ADHD in Women and Girls

But really, externalizing versus internalizing symptoms of ADHD

Intersections

Before we understand how ADHD presents differently in women in comparison to men, one must understand that gender is socially constructed.

Part of this means that we are socialized into (taught) our beliefs about gender norms, or how we believe people should behave based on their biological sex or gender presentation.

These socially constructed gender norms differ depending on context, generation, ethnicity, and culture.

For example, when I am hyperactive at sports, this is socially accepted, even welcomed. However when I was hyperactive in class, this was very much frowned upon and often got me into trouble as a kid.

I mention this because a lot of female-presenting individuals with ADHD either do not receive a diagnosis at all, or receive theirs much later in life. We are also more commonly misdiagnosed with mood and personality disorders.

Stereotypical ADHD

The DSM-5 criteria for ADHD is primarily based on external, behavioural symptoms observed in male-presenting white children. The stereotypical ADHD-kid is running around, unable to focus, loud, impulsive, messy, and easily distracted.

These are the children (usually little white boys) who are most often identified early, after they begin school, when the ways in which their behaviour differs from their peers become apparent.

This was my son. He was the adorable little white boy in kindergarten and first grade who struggled socially, was hyper and impulsive, had trouble waiting his turn, and sometimes acted out aggressively when he was frustrated.

When children’s behaviours are obvious (and inconvenient) to those around them, this increases the likelihood they will be referred for assessment.

Interestingly, this (mostly) describes me as a child too. I am female-presenting, so I was a cute little white girl, but otherwise all the behavioural signs fit.

Photo taken by author’s Grandmother — (image created by author)

My son was diagnosed at age 6, and I was diagnosed at age 36.

Granted, the diagnostic processes have changed significantly over 30 years, so that’s a confounding variable.

Nevertheless, there is ample evidence that female-presenting people, as well as people of colour, with ADHD are diagnosed later in life, and are less likely to be diagnosed at all.

Internalizing symptoms

People who were socialized as female are more likely to exhibit internalizing ADHD symptoms, though of course, not always.

Internalized symptoms are considered less problematic by teachers and parents. As a result, people whose ADHD symptoms are not disruptive at home or school are much less likely to be identified or diagnosed.

I experience some of these symptoms as well, and most people will have a combination of both internalizing and externalizing symptoms, not only one or the other.

Racing thoughts & distractibility

Racing thoughts is a form of internal hyperactivity. Either we don’t experience physical and behavioural hyperactivity, or we’ve learned to internalize it. Instead of our bodies moving around a lot, our thoughts are bouncing all over the place.

I usually have at least 10 different trains of thought going on at once, making it very difficult to focus on just one task or idea at a time.

This goes along with distractibility, which comes from difficulty regulating our attention.

Mood-related symptoms

Although mood disorders are highly comorbid with ADHD, people with untreated ADHD are at even higher risk for anxiety, depression, sleep disorders, and substance use disorders (SUD —aka, addictions).

This is especially true for those who have masked or camouflaged their neurodivergence, and have internalized their symptoms. The psychological effort and strain required to maintain the façade day after day takes a serious toll on us.

Created by author

Forgetfulness

Where are my keys? My glasses?

Where did I leave my phone? My sweater? My coffee cup? My G-D memory?!

I am forever losing something — it feels like nearly everything.

Some of these struggles come from deficits in working memory, which is a form of short-term memory that requires holding information in mind while mentally working with it.

Forgetfulness and frequently misplacing things also stem from inattention and distractibility. It’s a daily occurrence that I place my coffee in the microwave to warm it up, get distracted doing something else, then completely forget about my coffee until it has gone cold again.

I also regularly put down my phone or keys while my mind is attending to something else, so my brain doesn’t recognize a need to create a memory of their location, leading me to completely forget where I put them.

Disorganization & procrastination

Disorganization is also related to memory and inattention issues, and can create serious problems for neurodivergent adults. Procrastination has even more of a negative impact on the lives of many adults with ADHD.

My home office is usually a mess. My “nest area” (the area that is not my office, where I actually do most of my work) is usually a bigger mess. I frequently forget what is in my calendar, and I am either late or almost late for just about everything.

I am not irresponsible. I have been a successful entrepreneur for 12 years because I have learned to compensate for these challenges of mine. I must have a system for organizing my schedule and remembering important appointments and tasks, otherwise they will get missed.

Similarly if there is a task that I must do but do not want to do, or a task requiring significant use of executive functions, I need some kind of system or a strict deadline in order to get it done.

Calvin & Hobbes by Bill Watterson

ADHD brains don’t process dopamine as efficiently as neurotypical brains; dopamine being a neurotransmitter that affects pleasure, rewards, motivation, and satisfaction.

That’s a fancy way of saying if I don’t feel like doing it, it’s going to take significant measures to get it done.

This is not because I’m lazy. When I set my mind to something, I work my tail off to get it. I’ve achieved very highly when I’ve been motivated and passionate about something.

As Devon Price stated in Laziness Does Not Exist, there’s a certain stereotype about people with ADHD:

“ADHD sufferers are seen as unintelligent or lacking ambition… yet for many, the exact opposite is the case.”

Unfortunately many clinicians still believe this fallacy. I have met many late-diagnosed ADHDers who were once told they couldn’t possibly have ADHD because they were too successful or too smart.

Being smart and successful may have come at an extremely high cost, and does not mean we didn’t encounter significant struggles along the way.

Final thoughts

If you’re a female-presenting individual and have long wondered whether you might be neurodivergent (autistic, ADHD, etc.), there’s a good chance there is something different about your brain, otherwise you wouldn’t be googling “ADHD symptoms in women” or “how do I know if I’m autistic?”

(Trust me, we’ve all done it).

If you know more than your doctor about ADHD when you ask them about an assessment, ask them to refer you to a specialist. Don’t allow them to steamroll you or dismiss your concerns.

I’m in Canada and access to my GP and psychiatrist was entirely free, so I write this with a painful awareness of my privilege. I had a long wait-list to see a specialist, but I didn’t have to pay a single dollar to receive my diagnosis.

If it’s financially feasible for you to go for an assessment, go for it. I’ve met adults who have said “I’ve survived this long, there’s no point in getting a diagnosis now” and I strongly disagree.

We don’t know what “normal functioning” feels like if we’ve never lived it — In truth, we probably never will. We also don’t know how proper accommodations, support, or treatment may significantly improve the quality of our lives if we don’t pursue them.

I highly recommend it. Everyone’s experience is different, but more than two years after my diagnosis, I can confidently say my life is better for it.

References

Alqahtani, Y., McGuire, M., Chakraborty, J., Feng, J.H. (2019). Understanding How ADHD Affects Visual Information Processing. In: Antona M., Stephanidis C. (Eds). Universal Access in Human-Computer Interaction: Multimodality and Assistive Environments. Springer. https://doi.org/10.1007/978-3-030-23563-5_3

Barkley, Russell A. (2015). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis & Treatment. The Guilford Press.

Blum, K., Chen, A. L., Braverman, E. R., Comings, D. E., Chen, T. J., Arcuri, V., Blum, S. H., Downs, B. W., Waite, R. L., Notaro, A., Lubar, J., Williams, L., Prihoda, T. J., Palomo, T., & Oscar-Berman, M. (2008). Attention-deficit-hyperactivity disorder and reward deficiency syndrome. Neuropsychiatric disease and treatment, 4(5), 893–918. https://doi.org/10.2147/ndt.s2627

Bozhilova, N., Michelini, G., Jones, C., Kuntsi, J., Rubia, K., & Asherson, P. (2021). Context Regulation of Mind Wandering in ADHD. Journal of Attention Disorders, 25(14), 2014–2027. https://doi.org/10.1177/1087054720956714

Curtis, Alexa, “Women & ADHD” (2020). Sociology Student Work Collection. 66. https://digitalcommons.tacoma.uw.edu/gender_studies/66

Fadus, M.C., Ginsburg, K.R., Sobowale, K. et al. (2020). Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth. Academic Psychiatry 44, 95–102. https://doi.org/10.1007/s40596-019-01127-6

Kurdziel, L.B.F., Dempsey, K., Zahara, M. et al. (2015). Impaired visuomotor adaptation in adults with ADHD. Experimental Brain Research 233, 1145–1153. https://doi.org/10.1007/s00221-014-4190-8

Lynn, N. M. (2019). Women & ADHD Functional Impairments: Beyond the Obvious. (Masters Thesis). 933. https://scholarworks.gvsu.edu/theses/933

Mowlem, F.D., Rosenqvist, M.A., Martin, J. et al. (2019). Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. European Child & Adolescent Psychiatry 28, 481–489. https://doi.org/10.1007/s00787-018-1211-3

Price, D. (2021). Laziness Does Not Exist. Simon & Schuster, Inc.

Saline, S. (2018). What Your ADHD Child Wishes You Knew: Working together to empower kids for success in school and life. TarcherPerigee.

Tsai, F. J., Tseng W. L., Yang, L. K., Gau, S. F. (2019). Psychiatric comorbid patterns in adults with attention-deficit hyperactivity disorder: Treatment effect and subtypes. PLoS ONE 14(2). https://doi.org/10.1371/journal.pone.0211873

Volkow, N.D., Wang, G., Kollins, S. H., et al. (2009). Evaluating Dopamine Reward Pathway in ADHD: Clinical Implications. JAMA 302(10):1084–1091. https://doi.org/10.1001/jama.2009.1308

Zevallos, Z. (2014) ‘Sociology of Gender,’ The Other Sociologist, 28 November. Online resource: https://othersociologist.com/sociology-of-gender