ADHD in women: signs, symptoms, why it is missed and how to get assessed

The NHS describes symptoms in three areas: being inattentive, having high energy levels (being hyperactive) and having difficulty controlling impulses. In adults it lists inattentive signs such as being easily distracted or forgetful, finding it hard to organise your time, finding it hard to follow instructions or finish tasks, and losing things often like a wallet, mobile or keys. Hyperactive and impulsive signs include having a lot of energy or feeling restless, being very talkative or interrupting conversations, and making quick decisions without thinking about what might happen.

Most people have symptoms of both types, though some show only one, the NHS says. It also says ADHD is thought to be recognised less often in women than men, perhaps because women with ADHD more commonly have inattentive symptoms, which can be harder to recognise than hyperactive symptoms.

In an article by the chair of the ADHD Foundation, a GP, females with ADHD are described as generally reported to have fewer hyperactive and impulsive symptoms and more inattentive symptoms than males, and to be less likely to be disruptive, so they can fade into the background. It lists signs and impacts that may be seen in females, with the caveat that not everyone has everything and that some signs can relate to other conditions.

• Starting something and not finishing it, then feeling bad about it.

• Working much harder to achieve things, with cycles of burnout.

• Drifting off while in conversation, or being distracted by other conversations around you.

• Impulsive decisions, such as saying yes and then regretting it.

• Being fidgety, doodling or finding it hard to sit still or stay quiet for long.

• Sleep disturbance, a busy brain and rumination.

• Feeling anxious, losing possessions and feeling disorganised.

• Poorer sense of time passing, and working hard to hide mistakes and camouflage difficulties.

The ADHD Foundation article suggests several reasons. Teachers and health professionals may know less about how ADHD presents in females, so it can be missed until adulthood. Teachers more often refer boys than girls for treatment even when showing equal levels of impairment. Coexisting problems can also overshadow ADHD: it says that females tend to show more internalising difficulties, which are not always seen by others, and that low mood, emotional lability and anxiety may be especially common in females with ADHD, so these conditions are diagnosed first.

The same article reports that people often feel both relief and anger at gaining a diagnosis in adulthood, and that years of anxiety, depression, cycles of burnout and sleep difficulties may have been the norm. It is written by the chair of a charity and reflects an advocacy and clinical perspective rather than a formal guideline, so treat the broad picture as informative rather than as measured statistics.

The NHS says that at an appointment a GP may consider other conditions that could be causing your symptoms, such as autism, Tourette's or anxiety, and that people with ADHD often have other conditions too, such as depression, anxiety, addictions or a learning difficulty such as dyslexia. It also says that anxiety and depression can make ADHD symptoms worse, and that people with ADHD may be more likely to have mental health issues and are at higher risk of suicide. If you feel you want to end your life, the NHS says it is important to tell someone and that help and support is available right now. In an emergency call 999.

The NHS says that if your ADHD symptoms are affecting your studies, work or relationships you should make an appointment with a GP to find out what support is available. The GP will ask about your symptoms and how they affect your life and may decide to refer you for an assessment with a mental health professional specialising in ADHD. If you were diagnosed in childhood and need help now, it says to talk to your GP about a referral.

At the assessment, the NHS says an ADHD specialist such as a psychiatrist will ask about the history of your symptoms, especially whether they began in childhood and how they affected you at school, and about work and education, family and friends and medical history. They may want to contact someone who knows you well, such as a family member or close friend.

Waiting times vary and may be several months or years. In England, the NHS says you may be able to find a clinic with a shorter waiting list through your GP using the Right to Choose scheme, which allows you to ask for an NHS appointment at any clinic, including a private one, if it provides ADHD services for the NHS.

NICE Clinical Knowledge Summaries says ADHD should be suspected if the core symptoms of hyperactivity, inattention and/or impulsivity have been present since childhood, are age-inappropriate and result in significant psychological, social and/or educational functional impairment. It says symptoms typically appear in children 3 to 7 years of age but may not be recognised until after 7, especially if hyperactivity is not present, and that they should be present for at least 6 months and pervasive in at least two settings such as home, school, social situations or work.

It also says other causes for the symptoms should be excluded, such as learning difficulties, anxiety, depression, abuse, trauma, or rarely medical conditions such as unsuspected hearing problems or epilepsy, and that the diagnosis and treatment of ADHD requires referral and assessment by a specialist.

The NHS describes management as including lifestyle changes, changes at work and medicines, depending on symptoms and how they are affecting you. Lifestyle suggestions include physical activity you enjoy, good sleep with a regular bedtime and a quiet dark bedroom, avoiding screens, caffeine, sugar and alcohol close to bedtime, and a healthy balanced diet with regular mealtimes.

At work, college or university you can ask for reasonable adjustments, which may include a personalised workspace in a quiet area, written as well as spoken instructions and help from another person to plan and structure tasks. ADHD medicines must be started and monitored by an ADHD specialist; the NHS gives methylphenidate and lisdexamfetamine as examples, and says you may need to try more than one. A GP can take over prescribing only under a shared care agreement. Talking therapies such as cognitive behavioural therapy (CBT) or mindfulness may be recommended.

The NHS also says you must tell the DVLA if your driving is affected by your ADHD or your ADHD medicine, or both.

The NHS suggests making time for physical activities you enjoy, noting that exercise can be a good focus for energy and also helps reduce symptoms of anxiety and depression. It advises getting enough sleep with a regular bedtime and a quiet dark bedroom, avoiding screens, caffeine, sugar and alcohol close to bedtime, and aiming for a healthy, balanced diet and regular mealtimes.

NICE Clinical Knowledge Summaries says people with a diagnosis of ADHD should eat a balanced diet and take regular exercise, and that eliminating artificial colourings and additives from the diet is not recommended unless there appears to be a link between certain foods or drinks and a person's ADHD symptoms.

A diagnosis can change how past difficulties are understood. The ADHD Foundation article describes feelings of relief, and also frustration at not having achieved what people now see as their potential. National support organisations listed by the NHS include ADHD UK, ADHD Adult UK and AADD-UK, which offer information and peer support. Speaking to friends and family about your ADHD, as the NHS suggests, can also make it easier to explain what helps you.

On the NHS, the route usually starts with a GP, who may refer you to an ADHD specialist. The NHS says waiting times vary and may be several months or years, and that in England you may be able to use the Right to Choose scheme to ask for an NHS appointment at any clinic, including a private one, if it provides ADHD services for the NHS.

Some people arrange a private assessment. Check that the clinician is a specialist in ADHD, and ask how medicine prescribing and monitoring would continue, since the NHS says ADHD medicines must be started and monitored by a specialist and a GP can only take over prescribing under a shared care agreement.