ADHD diagnosis in women and girls: why is it so hard to get treatment?

NB:  If you’re a client or you’re thinking of working with me (I see folks in Athens, Georgia for therapy), consider whether you want to read on, as I talk some about my own life experiences here.

If you think it might be a distraction to your work in therapy, please refrain.

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It was two months into the pandemic and I was doomscrolling.

And then a Reddit post about time blindness captured my attention.

Yes, it was posts on Reddit that led me, a mental health professional, to figuring out I had ADHD.  (Thank you, Reddit.)

After reading posts on rejection sensitive dysphoria and time blindness that moved me to tears, I booked an appointment for an assessment.

How could I, a therapist with years of experience, have missed such a crucial fact about myself? 

And how did the six different therapists I worked with in the first four decades of my life also miss this? 

How did I end up here?

Why girls and women don’t get diagnosed with ADHD (even though they have it)

We have a huge blind spot– both socially and within the mental health field itself—when it comes to girls, women and ADHD.  There are several reasons for this:

Quiet vs loud ADHD symptoms

Women’s ADHD is often invisible–internal hyperactivity, emotional turmoil, and mental fatigue dominate more than external disruption

You know the expression “the squeaky wheel gets the oil”?

Parents and teachers are often the first line reporters of ADHD symptoms in children.

Many girls and women with ADHD have symptoms that cause them a lot of grief internally, but aren’t as easily observed by others because they aren’t as “troublesome.”

Girls and women are more often diagnosed with inattentive type ADHD, which is characterized by ‘quieter’ symptoms (eg, lack of concentration, daydreaming, etc).

Though these inattentive symptoms can and do cause complications in social and academic adjustment, they don’t cause as many overt problems as hyperactive type ADHD (eg, interrupting, impulsive behaviors, etc), which is more commonly diagnosed in boys and men.

 

 

ADHD and hormones

Symptoms worsen with hormonal shifts – menstrual cycle, perimenopause, and postpartum dramatically affect severity

Having symptoms that wax and wane can make it harder to track—both for patients and for providers trying to assess them.

During weeks when symptoms are less prominent, women may question whether they really have ADHD or are just having everyday trouble staying organized and motivated.

Many women manage to develop compensatory strategies and mask their symptoms until midlife when estrogen levels plummet, causing ADHD symptoms to go into unmanageable overdrive.

Irregularities in menstrual cycles during perimenopause can make tracking and identifying symptoms even more complicated.

ADHD, shame, and social expectations

The shame burden is heavier for women – societal expectations of orderliness and caregiving create added pressure

Many people with ADHD have shame about repeatedly forgetting tasks and failing to follow through on projects.

Without a diagnosis and treatment to offer context and support, they (and often those around them) conclude that it is a moral failing or character flaw (eg, laziness).

The added burden of woman-as-caregiver and household organizer compounds the problem, leading many women with undiagnosed ADHD to conclude that they simply aren’t trying hard enough.

This just leads to more redoubled efforts to improve, struggle and failure, and more shame.

Shame tends to make us withdraw and not talk about our inner experiences with others, which can make it harder to recognize what is happening.

ADHD and diagnostic bias

Diagnostic bias persists – criteria based on boys’ presentations miss subtler female manifestations

Diagnostic criteria for ADHD have been refined and improved in more recent versions of the DSM.

It now includes more examples of behaviors and experiences of ADHD in adults.  But, there’s still room for improvement.

Providers, particularly those who have been in the field a while, can carry internal biases they don’t see.

Unless they’ve sought out continuing education on ADHD, they may remain unaware of many undiagnosed people on their caseloads.  This can be especially true of general practitioners who do not specialize in mental health.

ADHD, masking, and 2e folks

Many succeed despite undiagnosed ADHD – achievement masks internal struggle, delaying recognition

Many people who are exceptionally bright and also have ADHD (aka, 2e or twice exceptional people) often struggle with getting an accurate diagnosis.

Their intellect allows them to brute force their way through work, often at the last minute, in order to succeed.

Often, ADHD isn’t detected until the academic or professional demands outstrip a person’s capacity to push through workload, such as in college or graduate school where the volume of reading and writing may simply not allow for last-minute completion.

There are also many misconceptions that having ADHD means you are of below-average intelligence.  This simply isn’t the case.

While there may be a mismatch between performance and ability, that has to do with having untreated ADHD rather than raw intellectual ability.  But, this myth persists and can make getting treatment more of a challenge for those with above-average intelligence.

How I ended up getting diagnosed

As a woman who was diagnosed with ADHD at 39 years old, I struggled first-hand with getting an accurate diagnosis.

When I finally arrived for my assessment, I was both relieved and fearful—hopeful I would get a diagnosis that could help me get treatment, and afraid of what it would mean –to me, and to others—if I did actually have ADHD.

And so there I was– staring at a screen, fingers poised over the spacebar, watching for Xs.

“This is like a game, it’ll be fun,” I thought.

“I wonder if I can get a perfect score.”

Except the Xs displayed only very sporadically.  And sometimes other letters showed up, and I wasn’t supposed to press the space bar for those.

In those long pauses between letters, my mind began to wander.  Without the prophylaxis of my phone to keep me stimulated, I felt my shoulders slump and my impatience build.

I began to feel resentful.

“This is so stupid.  What an absolute waste of time.”

I could feel my attention waning, so I reflexively began to jostle my legs to try and keep me focused and on task.

When the task was finally over, I stalked out to the car.

Intellectually, I knew what the task was for and what it was assessing.

Emotionally, I was pissed that it exposed so many unpleasant states of mind and circumstances that I try hard to conceal and manage everyday:  boredom, as a captive audience, with a task that requires my attention.

I don’t know that the evaluators bothered to watch me monologue in my car about my irritation over that task, but had they overheard me, I’m sure they could have checked the box “low frustration tolerance” twice, for emphasis.

Final thoughts

It is a humbling experience to work in your field for 15 years, only to find out that something has been happening right under your nose.

The journey to getting diagnosis and treatment had a very slow start for me.

It’s now part of my life’s work to help women who think they may have ADHD or some other kind of neurodivergence explore the possibilities, to get referral for formal assessment if they need it, and access to treatment if a diagnosis is confirmed.

If you are looking for ADHD therapy or ADHD assessment in the Athens, GA area, I may be able to help.

I offer free, 30 minute consultations for anyone thinking about working with me.  Feel free to reach out via the contact form on my website for more information.