Editor’s Column: Women & ADHD on Front Street

Adriane M. F. Sanders, TIP Editor

Inhale. Exhale. I have actively tried not to write this particular column. I have come up with various alternative topics, and yet, when I sat down to put words on the page, my hands and heart took over. In the summer of 2022, in the last year of my 30s, I was officially swept into the phenomenon that is late, female, ADHD diagnosis. Inhale. Exhale. I have said these words out loud to exactly 10 people: 3 of which were mental health care professionals, 1 of which was one of my graduating grad students who unknowingly contributed to me seeking the diagnosis, 0 of which are family members to whom I’m not married.

ADHD has been part of the DSM in some version since 1968: introduced as “hyperkinetic reaction of childhood,” followed by attention-deficit disorder (ADD) with or without hyperactivity in 1980, and then attention-deficit/hyperactivity disorder (ADHD) in 1987, with the inclusion of ADHD subtypes of predominantly inattentive, predominantly hyperactive-impulsive, and combined (Epstein & Loren, 2013). However, the disorder has been primarily studied and diagnosed in young white men, largely overlooking “female presentation in both research and clinical settings” (Hearing, 2023; Hinshaw et al., 2022). Research and therapeutic and clinical training have considerable catching up to do in order to better prepare professionals in understanding and recognizing female presentations of ADHD (kudos to the recent calls for a “paradigm shift” toward including more diverse and historically underrepresented groups in all clinical research and practice, e.g., Jaffee, 2022). However, women are not waiting for the field to catch up: “in 2018, the CDC reported an increase of 344% in women seeking medication for ADHD, while Google searches in the U.S. related to ADHD in women more than doubled between March 2021 and March 2022” (Anderson et al., 2018; Hearing, 2023).

Women tend to be diagnosed later in life, with the average age between 36 to 38 years old (Quinn, as cited in McCarthy, 2022). Other commonalities among women with ADHD is that they often present with the inattentive type and have adapted (often extreme and/or elaborate) coping strategies, many of which “mask” their symptoms, as a means to overcome struggles and adapt to living years without a diagnosis (Hearing, 2023). In other words, ADHD in girls and women often presents differently than in boys and men (Ruskin, 2022). One possible explanation for women being mis- or undiagnosed with ADHD is that it’s simply easier to notice (read: more disruptive) in young boys. Alternative theories suggest (a) the potential for “adult-onset” ADHD, particularly for women (i.e., the symptoms do not show up until later in life); (b) a “female protective effect” in which girls and women must encounter more stressors for underlying ADHD symptoms to emerge; and (c) hormonal fluctuations throughout the lifespan are to blame (e.g., the estrogen-dopamine relationship; McCarthy, 2022; OHSU Center for Women’s Health, n.d.; Young et al., 2020).

Ever since this diagnosis, I have felt mostly validated but also an overwhelming urge to poke holes in the diagnosis and explain it away. As I’ve been exploring this new layer of identity and community, I find that both the personal and societal urge to dismiss this type of diagnosis, particularly for adult women, is pretty typical. Perhaps you are also questioning some experiences you’re having and wondering if it could be ADHD, or maybe a friend has an old or new ADHD diagnosis. The following is a list of real statements that are often said (by the individual, well-meaning friends/family, and/or health practitioners) when trying to reconcile these patterns of thinking, feeling, behaving with an outdated understanding of ADHD, particularly when these patterns are presenting in women (see the resources list at the end for Tracy Otsuka’s own compiled list).

It’s not ADHD…:

1.  Everyone’s easily distracted at times.

• Sure! However, I have come to learn that not everyone needs an elaborate, exhausting daily system to remember things and tasks that range from very basic to very big/important.

2.  It’s just motherhood/parenthood.

• It is hard to refute this one. Depending on the age of your child(ren), you may not be able to finish a complete thought or sentence without being interrupted. However, if you too find yourself asking “Is it ADHD or is it just motherhood?,” you may be surprised to learn that ADHD is linked with our hormones (McCarthy, 2022). You may not be surprised to learn that one of the many many things to change with motherhood are your hormones. And like other types of psychological disorders and differences, major life changes can exacerbate even the most well-managed (or well-masked) symptoms. Motherhood is nothing if not MAJOR.

3.  It’s life in the 21st century with all its technology and social media.

• Though these dopamine-rich companions of daily life certainly don’t make sustained focus any easier, if this is all it took for a diagnosis, then we’d have a difficult time explaining all the other symptoms and behaviors that come along within the constellation of ADHD.

4.  I tricked the diagnosing mental health care provider. (This is a personal contribution to the list.)

• Setting aside the arrogance of this one, I do know lots of things about psychology, and I can be very convincing. However, I have little first-hand knowledge about clinical assessments (despite all the mental health talk around this column, I was I-O from the beginning!). There are several embedded deception scales across the self-report, peer-report, behavioral, and observational-based assessments; and I was evaluated/diagnosed by a vetted, established mental health professional. I’m good, but I don’t think I’m good enough to accidentally fake a disorder–I can’t even lie on my insurance company’s wellness checks.

5.  No one in my family has ADHD.

• Is it possible that no one in your family has an ADHD diagnosis (nor, perhaps, any other mental health diagnosis)? We know about the reduced likelihood of older generations to seek mental health support (APA, 2018).

6.  I was a straight A student in K–12 and very involved in and out of class—an overachiever. Doesn’t this show up in early childhood? Don’t children with ADHD have bad grades?

• This one derives from limited and outdated ADHD stereotypes (Mowlem et al., 2019). For example, I loved school and my teachers all the way into grad school, so much so that I wanted to stay in it for my career. Researchers (and diagnosed individuals) have known for some time that there actually isn’t a deficit of attention in this condition. For activities and tasks that are engaging and interesting to the individual, they can easily persist and perform. Despite these very pro-school behaviors, there were potential indicators that were overlooked because I was a girl (Young et al., 2020). I received multiple report cards noting endearing characteristics such as “talks excessively” and “worrywart,” but these were just seen as girl behavior.

7.  (Related to above) Don’t children with ADHD have behavioral problems in class?

• ADHD behaviors can show up differently across gender given our different gender norms and expectations. For example, young boys may keep getting up in class in a way that is considered distracting or problematic by adults. Young girls may get up so they are the first volunteer to help the teacher pass out materials. Both examples demonstrate a potential impulse-control or hyperactivity issue common in ADHD, but one is considered socially acceptable, and even desirable, particularly for young girls who are taught to be helpful and giving at a young age.

8.  I can sit still/I am not hyperactive.

• Get this–the hyperactivity can be cognitive (PsychCentral, 2022)! For example, I was shocked to learn that not everyone has an endless stream of thought from the moment they wake up until the time they fall asleep. Outside the classroom, the symptom of impulsivity can manifest in risk taking behaviors that are often brushed off as typical teenage “stuff” (Young et al., 2020). However, these may eventually turn into socially acceptable but maladaptive adult behavior (e.g., alcohol abuse).

9.  I earned a PhD! Or achieved some other demonstrable measure of adult success.

• Individuals with ADHD can have significant achievement/success, but consider my case as an example:
  • Exhibit A: Grad school is also when I was diagnosed with generalized anxiety (an incredibly common mis- and co-diagnosis with ADHD; Quinn & Madhoo, 2014); 
  • Exhibit B: It took me 8, productive and fruitful, years to finish (so many fun new opportunities!), and
  • Exhibit C: Potentially the only reason I finished at that point was because I had a successful run on the job market that provided an aggressive and finite timeline.

10.  I am objectively successful.

• Many individuals feel that any mental health diagnosis diminishes their value or worth in some way and society helps reinforce this stigma (much akin to the othering that occurs with bodies of every size). This “lesser” perception may be particularly true for disorders that impact learning and performance. Given this pervasive internalized messaging, it’s no wonder we may find ourselves assuming that ADHD and success are incompatible. 

Given the stereotypes, stigma, and outdated knowledge about ADHD, individuals who are struggling with this symptomology may feel caught in the middle of a (presently) losing battle of optics: work to acquire/use this label despite the stigma or skirt a diagnosis in favor of trying to blend in with neurotypical experiences of occasional, mild episodic sensations of struggle, overwhelm, overstimulation, short-temper, impatience, distraction, hyperfocus—only these can be everyday experiences for neurodivergent individuals. As is often the case when stigma is involved, there is an undercurrent of fear here too–fear of someone questioning our competence or using a diagnosis against us (only we can do that to ourselves, right?). The thought of someone thinking they “know” something about me without actually knowing me is unsettling. I straddled these battle lines and ultimately inched one toe further into the “label it” camp.¹ Despite immediately seeking an ADHD assessment (once it was on my radar), I too tried on each of the above statements and continued even after the diagnosis.

A Call to Action

But what if there was a different way? What if there was better understanding and easily accessible knowledge available as part of employee health, well-being, and work/life harmony so that every individual didn’t have to reinvent the wheel by piecing together social media videos and podcasts? What if we didn’t try to minimize and dismiss as though everyone has the same struggles and provided established pathways for neurodivergent employee advocacy and awareness? What if we skipped a step in this familiar chain of events and went straight to including voices of all gender identities and people of color for whom the uniquely intersectional challenges compound the neurodivergent experience at work? These questions go beyond ADHD and other forms of neurodivergence. These ideas sound like the work of diversity, equity, inclusion, and accessibility. This is the work of I-Os. To achieve these endeavors, it is our (I-O) responsibility to understand and recognize the need for comprehensive employee wellbeing. To do so, we must take an interdisciplinary, occupational health approach by learning from and partnering with clinical mental health professionals, among others. Such a partnership ensures we all stay in our lanes professionally and ethically to develop a new, informed framework for employee health and, in turn, organizational effectiveness.

In addition to this call to action, my hope in sharing these experiences is that (a) if you recognize yourself in any of this, you’ll feel a little less isolated, and (b) if you have diminished an ADHD diagnosis (yours or otherwise) you’ll join me in taking a step toward honoring and centering this identity right next to the ones we more readily accept.² Let’s put adult experiences of ADHD and how it impacts our work and nonwork domains out on front street (this issue’s column, The Bridge is ahead of the game). For me, having the lens of ADHD to corral these seemingly unrelated experiences, “quirks,” and difficulties is continually affirming and empowering. It may be for you too. There are many in our SIOP and work communities having similar experiences across gender identities, across forms of neurodivergence and other invisible health conditions. Let’s I-O the hell outta this!

Stay tuned for next issue where I’ll do a deep dive on my inner child! JUST KIDDING.

Resources:  

• Tracy Otsuka’s podcast episodes that clicked and got ADHD on my radar…
  • ADHD for Smart Ass Women, Episode 178: No, it's not ADHD…
  • ADHD for Smart Ass Women, Episode 40: How to prepare to meet with your ADHD doctor  
• The podcast I keep coming back to…
  • Women & ADHD: Interviews with Katy Weber
  • Episode 108 specifically: Robin Zheng: Performance anxiety, academia, & pressure to succeed

Special thanks to the 11th person I told, a dear colleague (and I-Oer) who reviewed an earlier draft of this column and offered thoughtful feedback and encouragement.

Notes

¹ As evidenced by running this column. However, I continue to go back and forth on this decision. Even as I’m finalizing it, I think, “could I just delete this and not have a Spring column?”

²  Still unsure of sending this. It's a very personal topic for many and I have agonized over getting the right mix of citations, striking the right tone, remaining inclusive while trying to highlight a very individualized experience…

References

American Psychological Association [APA]. (2018, October). Stress in America: Generation Z. APA. https://www.apa.org/news/press/releases/stress/2018/stress-gen-z.pdf

Anderson K. N., Ailes E. C., Danielson M., Lind, J. N., Farr, S. L., Broussard, C. S., Tinker, S. C. (2018). Attention-Deficit/Hyperactivity Disorder medication prescription claims among privately insured women aged 15–44 years — United States, 2003–2015. MMWR: Morbidity & Mortality Weekly Report, 67, 66–70. http://dx.doi.org/10.15585/mmwr.mm6702a3

Epstein, J. N., & Loren, R. E. A. (2013). Changes in the definition of ADHD in DSM-5: Subtle but important. Neuropsychiatry (London), 3(5), 455-458. doi: 10.2217/npy.13.59

Hearing, A. (2023, January 1). The hidden condition that could be crippling the women in your workforce. Fortune. https://fortune.com/well/2023/01/01/adhd-the-hidden-condition-that-could-be-crippling-the-women-in-your-workforce/

Hinshaw, S. P., Nguyen, P. T., O’Grady, S. M., Rosenthal, E. A. (2022). Annual research review: Attention-deficit/hyperactivity disorder in girls and women: Underrepresentation, longitudinal processes, and key directions. Journal of Child Psychology & Psychiatry, 63(4), 484-496. https://doi.org/10.1111/jcpp.13480

Jaffee, S. R. (2022). Editorial: The times they are a-changin’: Paradigm shifts in child and adolescent psychology and psychiatry. Journal of Child Psychology & Psychiatry, 63(4), 357-359. https://doi.org/10.1111/jcpp.13604

McCarthy, L. F. (2022, November 17). Women, hormones, and ADHD. ADDitude. https://www.additudemag.com/women-hormones-and-adhd/

Mowlem, F., Agnew-Blais, J., Taylor, E., & Asherson, P. (2019). Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms. Psychiatry Research, 272, 765–73. https://doi.org/10.1016/j.psychres.2018.12.128.

OHSU Center for Women’s Health. (n.d.). Women and ADHD: What’s the hype? Oregon Health & Science University’s Center for Women’s Health. https://www.ohsu.edu/womens-health/women-and-adhd-whats-hype

PsychCentral. (2022, November 1). What’s the connection between ADHD and racing thoughts? PsychCentral. https://psychcentral.com/adhd/racing-thoughts-adhd#:~:text=Racing%20thoughts%20in%20ADHD%20can,or%20a%20couple%20of%20days.

Quinn, P. O., & Madhoo, M. (2014, June 15). A review of attention-deficit/hyperactivity disorder in women and girls: Uncovering this hidden diagnosis. Psychiatrist.com https://www.psychiatrist.com/pcc/neurodevelopmental/adhd/review-attention-deficit-hyperactivity-disorder-women/)

Ruskin, K. (2022, September 12). For some women with ADHD, TikTok is the first place they felt heard. TIME. https://time.com/6211695/adhd-tiktok-women/

Young, S., Adamo, N., Ásgeirsdóttir, B.B., Braney, P., Beckett, M., Colley, W., Cubbin, S.., Deeley, Q., Farrag, E., Gudjonsson, G.., Hill, P., Hollingdale, J., Kilic, O., Lloyd, T., Mason, P., Paliokosta, E., Perecherla, S., Sedgwick, J.,…Woodhouse, E. (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, Article 404. https://doi.org/10.1186/s12888-020-02707-9