You are probably aware of the discussion ‘out there’ about the increase in adults being diagnosed with ADHD and in particular, women in their 40’s being diagnosed with ADHD. This is accurate. And I’ll add, the fact that this is being discussed so widely is a really good thing and I hope it continues.

However, there are times when this topic is raised in such a way that it implies this increase reflects a ‘trend’ i.e. everyone is jumping on the ADHD bandwagon. That’s not helpful and no, not everyone is jumping on the ADHD bandwagon.

TikTok does have something to answer for because the misinformation is rife and prompts many people to 'self-diagnose’. Self-diagnosis is not the critical issue here. The issue is that it’s often ill-informed; particularly when the information is from social media. As a result, we can all ‘be a little bit ADHD’. True, we can lose things and have trouble concentrating and a bit disorganised from time to time. But actually, that really invalidates the challenges that ADHDers face in a multitude of ways, EVERY DAY. So please don't say it. It’s really uncool.

Putting TikTok diagnoses aside, there IS an increase in people, particularly women, being diagnosed as ADHD ‘late’ in life - and accurately so. Surely this is not just a matter of ADHD being such a ‘trendy’ thing to have, that every Michelle, Kylie and Nicole is desperate to diagnose herself with it? Google told me they were the most popular names in Australia in 1974; the year I was born.

So what IS going on? Why is there an increase?

Put simply, we didn’t know what we didn’t know.

Why? Why Didn't We Know What We Now Know?

I’m going to start with what is a familiar rant of mine. The dearth of health / psychological / neurodevelopmental research that includes females and the limited research undertaken (because it’s not been funded) on female-specific conditions. Why? Well in the US, the devastating impacts of Thalidomide led to the introduction of a policy that clinical trials could not be undertaken with women of reproductive age. While this was lifted in 1993 in the US, the drug companies who fund most research did not have to comply. 

Here in Australia, females have also been excluded from research for decades. Not only due to impacts of Thalidomide but also because the menstrual cycle makes females harder to research. Angry yet? Good. Because even though Australia has the National Centre for Sex and Gender Equity in Health and Medicine to tackle this very issue, it's early days and we have a long way to go.

Despite this, over the past 5-10 years we have learned more about women’s health, mental health and neurodevelopmental conditions. And part of what we’ve learned is that the criteria for ADHD (and Autism) lacks the breadth and depth required to fully capture the experience of ADHD. This is particularly true for ADHD in females. 

However, even if we knew this ‘back then’, the rates of diagnosis still wouldn’t match what’s happening now. And that’s simply because ‘back then’ information like this is harder to disseminate. It would have been shared by professionals (slowly but surely) but it would have been far harder to get it into the minds of the everyday person. Now we have the World Wide Web which most people can and do access. And because of this, we are no longer solely reliant on a professional like a doctor or teacher, raising the possibility of something like ADHD with us. Instead, everyday people are exposed to information that prompts us to ask ourselves ‘am I ADHD?’ 

What Didn’t We Know Then That We Know Now?

We simply didn’t know how ADHD tends to show up in females. Given that the research was based on boys, the assumption was made that’s how it would also show up in girls. The diagnostic criteria was set based on that.

But we NOW know that’s not always the case (even for boys). In fact, the ADHD criteria has had a bit of a makeover. Having gone from ADD (Attention Deficit Disorder) to ADHD (Attention Deficit Hyperactivity Disorder) it is now; Attention Deficit Hyperactivity Disorder COmbined Type, Predominantly Inattentive Type or Predominantly Hyperactive Type. That’s a good start but I really hope the changes don’t stop there. Because the criteria itself still doesn’t truly reflect the nuances that are most often seen in females.

Given that we now know that girls and women tend to be more along the lines of the inattentive type, these changes are helpful. In these instances, they tend to be described as ‘daydreamers’ or ‘scattered’ and ‘flaky’. Urgh. I’m not a fan of those terms. 

But what are the nuances?

Well, females can still be hyperactive and impulsive. It just doesn’t ‘look’ the same way as it tends to in males. Instead, females tend to demonstrate their hyperactivity in more subtle ways such as hair twirling, tapping their nails on things or jiggling their legs. Impulsivity often shows up in being chatty, interrupting others when they talk and making inappropriate comments (think foot in mouth). These ‘versions’ of ADHD are less ‘obvious’ to others. 

Because we weren’t aware of this, in those instances where females experienced these challenges, they were often interpreted as signs of anxiety and/or depression. Given the challenges ADHDers face, they do often experience anxiety and’/or depression. However, for many women, these ‘diagnoses’ are incomplete and not surprisingly, treatment is limited in its effectiveness. As a result, women were left believing that they are inherently flawed, to blame, useless, hopeless, defective and simply haven’t tried hard enough. The list goes on and is truly painful to think about.  

There is also what’s known as ‘masking’ which essentially describes the efforts, skills and strategies someone uses to hide their challenges. Females are generally quite perceptive and subsequently more adept at knowing how to mask in order to ‘fit in’. Add to the picture that females are more likely to daydream than be disruptive (because they’re also socialised to be ‘good’ and ‘cooperative’) it's easy to see why ADHD in females has been ‘invisible’ for so long. 

Another Reason Why We Didn’t Know What We Needed to Know (But This Needs to be Highlighted Separately)

Because females have a menstrual cycle. 

Yes. 

Because having a menstrual cycle means that ADHD does not show up consistently. Sure, everyone has ‘good’ days and ‘bad’ days. Including males with ADHD. But females with ADHD, well the ‘good’ days were more frequent for them than it was for the males. And so with that many ‘good’ days, and the perspective at the time, ADHD wasn’t a viable diagnosis.

It seems no one (or not enough important people) thought to see if there was a pattern to their good/bad days let alone if this pattern reflected the menstrual cycle. Eventually, those ‘important people’ listened to the lived experience of ADHDers who told them that their ADHD ‘gets worse at certain times of the month’. 

Because for many females with ADHD, although not all, it often does. And THAT is really important to know.

So yes, we now also know, that there are stages in women’s menstrual cycles where women typically experience an increase in their ADHD challenges and/or a decrease in their capacity to mask and/or a reduction in the effectiveness of their compensatory strategies and/or a reduction in the effectiveness of their ADHD medication. 

Can you guess when that might be? Yep. At times when their oestrogen has declined. 

What neurotransmitter is relevant to ADHD? Dopamine. 

Hmmm so oestrogen might be, maybe, probably is important to dopamine?

It seems that way. And really, we know that females have oestrogen receptors throughout their entire body. It’s clearly important generally AND yes important to dopamine and therefore, ADHDers.

Essentially, dopamine plays better when its friend oestrogen joins in - and fully. When oestrogen plays in a half-hearted manner, dopamine just doesn’t play so well either.

So it’s no surprise that the challenges of ADHD (where dopamine plays a critical role) are magnified during perimenopause (when oestrogen is fluctuating but overall, is declining). 

It’s also very reasonable to assume that a stage in a woman’s life where her oestrogen is fluctuating and declining for such a long time (perimenopause) and which has been identified as characterised by distressing and stressful life events (midlife stressors and losses) so as to overwhelm her capacity to cope (compensatory strategies) and impede her ability to pretend she’s got it all sorted (masking) to such a degree that ADHD reveals itself for the first time. 

Time to Wrap it Up

So here’s my key points as to why there’s been an increase in midlife women being diagnosed with ADHD;

1. Research hasn’t included females until quite recently. We simply didn’t know how many conditions, including ADHD, tend to show up in girls /women. We assumed it ‘looked’ the same as it does for boys/men. It doesn’t and we know that now.

2. As such, when the current generation of midlifers were children and adolescents, they simply weren’t diagnosed because they didn’t fit the ‘picture’ of ADHD at that time. 

3. We now have a more nuanced understanding of how ADHD is experienced and expressed in females which means it is more visible now.

4. Information is accessible to most people now and as such, there is a greater chance of recognising themselves (or a loved one) in that information.

5. We know that ADHD is often less ‘visible’ in females because they are more

1. likely to be inattentive type (which is less ‘in your face’), 

2. adept at developing compensatory strategies 

3. able to mask

4. inconsistent in their ‘presentation’ i.e. likely to experience fluctuations in their ADHD challenges 

5. likely to be misdiagnosed with anxiety / depression

6. We know that dopamine is relevant to ADHD and that it works best, when there’s high levels of oestrogen. We know that during perimenopause our oestrogen fluctuates but that there is, overall, a decline.

7. Midlife is a particularly difficult time, characterised by significant events, many of which cause stress and grief. It's a time when women’s previously effective compensatory strategies simply can’t keep up and when their capacity to mask is impaired because there’s just too much going on within and outside of her. 

If you think you may be an ADHDer and have a hunch OR can clearly identify struggles with attention / concentration and hyperactivity / impulsivity at different stages of your life (or your menstrual cycle) AND/OR have a family member (particularly a parent or child) who has been diagnosed, then it might be worth your while to seek an assessment. That is, if you want to know ‘for sure’. Don’t rely on Tik Tok. Don’t ask your friend. Don’t even rely on this article alone. Because as many ADHD professionals say, ‘if you’ve met one person with ADHD, you’ve met one person with ADHD. And I’ll add, that person does NOT define the rest of us.

Raising awareness and deepening the understanding of perimenopause and ADHD is crucial—not just important—for timely and effective support. If you suspect you might be one of the many perimenopausal women with ADHD, check out the other articles in this ADHD and Perimenopause Series www.allabouthercentre.com.au and/or seek out a healthcare provider who knows this space well. Feel free to reach out to me via www.allabouhercentre.com.au if you need guidance as to how to go about being assessed or ongoing support.