying their behaviour to hide their differences and fit in with neurotypical people. Masking is a coping mechanism, hiding our struggles (under shame mostly) just to fit in to meet the normal way things are expected to be done. The embarrassment and shame attached to struggles with attention, focus and organisation lead to stress, anxiety and feelings of not being good enough while continuing to hide these feelings, bite the bullet and carry on, which sends us into a cycle of self-doubt and perfectionism, pushing to prove ourselves in every situation, spiralling into burnout. It can prevent us from forming relationships, leaving us feeling alone, isolated and again blaming ourselves. With the pressures to perform paired with internalised struggles, it’s no surprise our mental health suffers to the extent it does.
A LOOK INTO CO-OCCURRING MENTAL HEALTH CONDITIONS
In 2005, a study into the treatment of women with ADHD found that 14% of women were given antidepressants before considering an ADHD diagnosis and treatment compared to 5% of men, which is a shocking statistic.
The issue we’re facing with these medications for those who use them often leads to disconnecting from self at a time when that connection and self-awareness are crucial to help us manage our symptoms and implement tools and techniques that benefit us. Sheridan Smith recently touched on this after her recent late diagnosis.
It’s extremely common for ADHD to coexist with several mental health conditions and personality disorders. The most common being generalised anxiety and depression, which can also hinder daily functioning, exasperating ADHD. People with ADHD can also experience mood disorders, bipolar disorder as an example and personality disorders such as borderline personality disorder. Each co-occurring condition needs a more in-depth approach to treatment that involves a combination of therapy, medication and lifestyle changes that can be challenging with a seriously underfunded mental health sector and waiting lists that are getting longer and longer - more on this in my next article.
There are also some small similarities between these disorders and ADHD, such as inattentiveness, rejection sensitivity dysphoria and emotional dysregulation presenting in women, which you’ll find leads to misdiagnosis altogether, the wrong treatment and the wrong medication - again, exasperating symptoms of ADHD and deepening the feelings of inadequacy and low self-esteem.
All of this can have horrifying consequences. The University of Glasgow held a recent study about the correlation between suicide and ADHD. People with ADHD are known to have an increased risk of suicidal thoughts, attempts and death. This study is diving into why this is the case as they explore the association between psychological and psychosocial factors that increase suicide risk in people with ADHD.
Henry Shelford, Chairperson and co-founder of ADHD UK, said, “Research shows that one in four women with ADHD have attempted suicide. ”. - You can read more on this here. This is a frightening statistic for both men and women, and these statistics only cover those who are diagnosed.
SO, WHERE DO WE GO FROM HERE?
Although the impact of undiagnosed ADHD is also true for men (something that also needs to be addressed), the bottom line is that the issue for women lies in the lack of knowledge regarding our health overall and highlights how much is still to be done.
With this new knowledge (if it is new to you), I hope that you can see and understand the disparity when it comes to ADHD diagnosis in women. Recognising the challenges we face is important so you can participate in the call for change. We need to educate ourselves on this difference and process the micro trauma that has come from living a life not understanding our brains, empowering those with ADHD to embrace their differences without shame or stigma. This is inclusion; this is equity!
Whether you have an ADHD diagnosis or not, it’s important to listen to yourself, and while you wait to be seen, give yourself the tools you need so you can self-regulate and manage your symptoms. A great way to do this is with a specialist ADHD Coach like myself.
If you or anyone you know is facing something similar, please don't hesitate to ask your medical practitioner for support and lean on those you love to help you through.
You are going to be ok, and you are not alone. If ADHD diagnosed or otherwise is affecting your career or work and you would like support with techniques to thrive exactly as you are, please do get in touch for support if it's something you feel you need.
ABOUT CAREER COACH NAT HARRISON OF AYAMA COACHING
Hi, I am Nat. I help people become more fulfilled and happy in their working lives by aligning their careers or businesses with their skills, values, and interests and helping them overcome barriers to making the desired change.
I am also a trained ADHD coach. I work with neurodivergent people who want to harness their brains for the better and improve their relationships with themselves.
Book a FREE consultation below if you would benefit from some coaching on your work life.
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