For Olivia Dreizen Howell, living with undiagnosed, untreated ADHD meant hearing a constant cacophony.
"It's like being at a Broadway show with headphones, and with TVs surrounding [you]," she says. "My brain is full of these dialogues and conversations that are never going to happen," she says.
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With a mix of chatter and commercial jingles as interior noise, the Long Island, New York-based Dreizen Howell struggled to get work done and complete household tasks.
In 2022, she was diagnosed with ADHD by the same therapist who'd previously treated her for the anxiety that's been present throughout her life. Dreizen Howell has both conditions: ADHD and anxiety.
It's common for a person to have anxiety but get diagnosed with ADHD — and the misdiagnosis can occur in the other direction, too, Rakesh Jain, MD, MPH, associate clinical professor at the department of psychiatry and behavioral sciences at the University of Texas Medical School tells LIVESTRONG.com. "And then there's a third possibility, which I must tell you is probably the one I see most often, which is [that] women tend to have both disorders."
Both underdiagnosis of ADHD and misdiagnosis in people assigned female at birth (AFAB) are likely the result of several factors, including biases, overlapping symptoms between the two conditions and well-developed coping mechanisms.
A Note on Language
Here at LIVESTRONG.com, we believe gender is a spectrum and try to avoid using language that implies a sex or gender binary in favor of more accurate and inclusive language, such as assigned female at birth (AFAB) or people with uteruses. That said, many experts and studies around ADHD tend to use the words "men" and "women," so for accuracy, we have done so as well in some cases in this article to match the language of the primary source.
ADHD — which stands for attention-deficit/hyperactivity disorder — is a neurodevelopmental disorder. While the cause is unknown, genetics play a role, and some environmental factors, such as lead exposure, can increase risk, according to the Centers for Disease Control and Prevention (CDC).
ADHD is classified into three types, per the CDC:
- Predominantly inattentive presentation: With this variety, a person may have trouble finishing tasks or struggle to follow instructions. Daydreaming is common for people with this variety, as are being bored or distracted and losing things, according to the National Alliance on Mental Illness (NAMI).
- Predominantly hyperactive-impulsive presentation: Here, people have trouble sitting still and fidget frequently. They may talk nonstop, according to NAMI. And impulsivity can be seen in interrupting people and struggling to wait your turn.
- Combined: As the name implies, people with the combined form have a mix of the symptoms listed above.
Regardless of when you were diagnosed, if you have ADHD as an adult, your symptoms began as a child, according to the Mayo Clinic. With age, ADHD symptoms can lower in intensity, Dr. Martinez says.
But not necessarily: In adulthood, the expression of symptoms may shift — a child may not be able to pay attention in class, while an adult has that experience in meetings.
Some of the symptoms of ADHD in adults include poor time management, trouble prioritizing tasks (e.g., spending April 14 cleaning out the fridge instead of prepping taxes), mood swings and trouble coping with stress, according to the Mayo Clinic.
The DSM-5, the diagnostic manual for mental health, breaks out the symptoms, and specifies that for people age 17 and older, at least five symptoms must be present for a diagnosis.
It may be easy to see yourself in the symptoms of ADHD. Who among us hasn't zoned out during a meeting or neglected to pay a bill?
But to be diagnosed, in addition to having a certain number of symptoms, symptoms need to occur in at least two settings, interfere with your ability to function and not be attributed to another mental health concern, per the DSM-5. "The diagnostic criteria are in fact designed to protect from an overdiagnosis," Dr. Jain says.
Why People AFAB Are Underdiagnosed With ADHD
There's a gap when it comes to ADHD diagnosis: People assigned female at birth are "more likely to go undiagnosed or get a misdiagnosis," according to the Cleveland Clinic. There's a few reasons why that might be:
Historical Attitudes Persist
First up: While the fifth — and most current — version of the DSM includes ADHD with the three varieties mentioned above, earlier editions focused on the hyperactive aspects, with it originally being termed "Hyperkinetic Reaction of Childhood" in the 1960s, and then "Attention Deficit Disorder (with and without Hyperactivity)" in the 1980s edition, according to an older but frequently cited October 2013 article in Neuropsychiatry (London).
It may be that those original definitions of the disorder, with their focus on hyperactivity, still dominate how parents, teachers, sports coaches, pediatricians and others who might recommend evaluation for children think of the disorder.
"If an individual only has inattentive symptoms, then she may be more likely to [be] misdiagnosed as having anxiety, depression or even a learning disability," Dr. Martinez says.
Squeaky Wheels Get Attention
There's also a logic to more attention being paid to children displaying hyperactive or impulsive tendencies. Those behaviors can be disruptive — a classroom may not function smoothly when there's a student talking nonstop or running around, unable to sit still.
A teacher may be more likely to talk to parents about a child with those behaviors than one who is unfocused, unmotivated or doesn't complete homework, which tend to be quieter, less disruptive symptoms.
Girls can fall through the cracks, says Mayra Mendez, PhD, LMFT, licensed psychotherapist and program coordinator for intellectual and developmental disabilities and mental health services at Providence Saint John's Child and Family Development Center in Santa Monica. "If you're not a problem, you're not really attended to much," she says.
Biases Are Baked In
Preconceived notions play a role, Mendez says. It's common for people to consider boys as more disruptive than girls, she notes. So people may be less likely to think of ADHD "because they forget that inattention could be ADHD," she says.
Old-fashioned notions about gender norms may play a role. An August 2018 study in European Child & Adolescent Psychiatry looked at both population and clinical data and found externalizing behavior problems (think: disruptive behavior) are more predictive of diagnosis and treatment with medication in women than in men. This may be "because they contrast more with perceptions of normative behaviour in females," the study authors write.
There are structural reasons why the building block of ADHD knowledge may be biased, including studies that include more men than women and building an understanding of ADHD from clinical samples (which may also underrepresent women), according to a February 2019 study in Psychiatry Research.
Symptoms May Come on at Different Ages
Girls are more likely to have a later onset of symptoms than boys, who show symptoms throughout childhood, per a January 2019 study in Developmental Science.
That can affect girls being diagnosed, because diagnostic criteria in the DSM-5 call for symptoms to be present before age 12, the researchers point out.
Masking May Be More Developed
Some people with ADHD (whether diagnosed or not) may develop strategies to avoid showing their symptoms. Dreizen Howell recalls incredible teachers. "[They] would let me quilt while I was in class, and I look back now and I'm hysterically laughing and thinking my hands constantly needed to be doing something for my brain to function. And I didn't know that at the time," she says.
Sometimes people with ADHD learn these strategies from a therapist, Mendez says. But it's also possible that a person would be able to learn ways to compensate and succeed on their own, she says. "And that's easier to do with the inattentive type [of ADHD and] not so easy to do with the hyperactive-impulsive type," Mendez says.
Girls may be more likely to develop and implement coping strategies compared to boys, according to a June 2014 review in Psychiatrist that examined studies over a 10-year period. Compared to boys, girls may also develop more resilience to symptoms, per a February 2019 study in Psychiatry Research — that can make them seem less affected than boys unless symptoms are severe.
A 2021 annual research review in the Journal of Child Psychology and Psychiatry also found compensatory behaviors in girls — like disguising distress caused by their symptoms and strengthening social bonds — may be a factor leading to lower levels of diagnosis.
But it's not just a missed diagnosis that can occur. Sometimes, ADHD is misdiagnosed as anxiety.
Why It's Hard to Differentiate Anxiety and ADHD
There's a lot to consider when it comes to distinguishing ADHD and anxiety. The conditions have similar symptoms, but a different root cause — and can occur at the same time.
"Because of genetic reasons, we think that a woman is actually quite likely to have both disorders at the same time," Dr. Jain says. "It's like having hypertension and diabetes. They travel together, ADHD and anxiety disorders."
About half of adults with ADHD have an anxiety disorder, per the Anxiety & Depression Association of America (ADAA). Anxiety disorders are far more prevalent in women than men, according to a June 2016 systematic review in Brain and Behavior. About 30 percent of children with ADHD have anxiety, according to the CDC. Adults with ADHD are also likely to have other psychiatric disorders, such as depression or bipolar disorder, according to the ADAA.
So, in some cases — as with Dreizen Howell — a diagnosis of anxiety is not incorrect. But it does fail to capture the entire situation.
Make a Venn diagram of ADHD and anxiety symptoms, and it'll have an overstuffed middle section to accommodate overlapping symptoms. "Problems with concentration [and] academic or job performance problems are common in all these diagnoses," Dr. Martinez says.
"The symptoms on the surface are similar, but if you dig a little bit deeper, they actually are in fact quite different," Dr. Jain says.
Here are a few examples of what that overlap looks like:
- Lack of focus: When a person with ADHD "has difficulty focusing and concentrating, it's because their brain is wired in a different way," Mendez says. But with anxiety, the root cause is fear, worry, apprehension. "What we see when the person with anxiety is having difficulties with attention, it's not because they can't focus. They can focus really well. But the fears get in the way and interrupt the focus, because they're overwhelmed by fears, worries, nervousness," Mendez says.
- Low self-esteem: There's a connection between lower self-esteem in adulthood and ADHD, according to a March 2014 systematic review in ADHD Attention Deficit and Hyperactivity Disorders. This can be a result of never-ending negative feedback from peers and family. With anxiety, low self-esteem can occur "because the person feels incompetent to manage their fears" and because anxiety and fear may "interfere with their thinking logically about themselves," Mendez says.
- Social functioning: Where a person with anxiety might fear doing the wrong thing in a social setting, for someone with ADHD symptoms, behavior (think: interrupting or not taking turns) can cause difficulties forming and maintaining relationships, Mendez says.
A skilled diagnostician can tell whether the cause of symptoms is ADHD or anxiety, or for a person with both disorders, if one is primary over the other — determinations that help steer treatment.
If You Think You Have ADHD
Some of the primary symptoms for adults are problems with attention and distractibility, Dr. Martinez says. This can "manifest as a hypersensitivity to sounds in the workplace or home, difficulty completing tasks [and] organizational problems," she says.
Other common symptoms of the inattentive form of ADHD seen in adults include not paying attention to details, difficulty listening, lack of follow-through, losing things frequently, procrastinating and forgetfulness, according to the Cleveland Clinic.
If you believe you may have ADHD — or that your anxiety diagnosis might be off the mark — talk to a trusted health care provider.
Despite all the symptom overlap, ADHD is "simply not a difficult diagnosis to make accurately if one follows the basic rules of engagement, which every clinician should be taught," Dr. Jain says.
During diagnosis, you can expect a lot of questions. "You really have to take a longitudinal history," Dr. Jain says. This can help doctors make a differential diagnosis — that is, understand if the symptoms are due to ADHD, anxiety or something else entirely. Your health care provider may also use ADHD rating scales or physiological tests, according to the Mayo Clinic.
It's easy to do a search online and uncover these types of questionnaires. But Dr. Jain warns against self-diagnosis. "Just don't do it by yourself. It's a bit tricky, and we need a competent physician to help us and guide us."
How to Find a Therapist
Both mental health and primary care providers can make an ADHD diagnosis, according to the CDC. Here are some ways to find someone to make the diagnosis — and offer support afterward:
- Get a referral: Ask your primary care physician or your therapist for a referral. (Your therapist may or may not be comfortable diagnosing you with ADHD.)
- Check with your insurance (if you have it): "If someone has insurance, they can contact their insurance company to ask for a list of approved therapists. Some clinics where an individual may have a primary care provider may make recommendations," Dr. Martinez says.
- Ask friends and family: Good old-fashioned word of mouth is a great way to find a therapist.
- Look for support groups and check your local college or university: Along with groups, which are often a free or lower-cost option compared to individual therapy, there may be research groups or lower-cost therapy options available through nearby schools, Mendez suggests.
Treatment Options for ADHD
"Whenever an individual is struggling at work or home due to mental health or behavioral issues, it can be helpful to work on these emotions and behaviors with a therapist," Dr. Martinez says.
An ADHD Diagnosis Can Be Transformative
Like many, Dreizen Howell began to wonder if she had ADHD after watching a TikTok video about someone with ADHD that her sister sent her. "I'm not a hyperactive person ... I never would have thought I had any neurodiversity," she says. But she has always felt like there was something a bit different about her.
"I went down a TikTok rabbit hole and I was like, oh my god, this is what it's like to be in my head," Dreizen Howell says.
Getting diagnosed — and treated — has been life-changing for her.
"My focus is very different. I don't hear constant noises and discussions in my head all the time. So my brain is definitely a lot more quiet," she says.
It's not just that she can complete long-deferred tasks and projects, like putting up a gallery wall. It's the end to the exhaustion that accompanied her undiagnosed ADHD: "It's like debilitating anxiety, that your brain won't show up for you in the way you need it to," Dreizen Howell says.
"It's never too late to get the right diagnosis of ADHD," Dr. Jain says. "My oldest patient I've ever diagnosed was in their late 50s, and ... this individual made so much progress."
- Centers for Disease Control and Prevention: "What is ADHD?"
- National Alliance on Mental Illness: "Attention Deficit Hyperactivity Disorder (ADHD)"
- Mayo Clinic: "Adult attention-deficit/hyperactivity disorder (ADHD)"
- DSM-V: "DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]."
- Cleveland Clinic: "ADHD in Women"
- Neuropsychiatry (London): "Changes in the Definition of ADHD in DSM-5: Subtle but Important"
- European Child & Adolescent Psychiatry: "Sex differences in predicting ADHD clinical diagnosis and pharmacological treatment"
- Developmental Science: "Sex differences in ADHD trajectories across childhood and adolescence"
- Psychiatrist: "A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis"
- Psychiatry Research: "Do different factors influence whether girls versus boys meet ADHD diagnostic criteria? Sex differences among children with high ADHD symptoms"
- Journal of Child Psychology and Psychiatry: "Annual Research Review: Attention-deficit/ hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions"
- Anxiety & Depression Association of America: "Adult ADHD (Attention Deficit Hyperactive Disorder)"
- Brain and Behavior: "A systematic review of reviews on the prevalence of anxiety disorders in adult populations"
- CDC: "Data and Statistics About ADHD"
- ADHD Attention Deficit and Hyperactivity Disorders: "The self-esteem of adults diagnosed with attention-deficit/hyperactivity disorder (ADHD): a systematic review of the literature"
- Cleveland Clinic: "18 Symptoms That Could Indicate Adult ADHD"
- Mayo Clinic: "Adult attention-deficit/hyperactivity disorder (ADHD) — Diagnosis"
- CDC: "Symptoms and Diagnosis of ADHD"
- Cleveland Clinic: "Attention-Deficit/Hyperactivity Disorder (ADHD) in Adults"
- NAMI: "Attention Deficit Hyperactivity Disorder (ADHD)"
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