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Understanding your Diagnosis

Emma

Attention deficit hyperactivity disorder (ADHD) was first described in 1902 by George Still, a paediatrician. It is now recognized as a common, highly disruptive, disabling neurodevelopmental disorder that affects up to 6% of children (Thapar, O’Donovan & Owen, 2005).

 

A generation ago, clinical wisdom strongly suggested that ADHD rarely existed in girls. It is in fact true that, as with all other neurodevelopmental disorders—including autism spectrum disorders, aggressive conduct problems, and Tourette's disorder—boys show a higher prevalence than do girls (Lahey et al. 1994, Novik et al. 2006, Willcutt 2012).

 

However it is important to note that by adulthood, the sex ratio narrows considerably (Hinshaw, 2018). In childhood, the ratio of boys to girls with ADHD is about 3:1 whereas in adulthood it is closer to 1:1. This suggests that women and girls are underdiagnosed in childhood (Da Silva et al., 2020)(Mowlem et al., 2018; Quinn, 2004; Waite, 2010; Attoe & Climie, 2023).

 

The disparity between boys and girls may stem from a variety of potential factors, including; greater genetic vulnerability, endocrine factors, psychosocial contributors, or a propensity to respond negatively to certain early life stressors in boys (Hinshaw, 2018) (Thapar, O’Donovan & Owen, 2005) (Young et al., 2020). Gender differences have been reported in various aspects of adult ADHD, such as prevalence, comorbidities and social functioning (Hayashi et al., 2019).

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Symptoms such as inattentiveness, poor school performance, and depressive affect are seen as the hallmark signs of ADHD in girls, yet they elicit less attention from teachers and parents than characteristic ADHD symptoms seen in boys, such as disruptive behaviour and “acting out.” (Quinn & Wigal, 2004).

 

This is partly because girls' symptoms are not recognized as typical indications of ADHD and partly because these symptoms are less noticeable and less troublesome to adults than are boys' symptoms (Quinn & Wigal, 2004).

 

Without a diagnosis, women with ADHD often report spending their lives feeling “different,” “stupid,” or “lazy” and blaming themselves for their underachievement (Lynn, 2019) (Attoe & Climie, 2023). Consequently, receiving a diagnosis of ADHD can be instrumental for a woman’s self-esteem and identity (Waite, 2010) (Attoe & Climie, 2023).

 

Now that you are aware of your diagnosis, you can learn more about it, thus finding the best methods to help you manage your symptoms and lead a healthy and happy life!

References and further resources: Attoe, D. E., & Climie, E. A. (2023). Miss. Diagnosis: A Systematic Review of ADHD in Adult Women. Journal of Attention Disorders, 27(7), 645–657. https://doi.org/10.1177/10870547231161533 da Silva, A. G., Malloy-Diniz, L. F., Garcia, M. S., & Rocha, R. (2020). Attention-deficit/hyperactivity disorder and women. Women's Mental Health: A Clinical and Evidence-Based Guide, 215-219. Hayashi, W., Suzuki, H., Saga, N., Arai, G., Igarashi, R., Tokumasu, T., Ota, H., Yamada, H., Takashio, O., & Iwanami, A. (2019).

Clinical Characteristics of Women with ADHD in Japan

Neuropsychiatric Disease and Treatment, Volume 15, 3367–3374.https://doi.org/10.2147/ndt.s232565 Hinshaw, S. P. (2018). Attention Deficit Hyperactivity Disorder (ADHD): controversy, developmental mechanisms, and multiple levels of analysis. Annual Review of Clinical Psychology, 14(1), 291–316. https://doi.org/10.1146/annurev-clinpsy-050817-084917 Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L., Hynd, G. W., ... & Richters, J. (1994). DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. The American journal of psychiatry, 151(11), 1673-1685. Lynn N. M. (2019). Women & ADHD functional impairments: beyond the obvious [Master’s thesis, Grand Valley State University]. Graduate Research and Creative Practice at ScholarWorks. Mowlem F. D., Rosenqvist M. A., Martin J., Lichtenstein P., Asherson P., Larsson H. (2018). Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment. European Child & Adolescent Psychiatry, 28, 481–489. https://doi-org.ucd.idm.oclc.org/10.1007/s00787-018-1211-3 Novik, T. S., Hervas, A., Ralston, S., Dalsgaard, S., Rodrigues-Pereira, R., & Lorenzo, M. J. (2009). Erratum: Influence of gender on attention-deficit/hyperactivity disorder in Europe ADORE (Eur Child Adolesc Psychiatry [Suppl 1]) 15 (1524. European Child and Adolescent Psychiatry, 18(3). Quinn P. O. (2004). ADHD not for ‘boys only’ girls and women are affected. Behavioral Health Management, 24(4), 30–33. Quinn, P., & Wigal, S. (2004). Perceptions of girls and ADHD: results from a national survey. MedGenMed : Medscape general medicine, 6(2), 2. Thapar, A., O'Donovan, M., & Owen, M. J. (2005). The genetics of attention deficit hyperactivity disorder. Human molecular genetics, 14(suppl_2), R275-R282. Waite R. (2010). Women with ADHD: It is an explanation, not the excuse du jour. Perspectives in Psychiatric Care, 46(3), 182–196. https://doi-org.ucd.idm.oclc.org/10.1111/j.1744-6163.2010.00254.x Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 9(3), 490-499. Young, S., Adamo, N., Ásgeirsdóttir, B. B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., Farrag, E., Gudjónsson, G. H., Hill, P., Hollingdale, J., Kılıç, Ö., Lloyd, T., Mason, P. R., Paliokosta, E., Perecherla, S., Sedgwick, J., Skirrow, C., . . . Woodhouse, E. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02707-9

Neuroanatomical basis

Genetic, pharmacological, imaging, and animal models highlight the important role of dopamine dysregulation in the neurobiology of Attention-Deficit/Hyperactivity Disorder.

 

Structural imaging studies show the brains of children with Attention-Deficit/Hyperactivity Disorder are significantly smaller than unaffected controls. Additionally, the prefrontal cortex, basal ganglia and cerebellum are differentially affected (Curatolo et al., 2010).

 

In ADHD patients, reductions in volume have been observed in total cerebral volume, the prefrontal cortex, the basal ganglia (striatum), the dorsal anterior cingulate cortex, the corpus callosum and the cerebellum (Émond et al., 2009).

 

Neuropharmacological studies have provided evidence that ADHD involves dysregulation of both noradrenaline (NE) and DA neurotransmitter systems (Pliszka, 2005) (Curatolo et al., 2010). Stimulants, such as methylphenidate and amphetamine, block the reuptake of both NE and DA at their respective transporters (Pliszka, 2005).

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References and further reading: Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics, 36(1), 79. https://doi.org/10.1186/1824-7288-36-79 Émond, V., Joyal, C. C., & Poissant, H. (2009). Neuroanatomie structurelle et fonctionnelle du trouble déficitaire d’attention avec ou sans hyperactivité (TDAH). L’Encéphale, 35(2), 107–114. https://doi.org/10.1016/j.encep.2008.01.005 Pliszka, S. R. (2005). The Neuropsychopharmacology of Attention-Deficit/Hyperactivity Disorder. Biological Psychiatry, 57(11), 1385–1390. https://doi.org/10.1016/j.biopsych.2004.08.026

Risk factors

ADHD is a complex disorder influenced by genetic and environmental factors (Thapar, O’Donovan & Owen, 2005). A substantial body of evidence exists for the heritability of ADHD in childhood and adolescence, with estimates centering on values near 0.75 (Burt, 2009) although higher numbers have been reported (Larsson et al., 2014) (Hinshaw, 2018). 

 

Prenatal factors are associated with maternal lifestyle during pregnancy (Curatolo et al., 2010). Maternal smoking produces a 2.7-fold increased risk for ADHD (Milberger et al., 1996). Children exposed prenatally to alcohol can become hyperactive, disruptive, impulsive, and are at an increased risk of a range of psychiatric disorders (D'Onofrio et al, 2007) (Sen & Swaminathan, 2007) (Curatolo et al., 2010).

 

Adolescents with ADHD often report low self-esteem and poor peer relationships; and are at high risk of smoking and substance abuse early in life (Elkins et al, 2007) (Loe & Feldman, 2007). 

 

A study done on ADHD in Japan, found that women had a significantly higher psychiatric comorbidity rate, were significantly less likely to be a full-time employee, and were significantly more likely to be divorced than men with ADHD (Hayashi et al., 2019).

 

A longitudinal study investigating the prevalence of psychopathology in girls with and without ADHD, found that by young adulthood, girls with ADHD were at a higher risk for antisocial, addictive, mood, anxiety, and eating disorders as well as cognitive impairments and academic problems (Biederman et al., 2010).

References and further reading: Burt, S. A. (2009). Rethinking environmental contributions to child and adolescent psychopathology: a meta-analysis of shared environmental influences. Psychological bulletin, 135(4), 608. Biederman, J., Petty, C. R., Monuteaux, M. C., Fried, R., Byrne, D., Mirto, T., Spencer, T., Wilens, T. E., & Faraone, S. V. (2010). Adult Psychiatric Outcomes of girls with Attention Deficit Hyperactivity Disorder: 11-Year Follow-Up in a Longitudinal Case-Control Study. American Journal of Psychiatry, 167(4), 409–417. https://doi.org/10.1176/appi.ajp.2009.09050736 Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics, 36(1), 79. https://doi.org/10.1186/1824-7288-36-79 D’Onofrio, B. M., Van Hulle, C. A., Waldman, I. D., Rodgers, J. L., Rathouz, P. J., & Lahey, B. B. (2007). Causal inferences regarding prenatal alcohol exposure and childhood externalising problems. Archives of general psychiatry, 64(11), 1296-1304. Elkins, I. J., McGue, M., & Iacono, W. G. (2007). Prospective effects of attention-deficit/hyperactivity disorder, conduct disorder, and sex on adolescent substance use and abuse. Archives of general psychiatry, 64(10), 1145-1152. Hayashi, W., Suzuki, H., Saga, N., Arai, G., Igarashi, R., Tokumasu, T., Ota, H., Yamada, H., Takashio, O., & Iwanami, A. (2019). Clinical Characteristics of Women with ADHD in Japan. Neuropsychiatric disease and treatment, 15, 3367–3374. https://doi.org/10.2147/NDT.S232565 Larsson, H., Chang, Z., D'Onofrio, B. M., & Lichtenstein, P. (2014). The heritability of clinically diagnosed attention deficit hyperactivity disorder across the lifespan. Psychological medicine, 44(10), 2223-2229. Loe, I. M., & Feldman, H. M. (2007). Academic and educational outcomes of children with ADHD. Journal of paediatric psychology, 32(6), 643-654. Milberger, S., Biederman, J., Faraone, S. V., Chen, L., & Jones, J. (1996). Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children?. The American journal of psychiatry, 153(9), 1138-1142. Sen, B., & Swaminathan, S. (2007). Maternal prenatal substance use and behaviour problems among children in the US. Thapar, A., O'Donovan, M., & Owen, M. J. (2005). The genetics of attention deficit hyperactivity disorder. Human molecular genetics, 14(suppl_2), R275-R282.

Diagnostic tests

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Assessments often include medical and psychological evaluations.  At the very minimum they will involve a clinical interview, with each specialist differing in their approach.

There are strict diagnostic criteria however, under the DSM-V, a clinical handbook for the diagnosis and reference of mental disorders, created by the American Psychiatric Association.

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DSM-V Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development:

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​Inattention

Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

  • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

  • Often has trouble holding attention on tasks or play activities.

  • Often does not seem to listen when spoken to directly.

  • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

  • Often has trouble organising tasks and activities.

  • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

  • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

  • Is often easily distracted

  • Is often forgetful in daily activities.

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Hyperactivity and Impulsivity

Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

  • Often fidgets with or taps hands or feet, or squirms in seat.

  • Often leaves seat in situations when remaining seated is expected.

  • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

  • Often unable to play or take part in leisure activities quietly.

  • Is often “on the go” acting as if “driven by a motor”.

  • Often talks excessively.

  • Often blurts out an answer before a question has been completed.

  • Often has trouble waiting their turn.

  • Often interrupts or intrudes on others (e.g., butts into conversations or games)

Symptoms

This alternative resource from Young et al, (2020) provides a more holistic understanding of the symptoms and associated features, vulnerabilities and behaviours of ADHD for women.

It is broken down into four sections:

  • ADHD Symtoms 

  • Comorbidity

  • Associated features and vulnerabilities 

  • Compensatory and coping behaviours 

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