Why are women less likely to be diagnosed?
For both ADHD and autism, the criteria for the disorders were formed based on observations of boys. Firstly, because in those days only boys attended school. Secondly, because boys had more externalised symptoms than girls: something that could be seen from the outside. Hyperactivity, banging their heads against the wall, not answering the doctor’s questions can be seen from the outside. But the internalised criteria (racing thoughts, inner restlessness, inability to relax) were merely not taken into account and were not known about. Girls have more internalised symptoms – it’s harder to notice those, and they are less taken into account in diagnosis.
There have been some great studies of underdiagnosis of girls in recent decades. For example, the same cases of children with ADHD were read to school teachers with both girls’ and boys’ names. Where there were boy’s names, the teachers expressed a desire to refer the child to a psychologist, while the ‘girl’ cases were ignored. Another neat study was on autistic children, where researchers followed 15,000 twins. With the same problems, boys were diagnosed much more often than girls (Francesca Happe and colleagues).
The lack of a correct diagnosis has consequences:
- Severely reduced self-esteem, even compared to men of the same neurotype
- Difficulties in work and relationships
- Increased risk of codependent relationships
- Risk of comorbid disorders
- Burnout and exhaustion from masking.
Features of ADHD in women
As mentioned above, there are more symptoms that are not visible to others. On the one hand, this is due to gender socialisation, women are more likely to be expected to suppress everything (you twitch inside and run in circles on the ceiling, but because of the habit of suppressing everything and sitting quietly, it is almost invisible from the outside). Or you get angry and boil inside, but you don’t express it on the outside). On the other hand, women are more likely to have the inattentive subtype of ADHD than the hyperactive subtype.
Women are more prone to comorbid anxiety and depression than men, so psychiatrists are more likely to attribute all women’s problems to anxiety and depression.
A tendency to perfectionism and comorbid obsessive-compulsive disorder can also complicate the diagnostic process.
Women with ADHD have fewer symptoms overall according to DSM criteria, but the same level of distress.
In addition, women tend to mask and suppress more, suffer more from emotion dysregulation, and the menstrual cycle also affects the manifestation of symptoms.
What ADHD in women may look like
- Difficulties with time management, although women often have more pressures and demands on them than men.
- Difficulties with organising themselves and the space around them.
- Frequent feelings of low mood (not to the point of depression, but along the lines of ‘I must be missing something’).
- A history of anxiety and depression.
- Difficulty managing money.
- Sensory overload (more common in women than men).
- Somatic complaints such as headaches, migraines, stomach aches and nausea (also due to sensory overload).
- Sleep problems.
- High-risk behaviour – speeding, extreme sports, etc.
- Tendency towards addictions.
- Hyperactivity often manifests as self-harm or skin picking, nail biting, lip biting, hair pulling. This is not done as a punishment, but because it is the only thing available.
Features of autism in women
Girls tend to have less stereotypical behaviour, less specific, noticeable interests than boys. They may be interested in the same Barbies and ponies as neurotypical girls, but the immersion of interest will be more profound and specialised. For example, an autistic girl may be just as interested in a teen series as a neurotypical girl. But an autistic girl is more likely to know everything about the characters but nothing about the plot, for example. And show little interest in talking about anything beyond that.
What can a woman be diagnosed with instead of ASD? If ADHD is present, the diagnosis favours ADHD because it is easier to observe. The chances of being diagnosed with OCD or an eating disorder are high. People with ASD are selective about what they eat and follow strict rules – hence the inference of restrictive behaviour and, for example, anorexia (which can actually be comorbid with autism).
What autism in women may look like
- A tendency to rely on other people to act and speak for you.
- Dependency and co-dependency in relationships – because it’s generally unclear what to do with the outside world, and it’s easier to adapt with the help of someone else. Where an autistic boy won’t do anything, a girl will cop out, try by imitation, ask others to do it for her.
- High sensory sensitivity.
- The presence of passionate but limited interests.
- Difficulty making and keeping friends.
- Conversation limited to a few topics of interest.
- A behaviour that appears outwardly shy, quiet and passive.
- Problems controlling emotions.
- High sensitivity to rejection.
- Presence of symptoms of anxiety and co-occurring disorders in general.
And lastly, about masking
Masking is common in both autistic and ADHD women. Women are good at adjusting to high demands, but adjusting doesn’t mean adapting. Adaptation is exactly what doesn’t happen. A woman who is forced to participate in small talk at work doesn’t hate it any less, but she sees that others approve of her participation and suppresses her natural desire to leave immediately. And she can feign interest in colleagues’ holidays so well that others have no idea.
You may have guessed how much effort it takes to constantly check yourself and worry about the outcome. This leads to burnout, exhaustion, depression and relapse of all that can relapse.
This is why working on masking is as important a goal in therapy as, for example, working on sensory sensitivity.