How ADHD is Different in Women versus Men
So why is it that we have these two “types” of ADHD (with and without hyperactivity), and why is it that hyperactive ADHD is more prevalent among boys and daydreaming ADHD more common among girls?
In men, we various ruling passions find, in women, two almost divide the kind; Those only fix’d, they first or last obey, The love of pleasure, and the love of sway.
—Alexander Pope, Epistle to a Lady
The NBC TV show Today published an article last week about Angela Carpenter Gildner, a Washington, DC social worker, whose son was diagnosed with ADHD. As the doctor was recounting her son’s behaviors that added up to his being labeled with this disorder, she was apparently thinking to herself, “Me, too!”
She told reporter Meghan Holohan:
“When my son was in the second grade, he was diagnosed with ADHD. As I learned more about it, I started seeing those traits in myself.”
Gildner was fortunate that she found a physician who was willing to take her self-reported self-diagnosis seriously; often women and girls are denied an ADHD diagnosis that could, if property treated, be tremendously helpful to them in their lives because the condition often presents differently in men versus women, boys versus girls.
In other articles on this site, I offer complete and detailed psychological and neurological explanations for the driving mechanism behind ADHD. In quick summary, I showed why and how those who think ADHD is a “top down” problem, such as a failure of cognition, inhibition, or even poor parenting, are mistaken (although there are differences in these realms).
In fact, I argue, these differences in levels of distractability, impulsivity, and risk-taking track back to humanity’s hunting and gathering past: a time when noticing everything around you all the time, making quick decisions, and being willing to go hunting after things that might want to eat you as much as you want to eat them were strengths that insured a tribe’s survival.
I also proposed that the core mechanism, the driving force behind ADHD, is that need that Maslow overlooked when he assembled his hierarchy of human needs: the need to know one is alive.
As mentioned, because of genetically determined differences in the set-point of the thalamus, which controls how “in touch” we each are with the sensory world, some of us are born knowing we are alive and never questioning it because lights are bright, sounds are loud, and touch is vivid.
Others of us, however, feel the constant need to reach out for stimulus that will verify our aliveness, proving to us that we are really here and now and fully alive. This is the “urge” that propelled hunters into the forest or jungle in past times, and today drives disruptive behavior in the classroom or workplace.
In her book Women With ADHD, psychotherapist Sari Solden points out that women with ADD are often “daydreamers,” who drift through life paying only partial attention. They’re often not diagnosed as having ADHD because the eruptive or externally impulsive behaviors so commonly identified with ADHD are not showing.
This is the face of what’s come to be differentiated from ADHD, known popularly as “ADD without the hyperactivity.” It seems that while most of the time boys and men are diagnosed with ADHD, girls and women are more often diagnosed with ADHD “without hyperactivity” or simply overlooked.
There are also, of course, females who have the “typical boy” type of ADHD: outgoing, expressive, aggressive, and impulsive, just like there are males who are the “typical girl” type of ADD-quiet and withdrawn, but constantly off in their own little dream world. But both of these outliers seem to represent a minority, something on the order of around 20 percent in each case.
So why is it that we have these two “types” of ADHD (with and without hyperactivity), and why is it that hyperactive ADHD is more prevalent among boys/men and daydreaming ADHD more prevalent among girls/women?
The approach/withdrawal continuum provides one possible answer to help explain these two types of ADHD. According to Dr. Robert Ornsteen (Roots of the Self), this continuum is a function of whether a person is primarily dominated by their left or right brain hemisphere. When a person is a born “left-hemisphere approacher,” they’ll exhibit their ADHD in an external and expressive way. They’ll lurch toward things they want, move from thing to thing, person to person, and have a life filled with wild variety and activity.
A “right-hemisphere avoider,” however, will act out their ADHD differently. Although they have the same internal “need for aliveness,” they’re prevented by their right hemisphere from expressing their impulsivity in the external world and in an external fashion.
As a result, instead of interrupting others they interrupt themselves within their own heads. Their daydreams and unwanted thoughts constantly interrupt their own stream of attention. They find that they can’t pay attention in class, can’t keep up with conversation, and are constantly losing things.
One reason we see the two types expressed largely through gender lines is because in our society men are more likely to be what Ornsteen calls approachers and women are more likely to be what he calls avoiders.
Scientists hypothesize a genetic/evolutionary basis for at least a part of this.
Anthropologists and social scientists point out that across the animal kingdom the male imperative is to sow its genetic material as far and wide as possible, whereas the female imperative is to be cautious and careful on behalf of the young who are incapable of fending for themselves. While a male can theoretically impregnate hundreds of females in the course of a year (and with many species, does), in most species a female can only become impregnated once.
Translated into the human species, this could lead to a natural tendency for men to be outer-directed approachers, and for women to be inner-directed avoiders. That there are men who are avoiders and women who are approachers shows us the tremendous variety and adaptability of the human species, and may even, in itself, be a sort of ancestral/genetic adaptation.
Another reason we see such a gender split has to do with how our society is organized.
According to our most primal cultural stories, men should be out in the world conquering, changing, and transforming things, while women should be barefoot, pregnant, and quietly at home.
If that sounds like an extreme statement, consider the stories that ground our culture. I remember well when our oldest daughter was about four years old and I was reading her the story of Cinderella. Halfway through the story, I got a creepy, shocked realization: The “good girl” in the story was quiet, demure, and did what she was told. The “bad and ugly” girls in the story were out in the world trying to get what they wanted. And the prize was a man!
The simple fact is that no matter how egalitarian we think we are as parents, our culture itself, from fairy tales to TV shows to advertising (probably the biggest offender) often promulgate the stereotype of males as outer-directed “doers” and females as passive, quiet, and demure.
At an early age, our children figure this out. Those little girls (and a small percentage of little boys) who are born Hunters discover that when they act that need out in the world, they get slapped down.
“Be quiet,” they’re told, or, “Act like a lady.”
But the need for aliveness, the need for the hunt, is still there, and, being a primal need, it will find a way to be satisfied. So instead of producing external stimulation by running, jumping, fighting, interrupting, or acting out, these girls (and a small percentage of boys) learn how to stimulate themselves inside their own heads.
If internal self-directed-stimulation sounds esoteric, stop and remember the last really good movie you watched or book you read. Did you laugh or cry? Did your heart race?
Yet the stimulation producing those physiological responses was entirely internal — it was all in your head. You were simply reading words on a page and creating an imagined world inside, or watching images flickering on a screen and giving them reality in your own mind.
So this majority of girls and minority of boys with a strong “need for aliveness” or urge for the hunt who are not externally hyperactive find they can satisfy that need internally. They create worlds of fantasy and imagination to explore while the teacher is droning on about something boring.
They carry on wild, non-stop conversations in their own heads, providing them with a ready source of internal stimulation and distraction. They’re interrupting every bit as much as their hyperactive peers, but it’s invisible on the outside because they’re interrupting themselves. Instead of seeming hyperactive (which they are, inside), they appear to be in a daze, off in a dream, their head in the clouds.
But it’s the same root cause to both ADHD and non-hyperactive ADD: the need for aliveness, the need for the hunt. What we’re seeing here are simply two different ways of getting that need fulfilled.
Boys are encouraged by our culture to be physical to meet that need, and carry around testosterone that further aggravates the situation. Girls are encouraged by our culture to be mental/internal/emotional to meet that need, and may carry hormonal and biological imperatives to be less aggressive then men.
Again, if this sounds sexist, ask yourself what percentage of serial killers, rapists, and mass shooters — all dysfunctional hunters of humans — are women.
Along those same lines, some have suggested in the context of my Hunter/Farmer hypothesis that prehistoric men were hunters while women, in those societies, were typically gatherers of local plants. This is, broadly, conventional wisdom, although history shows that there have been numerous ancient societies where women were both hunters and warriors.
In fact, Scientific American recently published an article completely refuting the theory that there’s a genetic difference in hunting ability between men and women. It’s titled The Theory That Men Evolved to Hunt and Women Evolved to Gather Is Wrong and makes a lot of sense. Which mostly brings us back to acculturation as the main variable.
The proof that in both males and females with ADHD what we all experience is the need for aliveness, for the hunt (rather than neurochemical imbalances, brain damage, frontal lobe dysfunction, cognitive impairment, failure of inhibition, or any of the other theories to explain ADHD) is that the symptoms of both “dreamy” and “hyperactive” ADHD are relieved by the same thing: stimulation.
When dreamy types or hyperactive types are put into a classroom with a Robin Williams-like teacher, they can both suddenly learn and pay attention: their need for aliveness is met by the high-stimulation environment.
Similarly, when boys/men or girls/woomen with ADHD are given stimulant drugs, the hyperactive ones calm down externally and the dreamy ones report that their “internal conversation” quiets down: by turning up their sensory volume control, the stimulant drugs are chemically meeting their need for aliveness.
Thus, we can understand what we’ve been seeing and knew intuitively to be true: these stereotypes of male and female ADHD are simply two faces of one in the same thing: an unmet need for aliveness, a craving to engage in the hunt.