When It Comes to ADHD in Women, There's Still So Much to Learn

For girls and women living with attention-deficit/hyperactivity disorder (ADHD), and the clinicians who treat them, there are still more questions than answers regarding how the condition evolves over the lifespan.

In this exclusive Q&A, Michelle Martel, PhD, full professor and chair of the psychology department at the University of Kentucky, shares preliminary findings from her lab’s research on how hormone fluctuations throughout the female lifespan may influence the way ADHD uniquely manifests in this patient population.

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Editor’s note: This interview has been lightly edited for length and clarity.

Psych Congress Network (PCN): How do we know that ADHD is underdiagnosed or misdiagnosed in women, and what might be contributing to this trend? 

Michelle Martel, PhD: Recent data shows that ADHD in women exhibits dramatic changes across reproductive periods like adolescence and across the menstrual cycle. Such fluctuations in ADHD symptom levels make it more challenging to accurately diagnosis in girls and women. In addition, many common comorbid presentations (e.g., depression, anxiety, borderline personality disorder, eating disorders, substance use) also vary with hormone levels and by reproductive period. Most assessments do not even consider the reproductive period, menstrual cycle phase, or use of hormonal medications, leading to insensitive information that likely overlooks these risky periods in women.

In contrast, the hyperactive symptoms and comorbid disruptive behavior disorders more often exhibited by males are more noticeable, more stable, and easier to assess behaviorally. 

PCN: What are some of the most significant challenges specific to diagnosing ADHD in women, and how do they differ from those in males?

Dr Martel: ADHD in women often presents differently, more likely through inattention and associated impairment instead of the more visible hyperactive symptoms, making the disorder less obvious and more difficult to assess. In addition, hormone-based fluctuations make it more difficult to assess ADHD in women accurately, particularly given that current assessments do not usually ask for this information. 

PCN: How do hormonal changes across the lifespan (e.g., puberty, pregnancy, menopause) influence ADHD symptoms in females?

Dr Martel: We largely do not know how hormonal changes across the lifespan influence ADHD symptoms. New data from our lab shows that hormones underpinned fluctuations in ADHD symptoms across the menstrual cycle beginning as early as late adolescence, but earlier periods have not been evaluated for these effects, and there is almost no data on these questions during pregnancy, the postpartum period, or perimenopause or menopause. 

PCN: What are some unique symptoms or behavioral patterns of ADHD that clinicians should be aware of in females?

Dr Martel: Clinician should pay more attention to ADHD-associated impairment, inattentive symptoms, and comorbid conditions (e.g., depression, anxiety, substance use, emotional eating, borderline personality disorder) in women (vs. men). 

PCN: Any misconceptions on this topic that you’d like to clarify for our audience?

Dr Martel: Women have been historically understudied but advances in personalized medicine will require more attention to this group's needs. 

Michelle Martel, PhD, is a full professor and the new chair of the psychology department at the University of Kentucky. Dr. Martel has a federally funded research program on ADHD and transdiagnostic externalizing problems, including substance use and conduct disorders. The goal of her clinical research program is to elucidate sex differences and hormonal mechanisms of externalizing psychopathology across the lifespan. Her innovative work on hormonal effects on impulsivity is leading to cutting-edge advances in personalized assessment and treatment of women’s health. She has published over 90 high impact peer-reviewed articles, as well as three books disseminating her work to clinicians. She is also a licensed child clinical psychologist who assesses and treats a wide variety of child clinical problems in private practice, hospital, and academic settings with particular expertise in assessment and treatment of externalizing problems between early childhood and young adulthood.

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