Diagnosing ADHD in females: 'The relief was unreal - there was euphoria, but also grief'

Attention deficit hyperactivity disorder presents differently in girls than in boys. This means many females with the condition are undiagnosed or not diagnosed until adulthood

Claire Twomey, advanced ADHD coach. Photograph: Moya Nolan

FEMALE ADHD symptoms don’t look like boys’ symptoms, so girls aren’t diagnosed as often. In Ireland, 5% of children up to 18 have ADHD, but within the eight-to-12-year age range, four to five times more boys than girls are diagnosed.

Why girls aren’t diagnosed as frequently is because our understanding of ADHD is outdated, says advanced ADHD coach Claire Twomey. Males tend to present with ADHD externally. “The typical concept we have of ADHD is excessive energy, aggression, bouncing off the walls, appearing to be lazy or not interested in schoolwork.”

Knowledge of how the condition presents in girls is documented, but the public and clinicians need to catch up. “Women tend to present with daydreaming, zoning out, sensitivity, being bossy; for so long these have been excused away as character traits,” says Ms Twomey, adding that women internalise their challenges, work harder to compensate, and mask what is going on.

“The bottom line is most clinical professionals aren’t screening for ADHD. And teachers and parents, who don’t have the resources or information, aren’t looking for ADHD in girls. When anyone is looking, they expect to see typically ‘bold’ behaviours, but these indications aren’t always present, because no two ADHDers are the same.

“Each person will have different levels of challenges, and they’ll respond to their challenges differently. They’ll also have various strengths and coping mechanisms that’ll impact the impairments society expects to see.”

While a late diagnosis often brings relief and understanding, it can also bring grief. “Many women have a lifetime of constant struggle, mental-health issues, trauma, failed relationships/marriage, difficulty raising children, disruptions or drop-outs academically. They can have a really hard time finding a career that suits them. The list goes on,” says Ms Twomey.

Also, the dysregulation of neurotransmitters — and masking and overcompensating — can lead to cycles of boom and bust.

No surprise then that women with ADHD burn out. “They try harder, using processes and systems designed for neurotypical people. Eventually, they run out of steam.”

Claire Twomey: Post-discovering how my brain works — how I can work with it instead of against it — everything changed. Photograph: Moya Nolan

Finally, a diagnosis

When Ms Twomey was diagnosed with ADHD eight years ago, aged 28, she was relieved to have an explanation for the years of struggle she’d had with concentration and emotional regulation.

But she also felt sadness and regret “for all the years of struggle, and wondering why nobody had picked it up”.

Her undiagnosed ADHD was “definitely very impactful” in preventing her from enjoying the usual college experience. “I dropped out of college three times; it took six years to do my undergrad.”

For someone with undetected ADHD — where symptoms can include difficulty concentrating and completing tasks, being easily distracted and forgetful, and having organisation and memory challenges — Ms Twomey says the post-primary-college transition is too wide and there is no bridge.

“In post-primary, the timetable is pre-made. You’re told what to do. Then, you jump into college and you’re expected to find your own way. I lost myself in that.”

The contrast between life pre- and post-diagnosis has been “like night and day”, she says. “Post-discovering how my brain works — how I can work with it instead of against it — everything changed. My hobbies, friendships, career, my sleeping and eating habits, my interests: It was like a life overhaul. I connected to myself. Everything was easier.”

Until a few years ago, Alice (name changed) knew nothing about neuro-divergence. Now 43, she was diagnosed with ADHD at 40, but had asked her GP 15 years before if she might have the condition. “The GP said: ‘Absolutely not. You’re too successful. You couldn’t have ADHD’.”

Alice’s query had been prompted by a book about time management for people with ADHD. “In my job, I had to set my own routine, structure, and systems completely from scratch. I really struggled. I knew it wasn’t depression; mentally and physically everything was fine. Something was very wrong with how I struggled with routine and structure.”

For Alice, ADHD brings ‘time blindness’. She explains: “Time doesn’t move in a linear way. It can move very fast or very slow. It makes it very difficult for me to plan how long something will take.”

After her GP’s response, Alice didn’t think about ADHD for a long time. Describing how adept she was at masking daily work challenges, she says: “I struggled anytime I was left on my own to do a task. I’d lose interest or lose track of time. I learned to put myself into a team. Everybody wanted me on their team, because I’m a problem-solver and can see the big picture.

“But I struggled to work on my own. I’d likely be late and need regular reminders of deadlines. Whereas, if I’m encouraged and have something to look forward to, I’m a flier.”

Having worked for different companies, Alice quit her job, and became self-employed. And then she got sick. “I was having heart problems: regular chest pains, struggling to breathe, exhausted all the time.”

A cardiologist said her heart was healthy. “But clearly something was very wrong in my life.”

A different GP took Alice’s ADHD question seriously, referring her to a psychiatrist. Due to the long wait, Alice first saw a psychologist and, following multiple tests, got an ADHD diagnosis.

“The relief was unreal. There was euphoria, but also grief, which I was unprepared for,” Alice says. “I revisited things in my life that might have been different if I’d known, times I could have been kinder to myself, when it would have helped if I’d understood myself.”

Supported by an ADHD coach, Alice re-evaluated her coping mechanisms so as to now shape healthier strategies. “My coping skills were alcohol and binge-eating. As soon as I got diagnosed, I cut back on alcohol straightaway and now I hardly drink at all. My GP reassured me I wasn’t an alcoholic, but self-medicating my ADHD.”

Working with her coach she unpicked all the ways she’d previously lived and “found better ways of managing with the brain I have”.

Alice’s psychiatric referral finally came through. She was prescribed Ritalin, which has worked “brilliantly” for her. “I sleep better, I don’t binge-eat as much. I exercise more. I focus in a way I couldn’t before. The coaching has been the big thing: It meant when I got the medication, I knew how to use my new capacity.”

Claire Twomey, advanced ADHD coach. Photograph Moya Nolan

Symptom confusion

Ms Twomey says people with ADHD symptoms often get misdiagnosed with other disorders; for example, major depressive disorder, general anxiety disorder and bipolar disorder. “But the symptoms never resolve, despite treatment, because they never get to the root cause of the problem.”

Research shows that 44% of un-medicated ADHDers experience depression by the age of 30. Another study found 28% of individuals referred for mood and anxiety assessment had undetected ADHD (exa.mn/BMC-adult-ADHD).

Liz Quish, psychotherapist and neurodiversity-informed practitioner, has had clients whose presentations suggested they have ADHD. “Out of 10 women I’ve worked with in the last few months, two have been diagnosed with ADHD and another is in the process of exploring assessment.

“Women with ADHD can present very anxious, depressed, and with low self-esteem but they can’t identify why,” Ms Quish says. “I look at their executive function skills, how are they managing with planning, what are their levels of attention and motivation, what’s their impulse control like. Do they have problems organising/prioritising/starting/finishing tasks?”

Ms Quish doesn’t assess for ADHD; rather, she hypothesises with the client as to whether there might be something else underlying their depression/anxiety/poor self-esteem. “I ask: Are these secondary symptoms to something else that could possibly be ADHD?”

Aside from an awareness deficit that ADHD symptoms present differently in women, Ms Quish says other barriers to female diagnosis include significant waiting lists for assessment, which, in the public system happens through GP referral to a psychiatrist or psychologist.

At the Greenane Centre, where Ms Quish practises, training is delivered for psychotherapists in neurodiversity-informed psychotherapy. “So therapists can pick up on the nuances clients present with, and think in a neurodiverse-informed manner.” Facilitators who deliver the programme are psychotherapists, and are themselves neurodiverse.

“It’s about expanding the neurodiversity-informed lens.”

Alice says that when people hear about ADHD and neuro-divergence, they think about challenges and drawbacks. “But when you find the supports you need, and your strengths come to the fore, life changes significantly. Because those strengths were always there.”

• Advanced ADHD coach Claire Twomey, see www.internalconnections.ie
• Also see exa.mn/HSE-ADHD

Recognise the signs

Tell-tale signs a woman may have ADHD:

• “The ADHD brain needs higher levels of stimulation – when it experiences boredom/pressure/overwhelm, it shuts down,” says advanced ADHD coach Claire Twomey.
• She says traits – for example, difficulty concentrating or completing tasks, being easily distracted or forgetful, having organisation or memory challenges, blurting things out, and interrupting others – are usually experienced by ADHDers in environments that don’t meet their needs.
• The hyperactivity element of ADHD may be cognitive (rather than physical) in females, manifesting in bombarding thoughts and racing minds. “Also in women, we tend to see a lot of nail-biting, skin-picking, repetitive behaviours – all quite discreet ways of fidgeting.
• “Women with ADHD report getting easily overwhelmed and finding it hard to make decisions. They experience underachievement and being easily frustrated. They may give up easier and remove themselves from social situations.”