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Women With ADHD: Zoned Out and Lost

  • 20 Sep 2022
  • 5 mins

Attention deficit hyperactivity disorder (ADHD) has long been thought of as a condition affecting males. More females are being diagnosed as our understanding of the condition deepens. We find out more from Dr. Tay Kai Hong, our psychiatrist.

"Girls with ADHD are usually not hyperactive like the boys"

The idea that young women can have ADHD can evoke doubt in some quarters.

It is a condition traditionally characterized by the disruptive behavior of boys, though on most measures, data suggest that girls can experience the same symptoms and poor outcomes from the condition.

“ADHD brains are driven by novelty, excitement, urgency, and a sense of challenge, rather than by conventional notions of labels such as responsibilities and priorities," Dr. Tay explained.

As modern-day institutions value organizational skills and efficiency over spontaneity and creativity, people with ADHD may struggle to thrive in schools and workplaces. In addition, it can lead to low self-esteem, anxiety, and other mental health difficulties.

“Globally, it is estimated that 5% of children are born with ADHD, a brain condition characterized by inattention, impulsivity, and hyperactivity,” he added.

Young girls with ADHD are usually less disruptive in their behaviors, so it is not always apparent that they are struggling.

Generally, girls are more likely to daydream and are shy. Compared to boys with ADHD, who manifest more hyperactive and impulsive symptoms which attract more attention, fewer girls are diagnosed with ADHD, resulting in some women struggling to cope with the symptoms for years or even decades.

Dr. Tay said that about half of the children with ADHD would have symptoms that persist into adulthood.

In both childhood and adulthood, women with ADHD are much less likely to exhibit symptoms of hyperactivity compared to males. Due to women’s tendency to internalize their feelings, their subtle presentations can easily be misinterpreted and dismissed as anxiety or pre-menstrual mood swings.

ADHD Presents Differently in Women

“Women with ADHD tend to manifest predominantly symptoms of inattention, which are more subtle and difficult to detect.”

“Symptoms of inattention include carelessness, forgetfulness, distractibility, and persistent difficulty in sustaining attention. In addition, there is a chronic tendency to procrastinate on tasks requiring sustained mental effort. They also have great difficulty organizing tasks, activities, and physical spaces," Dr. Tay explained.

As a result of poor time management, deadlines are often missed, even for simple tasks like finishing the laundry or picking up a child from school.

“They may appear day-dreamy and caught up in their own thoughts. Their carelessness and forgetfulness may be overlooked as personality traits or attributed to a lack of effort,” he added.

On the other hand, the symptoms of hyperactivity and impulsivity include restlessness, being unable to stay in one's seat or stay in the queue, excessive talking, frequently interrupting others, and appearing to be tactless and impatient in social interactions.

“As women with ADHD rarely show symptoms of hyperactivity, the symptoms are ‘hidden’ and may go unnoticed.”

Undiagnosed or Misunderstood in Women

Though women with ADHD face many similar symptoms as their male counterparts, they labor under the added burden of restrictive gender roles. Conforming to the entrenched societal gender expectations of being the family's primary caregiver for children and the elderly, they are more likely to internalize emotions, which can result in withdrawal, loneliness, and depression.

“The symptoms of inattention may be conflated with anxiety or depression, which do occur at higher rates in women than men," Dr. Tay said

“Indeed, anxiety disorders and depression commonly co-occur with underlying ADHD. They may in fact be a secondary consequence of ADHD-related impairments. Clinicians may diagnose the anxiety disorder and overlook the possibility of underlying ADHD. In other words, the higher prevalence of depression and anxiety in women tend to mask and overshadow more subtle ADHD symptoms,” he explained.

Furthermore, diagnostic tools for ADHD were originally designed to detect ADHD in young children, particularly hyperactive boys with disruptive behaviors in the classroom.

“These diagnostic tools are not perfect and have their limitations when directly applied to an adult female population. ADHD in women is less well understood and research in the field is evolving. It is important for doctors and patients alike to discard the historical perspective of ADHD as a purely behavioral problem, and pay more attention to the subtler and more internalized experiences of women with ADHD.”

Getting Diagnosed

To make it easier to cope with the symptoms of ADHD, first get a diagnosis,

“Locally, assessment and diagnosis of ADHD are typically conducted by psychiatrists. The specialist will take a thorough history delving into the nature and timeline of symptoms, and perform a mental state examination through observation and conversation," Dr. Tay explained.

He also advised identifying co-existing conditions such as anxiety, depression, addictions, or other developmental or learning disorders, including autism and dyslexia.

“Historical accounts from parents and teachers’ comments in report books are useful to get an idea of how the person was as a young child, and to establish that symptoms and related impairment were present from childhood. In complex or borderline cases, a more detailed neuropsychological assessment may be necessary. This is performed by a neuropsychologist and will take a longer time.”

Manage Symptoms with Medications and Lifestyle Changes

Medication is not a cure for ADHD, but when paired with knowledge and self-awareness granted by a diagnosis, it helps to make symptoms more bearable.

“Methylphenidate is the first-choice medication in Singapore and is a prescription-only medication available at most mental health clinics and restructured hospitals,” he said.

“The medication increases levels of certain neurotransmitters in parts of the brain which governs executive functioning, impulse control, and focused attention, thereby strengthening the control center of the brain.”

“There are different formulations of the medication. They vary in terms of their duration of action, which can last from 4 hours to 12 hours.”

He also cautioned about side effects, which include suppression of appetite, weight loss, increased jitteriness, anxiety, insomnia, and headaches.

In terms of lifestyle strategies, he suggests breaking big tasks into smaller ones to make work more manageable. Use written lists, timetables, calendars, and arbitrary deadlines to promote routines, structure, and more effective time management.

"Declutter, simplify and organize work and living space to facilitate clarity of thought and reduce distractions." (Always put the handphone away and face down to reduce distractions.)

"Exercise daily or at least three times per week. It will help people with ADHD to relax, sleep better, and improve their focus."

He also recommends practicing positive procrastination. “This involves taking short breaks from work to do other productive tasks instead of mindless and unproductive activities. Changing things up keeps the ADHD brain engaged and can improve productivity.”

A Semblance of Control

According to Dr. Tay, ADHD symptoms often improve with age.

“As they get older, they implement new habits and put in place routines to manage the symptoms. However, these happen over time as they learn by trial and error what works and what does not.”

“The price of missed diagnosis and delayed treatment, however, may be lost opportunities and unfulfilled potential in the most productive and fruitful years of a person’s life,” he advised.

Contributed by

Dr. Tay Kai Hong
Farrer Park Hospital