ADHD, Girls, Women & The Menopause

Disclaimer

Since being diagnosed with ADHD in May 2022 I have been looking into the condition to understand it and how it impacts me. During this journey, one of the things that has kept coming up is the difference in the experiences around ADHD for girls and women versus most boys and men, so in the spirit of trying to share my learnings I decided quite early on that I would have a go at trying to highlight this issue. I’m not a professional writer with an editor to lean on for advice and help, so if I stray into the realm of ‘mansplaining’ then please let me know, but don’t judge me too harshly, I am trying, with the best intentions, to throw some light on the subject.

ADHD is not just about boys!

ADHD has no gender bias, and yet, shockingly, diagnosis rates are almost 3 times higher in males than females! (the difference in M:F prevalence ratio used to be as bad as 25:1!) Why is this? The tools used to diagnose and screen for autism and ADHD are based primarily on data from boys. They do not adequately allow for the variations in symptoms across sexes. The root of the problem comes from the simple misconception that I have described in previous blogs; ADHD is all too often thought of as being all about the disruptive schoolboy that we have all encountered, either in person, in popular culture or in the media.

The differences in male and female presentation of symptoms are quite a revelation. Research has shown that boys tend to externalise symptoms, leading to them showing more impulsivity, running around more and being more prone to being physically aggressive when frustrated. Girls tend to internalise their symptoms, leaning more towards being inattentive and living with low self-esteem, which in turn pushes them more in to the background, with reactions tending to be more verbally aggressive. I must stress that the words ‘tend to’ are doing a bit of heavy lifting here, either sex can show any combination of symptoms, but this is also far from being a sweeping generalisation.

Symptoms by gender are likely to include:

Girls

being withdrawn
low self-esteem
anxiety
intellectual impairment
difficulty with academic achievement
inattentiveness or a tendency to daydream
trouble focussing
appearing not to listen
verbal aggression, such as teasing, taunting, or name-calling

Boys

impulsivity or ‘acting up’
hyperactivity, such as running and hitting
lack of focus, including inattentiveness
inability to sit still
physical aggression
talking excessively
frequently interrupting other people’s conversations and activities

With these differences in displaying ADHD traits, it’s easy to see why it’s a perfect example of the idiom “the squeaky wheel gets the grease”, and why girls are often overlooked, leading to lower referral, diagnosis, and treatment rates. In turn this often leads to more self-esteem problems, which can develop on to wider mental health issues, such as depression, anxiety, eating disorders and self-harm. These then become the focus of any referral, and because these often require a different level of specialist* to diagnose and treat, the classic situation arises where all the focus goes on treating the symptom, not the cause. This is such a toxic cycle, and the way that mental health services are structured within the NHS (UK) it would appear to be one that is incredibly hard to break.

*In the UK the 1^st point of referral tends to be Children and Young People’s Mental Health Services (CYPMHS – previously known as CAMHS) which is a multi-disciplinary team approach to child/young person’s mental health. In my experience it uses counsellors and psychologists more than psychiatrists. In the UK Psychologists can’t prescribe medication, psychiatrists can; specialities like ADHD rely on the latter, hence my suggestion that the wider mental health symptoms are more likely to be the focus of treatment in the current model.

ADHD in women

If girls with ADHD get through their education without being diagnosed, then the challenges become even more complex. Something called the ‘female protective effect’ develops with age and experience and is believed to be a strong factor in women with ADHD and/or Autism. It is fundamentally a highly developed ability to camouflage or mask the traits of their condition to fit in or survive. Research shows that, because of female protective effect, women require greater genetic or environmental impacts to trigger the same level of impairment to warrant diagnosis as males with ADHD and/or Autism.

When I look at the way that women often must cope with more sustained and varied pressures than men it makes a lot of sense to me. Juggling home and career, especially with children involved, while having to work harder for recognition in the workplace, dealing with the glass ceiling and so on shows a level of mental resilience that to my mind goes a long way towards proving this point. We seem to have taken steps forward as a society to redress some of this dynamic, but look at any report on the UK gender pay gap and you’ll soon see that there is still a way to go.

‘Sure he (Fred Astaire) was great, but don’t forget that Ginger Rogers did everything he did…backwards and in high heels.’

Perimenopause, Menopause and Post Menopause - the basics

Note for the gentlemen reading this, the following section is important! Until recently I had no idea what perimenopause and the menopause really are, in fact I’d never heard the word perimenopause. I grew up in a world where people barely managed to whisper phrases like ‘the change’, let alone properly explain it. I never once heard my mother mention the menopause, she never once to my knowledge talked about the impact it had on her, so thanks to Sam, my wife, partly through her work in HR and partly through her own journey I’m starting to learn about what the symptoms and impacts are, how long it may take to navigate, and what is happening to women as they go through this. We men need to educate ourselves so that we can be fully supportive of all the women in our lives during what can be a very challenging time for them. I’d recommend watching ‘this’, but in the meantime the absolute basics that we need to know for this ADHD conversation are:

Perimenopause – the time leading up to the menopause is when hormone levels are still fluctuating.
Perimenopause doesn’t transition into menopause until 12 months have gone by without a menstrual period.
On average perimenopause lasts for 4 years, but can be as short as a few months, and as long as a decade.
The menopause itself is fundamentally an instant in time that defines the switch from peri to post menopause. It is that moment when 365 days have elapsed since the last menstruation.
The main hormonal change that is happening is the slowing down and stopping of estrogen production. When this happens, dopamine and serotonin are often affected. Dopamine deficiency is integral to ADHD, so anything that makes it worse in a neurotypical brain is going to have a compound effect in an ADHD brain.

ADHD & the Menopause

I attended an online drop-in session with ADHD UK not long after I had my ADHD confirmed, and it was aimed at people who received a late diagnosis like mine. I was staggered by the proportion of women on the call who had been struggling with the menopause and somehow had ended up with an ADHD diagnosis. Having read more about it since then it has started to make a lot of sense. The impact of the menopause seems to have effectively reduced their ability to maintain the ‘female protective effect’ outlined above, stripping them of much of their symptom masking and leading them on a convoluted, difficult journey to an ADHD diagnosis; yet another thing to take onboard during an already challenging period in their lives.

One of the lists below relates to the psychological symptoms of the menopause, the other to ADHD. Spot the difference….

Symptom List A

a lack of focus
depression
a lack of motivation
aggressiveness
irritability
stress
forgetfulness
emotional instability

Symptom List B

being easily distracted
frequently failing to complete tasks/work/chores
making careless mistakes
having difficulty with organisation
easily losing things
forgetting to do things
appearing to zone out during conversations
having difficulty making plans
easily overwhelmed
inability to commit to a decision
emotional instability
time management issues

Symptom List A is menopause and B is ADHD, but I doubt I’d get in trouble with the word police if I got them the wrong way around!

My wife is going through the menopause, and the way some of her symptoms were presenting led me to asking her to do an ADHD test because I was starting to genuinely believe that she might be one of my people! It turns out that she isn’t, but the crossover between the 2 is staggeringly similar.

The above menopause symptoms are caused by hormonal changes, and those with ADHD will likely experience an increase in the intensity of symptoms that they are already familiar with. If they have been diagnosed with ADHD then their experience, existing support structure and medication (where taken) will all play a part in managing this, but for the undiagnosed this must be a nightmare! In the UK we have poor access to the kind of services that would pick up on the nuances of the two sets of symptoms, meaning that a correct diagnosis is a long way from certain, indeed misdiagnosis is an alarming reality.

Conclusion

As research into ADHD develops, more and more of the standard assumptions based on the naughty boy model are exposed as being inadequate and as a result the broader symptoms of ADHD are slowly being recognised and diagnostics are beginning to evolve, but there is a long way to go. This issue currently has a much larger impact on women and girls, though there are a large proportion of boys and men with more inattentive than hyperactive symptoms that are also being let down. Until recently I was one of them, and my journey started with self-diagnosis.