Insights Into ADHD Diagnoses in Adult Women

In an interview with Pharmacy Times®, Judith Joseph, MD, board certified psychiatrist, content creator, and author of the book High Functioning, shared her knowledge about ADHD, dispelling stereotypes and addressing the growing number of diagnoses in adult women.

Pharmacy Times: What is ADHD?

Judith Joseph, MD: ADHD is a very common neurological psychiatric condition and typically diagnosed in children. However, children can grow up into adulthood and continue to have symptoms of ADHD, such as inattention, hyperactivity or impulsivity. And in order to truly meet criteria for ADHD, you have to have symptoms of those 3 buckets of symptom types before the age of 12. It used to be before the age of 6, but things were changed within the Diagnostic and Statistical Manual for Psychiatric Conditions, and now they've allowed a later date of symptoms in terms of when they have to start.

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People with ADHD tend to have problems with focusing and attention, with organization, with time management, planning, and they may also have symptoms of hyperactivity, such as fidgeting, difficulty sitting still and restlessness. Sometimes you could describe them as being on-the-go, like a motor. The impulsivity comes into play in terms of talking excessively, having a hard time waiting your turn, feeling impatient and making decisions that you otherwise wouldn't make when if you were in a mind state where you were actually weighing the risk versus benefits versus the alternatives.

The symptoms can be problematic, and they can impact your functioning in the home, in a workplace setting, in an academic setting, but to meet criteria, the symptoms do have to impair your functioning. If you're someone who focuses on and off, but your impairment really isn't there, you know that's likely not ADHD, because problems with focusing and concentration can occur in other conditions as well. So, it's important to have a diagnosis where you're working with a health care professional who knows what ADHD looks like in children and adults. Because if you're looking for symptoms in children, they're not going to be the same in adults. You want to be sure that you're getting an appropriate diagnosis from someone who sees ADHD and treats it every day.

Pharmacy Times: What is the impact of an adult ADHD diagnosis? Is adult-onset ADHD real, or did these patients slip through the cracks?

Joseph: I think that with adult-onset ADHD, if it's true ADHD, it wasn't in adulthood. However, it was probably missed. So, I've seen this a lot in my office, where people come in and they say, “you know, when I was a kid, I had a really hard time sitting still. I would kind of like days off and not stay focused. I often got into trouble because I couldn't pay attention, or I was so hyperactive and impulsive.” When I hear things like that, and the person wasn't diagnosed, then that was a missed diagnosis. And usually if the person still has access to their parents, if the parent is in their life, then I ask them to talk to the parents about, “what were you like as a kid. When did these symptoms start?” And that's how we can make a retro diagnosis.

However, I've also seen cases where people come in and they saw a Tiktok, or they saw a reel and they were like, “Oh, I think I may have ADHD, and I'm only getting diagnosed in adulthood, but the symptoms weren't there before. They weren't persistent, they weren't pervasive throughout childhood, and so that's less likely to be the case. So, with someone who I don't have that history, and they didn't have these symptoms in childhood, then I want to rule out things like a generalized anxiety disorder, where someone could have anxiety to the point where it's distracting them at times. But they're not having all the other symptoms of ADHD that I mentioned, or they could have depression, because one of the symptoms of depression is poor concentration. So, I'd want to rule out depression in those individuals.

Also, sometimes there is no condition, there is no diagnosis, but the person's environment is not conducive to focusing. For example, if you know the person is in a job where they're constantly looking at different things and they're different stimuli, and it's difficult to focus, then that's the environment. So, I'll ask that individual, what's it like when you're at home? And let's say you're doing something at home that requires focusing, like doing your taxes or organizing your finances. If their focus is fine there, and it's not in both settings, then it's likely something else due to the to the environment.

There are some cases where people have medical reasons as to why they're having poor concentration. For example, sometimes when some of my patients who have their periods or hormonal fluctuations, they may have problems with concentration and focusing and then get a misdiagnosis of ADHD. Or people who are going through perimenopause or menopause and they're experiencing brain fog, they may get an incorrect diagnosis of ADHD when it's really due to hormonal fluctuations.

Pharmacy Times: What do you think has contributed to the increased diagnosis of ADHD in women in their 20s and older since 2020?

Joseph: I do think that women were missed a lot of times. I've seen cases where if a girl as a student, let's say in elementary school or middle school, and in high school was well behaved but still had issues with focusing. They didn't have the behavioral agitation or restlessness that, let's say, a boy would have had, then that could be under diagnosed or a misdiagnosis.

Because in society, girls are acculturated to be ladylike and to sit still, they may exhaust themselves trying to mask symptoms of ADHD that would otherwise be caught by someone who is a trained clinician. Additionally, there is inherent bias within medicine to think of ADHD as being like a little hyper boy’s diagnosis. You're not going to be thinking about ADHD if you have that inherent bias. You see a girl who's well behaved, who's not hyperactive; however, she has problems with focusing on attention, and she is exhausting herself trying to mask all those other symptoms. So I've seen cases like that, where women would come into my office and said that they think that they had a misdiagnosis because they didn't have the classic symptoms of what a boy would have looked like in childhood, but that they're realizing based on what they saw online or read or have learned from friends that ADHD is not just hyperactivity. There are inattentive symptoms, they likely had that their entire lives, and they didn't get the support that they needed.

Pharmacy Times: What treatments are available for ADHD, and how is ADHD managed in adult women?

Joseph: The gold standard for treatment of ADHD is stimulant medications. But not everyone can tolerate stimulant sometimes; people lose weight or they have a decreased appetite or poor sleep. There are non-stimulant medications for ADHD, and also there's therapy for ADHD. There's something called organizational skills therapy, where they these are behavioral modifications that you work with a coach and executive skills functioning coach or an organizational skills therapist to develop coping mechanisms and behavioral changes that to support you. For example, you may work with someone to organize your schedule in a way that you're not multitasking or that you're prioritizing certain tasks, or organizing your home in a way to declutter so that things are easy to find when you're planning your schedule, you're making sure to allot time enough time at the beginning of the day or beginning of tasks, or between transitioning tasks. You may organize your office in a way that you have your most used items in one area so you're not spending a lot of time looking for them.

So, there are systems that you can use, like color coding systems and digital systems. There are all of these tools that an organizational skills therapist can help you with. If medication is not something that you can either tolerate or want to try first, or in some cases, I have clients that have that utilize a little bit of both. And it's also important to know that ADHD travels, or possibly travels with depression and anxiety. It is possible to have multiple conditions at once, because if you can imagine having a difficult time with time management, focusing and so forth, that can put a lot of stress on your life. That may make you more at risk for anxiety and depression and you want to make sure that you're addressing all of these.

Lastly, sleep is really important, because people with ADHD tend to struggle with sleep. So, you want to think about your sleep hygiene. You want to make sure that you're sticking to a sleep routine where you're waking up and going to bed at the same time that you're not working in your bedroom, that the bedroom is only for intimacy and sleep, that you're keeping the bedroom cool and not having a lot of caffeine that disrupt your sleep, not eating too late. Things like journaling and unloading your worries in a journal before going to bed can be helpful, but you want to keep sleep sacred, because sleep is restorative and it's really helpful and important in people with ADHD.