What are the signs and symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in women?

Signs and Symptoms of ADHD in Women

Women with ADHD predominantly present with inattentive symptoms rather than hyperactive-impulsive symptoms, and their manifestations are often less overt but equally impairing, leading to frequent underdiagnosis and delayed recognition compared to men. 1, 2

Core Symptom Profile in Women

Women with ADHD exhibit specific patterns that differ from the classic presentation seen in males:

Inattentive Symptoms (Predominant)

• Poor attention to detail and difficulty concentrating or sustaining attention on tasks 3
• Appearing preoccupied or having an "unclear mind" (often described as "brain fog") 4
• Difficulty completing tasks and significant organizational challenges 3
• Reluctance to engage in tasks requiring sustained mental effort 3, 4
• Difficulty keeping track of personal belongings 3
• Being easily distracted and frequently forgetful 3

Behavioral and Emotional Manifestations

• Internalization of symptoms with associated anxiety and depression rather than externalizing behaviors 1, 5
• Emotional dysregulation and labile mood 6
• Quick temper and impulsivity (though less overt than in males) 6
• Restlessness and disorganization 6

Unique Clinical Features in Women

Comorbid Conditions

Women with ADHD show distinct comorbidity patterns that can mask the underlying ADHD diagnosis:

• Girls with ADHD are 5.4 times more likely to be diagnosed with major depression and three times more likely to be treated for depression before their ADHD diagnosis 5
• Heightened risk for anxiety disorders, with anxiety often occurring secondarily when experiencing cognitive difficulties 4
• Increased rates of eating disorders, particularly binge eating and bulimia 5
• Approximately 10% of adults with recurrent depression or anxiety have underlying ADHD, making differential diagnosis critical 7, 3, 4

Hormonal Influences

• ADHD symptoms fluctuate with the menstrual cycle, predictably worsening during early follicular and early luteal phases when estrogen levels drop 7, 4
• Symptoms may worsen during pregnancy when medication is often discontinued 7
• The postpartum period presents unique challenges with greater parental distress 7

Functional Impairments Specific to Women

Women with ADHD experience serious impairments that may differ from male presentations:

• Particularly heightened risk for problems in close relationships 1
• Increased engagement in self-harm 1
• Developmental progressions to intimate partner violence and unplanned pregnancy 1
• Difficulty managing prenatal care, appointments, and preparation during pregnancy 7

Diagnostic Challenges and Pitfalls

Why Women Are Underdiagnosed

• Symptoms are less overt but still impairing, making them easier to overlook 1, 8
• Women frequently adopt compensatory strategies that mask their symptoms 1
• Females often receive a diagnosis of ADHD significantly later than males 2
• Coexisting conditions (anxiety, depression, eating disorders) often complicate the clinical picture and are treated first 5, 8
• Adults with ADHD often have poor insight and underestimate the severity of their symptoms and resulting impairments 3, 4

Critical Diagnostic Considerations

• Absence of mood symptoms argues strongly against primary depression 4
• The presence of reactive anxiety to cognitive difficulties suggests ADHD rather than primary anxiety disorder 4
• Symptoms must have been present for at least 6 months, with onset before age 12, causing functional impairment across multiple settings 3, 4

Screening Approach

The American College of Obstetricians and Gynecologists recommends using the Adult ADHD Self-Report Scale (ASRS-V1.1) as the primary screening tool for ADHD in reproductive-age females, with a positive screen defined as checking "often" or "very often" for 4 or more of the 6 questions in Part A 7, 3, 4

• Document functional impairment using the Weiss Functional Impairment Rating Scale-Self (WFIRS-S), which captures ADHD-specific impairment across multiple life domains 7, 4
• Obtain collateral information from someone who knows the patient well, as self-report alone may be unreliable 3, 4
• Screen systematically for comorbid depression and anxiety using validated tools 7, 4