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AuDHD in women: ADHD and autism, burnout and other symptoms are often overlooked. Learn more about ADHD and autism and their overlaps.

The overlooked group: AuDHD in women – why the diagnosis often comes too late

Have you functioned your entire life, yet every day still takes an enormous amount of energy? Were you considered "sensitive," "dreamy", or "too emotional," but never someone with neurodivergent neurobiology? Then you may be one of the many women whose AuDHD is only recognised in adulthood. AuDHD in women, the co-occurrence of autism and ADHD, is one of the most underdiagnosed phenomena in psychiatry. Not because women are less likely to be affected, but because their symptoms look different from what is being sought.

🧠 A note about our design (neuro-inclusive reading)

We know that long texts are often exhausting for neurodivergent brains. That's why this article is designed to be accessible:

·         TL;DR: A summary is provided below.

·         Scannability: Important terms are printed in bold so that you can grasp the key points at a glance.

·         Clarity: Short paragraphs, no walls of text.

TL;DR (the most critical points in brief):

·         AuDHD in women often manifests itself internally: as daydreaming, social exhaustion, inner restlessness and chronic overload, rather than visible hyperactivity or obvious social conspicuousness.

·         Girls with AuDHD rarely stand out because they adapt rather than disrupt. They wear a double mask, hiding both autistic and ADHD-typical traits.

·         Emotional dysregulation in women with AuDHD is often misdiagnosed as borderline personality disorder or bipolar disorder.

·         Hormones directly influence AuDHD symptoms: oestrogen modulates the dopamine system and sensory threshold. This is why the overall symptom burden fluctuates with the menstrual cycle, during pregnancy and during the menopause.

·         A late diagnosis is not a failure; it is the result of a system that systematically overlooks AuDHD in women.

Why is AuDHD so often overlooked in women?

When experts think of autism, they usually have a specific image in mind, and when they think of ADHD, they have another. Both photos are male-dominated. The autistic prototype: a boy who is interested in timetables and avoids eye contact. The ADHD prototype: a boy who cannot sit still and disrupts class. Women with AuDHD do not fit either of these images and therefore fall through the diagnostic grid twice.

The problem starts with the diagnostic criteria themselves. For decades, both autism and ADHD research relied on predominantly male samples. The behavioural markers derived from these samples are not gender-neutral symptoms. They represent male-coded expressions of neurological conditions that can manifest themselves in fundamentally different ways in girls and women.

There is also a special feature of AuDHD: autism and ADHD can mask each other. The spontaneity and social impulsiveness associated with ADHD can weaken the impression of autism. The woman appears "sociable," even though social interaction exhausts her. Conversely, the autistic need for structure can compensate for the disorganisation typical of ADHD: the woman appears "organised" even though she collapses from exhaustion in the evening. In women who have also learned to hide their difficulties from the outside world, this double masking becomes almost perfect and virtually invisible to diagnosticians.

The "well-behaved" child: how girls with AuDHD fall through every grid

The so-called gender diagnostic gap is even more pronounced in AuDHD than in individual diagnoses. For ADHD alone, the gender ratio in clinical samples is about 3:1 to 4:1 in favour of boys. For autism, it is up to 4:1. With AuDHD, this effect is magnified: the intersection of both diagnoses in women is the most underrepresented field in all neurodivergent diagnostics.

Girls with AuDHD develop a dual compensation strategy at an early age. The autistic part learns to memorise social scripts, imitate others' facial expressions and gestures, and force eye contact. The ADHD part learns to suppress inner restlessness, curb impulsivity, and compensate for forgetfulness by obsessively writing lists. From the outside, the result looks like a "normal," perhaps somewhat quiet or sensitive girl. From the inside, it feels like a full-time job without a break.

Teachers, the central gatekeepers for diagnostic referrals, reliably recognise expansive behaviour. A child who disrupts class triggers a reaction from the system. A child who struggles quietly, who bites their nails bloody under the table (stimming), who stands alone during recess because the stimuli of the schoolyard dynamics are too much, who forgets their homework but doesn't bother anyone. The child is classified as "shy," "sensitive," or "dreamy." The symptoms of AuDHD are present, but they do not fit the pattern being sought.

How does AuDHD manifest itself in adult women?

Many women are not diagnosed with AuDHD until they are 30, 40 or 50 years old, often after years of experiencing symptoms that they could not explain to themselves and for which they have accumulated a whole collection of misdiagnoses. The presentation of AuDHD in adult women differs significantly from the clinical prototypes of both individual diagnoses.

The inner conflict as a constant companion: The core characteristic of AuDHD, the tension between the autistic need for routine and the ADHD-driven desire for novelty, takes on a specific form in women. Many describe the feeling of being constantly torn between two poles: the desire to leave everything as it is and the unbearable boredom of repetition. This conflict is rarely visible to the outside world. It rages inside and wears them down.

Compensation as a survival strategy: Adult women with AuDHD often develop highly complex systems to hide both their autistic and ADHD-related difficulties. Colour-coded calendars for executive dysfunction. Rehearsed small talk scripts for social interaction. Obsessive routines for morning organisation. Strategic retreat after social events, disguised as "introversion". Each of these systems works, but the energy consumption is enormous. The woman "gets everything done", but the fact that she expends three times as much energy as neurotypical people is invisible to outsiders.

Chronic shame and the feeling of being fundamentally wrong: Women with AuDHD report a strikingly high incidence of a deep-seated sense of inadequacy. All their lives, they have been told that they are "too much" (too emotional, too intense, too sensitive) and at the same time "too little" (too disorganised, too forgetful, too slow). Without the explanation of an AuDHD diagnosis, they internalise these contradictory attributions. The result is toxic shame that permeates all areas of their lives.

Emotional dysregulation in women with AuDHD: Why borderline or bipolar disorder is so often diagnosed

One of the most consequential diagnostic problems in women with AuDHD is the confusion of emotional dysregulation with borderline personality disorder (BPD) or bipolar disorder. In AuDHD, emotional dysregulation is not a side effect; it is a central feature of both conditions. ADHD impairs the ability to modulate the intensity of emotional responses. Autism impairs the ability to identify and process emotions at all (alexithymia). When the two come together, a pattern emerges that superficially resembles borderline disorder.

AuDHD versus borderline – what are the differences? In BPD, emotional instability is typically linked to relationship dynamics and fears of abandonment: idealisation and devaluation, unstable self-image, and fear of being abandoned. In AuDHD, on the other hand, the triggers are specific: sensory overload, disruptions to routine, executive overload and social exhaustion. An unexpected change of plan triggers a meltdown, not because the woman is "overreacting", but because the autistic nervous system needs predictability and the ADHD brain does not have the resources to reschedule flexibly.

Confusion with bipolar disorder also occurs: phases of intense productivity and euphoria (hyperfocus in ADHD) can be misinterpreted as hypomanic episodes. The subsequent breakdowns, often autistic shutdowns after sensory overload, are interpreted as depressive episodes. The crucial difference: in bipolar disorder, episodes last for days to weeks and frequently occur without external triggers. In AuDHD, the changes are rapid, situation-dependent and directly linked to sensory overload or energy balance.

The consequences of misdiagnosis are serious: mood stabilisers or atypical antipsychotics address neither the dopaminergic deficit (ADHD) nor the sensory processing issues (autism). Stimulants that could treat the ADHD component are usually not even considered in cases of borderline or bipolar diagnosis. Women with undiagnosed AuDHD may thus spend years in therapies that miss the actual cause or are even harmful: DBT elements such as "radical acceptance" can reinforce masking in autistic women who have already suppressed their needs throughout their lives, rather than resolving it.

How do hormones influence AuDHD symptoms in women?

One aspect that has a particularly drastic effect on women with AuDHD is the influence of sex hormones on the overall symptom burden, affecting both components simultaneously. Oestrogen not only modulates dopaminergic neurotransmission (relevant for ADHD), but also influences serotonergic activity and sensory stimulus threshold (relevant for autism). This means that hormonal fluctuations affect two systems in women with AuDHD.

Specifically, oestrogen increases dopamine synthesis, enhances dopamine receptor binding and inhibits dopamine degradation by the enzyme COMT. At the same time, it modulates sensory processing: when oestrogen levels are higher, the stimulus threshold tends to be higher, and when oestrogen levels are lower, it decreases.

Follicular phase (days 1–13): Oestrogen rises. Many women with AuDHD report better concentration, higher frustration tolerance and, equally important, higher sensory resilience. Noises, light and social stimuli are easier to process.

Ovulation (day 14): Estrogen peak. Clinically, those affected report their "best phase": highest cognitive performance, most stable mood, and the best tolerance for sensory and social demands.

Luteal phase (days 15–28): Oestrogen drops. For women with AuDHD, this means a double setback: ADHD symptoms worsen (concentration, emotion regulation, impulsivity) and, at the same time, the autistic stimulus threshold decreases. Noises that were tolerable during the follicular phase become unbearable. Clothing that was previously no problem becomes torture. The masking that was still successful in the first half of the cycle breaks down. Many women describe the second half of the cycle as "being a different person".

Premenstrual phase (days 25–28): Oestrogen at its lowest point. AuDHD symptoms reach their peak. Here, the deterioration often overlaps with premenstrual dysphoric disorder (PMDS), which occurs significantly more frequently in women with ADHD. When combined with autism, the premenstrual phase can lead to massive shutdowns, meltdowns and the complete breakdown of social functioning.

AuDHD and menopause: Why perimenopause is often a diagnostic turning point

A clinically particularly relevant phenomenon is the initial manifestation or dramatic worsening of AuDHD symptoms during perimenopause, typically between the ages of 40 and 55. The progressive decline in oestrogen leads to a permanent reduction in dopaminergic activity and a permanently lowered sensory stimulus threshold. Compensation mechanisms that have worked for decades break down simultaneously on both levels.

Many women seek psychiatric or psychotherapeutic help for the first time during this phase of their lives. The symptoms are often classified as "menopausal symptoms" burnout,, or depression. Concentration problems, forgetfulness, sensory hypersensitivity, emotional instability, chronic exhaustion, and social withdrawal – all of these fit into the menopause narrative. If no one asks about AuDHD, no one will find AuDHD.

A careful questioning of the patient's history is crucial in these cases: Have there always been difficulties with organisation and time management? Was school "doable, but endlessly exhausting"? Has there always been a particular sensory sensitivity? Have social situations always been exhausting, even if they didn't appear that way to others? If so, this may not be a new problem, but a lifelong one that is decompensated by the drop in hormones.

This has direct consequences for treatment: coordinating hormone replacement therapy and ADHD medication can make a significant difference for women with AuDHD going through the menopause. Some clinicians are already working with cycle-adapted stimulant dosing in perimenopause; the evidence is still limited, but clinical experience is promising.

Recognising AuDHD in women: what to look for in diagnosis

No standardised screening tool captures AuDHD as a whole. Autism and ADHD are diagnosed separately, and both procedures have limited sensitivity for female presentations. The AQ (Autism Quotient) asks about behaviours that women conceal through masking. The WURS (Wender Utah Rating Scale) focuses on externalising ADHD symptoms, which are less likely to be the main complaint in women. The ADOS-2 can lead to false-negative results due to effective camouflaging.

Gender-sensitive AuDHD diagnostics should take the following aspects into account:

To assess development, specific questions should be asked about "silent" difficulties. Not just "Did you disrupt the class?", but: "How much energy did school cost you? Did you copy the behaviour of other children to function socially? Did you have intense interests that you hid from others?"

Compensation strategies are a key diagnostic indicator and often the visible symptom in women with AuDHD. The crucial question is not "Are you functioning?" but "What does it cost you to function?"

The psychiatric history deserves special attention. Multiple previous diagnoses, the classic cascade of depression, anxiety disorder, eating disorder and possibly borderline personality disorder, can reveal a pattern that points to undiagnosed AuDHD. Each diagnosis may have been plausible on its own. Only when viewed together does the everyday basis become apparent.

In women, a history of hormonal changes often provides the decisive clue: are there cycle-dependent symptom patterns? When did the symptoms first appear, during puberty, after pregnancy, or during perimenopause? If the severity of the symptoms correlates with hormone levels, this is a strong indication of a dopaminergic sensory basis.

What helps? Therapy and everyday strategies specifically for women with AuDHD

The treatment of AuDHD in women requires an approach that addresses both conditions simultaneously and incorporates the specific female experience.

Information as a foundation: Understanding that the internal conflict between routine and novelty, exhaustion after social situations, and emotional intensity have neurobiological causes and are not character flaws can resolve decades of self-reproach. For many women with AuDHD, the moment of diagnosis is the beginning of reconciliation with themselves.

Medication that takes the cycle into account: Stimulants address the ADHD component and can indirectly reduce the overall burden because improved executive functions also facilitate the management of sensory needs. The dosage should take the hormonal cycle into account: the correct dose in the follicular phase may be too low in the luteal phase. Open dialogue with practitioners about cycle-dependent fluctuations is crucial.

Psychotherapy: Adaptation rather than the standard protocol. CBT can be effective, but must be adapted to neurodivergent cognition. Schema therapy approaches are particularly well-suited to working on the schemas that arise from decades of double compensation in women with AuDHD, especially the inadequacy schema and the submission schema. Mindfulness-based techniques should be used with caution: interoceptive attention can cause sensory overload in autistic women rather than help them.

Everyday strategies that serve both poles: "flexible structure," fixed framework conditions within which variability is possible, address the core conflict of AuDHD. Specifically, the following has proven effective for women with AuDHD: consciously planning sensory breaks (especially in the luteal phase), externalising executive functions (visual timers, body doubling), consciously reducing masking in safe contexts, and, perhaps most importantly, adapting one's own energy balance to the cycle instead of demanding the same amount from oneself every day.

AuDHD in women in relationships and motherhood: what changes when the system becomes overloaded

One aspect that is underrepresented in the clinical literature is the impact of AuDHD on partnerships and parenting. Women with AuDHD often bear a triple burden in relationships: the mental load (appointments, household chores, social organisation), sensory processing of the home environment (children crying, mess, constant touching), and the emotional work in the partnership. Each of these levels would be stressful on its own, but together they create a level of chronic overload that is not visible from the outside.

Motherhood poses a particular challenge for women with AuDHD because it exponentially increases demands on executive functions while drastically reducing resources for compensation: sleep deprivation worsens ADHD symptoms, the constant sensory overload from a toddler strains the autistic nervous system, and hormonal changes after birth destabilise the dopamine system. Many women are not diagnosed with AuDHD until they become mothers because their previous compensation strategies collapse under this new stress, and it becomes apparent for the first time how much energy their previous "functioning" actually cost them.

Without knowledge of the AuDHD diagnosis, the resulting difficulties, forgetting agreements, emotional overreactions, and the need to withdraw are interpreted as a lack of interest, an inability to form relationships, or "overwhelm that others also experience." The shame and self-reproach intensify. A diagnosis does not change reality here, but it does change self-perception. And that changes everything.

Summary: The most important findings on AuDHD in women

·         AuDHD in women is not less common; it is just less frequently recognised. The diagnostic gap is even greater for dual diagnoses than for single diagnoses of ADHD or autism.

·         Girls with AuDHD wear a double mask: they compensate for both autistic and ADHD-typical difficulties and thus do not stand out as either "ADHD children" or "autistic".

·         Emotional dysregulation is a core feature of AuDHD, but in women, it is often misdiagnosed as borderline or bipolar disorder. The mechanisms are fundamentally different: in AuDHD, triggers are sensory and situational, while in BPD, they are relationship-dynamic.

·         Hormones have a dual effect on AuDHD: oestrogen modulates both the dopamine system (ADHD) and the sensory threshold (autism). Symptoms fluctuate with the cycle and may first become apparent during perimenopause.

·         Multiple previous diagnoses, especially the cascade of depression, anxiety disorder, eating disorder, and borderline personality disorder, may indicate undiagnosed AuDHD.

·         Effective therapy must address both conditions simultaneously, take the cycle into account when prescribing medication, and help the woman reduce the double masking rather than reinforce it.

·         It is never too late for a diagnosis. For many women with AuDHD, the moment of diagnosis is the beginning of reconciliation with themselves and the start of a life in which they no longer have to fight against their own neurology.

Related:

AUDHD: Autism and ADHD – A complex combination

ADHD and autism: Diagnosis within the spectrum of neurodiversity

AuDHD, Masking & Burnout: Causes and help for those affected by burnout in ADHD and autism

AUDHD & Spoon Theory: More energy in everyday life with ADHD and autism