I’ll start with a sort of confession, which is that I have notes for things I have wanted to include in this essay dispersed over at least five places: my notes app (obviously), emails I send to myself, a google doc, a online list-making tool, and in a folder on my digital notebook. It’s interesting to realize there’s no physical paper among these various modes of note-taking, but I – of course – digress.
My lists – scattered over various platforms, each with an eternal promise of keeping me organized and on task – were in fact what I presented to my doctor the day that I told her that I think I might have a bit of a problem.
Talking about my list-making felt like I was someone with hoarding disorder tentatively opening the door to my overflowing bedroom. I didn’t think it would come as a shock by any means, but I doubted she had a sense of how intense things actually were.
“It’s definitely a microcosm of my mind,” I told her. “I have so many lists that I had to make a list of the places I have the lists. But then I couldn’t remember where I’d put that one.” I put my hands over my eyes.
I was tearful. “I don’t know if this is normal,” I told her. “But I know I feel tortured by it.”
She looked at me sympathetically, taking in my distress. “And yet you’ve been pretty successful. The lists have been working in a way?”
“I get things done, yes,” I acknowledged. While I never fully checked off a list – and some seemed to disappear into the ether – I got a lot of things accomplished by most people’s standards. I managed a large family, a business, a caseload of patients.
This high level of effectiveness, in many ways, was the exact inconvenient fact that kept me circling back away from the idea that maybe I could have some sort of executive dysfunction. Planning ahead? Problem solving? Inhibiting my own desires? By those standards, I was the picture of executive functioning.
And yet, something about it all still felt incredibly difficult. And it felt like it followed me all of the time.
I left my appointment that day disheartened, still feeling lost, still feeling like the lists were going to be the death of me. I felt like a cat chasing its own tail: desperate to catch something, desperate to get away from it.
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After I got home that night, I ended up in a conversation with my right-hand colleague and close friend. I told her about what I’d shared that day with my doctor and how I’d been starting to wonder about whether ADHD could be true for me. I’d given it consideration over time, I told her, and even had tried medication a couple times in the distant past. But I hadn’t ever felt sure, always plagued by the reminders of how well I was told I seemed to function in the world. A core part of the criteria for ADHD, like every mental health condition, I was reminded by my training, was that it had to cause impairment in functioning.
But what if all that functioning came at enormous cost, I wondered to her. And what if the functioning could actually be even better if this was addressed? Functional impairment as a concept falls apart when we don’t know a person’s individual potential.
“The cost,” my friend said. “I see it.” And she did. She had a unique window into my inner world given she was literally in my email in her work role. She saw the lists, and she also saw the indecision, the overwhelm, the anxiety and stress. She loved me for the ways that my brain could go in a million directions, even when it made her life that much harder. She laughed at my forgetfulness, responding by putting things on my calendar for me like, “Eat lunch now.” She tolerated the urgency with which I approached most things, often helping me slow down.
As we talked, I realized that she herself was one of the resources I had used to manage this way that my mind operated. I had outsourced much of my executive functioning to her. I started to think about other things I’d been using to manage or compensate, and the insights started coming fast.
The lists were another way, of course, to address the barrage of thoughts and my maxed out working memory. But there were also other behaviors and relationships I’d cultivated in response – scheduling everything, narrating experiences, constantly reading or listening to podcasts to quiet my noisy brain.
What I noticed was that the strategies that I had developed to account for my scattered mind were, somewhat fortunately, things that society had deemed not only acceptable, but often desirable. They’d been given this almost elevated moral status in our culture to the point where I could be considered the picture of high-functioning rather than the busy-brained mess that I often felt I was.
But at the end of the day, I recognized, there wasn’t as much difference between obsessional list-making or hyper-working mode that I used and the alcohol, high risk-taking behavior, or disordered eating that served as means for other people to do the same thing: quiet the noise. Society had for the most part deemed my modes of functioning superior, but I still felt locked to them to survive being in my own head.
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The way in which early gendered socialization impacts the detection of ADHD has been discussed by a lot of neurodiversity writers, but let’s recap for a moment. Before that though, in order to talk about the impact of socialization, it helps to start a little further back with what we know to be true about ADHD as a biological condition.
In fact, what we know to be true about ADHD as a biological condition is more limited than most of us realize. In a very similar fashion to what happened with depression as a disorder, efforts to both destigmatize the condition and to market pharmaceutical interventions led the wider culture to believe that we have much clearer evidence for biologically-based brain differences than we do.
The reality is that despite concerted effort by highly motivated researchers over decades, we still don’t have any clear biomarkers for ADHD – something like we could gather from a blood test or a brain scan. And we’ve come up empty when looking for any specific gene that could predict the condition, though there are some constellations of genes that might help predict risk. As MIT neuroscientist John Gabrieli said in a recent New York Times article, “There is no single-gene story. Fifteen years ago, there was incredible optimism, and now we realize how far away we are.”
To be clear, the lack of neurobiologically-based markers does not suggest the condition isn’t real, significant, and debilitating for plenty of people. But it does invite us to widen our lens a bit on how we think about ADHD. If we can detach from it being solely a neuroanatomical difference that some people have, we can get curious about what other factors might be at play.
The theory that I gravitate to is that ADHD develops out of a genetically-determined difference in our intensity, sensitivity, and reactivity. When that sensitivity comes into contact with environments that are, at least in some ways, a mismatch for them, our minds develop what we’ve come to think of as the core ADHD symptoms – things like our distractibility, forgetfulness, antsiness, or impatience.
Let’s diverge for a moment here – something ADHDers are great at doing, of course – to notice something. Each of the experiences that I just listed as symptoms could be framed as quite useful and adaptive qualities in the right context. What we describe as distractibility in a culture focused on compliance could be seen as intense curiosity or an ability to notice. What we label forgetfulness could be a high degree of present-moment focus (even if at the expense of what I had been planning to do). I’m not suggesting that these experiences aren’t challenging or that we should just reframe them to feel better, but I am wanting us to notice how much our culture itself – given its existing structures and demands – shapes the way that we perceive these brain adaptations. One could imagine that in a different environment – let’s say, one without as many deadlines or one in which being all in on the present moment, could actually really privilege these traits.
What a conceptualization of ADHD as a biology-environment interaction also does is to help us understand better the story of how so many over-functioning women with ADHD get missed, and why we are starting to see it get detected in certain phases of life.
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When we are able to think about ADHD as slightly more flexible, not as stable and rigid as eye color or blood type, but perhaps even like a personality construct like introversion, we start to see more clearly how this plays out.
Consider the child who enters the school environment and has already been socialized by the world at large to know implicitly – in her bones – that she will be given more approval, praise, and even affection if she can present as easy. Let’s say she has an ADHD mind and is more naturally pulled toward thinking divergently, feeling things intensely, and getting focused on certain ideas. She will often quickly – almost immediately – observe the mismatch in who she is and what’s expected of her.
What I know to be true about most humans is that they will do what it takes to survive. For girls and women historically, and even evolutionarily, survival was tied directly to social approval. And so as much as is possible, depending on the degree of these traits (or symptoms, if you prefer) and a few other factors, this child will figure out any way possible to be what she is expected to be. She will develop as many tools and tricks and ways of coping as she can in order to stay safe and succeed.
I want to note that there are girls and women with ADHD and other forms of neurodivergence who are less socially-motivated, and for whom this may have looked a bit different. This is important to recognize, and the trajectory for these girls may look quite different than what I’m describing overall in this piece. These girls may be less attuned or impacted by the expectations of others, and so more able and willing to counter those. The outcome depends a lot on the context. For some, this willingness to go against the social grain is key to thriving in an oppressive world. Others though quickly get labeled in pejorative terms and very tragically start to see themselves as defective.
Meanwhile, the more approval-seeking set rarely gets identified as having differences, or at least that’s been true historically. Their adaptations tend to work in helping them get by, despite the heavy cost. Going back to the analogy of introversion, these are girls for whom going to the party is difficult and stressful and taxing, but they do it. They leave feeling depleted and second-guessing themselves and needing a lot of down time to recover, but because they did it everyone just keeps inviting them.
Beyond the pressure of culture, their ADHD traits may be more obscured also by the fact that our diagnostic criteria were developed out of a hugely disproportionate focus on boys. Consider this in conjunction with the fact that the criteria are largely observational rather than self-report. We are asking if the person interrupts, makes “careless mistakes” or “seems to not listen.” We aren’t asking whether the person is listening, only whether they seem to be.
The significance of this is that most diagnosticians aren’t asking, “What is this like for you in your mind? How hard are you having to work to not interrupt? What strategies are you using to keep from making errors and how absolutely crazy do you feel having to keep doing them all the time?”
We would never diagnose depression or anxiety based only on what other people see. People’s internal experiences are usually fundamental when we are discussing mental conditions.
Further still, a big portion of those symptom criteria fall under the subtype of “hyperactivity” and correspond to what’s perhaps most stereotypically associated with ADHD – fidgeting, running, climbing, excessive talking. I started thinking recently about what if we asked those questions not of how the person’s physical body responds, but how their mind is operating.
“Do you feel like your brain is always running?”
“Is it hard for your mind to sit still?
“Does your brain talk non-stop?”
I imagine that a huge proportion of highly-achieving or over-functioning women would say yes. Just because our arms and legs are not always moving (though for some of us they absolutely are) doesn’t mean that there isn’t hyperactivity to our experience.
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The surge in ADHD diagnosis in the last few decades has led some to express wariness or even skepticism. Indeed, the rate of children diagnosed has risen from 6.1 percent of 3-17 year olds in 1997 to 11.4% of those in 2022, accounting for millions more children. However, despite some researchers’ concerns about over-diagnosis, even most of those acknowledge that ADHD continues to be under-diagnosed among certain populations – including in girls and women, as well as in Black and Indigenous people of all ages and genders.
What has been seen is that when the diagnostic criteria started emphasizing inattention more than hyperactivity, more girls were diagnosed – with the increase in the rates of girls being diagnosed far surpassing the increase boys saw in the same period. This perhaps seems obvious but reflects such a vital reminder: our beliefs about the incidence of a condition can change dramatically when we address bias.
But in addition to the issue of non-representative criteria, a diagnosis can be hard to come by as an over-functioning woman for other reasons too. For one, most women I know who over-function in life would describe themselves as having anxiety, and often are even treated for this with medication or otherwise. Anxiety and ADHD can often go hand in hand, but also can mirror or mask each other. Understanding their relationship requires a lot of nuance.
Another challenge has to do with simply getting in to see a provider. Jokes about ADHD and calling for an appointment aside, over-functioning women in our society are too often carting every other person in the household around to appointments and putting their own healthcare of all kinds on the back burner.
And many of these women wisely wonder if a diagnosis is really necessary. My answer to that is that it depends. What I’ve found overwhelmingly, both for myself and for many people I’ve worked with in therapy, is that a diagnosis felt like an unlock. It shed light on an entire history of experiences in a way of discovering a core family secret might be.
For me, recognizing many of my traits as part of a constellation called ADHD helped me to approach them quite differently. I hadn’t even realized how many of them I had spent a lifetime chiding myself for – things like always running late or misplacing things. It wasn’t as if attributing them to ADHD changed them overnight, but it enhanced my understanding and compassion for them, which finally gave me the space to start to address them in new ways.
For example, seeing my “time blindness” as part of this condition helped me start adding on five minutes to whatever my default estimate of a commute time would be. Disclaimer for those who know and frequently wait on me in real life – yes, I am still working on this. The changes were in large part small, but seen through a new lens, they became possible.
Is a diagnosis necessary to develop compassion for the parts of ourselves that frustrate us? No, but I’ve found it can sometimes help. I think the reason for that is because it gives coherence. The fact that I could understand so many of the ways I felt challenged and exhausted in a unified way helped me no longer feel like there was just a laundry list of things I was failing at.
And then, of course, there’s the question of medication. It’s a big question and a complex one. The current medication-based treatments for ADHD don’t treat the underlying condition, but rather help to mitigate some of the challenges. I compare it to a pair of glasses. They aren’t correcting the structure of the eye, but they are giving you a tool for when you need to see things in the distance. Some of us have lives where we need to see distance regularly, and glasses feel like a life-saver. Others have been able to set up their lives where most things are fairly near, so glasses aren’t really necessary. This is where understanding the biological and environmental interplay is really helpful.
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By the next time I saw my doctor, I had read at least two books on the topic and had a notes app full of comments and observations to share. I started by telling her that I was fairly certain that I had ADHD, and could I tell her about my reflections?
“Of course you can,” she said. “But I trust you have ADHD.”
“You do?” I asked, thinking back to her comment about being so successful. And I realized that my own bias had become a projection onto her. I had assumed that she was negating the possibility by pointing out my relative success. In fact, that success had made her suspect it more.
Speaking of success, as time has passed and I’ve been able to manage some of my experiences so differently since then, it’s been interesting to see how significantly my own version of it has changed. It certainly stopped being associated with over-functioning, which I recognized as both cause and effect of my symptoms.
I’ve come to see success as my ability to live a less frantic life. To practice sustained attention, such as through meditation and breathwork. To be on time more often for the people I care about. To get a good night’s sleep and rely less on coffee. To let the dirty dishes go. And one of these days, maybe I’ll even have fewer lists.
