ADHD in Women: Why is it often missed?
How do ADHD present differently in men and women? What are the implications of these differences, and why is it important for doctors and the public to be more aware of this? Dr Tay Kai Hong, Psychiatrist from Private Space Medical, shares his insights and more in this 5-question series.

1. What is ADHD?

ADHD stands for Attention-Deficit Hyperactivity Disorder. Globally, it is estimated that 5% of children are born with ADHD, a brain condition characterised by inattention, impulsivity and hyperactivity. About half of the children with ADHD will have symptoms persist into adulthood.
ADHD brains are driven by novelty, interest, urgency and a sense of challenge, rather than by traditional notions of "responsibilities" and "priorities". Because many modern-day institutions value organisational skills and efficiency over spontaneity and creativity, people with ADHD may struggle to thrive in schools and workplaces. This can lead to a low self- esteem, anxiety, and other mental health difficulties.

2. What are some symptoms to look out for? Do they present differently in women?

There are 2 clusters of symptoms to look out for – symptoms of inattention, and symptoms of hyperactivity/impulsivity.
Symptoms of inattention include carelessness, forgetfulness, distractibility, and a persistent difficulty in sustaining attention. There is a chronic tendency to procrastinate on tasks which require sustained mental effort, and great difficulty in organising tasks, activities and physical spaces. Because of poor time management, deadlines are often missed. The person may appear to be daydreamy and often preoccupied in his or her own thoughts, even when spoken to.
Symptoms of hyperactivity/impulsivity include restlessness, being unable to stay in one’s seat or stay in queue, excessive talkativeness, frequently interrupting others, and appearing to be tactless and impatient in social interactions. For example, the person with ADHD may blurt out answers even before the question is asked, because he or she is not able to resist the impulse to talk.
ADHD symptoms start from childhood and are persistent and impairing, such that the person’s life is adversely affected. The symptoms may affect the person’s academic achievement, work performance, social relationships or leisure activities.
Women with ADHD tend to manifest predominantly symptoms of inattention, which are more subtle and difficult to detect compared to symptoms of hyperactivity and impulsivity. They may appear daydreamy and caught up in their own thoughts. Their carelessness and forgetfulness may be overlooked as personality traits or attributed to a lack of effort. Symptoms of inattention may be conflated with anxiety or depression. Because women with ADHD rarely show symptoms of hyperactivity, the symptoms are “hidden” and may go unnoticed.

3. What is the process for diagnosing ADHD in Singapore?

Locally, assessment and diagnosis of ADHD are typically done by psychiatrists. In younger children, developmental paediatricians are well-versed in evaluation of ADHD. The specialist will take a thorough history from family members and perform a mental state examination through observation and conversation.
It is essential to assess for other conditions such as anxiety, depression, addictions or other developmental or learning disorders including autism and dyslexia. Historical accounts from teachers in report books are useful to get an idea of how the person was as a young child, and to establish that symptoms and related impairment were present from childhood. In complex or borderline cases, a more detailed neuropsychological assessment may be necessary. This is performed by a neuropsychologist and will take a longer time.

4. What is the usual treatment offered for ADHD in adults?

Treatment usually comprises a combination of lifestyle strategies and medications. Habits which may prove helpful for ADHD include:
  • Break up big tasks into smaller ones to make work more manageable and less daunting. This can help reduce the tendency to procrastinate.
  • Write down a to-do-list and set arbitrary deadlines to sustain motivation to progress towards a
  • Use time-tables, calendars, and arbitrary deadlines to give more structure to the day.
  • If workspaces are too messy, take time to declutter and organise the space to facilitate clarity of thought and reduce distractions. Put your phone away while working.
  • Balance between the need for structure and routine, with the ADHD brain’s need for stimulation,
    novelty, variety and challenges. Swinging from one extreme to another is seldom sustainable.
  • Exercise daily or at least three times per week. This will help people with ADHD to relax, sleep
    better, and improve their focus.
  • If you have to procrastinate, use positive procrastination. This involves taking short breaks from
    work to do other productive tasks instead of doing mindless and unproductive activities.
    Changing things up keeps the ADHD brain engaged and can improve productivity.
Medications are proven to be safe and effective for ADHD when used in conjunction with lifestyle strategies. Methylphenidate is the first-choice medication in Singapore and is a prescription-only medication available at most mental health clinics and restructured hospitals. The medication increases levels of certain neurotransmitters in parts of the brain which governs executive functioning, impulse control, and focused attention, thereby strengthening the control centre of the brain.
Side effects of medication includes suppression of appetite, weight loss, increased jitteriness, anxiety, insomnia and headaches. There are different formulations of the medication. They vary in terms of their duration of action, which can last from 4 hours to 12 hours.
Medication is not a cure for ADHD, but a tool to manage symptoms. ADHD symptoms often improve with age as adults with ADHD implement new habits and put in place routines to manage the symptoms. This happens over time as they learn by trial and error what works and what does not. The price of missed diagnosis and delayed treatment, however, may be lost opportunities and unfulfilled potential in the most productive and fruitful years of a person’s life.

5. Why is ADHD often undiagnosed or misunderstood in women?

Firstly, because women with ADHD rarely show symptoms of hyperactivity, the symptoms are “hidden” and may go unnoticed. Women with ADHD tend to manifest predominantly symptoms of inattention, which are more subtle and difficult to detect. They may appear daydreamy and caught up in their own thoughts. Their carelessness and forgetfulness may be overlooked as personality traits or attributed to a lack of effort.
Secondly, symptoms of inattention may be conflated with anxiety or depression, which do occur at higher rates in women than men. Indeed, anxiety disorders and depression commonly co-occur with underlying ADHD. They may in fact be a secondary consequence of ADHD-related impairments. Imagine the immense anxiety generated due to constant procrastination of major assignments to the very last minute. Clinicians may diagnose the anxiety disorder and overlook the possibility of underlying ADHD. In other words, the higher prevalence of depression and anxiety in women tend to mask and overshadow more subtle ADHD symptoms.
Furthermore, diagnostic tools for ADHD were originally designed to detect ADHD in young children, particularly hyperactive boys with disruptive behaviours in the classroom. These diagnostic tools are not perfect and have their limitations when directly applied to an adult female population. ADHD in women is less well-understood and research in the field is ongoing. It is important for doctors and patients alike to reconsider the historical perspective of ADHD as a purely behavioural problem, and pay more attention to the subtler and more internalised, but no less impairing, experiences of women with ADHD.
Dr. Tay Kai Hong
Psychiatrist, Medical Doctor
Private Space Medical