ADHD Is Different for Women

KATHLEEN NADEAU: I have ADHD myself. My daughter does, my granddaughters do, my sister does, and we all look very different. But I can tell you that it’s a real task for me to stay focused on anything, on something I’m working on, because I have a very creative brain in which ideas are pinging all the time.

AMY BERNSTEIN: Kathleen Nadeau is a psychologist who for the past 40 some odd years has specialized in the diagnosis and treatment of ADHD. Her mission is to help people – above all girls and women – understand and deal with the disorder, because we’re the ones doctors have historically underdiagnosed and undertreated. Why? The Duke Center for Girls and Women with ADHD says that boys are twice as likely to get a referral as girls because boys with ADHD tend to be hyperactive and impulsive and, therefore, disruptive.

KATHLEEN NADEAU: I had a younger brother, this is true in my case, who was so hyperactive. He was always leaving the yard as a toddler. My mother was tearing her hair out because he just had to roam.

AMY BERNSTEIN: That’s why they get all the attention. Girls with ADHD tend to be inattentive and they also tend to develop coping skills that hide their symptoms.

KATHLEEN NADEAU: I’ve had girls tell me, “I always look at the teacher because I know I’ll get in trouble if I’m not looking at her, but I’m not always listening to the teacher.” So, they’re aware of having to pretend and accommodate.

AMY BERNSTEIN: The gender gap, the Duke Center notes, appears to go away in adulthood when women can simply ask to be assessed. If only the process were that simple. Diagnosed or not, researchers estimate that somewhere between two and 5% of adults have this disorder, which messes with people’s ability to remember stuff, manage their time, do paperwork, communicate clearly, maintain relationships. The list is long. Without proper diagnosis and care, NYU’s Adult ADHD Program warns, ADHD can create personal and professional difficulties. What sort of professional difficulties? Let me share some of the titles I found when I scrolled through the ADHD women subreddit. “Why can’t I just work during work hours?” “How the hell do you decide what career to do or how to make any decisions at all?” “My boss told me today that she doesn’t believe I have ADHD.” “I’m terrified to get a job.” “I’ve reached the pinnacle of my career and my life is falling apart.” Boy, that forum actually seems like perfect place to rant and reflect and swap tips. Kathleen says women really benefit from peer support, and she and I will get into that. But before we do, just a bit more on her background and expertise. She’s the clinical director of The Chesapeake Center. She and her staff provide a full range of services including neuropsychological evaluations, medication management, and group therapy. Kathleen’s also written a bunch of books like The ADHD Guide to Career Success. Her latest is Still Distracted After All These Years, and it centers on older adults. And because I refer to it in our conversation, there’s a video of her on YouTube. The title is “How Women with ADHD Can Transform the Challenges of a Late Diagnosis”, which I found extremely interesting, so go watch that afterward. Thank you for doing this.

KATHLEEN NADEAU: Oh, well, it’s a pleasure and it’s important to know there are lots of things we can do to feel better and function better.

AMY BERNSTEIN: So, let’s start with the acronym ADHD. It’s attention deficit hyperactivity disorder, but that’s a misnomer, right?

KATHLEEN NADEAU: I would say it’s more than a misnomer, and clinging to that name is one of the reasons why so many women don’t get diagnosed. I really think of it as a type of a brain, which in its extreme version is a serious disorder, but that it really exists along a spectrum. You can have a little or a lot of this thing we call ADHD, and that the degree to which we’re impacted varies depending on her circumstances. But to start off with your question, it’s not a deficit of attention. It’s really a dysregulated attentional system, not a deficit of attention. So, that the very same person that may wildly hyper-focus for hours more than the average person can also be highly distractible in a situation where they’re not really plugged in and interested in the activity. So, it’s a dysregulated attentional system, and I think what’s so important for teachers of younger people, for bosses of older people to understand is it’s not voluntary. We can’t make ourselves hyper-focused. It’s something that happens to us. We become engaged and fascinated sometimes at very awkward times when we should be doing something else.

AMY BERNSTEIN: So, you say that it’s about regulation. It just seems that in the course of one’s day you are able to focus at certain times, not that able to focus at other times. That’s been documented. Some of us are good in the afternoon, some of us fall asleep in the afternoon. When does that become ADHD?

KATHLEEN NADEAU: Well, let me go back to saying it’s a spectrum. There is nothing in general that people with ADHD struggle from that everyone hasn’t to a certain extent. But let me give you an analogy. The exact same thing is true of anxiety. Everyone’s been anxious, but that doesn’t mean everyone has an anxiety disorder. Everyone’s felt depressed, down, low mood. All of these exist on a continuum, and I think the whole view in psychiatry is rather than having these little categorical boxes, if we can check five items, six items, then you have it, and if it’s only four, you don’t. That’s absurd, because you might qualify for four items in the morning and seven items in the afternoon depending on what’s going on in your day. So, it is a continuum, and it really is very related to what we are required to do during the course of our workday. So, ADHD has to be looked at in the context of the woman who is living with this kind of a brain. If we’re living in a calm, orderly context, a few of us are that fortunate, then our ADHD is going to be much less in evidence, and calm and orderly are the two important factors. It can be calm with no structure, and then ADHD can become rampant.

AMY BERNSTEIN: So, I watched that great video of you. It’s about an hour long. It flies by because you are imparting so much incredibly valuable, to me, new information, and I think we’ll probably put that video’s links in our show notes. But you describe ADHD is for women, you call it ego-dystonic. Explain what that means.

KATHLEEN NADEAU: Well, I’m so glad you asked that because that’s psychobabble. We don’t have to use psychological terms. What I mean is, starting with kids, if you look at little girls with ADHD versus little boys, the traits of little boys are so in accordance with the way we expect little boys to be. Little boys are supposed to be active and impulsive and athletic and jumping around. And of course, little boys don’t like school. And we’ve had so many fathers say, “He’s just all boy. He doesn’t have ADHD.” So, in that sense, in psychobabble, we would call that ego-syntonic, as in they go together, whereas nobody says, “Oh, she’s just all girl,” because girls are supposed to be polite and orderly and self-controlled. It’s a real struggle when you have ADHD to do what you are supposed to do. So, studies have shown, for example, that mothers in general are harder on daughters with ADHD. They’re more upset that their daughters have a messy room, that their daughters get dysregulated emotionally, get very upset, might be very argumentative because they’re feeling picked on, might have trouble finishing anything that they start. Sugar and spice and everything nice is not a description of ADHD in little girls, so that’s what I mean by ego-dystonic and syntonic. A simpler way to put it is that it’s much harder for us as women, as well as girls, to have ADHD because the world expects all kinds of things of women that I think are unreasonable expectations if we don’t have ADHD. But we need-

AMY BERNSTEIN: Well, let’s project that forward into the workplace. There are expectations of professional women that run headlong into some of these problems of dysregulation. Women are expected to have the social skills, for example.

KATHLEEN NADEAU: Yes.

AMY BERNSTEIN: They’re supposed to have the executive functioning, so the ability to keep a hundred balls in the air, pay attention to the details, make sure everything is moving forward at once, the self-control. How have you seen this play out in your work?

KATHLEEN NADEAU: I’ve seen it play out with utter exhaustion. One of the patterns I see is a way to think of it is we only have so much bandwidth, and I have worked with women who have told me, “No one at work would ever guess I had ADHD. But, because it’s so exhausting for me to keep all that organized, that the rest of my life is in chaos, my home is in chaos. I don’t have a social life because I can’t even organize one. I can’t plan one. I forget to return phone calls. I forget to write thank you notes. I forget to remember it’s my best friend’s birthday, because so much of my bandwidth has been used up at the office.”

AMY BERNSTEIN: That’s so interesting to me because everything you’re saying rings painfully true for me. So, what do you tell women who say, “It’s ticking some of the boxes?” I know we’re not supposed to think in terms of box-ticking.

KATHLEEN NADEAU: Well, no, that’s a good question. And the first thing I think women should look at is ADHD is so highly, highly genetic. Many, many people in my family, males as well, have this thing called ADHD. So, the first thing that I would ask a woman is, look at your siblings. Look at your parents, aunts, uncles, grandparents. Now, I’m not asking you were these people diagnosed with ADHD? But what I am asking you is did they demonstrate ADHD traits? For example, have there been people in your family that were really smart but dropped out of college and never went back? Is there anyone who is notoriously messy and a running joke in the family? They can never find their glasses, their shoes, their car keys. So, when a woman is wondering if she has ADHD, it’s not likely to be ADHD if everybody else in the family on multiple generations, all sides, just seems to be chugging along and don’t get in trouble at work, don’t have trouble managing their finances or managing their time. And so, that’s the first thing. Look at your family. Second thing is, and I’m speaking to businesswomen now, not so much what have you been able to achieve, but at what cost to yourself have you achieved it? Because the analogy of the duck that’s gliding along the water, but their feet are furiously paddling underneath, that’s a great analogy for what it’s like to be a woman with ADHD who is managing her life well, but at enormous cost to herself.

AMY BERNSTEIN: I’d like to just dig in on the cost. What are the costs that you have seen professional women paying?

KATHLEEN NADEAU: The word overwhelm is I think, the word that most women just readily use to describe their life. I feel overwhelmed most of the time. I’ve almost never had a man walk into my office and say he felt overwhelmed. So, women… we women take it out on ourselves, and by that I mean that women are more likely women with ADHD to feel anxious, to feel depressed. Men are more likely to feel frustrated and angry. My boss is a jerk. My wife is unreasonable. I hate my job. They’re sort of externalizing. We take it out on ourselves, and that starts in girlhood.

AMY BERNSTEIN: So, just curious. During the pandemic, when women who always take on more of the household work, the family responsibility, had to do this all at the same time as they were working from their dining tables. Did you see an uptick in calls? Did more people come seeking your help?

KATHLEEN NADEAU: Oh, there’s an interesting statistic that I only recently read, that the number of women diagnosed and prescribed stimulant medication for ADHD doubled between 2020 and 2022, doubled.

AMY BERNSTEIN: Wow.

KATHLEEN NADEAU: And it’s because we were at home. I wasn’t at home with kids because of my age, but I’ve talked many times to my daughter, who has a very demanding job. She is the CEO of my large clinic, and she had two children at home, and they were special needs children. They both had ADHD. And I think those were the hardest years of her entire life. I think that many women who could hold it together with, mind you, a great deal of stress completely lost it during the pandemic and sought a diagnosis and were diagnosed with ADHD. And so, I think the thing that’s so important for women that are listening to this need to understand is that this thing we call ADHD is very dynamic. It’s not static. It comes and goes. It gets worse, it gets better. It gets worse when we’re tired, it gets worse when we’re sick, it gets worse when we are anxious and depressed, it gets worse when we have huge problems at home with our families. Anything that’s going to cause greater stress or distress makes our ADHD worse. The important thing to realize is that also gives us all the clues about what we need to change in our life to reduce the impact of ADHD, that we need to… I really encourage women to underdo it.

AMY BERNSTEIN: Underdo it. What do you mean? What does that look like?

KATHLEEN NADEAU: What I mean is that, often, we are the victims of our own unreasonable expectations, that we need to give ourselves permission to not try to do it all. I really help women go through a stress analysis. Let’s look at what are the major stressors in your life. And for women on the job, a major stressor may be that their supervisor or boss may be difficult, unreasonable, demanding. Maybe they don’t need a different career, maybe they need a different job with a boss who is more ADD-friendly. Are they under financial stress? Have they created a life where they just can’t do it all, that their commute is too long, their children’s needs are too great? And I really go down a list of what are the major stressors, maybe you have a relative who’s ill, maybe you have an aging parent, all of these things, and just do some pragmatic problem solving. How can we lower the stress level in your life? And so a big piece of getting treated for ADHD is simplify, simplify, simplify. And no one has done any research on this. In fact, there’s remarkably, painfully little research on what is most helpful to women with ADHD. And one of the things I believe is most helpful is to be in coaching/support groups with other women with ADHD so that you can really receive affirmation and understanding and, “That happens to me, too,” and giving each other permission to not try to do it all.

AMY BERNSTEIN: You mentioned all kinds of external factors in just the occurrence of ADHD-related type behavior symptoms. What is the role of hormones?

KATHLEEN NADEAU: Oh, I’m so glad you asked that. And we are not paying attention to that in this country. Wonderfully, people in Canada and Europe are paying attention to it, and I think that that will eventually influence more research in this country. But my longtime friend and writing partner, Patricia Quinn, is an MD, and we have worked together for 30 years, and she was the lone voice beating that drum of the huge impact of hormonal fluctuations on women with ADHD. Why is that? Because estrogen has a huge impact on the receptors in the brain for anxiety, depression, and ADHD. When estrogen levels are high, we’re less anxious, we’re more focused, we’re less moody. And that’s true of all females. That’s what PMS is all about, that as estrogen levels drop in that week before our period, some women severely feel anxious, moody, almost feel like a different person, others more moderately so. But there’s a very interesting phenomenon that there are two points, historically, at which females were typically diagnosed. One was when they hit puberty, and the second thing that was noted 20 years ago or more is that the most common age for diagnosis as an adult female was 39. Guess what happens on average at age 39? That is the beginning of perimenopause for almost all of us. And so, psychiatrists, gynecologists are not trained in how hormones impact cognitive and emotional functioning. They’re really not. And they think that, if we just measure your hormone levels and they’re in the, quote, normal range, then you’re fine, couldn’t be hormones. What has been discovered is it’s not the absolute amount of estrogen, but the fluctuation of estrogen that causes the ADHD symptoms. So, we’ve got these two points that just are screaming for hormones are so important.

AMY BERNSTEIN: Okay. I have so many questions about this. First of all, women in perimenopause, and we’re talking about years, many-

KATHLEEN NADEAU: It’s a decade. It’s a full decade.

AMY BERNSTEIN: So, what do they do? How do they get help? What does the help look like? How do they handle this?

KATHLEEN NADEAU: Well, if they’re lucky, and not many of us are so lucky, they live in a metropolitan area where there are usually women, not always, gynecologists or hormone replacement specialists, that understand the huge impact of mood and attention caused by hormonal fluctuations. We have a completely distorted, distorted view of the danger of hormone replacement therapy, HRT, for women with ADHD. It is true that, for women who have a strong family history of breast cancer, that they have to be very careful and probably aren’t candidates for hormone replacement therapy but the rest of us are, and the rest of us is most of us.

AMY BERNSTEIN:

What if you’re not a good candidate for hormone replacement therapy? What do you do then?

KATHLEEN NADEAU: Well, there are many, many things that we need to do to improve brain functioning; stress management, whether it’s yoga, meditation, deep breathing, you name it, anything to do to lower our stress, a low glycemic diet, because, for people that don’t know, the glycemic scale basically measures how rapidly we metabolize food. And so, pure sugar is the highest on the glycemic scale, pure protein is at the bottom. And eating foods, what we used to call starches, rice, potatoes, pasta, sugar, bread, leads to brain inflammation. We know that aerobic exercise improves cognitive functioning. You don’t have to go run marathons. You can just keep your heart rate up for 15 or 20 minutes a day by walking briskly.

So exercise, diet, stress management, social connection. And one of the things that worries me about older adults with ADHD is the danger of social isolation. That is more likely when you have ADHD for a whole bunch of reasons; my place is a mess, I would never want anybody to walk in the front door, I just don’t seem to be able to organize myself to commit to something, to reach out to people, to make a date to get out there, I lose touch with friends because I’m just not focused and organized enough to stay in touch with them. It takes some executive functioning skills to have a good supportive social life.

AMY BERNSTEIN: So, many of just the ways that ADHD shows up in our lives strike me as embarrassing, “My house is a mess,” or, “I don’t really want to talk to you about my menopause problems,” or whatever it is. What is the role of shame in all of this?

KATHLEEN NADEAU: I think the role of shame is enormous for women, and it goes back to all these expectations. If you have ADHD, you’re bad at being a woman. That’s why I think groups are so wonderful in pulling women out of that overwhelming sense of shame that, “I’m a mess. My house is a mess.” I just really try to help women think of how can you simplify. If you look at my wardrobe, you would find that, first of all, it’s not a very exciting wardrobe, but it works fine, and every single thing goes with black because I just realized, if I’ve got navy blue and brown-

AMY BERNSTEIN: I feel like you’re my sister from another mother.

KATHLEEN NADEAU: Yes.

AMY BERNSTEIN: So, just back to shame for a second, when the behaviors, the way you feel, what you know about what’s going on inside your head and inside your body cause you shame and it’s affecting your work, talk about how you help clients handle that.

KATHLEEN NADEAU: That’s a very good question, and the answer is, I do not recommend that they go in and announce, “I have ADHD,” and the reason I don’t is because people make all sorts of awful assumptions about you if you make that announcement because most people think they know about ADHD, but what they know about ADHD really only pertains to hyperactive, impulsive little boys. They make an assumption – Well, if you’ve got ADHD, you can’t possibly do this job. And so, I’ve had so many people tell me they, A, didn’t get the promotion, or lost their job, or projects were taken away from them if they announced they had ADHD. So, what I tell people is don’t name the diagnosis, which can mean different things to different people. What I try to do is get them to think deeply about the circumstances of their workplace and their particular job. What am I naturally good at? How much structure do I need? Do I want to work on a team rather than solo? Do you work best on really short-term projects? Can you turn something around in a week because it’s intense and exciting, but get lost if you’re on a six-month project? You really need to get to know yourself. I think what I’m trying to tell you is that ADHD exists within a context and that one of the most important things that we can do is find or create a context that will support us at doing our best because there are also very positive things about having this kind of brain. I enjoy my ADHD. I’ll read an article in the Atlantic, and an article in the Times, and an article in Scientific American and go, “Wow, I’m connecting all these things, and that’s going to be the next article I write.” And it takes an ADHD brain to be constantly doing that.

AMY BERNSTEIN: Yeah, that’s what I was chuckling at. There is something wonderful about it, is that you skitter across so many topics, but on the topic of getting to know yourself, you’ve described a lot of different symptoms, the way this condition shows up. How do you know if you have this? What’s the screening process?

KATHLEEN NADEAU: Well, the ideal screening process is an in-depth clinical interview. There are lots and lots of questionnaires that can, quote, diagnose ADHD; “If you can say yes to 22 of these 29 symptoms, then it’s extremely likely that you have it.” And I think a lot of professionals that are less expert in ADHD rely on those questionnaires, and that’s not a bad thing, but that in-depth interview to find out if you have it, going back to what I talked about at the very beginning, it’s so important to look at your family. It’s genetic. The most common way that a woman gets diagnosed with ADHD as an adult is because one of her children is diagnosed. And the child is diagnosed and they start thinking that, I did a lot of this stuff when I was a kid. And then they seek a diagnosis.

AMY BERNSTEIN: But for those of us without children to sort of-

KATHLEEN NADEAU: Without children-

AMY BERNSTEIN: … provide that clue.

KATHLEEN NADEAU: Without children for that trigger it is in my experience much more common for a woman than for a man to seek a diagnosis. It’s very often that they saw a documentary, that they saw a podcast, that they read an article, and there’s a lot out there by women with ADHD for women with ADHD. There’s just been a blossoming of help and support on the internet. And I would encourage women to go out and really search around, because you’re going to begin if you have ADHD to recognize all kinds of things in yourself that you’re hearing about. And it’s really a matter of us identifying ourselves through the growing information and then going to seek the diagnosis and treatment.

AMY BERNSTEIN: So, say more about that.

KATHLEEN NADEAU: Well, the standard treatments sadly are only scratching the surface. The standard treatments which are helpful, no doubt about it, are to be prescribed stimulant medication. Not all women can tolerate stimulant medication. If you’re on the anxious side it can make you feel more anxious. So, they’re quite a few women that take some kind of anti-anxiety medication in combination with their ADHD. So, the easiest and the most standard treatment is here’s a stimulant. If you’re lucky, you get the right dose, you get the right medication. It’s very helpful. What I would say to women is be patient. Don’t be skeptical of medication. We’ve come so far. There are so many different delivery methods of stimulant medication now. There are so many different types. If one makes you feel terrible, don’t assume they all will. There are lots of opportunities out there.

AMY BERNSTEIN: Kathleen, this has been so informative and thank you. I’ve just learned so much from you.

KATHLEEN NADEAU: And thank you so much for inviting me.

AMY BERNSTEIN: Kristen Carder with her podcast, I Have ADHD Podcast, is part of that blossoming of help and support on the internet that Kathleen just mentioned.

KRISTEN CARDER: When we go looking for research on ADHD as an adult and we’re met with the clinical symptoms, we have a hard time often imagining what that might look like and how they might manifest in our real lives.

AMY BERNSTEIN: Take impulsivity – a symptom that Kristen remembers Googling.

KRISTEN CARDER: And not really understanding, okay, well, am I impulsive? What does that mean? What does that look like in my real life? How would I know if I’m impulsive? Because a little known fact about people with ADHD is one of our deficient executive functions is self-reflection.

AMY BERNSTEIN: A fact among many that she learned over the next decade in reading a shelf full of books by a host of authors, some of whom later on she’d interview on her show where she was talking about shame and emotional explosions and setting and achieving goals. Listeners kept asking for practical, personalized advice. And so, in 2019, she became a full-time life coach. Kristen translated all the information she’d ingested and the stories she’d heard into a list of symptoms, each with several vivid, easy to understand, scary, relatable examples, and she put that list on her website. Under poor working memory, she has, you forget to do the things you say you’re going to do Under Gratification Junkie, she writes, “Tedious menial tasks make you feel like you want to die. Under time blindness you cannot accurately estimate how long a task will take you.” Kristen Carder is here with more straight talk about being an adult, particularly a working woman with ADHD. She’s also here to nudge you to ask for the kind of help you actually need. Kristen, one thing that Kathleen touched on is the tendency among people with ADHD to over commit, the bandwidth issue. And what she advises is that you simplify your life. Is that the same thing you say to your clients?

KRISTEN CARDER: Yeah, I really encourage my clients to produce B- work. That’s something that I heard a life coach say years ago. And it changed my life because I’ve always been striving for A+ work. But what that looks like for an intelligent over-functioning woman is that I take on way too much, I’m spread way too thin, and I’m always feeling shame and I’m never able to keep up. So, if I can flip the script and say, what would B- look like today? That would look like taking care of my basic needs, taking care of the things that work that just really need to be done, it would look like actually functioning on a typical level, in my opinion. I think there are so many high achieving women with ADHD who are overextending themselves partially because we have ADHD and we want to make up for the symptoms.

AMY BERNSTEIN: So, I have to ask about this because so many of these high performers, these driven, ambitious women are perfectionists. And you’re saying to a bunch of perfectionists, figure out what good enough is and strive to be good enough. And how does that go over? Do they accept it? Does it take time? How do you get that message to land?

KRISTEN CARDER: I mean, I think when people first hear my approach they’re either really put off by it or they’re completely drawn to it. It can be very difficult for perfectionists to hear, “Listen, you need to do less, do less.” But what we know in the research, Dr. Russell Ramsey, he’s at UPenn ­– or he was at UPenn – and he did research on adults with ADHD, and he found that perfectionism is the number one, the most frequently endorsed thought distortion of adults with ADHD. So, perfectionism runs rampant in men and women with ADHD. To be able to identify that in yourself and understand that that’s a coping mechanism, it’s not actually helping, it’s maladaptive. It’s making my life harder, it’s making my symptoms worse. And that’s a whole process. I mean ADHD treatment, ADHD recovery, this is a long process, but perfectionism is something that I tackle over and over and over.

AMY BERNSTEIN: So, your former, I hope, perfectionists, these ambitious professional women whom you’ve encouraged to do B- work, how has that affected their careers? Are they moving forward? Are they getting where they want to go?

KRISTEN CARDER: Yes, because the truth is that a perfectionist version of B-work is a typical person’s version of A+ work. And so, when I complete a project, and to me it is not perfect and I can identify flaws and I just want to keep tweaking it, keep tweaking it, keep tweaking it to the point of not turning it in, not meeting the deadline, not getting it in on time, making everyone on my team at work upset and angry, that doesn’t work. So, if I can say, “Okay, I see the flaws, but it’s good enough, I’m going to turn it in and if there’s feedback, I will totally work with it.” That actually propels me forward at work because now I’m meeting deadlines, now I’m working collaboratively with my team. Now I’m accepting of feedback and saying, “Okay, great. I’ll go tweak that and then give it back.”

AMY BERNSTEIN: So, Kathleen also talked about how career success for women with ADHD depends heavily on having a strong structure and a lot of support in the workplace. But what if you are self-employed? You yourself are self-employed, how have you gone about setting yourself up for success?

KRISTEN CARDER: Kathleen is absolutely right. It’s structure and support, and I do that. I implement that on my own. So, I don’t have a boss telling me what to do, but I do hire team members and I ask them to hold me accountable. So, I have a director of operations, I have an executive assistant, and they know exactly what I need to work on, and we have clear deadlines and we have a lot of accountability. We meet together four times a week because your girl needs that much accountability. I mean, I really do. The tasks at work that I am amazing at, the coaching, the interacting with clients, the supporting people, that comes so easy. I don’t need accountability with that. What I need accountability with is making sure the bills are paid, making sure the emails are written, making sure that everything is running smoothly in the background. All of those little details need to be running smoothly in order to not be stressed and overwhelmed 100% of the time. And so, my team knows that hey, if Kristen’s going to write an email, somebody needs to be sitting in a Zoom meeting with me to make sure that happens because I’m not going to write an email on my own. And I know that sounds simple. It sounds childlike, and guess what? I don’t care. I have ADHD, I have some amazing strengths and I have some very stark weaknesses that I need to have support for. And support for me looks like a lot of body doubling, which I really recommend for anyone in corporate or working on their own is use other people working, co-work with other people so that you are held accountable in that way. It is so much easier for your brain to comply and do what it’s supposed to do when you have the accountability of somebody else working next to you.

AMY BERNSTEIN: Okay, but how do you make that happen?

KRISTEN CARDER: Okay, so if you’re in a corporate setting, you can either have a friend, a safe person at work where you can say like, “Hey, can we work on this project together? You sit at your desk, I’ll sit at my desk, we’ll be on Zoom together. We’ll just co-work on Zoom.” But not everyone has safe people in the office, in the workplace where you feel comfortable saying like, “Hey girl, I need a little accountability. Will you sit with me please?” There are a lot of online resources in my coaching program. We have body doubles around the clock so people in all different time zones can join a body double 24/7 and just show up and work together. So, you’re sitting in your office and you’re on a body double with other ADHDers around the world. There are also online just coworking sessions that people can pay for and join like Focusmate or Caveday. But those kind of accountabilities are so important, and here’s what stops us from taking advantage of that. Most humans with ADHD, especially women with ADHD think, “I shouldn’t need that. I shouldn’t have to have someone sitting next to me. What am I a child?” And I will say that if you have ADHD, you should need it. If you don’t need it, you might not have ADHD. Okay? If you do have ADHD you do need accountability. If you do have ADHD and you want to be a high performer who gets stuff done and who gets it turned in on time, you’re going to need accountability. So, what might that look like? When you fully accept your ADHD and the deficiencies that come with it then you can support yourself. But if you think, “I shouldn’t need this, this is so ridiculous. I’m being immature. I should just be able to do this.” I’m sorry, but that’s probably something that you heard from a caregiver or a teacher like, “This shouldn’t be so hard for you because I know you’re smart.” Sometimes those become our internalized thoughts as adults, and I would just really encourage people to say, “No, no, no. I should need it. I have ADHD. I should need accountability. I should need support.”

AMY BERNSTEIN: But women, particularly, Kristen, we both know this, for us, just appearing competent is so important. And I wonder how you square that need to appear competent and to gain confidence from that competence. How do you square that with what you’re suggesting, which is to say, “Listen, I need help and I’m getting the help I need.”?

KRISTEN CARDER: Yep. I think that there’s a couple threads that we need to follow here. Someone first needs to have a very robust understanding of what it means to have ADHD. I am not going to have the confidence to ask for help if I don’t truly understand what it means to have ADHD. If I just think, “Oh, I just struggle to focus.” Then I’m not going to understand that it actually affects every single aspect of every single minute of my life and therefore I need help. But additionally, I think we need to understand who the safe people are and the unsafe people are in our lives. So, understanding that maybe I’m not going to go to this coworker or this coworker and ask for help, but I know that this coworker over here is safe or I know that this particular manager is going to treat me with respect. Additionally, ADHD is covered under the Americans with Disabilities Act. So, you do have a right to accommodations. However, I know that Kathleen said like, “Hey, I don’t encourage you to announce it,” and I am of the same vein that you need to know your audience. But I think a big and pretty easy, in theory, approach to this is truly understanding the scope of your job description and working exclusively within your job description. I think that one thing that women with ADHD often do is we over commit beyond the scope of our job description in an effort to prove that we’re competent. And instead, what we need to do is see the job description as the guardrails and the boundaries, and just work within that. Be really good within the scope of your work. And don’t say to your co-worker, “Sure, I’ll take that. Yeah, I can do that. Yeah.” Why are we saying yes to everything? We need to say no more often.

AMY BERNSTEIN: Back to simplify, simplify.

KRISTEN CARDER: 100%.

AMY BERNSTEIN: So, in your podcast, you did some episodes on the various executive functions, which were absolutely terrific.

KRISTEN CARDER: Thank you.

AMY BERNSTEIN: And I wonder if you would walk us through each one of them.

KRISTEN CARDER: Yes. I’m going to look over here, because I have them written out, because one of the executive functions that we struggle with is nonverbal working memory, which is recalling these things. So, here we go. There are 1, 2, 3, 4, 5, 6. Okay. There are six executive functions that every adult has and uses to help them stay on task, perform, and get things done. For an adult with ADHD, the frontal lobe of the brain is underdeveloped, and that’s where our executive functions are housed. However, as Kathleen mentioned, it is a spectrum disorder. And so, some executive functions you might find are working great and others maybe are really, really deficient and debilitating. And it’s going to depend on the person. So, first we have self-awareness, which is the ability to evaluate, reflect, and look at your behavior over time. Someone with ADHD is going to make the same mistakes over and over and over, because we don’t do the math of; this behavior, plus this behavior equals this outcome. And so, the self-evaluation skill is way underdeveloped. It can of course be enhanced, and we can go to therapy and we can get coaching and we can improve it, but if we are unmedicated, unsupported, it’s going to be real bad. Next we have inhibition, which is your ability to stop and think before you take action. This is where medication really helps, because medication affects the area of the brain where the breaks are. Our nonverbal working memory is very deficient, which is the ability to just keep something in your mind long enough to complete the task. Your verbal working memory is also deficient, which is your ability to narrate and say, talk to yourself internally, “Kristen, what we need to do now is we need to sit down and we need to write these three emails and it’s going to be fine. It’s going to take you 15 minutes. Just do the work. It’s going to be great when it’s over.” We don’t have that, so we have to externalize it. I got to write myself a note, “Girlfriend, you get this done. It’ll be done in 15 minutes.” And so, I need to be able to look at it, because I’m not doing the internal dialogue. Emotional regulation is very deficient, so our ability to identify, process our emotions, it is not there. And in a child it looks like temper tantrums and meltdowns. In adults, it can look like a lot of avoidance, a lot of explosions, yelling at your boss or yelling at your coworker, or fights with your wife, or getting really triggered by your kids. We struggle so much to regulate. We have a lot of trouble self-motivating, so that has to do with our dopamine. It has to do with our task initiation, but getting started on something, especially something that we don’t want to do. So, I know exercise is good for me. I know if I just worked out 30 minutes a day, my life would change. Do I want to do it? No. Can I make myself do it? Huh, for some reason no. No one likes to work out, but I see a lot of people doing it. Why am I the one that struggles to get this started? And so, that would fall under the category of self-motivation. And then last, there’s a cluster here that is planning and problem solving and prioritizing. And if we want to talk about women at work, hello, hello.

AMY BERNSTEIN: Hello.

KRISTEN CARDER: Hello. Planning, prioritizing, problem solving. And I want to say that ADHDers are often really good at problem solving. We’re really good at the big picture, the big vision. But when it comes to the nitty-gritty details of following through and knowing, “Which step do I take first?” And, “What’s the most important?” It’s over.

AMY BERNSTEIN: I still imagine that a lot of our listeners are hearing about how ADHD shows up and they’re saying to themselves, “Huh, this sounds a lot like some of the stuff I’m struggling with.” At what point do you say to them, “Go get screened, go see if this is the problem”?

KRISTEN CARDER: Yeah, I think that’s a great question. And one thing that I just want to add to what Kathleen said is that when your behaviors or symptoms are at a level where they’re debilitating, where you’re realizing, “I’m not sleeping, I’m not eating, my life is so chaotic and it looks really different from my coworkers lives.” Yes, we’re all getting the project turned in, but I had to pull three all-nighters to get it finished, and they didn’t. It’s not just like… Yeah, everyone struggles with distractibility, everyone struggles with their emotions. Yeah, that’s just being a human. But when it’s at the level that it is impairing you, where you are not reaching your potential, where you’re able to say, “I know I’m smart and I am just not able to follow through. I know I could be working at a better level, but for some reason I cannot.” When you feel like there’s a gap between your potential and your performance, that’s when you really want to investigate and see if there’s something going on.

AMY BERNSTEIN: And what is your next step?

KRISTEN CARDER: Yeah. This is where it can get interesting, because it really does depend on where people are in the world. I always love to say; first, do some research, because unfortunately, most clinicians are not trained in adult ADHD at all. And the diagnostic criteria for ADHD was developed for children, which is, I know, I know, it’s ridiculous. So, the DSM-5, they tried to come up with a diagnostic criteria for adults, and they couldn’t agree. So, they’re just like, Oh, I guess we’re just not going to do it. So now, all we have is diagnostic criteria for children that clinicians are using for adults. And so, what I want to say is educate yourself on the symptoms and maybe make notes as to how you see it playing out in your life. So, just run through, I have a symptoms list on my website, you can run through that symptoms list and say, “Oh, yeah, I do this, blah, blah, blah. I do this, blah, blah, blah.” And you can just understand how it looks in your life. And I loved Kathleen’s suggestion of doing an intake of your family to say, “Who else is exhibiting these types of symptoms?” If they’re older than you, it’s likely that they’re not diagnosed, because most people in the boomer generation don’t have the privilege of being diagnosed, which is so sad. And then also think through and ask your family members, “Did you notice this in my childhood? How did this play out?” You might not remember, but maybe your mom will, maybe your sister will. Just talk about that. So, I always encourage people to arm themselves with some data, because your clinician might be dismissive, especially if you’re a woman, especially if you’re a woman of color and astronomically more if you are accomplished. If you are an accomplished woman, there is a huge probability that your clinician will look at you and say, “You can’t have ADHD. You went to Harvard.” I just did a podcast interview with a PhD candidate from Georgia Tech who, and that’s what her clinician told her, “You can’t have ADHD. You went to Harvard.” And so, because women especially hear things like that, it just magnifies the shame that we feel; “Oh, I guess I am just lazy. I guess I am just not trying hard enough. I guess I do just need the right calendar or the right system.”

AMY BERNSTEIN: I’m undisciplined. Yeah.

KRISTEN CARDER: Exactly. And so, if someone says that to you, find somebody else that will actually take you seriously. I’ve heard clients of mine say, “My first clinician said; you can’t have ADHD. You’re a lawyer. You never would’ve gotten through law school.” That’s not true. And Kathleen said these exact words, “At what cost?” And I loved that. I loved it, because when you compare yourself to your colleagues or you compare yourself to your fellow students, to your peers in graduate school, were you the same? Because I know I wasn’t. I would look around and be like, How are these people handling this? I do not understand. They’re writing things down in planners and checking things off a list. I do not understand how this is happening. I’m pulling all-nighters and full of chaos. Am I smart? Yeah. Did I do well in school? I did. But it was not cute. It did not look good. It was not cute. So, to answer your question, I recommend that people start with their general practitioner and either demand that they screen you or demand that they refer you. Don’t let them say, “Nah, you can’t have it.” And they might refer you to a psychologist for a diagnosis. They might refer you to someone that they know, an ADHD expert. Now, it is important, maybe it’s not ADHD, maybe it’s something else, and that’s totally fine. It’s not that we’re demanding a diagnosis. What we’re doing is we’re demanding to be heard, and we’re demanding to be screened, because something’s going on. So, if it’s not ADHD, what is it?

AMY BERNSTEIN: Well, that is such a good note to end on, that if something seems off to you, it’s probably off and it’s worth investigating.

KRISTEN CARDER: 100%.

AMY BERNSTEIN: Because the cost is too high.

KRISTEN CARDER: Yes. I’m sorry I interrupted you there.

AMY BERNSTEIN: No worries. Well, there you go again.

KRISTEN CARDER: I know. Look at me being impulsive. 100%. Yes. If something feels off, please seek a screening of some sort, because it can lead you to so much help and support.

AMY BERNSTEIN: Well, Kristen, you have been fantastic. Thank you so much for sharing all of this insight and wisdom with us.

KRISTEN CARDER: Thanks so much for having me.

AMY BERNSTEIN: Next week, if and when you get married, how does your career factor into the decision to keep or change your last name?

TANIYA UPPAL: So, if I look at myself differently, if my families treat me a little bit differently, then why wouldn’t my coworkers treat me differently?

AMY BERNSTEIN: HBR has more podcasts to help you manage yourself, your team, and your organization. Find them at hbr.org/podcasts or search HBR in Apple Podcasts, Spotify, or wherever you listen. Women at Work’s editorial and production team is Amanda Kersey, Maureen Hoch, Tina Tobey Mack, Rob Eckhardt, Erica Truxler, Ian Fox and Hannah Bates. Robin Moore composed this theme music. I’m Amy Bernstein and you can get in touch with me, as well as Amy G, by emailing womenatwork@hbr.org.