Ellen B. Littman is a clinical psychologist who has specialized in understanding neurodiverse people for more than 30 years and is the author of Understanding Girls with ADHD. In a recent podcast produced for ADHD Awareness Month, she spoke of the reasons why more boys than girls are being diagnosed with attention deficit hyperactivity disorder.
According to Littman, the history of ADHD diagnosis plays a role.
At the beginning of the last century, parents struggling to manage their unruly boys referred them to a clinic. Hyperactive and impulsive girls, however, were considered shameful and were not referred. Thus, even to this day, the criteria used to diagnose ADHD are based on studies analyzing the behaviors of boys who, unlike girls, are more likely to exhibit hyperactive and impulsive tendencies. These criteria — those that are readily observed — still skew the bias toward recognizing ADHD in boys today, Littman notes.
It wasn’t until 1980 that the inattentive version of ADHD — that which is more common in girls than boys — was recognized by the psychiatric community. And because the inattentive form is less disruptive in, say, a classroom, those with this form of ADHD are often overlooked.
Girls with the combined form of ADHD (hyperactive and inattentive) are often referred to by their teachers as “chatty.”
“They can be very precocious and sometimes come up with ideas for a group in a very charismatic way. But they are even more emotionally reactive and there’s a lot of mercurial feelings of being really silly, and then they’re really angry, and then crying, and a lot of drama and slamming doors …” Littman says.
Omigosh, when I heard that, it brought back so many memories of my childhood wrought with good grades, charmed (albeit frustrated) teachers and lots and lots of crying and door-slamming. But I was a child of the 60s and 70s so I never really met the criteria of ADHD back then. Fast forward to today…
A consensus paper published in BMC Psychiatry in 2020 (available on the U.S. National Institutes of Health website) was signed by nearly two dozen ADHD experts and states (emphasis my own):
“There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males.”
The British experts go on to say:
“It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalized presentation that is common in females.”
Furthermore, Littman says that until very recently the cut-off for diagnosing ADHD in children was age 7. If your symptoms didn’t show up by then, you were not evaluated. Even now, she says, the cut-off is 12 in the Diagnostic and Statistical Manual (DSM) — the guide written and adopted by the American Psychiatric Association. These parameters dismiss girls whose puberty-fueled hormonal changes activate ADHD symptoms.
ADHD impacts the level of the female reproductive hormone estrogen which affects cognition, mood and sleep. Often then, girls with ADHD don’t begin to experience the symptoms of their neurodivergence until they reach puberty, or in my case, perimenopause.
Case, in point: I wasn’t diagnosed until I was in my 50s — the hormonal changes of perimenopause (waning estrogen levels, for one) triggered the symptoms in such a way as to hobble my ability to perform my job as a daily newspaper reporter — an award-winning one at that. That’s a story in and of itself but I’ll save it for another time.
So, if you are a woman and you suspect you might have ADHD but were never diagnosed, you could be right.
Happy ADHD Awareness Month. Here’s a link to an online expo with lots of resources that might be helpful.
I’d love to hear from you — whether you know you have ADHD, suspect it or know someone who does, say hi in the chat. And don’t forget to be kind to yourself and others.
Until next time, hugs!
Very informative article @Jodi, thank you for teaching me x :)
Fascinating, Jodi. Really making me think.