More and more women are being diagnosed with ADHD in adulthood. What's behind this increase?
“So many adult patients—women—come in and are being newly diagnosed with ADHD [attention-deficit/hyperactivity disorder] for the first time,” Pamela Wall, PhD, PMHNP, FAANP, told attendees of the American Psychiatric Nurse Association 36th Annual Conference. The goals for the session were to explain the reason for this phenomenon and to share some of the unique issues associated with ADHD in adult women.
Implicit bias was a top reason for missing the diagnosis earlier in women, Wall explained, as she conducted a mini-experiment with attendees. After asking attendees to visualize a child who is hyperactive, Wall surveyed the group to see what gender they saw; most of the audience pictured a boy.
In addition, she said what is known about ADHD now versus what was known 20 or 30 years ago has changed, which allows for new adult cases to be diagnoses. Similarly, children often have mechanisms in place during their childhood that may hide the functional issues associated with ADHD—parents who set schedules and monitor them, schools with regimens, etc. These “safety nets” disappear as patients age and become adults, move out of their family home, go off to college, enter the workforce, etc.
To help illustrate this point, Wall shared a case example of a 30-year-old woman who initially presented with depressed mood, anxiety, panic, racing thoughts, and sleep onset insomnia. The patient was very successful in school growing up and credits that partially to strict schedules and expectations by her parents as well as her swimming regimen. In later sessions, she admitted to a history of struggling with concentration and organization and said she was often forgetful. After seeing success at a community college, she decided to move way to finish her education. Unfortunately, she struggled and received failing grades, so she moved back home. The current concentration issues are causing problems at her work as well as with her marriage, and thus she sought help.
Wall said patients like this often respond well to pharmacological treatment, even to the point of addressing other comorbidities like anxiety and depression. It is not uncommon, she added, for patients to tell her, “I feel calm for the first time in my life,” after initiating ADHD treatment.
There are differences between men and women with adult ADHD, Wall added. For instance, females may have higher hyperactivity and impulsivity than males, but it might register instead as restlessness. In some cases, the “restlessness” in women gets confused with anxiety, Wall noted. In terms of comorbidities, males usually have externalizing varieties like conduct disorder and oppositional defiant disorder. On the other hand, females tend to present with complaints of pain, anxiety, and somatoform disorder, she said. Girls with ADHD are also more likely to have disruptions in their relationships than boys, which results in lower self-esteem. Also important are the hormonal effects on ADHD in girls and women, she said. Finally, not all rating scales are normed for gender, Wall added. She said she uses the Conners rating scale for ADHD, as it has been normed for gender.
Both psychopharmacological and nonpharmacological treatments are successful for female patients, Wall noted. Stimulants are not recommended for women who are pregnant or breastfeeding, she added. Interestingly, she said girls respond better than boys with combined pharmacological and nonpharmacological treatment.
The APNA 36th Annual Conference was held October 19 - 22, 2022, in Long Beach, California.