ADHD In Women: Why It's So Hard To Get Diagnosed & How To Get Relief
Raise your virtual hand if you're currently procrastinating on a project. Or if your leg is tap, tap, tapping under your desk. Or if you can't seem to read through an entire paragraph without your eyes prematurely darting to the end. Or—and this is a big one—if you don't trust yourself to get tasks done by a deadline even though you know you have the skills and time to complete them.
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These are just a few of the ways that ADHD (attention deficit hyperactivity disorder) can manifest. This disorder, which is often associated with overly energetic and disruptive kiddos, is estimated to affect 2.5% of adults. And it's getting a lot of attention lately in regard to the unexpected ways it can affect women, who are more likely to go undiagnosed as children because their symptoms often don't include the obvious hyperactivity and they may not have struggled academically.
Thanks in part to Instagram and TikTok influencers educating the masses on ADHD symptoms (helping to de-stigmatize it in the process) and the emergence of startups that pair people with practitioners for ADHD evaluations, many women are finally realizing that their ongoing struggles with organization, productivity, forgetfulness, and self-doubt may not actually be due to laziness or personality flaws after all—and this can be a huge relief.
Of course, not everyone who's highly distractible has ADHD—and not everyone with ADHD responds to the same treatment. For example, around 50% of adults with ADHD also have an anxiety disorder, so getting relief may involve some different strategies. That's why it's so important to educate yourself and seek out a qualified practitioner before you self-diagnose.
Whether you know you have ADHD or you're just exploring the possibility, mbg has gathered valuable insights on how it can manifest in adults and women, what lifestyle factors exacerbate symptoms, and how both natural approaches and medication can play a role in treatment.
What exactly is ADHD?
By definition, ADHD is a neurodevelopmental disorder that develops in childhood or adolescence—but may not be diagnosed until adulthood—and people with ADHD show a persistent pattern of poor attention and/or hyperactivity-impulsivity that interferes with daily life. It's also highly heritable, meaning it often runs in families and you're much more likely to have it if a parent or sibling has also been diagnosed.
But there are no hard-and-fast rules for what ADHD looks like in every case. These core elements of ADHD (inattention, hyperactivity, impulsivity) encompass a range of different behaviors, experiences, and symptoms depending on the individual. Excessive fidgeting, chronically interrupting friends and colleagues, daydreaming, forgetting to pay bills, misplacing items, abusing drugs or alcohol, feeling inadequate, constantly having to pull all-nighters to finish work, losing your cool at the drop of a hat, not being able to focus on some things while hyperfocusing on others—these are all ways ADHD can manifest in adults.
Some prominent experts in the field including Russell Barkley, Ph.D., also consider ADHD to be an executive function deficit disorder. Meaning, many adults who have it tend to struggle with the cognitive processes that allow you to organize thoughts and activities, manage time, prioritize tasks, and make decisions. With poor executive functioning, things like focusing, meeting deadlines, following directions, and regulating emotions can be extremely difficult—and, unsurprisingly, this can take a real toll on self-esteem, especially when those around you appear to have no problem juggling equivalent responsibilities.
What's incredibly important to understand, however, is that ADHD doesn't mean you lack the intelligence, skills, or desire to succeed or change. Many people with ADHD start their day determined to be productive and organized, only to end up feeling defeated. "A phrase that comes up a lot for people with ADHD is 'consistent inconsistency,'" says Russell Ramsay, Ph.D., co-director of the University of Pennsylvania's Adult ADHD Treatment and Research Program. "You know you can do something, but you don't know if you can get yourself to do it when you need to do it."
How is ADHD diagnosed?
There are three types of ADHD, depending on what type of symptoms are most prevalent: inattentive type, hyperactive-impulsive type, or combined type. In order to be diagnosed with any of these, you have to experience at least five inattentive and/or hyperactive-impulsive symptoms—and you must have experienced significant symptoms before age 12, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5).
But, according to Ramsay and other experts, the psychiatry field is starting to realize current DSM symptoms may be incomplete and not adequately portray what ADHD looks like in adults—since they were initially developed for children. There's also evidence that the age 12 cutoff is somewhat arbitrary and that in about 10% of cases, ADHD symptoms may actually present after age 18 or 21. So, there's a certain amount of subjectivity with the guidelines, and clinicians often have to make a judgment call when making a diagnosis.
What ADHD looks like in women & why it's often undiagnosed.
Inadequate and outdated diagnostic criteria can make it difficult for any adult to be diagnosed with ADHD—but particularly women, whose symptoms often manifest differently than men's, with many slipping through the cracks and evading a diagnosis until their late 30s or early 40s.
"ADHD typically presents in women or girls as lower severity but more pervasive inattention and hyperactivity than in males, and tends to become more obvious with age," says Uma Naidoo, M.D., a Harvard-trained nutritional psychiatrist and author of This Is Your Brain on Food. "This can often be recognized through disorganization, quickness to feeling overwhelmed, and a lack of effort or motivation."
Additionally, women with ADHD tend to have the inattentive type, which is harder to diagnose at an early age in girls because it doesn't present as the disruptive, hyperactive stereotype common among boys, says Lidia Zylowska, M.D., a psychiatrist at the University of Minnesota Medical School and author of The Mindfulness Prescription for Adult ADHD. This can delay a diagnosis, sometimes until a stressful life event or change in a woman's life (e.g., changing jobs, having a baby, getting a divorce, living through a pandemic) exacerbates ADHD symptoms to a point that they are no longer manageable with existing coping mechanisms. Inattentive-type symptoms are also more likely to be misdiagnosed or incompletely diagnosed as anxiety, stress, or depression.
Women's ADHD symptoms tend to be more internalized than men's, too, including symptoms of low self-esteem, anxiety, and depression. Even hyperactivity can be internalized. "Internal hyperactivity in females often leads to feelings of overwhelm, while external hyperactivity in males leads to excess energy or activity," says Naidoo. This internalization may be partly the result of biology, but some experts believe longstanding societal pressures for women to be nice, quiet, and polite play a role, too.
Another major characteristic of women with ADHD is their tendency to struggle with emotional regulation—and yet, this aspect of ADHD is not fully acknowledged in the DSM-5 criteria and can sometimes lead to a misdiagnosis of borderline personality disorder or depression. "Things like intense impulsive emotional outbursts of anger can be common, along with rejection sensitivity, in which you spiral into feeling bad about yourself in situations where you sense rejection from another person," says Zylowska.
So, what's going on in the ADHD brain?
What exactly causes all this cognitive turmoil? There are a lot of factors at play (not all of which are fully understood), so we'll just scratch the surface here.
"We do believe there's a biological difference in people with ADHD," says Zylowska. "If you study those with ADHD and those without, you do see brain differences in how information is being processed." For example, connections between the prefrontal cortex (the "thinking" brain) and the striatum (which deals with reward behaviors) may be disrupted in people with ADHD.
Neurotransmitters play a role, too—and in many people with ADHD, the dopamine and norepinephrine systems don't activate as robustly in certain settings compared to people without ADHD. This can affect focus and motivation and make it more difficult to power through a task when something is boring or overwhelming to you. In fact, one reason people with ADHD tend to procrastinate until the last minute may be because they experience a surge of activation in these neurotransmitter systems when faced with an imminent deadline—"this can make the person more alert, focused, and productive, which is helpful in the moment but exhausting and unsustainable in the long run," says Zylowska. "Of course, procrastination can backfire, too. If the stress of the deadline is too overwhelming, you can have more of a freeze response."
We also know ADHD runs in families, so there's a genetic component. However, there's not one single ADHD gene that you either have or don't—rather, a variety of genes likely influence whether someone has ADHD, and a person's particular "genetic loading" will place their symptoms anywhere from mild to severe on the ADHD spectrum, according to Zylowska.
The good news: There's a constant interplay between genes and environment—and as with any genetic predisposition (like a family risk of high blood pressure), certain healthy lifestyle practices can influence how much you express a trait, and thus, how severe your ADHD symptoms are.
How your lifestyle habits & health can affect ADHD.
Some women may be genetically primed for ADHD, but their habits can significantly affect how much or how little their symptoms manifest, according to Zylowska. The good news: An increasing number of integrative and functional doctors are helping patients identify their main lifestyle contributors and address them at the root, as opposed to simply prescribing medication that only resolves some symptoms.
For many people with ADHD, experts believe these factors can make symptoms worse:
- Inadequate sleep: Studies suggest that almost anyone getting insufficient sleep will have issues with executive functions, and this effect would likely be even more pronounced in someone with ADHD who already struggles with these tasks.
- Unbalanced blood sugar: When your blood sugar dips too low, your brain is the first thing to "go on strike," according to integrative psychiatrist Ellen Vora, M.D. Blood sugar can dip if you miss a meal or if you recently ate a meal high in sugar or refined carbs.
- Poor gut health: "Dysbiosis of the gut has been associated with certain neuropsychiatric conditions such as ADHD," says Naidoo. This is likely due to the fact that healthy gut bacteria play a key role in synthesizing precursors for dopamine and other neurotransmitters—and if your gut's not happy, this process may be impaired.
- Problematic foods: Evidence suggests gluten, dairy (particularly A1 milk caseins), plus artificial food colorings and additives may contribute to ADHD symptoms in certain sensitive individuals. "Any type of inflammatory, highly processed packaged food may also alter the gut microbiome in a way that worsens ADHD symptoms," says Naidoo.
- Micronutrient deficiencies: Deficiencies in zinc have been associated with hyperactivity, while other studies suggest that people with ADHD may have low levels of vitamin D, iron, and magnesium, which are involved in dopamine synthesis.
- Poor stress management: As mentioned earlier, many women with ADHD may find their symptoms really get out of control during stressful periods or transition periods, like starting a new job, being slapped with new responsibilities at work, having a baby, etc. These can limit their already taxed executive functioning—particularly if they don't have a stress-relieving outlet or regular daily routines.
- Toxin exposure: While research in this area is limited, some functional medicine physicians, including George Papanicolaou, D.O., have found associations between heavy metals and ADHD symptoms, which he discussed on a recent podcast. Some studies have also suggested that people may develop ADHD symptoms after exposure to mold toxins.
It's important to note that certain habits and health conditions can lead to symptoms that mimic some ADHD symptoms—but these symptoms alone don't necessarily indicate true ADHD. Poor sleep, for example, can both mimic ADHD and exacerbate true ADHD. According to Zylowska, some other issues with symptoms that mimic ADHD include thyroid problems, hormonal imbalances, perimenopause, and micronutrient deficiencies, among others.
ADHD treatment options (beyond just medication).
Optimal treatment for ADHD can be highly variable depending on the individual and where they lie on the spectrum of ADHD severity—and working with a qualified professional who aligns with your values will be a tremendous help in figuring out the ideal combination of strategies. Sometimes that involves stimulant medication. Sometimes it involves changes to your diet and daily routines. Sometimes it involves both.
9 natural strategies to help manage your ADHD.
Making changes to your daily habits—from what you eat to how you organize your time—can have a major positive impact on ADHD symptoms. Here are some expert-approved strategies:
- Get serious about sleep. According to Vora, sleep is the single most important factor in ADHD management. Aim for seven to nine hours of sleep nightly. Going to bed and waking up at the same time every day can help you fall into a consistent pattern, but if you struggle, try curbing your light and screen exposure at night and consider a magnesium glycinate supplement, which can promote relaxation.
- Ramp up your physical activity. A good sweat session delivers multiple ADHD benefits—it's great for curbing the negative effects of stress and anxiety, promoting restful sleep, reducing impulsivity, improving executive function, and increasing levels of brain-derived neurotrophic factor (BDNF)—a protein involved in learning and memory. While all exercise is good, one research review found that regular aerobic exercise improved people's executive functions, including their ability to pay focused attention, switch among tasks, and hold multiple items in working memory.
- Eat a balanced, nutrient-rich diet. While there's currently no ADHD-specific diet, the Mediterranean diet is generally thought to be supportive of mental and cognitive health, and some research suggests it may be beneficial for ADHD. The healthy fats, fish, nuts, and variety of colorful plant foods that are typical of a Mediterranean diet not only help balance blood sugar and support a healthy gut microbiome, but they're also rich in vitamins, minerals, and polyphenols that are important cofactors for neurotransmitters, says Zylowska. Polyphenols may also help calm oxidative stress in the brain, which can occur in ADHD patients.
- Consider an elimination diet. Due to the potential impact of gluten, dairy, and artificial colors and flavors on the gut microbiome and ADHD symptoms, consider trying an elimination diet free of these and potentially other foods to help identify potential food triggers. If you tend to suffer from digestive issues, this may be a particularly good idea.
- Supplement strategically. If it's hard to implement the ideal diet, or you know you're at risk for micronutrient deficiencies, consider taking a high-quality multivitamin/mineral supplement. An integrative or functional medicine physician can help guide you on appropriate supplementation and run micronutrient-level tests as needed.
- Implement routines whenever possible. Any type of regular daily routines you can implement in your schedule—whether it's what time you wake up, what you eat for breakfast, where and when you work out, how you break up your workday, laying out your outfit at night—can be hugely beneficial. "Having regular habits that become second nature frees up executive functions for other things," says Zylowska. "Routines break up your day and provide start and stop times for things, too, which can both keep you on task and prevent hyperfocus."
- Try the Pomodoro method for focus. Also called time-blocking, the Pomodoro method is a strategy for getting work done efficiently. To try it: Simply figure out what you want to work on, then set a timer for 25 minutes and work on only that task—shutting out all other distractions. When the timer dings, take a three- to five-minute break, then repeat the cycle. Because you are working against the clock, there's a sense of urgency that many people find beneficial for staying focused. During your breaks, doing something physically active like a few pushups or squats can help boost energy and focus.
- Learn to embrace mindfulness. Mindfulness can be a difficult skill to master for someone with ADHD, but research suggests it can reduce symptoms by training the brain to be focused and present. You can start small, too. Even something as simple as the breath awareness that you practice during meditation can train your mind to focus and to catch yourself when you break focus. Breathing exercises, yoga, and meditation can boost mindfulness, as well as resources specifically targeted for ADHD such as Zylowska's book The Mindfulness Prescription for Adult ADHD.
- Try CBT, ADHD coaching, or both. Cognitive-behavioral therapy (CBT), an approach utilized by many therapists, can help you understand your ADHD symptoms and learn strategies to manage them. For example, it can help you change irrational thought patterns (think "This needs to be perfect" or "Why am I so bad at this?") that prevent you from staying on task or getting things done. Working with an ADHD coach is another option. They're specifically trained to help adults with ADHD set realistic and specific goals, prioritize and manage tasks, and develop a sense of self-efficacy. They also hold you accountable, which creates external motivation that's very helpful for people with ADHD, says Zylowska.
Understanding the benefits (and limitations) of ADHD medication.
The main type of medication used for ADHD patients is stimulant medications. This helps improve your attention and focus by boosting the availability of dopamine and norepinephrine in the brain, which can be beneficial because—as mentioned earlier—people with ADHD tend to have a less robust activation of these neurotransmitter systems.
But these medicines aren't a magic bullet, and it's important to understand what they can and can't do. Medication is generally effective for improving focus, impulsivity, hyperactivity, and motivation, but these drugs don't specifically help with executive function challenges such as time management, organization, and prioritization, says Zylowska. So you'll need to deliberately work on things like implementing routines, creating detailed to-do lists, and practicing mindfulness if you want to reap the biggest mental rewards.
Medication can be life-changing for some—particularly those with severe ADHD symptoms that can't be managed solely with lifestyle. They can also be beneficial for people in the short term, says Zylowska, to help them get over that initial hump where they may feel completely overwhelmed and unable to implement certain lifestyle strategies on their own. For others, these medications aren't always tolerated, effective, or necessary. And while these drugs are relatively safe and well researched, you can form a dependence on them. You and your doctor will work together to decide if medication is right for you.
Think you have undiagnosed ADHD? Here's how to get help.
If you've made it this far, you probably suspect you have ADHD. If that's the case, it's time to seek out a provider who can do an ADHD evaluation. ADHD in adults is often diagnosed by a primary care provider, a psychiatrist, or a psychologist. You can start by having a conversation with your primary care provider and see if they feel comfortable evaluating you or could recommend someone who can. Some startups, including Done, can hook you up with a practitioner for a virtual visit and ADHD evaluation.
It's also important to seek out a practitioner who can help you manage your treatment in a way that aligns with your goals and values. If you're interested in working with someone who can help you identify and address the main lifestyle, environmental, and dietary contributors to your specific ADHD symptoms and, if needed, go the extra step of testing you for micronutrient deficiencies and various toxin exposures, consider searching for an integrative or functional medicine psychiatrist or physician with a focus on ADHD.
This type of whole-body approach to tackling ADHD can be a total game-changer for productivity, confidence, and long-term well-being.