Click each image below to read expert insights, personal stories, facts, and important new research on ADHD in women.

April 25, 2023

New York – ADDitude magazine, the world’s most trusted resource on ADHD, is honoring Women’s Health Month with the publication of groundbreaking research on the impact of hormonal fluctuations on female ADHD symptoms during each life stage, from puberty and pregnancy to menopause. The upshot: Wild swings in estrogen levels dramatically worsen ADHD symptoms, and the severity grows more pronounced with age, according to more than 2,000 women surveyed aged 18 to 82.

ADDitude’s new survey also found that men with ADHD were equally affected by the rise and fall of testosterone levels during distinct life stages, and that andropause (often called male menopause) seemed to incite the most dramatic life changes. The survey included more than 2,711 men and women with ADHD between the ages of 18 and 82.

Women and men alike reported the greatest symptom severity from ages 50 to 59 — during menopause and andropause, respectively. Women reported that plummeting estrogen levels during menopause magnified the effects of ADHD, echoing the results of a 2022 ADDitude survey of 3,930 women that found hormonal changes exerted an outsized impact on ADHD functioning during this life stage.

How did the ebb and flow of hormones affect other life stages?

ADHD Link to PMS, PMDD

A staggering two-thirds of women surveyed said they experienced premenstrual syndrome (PMS) and/or premenstrual dysphoria disorder (PMDD) — well over national rates of PMS and PMDD. The overwhelming majority of women surveyed cited irritability, mood swings, cramps or discomfort, anxiety, and lack of concentration as the most impairing symptoms.

“For me, PMDD meant suicidal ideation, increased meltdowns and shutdowns, a decrease in emotional regulation, extreme sensitivity to rejection, and intrusive thoughts,” a woman, 39, who was diagnosed with ADHD, anxiety, and autism, told ADDitude.

Postpartum Depression and ADHD

The hormonal drop associated with postpartum depression, cited by 61 percent of women surveyed, was debilitating and, for many, lasted about one year. Worse, many women said they were not forewarned by their healthcare providers of the potentially debilitating effects of plummeting hormone levels after birth — and almost half said they were offered no treatment options, such as antidepressants or recommendations for therapy.

“The nurses I spoke to did not recognize my postpartum depression and told me it was probably a normal hormonal drop, but things never improved,” a 36-year-old mother in Pennsylvania told ADDitude.

Another woman, now age 50, said she thought she was a “bad mom” for feeling as she did, “so I masked my issues.”

ADHD in Puberty

During the hormonal swings of puberty, men were more likely to report illegal drug use, hypersexuality, and anger-management problems than were women, according to the ADDitude survey. Testosterone levels typically reach their peak around age 20, when challenges shift to procrastination, emotional dysregulation, and relationship problems, the men reported in the survey.

ADDitude will be publishing and promoting insights from its research, as well as other content chronicling the female experience with ADHD and its comorbid conditions, during the month of May at ADHD in Women: In Women We Trust.

For more information on ADDitude’s proprietary surveys of women and men with ADHD and possible interviews with patients, medical review board members, and/or ADHD experts, please contact Carole Fleck at carol@additude.com.

About ADDitude magazine:

Since 1998, tens of millions of readers have trusted ADDitude to deliver expert advice and caring support, making us the leading media network for clinicians, educators, parents, and adults living with attention deficit hyperactivity disorder (ADHD). ADDitude is the world’s most trusted source of strategies and information about ADHD and related conditions, such as learning disabilities, anxiety, depression, and oppositional defiant disorder. In 2021, ADDitude, the voice of and advocate for the ADHD community, joined the WebMD family of health brands.

Half of all women with ADHD receive a misdiagnosis or an incomplete diagnosis before finally identifying and treating their attention deficit disorder. This staggering statistic, revealed in a recent ADDitude survey of 2,760 women, confirms the anecdotal reports we hear often of medical gaslighting, distrust of self, unnecessary suffering, delayed treatment — and the grave consequences of each.

“I was misdiagnosed and received treatment that did not help me,” wrote one survey respondent misdiagnosed with depression and anxiety. “This led to me never getting better and ending up having a mental breakdown before I got my proper ADHD diagnosis 10 years later.”

“I believe if, instead of being diagnosed with bipolar 2 (cyclothymia), anxiety, and depression, I had been appropriately diagnosed with ADHD and given coping skills and treatment for that, my life would be completely different,” wrote another ADDitude reader.

“Antidepressants worked for a while, but my anger and frustration flare-ups were still an issue,” wrote a woman diagnosed with ADHD in her 50s. “Eventually, the antidepressants didn’t work anymore and I hit bottom… By the time I was diagnosed with ADHD, I was on long-term disability and felt I had no control over my life.”

The reasons for incomplete or inaccurate diagnosis range from outdated ADHD and gender stereotypes to low self-esteem and self-trust, seeded by years of criticism for unrecognized and untreated symptoms of ADHD, according to ADDitude‘s Women’s Health Month survey.

“Not being able to verbalize my emotions well continues to be a difficulty, likely due to not being able to trust my own emotions, whether they are valid or an under or over reaction,” wrote an ADDitude reader misdiagnosed with bipolar disorder. “In my opinion, this led to being misdiagnosed.”

This prevalent and debilitating roadblock to an ADHD diagnosis was a topic of discussion with Olympic marathon medalist Molly Seidel during her recent conversation with WebMD about barriers to mental health care for women.

“I wish that I had been more vocal about exactly how I was feeling earlier, because we might have gotten to the solution a lot earlier,” said Seidel, a world-class professional runner who was diagnosed with obsessive compulsive disorder and eating disorders before finally receiving an ADHD diagnosis a few years ago. “Especially as women, a lot of us are willing to almost gaslight ourselves by saying, ‘Oh it’s not really that bad.’ And then you look objectively at it, and you’re like, ‘No, this is objectively pretty bad and there has to be a better way to live than this.’”

For Seidel, an ADHD diagnosis was nothing short of life changing.

“My diagnosis came with such a sense of relief from knowing, Oh my God, there is a reason why I feel the way I feel. Maybe I’m not just thoroughly messed up and thoroughly a terrible person. My brain just works a little bit differently,” said Seidel, who earned the bronze medal in the Olympic marathon in Japan. “That diagnosis was the most freeing thing and the thing that has gotten me to the place that I am now.”

“What it took me years to figure out is that, if you are just trying to treat the symptoms and not addressing the underlying causes, it will just tend to jump from diagnosis to diagnosis to diagnosis,” said Seidel, who reported that she’s “in a much better and more stable place than I’ve been in a long time.”

Seidel’s ADHD treatment plan today includes mindful meditation, fine-tuned nutrition, miles upon miles of exercise, and therapy.

“Ultimately, the point of therapy is learning to have a better relationship with your own brain and understanding the mechanisms by which your brain works,”she said. “That has been the biggest thing in becoming more confident and trusting myself.”

ADHD Diagnosis in Women: Next Steps

• Self-Test: ADHD Symptoms in Women and Girls
• Read: Why ADHD in Girls Is Often Overlooked
• Read: Why Women with ADHD Feel Disempowered — And What We Can Do About It

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April 14, 2023

ADHD increases the likelihood of postpartum depression (PPD) and postpartum anxiety in more significant and impactful ways than do other well-established risks like comorbid psychiatric disorders or sociodemographic factors in women, according to a recent study published in the Journal of Affective Disorders. ¹

The research found that 25% of women with ADHD had postpartum anxiety, compared to 4.61% of women without ADHD. In addition, almost 17% of women with ADHD had PPD, compared to 3.3% without ADHD.

“ADHD is an important risk factor for depression and anxiety disorders postpartum,” the researchers wrote. “Therefore, ADHD needs to be considered in maternal care, regardless of sociodemographic factors and other psychiatric disorders.”

Using population-based registers from Sweden, the researchers identified 773,047 women who gave birth to their first or second child between 2005-2013. Of that number, 3,515 had received an ADHD diagnosis before their pregnancy. They also analyzed data on women’s depression and anxiety diagnoses before pregnancy, maternal age at delivery, highest achieved maternal education at childbirth, cohabitation status with their child’s father, and family history of depression and anxiety disorders.

The study found that the risk of PPD and postpartum anxiety was lower for women diagnosed with a psychiatric disorder before pregnancy and those with a history or family history of depression or anxiety. The researchers suggested that women diagnosed before pregnancy with ADHD and depression or ADHD and anxiety may have received greater support and treatment during and after their pregnancies compared to women diagnosed with ADHD alone.

Women with ADHD Become Pregnant Younger

Women diagnosed with ADHD were more likely to have a lower education level and less likely to live with the father of their child compared to women without ADHD, according to the researchers.

The study also reported that women with ADHD gave birth to their first child at a younger age (15–24 years) than did women without ADHD (25–34 years), supporting previous research. A study published in the Journal of Attention Disorders of more than 7,500 adolescents with ADHD and 30,000 adolescents without ADHD in Taiwan found that participants with ADHD became pregnant younger, more frequently, and had a higher risk of early pregnancy than did their neurotypical peers.² A large Danish study published in the Journal of the American Academy of Child & Adolescent Psychiatry reported that girls with ADHD were more than three and a half times as likely as their peers to become pregnant between the ages of 12 and 15.³

“It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD,” said Ellen Littman, Ph.D., in discussing how hormonal fluctuations impact women in the ADDitude webinar titled Why ADHD is Different for Women: Gender Specific Symptoms & Treatments.

In addition, the Swedish study found that 59% of the women diagnosed with ADHD had an additional psychiatric disorder compared to only 5% of the women without ADHD.

“The combination of being diagnosed with ADHD and being pregnant at a young age could increase the vulnerability and therefore the risk of being diagnosed with a psychiatric disorder postpartum, such as depression and anxiety,” researchers wrote. “However, results from the present study also show that women diagnosed with ADHD have an increased risk of depression and anxiety disorders regardless of age. This highlights the importance of health care providers to evaluate women diagnosed with ADHD across the lifespan.”

Postpartum Depression and ADHD

In a recent ADDitude survey of 2,027 women with ADHD, one-third of mothers reported that they experienced PPD, including the following symptoms:

• crying spells: 76%
• feelings of worthlessness, shame, guilt, or inadequacy: 76%
• mood swings: 66%
• irritability: 62%
• lack of concentration: 58%
• sleep problems: 57%
• withdrawing from friends and family 55%
• restlessness 46%
• appetite changes (increase or decrease) 37%
• thoughts of harm to self or others 31%
• other 24%
• extreme mood disorder or psychosis 13%
• self-harm 6%

“My ADHD got significantly worse postpartum,” said a survey respondent. “I felt overwhelmed and was not supported by my husband. He’d say things like, ‘Sarah next door has four children, and she copes. I don’t understand why you can’t even manage to keep things organized when you only have one!’”

“Something in me definitely changed after giving birth,” said an ADDitude reader from Ontario, Canada. “My doctors told me it was ‘anxiety’ and hormones. Although tired and sleep-deprived from the baby, I could not shut down my racing mind. I was constantly irritable, impatient, and a complete space cadet. I did suffer from postpartum depression after the birth of my second child. That is when I looked deeper into the root of my troubles. I have always wondered if I had PPD after my first child, or was my ADHD so out of control that I didn’t even notice?”

ADDitude survey respondents reported that their PPD symptoms lasted:

• 1-3 months 13.14%
• 4-6 months 18.63%
• 7-13 months 21.63%
• 14-24 months 13.63%
• Longer than two years 14.14%

Women Lack Treatment for Postpartum Depression

Almost half of ADDitude survey respondents said their healthcare providers did not offer treatment for their postpartum depression or anxiety.

“The medical community didn’t take baby blues seriously when my children were born,” said one ADDitude reader. “I just ‘needed to exercise, lose the rest of the baby weight, and focus on my family.’ Then I would be all better.”

“No one talked about it, and my doctor never asked how I was doing. So, I assumed I was weak,” said another survey respondent.

One ADDitude reader found the help she needed on her own. “No doctor cared,” she said. “So I self-treated by researching natural treatments and took several supplements that helped.”

According to the ADDitude survey, 41% of respondents received prescriptions for antidepressants, and 20% received therapy for PPD.

“PPD made it hard to get through anything without going into a guilt-depression spiral,” an ADDitude reader said. “It was awful. Antidepressants changed everything so I could function without spiraling or wanting to disappear.”

Postpartum Depression with Undiagnosed ADHD

Many ADDitude readers who experienced postpartum depression or postpartum anxiety were unaware of their ADHD diagnoses at that time.

“I had depression, anxiety, and just went into full paralysis,” an ADDitude reader said. “I didn’t know I had ADHD. I thought I sucked at everything, so I might as well add motherhood to the list.”

“I lost all sense of myself and pretended to cope,” said an ADDitude reader from Edmonton, Canada. “It wasn’t until I was diagnosed and looked back on my pregnancy that I realized how much ADHD and hormones played a role in my lack of coping. I wish I could go back and talk to that frightened, overwhelmed, and so very sad me and let her know there was a reason for it all.”

ADHD and Maternal Care: Next Steps

The Swedish researchers recommended that primary healthcare providers assess women with ADHD for the risk of PPD and postpartum anxiety beginning with the first prenatal visit. In addition, they said, women with ADHD should receive parental education before conception, psychological surveillance during pregnancy, and social support after childbirth.

According to Littman, women should find a doctor who understands the impact of hormones on ADHD and the interplay with medication. “Finding this professional is perhaps the most important and most difficult thing to do,” she said. “Be sure to ask about their experience treating ADHD in women.”

Sources

¹Andersson, A., Garcia-Argibay, M., Viktorin, A., Ghirardi, A., Butwicka, A., Skoglund, C., Bang Madsen, K., D’onofrio, B.M., Lichtenstein, P., Tuvblad, C., and Larsson, H. (2023). Depression and Anxiety Disorders During the Postpartum Period in Women Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2023.01.069

²Hua, M.H., Huang, K.L., Hsu, J.W., Bai, Y.M., Su, T.P., Tsai, S.J., and Chen, M.H. (2020). Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study. Journal of Attention Disorders. https://doi.org/10.1177/1087054719900232

³Østergaard, S.D., Dalsgaard, S., Faraone, S., Munk-Olsen, T., and Laursen, T, (2017). Teenage Parenthood and Birth Rates for Individuals with and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study.  Journal of the American Academy of Child and Adolescent Psychiatry. https://doi.org/10.1016/j.jaac.2017.05.003

Masking, specifically ADHD masking, is a burden for people with ADHD. For women, it’s even more intense because many may have already adjusted themselves to fit an outdated definition of feminine success.

Creating a more inclusive professional environment for neurodivergent women — one where companies can leverage the very unique and needed strengths neurodivergent talent brings to the table — depends on having an accurate view of the obstacles tripping up women with ADHD.

Missing this perspective often leads to well-meaning but harmful advice such as, “Just be yourself, and success will follow.”

What is ADHD Masking?

In general, ADHD masking is a concept and strategy that women with ADHD may intuitively understand before they hear the definition. Put simply; masking is intentionally shifting your behavior to hide your differences. For example, a woman with ADHD might smile and nod during a conversation even though she tuned out long ago, or she may secretly work late into the night to overcompensate for not staying on task for a deadline.

[Free Webinar: “‘Invisible Disabilities’ at Work – How to Foster Neurodivergent Advocacy and Acceptance”]

Masking is often preceded by asking, “What would a ‘normal’ person do?” And then working hard to mimic that. It’s a survival strategy that neurodivergent individuals use to navigate and thrive in a workforce not designed for them.

And it is completely and utterly exhausting, contributing to fatigue, burnout, and feelings of self-deprecation. The emotional, cognitive, and even physical labor that comes with trying to fit a mold not built for women with ADHD can feel like holding down multiple jobs at once.

Women are More Likely to be Undiagnosed, Misdiagnosed for ADHD

Women are less likely to be accurately diagnosed with ADHD in childhood. ¹ (According to the Centers for Disease Control and Prevention (CDC), boys are twice as likely as girls to get diagnosed with ADHD.) ²

Now we are seeing a fast-growing cohort of women in their 30s, 40s, and 50s getting diagnosed with ADHD for the first time. Their diagnoses aren’t benign. They occur after decades of being misdiagnosed with depression or anxiety or repeatedly being told to “get their act together.” Such sentiments often leave women wondering, “What is wrong with me?” and becoming extremely good at masking.

[Free Resource: What to Ask Yourself to Find the Perfect Job]

When a neurodivergent woman lacks a diagnosis that could help her understand and accept her unique wiring, the impulse to hide oneself can arise. Masking may become unconscious and automatic, so much so it becomes ingrained in her brain and, nonetheless, exhausting.

Women in the Workplace Walk a Tightrope

In January 2023, Fortune reported that women, for the first time, lead more than 10% of Fortune 500 companies as CEOs. ³ Those numbers may mean progress, considering that in 2015, The New York Times famously reported, “Fewer women run big companies than men named John.”  ⁴

But surely, it’s not enough. Gender disparities aren’t limited to the C-suite. For the eighth consecutive year, McKinsey and Company’s annual Women in the Workplace report found that women struggle to advance in the ranks, beginning with entry-level positions, thanks to “broken rungs” on the corporate ladder.⁵

And the disparity is much more significant for women of color and non-binary individuals.

Women must walk across a fragile tightrope at work, and neurodivergence makes this more challenging: One issue is that feminine traits are not the standard for leadership. But at the same time, women who don’t exhibit femininity are judged as less likable. Often, women in leadership positions are amazingly aware of their emotions — and the reactions of others when those emotions become visible. Knowing this compounds the fear neurodivergent women may carry that neurotypical people may notice the things they try and conceal.

Women in the Workplace: Expectation Bias

Unconscious bias causes people to unknowingly alter how they see the world to fit their expectations. Expectation bias occurs when people dismiss others who don’t fit their expectations.

Now, consider stereotypical expectations for women in the workplace — like note-taking, event planning, and saying “yes” to menial projects outside their role — against the backdrop of common ADHD symptoms and executive function weaknesses with planning, organization, and multitasking.

The cost of not conforming to expectations, even unreasonable ones, may involve a backlash that impacts a neurodivergent woman’s standing or security at work.

Let’s Stop Failing Women: How to Navigate the Journey Together

Neurodivergent women can work to cease and desist unhelpful masking behaviors. But until workplaces move the needle on bias in general, this leaves a disproportionate burden on women’s shoulders.

While unmasking has tremendous benefits, it also carries a risk. The American Disability Act (ADA) protects individuals with disabilities; however, unconscious bias is real. There is no shortage of stories about individuals who experienced career consequences after revealing their neurodivergence to employers and colleagues.

For women, gender bias at work makes unmasking more complicated. However, there are plenty of good reasons to show up more fully.  One safe place to start could be discussing work preferences and needs with one or two close colleagues. For example, a woman could say, “The back-to-back Zoom meetings really wear me out and prevent me from being fully productive. Do you mind if we make our weekly check-in a phone meeting?”

As neurodivergent women navigate their journeys in the workplace, one thing we know for sure is that ADHD masking is not simply an individual issue.

Sarah Greenberg, MFT, MA, M.Ed., BCC, is a psychotherapist, board-certified coach, and Executive Director of Behavior Change & Expertise at Understood.org. 

Neurodivergent Women in the Workplace: Next Steps

• Free Download: Use This ADHD Blueprint to Find Your Passion
• Read: The Real-Life Risks and Rewards of Disclosing ADHD at Work
• Learn: How to Help Your Boss Help You
• Blog: “I’m Not Hiding My ADHD Anymore”

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Sources

¹Glasofer, A., Dingley, C., Kim, J., Colosimo, R., & Gordon, H. R. D. (2023). Medication Decision Making in Low-Income Families of Black Children With ADHD: A Mixed Methods Study. Journal of Attention Disorders, 0(0). https://doi.org/10.1177/10870547231158382

¹Young, S., Adamo, N., Ásgeirsdóttir, B.B., Branney, P., Beckett, M., Colley, W., Cubbin, S., Deeley, Q., et al. (2020) Females with ADHD: An Expert Consensus Statement Taking a Lifespan Approach Providing Guidance for the Identification and Treatment of Attention-Deficit/Hyperactivity Disorder in Girls and Women. BMC Psychiatry. 20(1):404. https://doi.org/10.1186/s12888-020-02707-9

²Centers for Disease Control and Prevention. Data and Statistics About ADHD. https://www.cdc.gov/ncbddd/adhd/data.html

³Hinchliffe, Emma. (January 12, 2023) Women CEOs Run More Than 10% of Fortune 500 Companies for the First Time in History. Fortune. https://fortune.com/2023/01/12/fortune-500-companies-ceos-women-10-percent/

⁴Wolfers, Justin. (March 2, 2015). Fewer Women Run Big Companies Than Men Named John. The New York Times. https://www.nytimes.com/2015/03/03/upshot/fewer-women-run-big-companies-than-men-named-john.html

⁵McKinsey & Company. Women in the Workplace 2022. (October 18, 2022). https://www.mckinsey.com/featured-insights/diversity-and-inclusion/women-in-the-workplace

The use of ADHD medication during pregnancy causes no impairment of a child’s neurodevelopment or physical growth, according to research published in Molecular Psychiatry.¹ A large population-based register study found in-utero exposure to medication for ADHD, including stimulants, did not impair a child’s neurodevelopment or growth compared to children whose mothers stopped taking ADHD medication prior to conception.

Research was conducted using data from Danish nationwide registers, including more than one million children born between 1998 and 2015. Of those, 898 children were delivered by mothers who started or continued taking ADHD medication during pregnancy; this became the study’s “exposed” group. The “unexposed” group included 1,270 children whose mothers discontinued — but had previously taken — ADHD medication before conception.

Prenatal & Postnatal Exposure to ADHD Medication

After adjusting for maternal demographic characteristics and psychiatric data, researchers found no difference in long-term neurodevelopmental or growth outcomes between the two groups. In other words, women could stop taking medication before conception or continue during pregnancy without putting their child at greater risk of neurodevelopmental psychiatric disorders (ADHD, ASD); neurodevelopmental impairments (vision, hearing, seizures, epilepsy); or growth impairments.

Though the percentage is small, the number of pregnant women taking ADHD medication has steadily increased over time.^{2, 3} In fact, ADHD medication is one of the most common medications prescribed during pregnancy.^{3, 4}

In a recent survey of ADDitude readers, 2.39% of 1,170 women who had been pregnant reported taking medication for their ADHD following conception. Many of those who did not take medication said they remained undiagnosed and untreated at the time of their pregnancies, and therefore had no prescribed medications. Just 2.58% took ADHD medication while breastfeeding.

If a woman decides to discontinue use while both pregnant and breastfeeding, she may go a year or longer without pharmacological treatment — a first-line treatment for ADHD.

“I stopped [taking] Adderall leading up until delivery, and had been told I couldn’t take it at all during breastfeeding,” wrote one 33-year-old woman in Texas. “I went back to work three months postpartum. I really struggled with symptoms and felt unable to do my job.

“I did some additional research… that suggested a low breastmilk transfer rate for Adderall, and an even lower rate with Ritalin. Five months postpartum, I brought that data to my GP, who agreed to prescribe 5mg of Ritalin twice daily. I continued exclusively breastfeeding for two more months, then did a combination of breastfeeding and formula until weaning completely when my daughter was nine months. At that time, my GP switched me back to Adderall. During this time, my daughter showed no adverse effects, remaining on her growth trajectory in the 90th percentile and sleeping like a champ!”

Impact on Children

The decision to cease or continue treatment for ADHD while pregnant is difficult, in large part because the effects of ADHD medication in utero are not well-documented. Due to the nature of the problem, research is limited to register studies like this most recent one — the second and largest long-term register study to examine the effects of ADHD medication during pregnancy.

In addition, the research is conflicting. A 2015 U.S. population-based study found that ADHD medication use in early pregnancy was associated with three specific, selected birth defects.⁵ Another U.S.-based study, published in 2017, suggested an increased risk of cardiovascular defects from prenatal exposure to methylphenidate — but not amphetamines.⁶

While exposed children faced no increased risks for common neurodevelopmental outcomes in the present study, researchers found that exposed children born to mothers who used other psychotropic medication during pregnancy were more likely to develop ADHD. This was also found when the mother had filled two or more prescriptions for ADHD medication during pregnancy.

Because the increased risk was limited to ADHD only, researchers speculate these results may be “driven by severity of maternal ADHD” through “higher disease liability for ADHD and through referral bias, that is, offspring of mothers with severe ADHD are assessed more carefully for ADHD.”

Impact on Women with ADHD

On average, women in the U.S. have their first child by age 27.⁷ According to the ADDitude survey, it’s around this time that women report a major impact caused by their ADHD symptoms. The majority — 64% to 70% of 2,010 respondents — said the overall impact of ADHD was major or life-altering in their 20s and 30s.

Half of survey respondents who had been pregnant said their ADHD symptoms remained stable during pregnancy. But following delivery, 56.7% of them said they experienced symptoms of postpartum depression. Around more than one-third told ADDitude these symptoms lasted for more than 6 months; for nearly 10%, postpartum depression lasted more than two years.

Similar findings were discovered in a 2020 survey conducted by the MGH Center for Women’s Mental Health. No significant changes in ADHD symptoms were reported by women during pregnancy, but those who chose to discontinue psychostimulant medication experienced a significant increase in postpartum depressive symptoms. Women who elected to adjust their ADHD medication use, or maintained the same prescription schedule, did not experience a significant change in depressive symptoms.

Limitations and Future Research

“Pregnant women who depend on stimulants for daily functioning must weigh the potential of exposing their fetus to unknown developmental risks against potential medical, financial, and other consequences to both mother and child that are associated with exacerbation of ADHD symptoms when stopping the medication, such as inability to maintain employment and unsafe driving,” the researchers stated.

ADHD medication in the present study included stimulants (methylphenidate, amphetamine, dexamphetamine, lisdexamphetamine) and other treatments (modafinil, atomoxetine, clonidine).

“The present study provides reassurance that several essential categories of child outcomes that could reasonably be suspected to be affected by stimulants, including body growth, neurodevelopment, and seizure risk, do not differ based on antenatal stimulant exposure.”

Compared to women without ADHD, the study’s sample population of women with ADHD tended to be younger at the time of childbirth, more likely to smoke during pregnancy, and more likely to have children born preterm or with low birth weight. This finding was consistent regardless of whether the mother took ADHD medication during pregnancy.

Finally, more research is needed to differentiate between the effects of ADHD medication types, dosage, and trimester. This study was limited to diagnoses formally entered into the Danish register. Future research should be expanded to include a larger sample population.

Sources

¹Madsen, K. B., Robakis, T. K., Liu, X., Momen, N., Larsson, H., Dreier, J. W., … Bergink, V. (2023). In utero exposure to ADHD medication and long-term offspring outcomes. Molecular Psychiatry, 1–8. doi: 10.1038/s41380-023-01992-6

²Lemelin, M., Boukhris, T., Zhao, J. P., Sheehy, O., & Bérard, A. (2021). Prevalence and determinants of attention deficit/hyperactivity disorder (ADHD) medication use during pregnancy: Results from the Quebec pregnancy/children cohort. Pharmacology research & perspectives, 9(3), e00781. https://doi.org/10.1002/prp2.781

³Haervig, K. B., Mortensen, L. H., Hansen, A. V., & Strandberg-Larsen, K. (2014). Use of ADHD medication during pregnancy from 1999 to 2010: A Danish register-based study. Pharmacoepidemiology and drug safety, 23(5), 526–533. https://doi.org/10.1002/pds.3600

⁴Louik, C., Kerr, S., Kelley, K. E., & Mitchell, A. A. (2015). Increasing use of ADHD medications in pregnancy. Pharmacoepidemiol Drug Saf, 24, 218– 220, doi: 10.1002/pds.3742.

⁵Anderson, K. N., Dutton, A. C., Broussard, C. S., Farr, S. L., Lind, J. N., Visser, S. N., Ailes, E. C., Shapira, S. K., Reefhuis, J., & Tinker, S. C. (2020). ADHD medication use during pregnancy and risk for selected birth defects: National birth defects prevention study, 1998-2011. Journal of Attention Disorders, 24(3), 479–489. https://doi.org/10.1177/1087054718759753

⁶Huybrechts, K. F., Bröms, G., Christensen, L. B., Einarsdóttir, K., Engeland, A., Furu, K., Gissler, M., Hernandez-Diaz, S., Karlsson, P., Karlstad, Ø., Kieler, H., Lahesmaa-Korpinen, A. M., Mogun, H., Nørgaard, M., Reutfors, J., Sørensen, H. T., Zoega, H., & Bateman, B. T. (2018). Association between methylphenidate and amphetamine use in pregnancy and risk of congenital malformations: A cohort study from the international pregnancy safety study consortium. JAMA psychiatry, 75(2), 167–175. https://doi.org/10.1001/jamapsychiatry.2017.3644

⁷Osterman, M.J.K., Hamilton, B.E., Martin, J.A., Driscoll, A.K., & Valenzuela, C.P. (2023). Births: Final data for 2021. National Vital Statistics Reports; 72(1). DOI: https://dx.doi. org/10.15620/cdc:122047.

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Pregnancy is magical and excruciating. Exciting and overwhelming. Demanding and the calm before the storm.

This is true for most people who experience pregnancy, but it’s doubly true for those with ADHD, roughly 96% of whom cease taking stimulant medication while pregnant and nursing. On top of that, the new and unrelenting demands of caring for an infant, while experiencing changing hormone levels and disrupted sleep, can amplify ADHD symptoms and bring a new level of difficulty to daily functioning.

For women who discontinued ADHD medication use during pregnancy, in particular, coping with raw emotions, a new routine, and a new baby may feel next to impossible and lead to comorbid anxiety and depression. It is important for clinicians treating perinatal women with ADHD to consider the benefits and risk of stimulant use in this critical time of transition.

In this webinar, women, partners, and professionals will learn:

• About the intersection of ADHD symptoms and neurobiology in perinatal women during and after pregnancy
• About the risk analysis of stimulant use versus discontinuation in pregnancy and postpartum
• How to anticipate the demands of early motherhood and risk for depression and anxiety in women with ADHD
• About the impact of hormones on ADHD throughout the lifespan, and the interplay with medication

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meet the Expert Speaker:

Allison Baker, M.D., is a clinician, researcher, and educator with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital, with an appointment at Harvard Medical School. She has expertise in pediatric obsessive-compulsive disorder, ADHD, adolescent mood disorders, and perinatal psychiatry. Dr. Baker frequently lectures and leads workshops on a variety of topics in child and perinatal psychiatry.

Dr. Baker received her medical degree from the University of Virginia, where she was elected to the Alpha Omega Alpha Honor Society for her excellence in scholarship and professionalism. She completed her residency in general psychiatry at Columbia University, serving as Chief Resident. Dr. Baker trained in child and adolescent psychiatry at the combined program of Columbia and Cornell Universities. Dr. Baker then served on the faculty at Columbia University Medical Center and was a Senior Pediatric Psychopharmacologist at The Child Mind Institute before moving to Boston.

Webinar Sponsor

The sponsor of this ADDitude webinar is….

Inflow is the #1 app to help you manage your ADHD. Developed by leading clinicians, Inflow is a science-based self-help program based on the principles of cognitive behavioral therapy. Join Inflow today to better understand & manage your ADHD.

ADDitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content.

Certificate of Attendance: For information on how to purchase the certificate of attendance option (cost $10), register for the webinar, then look for instructions in the email you’ll receive one hour after it ends. The certificate of attendance link will also be available here, on the webinar replay page, several hours after the live webinar. ADDitude does not offer CEU credits.

Closed captions available.

Fluctuations in estrogen affect all women but are often felt more acutely in women with ADHD, who are more likely to experience debilitating premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

In this download, you will learn how fluctuations in estrogen impact women with ADHD:

• in adolescence
• during PMS and PMDD
• throughout pregnancy and post-partum
• during menopause
• as well as what interventions may help women manage their ADHD symptoms at different stages in their lives.

NOTE: This resource is for personal use only.

The risk of developing depression is three to six times higher in girls and young women with ADHD who take oral hormonal contraceptives (HCs) than it is among their neurotypical peers on similar birth control, according to a population-based cohort study published in the Journal of the American Academy of Child & Adolescent Psychiatry. ¹

Women with ADHD were three times more likely to develop depression than women without ADHD, regardless of HC use, according to the research. However, the risk for depression increased substantially for women on a combined oral contraceptive (COC) or progestogen-only pill (POP). Women with ADHD who used oral combined HC were five times more likely to develop depression than were neurotypical women not using hormonal birth control. The risk increased sixfold for women with ADHD on a COC compared with neurotypical women using a COC.

Overall, 42% of women with ADHD developed depression or were prescribed antidepressants during the study period; the same was true for only 11% of subjects without ADHD.

The Swedish study was based on data from national population-based registers and included 29,767 girls and young women with ADHD aged 15 to 24 years, plus 763,146 controls without ADHD. Seven hormonal birth control groups were analyzed. These included women using any HC, COC, combined non-oral contraceptives (i.e., patch or vaginal ring), POP, progestogen implants, progestogen injection, and the hormonal IUD.

The study found that medical reasons for taking hormonal contraceptives, such as menstrual bleeding, irregular menses, dysmenorrhea, and acne, were more common in women with ADHD, further placing them at risk for depression. ¹ Women with ADHD who used non-oral HCs, such as progestogen implants or hormonal IUD, had a moderate risk of developing depression no different than that for women without ADHD.

Women with ADHD at Risk for Unplanned, Unwanted Pregnancies

Researchers noted that women with ADHD face an elevated risk of becoming teenage mothers. In Sweden, women with ADHD are six times more likely to give birth as teenagers than women without the disorder.²

“Adverse effects of hormonal contraception, including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD,” researchers said. “To prevent subsequent unplanned pregnancies and to overcome health disparities among women, health care providers need to identify women at risk and provide them with the most-effective contraceptive methods that are easily available and that do not confer unnecessary risk of depression.”

Additional research has confirmed the risk for unplanned pregnancies among women with ADHD. Stephen P. Hinshaw, Ph.D., professor of psychology at the University of California, Berkeley and principal investigator of the ongoing Berkeley Girls with ADHD Longitudinal Study, told ADDitude: “By the time they reached their mid to late 20s, about 43% of the BGALS participants in the ADHD group had one or more unplanned pregnancies compared to about 10% of individuals in the comparison group.”

Ellen Littman, Ph.D., discussed why women with ADHD are more likely to engage in risky sexual behaviors than women without ADHD during the ADDitude webinar titled, “Why ADHD Is Different for Women: Gender-Specific Symptoms & Treatments.”

“One theory for this is the early recognition of sexuality as a shortcut to social acceptance,” she explained. “It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, sexually transmitted infections, and more unplanned pregnancies in women with ADHD than women without ADHD.”

While researchers hope the study’s findings provide clinicians with guidance in contraception counseling, they also recognize several limitations, including “selection bias and residual confounding due to a lack of intact information on exposures, outcome variables, and missing covariates.”

“Given the increased risk of depression in women with ADHD, which may be further increased by oral HC use, future clinical trials on contraception need to include women with mental health problems, including ADHD, to guide prescribers on the best available choices for these women,” they said.

Sources

¹Lundin, C., Wikman, A., Wikman, P., Kallner, H.K., Sundström-Poromaa, I., Skoglund, C. (2022). Hormonal Contraceptive Use and Risk of Depression Among Young Women with Attention-Deficit/Hyperactivity Disorder. J Am Acad Child Adolesc Psychiatry. S0890-8567(22)01894-9. https://doi.org/10.1016/j.jaac.2022.07.847

²Skoglund C., Kopp Kallner H., Skalkidou A., et al. (2019). Association of Attention-Deficit/Hyperactivity Disorder with Teenage Birth Among Women and Girls in Sweden. JAMA Network Open.  https://doi.org/10.1001/jamanetworkopen.2019.12463

What Is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a hormonal health condition that causes clinically significant and impairing depression, anxiety, mood swings, and uncomfortable physical symptoms in the week leading up to menses, the onset of a period. PMDD symptoms improve following menses and are minimal, if not absent, in the weeks following. PMDD disproportionately affects people with autism and ADHD. Various medications can help control PMDD symptoms¹.

PMDD Symptoms

A patient meets the diagnostic criteria for PMDD if at least five of the following symptoms are met, including at least one from each category. The symptoms must cause distress or interfere with activities of daily living during most menstrual cycles over the preceding year:

• Category A:
  • Unstable and easily influenced mood
  • Irritability
  • Depressive or hopeless mood
  • Anxiety or tension
•  Category B:
  • Decreased interest in usual activities
  • Difficulty concentrating
  • Fatigue
  • Appetite changes
  • Sleep difficulties, either insomnia or hypersomnia
  • Feeling of overwhelm
  • Physical symptoms: breast tenderness, joint or muscle pain, a sensation of bloating, or weight gain²

PMDD vs PMS

While PMDD shares symptoms with premenstrual syndrome (PMS), PMDD is less common and more severe. PMS may occur in up to 48% of people who menstruate, while PMDD only occurs in 3 to 9%³⁴. In addition, PMDD symptoms interfere with daily functioning, and often require medication to resolve. People with PMDD are at risk for suicidality and suicide attempts, so diagnosis and treatment are vital⁵. Some people who do not meet the criteria for PMDD may have severe PMS and benefit from similar treatment.

[Read: PMS and ADHD: How the Menstrual Cycle Intensifies Symptoms]

Autism, ADHD, and PMDD

PMDD disproportionately affects people with ADHD and autism, with up to 92% of autistic women and 46% of women with ADHD experiencing PMDD, though estimates vary^{6 7}. There is no agreed-upon cause of PMDD, nor is it known why it affects certain populations more than others, though there are various theories. Possible explanations include:

• Genetics. PMDD is highly heritable, indicating that there is a genetic link.
• Hormone sensitivity. As people with ADHD have reduced dopamine levels across the brain, hormone fluctuations may be more likely to reduce dopamine to critically low levels, leading to more severe feelings of exhaustion, moodiness, and lack of motivation. In addition, estrogen may affect cellular pathways that have been implicated in ADHD⁸.
• Sensory sensitivity. Autistic people generally have greater sensory sensitivity, and therefore may be more likely to be negatively affected by menses-related symptoms.

Treating PMDD

PMDD has various treatments ranging from lifestyle changes to medication.

• Antidepressants. Some selective serotonin reuptake inhibitors (SSRIs) have been proven effective at reducing psychiatric PMDD symptoms.
• Contraceptives. Hormonal contraceptives regulate hormones and can alleviate both physical and psychiatric PMDD symptoms⁹.
• Lifestyle changes. Though most people with severe PMDD benefit from medication, lifestyle changes such as improved diet and exercise may improve some symptoms.

PMDD, Autism, and ADHD: Next Steps

• Read: ADHD and Menopause: How Changing Hormones Exacerbate ADHD Symptoms
• Download: Treating ADHD During Perimenopause and Menopause
• Listen: Why ADHD is Different for Women — Gender-Specific Symptoms & Treatments

Sources:

¹American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), 171. https://doi.org/10.1176/appi.books.9780890425596
²American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.), 171, 172. https://doi.org/10.1176/appi.books.9780890425596
³ A, D. M., K, S., A, D., & Sattar, K. (2014). Epidemiology of Premenstrual Syndrome (PMS)-A Systematic Review and Meta-Analysis Study. Journal of clinical and diagnostic research : JCDR, 8(2), 106–109. https://doi.org/10.7860/JCDR/2014/8024.4021
⁴Thakrar, P.D., Bhukar, K., & Oswal, R.M. (2021). Premenstrual dysphoric disorder: Prevalence, quality of life and disability due to illness among medical and paramedical students.
⁵Osborn, E., Brooks, J., O’Brien, P.M.S. et al. Suicidality in women with Premenstrual Dysphoric Disorder: a systematic literature review. Arch Womens Ment Health 24, 173–184 (2021). https://doi.org/10.1007/s00737-020-01054-8
⁶Obaydi, H., & Puri, B. K. (2008). Prevalence of premenstrual syndrome in autism: a prospective observer-rated study. The Journal of international medical research, 36(2), 268–272. https://doi.org/10.1177/147323000803600208
⁷Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021 Jan;133:10-15. doi: 10.1016/j.jpsychires.2020.12.005. Epub 2020 Dec 3. PMID: 33302160.
⁸Dorani F, Bijlenga D, Beekman ATF, van Someren EJW, Kooij JJS. Prevalence of hormone-related mood disorder symptoms in women with ADHD. J Psychiatr Res. 2021 Jan;133:10-15. doi: 10.1016/j.jpsychires.2020.12.005. Epub 2020 Dec 3. PMID: 33302160.
⁹Hofmeister, S., & Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American family physician, 94(3), 236–240.

I have ADHD, and I’ve been using a period-tracking app for a long, long time. The ability to digitally track my period has been nothing short of life-changing. It has meant tracking – and managing – my ADHD symptoms, too.

I know, for example, that I’m going to have a particularly bad brain day about six days before my period. I also know that I’m going to be particularly impulsive around ovulation. This data, and a lot more, is vital to me and informs how I plan my days and manage all aspects of my life – no exaggeration.

[Special Report: Roe v. Wade Ruling May Disproportionately Impact Girls with ADHD]

So I simply cannot afford to delete my period-tracking app.

I know what you’re thinking: Can’t you just track all of this on paper?

I can’t. I’ve tried pen-and-paper methods countless times, and I’ve failed miserably. I’d feel awful and scold myself every time I forgot to write something down. (“It’s not that hard! It only takes two seconds,” I’d tell myself). Apps and digital tools are the only things that have made a difference.

The ability to just enter a start date for my period and let the app figure out the rest helps. Being able to wear a Bluetooth thermometer around my arm at night to track my ovulation — and not have to think about taking my temperature in the morning before my brain turns on — helps.

[Read: 5 Things Every Doctor (and Parent) Should Know about Girls and ADHD]

Some apps may promise more stringent security and privacy measures than others, especially in light of the Supreme Court’s ruling, but it’s also not so simple to stop using one method that has worked well all this time and switch to another.

Even if these concerns are unfounded, it is endlessly frustrating that I’m on edge and can’t expect privacy in this area after the Supreme Court’s stunning reversal on abortion rights. I’m so, so sad. And heartbroken. And disappointed.

Menstruation, Hormones, and ADHD: Next Steps and Related Resources

• Symptom Test:Signs of ADHD in Girls
• Free Download: Menopause & ADHD — Treatments & Interventions
• Research: Girls with ADHD Face Increased Risk for Teen Pregnancy
• Read: Women, Hormones, and ADHD
• Read: Perimenopause Problems — How Changing Hormones Exacerbate ADHD Symptoms
• Read: Women with ADHD — No More Suffering in Silence

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