Evaluating Females for ADHD

During brief phone calls with potential clients, I frequently discuss the importance of finding an evaluator that understands and specializes in female presentation of ADHD symptoms. Stereotypes for ADHD tend to cater to male symptom presentations. Hyperactive, impulsive, oppositional, defiant, etc. ADHD diagnostic criteria is descriptive of 5 to 8 year old males more so than any other population. These individuals are unable to sit still on the reading rug in kindergarten. Impulsivity and related behavioral issues are negatively impacting their relationships with peers, teachers, and family. It is no wonder why this is the most diagnosed, and at times over-diagnosed, population. Every other age group and population is under diagnosed, especially for females. And I would add, for intelligent females in particular. Not only are ADHD diagnostic criteria geared for young males, but our understanding of what is considered “clinically significant” symptom presentation is heavily skewed towards what is expected for young males.

Many providers, as well as a vast majority of public sentiments, struggle to conceptualize what ADHD looks like for females both young and old. Lets address some of the assumptions I routinely see and hear.

• There is an assumption that females are not hyperactive. Hyperactivity is better conceived as primarily internal, what I refer to as Hyperactive Thought Process. Simply defined- it is the limited ability to control the speed of your thoughts and the flow of simultaneously occurring thoughts. Whether one manifests this internal hyperactivity externally varies significantly from one person to the next. Females, often being more sensitive to social feedback than their male counterparts at young ages, frequently start socially masking fidgeting, restlessness, and hyperactivity in kindergarten. Fidgeting is minimized to rubbing textures with fingertips, moving toes in shoes, rubbing teeth with their tongue, playing with their hair, etc. Hyperactive Thought Process also contributes to sleep difficulties for individuals with ADHD as they are unable to turn their mind off to fall asleep easily at night. This is often not considered a hyperactive symptom.

• There is an assumption that females with chronic anxiety cannot possibly have ADHD. I would argue that many females actually present ADHD as primarily anxious. When the inability to control one’s thought process (ADHD hyperactive thought process) collides with a limited ability to regulate one’s emotions (ADHD emotional dysregulation), the result is often anxious presentation. Depression then naturally trails behind such anxiety. For many of these individuals, stimulant medications are nothing short of miraculous. I had a 64 year old women call me crying after 10 minutes of being on her first dosage of Concerta who stated, “Where did my anxiety disorder go?”

• There is an assumption that females are not impulsive. Again, females are generally socially masking executive functioning difficulties earlier than males. Impulsivity can take countless forms for females including spending habits, speech (interrupting others and/or saying things without planning them), invading other’s personal space when excitable, poor motor planning results in clumsiness or injuries, driving too fast, adrenaline junky, rushed school/employment work, impatience/irritability, relationship decisions (affairs, frequent fighting/arguing, premature breakups), burning bridges at jobs, lack of planning in daily decisions, etc. When I really ask in depth questions, it is rare to find ADHD females who have no difficulties with impulsivity. And wherever there is a history of impulsivity, there will generally be significant shame also.

• If females do not struggle in school then they cannot possibly have ADHD. Regardless of intelligence level, individuals with ADHD chronically underperform in school. For smart females, this may look like coasting by on grade level, despite teachers and themselves often knowing that they could do better. Lack of school difficulties is deemed sub-clinical in severity and is not treated with medications for many. It is important to add that many intelligent individuals with ADHD attempt to compensate for variable executive functioning with obsessive and/or compulsive coping strategies. Adult, intelligent, obsessive females who did fairly well in school is often not considered a stereotype for ADHD symptom presentation. Well I am telling you it should be considered. And that same profile should also be considered for males as well.

• There is an assumption that females only have ADHD if they are extremely inattentive. Females can certainly be extremely inattentive, as well as males, but it is important to consider that  individuals with ADHD struggle with both inattention and over-attention (i.e., hyper-focusing). There is often limited middle ground in their motivation for attention/task initiation, which results in all or nothing attention patterns. Hyper-focusing is often seen as a positive ability, or at least not as severe as inattention deficits, but this is often not the case. Hyper-focusing for females results in spending too much time, energy, and resources into stimulating activities, which can result in forgetting to complete school/employment work, not doing chores, excessive spending, not keeping up with important relationships, poor time management, not keeping up with basic hygiene, forgetting to eat meals, etc. Females are more likely than males to display hyper-focusing on relationships. For young females, it may appear that they have a new BFF every week or they tend to burn bridges with friends quickly because they are too clingy. For adult females, it is more common to see significant rejection sensitivity and over-compensation in how they manage relationships. They have a history of executive functioning symptoms impacting relationships negatively, and they are often overly careful to not lose other relationships. If they like being social they are also more likely to just become hyper-focused in conversations, with particular friends, or with particular social groups.

• There is an assumption that females in the family cannot possibly have ADHD. ADHD does not discriminate between males and females in a family. With a heritability rate of approximately 90%, if a family has a confirmed diagnosis of ADHD in it (statistically more likely to be a male diagnosed first) then all females (and even other undiagnosed males) should also be evaluated. And it is worth mentioning that it is common to see entire families, who all have ADHD, to present entirely differently. ADHD more so than many other medical conditions really presents through one’s personality. How one seeks social interactions, manages emotions, makes decisions, manages energy and activity levels, etc. And when executive functioning is variable chronically, then shame accrues and individuals seek to compensate for their difficulties. This is why evaluating ADHD for females in particular requires careful consideration of both overt symptom presentation and covert compensation strategies.

• There is an assumption that emotional dysregulation and/or depression for females is just hormonal. If the emotional dysregulation and/or depression is not attributed to anxiety, then it is often attributed to hormonal issues. ADHD is often never considered for these females, even when it has clearly already been diagnosed in the immediate family. The reality is that untreated females with ADHD have a x14 higher risk of suicide attempts by age 16 (CHADD, 2024). This is a rather frightening statistic, especially when compared to the average age of ADHD diagnosis for females is 36 years of age (UK NHS audit, 2024). In my clinical experience, a common mis-diagnosis for females with ADHD is Borderline Personality Disorder, especially when these individuals are younger than 18 years old. It is also worth noting that from my clinical experience, that  females are more likely to come in for ADHD evaluation during specific time periods including puberty onset, postpartum, pre-menopause, and after having started medication for Thyroid conditions (impacts hormones). Changes in hormonal functioning exacerbate and/or provide clarity on underlying executive functioning difficulties.

In summary, evaluation and diagnosis of ADHD for females requires exploration beyond the typical stereotypes and diagnostic criteria. Thorough understanding of one’s personality and related functioning is required to determine what is a symptom, a compensation strategy, or a secondary symptom of ADHD (e.g., anxiety, depression, etc.). Unfortunately, comprehensive evaluation for ADHD with a specialized provider is often one of the few ways that females get diagnosed. The number of women that I have diagnosed mid-life who have had prior negative ADHD evaluative experiences is high. I recommend seeking the right specialized provider for everyone, whether it is your first or your fifth ADHD diagnostic evaluation.