October, the month of attention-deficit/hyperactivity disorder (ADHD) awareness, is an opportune moment to reflect upon a prevalent condition that frequently eludes diagnosis in women and girls. In childhood, boys are twice as likely to be diagnosed as girls, but in adulthood, the ratio of diagnosis is closer to 1:1. This suggests that ADHD is largely underdiagnosed in girls. Girls are more often diagnosed with ADHD-inattentive, whilst boys with ADHD-hyperactivity/impulsivity. The associated traits of externalised hyperactivity/impulsivity are more disruptive in school settings, leading to a higher likelihood of a referral for diagnosis. This difference in presentations between genders could be a likely cause of the underdiagnosis in girls.

Often, adult women with ADHD have adeptly masked their struggles, making detection a complex challenge. For early career psychologists, it's essential to identify the more subtle and internalised signs of ADHD for accurate diagnosis and treatment planning.

1. Understand the nuances of ADHD in internalised presentations: Childhood hyperactivity often shapes our perception of ADHD. In adults, hyperactivity might manifest as internal restlessness or mental hyperactivity. As women are more likely to present with inattentive or internalised expressions, they may be less identifiable in the therapy room. Women often present with diagnoses such as depression, anxiety disorders, substance abuse, and low self-esteem. These can often complicate the assessment and identification of ADHD, as they are more likely to be treated for these comorbid conditions first. Men, with more externalised symptoms, may be more straightforward to diagnose.
2. Recognise the power of compensatory strategies: Many adults devise strategies to compensate for their ADHD symptoms, with or without an official diagnosis. They might over-rely on digital reminders, planners, or lists. Whilst these are adaptive strategies, they can inadvertently mask underlying challenges. Some with ADHD have learned to compensate so effectively that they appear highly organised. Delving deeper into the time, effort, and impact of these strategies is vital. The emotional and cognitive toll of these compensatory strategies is often telling.
3. Be aware of the double-edged sword of high IQ and ADHD: The intersection of high intellectual ability and ADHD can lead to diagnostic overshadowing. In this population, inconsistencies may be evident: excelling in areas of personal interest but faltering with routine tasks. The challenges of organisation, task completion, and inattention can often overshadow their abilities. Intellectual overexcitability can mean a rapid and intense flow of ideas. Combined with ADHD, this can result in a overflow of thoughts, complicating focus on a singular task or idea.
4. Understand the emotional impact: Emotion is integral to ADHD. Although not in the diagnostic criteria, emotional dysregulation—mood swings, intense frustration, or heightened sensitivity to rejection—is commonly reported. Recognising that these emotional challenges can co-exist with ADHD, especially when clients aren't responding to traditional methods, is vital.
5. Realize the importance of a comprehensive history: Exploring an individual's past can hint at undiagnosed ADHD. Patterns of academic underachievement, organisational challenges, and a history of mood or anxiety disorders, substance abuse, or low self-esteem can be indicative. For early career psychologists, mastering the art of differential diagnosis is crucial. Inquiries about the consistency of challenges or struggles with organisational tasks can be enlightening. Questions like, "Do mundane tasks often feel overwhelming?" can be a good starting point.
6. Recognise the gender bias: Historically, females with ADHD have been overlooked due to symptoms leaning more toward inattention than hyperactivity. Awareness of this bias ensures fair treatment.
7. Understand the role of psychological assessment: Currently, our screening tools for adults with internalised ADHD presentations are limited. While it's best practice to include psychometric screeners when assessing, qualitative evidence is crucial for this population due to the likelihood of them being overlooked.

Conclusion

ADHD in women remains an intricate space of under-recognition, nuanced presentations, and masked symptoms. As early career psychologists venture into the therapy room, a blend of knowledge, sensitivity, and detailed assessment is paramount. Recognising and addressing ADHD in adult women not only ensures comprehensive care but also recognises the deep impact of missed diagnosis.