Emma Offord is a clinical psychologist specializing in neurodivergence. She is the founder of Divergent Life, a neuroaffirming private practice. Emma is passionate about the neurodiversity movement, developing more empowered ways to think about neurodivergence, providing creative and somatic forms of therapy for the ND community.
At DL, we dive deep into the 'why' behind overlooked diagnoses, particularly focusing on why ADHD in women often isn't identified until their late thirties or even later. Despite more males being diagnosed with neurodivergence, there's a growing awareness of ADHD in women, raising questions about the links between female hormones and neurodivergence. In this article, we explore five key reasons why women may not receive an ADHD diagnosis until later in life, offering insights that challenge the conventional medical model and shed light on the unique experiences of women with ADHD.
Strap yourselves in, this is a long one.
At DL, we are curious about ‘why’.
Why are more males than females still getting diagnosed neurodivergent?
Why isn’t more research happening on the links between female hormones and neurodivergence?
Why are so many women seeking diagnosis for ADHD (and autism and other ND traits, but in this article we are looking specifically at ADHD) in their late thirties and into their forties and fifties?
The answers may surprise you.
(note: throughout this article we refer to ‘women’ ‘girls’ and ‘females’. We use women and female with the intention of including all other gender identities who menstruate).
What is ADHD?
ADHD is characterised in the medical model as being a disorder. In this model, individuals experience deficits, the key criteria for diagnosis being, in simple terms, inattentiveness, hyperactivity and impulsiveness. Elements of each need to have been present for six months or more, and are ‘inappropriate for developmental level’.
It is worth noting that the neuroaffirming approach of neurodiversity doesn’t subscribe to the terminology used within the medical model. But as yet, there is no other way to diagnose an individual, and clinicians have to adhere to a strict medical code and diagnostic criteria as outlined in the DSM-5 and determined by the World Health Organisation.
In the medical model, ADHD is termed as being a problem, and the list of criteria are challenges. These include (and we’ve significantly softened the language here) on the inattentive side of things:
Often making mistakes
Trouble holding attention on a task
Finds focusing on verbal instruction challenging
Often finds completing tasks difficult
Can have trouble organising a task
Avoids or dislikes doing tasks that require mental effort over a long period of time
Loses things often
Is distracted easily
Is often forgetful
And for hyperactivity and impulsivity:
Has trouble sitting still
Leaves their seat inappropriately during meetings
Feels restless
Finds taking part in leisure activities quietly challenging
Talks excessively
Blurts out answers or interrupts
Although hyperactivity and impulsivity in children has been recognised since the early 1900s, the more modern definition of it being a disorder that included inattention wasn’t coined until the 80s.
Identified as largely a childhood issue related to development, the terminology and explanation of ADHD has been rooted in deficit since it was first observed.
If you’ve been reading DL’s other articles, you’ll know we do not align with the medical model of disability ands neurodivergence. We take a neuroaffirming approach (you can read our guide to becoming neuroaffirming here) which recognises that ND people may well experience challenges, but this is because of society’s expectations and lack of acceptance of and provision for diversity. And we celebrate the strengths and unique perspectives of ND people. We see neurodivergence as a natural diversity borne of millions of years of evolution.
The medical model of ADHD, then, is limiting. Too focused on challenges. And we believe is damaging to people’s mental health by labelling it a disorder and that somehow ADHDers are less than their peers in the predominant neurotype.
The medical model is also based on decades of research conducted on young boys and doesn’t take into account the more internalised presentation of the challenges it lists. This means diagnosis is biased toward outward presenting versions of the challenges, which is at the root of why women often get missed or misdiagnosed. But more of this later.
A more rounded look at ADHD might be more along the lines of
High energy: ADHDers often have a great deal of energy, which can be channelled into positive outlets such as sports, dance, and other physical activities.
Out-of-the-box thinking: ADHDers often think outside the box and have a unique perspective on the world, which can lead to innovative ideas and solutions. They may make unique connections between ideas, and approach problems in unconventional ways.
Enthusiasm: ADHDers often approach new experiences and challenges with enthusiasm and a sense of adventure.
Sense of humour: Many ADHDers possess a great sense of humour and quick wit, often making others laugh and easing tension in social situations.
Resilience: ADHD individuals face challenges in daily life, which builds resilience and determination. They learn to persist in the face of adversity, bounce back from setbacks, and develop a strong sense of perseverance.
While the challenges may look more along the lines of (but not limited to):
Challenge | Why it happens |
Difficulty switching tasks or having plans changed without notice.
| Hyperfocus is when a person is intensely interested and focused on a particular task or activity. They may lose many hours to this favoured topic, forgetting to eat or drink and ignoring or unable to interpret interoceptive cues like needing to go to the toilet.
|
Difficulty remembering more than one instruction or question being asked at a time.
| ADHD people can sometimes find verbal or written instructions very challenging to follow if there are too many stages. This is because their brains process information differently to a neurotypical brain. It is not a deficit, it simply means information needs to be served differently.
|
Can get bored easily especially if they get a lot of work done in less time than a neurotypical brain but still have to remain ‘attentive’ or logged on at work. This can lead to a kind of burnout called bore-out
| An ADHD person in hyperfocus can get enormous amounts of work done very quickly. Forcing them to ‘clock watch’ rather than be rewarded for completing something more quickly than someone else can feel like torture to their nervous system.
|
May need flexible deadlines or shorter deadlines
| Some ADHD people thrive to a deadline. They need the stimulus of responding to a tight deadline to produce enough dopamine to get the task done.
|
ADHD people who are forced to sit still for long periods of time can experience this as deep physical discomfort – although it might not visibly show to an onlooker!
| This is because the hyperactivity element of ADHD can be completely internalised. Having to sit for long periods of time can dysregulate the nervous system and cause deep physical discomfort from our interoception – how the brain receives and perceives cues from bodily functions.
ADHD people may also be highly sensitive to cues from interoception. Or may experience Alexithymia, where they are unable to interpret some or all cues from their interoception, meaning they don’t know what they are feeling.
|
Can find an environment that is too quiet makes their thoughts too loud which can be distracting.
| ADHD people can be sensory seekers or sensory avoiders or a mix of the two. Not being allowed to be in an environment suited to their sensory needs can give ADHDers sensory trauma.
|
May experience PMDD or intense PMT | ADHD people are more likely to experience PMDD – a debilitating form of PMT, or more intense PMT. This is due to hormone sensitivity and the role that oestrogen plays with serotonin (impacting our moods) and progesterone plays with GABA (impacting how able we are to relax and to sleep).
|
Experience severe brain fog causing forgetfulness. | This is related to the neocortex, the front part of the brain that manages our cognition, executive function, planning, and future projecting. An ADHD brain can look very similar to a traumatised brain in as much as parts of the limbic system and brain stem are larger and more switched on to respond to cues of danger. And the neocortex is smaller and isn’t as responsive to cues of safety.
Brain fog can also be related to oestrogen production, hormone sensitivity and dopamine synthesis.
|
Bright neon overhead lighting causing headaches, nausea, and hyperactive behaviours. | ADHD brains can become extremely overstimulated and overwhelmed with certain types of lighting. A simple shift from neon overhead strip lighting to more minimal, softer lighting can make huge differences to how an ADHD person feels in their body.
This can also be related to a condition called Irlens Syndrome which can make people extremely tired because of the way the brain is processing visual information.
|
Many ADHDers thrive with spontaneity, but others don’t and find making on the spot decisions very challenging
| It should never be assumed that an ADHDer will always be able to make a decision in the moment. They may generally thrive on spontaneity and appear impulsive, but on another occasion may be crippled with self-doubt and an overwhelming urge to question the situation.
|
What is late diagnosis of ADHD?
The late diagnosis of ADHD is simply a self-identification, self-diagnosis, or formal diagnosis of ADHD later in life, usually after a person becomes an adult.
In the case of many women, we are experiencing this identification or seeking of diagnosis during our 30s, 40s and 50s.
Let’s move on now to why that may be the case. Here are five reasons women are getting diagnosed later in life.
1. ADHD is not a useful label
As already explored, the label of ADHD is not exactly helpful, because the diagnostic criteria are so limiting. They don’t take into account the full spectrum of experience that ADHD people feel.
Fortunately, there are other methods of identification of ADHD traits emerging, including the QbCheck. This is an online system that monitors an individual’s micro movements as they complete a task. It is much more objective than just completing an ADHD assessment and at DL, we use it alongside the diagnostic criteria for a more in depth view of an ADHD person’s experience.
And as we’ve seen already in this article, there is so much more to an ADHDer’s experience beyond their hyperactivity. Or their ability to focus in any given situation.
And for women specifically, the traits they experience are often internalised and hidden away. They are not the ones bouncing off the walls in a classroom. But are the ones masking very successfully for most of their school life, then burning out once they get to their teens and having to take periods of time off sick.
2. The biases of the medical model
The medical model is not serving women in particular. We are being ignored, gaslit, misdiagnosed and sent in circles to find out what is ‘wrong’ with us.
A colleague of DL’s spent 15 years trying to find out what was going on with her before she discovered neurodivergence in her early 40s. During that time she was referred for several MRIs to scan her brain for tumours because she was experiencing ongoing dizziness and brain fog. Went to psychologists and psychiatrists to look at BPD and bipolar. Was referred for fibromyalgia and ME. Had blood tests for early menopause. Was explored for cancer. While her GP’s were excellent and well meaning, at no point was anyone ever discussing neurodivergence.
She has since gone on to be diagnosed as being ADHD, autistic, OCD, and has hypermobility disorder, bradycardia, and probably POTs. She’s previously struggled with PMDD with the only medical solution being Prozac for the last two weeks of her cycle each month. At no point was anyone looking at cortisol and stored trauma.
Now, she has finally been able to learn about the nervous system, how the body stores trauma, and has balanced her cortisol levels through applying somatic exercise. She’s worked on supplements and cycle syncing, understanding her neurodivergence and advocating for accommodations. She is moving through perimenopause less like a trolley with a wonky wheel, and more like an elderly cat. In as much as cats seem to know when to sleep, when to play, and when they have energy for all out zoomies. She has now ‘cured’ her PMDD through radical acceptance of herself, her energy levels, and living in a way that is more aligned with her needs.
The moral of this particular story is that only when we listen to our bodies, our neuroception, interoception, nervous systems, hormones, and trust that we have all the answers can we truly find freedom in our own bodies and minds.
Medical intervention is sometimes needed of course, but if you are on a journey where nothing seems to fit and nobody can find anything ‘wrong’ with you, it may be time to explore neurodivergence.
3. The hormone connection
ND brains, especially ADHD brains, have a different relationship with certain neurotransmitters than NT brains. ADHD brains make and use dopamine differently.
Oestrogen has uses in our bodies beyond regulating our menstrual cycle. One of the functions of Oestrogen is to help us make and use dopamine.
So if the level of Oestrogen is fluctuating throughout our cycle, the lower the level, the less able it is going to be at supporting the functions of dopamine. Oestrogen rises during the first week or two of our cycle, peaking at ovulation and then dropping rapidly. It goes up a little bit again, and then crashes just before we bleed. The drop of Oestrogen between ovulation and our bleed is around 75%. This then is the reason why we get more brain fog, executive dysfunction, feel more tired and lethargic, and can’t focus in the second half of our cycle. We also experience a 60% decrease in dopamine regulation during that same period. Because Oestrogen isn’t supporting the function of dopamine.
Oestrogen also has a special relationship with serotonin, which regulates our mood among other things. The decrease of oestrogen in the second half of our cycle is responsible for our change in mood and energy levels during that time. And is why ADHD women are more likely to experience debilitating PMDD (Pre-Menstrual Dysphoric Disorder).
Menopause can also be extremely challenging for ADHD women, the severity depending upon an individual's overall sensitivity to their hormones. For example, if you have experienced intense PMT or PMDD throughout your reproductive years, you are more likely to experience more intense symptoms during perimenopause and menopause.
During perimenopause, which can last ten years or more, oestrogen levels drop around 65%. This isn’t a linear process either. It fluctuates wildly which is why each cycle can be so different throughout this time.
ND women will experience an increase in their ND challenges through perimenopause, as a direct result of dropping/fluctuating levels of oestrogen, because of the special relationship oestrogen has with dopamine and serotonin.
The key message is, our hormones run the show. And oestrogen is the powerhouse of our hormonal function, far beyond simply regulating our menstrual cycle. It has a huge impact on our dopamine and serotonin levels and optimised use of these hormones throughout the body, not just the brain.
The delicate balance between Oestrogen and serotonin and dopamine synthesis is one of the key reasons so many women seek diagnosis during perimenopause and menopause. The challenges we’ve been able to successfully mask for decades suddenly become so severe, we cannot mask them anymore.
But as we’ve seen, it isn’t always a simple case of going to your GP and getting a referral. Often women spend years circling round the system as other options are explored first. Leading to burnout, breakdown of families, and women leaving their careers. All of which would be completely avoidable with a neuroaffirming approach to understanding our unique neurobiology.
4. Research misgivings
The sad thing is that one of the reasons women aren’t getting the right support and diagnosis is because there just hasn’t been the same level of research conducted on women and girls as there has been on boys and men.
Research on women is generally very behind where it should be, simply because our bodies and cycles are more complex than that of males. Our periods and hormonal changes throughout the month present a challenge that modern medicine has preferred to ignore rather than incorporate into its research. While this is understandable to a point due to the complex nature of conducting robust and quantifiable research, it is nonetheless disappointing. Because the fact is, that some things simply don’t work on female bodies that research is missing because they are only looking at male bodies. And neurodivergence is an excellent case in point.
A review of medical literature relating to ADHD was conducted in 2021 with interesting results.
How research participants were recruited has an impact on the findings of the research
Clinicians may overlook challenges that females experience because they are more internalised and overt which is a direct result of not understanding the clinical presentation of ADHD in females due to the lack of research available
There was no systemic research conducted on females with ADHD before 1979
Since that time, most studies have included ‘a few’ female participants – but that is clearly not enough
The same study found that further research on the long term impact of unsupported ADHD on females was needed alongside an appreciation that ‘most diagnostic criteria were initially developed to describe boys’, and; ‘the perception that ADHD presents only in hyperactive boys is not correct’.
5. Camouflaging and fitting in
Women and girls are taught to sit down, be quiet, and fit in from a very early age. We are teaching our girls to be good listeners and to carry the mental load of their families, children, and spouses. And the behaviours of their (often male) peers from a very early age are indirectly influencing girls to be quiet.
That’s not to say that boys don’t have to self-censor they do, usually in response to pressures to be seen to be more masculine. It is actually the same process at work, toxic masculinity telling our boys to be boys loud, brash, stoic and emotionally stifled. And our girls to be quiet, domesticated, pliable, and thoughtful.
This is at the root of why girls and women internalise their ADHD challenges. We are taught to mask.
Let’s take having a period as an example. From a young age, sometimes as young as 11 years old, girls are struggling with dysmenorrhea (heavy periods) and period pain. Yet we can’t not show up at school and clubs. We have to just get on with it. We have to mask our pain and discomfort. Even period product adverts show women having it all and cavorting about. What we really want to be doing is snuggling under a duvet at home. But we are teaching our girls that remaining productive, attentive, and present no matter what is more important than caring for our bodies.
So it’s no wonder then that our internal struggles from our own inner landscape are also compressed deep within us. Because to be ourselves to show our discomfort, distress, pain, confusion, and dysregulation is highly frowned upon.
Because of this, our children, especially our girls, are growing up to be dysregulated adults. Masked, exhausted, worn down. Until we get to a point where we just can’t handle it anymore.
Women are seeking diagnosis of ADHD later in life because they have reached breaking point. Our hormones have become dysregulated. Our children, probably also neurodivergent are needing accommodations from us that are becoming incredibly demanding. We are burning out because we aren’t understood. And society has taught us that to be acceptable means being polite and productive at all costs.
But those costs are mounting up. And we are getting into energy debts we can’t repay. Our bodies and minds are grinding to a halt with chronic inflammation. The microtraumas from our past piling up like last year’s autumn leaves. We are burning out.
If you would like to know more about your hormones, perimenopause and neurodivergence, we are running our next Hormone Freedom and Wisdom Programme soon. Sign up or get more information here.
Divergent Life is a private psychology and coaching service specialising in remote neuroaffirming neurodivergent assessment.
Our mission is to support neurodivergent people to flourish and thrive.
Understanding your neurobiology and how it interacts with the world around you is a basic human right. Through your neurobiology, we will help you forge a path towards relational, educational, physical, and psychological safety.
We provide diagnostic assessments, therapy, coaching, and group programmes, specialising in the experiences of neurodivergent women and men, and supporting children and families, too. We use a neuroaffirming, trauma informed approach, getting curious with our clients about their vulnerabilities, challenges, and strengths.
We work with you to understand your diagnosis and self-identification through a trauma lens. This helps you reduce the impact of neurodivergent trauma, becoming confident and knowledgeable about your own neurobiology.
Divergent Life has a small team of specialists who work alongside Dr Offord to provide a range of therapeutic and coaching services.
Read more from Emma Offord
Emma Offord, Neuroaffirming therapist, coach, and thought-leader
Emma is a thought-leader in neuroaffirming approaches to neuro divergence diagnosis and support. She is trailblazing new ways of defining neurodivergence through the lens of giftedness and strengths. While still recognizing and validating the challenges and stigma neurodivergent people face, Emma is leading the way in dismantling societal norms associated with the medical model of disorder. She’s the founder of Divergent Life, a neuroaffirming organisation providing diagnosis, therapy, and coaching to individuals, and guidance for organisations to become neuroinclusive.
