Monash decoded ADHD in girls and women

What do you think someone with attention deficit hyperactivity disorder (ADHD) looks like? Chances are you’ll picture a boy who’s disruptive in class, who can’t sit still or concentrate, who takes risks. But that stereotype needs to change, says Professor Mark Bellgrove. Because adults – including girls and women – are also likely to have ADHD, and if we let the condition go unrecognised, undiagnosed and untreated, the consequences can run deep.

In fact, best estimates suggest that around six to 10 per cent of Australians have the condition, a neurodevelopmental disorder which begins early in life – under 12, according to current diagnostic criteria. Contrary to what you might have read, the fundamental traits that comprise ADHD - inattention, hyperactivity and/or impulsivity haven’t really changed over the years in terms of their frequency and distribution. To put it simply, ADHD traits have been around in the general population for a long time. But there has been a rise in diagnoses – likely due to changes in reporting and better awareness.

People with ADHD have difficulties in three main areas: inattention, hyperactivity and impulsivity, but these are often accompanied by strengths such as hyperfocus and creativity, says Bellgrove, director of the Turner Institute for Brain and Mental Health at Monash, and founder of the Australasian ADHD Professionals Association.

They can be divergent thinkers, able to generate a whole heap of novel ideas. They can be great problem-solvers and can hyperfocus on something that’s of particular interest to them. That makes them very valuable in the workplace.”

- Professor Mark Bellgrove, Director of the Turner Institute for Brain and Mental Health and a Professor in Cognitive Neuroscience in the School of Psychological Sciences

Spotting the signs

Of course, many people struggle with staying focused and being overwhelmed – and don’t have ADHD. That’s because human traits exist on a spectrum, explains Bellgrove. “There are many people in the middle who experience a medium level of these traits, fewer people at one end who experience almost none and fewer people at the other end who experience high levels.”

Most of us won’t ever require treatment for these traits. They’re part of being human. “But at a certain point on the spectrum, these symptoms may have a functional impact on a person’s life – for example, family conflict, mental health disorders, reduced educational or occupational achievement or sleep difficulties,” says Bellgrove. “That’s when they may be diagnosed and treated.”

Diagnosis, of course, can only be done by a qualified and trained professional. “It’s often lost in the public discourse and on TikTok that diagnosis requires symptoms in at least two settings, and they must negatively impact on your function,” says Bellgrove. “It’s a detailed clinical interview assessing all aspects of a person’s mental health. You don’t tick off the items on a checklist and get a diagnosis of ADHD.”

A heavy burden

But for girls and women, it can take far longer to get diagnosed and treated. A Monash study found that more boys are diagnosed with ADHD in childhood than girls, and that women were likely to be diagnosed five years later than men. They also had lower socioeconomic status and experienced more ADHD symptoms and trauma.

And this matters, because undiagnosed or untreated ADHD can be a heavy burden to carry, with impacts throughout your life. “If you look at domains such as academic performance, social and family relationships, physical health, traffic accidents, increased mortality, even lower life expectancy – these all go along with poorly treated or untreated ADHD,” says Bellgrove. “And data shows us that many of these negative outcomes are improved by medication.”

ADHD presents differently in girls and women, says Bellgrove. Girls with the inattentive presentation of ADHD may be shy daydreamers who are easily overwhelmed and unwilling to take risks. They may be anxious, self-blaming and depressed, and have anxiety around school performance.

Those with a hyperactive/impulsive presentation may be overly talkative, fidgety, bossy, risk-taking and unable to keep up with their workload. And girls with either type may display other traits such as problems with transitions (such as moving schools), being perceived as ‘immature’ by others, or unable to read social cues. They may not have friends and have problems ‘fitting in’.

Building pressure

So why aren’t girls with ADHD being spotted earlier? It’s complicated. Women are more likely to present with inattentive symptoms rather than disruptive hyperactivity, Bellgrove points out. They are perceived as less ‘disruptive’ to have in, say, a classroom – and therefore their struggles go unnoticed.

Girls are still socialised into internalising problems such as low self-esteem, anxiety and depression, rather than speaking up. Consequently, girls with ADHD tend to ‘mask’ their symptoms. “And this gives rise to under-recognition, under-referral and, hence, under-diagnosis,” says Bellgrove.

But masking is exhausting. It takes a lot of effort – and it gets harder as you get older. “As demands on their lives start to increase, masking becomes increasingly difficult, particularly around puberty,” says Bellgrove. “Their social relationships become more complex and the academic demands start to pile up.”

In this scenario, girls with ADHD often initially seek help for anxiety. “But they may not be anxious in the sense that they have an anxiety disorder. Many clinicians say that when they treat the ADHD, anxiety abates or reduces.”

For those who aren’t diagnosed as children or adolescents, pressure continues to build as they get older and the demands of managing kids, work and family kick in. “And at this point, women start to ask themselves: why is it so hard for me to manage? Why can’t I keep it together like my friend who lives down the street?”

Changing the focus

Recognising that ADHD affects women and girls differently could make a big difference to many people’s lives – and will also enable better research, says Bellgrove. “For example, a big question now is how ADHD symptoms might be exacerbated or treatments work differently throughout a woman’s life.”

Together with a team of Monash researchers led by Caroline Gurvich, Bellgrove has found that a large proportion of women report a worsening of their ADHD symptoms during menopause, and in the postpartum period.

Even during a woman’s regular monthly hormonal cycle, there are well-established changes. Many women are reporting increased symptoms during the luteal phase, where oestrogen drops.”

- Professor Mark Bellgrove

The increased academic focus is encouraging, but right now, says Bellgrove, the research base into ADHD in women and girls is still limited. He’s hoping that will change as awareness rises, and women and girls feel more empowered to talk about their experiences. “We lack data, and the existing literature is biased towards male diagnoses. We now need many more and better-designed studies. Importantly,  lived experience is driving the agenda – and women are telling us what they want us to research.”