More women than ever before are receiving ADHD diagnoses. From 2020 to 2022, the percentage of adult women with a new diagnosis nearly doubled, and clinicians continue to encounter higher rates of women seeking assessments.

It’s reassuring that, after decades of association with rambunctious little boys, ADHD is finally being acknowledged as a condition that can affect anyone, regardless of age or gender.

However, we still have a long way to go to ensure women with ADHD receive care attuned to their unique needs. From initial testing to treatment pathways, women face barriers to care. For some, it’s unconscious biases affecting their or their clinicians’ interpretations of what ADHD symptoms look like. Others struggle with the impact of their hormone cycle on symptom severity and treatment effectiveness.

As the behavioral health field continues to refine its approach to caring for all individuals with ADHD, we must ensure that we understand the unique experiences of women with ADHD so we can assess our patients accurately, diagnose confidently, and treat successfully.

Diagnostic differences

The first step in any ADHD care pathway is diagnosis. Thanks to years of advocacy and, admittedly, social media, teenagers and adult women now recognize that their challenges with focus, organization, impulsiveness, or hyperactivity could be signs of ADHD.

That’s a great start, but the conversation initiated when women request an ADHD assessment has historically been a complicated one, exacerbated by long-held gender biases impacting diagnostic decisions. Part of this is because for decades, ADHD was thought to be something that only occurred in young boys.

Many women report negative clinical experiences in behavioral health and beyond; in the 2022 KFF Women’s Health Survey, 29 percent of women reported doctors had dismissed their concerns. Those patients who are heard and referred for ADHD assessment must hope their clinicians are caught up on the latest research and can recognize how the condition manifests in women.

A great example of this is hyperactivity. It was long believed that women were less likely to suffer from hyperactivity than men, which contributed to under- and misdiagnosis of ADHD in women and girls. However, recent research has affirmed that men and women with ADHD equally exhibit clinically relevant signs of hyperactivity. An adult woman seeking assessment is probably not running around the waiting room, but she likely still feels restless, gets fidgety, or has racing thoughts. Many women feel that their hyperactivity is internal, with their brain jumping from topic to topic. Their hyperactivity can also manifest with chattiness, which parents, teachers, or colleagues may interpret as a personality trait instead of a symptom.

Clinicians must also rule out several comorbidities. Many conditions, such as depression or anxiety disorders, share symptoms with ADHD, which can worsen memory and attention or cause feelings of overwhelm and restlessness. Notably, both these conditions are more common in women than men.

Sifting through varying symptoms and multiple conditions can be challenging when relying solely on subjective assessments. Patients’ memories of their childhood are not always accurate, and they may lack insights from a guardian or former teacher to corroborate their lifelong experiences with ADHD symptoms. Even their understandings of their current experiences are not always sufficient; many adult women internalize ADHD symptoms as inherent character flaws, believing themselves to be lazy and incapable.

To account for this, my practice has integrated objective testing into our standard approach to ADHD assessment. This allows us to enhance our overall diagnostic picture with biometric data that differentiates ADHD patients from those without the condition. Additionally, it can catch subtle presentations of hyperactivity that we may not detect while gathering patient history or reviewing self-administered rating scale results.

Hormonal cycles of care

Despite advancements in behavioral health research and our approach to treating women with ADHD, the influence of maturity and hormonal cycles on symptoms and treatment effectiveness remains largely unrecognized.

Research has linked estrogen levels to the impact of ADHD symptoms. When estrogen levels are higher, attention and critical thinking skills improve, and when they are lower, these skills worsen. As women’s estrogen levels fluctuate throughout their lives, this can make it more difficult to manage ADHD symptoms.

Evidence demonstrates that ADHD symptoms may worsen in the last two weeks of the menstrual cycle as progesterone levels rise. One study found that women with ADHD are more likely to experience premenstrual dysphoric disorder (PMDD), which can lead to increased negative behaviors like self-harm and suicidal thoughts. This same research found that some women were self-managing the changes by increasing their doses of ADHD medication without looping in their clinician.

Other significant life events, such as puberty, pregnancy, and menopause, can further influence ADHD symptoms. Pregnant women, for example, may face worsened symptoms during their first trimester. However, the impact of hormones on ADHD symptoms and treatment efficacy remains under-studied. A top concern for many women is the limited research on use of ADHD medication during pregnancy, placing expectant mothers in a tough position when deciding how to manage symptoms. We have also observed that hormonal changes can exacerbate ADHD symptoms, be that the mood swings of puberty or brain fog brought on by menopause. However, there are few studies on these topics, making it harder to support our patients with evidence-based care through these seasons of life.

To ensure we provide women with the most effective ADHD treatment, regardless of hormonal fluctuations, we can utilize technologies that enable us to precisely measure symptom severity and the effectiveness of specific treatments. With an objective ADHD test, we can evaluate a patient’s symptoms throughout her menstrual cycle. If we find that her symptoms worsen significantly during a particular week, we can modify her medication or implement other therapeutic strategies to support her. This testing can also be incredibly validating, affirming through data, the lived experiences of our patients.

While we aim to provide equitable ADHD care for men and women, it is a disservice as clinicians to overlook the unique experiences and challenges that women’s health presents, which impact their symptom presentation and the path to successful treatment. By screening and assessing for boys and girls equally, we can improve this equity. We must listen to our patients, advocate for ongoing research, and prioritize objective, data-driven solutions to ensure women with ADHD receive the care they deserve.

Arti Lal is a pediatrician.