Autism and ADHD in Adult Females
Attention Deficit Hyperactivity Disorder (ADHD)
Attention-deficit hyperactivity disorder (ADHD) is defined as a pervasive neurodevelopmental condition which impacts on the ability to control attention resulting in chronic difficulty with completing cognitive processes effectively. The DSM-5 specifies that ADHD comprises of 3 traits namely Impulsiveness, Hyperactivity and Inattentiveness.
Although much of the following may be more related to females, there are crossovers in presentation to many males as well. This predominantly relates to those who do not present with intentional disruptive behaviours, conduct disorder or oppositional defiance disorder which can be comorbid with ADHD and are assessed at the same time for young people.
The stereotypical view of ADHD involves excessive energy levels, impulsiveness, constant talking and an inability to be still and quiet. There are also comorbidities including oppositional defiant disorder and conduct disorder which are considered when assessing and diagnosing particularly children. The latter two are also considered to be disruptive behaviour disorders similarly to ADHD. A person with a diagnosis of ADHD is more likely to be diagnosed with Conduct Disorder that someone without ADHD, however importantly a person with ADHD is not typically aggressive and the majority do not have Conduct Disorder.
Aggressiveness, violence, lack of empathy and being antisocial are characteristic of conduct disorder. The two distinct conditions (ADHD and Conduct Disorder) do appear to have been confused or somewhat amalgamated at times so common perceptions surrounding ADHD may be quite inaccurate.
Every person is unique, and this is the same for ADHD individuals and it is equally as important that a person’s strengths are acknowledged and harnessed. It is also important to consider each person’s background and experiences. ADHD has no bearing on intelligence level and has numerous positive attributes. Irrespective of whether a person is neurotypical or neurodiverse everyone experiences positives as well as difficulties.
ADHD has attracted many negative connotations which engenders fear of the condition for many as well as trepidation in seeking a diagnosis due to the stigma. Perceptions of ADHD appear somewhat outdated and often underestimate the many positives of ADHD such as:
the creativeness
the imagination
successes from inherent hyperfocus
the enhanced empathy
the generosity
the strong moral code or sense of right and wrong that promotes a protective nature towards others and a desire to help and support people to ‘make things better’
the benefits of more energy
the inventiveness
being adept with multitasking both in mind and physically
the abstract ‘out the box’ thinking
the humour,
the capacity to problem solve
the ability to process information and stimuli rapidly
the resilience, sensitivity, spontaneity
the passion and motivation
the compassionate nature and the absolute tenacity
Based on DSM-IV screening of 11,422 adults for ADHD in 10 countries in the Americas, Europe and the Middle East, the estimates of worldwide adult ADHD prevalence averaged 3.4% (Fayyad et al. 2007)
Many individuals but predominantly females are often misdiagnosed or diagnosed as adults with as few as 25% being accurately assessed as having ADHD.
Evidence suggests that males are more likely to be diagnosed than females, however, female and male ADHD presentations significantly contrast and generally emerge at different developmental stages. In contrast to males, female symptoms actually increase with hormonal changes (oestrogen) and as such, traits may not initially manifest or be identifiable until somewhere between 7 and 10 years old or even much older!
Misconceptions regarding female ADHD are primarily attributable to how ADHD was studied and subsequently characterised five decades ago. ADHD, being classified typically as a male child condition was essentially determined by the research participants being hyperactive young males, which consequently derived the diagnostic criteria. Hence this criteria was, and remains not befitting for females as no differentiation was considered and the resulting preconceptions about ADHD being simply applicable to hyperactive male children frequently prevails. Equally there are indications that information regarding males with ADHD may also be outdated.
Frequently individuals’ report being diagnosed with different conditions prior to ADHD which may have some overlap in symptomology. ADHD is commonly misdiagnosed as anxiety or depression although some express, they don’t feel that such diagnoses fully explain how they feel.
Other conditions can also include:
trauma
attachment difficulties
eating disorders
autism spectrum
sensory processing difficulties
learning difficulties
substance misuse
As ADHD is a developmental disorder, it's believed it cannot develop in adults without it first appearing during childhood. But symptoms of ADHD in children and teenagers often continue into adulthood.
The way in which inattentiveness, hyperactivity and impulsiveness affect adults can be very different from the way they affect children.
For example, hyperactivity tends to decrease in adults, while inattentiveness tends to remain as the pressures of adult life increase.
Adult symptoms of ADHD also tend to be far more subtle than childhood symptoms.
Some specialists have suggested the following as a list of symptoms associated with ADHD in adults:
carelessness and lack of attention to detail
continually starting new tasks before finishing old ones
poor organisational skills
inability to focus or prioritise
continually losing or misplacing things
forgetfulness
restlessness and edginess
difficulty keeping quiet, and speaking out of turn
blurting out responses and often interrupting others
mood swings, irritability and a quick temper
inability to deal with stress
extreme impatience
taking risks in activities
Not all of the above will apply to every person and will be to varying degrees. Other factors will be relevant to consider.
Many females are considered to internalise their symptoms and as such, may have fewer observable traits than some males. Hyperactivity in females however may take the form of subtle fidgeting or bouncing, fiddling with or flicking their fingers or mails, twirling their hair, or playing with a small object such as a sensory toy, piece of material, blue tac, doodling, talking excessively or having racing thoughts. Some of these will also be relevant to males.
As females are societally seen as, and expected to be, ‘well-behaved’, they often seek approval and try to ‘fit in’. A desire to fit in may also be the case for males too. As such traits are often masked and outwardly, they are rarely noticed to be observably different from their peers. Sometimes behaviours or responses are recognised at home but not within, for example, school or work. Females are generally deemed more likely to ‘mask/contain’ at school, work or in public which means they ‘work hard’ not to be themselves, to act appropriately, to hide their feelings or maintain a façade. Once home, and in their safe zone, their dysregulated behaviours and responses are more evident due to the pressure building from the day, but this is often interpreted as elevated anxiety, being awkward or difficult or just being overreactive and oversensitive. Time to decompress (like a ‘time out’ from the social world) after school, work or a social event can also be important.
Why does all this matter?
This post cannot do justice in attempting to fully explain and set out the complex relationship between Autism and ADHD in females. What it does hope to show is that a complex relationship exists, and that clients and clinical practitioners need to understand how female presentation in both conditions differ to that of males.
During an initial consultation with one of our Clinical Psychologists, clients who are undecided about whether they should consider an assessment for ADHD or Autism can discuss this very concern. The psychologist will talk through with you which pathway may be best to consider given your current situation.
Do you offer assessments for both Autism and ADHD?
The practice does not offer full diagnostic assessments for ADHD as we believe a psychiatrist who specialises in ADHD is best suited for this. Although psychologists may assess and diagnose ADHD (if trained and experienced) they are unable to prescribe medication. As this is most often the recommended treatment, clients diagnosed by a psychologist would need to see a psychiatrist to have any medication prescribed.
Psychiatrists should not be prescribing medication to clients off the back of a psychologist’s assessment as they must see the client and assess them for themselves. This in effect means that clients will end up paying more than is needed to achieve the outcome.
As part of our Autism Diagnostic Assessment Service, we do offer enhanced screening for ADHD. This provides clients with a good evidence base as to whether further assessment is warranted.
In May 2023 BBC’s Panorama investigated some ADHD clinics and uncovered worrying practises in how clients were being diagnoses and medicated wrongly.
https://www.bbc.co.uk/programmes/m001m0f9
In some cases, clients were being assessed and diagnosed by practitioners other than a psychiatrist, and then prescribed medication by a psychiatrist who had not even met the client in person.
We also strongly recommend clients only undergo assessment for ADHD if the psychiatrist will provide the assessment in person and avoid all online services.
