“You Are Way Too Hard on Yourself…”

In a recent ADDitude roundtable titled “Living with ADHD: It’s Different for Women,” five experts addressed the impact of hormones, diagnostic gaps, gender bias, the unique experiences of neurodivergent Black women, and therapeutic strategies for building skills and self-esteem. Here are highlights from that conversation.

“Women with ADHD Are More Sensitive to Hormonal Fluctuations.”

Women with ADHD experience significant hormonal fluctuations from puberty through menopause, as sex hormones like estrogen and progesterone directly affect brain regions linked to ADHD’s challenges.

Studies suggest that women with ADHD may be more sensitive to hormonal fluctuations across the cycle than are women without ADHD.¹, ² Of course, ADHD varies from person to person, and individual reactions to hormonal fluctuations differ based on the ADHD profile.

[Read: Let’s Talk About Perimenopause and ADHD]

If your ADHD profile is defined by inattention and emotional dysregulation, higher estrogen levels around ovulation may come as a very welcome energy and mood boost. On the flipside, you may suffer tremendously from depressive symptoms and rejection sensitivity during the premenstrual or luteal phase.

One small study from the Netherlands has explored cyclic or flexible dosing — increasing the dose of ADHD stimulant medication around the premenstrual period.³ We need more research, but the theoretical model is there for cyclic dosing. However, as clinicians, we have no guidelines and very little support on which to rely. We must consider every woman’s individual hormonal profile and make treatment decisions in that context.

Treatment and diagnosis become more complicated during perimenopause and menopause, when women with and without ADHD are affected cognitively and physically. Then the challenge is trying to disentangle whether symptoms are related to midlife hormonal changes or stem from undetected ADHD that a woman has been able to mask for a lifetime.

Research on menopausal women with ADHD is scarce, but some studies show that women without ADHD in perimenopause experience improved cognitive function while taking stimulant medications.⁴,⁵,⁶ We also see that women with ADHD may experience reduced ADHD symptoms when taking hormone replacement therapy. (https://www.additudemag.com/low-estrogen-adhd-menopause-treatment-hrt/) This is an extremely important topic, and we are just scratching the surface.

— Lotta Borg Skoglund, M.D., Ph.D., is an associate professor at Sweden’s Uppsala University, Department for Women’s and Children’s Health

[Watch: Free Replay of ADDitude’s Expert Roundtable on Women with ADHD]

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“There’s Pride in the Struggle.”

ADHD in Black women is often completely overlooked because they generally don’t want to be observed. Black women are specifically taught not to be observed as a protective measure for their own safety in a society with racial and gender biases. Clinicians then misinterpret their outward challenges as signs of mood disorders or bipolar disorder, which is a stigmatizing mental health diagnosis.

I’ve worked with women who were given multiple mental health diagnoses without anyone considering ADHD. Misdiagnosis delays access to the right treatment and leaves women feeling frustrated and even more misunderstood. They come to believe, “Something is inherently wrong with me.”

Secondly, Black women often don’t recognize their own symptoms of ADHD because they’ve been so conditioned to push through struggles on their own. And symptoms tend to align with society’s toxic stereotypes about Black people as a whole: emotionally unstable and lazy.

Many of us grew up hearing that we had to be twice as good to be recognized as even half as much. When executive function issues make it hard to keep up, we internalize them as a personal failure instead of seeking help. We think, “I just need to try harder.” This leads to overcompensating, overworking, overachieving, and constantly masking to appear competent.

And that works until it doesn’t. Eventually, it leads to burnout and anxiety, and sometimes, to physical health issues like migraines, chronic fatigue, and even high blood pressure. Research is now suggesting a connection between autoimmune diseases and chronically high levels of cortisol in the body.⁷It’s an exhausting cycle and one that many Black women don’t realize is tied to undiagnosed ADHD.

Finally, we can’t ignore the fact that many Black women don’t seek care due to a well-founded mistrust of the healthcare system. Black women historically have been over-pathologized and mistreated in medical settings. Many women fear that they will be dismissed, judged, and over-medicated, so they avoid even seeking out a diagnosis because they don’t know whom to trust.

For neurodivergent women, it’s all or nothing. If the task looks daunting and is riddled with a high probability of rejection or harm versus help, do we take the chance? Usually, we don’t. So the long-term impacts are just massive for Black women, who experience continually deteriorating mental health as they try to figure out, “Is this me? Am I just a failure?”

The key is normalizing these feelings so Black women have words to clearly communicate what they are experiencing. Unfortunately, the strong Black woman stereotype makes that very difficult. Have Black women even been shown the possibilities of living life without it being so defined by struggle? There’s pride in some of the struggle. We need to let go of that. It’s not great to work in hard mode constantly. There’s no prize at the end of the race for that.

— Diane Miller, Psy.D., M.Ed., is a clinical psychologist who specializes in adult ADHD, racial identity issues, and sex therapy.

[Are You Burned Out? Take This Self-Test]

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“I Call It the Chasm.”

Women internalize their ADHD symptoms. They do not volunteer the pain they experience living in a world built for non-ADHD brains.

When women internalize their experience with ADHD, they are more likely to use isolation and perfectionism as ways to manage their symptoms. These behaviors contribute to an inauthentic picture that’s intended to appear more “socially acceptable.”

In their clinicians’ offices, women often respond to gender role expectations by people pleasing, controlling their behaviors, and downplaying their struggles. Without observing hyperactive or impulsive behaviors, clinicians may not consider an ADHD diagnosis, and women will continue to go untreated.

What’s more, if a woman meets a clinician in the week after her period, when estrogen is high, she will appear to be really together and may feel good. The clinician may dismiss a woman who masks successfully as not meeting diagnostic criteria. Two weeks later in her menstrual cycle, that woman may feel stressed, worried, tearful, or hopeless, which may be mistaken for observable signs of anxiety or depression and lead to misdiagnosis.

Most women with ADHD have spent a decade or more not knowing that the challenges and stressors they’re experiencing are the result of undiagnosed ADHD. They believe their difficulties reflect flaws in their character. They compare themselves harshly to their neurotypical peers. Over time, they are likely to develop unhealthy coping strategies.

We can’t change brain wiring, but we can help women reframe their behavior and view themselves through a more forgiving lens. We can help them understand that they are living with a different set of strengths and weaknesses. We can drive home the idea that the societal expectations for women are antiquated and unhealthy. We can help them release those internalized judgments and allow themselves to feel empowered and confident.

— Ellen Littman, Ph.D., is a clinical psychologist and pioneer in the identification of gender differences in ADHD.

[Get This: ADHD Diagnosis Guide for Women]

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“Parenting Requires a Great Deal of Executive Functioning.”

Mothers with ADHD often experience two types of core parenting challenges: First, ADHD impairs executive functioning, which is responsible for planning, organization, problem-solving, and memory. As we all know, parenting a child with ADHD requires a great deal of external structure and scaffolding. When parent and child both have ADHD, it is tough to consistently maintain routines, household structure, calendars, and to-do lists.

Another challenge is emotional regulation. Though this feature isn’t in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), emotional dysregulation is prominent for many people with ADHD and can make it much harder for parents to maintain their cool or practice patience when they have a challenging child who might be pushing their buttons. Parents with ADHD might yell, which contributes to negative feelings about their parenting.

Traditional interventions for kids with ADHD require a parent to be extra structured, very consistent, reliably calm, and patient. In my practice, we break this down.

We work with parents on keeping just one calendar where they put every single activity, including things they need to do for themselves. We help them keep a prioritized to-do list where they begin by writing down everything they need to do and then asking, “Are these items all vital? Am I putting way too much pressure on myself as a parent?” The magic is in prioritizing and weeding out unnecessary tasks so parents can focus on what’s most important.

We also try to emphasize the value of self-care. Mothers who make time to do the things they enjoy and value end up in a happier, more relaxed place when they’re with their child. We help parents build small activities into their day-to-day lives to prioritize. They can observe how these things help facilitate more positive interactions with their kids.

Finally, we teach mindfulness and relaxation so that mothers with ADHD can learn how to remain calm and ignore some of their kids’ minor annoying behaviors. Most of all, we work with parents to give themselves grace and not be so hard on themselves. Parenting is difficult. When parents have ADHD, they don’t need more blame or shame. They need support and skills.

—Andrea Chronis-Tuscano, Ph.D., is the director of the ADHD Program for SUCCEEDS College ADHD Clinic at the University of Maryland.

[Free Download: Mindful Meditations for ADHD]

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“ADHD Often Underlies Women’s Mental Health Conditions.”

The DSM is our system, as clinicians, for deciding who qualifies for a clinical diagnosis of ADHD. At the American Professional Society of ADHD and Related Disorders (APSARD), we don’t have the authority to rewrite the DSM, but the Diagnostic and Screening Subcommittee, on which I serve, is developing guidance to help clinicians identify adults who have ADHD and make sure that people who don’t meet the criteria for ADHD aren’t mistakenly given the diagnosis. The subcommittee includes seven women and two men, and we have very much been thinking about addressing issues with women’s diagnoses, specifically.

ADHD often underlies the anxiety, depression, and substance use problems that bring women in contact with the mental healthcare system. But clinicians working in those settings often miss that these disorders are a consequence of ADHD. The APSARD adult diagnosis guidelines, due to be published later this year, hope to address this by suggesting and recommending ways for clinicians to gather the key information they need to make the right diagnosis, and by offering advice and guidance about overcoming the issues that can sabotage a woman’s diagnosis.

Part of our work is developing a clinician education program that will make possible system-level changes, like screening and catching people where they’re likely to show up in the healthcare system. Also, if clinicians are not confident in diagnosing ADHD in women, they’re going to play it safe. They may not diagnose ADHD in women who didn’t show clear symptoms when they were younger because, as providers, there’s a stigma around just handing out ADHD diagnoses.

APSARD is working to address factors on both the provider and patient sides by publishing clear, accurate information that clinicians can point to and say, “I’m following these guidelines responsibly.” I’m hopeful these guidelines will bring the country onto a level playing field in terms of what’s acceptable, what procedures should be followed, and what best practices look like.

—Maggie Sibley, Ph.D., is a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children’s Hospital.

[Free Download: The Facts About Major Depressive Disorder in Women]

Neurodivergent Women: Next Steps

• Free Workbook: Track ADHD Symptoms During Your Menstrual Cycle
• Read: Falling Estrogen, Soaring ADHD: Menopause Care for Neurodivergent Women
• Read: Hormonal Changes in Women with ADHD: 4 Gaping Holes in Research
• Learn: ADHD in Adults Looks Different. Most Diagnostic Criteria Ignores This Fact.

 

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