Adult Diagnosis of ADHD in Women: A Mixed Methods Investigation

Abstract

Objective:

The goal of this study was to examine the experiences of women diagnosed with ADHD in adulthood.

Methods:

Benefits and costs associated with obtaining the diagnosis were examined in two focus groups conducted virtually. Factors hindering and facilitating the identification, assessment, and subsequent treatment of ADHD were also explored. Focus groups were conducted virtually and together included 14 women (M_age = 39.43, SD = 6.37) who were diagnosed with ADHD in adulthood.

Results:

The majority of women described numerous benefits of receiving a diagnosis of ADHD, including validation/self-compassion, adaptive coping, and social support. Negative aspects of the diagnosis, including difficulties accessing care, the burden of care, limitations to existing evidence-based treatments, and stigma were also identified by some women. Furthermore, women described variable diagnostic experiences, with many indicating that they had not recognized their own symptoms of ADHD, as well as diagnostic complexity and other factors that masked identification of ADHD. Women described a range of diagnostic assessment procedures, as well as considerable self-advocacy to convince their providers to consider the diagnosis of ADHD.

Conclusion:

These lived experiences of women diagnosed with ADHD provide critical insight into improving clinical care for ADHD in women. Recommendations to increase accurate and timely identification of ADHD in women and advance efforts toward effective and equitable care are discussed.

ADHD is a neurodevelopmental disorder purported to emerge in childhood (American Psychiatric Association, 2013). An estimated 11% of children in the United States are diagnosed with ADHD, the majority of whom are male (Visser et al., 2014). However, in adulthood, nearly equivalent numbers of men and women are diagnosed with ADHD (Jensen & Steinhausen, 2015; Kessler et al., 2006), suggesting that opportunities to identify ADHD in childhood may be disproportionately missed for girls and women. Failure to accurately diagnose and treat ADHD earlier in development may have profound consequences, potentially contributing to lower self-esteem and relationship difficulties, limiting income potential, and increasing risk for psychiatric comorbidity and early mortality (Dalsgaard et al., 2015; Hamed et al., 2015). However, very little research has examined how women with ADHD eventually obtain a diagnosis of ADHD in adulthood, limiting opportunities for providers to improve clinical care for this underserved population.

Urgency to understand the diagnostic process for women with ADHD is of utmost importance, in light of a recent report from the Centers for Disease Control and Prevention (CDC) documenting a marked increase in the prescription of stimulant medication in the United States from 2020 to 2021, particularly for adult women ages 35 years and older (Danielson et al., 2023). Although these data reflect prescription of stimulant medication, and do not specifically address the diagnosis of ADHD, these data may signal a changing trend toward addressing the needs of women with ADHD, who have long been overlooked in clinical and research settings. Yet questions remain about the pathways through which women are ultimately diagnosed with and treated for ADHD in adulthood, and very little is known about the benefits and costs of obtaining an ADHD diagnosis for women.

Qualitative research examining the firsthand experiences of women diagnosed with ADHD in adulthood may provide new opportunities to contextualize and better understand quantitative data showing increases in the diagnosis of ADHD (Cornwall & Jewkes, 1995). There have been a few emerging qualitative studies focused on women’s experiences obtaining a diagnosis of ADHD focused primarily on young adulthood or later adulthood (Henry & Jones, 2011; Morgan, 2023; Vincenti et al., 2023). These studies have identified a number of converging themes, showing benefits associated with diagnosis of ADHD, including relief from finding an explanation for their difficulties and new opportunities to pursue treatment. However, this work has also identified significant barriers to accessing appropriate care. Notably, only one study, including five women with ADHD, has specifically examined diagnosis of ADHD among women in middle adulthood (Holthe & Langvik, 2017). Given the precipitous rise in treatment for ADHD among women at this developmental period, there is a critical need to prioritize understanding the perspectives of women with ADHD during this time.

The goal of this study was to describe and interpret the shared experiences of women diagnosed with ADHD in adulthood. A mixed methods approach was used, in which quantitative and qualitative data was obtained from focus groups of women diagnosed with ADHD in adulthood. The research was aimed at understanding benefits and costs associated with obtaining the diagnosis. Factors hindering and facilitating the identification, assessment, and subsequent treatment of ADHD were also explored. It was intended that findings emerging from these groups would help to inform the development of future qualitative and quantitative research aimed at reducing barriers to care for females with ADHD.

Method

Women were recruited through social media postings advertising a study for women diagnosed with ADHD in adulthood. Participants were required to have been diagnosed with ADHD in middle adulthood (i.e., 29–55 years old), presumably past the developmental milestones of emerging adulthood (Arnett et al., 2014). Participants were required to live in the United States, have the capacity to provide consent, and English language proficiency. Informed consent and eligibility criteria were collected electronically. Diagnosis of bipolar disorder, autism spectrum disorder, schizophrenia, or other psychotic disorders was exclusionary. Eligible participants completed additional functional and demographic rating scales via a web-based survey platform, and were contacted by email to participate in a focus group. Participants completing all study procedures were compensated with a $50 gift card. All procedures were approved by the Penn State University Institutional Review Board and were consistent with the 1964 Declaration of Helsinki.

A total of 31 women provided consent, completed rating scales, and were eligible to participate; 21 were able to be contacted and scheduled to participate in the focus groups, with 14 attending the focus groups. There were no significant differences (p < .05) in current age, age of ADHD diagnosis, race, ethnicity, marital and employment status, ADHD severity, or treatment history between the women who did and did not participate in the focus groups. Diagnosis of ADHD was confirmed using the Adult Self-Report Scale (Kessler et al., 2005) which includes all 18 symptoms of ADHD. Endorsed symptoms were summed, with four women meeting symptom count criteria for ADHD Inattentive Presentation, one meeting criteria for ADHD Hyperactive-Impulsive Presentation, and nine meeting criteria for ADHD Combined Presentation. The Impairment Rating Scale for Adults (Dawson et al., 2020) was also administered to ensure that participants reported impairment (i.e., score of 3 or more) in at least two domains of functioning. Demographic and psychiatric characteristics of the women participating in the focus groups are presented in Table 1. All were diagnosed with ADHD in adulthood. Two participants were also diagnosed in childhood and they were included in this study because they had been required, upon initiating care in adulthood, to undergo assessment of ADHD again.

Table 1.

Demographic and Psychiatric Characteristics (N = 14).

	M (SD)	N (%)
Current age (in years; Min = 31, Max = 52)	39.43 (6.37)
Race
White		10 (71.4)
Asian		1 (7.1)
More than one race		3 (21.4)
Hispanic or Latino		2 (14.3)
Relationship status
Married		4 (28.57)
Single		4 (28.57)
Divorced		6 (42.86)
Education level
Attended college or trade school but did not graduate		1 (7.14)
Graduate of 2-year college or trade school		4 (28.57)
Bachelor’s degree		8 (57.14)
Master’s degree		1 (7.14)
Employment
Not employed		4 (28.57)
Employed full-time		5 (35.71)
Disabled/not able to work		4 (28.57)
Income
$10,000–19,999		2 (14.29)
$20,000–29,999		5 (35.71)
$30,000–39,999		1 (7.14)
$40,000–49,999		1 (7.14)
$50,000–59,999		3 (21.43)
$60,000–69,999		1 (7.14)
$70,000–79,999		1 (7.14)
Age of ADHD diagnosis	32.50 (10.30)
Provider diagnosing ADHD
Primary care provider		2 (14.29)
Mental health specialist		11 (78.57)
Other (neurologist)		1 (7.14)
Stimulant medication treatment		8 (57.14)
Any comorbid psychiatric disorder		12 (85.71)
Anxiety disorder		11 (78.57)
Mood disorder		9 (64.29)
Post-traumatic stress disorder		3 (21.43)
Psychotropic treatment for comorbid psychiatric disorder		9 (64.29)
Current psychotherapy		6 (42.86)

Two focus groups (eight participants in the first group, six in the second) were conducted via Zoom and were video recorded. Based on previous work (Guest et al., 2017), two focus groups are sufficient to capture 80% of themes. Upon beginning the recording, confidentiality was discussed and participants were given the opportunity to change the presentation of their name to protect their anonymity. Explicit rules for camera use were not provided. Groups lasted 2 hr, and were semi-structured to include a brief introduction to the group facilitators and the study. Then, participants were asked to type open-ended responses to the ice breaker prompt, “What does ADHD mean to you?” Responses were collated into a word cloud and shared with participants (Figure 1). Next, participants selected forced choice responses of “yes,” “no,” or “not sure” to indicate their responses to the following statements: “Being diagnosed with ADHD has changed my life for the better,” “Being diagnosed with ADHD has made my life harder,” and “It was hard for me to get a diagnosis of ADHD.” Responses were used to facilitate group discussion. Both authors co-facilitated focus groups. The authors have extensive clinical and research experience focused on females with neurodevelopmental disorders, including ADHD and autism, allowing them to ask informed follow-up questions to facilitate discussion in the focus groups.

Figure 1.

“What does ADHD mean to you?” Word cloud.

Focus group recordings were transcribed verbatim and checked for accuracy. Transcripts were used for all coding activities. An Interpretative Phenomenological Analysis (IPA) framework was used to guide analysis of data collected from the focus groups (Lefler et al., 2016; Smith & Eatough, 2007). IPA is focused on understanding a phenomenon through the perspective of those living with a particular condition, while also maintaining distance from the phenomenon in order to allow for critical analysis. In this approach, participants reflect on their own experiences and researchers subsequently attempt to make sense of individuals’ lived experience. Both authors coded study data. To analyze themes, they read through the transcripts independently in a series of steps, first to obtain a holistic perspective of each group, second to identify discussions that related to participants’ ADHD diagnosis while omitting off-topic discussion, and third to identify repeating ideas or codes. After identifying codes independently, they compared and discussed analyses, and refined a final list of common themes, which are presented in Table 2.

Table 2.

Focus Groups Comments.

Being diagnosed with ADHD has changed my life for the better
Validation/self-compassion	“It gives me answers to a lot right now. It’s [had] a soothing effect for me. I’m not up in the air, saying, ‘What’s wrong with me?—Why would I do this?—Why is this going on?’ The diagnosis has helped me mentally. Just having the diagnosis has helped me a lot.”
	“I was seeing a psychiatrist. And she was the only provider I’ve ever talked to because of my ADHD and meds that was affirming, that didn’t pick apart everything I said and try to break it down into like, something’s—I’m doing something wrong, basically. She helped me also to realize that my neurodivergent thinking is– it could be very good thing."
	“It has changed my life for the better because it was like really validating. There was an explanation to so many things that were written off as negative traits about me personally, like laziness, or not trying hard enough. It was like really helpful to have a reason, like no, it’s not just because I am not trying hard enough or whatever. I just find it interesting that a lot of parents I talk to are like, ‘I don’t want to get my kid tested,’ or whatever, because they think that having a diagnosis will be a bad thing, that their teachers will judge them if they have a diagnosis or whatever. I’m like, ‘No, it’s like the best thing possible,’ for me at least and I wish I had been diagnosed as a kid.”
	“For me, [the diagnosis provided] validation. I always knew I was different. The diagnosis helped me to know that I’m not crazy, that it’s valid, that it’s actually real—everything that I’m feeling—validation and relief, and just trusting in myself and believing what I’m feeling, and it’s OK to be different.”
	“[Before I had the diagnosis] I was either not good enough, or couldn’t do it, or had to push myself a whole lot harder [than other people did]. Having the diagnosis, it helps me work with and kind of be aware of when I am on the ball, when I’m not on the ball, and not beat myself up in my head when I can’t do things. It’s been extremely helpful.”
	“I also think that there are significant benefits to being ADHD—the way you think and the way you come up with creative things. I’ve kind of had a point in my life of deciding where I want to go next and what I didn’t want to do—thinking about how I can create my life to fit the way that my brain works, and the way I function, and what I need, and build boundaries based on that. Knowing and being diagnosed with [ADHD] also, aside from allowing myself grace, it also helps me decide how I want to live. So as hard as it is physically and emotionally, I also think there is a benefit to knowing that you have it.”
	“When I first started reading and seeing all the symptoms, I was like, ‘So how much of this is my actual personality and how much of this is actually ADHD?’ I wouldn’t be who I am today [if I didn’t have ADHD]. I wouldn’t have this brain. I think it has been part of me. It’s just a different way of being, but with wins and beautiful things, but also regrettable things because of my impulsivity.”
Adaptive coping and treatment	“[The diagnosis] definitely gave me some answers and gave me a direction to go in and helped me to find ways that I was able to cope.”
	“Having ADHD makes my life harder, but it was hard before the diagnosis, so it certainly didn’t make anything worse. It just gave me an option to get treatment and help.”
	“I barely graduated high school, like skin of my teeth, got out, started working right out of high school. Since I’ve been diagnosed at 30, I’ve now gotten my bachelor’s degree and I’m actually in school for my master’s. I’m able to actually be on the Dean’s List and I’ve gotten all sorts of stuff. It’s great. I could’ve never done any of that [before being diagnosed]. I’m able to hold a job. I’m able to actually get things done because I have tricks. I’m able to read tips and I’m taking [stimulant medication]. Everything’s great. There’s still a lot I’m working through and I‘m figuring out. Organization and procrastination [are] still a huge issue—these were problems I had my entire life, and suddenly, I can look up ways to fix those problems and work past them, so it’s been a huge thing for me.”
	“We were trying so many like antidepressants and things like that. It was like, nothing’s treated my depression better than treating my ADHD [LAUGHS]. And it’s like, we were always treating the wrong thing all along. I’m not even on antidepressants right now. And I’m feeling the best I’ve ever felt in my entire life. It was like literally 16 antidepressants. And all I needed was to treat the right condition.”
	“I had a wonderful doctor and psychologist who recognized that my anxiety was stemming from my ADHD. He really worked to manage the ADHD to see if that would eliminate or take away some of the anxiety, and it did, and that’s where I learned a lot of coping skills.”
	“My younger years I did a lot of drugs and I drank all the time. And I over-ate all the time searching for anything, you know. But now it’s kind of gone a little bit more positive. You know, I don’t drink anymore. I haven’t touched a drug in G-d knows how long. I mean, I still eat. But I do other things. I use Post-it notes. Post-it notes are my best friend. And alarms for everything just to help me get through simple things in the day now.”
Enhancing social support	“Without the ADHD diagnosis, I wouldn’t have the support system that I have now—being able to find friends and other people who have that same or similar experience, being able to talk with people openly about my mental health, and to be able to reciprocate as well. I think without it, I would just feel isolated. I would alienate myself. Because I’m a chronic people-pleaser, and so in order for other people to feel comfortable, I would just hide any symptoms or just not even interact because I don’t need people asking questions.”
	“Hearing everybody’s story and what they’ve gone through, it’s very validating and it makes me feel not alone. It feels really great to hear that I’m not the only one dealing with all of this stuff [LAUGHS].”
	“I do find social media, the humor and especially dark humor accounts about it are helpful. There are so many educational accounts like on TikTok and stuff. They give you little life hacks here and there that can make a really big difference. I find those to be really helpful. I’ve found more help from other people that have ADHD than I ever have from therapy. Most of my friends, if not all of my friends, are neurodivergent in some way and they can be really helpful and understanding and supportive.”
	“When you’re one on one with a doctor—in a doctor’s office—the doctor’s trying to hear what you’re saying but not necessarily giving you the validation to make you feel comfortable to continue talking. [Peer] validation is huge for me, to know that I’m not crazy. This is not just me going through this. I’m not just sitting in this doctor’s office talking to this doctor and this doctor’s just looking at me like, ‘And what else? And what else?’ I’m like, ‘Well, is that normal? Is that right? Are you shocked by what I’m saying? You’re not giving me anything.’”
	“When you only have your yourself to bounce this stuff off [of], do you ever grow? You look at [social media] videos, and [see] this—’Oh, this is acceptable. OK, I’m good. [LAUGHS] Oh, other people forget to pay their bills on time even though they wrote it on their list.’”
	“I think the only thing that’s really changed is I am able to connect with my son a lot better because he recently got diagnosed last year. It’s made a world of a difference for him. But now, like when he’s saying [he is] overstimulated or something, I understand how he feels. I try and help my husband understand and be like, ‘Hey, he’s not feeling it. Leave him alone. Stop talking to him.’ So, it’s built our relationship better.”
Being diagnosed with ADHD has made my life harder
Difficulty accessing care	“There are a few key things that have made it harder, and one of those is accessing psychiatry. I just moved a couple of months ago and I have called probably at least 20 different psychiatrists’ offices. As soon as I say, ‘I have ADHD,’ they say, ‘No, we don’t treat that,’ and I’m not allowed to become a patient there. So that’s one thing that has become a barrier just by having a diagnosis.”
	“I moved recently and I cannot find a new provider. I drive two and a half hours to see [my old provider] because she is such a good provider, and I can’t find anyone new anyway. I just got lucky with how easy it was [to get diagnosed], because I hear horror stories constantly. I can’t even find an office in my area who will take me when I’m already diagnosed, let alone seeking diagnosis. I can’t imagine how hard it would be for me to find a diagnosis now.”
	“My insurance will only allow me to see a therapist who is a psychologist. I cannot see a licensed professional counselor, but there’s plenty of them available. There [are] not very many psychologists who take my insurance, or they want to be paid up front and let me get reimbursed by the insurance. Access to care has been a [challenge].”
	“I don’t have enough coping skills. And I am aware of that. And I’ve been trying to seek out therapists that can help me. And I can’t find any therapists that are like neurodivergent affirming or like educated on how to deal with neurodivergent clients that like accept my insurance and like are taking new clients. Like everyone just seems to be full or they’re like out-of-pocket only. So, I know that I need more coping tools.”
	“When I had my son, and postpartum anxiety’s a whole other animal, I just wasn’t prepared. Like, I was, but I wasn’t, because of having dealt with anxiety before. I knew that that’s what it was. I found a therapist who specialized in postpartum anxiety. . . getting all the treatment for that and figuring that out. I started talking about my ADHD and everything, and [the therapist] did admit to me, ‘I don’t really specialize in this. I don’t really know how this works.” So, I’ve stepped back from seeing her because it just kind of left me feeling in this place of, like, ‘OK, great. I know I have postpartum anxiety. I know that’s something I’m dealing with, but I’m also dealing with ADHD, and how do those two things correlate? Who can I find and talk to that can help me deal with both of these things together?’ Because they’re not two separate things, as much as the medical field wants to say they are. They are not. Finding somebody that deals with both of those things has been tremendously difficult.”
Burden of care	“It just adds an extra burden to life stresses, like maintaining with medication and therapy. It’s almost like, you know, life’s unfair and normal people don’t have to deal with this. It gets in the way of life’s goals at times.”
	“The other thing is that I do deal with chronic physical illnesses as well and I have noticed that having an ADHD diagnosis and having [stimulant medication] on my record does affect how some doctors treat me with my physical healthcare. They will say, ‘Oh, well, that symptom, that’s just related to that [stimulant medication],’ or they’ll say, ‘No, you don’t have ADHD,’ or ‘You shouldn’t be on that medication.’ I would say overall my life is a lot easier having the diagnosis and having the treatment but there are a few specific exceptions.”
	“When I tried to fill the prescription when I was away at college—my college was six hours away from my primary doctor—and I would have to go back every three months to refill my prescription. Every three months was kind of hard, especially with being so far away, so I tried to see if I could have one of the on-campus doctors prescribe the medication. The process was really hard because they needed the actual diagnosis of me having ADHD—I was diagnosed over 20 years ago. The psychiatrist we went to didn’t have [my] medical records [anymore] and my file with my primary doctor just said that he was continuing the therapy from the psychiatrist. My medication wasn’t accompanied with any therapy. It was just, like, here’s the prescription, and go. Getting on the waiting list to get re-diagnosed as an adult would’ve taken a long time, and then it would take even longer to get an actual appointment with the on-campus doctors. Even then, I would still have to go back every month to get a prescription, and so it was like, fine, whatever. I just made it work.”
	“Just to make you laugh—this morning, I had to call my psychiatrist and let him know that the prescription he wrote a month ago can’t be filled. I’ve known for a month. He said, ‘Why did you wait?’ and I was like, “Um, because I have ADHD and I forgot [LAUGHTER].”
	“To really get on medication and treat everything for me in terms of the anxiety, the depression, the ADHD, everything being comorbid—to actually just get to a psychiatrist that I liked and that I trusted who wasn’t just going to throw a random thing at me—I had to pay out of pocket because my insurance wouldn’t cover anything but just a regular GP. I put myself into credit card debt at one point just to go through this—you know, not through the diagnostic process, but the getting on the right medication, trying different things, doing the medication appointments, and that’s almost $200 a visit.”
	“I had to remind [clinicians], like, ‘Just so you know, I have ADHD, so you don’t get it misdiagnosed with depression or anxiety.’”
	“I went for help. They were very quick to throw [depression medication] at me, and then, oh my gosh, [antipsychotic medication], and [sleep medication], and I had like 12 medications. That was OK, but they didn’t want to give you a stimulant—one medication that might help you. But they will give you 12 that aren’t going to help you and possibly cause you more harm. That just really—it—it kept me from getting the help—the help that I should’ve gotten maybe 20 or more years [ago]. That really makes me angry when I look back.”
	“I thought the process was really difficult. Before I came out here last year to start school, I asked if I could get on medication because I knew school was going to be challenging for me unmedicated and they were kind of hesitant. They gave me an antidepressant that was supposed to help with ADHD symptoms. I haven’t been diagnosed with depression or anything like that and it didn’t really help very much.”
	“I went to a whole ‘nother level, I guess. You know, the cannabis has always been there. And it’s always worked for my anxiety. But, you know, I tried the alcohol. But my family are all alcoholics, so I got away from that. But then, honestly, you know, I went into cocaine in the past. And cocaine didn’t help the anxiety. But it helped me concentrate with the ADHD. It can get things under control. Um, I’m away from all of it now. I just use the cannabis now. But it’s just strange, you know, how we self-medicate. And I think they don’t recognize that women can have ADHD and be diagnosed as an adult sooner than we are. Um, they should have some sort of screening for it a little earlier rather than having us go and ask, you know, ‘You think this is what’s going on?’ Why—why do we have to wait until that point?”
	“Yeah, and adding onto that, I had a very weird—because one doctor was like, ‘You should try cannabis. It’s really good. I mean, you’re trying amphetamines. These—you know, it’s just FDA. It might be good for you.’ And then the other doctor was like, ‘Oh, no, you have substance abuse problems. You have to go to rehab.’ So that was confusing. And I had to go to what I was feeling. I’m like, ‘You know what? This is working for me.’ So just having so many different trains of thought or theory, it’s confusing.”
	“Before I was diagnosed, I was self-medicating with cannabis. And that was great. But I wouldn’t feel comfortable doing cannabis and going to work because I don’t know what my brain is going to do. One doctor was like, ‘Try CBD.’ And that was good. But, um—but yeah, that’s been my go-to. But now that I’m on meds, I don’t want to mix it because I want to give the medicine [the opportunity] to work. But cannabis has been—like, I survived over 10 years with that, to be honest.”
Limitations of current evidence-based treatment	“The medication that I’ve gone through has not helped, and so, hearing people talk about this clarity that they receive, I haven’t experienced it. I still feel, even though I have a diagnosis, maybe it’s not correct, or what’s still going on with me to where I can’t even pay attention in class? So, my studies are struggling. And home life is struggling. It’s super frustrating.”
	“I’ve tried the medications and they definitely were like wearing glasses, but I still haven’t found the right dosage because I have terrible side effects. That’s very frustrating because I’m chasing what it feels like when I’m like—’Oh, this is what neurotypical people feel like. Wow, no wonder they can do everything.’ Not finding the right medication is still very, very frustrating. I’m still on that journey.”
	“The medication has been helpful. But I’m still trying to find the right dosage. That’s been a really difficult challenge for me. I think that the medication is helping a little bit, but motivation’s still pretty low. I’m not super interested in what I’m studying, so. . . [CHUCKLING].”
	“It’s easy to get a doctor to prescribe you drugs—that’s no problem but finding a therapist who can do CBT and cares—because I think a lot of times, ADHD kind of gets [dismissed], like, ‘Everybody has ADHD, whatever.’ [Doctors] don’t spend time with you. They don’t really want to think of you as an individual. You’re just another person who claims to have ADHD. That’s the attitude I get out of the few times I’ve tried to go to therapy. I’ve kind of given up on it entirely and have just started doing my own whatever, treating myself because just finding somebody who’s not just super dismissive of it, [or who finds] you boring because you just have regular old ADHD and anxiety—’Everybody has that’—That’s the struggle I’ve had.”
	“Navigating ADHD through motherhood has truly rocked my world in a way that I don’t even understand. Um, I’m still trying to figure it out. I’m still trying to, like—you know, because I went through therapy and medication as a kid and learned all these wonderful coping skills and mechanisms and things of how to manage along with medication. Those are great tools. But they’re not always conducive to having an infant and now a toddler. And so, you know, I’m—I guess where I’m at right now in my life is struggling to find the balance between parenthood and, you know, coping and dealing with my ADHD and, you know, dealing with my son and all of those things that come into play. And like, even last night, like, my husband and I were trying to do something. My son was asking me for things and my husband was asking me for things. And I finally had to look at [my husband], and was like, ‘I need you to stop.’ And, you know, and he kind of looked at me. And I was like, ‘I—I—like, I—I just—I can’t even—I don’t even have words. But like, right now, things just need to stop so that I can gather myself.’”
Stigma and isolation	“[What] made me so angry is when I first started sharing with certain friends that I was newly diagnosed, and they all said, ‘Oh, everyone’s a little bit ADHD.’ That will just make me so angry. I’m like, ‘Yeah, because everyone’s a little bit diabetic when they have a little bit of candy.’ That was the worst. Getting them to understand [ADHD] is a real thing, not just a trend—ugh—it still makes me angry a little bit, but now my closest friends are way more understanding. It was a struggle because at first they were like, ‘Oh, who do you go to? Do you think they can prescribe me too with a med?’ It was just hurtful, taking my condition easily. It just makes me feel really angry and upset.”
	“I have a 12-year-old son and I consciously honestly really think he has ADHD and I’m still afraid to have him tested because of the stigma that medication has with younger kids. I know it’s wrong in my head, but somehow, I can’t make the connection to go ahead and do that.”
	“It does make me doubt my brain a little bit. Before I didn’t have the awareness that I was that different. I mean, I knew I was different, but I would just follow through whatever I was thinking. Now I kind of doubt it a little bit. And I don’t think I like that. I guess it’s the awareness. I don’t know.”
	“As a kid and a teen, I felt like I didn’t fit in anywhere or with anybody. Then it was good for a little while. And then having a child made a huge difference, like, feeling—constantly comparing my level of functionality to every other parent in my kids’ school and everything—really felt awful. I really constantly felt like I was falling short. They were all doing next level things and their kids were in, like, 12 different activities and I could never have handled all that.”
	“Thankfully, my kid’s an introvert. She was perfectly happy just doing low key stuff at home and it made my life easier. But I did feel like I was failing her on so many levels and I never fit in with the other parents, which felt weird and bad. I chose not to have any more kids because I didn’t think I could handle any more kids. Like, I felt like—and my kid is amazing. She is spectacular. She’s in college now and doesn’t have ADHD and makes my life great. But, it’s rough when you’re constantly comparing yourself to others. And even if it may not be that other people are purposely leaving you out, you feel like you can’t keep up. And it’s pointless to even try. Like, so you just tend to—I tend to back myself off socially. I won’t go to the party, or I won’t do things—join in—because it feels like I’m just setting myself up to fail or something.”
It was hard for me to get a diagnosis of ADHD
Not recognizing one’s symptoms as ADHD	“I didn’t know it was ADHD. This was the ‘80s. Only boys got it. I wasn’t hyper. I was just daydreaming and couldn’t focus on what the teacher was saying. And you know, my notes would usually just be doodles on a page. I was classified as gifted. And the only class I enjoyed was my gifted and talented class where we got to go and be creative and kind of have more free thought. And now I know what all that was and why I was like that.”
	“I didn’t notice more symptoms until after I had started college—with the constant procrastination of schoolwork. I could never understand how these students took these beautiful notes. And I’m like—everything the teacher is saying—I can’t get it down. Looking back—how much I was in trouble in elementary school and everything, just for talking, or forgetting homework, or not doing assignments, and I didn’t know that that was my ADHD. My brother was going through the same thing. But because he had the hyperactivity and I didn’t, that’s when they’re like, ‘Oh, well, no, he’s just—just a little boy with ADHD. You’re just—you’re just a talkative girl.’ And that’s what it was often left at. I didn’t really notice a lot of it until, you know, during the pandemic when you’re what—bored, sitting there scrolling through social media. And all of a sudden people are talking about, ‘Oh, yeah, I have ADHD and this is what I deal with.’ I’m like, ‘Oh, I do that too.’ [LAUGHS] And it was—it was really eye-opening.”
	“I struggled all through school. I would do really well in certain subjects and I would completely and utterly fail others to the point where I had to be put in the super, super remedial math class. And I finally got to college. And I was just so frustrated because I had tried this one math course three times. And I went to the school counselor. And she said, ‘Have you ever thought about getting tested for ADHD?’ And that kind of clicked for me then.”
	“I wasn’t seeking to get a diagnosis for it. I didn’t know I had it. [My] therapist, the woman who also has ADHD, [said,] ‘I think you should get diagnosed,’ and administered the test.”
	“I didn’t get diagnosed until I was 33. It took my neurologist a couple years to convince me to accept it, because I didn’t. I didn’t think it was real or that I had it. We had a good relationship. He said, ‘You are classic adult ADHD,’ and I was like, ‘What? No.” He said, ‘Yes, you are.’ I said, ‘Um,’ and he said, ‘Well, come in and let’s do an assessment and we’ll see.’ So I came in and I did the computer test. I accepted it. I wasn’t looking. I didn’t know. When I finally accepted it and started telling people, everybody was like, ‘Yeah. Duh.’ [and] ‘Oh, OK, that makes sense’ [LAUGHS].”
	“The teacher would be talking and I would be like thinking about going to [an amusement park] on the weekend [LAUGHS]. I’m [thinking about] riding the rollercoaster—and I’m like, ‘Oh my God. I have a test. You have to listen to this guy.’ I look back and I think, you know, wow. There were a lot of signs. I just didn’t know. I don’t even think I knew what ADD was or ADHD. I would never have known to even diagnose myself until I got older.”
	“It took having a therapist who had ADHD, as a woman, to recognize it in me and tell me, ‘You know you have ADHD, right?’ I was like, ‘What do you mean?’ She had to spend three months convincing me like, ‘Hmm, you should probably get that, you know, checked. You should see about that,’ and she was absolutely right. Do you know how many therapists and psychiatrists I’ve seen over like the last 15 years or so? It’s outrageous that no one even had a glimpse of it.”
	“When I was out of school, I thought that ADHD was just a learning disorder for school children. Coming back into grad school and getting diagnosed and being medicated and realizing that this is a lifelong journey, it’s just been interesting to see the way that that manifests as an adult because there’s not really a lot of information out there for ADHD adults, and definitely not a lot for women. So yeah—it’s been interesting, and I’m really excited about this stepping stone.”
Masking impairment	“I was super active at school. My parents made sure [my siblings and I] all were. I was in marching band. I was in ROTC. I was in everything. I made good grades. I was a gifted and Honors student and all that stuff too. But when I was at home I was—and I wasn’t being distracted, constantly over-thinking, depressed, wondering like, ‘Why am I even here? I am so sad all the time.’ Like felt alone in my emotions. Like even though I had friends and family, I didn’t feel like anybody understood. So, because they’d just make fun of me or think, ‘Oh, you’re being silly,’ or something like that. So, for years I just struggled with not trusting my own instincts, even though I know I’m an intelligent person. [LAUGHS] And I’m not stupid. I struggled with that for so long. And I’m still working on it.”
	“What if you didn’t know it was a problem until you got diagnosed, [LAUGHS] and then realized you had a problem? I’m realizing my trauma—I have significant perfectionist and people-pleasing tendencies, so I did really well with masking. And I kept hyper-focusing on the things that I thought would get me things. I’ve always been like teacher’s favorite student, and got all A’s, and I almost have a Ph.D., and I did Olympic [sports] and finished fourth, and yada, yada, yada. So that was never a problem until I was going to start therapy for an assault. My therapist is also ADHD. When we were talking, she’s like, ‘I think you need to test.’ And I’m like, ‘There’s no way because look at all these things that I’ve done and I can do.’ And the more we talked and took the test, it made such a difference. And I was like, ‘I wish I knew.’ But kind of the same way, I grew up [outside of the United States]. So obviously, that wasn’t the conversation back then. But in school, still didn’t notice. And I wish I did. You know, because life would have been a whole lot easier. And I would have been a whole lot kinder to myself in my head.”
	“What was hard about it was when then I started school, getting the accommodations and help that I needed in school. It took me until my senior year of high school to officially get my [Individual Education Program] IEP because from first grade until then, every year I started the process of getting an IEP, when it came time to getting the actual approval of it, I wouldn’t get approved for it because my grades were high. But they weren’t taking into account what it took to get to those grades and the accommodations and help of my wonderful friends and teachers, doing out of just the kindness of their hearts, not necessarily because it was what was given to me. So, dealing with the—what was needed from the diagnosis was really hard.”
Diagnostic complexity	“I was misdiagnosed for a very long time. I took myself off all the medication and did nothing for years. I went in to see a new doctor, a general care doctor, and he said, ‘I think you have ADHD.’ He sent me for testing. He put me on medication and I’ve been on it ever since. So, it was like really simple when you got with the right person, but it wasn’t simple before that when, you know, when I was bipolar.”
	“Everything for me was written off as PTSD, borderline personality from trauma, depression, anxiety. I did have real trauma and real abuse, but it didn’t matter what I went to the doctor [for]. ‘Oh, it’s because you’ve been through trauma.’ I went to the doctor for my stomach. ‘It’s because you’ve been through trauma.’ I literally could not get anything addressed because I had been through trauma.”
	“It took four doctors to find the right one. The first one, she was like, ‘No, you have major depressive disorder,’ and then she realized, ‘Oh, no, you have ADHD.’ She gave me all the possible meds, but I had bad side effects, [so she said,] ‘Well, I can’t help you anymore. Good luck and find someone else.’ Then the other doctor, who was doing cognitive therapy, he wasn’t giving me medicine—I just felt he wasn’t really helping. Then I went to another doctor who didn’t believe in ADHD, who just told me, ‘You have to meditate,’ which was so incredibly frustrating. I felt like I was on my own, just doing research by myself, hoping and praying to find the right specialist.”
	“I used drugs and alcohol for years to cope with my problems, you know. And they would always tell me that that was the problem. [LAUGHS] . . .Instead of—you know, with ADD, if you’re not treated, then you’re probably self-medicating. And they didn’t—they never looked at it that way. They’re like, ‘Well, if you quit drinking, you won’t have all these problems. You’ll—you’ll—you’ll be able to do all these things that are required of you.’ And that—that never worked.”
	“I also was diagnosed with generalized anxiety and I’ve also seen traits of maybe autism. I have been working with a therapist for the past two years now and I have brought up the subject of autism a couple of times, or even bipolar disorder, because I have a hard time with emotional regulation. Every day is something different, and so every day, I’m like, ‘Oh, is this just like being a normal human? Or is this my ADHD? Is it my anxiety?’ I guess it’s more of the self-awareness. I’m just constantly thinking about it more rather than it being—like, it’s helpful. But at the same time, it’s like, well, am I confusing some of my ADHD symptoms with other diagnoses that I could possibly have?”
	“Substances helped me more with the emotional side of it and coping with rejection and coping with not feeling good enough. I had this huge thing of constantly being told, ‘you have so much potential and you’re wasting it.’ And I took that as a personal failure. And so, my substance abuse was mostly in college when I was feeling that failure. And I wasn’t succeeding in my goals. I wasn’t succeeding in the things everyone thought I could do. And I was just like, wow, I’m just a piece of crap, you know? I just need—like I needed that numbing. And I also specifically needed alcohol to slow down my brain, because I have too many thoughts all the time and can get like into a cyclical thinking, can get intrusive thoughts, can get stuck in these rumination patterns. And you know, sometimes having too many thoughts can be a good thing because you can come up with so many ideas and stuff. And I can use that to my advantage sometimes and be like really nerdy about it. But in those days, combined with my depression, my feelings of failure, my ruminating thoughts were all very, very dark. And I could not shut my brain up. I couldn’t focus on anything because of my brain. I literally was—I would drink wine so that I could study, because drinking wine quieted my brain enough that I could like think about French instead of thinking about how much I hated my shitty life.”
Variable assessment methods	“Once someone put the idea in my head, ‘Hey, I think you have ADHD,’ and I was like, ‘Hmm, I think you’re right,’ then it was easy to get the diagnosis by luck because my therapist worked in the same office as my psychiatrist. She talked to her first and was like, ‘Yo, like this client has ADHD,’ [LAUGHS] and my psychiatrist was just like, ‘Probably. Let me talk to her.’ Literally, all we did was just an interview.”
	“[The clinician said,] ‘The best way for me, I found, to test to see if my clients have ADHD is to give them a stimulant trial. So, let me give you the stimulant and if it amps you up, then you probably don’t have it, and if it kind of just calms you down and makes you focus or whatever, then you probably do.’ I took it, and I fell asleep, for like the first week. Every time I took a dose, I fell asleep for like two hours. She’s like, ‘Oh, yeah, I think you have ADHD.’ So once I knew I had ADHD or suspected it, then the diagnosis was easy.
	“My college already had a relationship with sending people to local psychology centers to do these assessments, so I feel like I didn’t really get questioned. I didn’t really have someone say, ‘I don’t think you have this,’ when a counselor who sees this all the time just kind of said, ‘No, you need to take this assessment.’ Oh my God. I had to do an interview. I had to do several cognitive tests. I had to go on a computer program that was very boring for like 20 minutes and drove me crazy. Then it’s like, OK, here you go. Here’s your diagnosis. And I’m like, ‘Huh, neat.’”
	“When I [moved], I tried to see if I could get prescribed something that would help me. Holy Toledo! I had to go on this super long waiting list and the process—the actual testing process to get diagnosed took, like, four hours. And the guy who was testing me was just not friendly at all and it was a difficult test—maybe not difficult, but it was just really annoying. It was three or four hours of sitting in a room with a man who was telling me stories and telling me to repeat back numbers and letters and colors. It was not a great experience for me and then something happened—the insurance didn’t cover it somehow. Then I got a bill for like, $800 in the mail. I still need to call and figure that out, so I guess I’m still not even quite done with that whole process currently [CHUCKLING].”
Self-advocacy	“I went to my PCP and said, ‘I have ADHD—I’m sure of it—don’t question me.’ He was like, ‘Fine. Yes, you have ADHD,’ and he didn’t question me. But it took me a lot to get to that point. Kid me needed help, you know? Adult me figured out a lot of coping mechanisms that got me through adulthood. It was hard as a kid because my parents didn’t want to give me an excuse to not do my best, so they didn’t want to get anything diagnosed. They didn’t want to take me anywhere, so that part was hard. But once I decided to go and say, ‘I need—I need help—I need to do something,’—it was pretty easy to get the diagnosis.”
	‘I tried to get in with an actual psychologist, wanting to get official testing, and was told they don’t see people with ADHD, so I called my PCP and he was like, ‘Yeah, sure, yeah—I mean, you’re an adult—you sound like you know what you’re talking about,’ and no problem. I’ve done screeners online and stuff a million times, so I already knew. I wasn’t really necessarily questioning anything, so my doctor just kind of trusted me and went along with it.”
	“I just proposed it to my doctor—[I] said, ‘Listen. I’ve been thinking about this—and since my son’s diagnosis—’ and I explained everything. He didn’t even do any official testing. I don’t know if he plans to, but he said, ‘Yeah, I agree with you.’ The frustration is I lived with it for many years before I realized. They didn’t say it. Earlier, they told me depression and anxiety, and that’s what I stood with.”
	“I just went to my therapist and was like, ‘Hey, so I think I might have ADHD.’ She’s all, ‘Oh, well, I do assessments. Do you want one? Let’s do one. OK, Let’s plan for next week. I’ll come over and we’ll get you assessed.’ We sat there for maybe a half an hour and she was like, ‘Yep, you definitely are ADHD. I will diagnose you as moderate to mild because of all of your coping skills.’ I’m like, ‘OK, but what if my coping skills weren’t there? How would it be?’ She was like, ‘No, I mean, you’re good. I think you work around it very well.’”

Results

Being Diagnosed With ADHD Has Changed My Life for the Better

Poll results are reported in Figure 2. A majority (64%) reported that receiving an ADHD diagnosis has changed their life for the better, and provided validation, increased self-compassion, new opportunities for adaptive coping and treatment, and greater social support. Some (29%) reported feeling unsure, and 7% denied that receiving the diagnosis had changed their life for the better.

Figure 2.

Participant poll responses.

Prior to obtaining an ADHD diagnosis, women described receiving negative feedback from others who attributed their difficulties to aspects of personality or moral character that were within their control to change. Women reported that such interactions, repeated across their lives, led them to internalize negative views of themselves. Women shared that prior to diagnosis, they had long perceived themselves as being “different” and “not good enough” but had not understood why they had struggled across life domains. Receiving an ADHD diagnosis provided external validation for their struggles and new language with which they were able to make sense of their lived experience and more accurately explain their challenges to others. Many women described feeling relieved or soothed upon receiving their ADHD diagnosis.

Women also reported that diagnosis of ADHD made their life easier by providing access to treatments and support. Receiving stimulant medication, often after years of unsuccessfully trialing medications for alternative diagnoses and/or relying on self-medication with drugs, alcohol, or food, was described as life-changing by many. Women reported benefits of stimulant medication in their academic and occupational functioning, emotion regulation, depression, anxiety, impulsivity, and relationship functioning, as well as in their ability to parent effectively. Women identified effective medication management as being key for advancing opportunities to improve their quality of life, enabling them to be successful in seeking higher education and maintaining employment.

Receiving a diagnosis of ADHD also provided women with new opportunities to connect with others with the diagnosis, including family members, neurodivergent friends, as well as internet-based ADHD communities, often accessed via social media platforms. Women not only reported feeling a sense of community that reduced feelings of isolation, but also indicated that these connections were helpful for exchanging information and learning coping strategies that had not been otherwise available to them.

Being Diagnosed with ADHD Has Made My Life Harder

Although only 7% reported that diagnosis of ADHD made life harder, while 50% reported feeling unsure, and 43% disagreed with the statement (Figure 2), women identified several challenges upon receiving an ADHD diagnosis, including barriers to accessing appropriate care, particularly specialized mental health care. Women reported difficulty finding providers accepting new patients, especially providers willing to treat ADHD in adults, and even greater difficulty identifying providers with experience treating adult ADHD with common comorbid mental health conditions like anxiety and depression. Additionally, many women reported encounters with providers who were reluctant to prescribe stimulant medication or consider treating ADHD as their primary presenting problem. This was especially true when providers had more familiarity with other comorbid mental health conditions, such as anxiety and depression. Participants recalled that providers seemed more willing, and in some cases were insistent, that antidepressant, anxiolytic, and/or antipsychotic medications be trialed first in order to address comorbid mood and anxiety symptoms prior to, or instead of, initiating medication treatment for ADHD. Cannabis products were also discussed by providers before considering prescription medication for ADHD. Such care experiences left women feeling confused, invalidated, and ignored. For women who were able to obtain pharmacological treatment for ADHD, some noted challenges due to the confluence of executive functioning differences and the need to regularly schedule and attend medication management appointments, request prescription refills, and refill prescriptions on time. Women also reported shouldering significant out-of-pocket costs due to insurance restrictions, challenges navigating care with multiple providers, and barriers to continuity of care and long-term management of symptoms.

Some women described feelings of anger and disappointment upon recognizing the amount of time and resources spent, and suffering endured, while trialing medications that were ultimately unhelpful for their needs or accompanied by significant side effects. Additionally, many women voiced frustration regarding the apparent lack of evidence-based treatments beyond stimulant medication available for management of ADHD, and especially in the context of life transitions, such as becoming a parent. For these reasons, many participants indicated seeking out and relying upon alternative methods of managing ADHD symptoms, including self-medication with alcohol, cannabis, and other substances.

Women discussed feeling stigmatized by health care providers, friends, and family, who they felt did not take their ADHD diagnosis seriously. Women described increased self-doubt and low self-esteem due to increased self-awareness of their ADHD symptoms, and concerns about negative evaluation by others. Relatedly, women reported concerns about recognizing symptoms of ADHD in their children, and apprehension about seeking related care out of a desire to shield their children from the stigma and judgement they have endured.

It Was Hard for Me to Get a Diagnosis of ADHD

Half of the sample denied difficulty obtaining a diagnosis of ADHD, while almost 36% indicated the diagnostic process was difficult, and 14% were unsure (Figure 2). Yet regardless of the ease with which women obtained a diagnosis of ADHD, the majority reported initially being unaware that their experiences were indicative of ADHD. Many shared that for much of their lives, they had understood ADHD to be relevant only to White school-aged boys, and they had previously lacked awareness of how ADHD could present among females and in other cultural backgrounds.

Numerous factors were identified that hindered diagnosis of ADHD. Co-occurring psychiatric concerns, including depression, anxiety, trauma, as well as potential autism spectrum disorder, and chronic physical health conditions, complicated detection of ADHD among women themselves and their health care providers. Furthermore, some women disclosed substance use that further precluded accurate diagnosis of ADHD. Women also described receiving support from their parents and teachers, as well as their own conscientiousness and desire to please others, which likely masked earlier detection of ADHD.

Variable practices were used to diagnose ADHD, some of which are not necessarily evidence-based. While some women completed brief assessments, others completed extensive evaluations that were costly and burdensome. In a number of cases, ADHD was identified first by a trusted care provider, in one case a neurologist initially focused on treating another pre-existing condition, and in two other cases while working with female therapists, both of whom disclosed their own neurodivergence. For others, considerable self-advocacy after long-term struggles and self-directed psychoeducation about ADHD was required.

Discussion

This study is arguably the largest and most comprehensive mixed methods study examining the experiences of women diagnosed with ADHD during middle adulthood. Findings provide important insights to guide future research on ADHD in women. Women mostly reported that an ADHD diagnosis was beneficial, providing them with validation as well as new opportunities for coping and support. At the same time, some negative aspects of the diagnosis were also discussed, particularly difficulties accessing and maintaining care, negative treatment experiences, and stigma. Notably, women described variable diagnostic experiences, with many indicating that they had not recognized their own symptoms of ADHD, as well as diagnostic complexity and other factors that masked identification of ADHD. Women described a range of diagnostic assessment procedures, as well as considerable self-advocacy to convince their providers to consider the diagnosis of ADHD.

The themes that emerged in this study of women are consistent with those previously identified in other qualitative studies conducted primarily among younger and older adult women with ADHD (Henry & Jones, 2011; Morgan, 2023; Vincenti et al., 2023). Altogether this work points to considerable benefits as well as barriers to care for women with ADHD. This qualitative data provides critical firsthand perspective that is needed to contextualize extant quantitative findings showing marked increases in treatment for ADHD among adult women (Babinski et al., 2022; Danielson et al., 2023; Sibley et al., 2023). By integrating quantitative and qualitative data through mixed methods research, the current work strives to ensure that findings are aligned with and reflect the values, priorities, and interests of women with ADHD (Holthe & Langvik, 2017). This is a notable advancement in the study of ADHD in women, as the majority of research on ADHD has prioritized school-aged boys. Our research group intends to use the themes identified from these focus groups to conduct one-on-one interviews with women with ADHD. Individual interviews may provide even more fine-grained detail on women’s experiences with ADHD beyond the findings that emerged from the focus groups.

This study included a relatively small sample and additional work is needed to expand the generalizability of these findings. For example, more than half of the women in the study were diagnosed with ADHD Combined Presentation and nearly 79% reported a co-occurring anxiety disorder, but consideration of other diverse presentations of women with ADHD are needed. Relatedly, only 14 of the 31 women eligible to participate in the study attended the focus group. Women self-selected for the study and were required to have been diagnosed with ADHD by a health professional, although more specific information on how diagnoses were made was not available. While self-reported symptoms of ADHD and related impairment were confirmed, emerging guidelines for first-time adult ADHD diagnosis recommend collection of additional assessments including informant ratings, chronicling a symptom timeline, and carefully ruling out alternative explanations for adult ADHD symptoms (Sibley, 2021). Additionally, other topics presumably relevant to understanding the diagnosis of ADHD in women (e.g., use of digital start-ups for pharmacological treatment, how ADHD diagnoses were established) were not directly addressed and member checking of results was not conducted. Additionally, while the focus of the study was on diagnostic experiences, there may be unique insight gained from further exploring the benefits and barriers to ADHD treatment among women. Despite these limitations, the mixed-methods approach, as described herein, helps to identify new priorities for research and ultimately to improve clinical care for women with ADHD. Based on the experiences disclosed by women in this study, several recommendations are provided to enhance the assessment and treatment of ADHD among women.

Recommendations to Improve Assessment of ADHD in Women

Increase Early Awareness of Female Expressions of ADHD

Despite enduring academic and peer difficulties throughout childhood, parents, educators, and primary care and mental health providers often failed to identify ADHD as a potential explanation for these challenges. Women also frequently had not considered ADHD to be relevant to their personal experiences, as they had viewed ADHD as a disorder relevant only to school-aged boys. There is a need for increased awareness of female expressions of ADHD (Chronis-Tuscano, 2022). While long-standing academic underachievement, difficulties forming and maintaining supportive relationships, and bullying may not be specific to ADHD, such factors should signal consideration of, and assessment for, ADHD, particularly in female youth.

Increase Screening for ADHD

When women expressed concerns about ADHD in clinical care, many described feeling invalidated by providers, who conveyed discomfort or a lack of familiarity with diagnosing ADHD in adulthood, minimized women’s concerns about ADHD, or were quick to identify and prioritize alternative explanations for symptoms of inattention and hyperactivity/impulsivity. Inattention is one of the most frequently reported mental health symptoms (Babinski et al., 2022; Forbes et al., 2023), and it is important that clinicians, both specialized mental health providers as well as primary care providers, routinely screen for ADHD as they do for other common conditions such as depression and anxiety (Barry et al., 2023; Siu et al., 2016) Several brief ADHD screening tools are freely available to providers and should be administered to validate women’s concerns and identify when ADHD may be relevant (Kessler et al., 2005; Ustun et al., 2017). Screening for ADHD in primary care may help identify cases for which additional assessment is worthwhile, and help mitigate the many serious negative consequences (Hamed et al., 2015) associated with not addressing ADHD.

Evidence-Based Assessment of ADHD in a Stepped-Care Approach

Women described various methods of diagnostic decision-making ranging from trialing stimulant medication to extensive assessment batteries, which were conducted in primary care and across a number of specialty practices, and often resulted in significant patient burden. Women also frequently lamented the amount of time they had struggled prior to receiving a diagnosis of ADHD. These accounts raise questions about the frequency with which providers rely on evidence-based practices to reliably diagnose ADHD in adulthood (Sibley, 2021) and how decisions are made about who must undergo extensive assessment procedures in order to obtain a diagnosis and further care. In cases with relatively low psychiatric complexity or when a patient has been engaged with their provider for an extended time, diagnosis may be appropriately made in relatively brief clinical encounters in primary or specialty care, while more comprehensive specialty assessment may be reserved for more complex cases. A stepped-care approach would help reduce barriers to the diagnosis of ADHD for women and potentially conserve mental health care provider resources.

Consideration of Contextual Factors That May Mask ADHD

Women described a number of contextual factors, including placement in gifted programs in school that provided opportunities to engage in more creative and stimulating pursuits, family support with homework and organizational tasks, and family stressors, including family members (typically male) with more severe ADHD presentations, that may have obscured earlier detection of their own ADHD. Additionally, women described aspects of their behavior such as being perfectionistic “people pleasers,” as stemming from experiencing adversity, including bullying and other traumatic events, which led them to withdraw from their environment, and made their ADHD symptoms less salient to outside observers. Failure to consider the impact of such contextual factors may lead to false negative diagnoses of ADHD.

Recommendations to Improve Treatment of ADHD in Women

Treating ADHD Alongside Other Comorbidities

Despite evidence that anxiety, depression, substance use, and trauma are common with ADHD (Owens et al., 2017) and may develop as a consequence of undiagnosed and untreated ADHD, women reported that co-occurring conditions complicated their ADHD treatment or were prioritized above ADHD in treatment. Unlike these co-occurring conditions, ADHD requires evidence of impairment dating back to childhood (American Psychiatric Association, 2013), suggesting that in many cases, ADHD may be the primary condition. Treating ADHD and addressing the broad functional impairments associated with ADHD, in school, at work, and in relationships, may greatly alleviate co-occurring difficulties such as anxiety and depression (Faraone et al., 2019). There is a dearth of research guiding management of ADHD and co-occurring conditions. Thus, patient choice should be considered in clinical decision-making about treatment sequencing.

Team-Based Care to Reduce the Burden of Treatment

Women described following-up for care with numerous providers to treat ADHD as well as a number of other psychiatric and physical complaints, such as sleep problems, disordered eating/weight concerns, and concerns about hormone changes during pregnancy and the menopausal transition. Multiple providers and appointments increase cost of care and risk for disjointed care that is difficult to maintain. As problems with sleep and eating are common among women with ADHD (Owens et al., 2017), and hormonal fluctuations likely contribute to executive dysfunction which appears similar to ADHD (Shanmugan & Epperson, 2014), models of integrated care that more comprehensively consider multiple concerns may lead to more streamlined and less burdensome care.

Accessible Alternative Approaches to Address ADHD

Although stimulant medication is the primary treatment for adult ADHD (Weiss & Weiss, 2004), women discussed difficulties that were not sufficiently addressed with medication. Non-medication options may hold great benefit for women, particularly during developmental periods when stimulant medication treatment may be associated with significant risk, such as during pregnancy and while breastfeeding. However, relatively few clinicians provide psychosocial treatment for adult ADHD and insurance coverage limitations often restrict access to such care. Accumulating evidence shows benefits of cognitive-behavioral therapy (CBT) for adults with ADHD (Knouse et al., 2017; Liu et al., 2023). CBT focuses on changing maladaptive cognitive and behavioral patterns and has been studied, primarily as a treatment for depression and anxiety. As many women with ADHD experience clinical concerns such as low self-esteem, anxiety, depression, and trauma that co-occur with or result from ADHD in women, it is not surprising that CBT may be worthwhile. There is also emerging evidence that CBT specifically addressing executive dysfunction may reduce ADHD symptoms and related impairment (Knouse et al., 2017; Liu et al., 2023; Safren et al., 2017; Solanto, 2011). CBT for executive dysfunction focuses on modifying the self-instructive cognitions and thereby behaviors that related to time management, organization, and planning, while also addressing maladaptive thoughts and behaviors that address co-occurring depression and anxiety (Knouse et al., 2017; Solanto, 2011). CBT treatment is designed to be short-term and is offered in individual or group settings in which homework is assigned for outside of the therapy sessions to facilitate regular practice and generalization of CBT skills. Continued effort to examine CBT as a treatment for women with ADHD is worthwhile as are efforts to reduce potential barriers to effective treatment. For example, telehealth may be an ideal platform to deliver CBT for women with ADHD as it eliminates additional time for travel to treatment. Additionally, CBT that emphasizes acceptance of, rather than changing or minimizing, ADHD symptoms, may be beneficial given that ADHD symptoms follow a chronic course (Sibley, 2021).

Neurodiversity-Affirming Care

Women discussed the value of accepting their neurodivergence and attending to their strengths and resiliency. Rather than focusing on “fixing” their traits and behaviors, there may be relatively greater benefit to supporting women in seeking out environments in which they can present authentically and thrive (Sonuga-Barke, 2023). Women described connecting with neurodivergent communities in their friendships and through social media. The brief, easily accessible, and stimulating format of social media content is ideally suited for individuals with attention and processing speed differences. Although the risk of misinformation exists on social media (Guntuku et al., 2019), women indicated that exposure to neurodiversity-affirming social media accounts provided validation, reduced stigma, and helped motivate some women to initiate care for ADHD, especially when such critical support was lacking from providers. Additionally, social media content may provide women with ADHD, who are often socially isolated, with meaningful support and community. Women viewed ADHD affirming social media content as invaluable in the absence of other available supports, and indicated that the potential therapeutic utility of social media should not be overlooked by providers and researchers.

Author Biographies

Dara E. Babinski, Ph.D., is a Licensed Clinical Psychologist and Assistant Professor of Psychiatry and Behavioral Health at the Penn State College of Medicine.

Erin J. Libsack, Ph.D., was a Pre-Doctoral Psychology intern when this work was completed. She is now a Post-Doctoral Scholar at the LifeSPAN ASD Lab within the Rutgers Center for Adult Autism Services (RCAAS), Psychological Services Clinic.