Left to suffer in silence: women with ADHD

Attention Deficit Hyperactivity Disorder (ADHD). It affects one in twenty people in the UK, yet four times more men are diagnosed with the condition than girls. Women typically have “inattentive” ADHD which can be harder to spot due to the way women can internalise it.

When you hear the word ADHD you think of a five year old boy throwing his chair at the teacher. You never think of the bright young girl, whose teacher affectionately calls her a chatterbox, who goes on to be the “life and soul of the party.” The girl who chews on her pen, picks away at her skin, a million miles away from the conversation she is part of. The girl who forms emotional connections in an instant yet struggles to maintain the closeness of the relationship or friendship after a certain point in time. The girl trying to relax during sex yet all she is thinking about is what she will make for dinner or when she will wash her hair next.

However, in the boardroom, when she is talking about the idea she has invested in and focused on for the past week she is brilliant. Until she is bored of the job and leaves for another company to do it all over again. The way she can perfect a skill or hobby in no time at all is attractive to herself and her CV, and her CV is a long, long list.

Scrolling through TikTok, my For You Page is littered with videos of girls in their Twenties talking about traits they possessed from childhood which they did not realise were because they had ADHD until they were diagnosed. So, why are girls not getting diagnosed until later in life?

Emma Mulhall is an English teacher, literacy consultant and OFSTED inspector. Her daughter was diagnosed at 19 years old with ADHD, yet it was a long journey to get there.

Emma’s daughter displayed neurodivergent behaviour from a young age and struggled in school until they moved her out of state school at 9 years old. She went through diagnosis after diagnosis of anxiety and depression, personality disorders, yet not one teacher nor doctor could recognise that she had ADHD.

“We eventually gave up on state school and the NHS. It is disappointing that you can’t put your trust in the education and health system, particularly as I am part of that.” Emma said.

“She couldn’t cope with noise or a lot of people. She suffered with rejection dysphoria and awful sleep issues right from a young age.”

Instead of recognising ADHD in Emma’s daughter, teachers called her out for forgetting equipment and missing deadlines.

“She is, and was, always so bright. I said I don’t care if she forgets her pen, look at the work she produces.”

After studying Psychology at university, Emma’s daughter made a self-diagnosis of ADHD.

She was referred for urgent diagnosis at 19 years old yet after being frustrated with being on the NHS waiting list, Emma’s family decided to take the private option.

During the diagnosis, Emma and her daughter found that many of the questions were geared towards the stereotype of boys who have ADHD.

For example, they asked at home did you jump up and down on the sofa?

Emma’s daughter simply replied “No, because that is not socially acceptable.”

This is what is known as masking. Masking means to intentionally shift your behaviour to hide your differences.

When they can’t sit still, girls with ADHD tend to fidget in a more subtle way compared to boys who stereotypically run around, disrupting the classroom or wherever they may be.

Often masking can be exhausting. It is keeping up an appearance in public. This can lead to changes in behaviour once home from work or school. They may seem disengaged from conversations at the dinner table, or they may display emotional outbursts, as girls with ADHD have trouble processing and expressing their emotions.

This act of masking could be a reason why girls are less likely to be diagnosed in comparison to boys.

Attachment Therapist Fiona has met many young women with ADHD over the years working in schools, and in Children and Adolescent Mental Health Services, including specialist, private and secure units.

“I could suggest that the boys are unable to mask as they show us outward behaviour that something is wrong. Girls develop the capacity to express themselves verbally a lot sooner than boys.

Within primary school there are fewer girls diagnosed compared to secondary school, but still very low numbers compared to boys. Yet around 30% of the female adolescents in secure units will be given a diagnosis whilst there. To be diagnosed at a tier 4 stage of course must indicate girls are falling through the net and so the ‘masking’ is successful.” she said.

Whether girls have been overlooked for a diagnosis of ADHD, or diagnosed but have been failed by not having it managed correctly, they often face more complex issues as they grow older.

“My wider experience is that the girl’s behaviour either becomes more anti-social or they retreat and are unable to function properly in society. In the case of anti-social behaviour, they are often the life and soul of the party but, as it is severe, they are more likely to end up in forensic services.

They can often hold down a job but have unsuccessful relationships, feel isolated and sometimes suffer with depression, anxiety, self-harm and develop suicide ideation.

In the older adolescent girl, they may present with the more challenging things like shouting back at teachers, being excluded often and, of course, these girls will be risk takers, like fellow males with ADHD. However, the previous more masked presentation we talked about will do things like breakdown in the class, need to go somewhere quiet, find environments overwhelming. They may hide under the table and literally not come out.”

Fiona says that the biggest difference is that behaviours in boys start very early in some cases.

“Or better is that we ‘see’ the behaviour, whereas we don’t see the cry for help from girls. By the age of 7 behaviours of boys are antisocial in the classroom. They are physically challenging, running out of school, fighting, throwing chairs or furniture, tearing displays off walls – I have been there, done all this. The same destructiveness will be seen at home.”

This behaviour would be highly unusual for a girl to display at this age.

“If a girl in primary school was presented to me like the above then I would question whether a very serious trauma has taken place. Presentation of girls is mainly relational in nature. Finding social interaction too complex to navigate which means they can only withdraw. These compound others experience of them which then leads to bullying. Billy no mates scenario. Educational attainment suffers but teachers don’t really understand why this is happening.”

Constantly burnt out and struggling to prioritise tasks, Sophie Bell was eventually diagnosed with ADHD at the age of 27.

“I have found quite a few challenges, especially since leaving school. University was a massive struggle, particularly in second year.”

Sophie showed all the traits of ADHD from when she was a student, yet she was another woman with ADHD who fell under the radar.

“My handwriting was unreadable, I had no co-ordination in PE, no organisational skills.”

Sophie grew up with a parent who is an SEN teacher and 6 half siblings all diagnosed with ADHD. With many neurodivergent friends, Sophie looked more into ADHD and neurodiversity to support her friends. From that came a life changing self-diagnosis.

“It doesn’t excuse my messy room or disorganisation, but there is a genuine reason for it.”

Alongside the reassurance for struggles, Sophie’s ADHD diagnosis also helps her understand how she can excel in many tasks.

“Yesterday I made a whole interactive map for work in an hour. Everyone was like how, what…?”

Like Emma’s family and many others, Sophie struggled with getting her diagnosis through the NHS.

“In December I spoke to a GP, and six months later I am still waiting for medication.”

Whilst Sophie is content with just the reassurance from her diagnosis, other women need the medication to help them.

After diagnosis, Emma’s daughter has been able to receive medication.

“The medication is life changing.” Said Emma. “When she takes it, she says her head goes completely quiet. She says is this what a normal person’s brain is like?”  

Waiting endlessly for referrals and medication after years of being overlooked in the classroom and society, women with ADHD have been left to suffer in silence. But more women are speaking up.

“Social media is helping a lot. Information is a lot more accessible these days and people are more willing to talk about their own experiences.” said Sophie.

Even celebrities have been speaking up about their diagnosis of ADHD, such as Loose Women presenter Nadia Sawalha and Sue Perkins. Like anything, once an influential person speaks out about something, it spikes a trend. In this case, the trend has become women both self-diagnosing and seeking referrals for ADHD, sinking the NHS mental health services further under.

Consultant paediatrician and co-founder of ADHD UK Dr Max Davie said “I think it’s probably as big a year as we’ve ever had. We are seeing a lot more people from all walks of life seeking a diagnosis later in life, particularly women,” he said. “At the same time waiting lists have gone through the roof. NHS services have been swamped for a while and private providers are also closing their lists – there are wildly inadequate services for ADHD diagnosis, particularly for adults.”

This further adds to the issue of women not being diagnosed with ADHD and overlooked in society, painting a not so bright picture of the future.

Emma feels attitudes need to change. “The general population’s idea of mental health is to do some yoga.” she said.

“I don’t see ADHD as an issue, I see society as an issue.”

Feature image by Natasha Pearce.