Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. For a long time now, the conversation around ADHD or attention deficit hyperactivity disorder has focused on children. I'm sure just hearing the term ADHD brings to mind images of a child who can't sit still or is disrupting the classroom.

But for many girls and women, ADHD can manifest differently and often be overlooked. A racing mind that never seems to quiet, chronic disorganization, losing track of conversations, intense emotions, or even feeling like you're working twice as hard just to make it seem as though everything is under control, and perhaps being labeled as lazy, messy, too sensitive, or not trying hard enough even when you're giving it your all.

In this episode, we'll explore why ADHD is so often overlooked or diagnosed later in girls and in women. Our expert guest will explain how symptoms can shift throughout the lifespan, whether in adolescence, college, work, pregnancy, perimenopause, or even after. We're also gonna take a look at the hidden cost of masking and how an accurate evaluation can connect you with the right kind of support.

Whether you're wondering about yourself, a friend, or a loved one, this conversation offers practical guidance for shifting away from self-criticism toward understanding. First, let me introduce my guest, Dr Monica Johnson.

Dr Johnson is a licensed psychologist and the owner of a group practice, Kind Mind Psychology. Her focus is on reducing healthcare disparities and barriers to quality care. She's also host of the "ADHD &" podcast through the nonprofit org understood.org. Welcome to the WebMD Health Discovered podcast

Monica Johnson, PsyD: Thank you so much for having me

Pathak: I am looking forward to sharing your health messages with all of our listeners. So today we're focusing on ADHD in girls and women. So what are some of the ways it can look different from the stereotypical picture that most of us have in our heads when we think of ADHD?

Johnson: Yeah, I think the picture that most people carry with them is kind of the class clown or the boy who's like bouncing off the walls in class, and that kid does exist. It's just not the whole story. So oftentimes, ADHD in girls and women can more often show up internally, so the hyperactivity may be in their head instead of in their body.

So they might have more of a racing mind, constantly feeling like they have multiple tabs open. They may have trouble really shutting down at night. And women often have the inattentive type of ADHD, and that can look more like daydreaming, losing your place in conversations, the book bag or the purse that's a black hole and has like 1,000 things in it.

And then the impulsivity parts can look like kind of talking over people, maybe blurting things out, impulsive spending, or saying yes to a lot of things. And a lot of parts of it are emotional as well. We've been learning more and more that emotional dysregulation is also a part of ADHD.

Pathak: So when you're seeing some of these symptoms or someone who's listening is thinking, "Wow, a lot of that sounds like me." Why is it that it's so often either diagnosed later or missed when it comes to the healthcare system?

Johnson: Yeah. The biggest reason that I find is that referrals are typically driven by disruption. So it's kind of like the squeaky wheel gets the oil. So the kid who's disrupting class is the one that's gonna get noticed. The little girl who's kind of staring out the window or turning in half-finished homework is not really gonna get the same attention, particularly at that age.

And we see the diagnosis rates in childhood run roughly like three boys to one girl, and that gap does start to narrow into adulthood

Pathak: So help us understand when you're thinking specifically around the ADHD piece of it, what does that look like across a woman's lifespan from childhood into adolescence and into later life?

Johnson: Oh, sure. So that's definitely gonna change over time. You're basically gonna have the same brain, but you're gonna have different demands across time. So in childhood, it can look like the dreamy kid or the chatty one, the quote-unquote "smart one" who's not living up to her potential.

But as you get into adolescence, that's gonna add hormones and social complexity and that's when you're gonna start to see more of the emotional dysregulation, and then there may be friendship struggles that show up as well. It's also important to understand that when kids are young, they have a lot of structure and scaffolding in their day.

Like, they have parents who wake them up or help them with their homework in the evening. When you shift into college, a lot of that scaffolding is removed, so you don't have anyone waking you up, you don't have anyone checking your homework, and, like, that adulthood starts to stack on top of you. And then, outside of college, then you get into, okay, I'm trying to work a full-time job, relationships, if I'm having children now I have parenting and caregiving responsibilities.

It's also important to note that estrogen interacts with dopamine, so many women notice their symptoms worsen premenstrually, postpartum, and also in perimenopause. And there have been studies that have found that women with ADHD report notably higher rates of PMDD, postpartum depression, and also severe perimenopausal symptoms.

So if you're a woman with ADHD and you're noticing or reflecting back on your life and going, "Oh yeah, things felt harder or different at various times," that is not your imagination. That is a true lived experience

Pathak: So I'm imagining the woman as you're talking, go across her lifespan where these symptoms are changing, shifting, sometimes overwhelming, sometimes more manageable. So how is it that some women and some girls even become good at masking their symptoms by overcorrecting?

Johnson: Yeah. Masking does work, but it comes at a high cost. A lot of women, because of social and cultural norms are trained in, how to mask. That's one of the reasons why sometimes it can look different between girls and boys because girls are often kind of taught to be ladylike, to try to be quiet and to kind of present in a certain way.

And so masking can end up looking like competence on the surface, but what you're not seeing is that this person stayed up until 3:00 in the morning to get this assignment done. They've got eight different notebooks and planners that all have different parts of their system in it and people don't always notice these things.

Masking can be dangerous because it runs on a lot of anxiety and effort, and that's one of the reasons why kind of ADHD burnout is a thing because oftentimes these people are doing 10 times the amount of work just to present on a quote-unquote "normal" kind of day-to-day basis

Pathak: And is that what you mean when someone says that this person has an invisible functional impairment? Is that sort of the description?

Johnson: Absolutely. Like, invisible impairment is kind of typically the gap between the output and the cost of that output. So, someone else may engage in a task and they say, "Well, that was easy. It took me an hour to do that." The person with ADHD may go, "Oh my goodness, it took me all day to get that task done that it only took you an hour to get done."

So, they may get the same amount of work done, but it's really digging deep into their resources to make that happen

Pathak: And so if someone's functioning like that for years and years, all of that effort for organization, for focusing, for managing her time and completing tasks, what does that look like with regard to self-esteem or emotional health over the long term?

Johnson: Sure. Yeah. So a lot of times women get the message, like if they don't know, particularly if they are undiagnosed ADHD, they often get a message that they're lazy or they're stupid or they're a mess. So when you don't have an answer to what's going on with you, you're usually gonna make one up, and the one that you make up is typically going to be incredibly cruel.

And so what happens a lot of times over the years is that their shame starts to compound. It can also feed into if they have a comorbidity of anxiety and depression, it can feed into that. And there is one Hinshaw's long-term study following girls with ADHD into adulthood found significantly elevated rates of self-injury and suicide attempts compared to their peers.

So I think it's important to really take this seriously. I'm not saying this to scare anyone, but kind of shame and self-esteem is often not a side effect when we're talking about ADHD. It should be one of the primary treatment targets.

Pathak: And how do you counsel girls particularly, I'm thinking, who you know and as you laid out at the beginning of our conversation may have, different demands as they age that, a strategy that works for you at this point in your life may need to shift and change. What does that counseling look like?

Johnson: Anyone I work with, I let them know that like, "Hey, you have ADHD. This is something that's gonna be with you throughout your lifespan." So something that I talk to my patients about all the time is this concept I have of just trial and tweak. We're gonna implement something, we're gonna try it out, and then we're gonna keep what works, we're gonna tweak what doesn't.

And similar to what I was talking about earlier in terms of how your ADHD can change throughout your lifespan, based on hormones and other factors, you wanna keep that into context because how I'm managing my ADHD at 20 may look different than 40. And if you don't have that as a part of your overall mindset, you may look at your 40s and go, "Oh my God, I'm failing.

I thought I had it together, and now all of a sudden everything's falling apart." I think having a growth mindset is really important when you're managing a chronic condition like ADHD and always having that willingness to say, "Okay, something's not working right now. It's not about me failing as a person or a character judgment.

It's about me being able to non-judgmentally and compassionately look at what's not working and then utilizing whatever resources I have available to me to adapt and adjust accordingly."

Pathak:

So can you then help us dig into the relationship between ADHD trauma? How does trauma impact how ADHD symptoms present and then the sort of the prognosis?

Johnson: When a person has ADHD and they also have PTSD, I think I wanna go back to what I was talking about in terms of emotional dysregulation.

You know, trauma in and of itself comes with its own emotional triggers that may lead to emotional flooding, dissociation, and impairment of memory as well.

And so there can be a lot of overlap in kind of the areas that the mental health kind of lands on. So you already have difficulty with executive function when you have ADHD, but then when you add in the PTSD on top of that, it can make it even more complicated to stay on top of your symptoms when you're also overloaded with maybe intrusive thoughts or with PTSD as well, you can have nightmares and sleep disturbances.

And poor sleep and poor kind of biological habits like eating well and things like that greatly impact ADHD symptoms on the day-to-day as well. So really having multiple diagnoses really compounds what it can look like and feel like for that person on the day-to-day

Pathak: I can imagine a lot of women, a lot of girls, a lot of families where people are seeing some of these symptoms and they're thinking, "Okay, these are some of our strategies that we're going to use to manage." When is it a sign that you really need to seek professional help rather than trying to figure this out on your own or potentially working with teachers on your own?

Johnson: One of the things I wanna caution is not waiting until you're in an absolute crisis in order to seek help. I do see a lot of people using a lot of really great, actually, like, online resources and kind of like self-help to do things. But even a short-term time in therapy with a therapist who specializes in ADHD or even with an EF coach can make a huge difference.

So I just really wanna say that out loud. You do not have to wait until things are actually, like, falling apart or imploding around you to get help. I think signs where, like, it's not a question anymore is if you are feeling like you're having thoughts of self-harm or suicidal thoughts at any time, that is a moment where it's like, drop everything, reach out to a clinician, like, get help.

But I would say in general, any time that your coping takes more energy than it gives back, you're burning out trying to keep your systems running. And what that also means is things like a life transition, like a new job, a baby if you start getting into perimenopause, all of those things can, like, break down whatever strategies you've already kind of crafted for yourself.

And so any time that, like, what's going on is outpacing your coping, please, please, please get help and get support 'cause it's available.

Pathak: Can you help us understand who it is that we should be looking to reach out to if in childhood versus if we're older and this is something you're discovering in yourself as a woman?

Johnson: Absolutely. So there can be multiple ways to get to the same destination. So I would say start where you are. If you have a primary care doctor, then tell them what you've noticed and then ask for a referral. They can refer you to a psychiatrist, to a psychologist, any of those type of people. For the evaluation itself, so for the ADHD evaluation, you wanna look for a psychologist, a psychiatrist, or a neuropsychologist because these people specifically evaluate adults typically and children as well.

And I would say because we're talking about women and girls, ask them about their experience with women because how ADHD can show up can look different in women than in boys. And so you wanna find someone whenever possible who has experience with treating ADHD in women. After doing all of this work, you may end up with like a small team.

So you may end up with a prescriber, a therapist, and possibly also an ADHD or EF coach. And so whatever you currently have available, I would use that as your starting point. So make that appointment, let them know what's happening for you, and then they should also have information on what resources are available to you in your local community

Pathak: And then can you talk a little bit about the bias, whether it's in school or social settings, that may impact particularly Black girls and women, from seeking help

Johnson: Oh, sure. In some ways I wanna take that question and turn it around because Black children are significantly less likely than white children to be diagnosed with ADHD even when accounting for other factors. And there's also research that talks about, like, the adultification of Black girls and the research saying that people view them as needing less nurturing and protection than their white peers of the same age.

So when you put all of that together, what you have is that the same behavior that earns a white little girl a referral for ADHD would be the one that earns the Black girl a label. So a label of having a bad attitude, of being defiant, of being disrespectful or too grown or too fast are some terms that can come up.

So it can lead to a perception that this little Black girl may require discipline rather than evaluation and intervention. So by the time adulthood comes around, something that's very common in the Black community is this kind of superwoman complex. So that takes over, and that goes back to what we're saying about masking, so, like, Black women are gonna mask to the maximum. I have so many Black women that are in college right now where their masking is starting to, like, fail them because going back to what I said earlier, the scaffolding kind of goes away, and so you have less structure, less support.

And so masking and figuring it out in college looks different than earlier years. And so for them, that struggling really reads as failure. They have a lot of shame because they don't wanna signal that they need help because there's so much bias and stigma around that. So I would really encourage anyone who is struggling that worries that they may have ADHD or any diagnosis, please walk through someone's door and get the support that you need.

What you're going through, you do not have to go through it in isolation. And yes, bias and stigma is real, and that's one of the things that therapy helps with. It helps you with figuring out tools on how to navigate both external and internalized shame and stigma so that you can walk through the world with whatever labels apply to you and hold your head up high and have a life that's fulfilling and worth living.

Pathak: This is so, so, so important because as you were talking and as I was thinking about my next follow-up to what you were saying, the stigma, the bias that you may feel extends not just from seeking an evaluation, but just some of the management strategies. I think when you have to potentially go to your teacher or to an employer to say, "As part of my accommodations, I might need extra time on this, or I might need a different strategy,"

So I'd love for you to kind of carry through what we were just talking about with regard to bias, stigma, when it comes also not just to evaluation, but also when it comes to converting that into a management strategy that's gonna work for you.

Johnson: Oh, absolutely. So typically, you're gonna get the best results from combining various things and not just picking one. Just to piggyback off of what you were saying before about accommodations, I wanna be very clear that ADHD can qualify under the ADA for workplace or academic adjustments. So this can be things like written instructions, flexible deadlines, or a quieter workspace.

I'm often coaching clients and patients that like, it has to be a reasonable accommodation, right? So like, if you struggle a lot with mornings and you decide to work at a bank, well, typically banks have to keep regular nine to five business hours. It's unlikely they'll be able to give you an evening schedule at a bank.

So there is some consideration that you have to make in terms of kind of what types of settings and types of work are best for me. But in whatever setting, reasonable accommodations are available to you. So it is important to practice being an advocate for yourself, and therapy and also coaching can help with developing capacities to be able to do that.

I think in terms of kind of core components for treatment, medication is one of the most effective treatments that we have, and many people with ADHD will be on medication. It's important to note that medication doesn't give you skills, it just gives your brain kind of access to skills, right? So it creates the space to be able to use skills throughout your life.

Therapy kind of targets what medication can't touch, and I've alluded to a lot of these things, so the shame, the emotional dysregulation, the anxiety that can be built up over years of struggling. CBT for adult ADHD has a lot of solid evidence, and also DBT (dialectical behavior therapy) skills are really strong for the emotional piece.

And some people will also get an EF or ADHD coach specifically for executive functions. So this can be around building external systems like body doubling, visual timers, alarms, and those sorts of things. At my practice, we provide all of it—all of the therapy and the EF coaching—at my practice

Pathak: And what is a body doubling?

Johnson: So body doubling is typically where you work alongside someone else. You can do this in person, like with people in your family. You can all kind of say, "Okay, we're gonna do like a power hour of cleaning," and then like everybody kind of cleans together. But you can also do this virtually. A lot of people will kind of log on at the same time as someone else to work on like academic assignments together, or sometimes what patients will do is watch videos of other people engaging in different tasks and then do that same task along with the video.

Body doubling has been found to be very helpful for a lot of people with ADHD

Pathak: That's helpful. So for someone who's listening and they've spent years just wondering, "Why can't I get it together? What is going on? Do I have ADHD?" Is it still possible to get an accurate diagnosis as an adult?

Johnson: Oh, absolutely. Please go and get an evaluation. In fact, a lot of the gains we've been making in closing the gap in the diagnosis has been people getting a diagnosis in adulthood. You can get the diagnosis at any time in life. It's just that the criteria for it requires that some symptoms are present in childhood.

But I've had people get their initial diagnosis in their 60s, so do not hesitate to, as I said earlier, start where you are, talk to your PCP, your psychiatrist, whoever you already have, and start the process for yourself

Pathak: So someone who's listening, if they are seeing themselves or a loved one in this conversation, what is the first step? Where do you recommend that they start? And can you recommend some resources they can reach out to, to start the process?

Johnson: Sure. Yes. So, because everybody's circumstances are different and their availability of insurance or lack thereof, I typically will tell people to start with primary care because most people do have access to that. And if you require a referral in order to get other services, that's always a good starting point to go in and let them know, "Hey, this is what's going on with me, and can you give me some recommendations that are within my insurance plan for a therapist or a psychiatrist that can evaluate me for ADHD?"

Primary care is so vital. I used to do primary care psychology as well, and one of the things I discovered is the great majority of mental health medication is actually prescribed by primary care doctors. And I don't think a lot of people recognize that, which is why I always use that as my starting point.

If you already have a therapist or psychologist but they just don't specialize in ADHD, they can be a good point of contact to recommend or to find someone for you that has more of that specialization. That doesn't mean you have to stop seeing that therapist. You can continue to see them for other things and then work specifically with the other therapist on things that are ADHD related.

I think in general for information there's CHADD, so it's C-H-A-D-D, and that's a national nonprofit and it has a professional directory. Also, my podcast, which is ADHD &

has a lot of information, but it's also done through the organization understood.org that their whole point is providing a huge library of free resources for people with thinking and learning problems.

And so I strongly encourage understood.org. There's also Attitude, so it's A-D-D is in all caps, ATTITUDE, and they have a lot of practical content and research summaries. So those are all things that I would recommend as kind of starting points for information or starting points for how to get treatment.

Pathak: I love it. It's so helpful too because I think some of us think of managing a health condition as sort of like a one-time, "I did it. Okay, I'm gonna take this medicine or I'm gonna do this and this is gonna basically be what I do now going forward." But I think the way you've laid it out and laid out all these resources is the recognition that this is the natural process: things shift and change.

So you may sometimes have to lean in more to help and sometimes you may be able to compensate or be completely able to adapt to your environment. So I'd love you to kinda give us some thoughts on that shift and change over time.

Johnson: Absolutely. I think one of the things I do often is I relate mental health conditions to physical health conditions because we just have a lot more understanding and experience of that. Managing something like ADHD or depression or borderline personality disorder, any of these things, and not just the ones I named, but just mental health in general, is no different than managing a chronic physical health condition, right?

Like, if you have a diagnosis of diabetes or high blood pressure, these are not things that are necessarily gonna go away at any point. You are gonna have a lifelong relationship with this condition. It's not everything about you, and it doesn't have to dictate everything about you, but you are going to have to have a relationship with it and manage it throughout your lifespan.

And in so many ways it's important to befriend the things that are going on with you. And I know that sounds like a silly or wild thing to say, but befriend it because befriending removes the judgment and it, brings about compassion. Like, I have patients who have ADHD and diabetes, and they'll be like, "My diabetes is flaring up today," or, "My ADHD is acting up today, and like, here's what I have to do in order to have a decent day." And so the way that they're talking about it is, "This is just a part of my experience. I have compassion for it. I have tools for it. It doesn't have to be this thing that's constantly on my back or in my face."

And so that kind of mindset shift and a willingness to just cope with what you have on the day-to-day. Willingness is so important. I see so many people kind of starve themselves of what it is that they need because they make a judgment that they shouldn't need what they need. You need what you need, okay?

Like, it's okay to need things. It's okay for what you need to be different from what someone else requires in their day-to-day life. Compassion and non-judgment is the biggest thing that I could tell you in terms of, like, managing anything you have going on long term.

Being upset about having something. One of the things I used to say to my patients is I would say something like, "If you're mad about being depressed, now you have two problems. You have the depression and you have the anger about the depression. And now we have to get through the anger before we can ever get to the depression.

And it's the same thing with ADHD. Coming to a radical acceptance, coming to a befriending and a loving of your full experience will make that experience less of an anchor for you

Pathak: Wow. That is so powerful. I think in any dimension of your life that you're struggling with, you can either fight it or you can befriend it, which I love. I love that framing. So I just wanna thank you for leaving us with that really, really important thought, regardless of what it is that we are traveling with in our lives, to befriend it and move with it with compassion and without judging ourselves.

So I wanna thank you so much for that message.

Johnson: Yes. Thank you for having me

Pathak: I'd like to share my three key takeaways from the discussion. First, many of us have a preconceived notion about what ADHD should look like. In women and girls, symptoms may include something completely different from daydreaming, racing thoughts, disorganization, emotional dysregulation, trouble sleeping, forgetfulness, impulsive behavior, or the enormous effort required to stay organized and meet expectations.

And when life demands more of us, these symptoms can become more challenging. Second, masking ADHD fuels burnout and shame, but there are options that don't include just trying to keep up a facade. Anxiety, perfectionism, late-night work, and efforts to keep up an outside facade that looks great may actually increase the struggle that you're having on the inside.

If your coping strategies leave you consistently depleted, overwhelmed, or unable to recover, it's probably time to reassess your systems and seek support rather than blaming yourself. And finally, it's never too late for an assessment, and a thorough evaluation can help connect you with the right kind of care.

An assessment with a knowledgeable healthcare provider will explore current symptoms, childhood history, and related concerns such as anxiety, depression, trauma, sleep problems, or medical conditions that can compound your ADHD symptoms. It's really important to approach ADHD with curiosity and compassion.

You don't have to navigate these challenges alone. To find out more information about Dr Monica Johnson and ADHD, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at [email protected].

This is Dr Neha Pathak for the WebMD Health Discovered Podcast.