Opinion

ADHD in females: Outdated criteria leading to missed diagnoses

Editor’s note: While this piece is written in Elena’s voice, the three authors have contributed equally to the article.

I have Attention Deficit Hyperactive Disorder (ADHD). It took nearly my whole life to receive a proper diagnosis, likely because I didn’t perfectly align with the accepted diagnostic criteria for ADHD. I am not hyperactive and I can follow through with tasks, although it takes a tremendous amount of energy to do so. Thus, doctors couldn’t check off all the ADHD-associated boxes.

Unfortunately, I am not alone. This is a common experience among females with ADHD. The underlying issue is that ADHD diagnostic criteria are male-oriented, but females do not necessarily present with the same symptoms. This is similar to how commonly known heart attack symptoms are predominantly representative of the typical male presentation.

As a result of outdated criteria, females with this condition often go either undiagnosed or misdiagnosed, a significant barrier to proper treatment or accommodations.

Difficulties with social interaction are common amongst individuals with ADHD. For example, there have been many instances where I was particularly passionate about a topic of conversation and spoke loudly and frequently to ensure others understood the point I wanted to make. This sort of assertive behaviour has often led to confrontation, which for many would be uncomfortable but is especially difficult for me to navigate since the way my brain interprets things makes me extremely sensitive.

Like many females with ADHD, my life experience has been further complicated by the discrepancy in the prevalence of diagnoses between sexes. For most of my life, I was part of the disproportionate number of women with no explanation for our difficulties with social interaction. These experiences can be especially damaging if they cause people to question whether they will ever “fit in,” since this can in turn lead to additional mental health concerns, including issues with self-esteem.

ADHD is also commonly associated with poor academic outcomes, although a 2014 study points out that “satisfactory academic achievement should not rule out an ADHD diagnosis.” Thus, academic performance is not necessarily a reliable predictor of ADHD, adding an additional layer of complexity to the diagnostic process. According to a 2021 article, this is especially problematic for females because they are more likely to put in the extra effort required to maintain good grades; a reality that is perfectly encapsulated by my personal experience. Throughout every step of my education, I have had to study two or three times as much as my colleagues just to earn an average grade, while they were able to get an A with considerably less study time. But despite needing to give all this extra effort, I have still succeeded at many educational levels, which likely contributed to my delayed ADHD diagnosis.

For almost 40 years, I believed that everything going through my mind was exactly what everyone else felt. When I finally realized that this wasn’t the case, I consulted my family physician, who then diagnosed me with depression and anxiety, which was not very helpful. It was not until after several additional appointments with my family physician, psychotherapist and psychiatrist that the missing piece of the puzzle was finally found; I have the inattentive, rather than hyperactive, subtype of ADHD – also commonly called ADD (Attention Deficit Disorder).

As a result of outdated criteria, females with ADHD often go either undiagnosed or misdiagnosed.

Receiving an initial misdiagnosis of this sort is quite common since both anxiety and depression are commonly comorbid with ADHD in females. In fact, depression is the most common prior diagnosis for females with ADHD. There is also a need to increase awareness regarding other comorbidities such as sleep disorders, anxiety disorders (e.g., obsessive-compulsive disorder), eating disorders (e.g., anorexia), and substance use disorders (e.g., alcohol addiction), all of which share similar symptoms to those of ADHD. In addition, according to a 2020 study, females are more likely than males to have “subtle and internalized presentations’’ of ADHD, which in combination with the commonly perceived notion that ADHD is a male disorder, further increases the likelihood of a misdiagnosis.

As is the case for so many other women, I was hesitant to tell anyone about my ADHD due to the ongoing stigma. This past year, I finally decided to be open about it, but unfortunately, the stigma crept in just as I had anticipated. People started looking at me differently, and some even accused me of attention-seeking. Despite the negative reactions from some, I am still thankful to have finally been properly diagnosed and that I am now aware of my ADHD.

It is experiences such as this one that emphasize how research is lagging in developing updated diagnostic criteria for females with ADHD. The brain is very complex, and it will take a long time to completely understand it, but we need to start somewhere. In the meantime, we should focus on promoting the idea that ADHD does not exemplify an illness, but rather neurodiversity, as this could help to mitigate some of the harmful consequences of the associated stigmatization.

It is also crucial to better understand the different presentations of ADHD and start establishing female-specific signs and symptoms in order to provide accurate and timely diagnoses for women and girls. This will not only improve their quality of life, but it can also be lifesaving. Considering that previous research has identified gender as a contributing factor to ADHD stigmatization, expanding the body of research on ADHD in females will also likely help destigmatize this condition.

The challenges associated with having ADHD – in any of its forms – are difficult enough to manage on their own merits. Thus, it is simply unacceptable that for many affected females, their situation is further complicated by side-effects of inadequate diagnostic criteria.

The need to research the signs and symptoms of ADHD for both sexes equitably is not only long overdue, it is imperative.

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Authors

Elena Rusu

Contributor

Elena Rusu is a registered nurse. She is currently pursuing a Master of Health Administration at the University of Ottawa’s Telfer School of Management.

Lucie Péléja

Contributor

Lucie Péléja is a MSc in Health Systems candidate at the Telfer School of Management and a recent Honours BSc in Psychology graduate at the University of Ottawa.

Marc Albert

Contributor

Marc Albert is a recent BSc in Biomedical Science graduate from the University of Ottawa and is currently pursuing an MSc in Health Systems at the University of Ottawa’s Telfer School of Management.

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