Mention the term ADHD and what comes to mind is usually a picture of a hyperactive boy. If that’s where your mind takes you when you think of ADHD, you’re not alone. Unfortunately, this perception means many women with the condition go through most of their lives without being diagnosed. And this is happening in Singapore too.

ADHD stands for Attention-Deficit Hyperactivity Disorder. Dr Tay Kai Hong, psychiatrist from Private Space Medical, explains it’s a brain condition characterised by inattention, impulsivity and hyperactivity. He also reveals it is estimated that, globally, 5 per cent of children are born with ADHD. And about half of the children with ADHD will have symptoms persist into adulthood.

“ADHD brains are driven by novelty, interest, urgency and a sense of challenge, rather than by traditional notions of ‘responsibilities’ and ‘priorities’,” says Dr Tay. “Because many modern-day institutions value organisational skills and efficiency over spontaneity and creativity, people with ADHD may struggle to thrive in schools and workplaces. This can lead to a low self-esteem, anxiety and other mental-health difficulties.”

The symptoms of ADHD

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Dr Tay says there are two clusters of symptoms to look out for – symptoms of inattention and symptoms of hyperactivity/impulsivity.

Symptoms of inattention include carelessness, forgetfulness and distractibility. There is also a persistent difficulty in sustaining attention. Dr Tay says people with ADHD have a chronic tendency to procrastinate on tasks which require sustained mental effort. They also have great difficulty in organising tasks, activities and physical spaces. Because of poor time management, deadlines are often missed. The person may appear to be daydreamy and often preoccupied in his or her own thoughts, even when spoken to.

Symptoms of hyperactivity/impulsivity include restlessness, being unable to stay in one’s seat or stay in queue, excessive talkativeness, frequently interrupting others, and appearing to be tactless and impatient in social interactions. Dr Tay gives an example of how a person with ADHD may blurt out answers even before the question is asked because he or she is not able to resist the impulse to talk.

“ADHD symptoms start from childhood and are persistent and impairing, such that the person’s life is adversely affected. The symptoms may affect the person’s academic achievement, work performance, social relationships or leisure activities,” says Dr Tay.

Women’s ADHD symptoms are different

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Another reason why ADHD is often undiagnosed in women is because symptoms show up differently in women. Dr Tay reveals that women with ADHD tend to manifest predominantly symptoms of inattention, which are more subtle and difficult to detect compared to symptoms of hyperactivity and impulsivity.

Women with ADHD “may appear daydreamy and caught up in their own thoughts”, he explains. Their carelessness and forgetfulness may be overlooked as personality traits or attributed to a lack of effort.

Also, symptoms of inattention may be conflated with anxiety or depression, which do occur at higher rates in women than men.

“Indeed, anxiety disorders and depression commonly co-occur with underlying ADHD, and they may be a secondary consequence of ADHD-related impairments,” Dr Tay shares. “Imagine the immense anxiety generated due to constant procrastination of major assignments to the very last minute. Clinicians may diagnose the anxiety disorder and overlook the possibility of underlying ADHD. In other words, the higher prevalence of depression and anxiety in women tend to mask and overshadow more subtle ADHD symptoms.”

“Furthermore, diagnostic tools for ADHD were originally designed to detect ADHD in young children, particularly hyperactive boys with disruptive behaviours in the classroom,” he adds. “These diagnostic tools are not perfect and have their limitations when directly applied to an adult female population.”

Dr Tay admits that ADHD in women is less well-understood and research in the field is ongoing. Therefore, it is important for doctors and patients alike to reconsider the historical perspective of ADHD as a purely behavioural problem and “pay more attention to the subtler and more internalised – but no less impairing – experiences of women with ADHD”.

How is ADHD diagnosed?

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In Singapore, the assessment and diagnosis of ADHD are typically done by psychiatrists. The specialist takes a thorough history from family members and performs a mental-state examination through observation and conversation.

“It is essential to assess for other conditions such as anxiety, depression, addictions or other developmental or learning disorders including autism and dyslexia,” says Dr Tay. “Historical accounts from teachers in report books are useful to get an idea of how the person was as a young child and to establish that symptoms and related impairment were present from childhood.”

When it comes to complex or borderline cases, a more detailed neuropsychological assessment may be necessary. It is performed by a neuropsychologist and takes a longer time.

Women with ADHD

34-year-old operations and marketing manager Andrea Koh was only diagnosed with ADHD at the age of 32. Credit: Andrea Koh

Andrea Koh, a 34-year-old operations and marketing manager, was diagnosed with ADHD at the age of 32. She recalls being “the feisty kid with big emotions that touched everything, was always late, kept losing things and a very slow eater (because I couldn’t sit still or stop talking!)”.

As she grew older, she developed an unhealthy gaming habit to cope with the stressors in life and spent most of her days hiding out in online games. Since becoming a mother, she suffered from extreme forgetfulness and fatigue and there were frequent instances of her heating up cold milk until it was bubbling in the milk warmer and leaving the house keys hanging outside for hours.

“I thought it was ‘baby brain’ or sleep deprivation but years later, when I was still stuck in the same cycle, constantly tethering towards being burnt out, it really made me question what was wrong with myself and why I was unable to adult properly,” she reveals.

“I struggled to stay afloat for my family until the pandemic came around, but my coping mechanisms fell through during circuit breaker and I had a breakdown. I mustered up the courage to seek professional help as my last resort and at age 32, I was finally diagnosed with ADHD and anxiety,” she adds.

Andrea went to the polyclinic to speak to a GP about her suspicions. When she later went to see a psychiatrist, she brought along her report books and her dad to help to share her history. She was diagnosed with ADHD during the first session.

“After diagnosis, besides the relief and self-doubt, there was a lot of grief afterwards,” Andrea shares. “ADHD is largely genetic so it means that I likely passed it on to my son. I knew how much ADHD had affected various parts of my life, from academics to relationships, so it made me feel grieved about the lost opportunities. I also feared that my son would also go through the same pain that I did.”

Before she was diagnosed, Andrea couldn’t find much information on ADHD in Singapore. She thinks that, in our Asian society, most of us grow up none the wiser about how to manage our mental health and there is a lot of shame and stigma attached to it. When she later searched for support groups, she found most were for parents with ADHD kids.

Since May 2022, she has a full-time job at Unlocking ADHD, a non-profit organisation that works to develop tools to equip the ADHD community in Singapore to manage life better.

“Being able to make a difference and play a part in building our community and being around others like me has helped me to accept myself and regain my confidence again. I no longer feel like the odd one out,” says Andrea.

For Chng Li Ming, her ADHD symptoms began in pre-school, but she only got diagnosed when her coping mechanisms were breaking down when the Covid lockdown hit. Credit: Chng Li Ming

Chng Li Ming, 37, says her ADHD symptoms began in pre-school. Her primary school teachers couldn’t understand why she was not consistent academically, despite appearing to be a bright child. A few teachers thought she was being rebellious on purpose when she made careless mistakes, forgot about homework/spelling or forgot to bring books/files and money to pay for school-related expenses. Despite all this, she went on to the top stream in secondary school. No one ever thought she had any learning difficulties and blamed the unexplainable behaviour on being rebellious and lazy.

She got by with mediocre grades later on as she had no coping mechanisms or structure to deal with studying and ended up sleeping in classes and not doing much homework throughout her secondary and junior college days. During her undergraduate days, she found lectures tough to pay attention to and was often gaming or chatting online in class. But when she did her part-time Masters program, she managed to juggle a full-time job and attend night lectures and graduated with pretty good scores.

The senior manager/administrator, like many others, thought ADHD was for hyperactive boys. When her coping mechanisms were breaking down once again in her adult life when the Covid lockdown hit, she started reading up about ADHD.

“When I googled my symptoms, I finally came across ADHD and the DSM-5 criteria, and it felt like everything was falling into place, I finally can explain many of my difficulties in life,” she recalls. “I went on to do an ADHD quiz online, which scored relatively high, and it told me I should seek a medical practitioner for diagnosis. By the time I went to see a psychologist and psychiatrist for assessment, I was already pretty sure about it..

“This also explains why a lot of adult ADHDers who just got their diagnosis tend to not feel so surprised, but more of a range of feelings from grief to relief,” she adds. “We know we struggled our whole lives and the diagnosis just puts a name to our misunderstood struggles and provides us with a chance to seek out therapy, medication and healthy coping mechanisms.”

The treatment of ADHD

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This usually comprises a combination of lifestyle strategies and medications. Dr Tay reveals habits which may prove helpful for ADHD include:

  • Break up big tasks into smaller ones to make work more manageable and less daunting. This can help reduce the tendency to procrastinate. 
  • Write down a to-do-list and set arbitrary deadlines to sustain motivation to progress towards a goal. 
  • Use time-tables, calendars, and arbitrary deadlines to give more structure to the day.
  • If workspaces are too messy, take time to declutter and organise the space to facilitate clarity of thought and reduce distractions. Put your phone away while working.
  • Balance between the need for structure and routine, with the ADHD brain’s need for stimulation, novelty, variety and challenges. Swinging from one extreme to another is seldom sustainable. 
  • Exercise daily or at least three times per week. This will help people with ADHD to relax, sleep better, and improve their focus.
  • If you have to procrastinate, use positive procrastination. This involves taking short breaks from work to do other productive tasks instead of doing mindless and unproductive activities. Changing things up keeps the ADHD brain engaged and can improve productivity.

“Medications are proven to be safe and effective for ADHD when used in conjunction with lifestyle strategies,” says Dr Tay. “Methylphenidate is the first-choice medication in Singapore and is a prescription-only medication available at most mental health clinics and restructured hospitals. The medication increases levels of certain neurotransmitters in parts of the brain which governs executive functioning, impulse control, and focused attention, thereby strengthening the control centre of the brain.”

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Side effects of medication includes suppression of appetite, weight loss, increased jitteriness, anxiety, insomnia and headaches. There are different formulations of the medication. They vary in terms of their duration of action, which can last from 4 hours to 12 hours.

Medication is not a cure for ADHD but a tool to manage symptoms. Dr Tay says that ADHD symptoms often improve with age as adults with ADHD implement new habits and put in place routines to manage the symptoms. This happens over time as they learn by trial and error what works and what does not. The price of missed diagnosis and delayed treatment, however, “may be lost opportunities and unfulfilled potential in the most productive and fruitful years of a person’s life”.