Attention Magazine June 2023

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Twenty-five years ago, when we published our first book on women, Understanding Women with ADHD, Patricia Quinn and I were primarily focused on making the case that lots of women have ADHD and that the prevailing diagnostic criteria are biased against the diagnosis of women. At the time, other ADHD researchers teased us about being “ADHD wannabes” as we beat the drum for greater awareness of the existence of and needs of women with ADHD. These male ADHD researchers viewed ADHD in women as a much paler version of ADHD as it presented in males.

We’ve learned a lot over these past twenty-five years, and it’s becoming clear that ADHD in women is not a milder version of the disorder but is, in fact, more challenging for women than for men. Let’s examine why this is the case.

ADHD challenges hamper the connections central to women’s well-being

It is well established that females have different communication styles and different social networks than men. Female social interactions tend to be more complex and more in-depth than those of males. Strong social connections form the very backbone of supports that allow women to lead healthy, satisfying lives. But ADHD gets in the way of building those essential relationships.

Stephen Hinshaw, PhD, at UC Berkeley, conducted groundbreaking work on the social relationships of girls with ADHD. He observed that girls with ADHD struggled to form and maintain friendships, with hyperactive/impulsive girls being “socially rejected” by peers while their more quiet, shy inattentive counterparts were “socially neglected,” that is, simply left out of social groups. These same patterns persist into adulthood.

Forming and maintaining friendships proves to be a major problem for many women with ADHD. The stress is twofold and of much greater significance than social distress reported by men with ADHD. First, women have a greater need for social acceptance and connectedness compared to men, so feeling isolated and unsupported by other women is very painful.

Second, many women with ADHD are particularly ill suited to meet the social expectations of other women. They may have difficulty showing up on time, remembering social commitments, suppressing urges to interrupt in conversation because “I will forget what I wanted to say if I wait,” suppressing thoughts and reactions that might be considered rude or inappropriate, curbing their tendency to talk too much, following rapid-paced group conversations, and becoming distracted, which gives the misimpression that they are not interested in what others are saying.

Social connections are central to women’s well-being, but ADHD social challenges hamper friendships for women. The sadness expressed by women with ADHD due to their feelings of “never fitting in” to social groups is a major part in the lived experience of women with ADHD.

Less acceptance of ADHD in females within the family

Females not only experience rejection in the outside world, they also experience it within the family. Studies have shown that mothers react more negatively to the behaviors of daughters with ADHD than to sons. ADHD symptoms of impulsivity, emotional over-reactivity, messiness, poor grooming habits, and general disorganization are inconsistent with societal expectations for girls.

While some parents interpret ADHD in their sons as simply being “all boy,” a girl with ADHD is not fondly referred to as being “all girl.” Girls often grow up, especially when their mother does not have ADHD, under a constant barrage of criticism for not being more agreeable, organized, pleasant, well-groomed, and compliant.

This lower acceptance of ADHD in females in the family setting continues in adulthood. Arthur Robin, a well-known authority on the impact of ADHD on couples, reported that he found husbands less tolerant of their wives’ ADHD compared to wives’ tolerance of their husbands’ ADHD.

Women’s reactions to stress differ from men’s

In contrast to the well-known “fight or flight” reaction to stress more typical of men, recent research suggests that women’s response to stress is better described as “tend and befriend.” Women reach out to each other for comfort, for validation, and for problem-solving in response to stress. Women with ADHD, who are less likely to have a well-developed social support network, are less able to find the supportive stress reduction that a strong social network can provide for many women.

Internalizing tendencies: women with ADHD blame themselves

Females with ADHD are more prone to internalize—blaming themselves for their struggles, leading to anxiety, depression, and complex trauma. Twenty-five years ago, ADHD in women was dismissed as a less problematic version of ADHD. Then, research came out of Scandinavia that females with untreated ADHD are more likely to make suicide attempts and more likely to be psychiatrically hospitalized than their male counterparts.

Furthermore, ADHD in females often leads to complex trauma, a more recently recognized concept of trauma that is the result of countless daily criticisms, rejections, and blame that add up into a significant and ongoing trauma response—“trauma by a thousand cuts.” Rather than a “paler version” of ADHD, ADHD in women is fraught with significant psychiatric risks throughout their lifetimes.

Their bodies pay the price

Chronic stress inevitably impacts women’s bodies. Over twenty-five years ago, Patricia Quinn and I wrote about fibromyalgia in women with ADHD resulting from constant activation of the HPA axis, but sadly, a generation later, fibromyalgia is only occasionally mentioned as a comorbid condition common among women with ADHD.

Fibromyalgia is widely recognized as a “stress-related” disorder due to its frequent onset and apparent exacerbation of its symptoms in presence of stressful events. Fibromyalgia, leading to significant chronic pain, affects many more females than males, and recent studies have shown a high rate of ADHD in women diagnosed with fibromyalgia.

Of additional concern, sleep disorders have been linked to both ADHD and fibromyalgia. Clearly there is a great need for awareness among pain specialists and sleep specialists that there is a strong connection between these disorders and ADHD in females.

Impossible role expectations

All women experience impossible demands today. Most women in the United States are working while also raising children, tracking schedules of all family members, organizing family events and celebrations, and managing their households. Even though there has been an ongoing evolution in society’s views of gender roles, the role of wife and mother continues to be far more demanding than the role of husband and father.

A recent Forbes Magazine article noted that despite women outpacing men in earning college degrees over the past twenty years, despite nearly half of women reporting that they are their family’s primary breadwinner, women are eight times more likely to have responsibility for caring for a sick child and managing their child’s schedule.

Today, 75% of mothers of school-aged children are employed. This huge social change has not been accompanied by affordable, available childcare, placing a huge stress on women that are working while raising children. Now, imagine that you are a woman with ADHD living under these expectations. It’s easy to see why the word “overwhelmed” is the most common word women with ADHD use to describe their lived experience. The very roles that wives are “supposed to play” are roles for which most women with ADHD are particularly ill-suited.

Masking

From an early age, girls with ADHD work hard to mask their struggles. Mothers of girls with ADHD often report that their daughters’ teachers seem unaware of their struggles, and certainly unaware of their daughters’ ADHD. “She may talk a bit too much to her friends, but she tries to do her work.” “She’s quiet, a bit shy and rarely raises her hand.” “She tries hard. I don’t see any problems in class.”

Girls diagnosed with ADHD report in therapy that they fear getting “in trouble” at school, that they feel anxious about school and worry that the teacher will reprimand them or embarrass them. Some experience this anxiety to the point that they develop school avoidance patterns.

Many of these girls are quiet and compliant in class, only to be tearful, explosive, or angry once they are in the relative safety of home. Sadly, mothers may be blamed for this discrepancy. “She’s fine at school, so it must be a problem between her and her mother,” the uninformed professional may conclude.

This pattern of “masking” ADHD in public starts early and continues into adulthood. Women feel exhausted and ashamed. Women with ADHD who can function well at work may report that no one at work would guess that they had ADHD, but they carefully never invite friends or colleagues to their homes where chaos reigns. Such masking is a pattern rarely reported by males with ADHD. We need to examine the emotional cost of this pattern and help women to find ways to lead more authentic, less hidden lives.

The comfort of connection

Although I know of no research supporting this observation, my clinical experience tells me that treating women with ADHD in a group setting is one of the most powerful and effective interventions they can receive. Being treated in a group setting introduces women with ADHD to their “tribe,” other women that understand and accept them as they are.

At my clinic, The Chesapeake Center, we offer women’s ADHD coaching groups that provide a combination of support, information, and strategies to help them cope with their daily challenges. Because these are online coaching groups, women from all over the country can participate. We organize these groups by life stage—young women dealing with their struggles to “adult” as they move out to establish their own homes, women in the midst of the challenges of motherhood, often raising children with ADHD, and empty nesters, many of whom have only recently become aware of having ADHD, moving past regrets and learning to appreciate themselves and their strengths.

The healing power of such groups cannot be overestimated. During the pandemic, a colleague and I offered an online support group for older women with ADHD. These women described the group experience as the first time they had ever encountered such acceptance and support from other women. This online group became the highlight of their week. We stopped facilitating this group a year into the pandemic; however, three years after its inception, this group is still meeting online as a self-led group. This group’s commitment to continuing to meet and support one another provides ample confirmation that women’s ADHD coaching groups that provide encouragement, understanding, acceptance, and support can be powerfully effective in addressing a lifetime of hurts and helping women connect and affirm their authentic selves.

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This article summarizes the opening section of the forthcoming book about women with ADHD, You Don’t Know What It’s Like!, coauthored by Kathleen Nadeau, PhD, Patricia Quinn, MD, and Michael Morse, MD.

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Kathleen Nadeau, PhD, is an internationally recognized thought leader on issues related to ADHD, the author of fifteen books about ADHD, and the founder of The Chesapeake Center for ADHD, Learning and Behavioral Health, the largest private ADHD specialty clinic in the United States.

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