ADHD has long been under-researched and underdiagnosed in women and girls. But as more of us seek answers, are we finally at a tipping point? MOJEH investigates on the occasion of Mental Health Awareness Month
"Certainly, there’s a possibility you have ADHD,” nods the psychologist. Like many women, ADHD was never on my radar until I embarked upon the neurodiverse journey with my child. And it is he who we are discussing when she asks about family history.
Heritability of ADHD is significant. Estimated to be at 77 to 88 percent, if a child is identified as having ADHD, there is a strong likelihood that at least one parent may have it, too. My husband is unquestionably neurotypical, which leaves me. A question mark.
Research has shown ADHD and OCD are comorbid disorders. In childhood, I was bound to a clandestine ritual of switching a light on and off multiple times to ensure my family would not die. Irrational fears and intrusive thoughts would continue to manifest over the decades. The untold worry of being infected with ‘contaminated blood’ via a swimming pool, the dentist’s chair or prepared food prevailed. Anxiety would be a constant in life. Chewing my insides and stalking my brain.
In school, I excelled in subjects I was interested in and lagged in those I was not. I daydreamed and found it decidedly difficult to concentrate in noisy classrooms and, later, in busy open-plan offices with the constant chatter and tapping of keys. In perpetual search of my mobile phone, I’ve misplaced more bank cards than my husband cares to remember. Sometimes, managing motherhood, a household and everything in between is a challenge. Part of the reason I only have one child is an inherent belief that I would deeply struggle with the juggle of a second.
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And before that, like many girls and women between the ages of 12-25, I found myself controlling my food intake. For a period, eating yoghurt-topped fruit for dinner because it was low calorie and effortless to purge, I fixated on the gym. Seven days a week, trainers thumping the black band of the treadmill or repeatedly pumping the arms of the cross-trainer, hour upon hour upon hour; relishing the delectable control I exerted over my body. All these nuances can be indicative of ADHD.
After my son’s initial consultation, I message a friend. “Oh, I’m pretty sure I have it, too,” she types back. I’m shocked. She always seems so together. So confident. So successful.
When I mention it to my mum, she appears mildly outraged; a generational scepticism that pervades much of society, particularly when you’ve slotted into life with relative ease. As and Bs in school. University degree. Media job. Married. Family. “You don’t have it,” she insists. “You’re not overly energetic.” But this, of course, is an ADHD myth. “One of the biggest misconceptions is the belief that you have to be hyperactive to have ADHD,” explains Jacqui Lawson of Insights Psychology. “While it’s true that this can be a symptom of ADHD in adults (especially women), it tends to manifest as a sense of internal restlessness instead and be part of a pattern of forgetfulness, difficulty sustaining attention and managing time.”
For Jacqui, a counselling psychologist, another common misconception is the belief that a woman can’t have ADHD if she is efficient. “Some of the most organised and high-achieving women in the world have ADHD. The reality is that many women with ADHD engage in compensatory strategies that mask their challenges. They can be perfectionists and put huge amounts of effort into appearing on top of things and maintaining external organisation. To make up for time spent being distracted, missing information and not completing tasks, they may engage in strategies such as working intensely for long hours, adhering rigidly to lists or digital apps, writing everything down religiously or spending large amounts of time checking and rechecking their work. These behaviours over a long period can lead to the accumulation of significant internal distress and overwhelm.”
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A lack of focus can also unjustly be associated with the disorder, given that ADHD is fundamentally an interest-based nervous system, meaning those who have it can hyperfocus on things they are passionate about. Therefore, women with ADHD can be extremely high achieving. Greta Gerwig, the director of the award-winning 2023 Barbie movie, was diagnosed with the neurological condition as an adult. Meanwhile, Olympic gold gymnast Simone Biles has taken ADHD medication since she was a child, as has English actress, UN Goodwill ambassador and all-round fashionista Emma Watson, although she has never openly discussed it.
At Insights Psychology, there’s been an increase in the number of adult women seeking assessment, ranging in age, nationality and socio-economic group. In the past, women were largely referred via medical professionals, but now there is a growing number of women self-referring.
“It is not uncommon for people with neurodevelopmental differences to go undiagnosed through childhood, adolescence and into adulthood,” explains Jacqui. “Many of these women have internalised their difficulties and masked their challenges, believing that they’re a failure and, sadly, this has massively impacted their self-esteem. I think what’s helped raise awareness and enabled women to be more open with seeking support is also the increased understanding that ADHD falls under the umbrella of neurodiversity, meaning that it is simply a different brain style that impacts how a person experiences the world.”
In many instances, companies have not yet caught up with such progressive thinking, and for Jacqui, more recognition in the workplace is required to enable needs to be met while maximising productivity. For example, rather than sitting an employee in the middle of an open plan office, it may be better to choose somewhere quieter with less distractions or agree to hybrid/remote work where possible. It can also be helpful for meetings to be concise, with minutes or summaries sent to break down projects. “There is no one size fits all approach and that’s why it’s important for the employer and employee to collaborate together,” she adds.
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Having spent over two decades studying ADHD when it was much less understood, Dubai-based psychiatrist Jose Belda has been at the forefront of deciphering the disorder. The former NHS and Harley Street doctor is responsible for some ground-breaking research in adult ADHD and ADHD in women. It was back in 2009 when he realised women were less likely to be referred or diagnosed — a trend that continues today.
“The reason was not that there was less prevalence among females,” Dr Belda tells MOJEH. “It was just a different presentation. They are less externally physically hyperactive but as much, if not more, mentally hyperactive, and internally restless. Girls are more likely to conform to social and behavioural expectations, and hence less likely to be identified at school.” Fortunately this seems to be changing, and mothers are gaining greater, personal insight via their daughters’ and, indeed, sons’ diagnoses.
“Journalists’ articles in non-clinical journals and mental health campaigns are helping to reduce the prevalence of undiagnosed ADHD in adult women significantly,” he says of the development. “The fact that more women across the globe are accessing higher education and employment brings the ADHD features to the surface.”
And what of TikTok? The ADHD tag has a gobsmacking 36.9 billion views. Is it raising awareness or fuelling inaccurate diagnosis?
“On the whole, it promotes the concept of ADHD, and many women question themselves and decide upon screening leading to an accurate assessment,” says Dr Belda who, through clinical observation, has also identified an irrefutable link between women’s body cycles and ADHD. “I realised that the week before the period, many women with ADHD would consistently report a worsening of what ADHD features — I would not call them symptoms as ADHD is not an illness, but the way the brain is structured,” explains the consultant psychiatrist. “I realised that it is when the progesterone is high, and the reason seems to be that the progesterone reduces the dopamine receptors reactivity to dopamine, which is already suboptimal in certain areas of the brain in ADHD.”
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Dr Belda also discovered that a reduction in oestrogen can worsen ADHD features in post-menopausal women. Certain contraceptives, hormone treatments or conditions like polycystic ovary can affect ADHD too, but more research is needed.
The ongoing relationship between ADHD and a woman’s reproductive cycle suggests that women could benefit from a diagnosis regardless of their age. “It can be life-changing,” agrees Jacqui. “Acknowledgment of ADHD can result in validation, relief and more confidence to self-advocate. When a person with ADHD has their needs met and well understood, they are less stressed and more successful in reaching their goals. One of the things I love most about working with women with ADHD is seeing them learn to forgive themselves for their differences and become more self compassionate.”
From a personal perspective, it is these words that resonate the most. After so many years, the prospect of clarity and self-forgiveness is comforting. As is the notion of rationalising the small, hidden, jumbled part of me that has forever felt awry.
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