Why ADHD Is Often Recognized Later in Life
Delaney Banzhof, MS, APC, NCC
Neurodivergent-affirming therapist
Key Counseling Group, Roswell GA
Many adults seek an ADHD evaluation after years of wondering why everyday responsibilities feel so difficult. For some, especially women, those difficulties have been overlooked or masked for decades. Understanding why ADHD can go unrecognized helps put those experiences into context.
How Our Understanding of ADHD has Changed
Adults in general are being diagnosed with ADHD later in life for several reasons, with some of the biggest being updated diagnostic criteria, increased awareness, and a generally better understanding of the intricacies of ADHD. For example, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) formally established three ADHD subtypes in 1994, distinguishing between predominantly hyperactive-impulsive, predominantly inattentive, and combined subtypes. However, changes in diagnostic criteria do not always translate immediately into changes in clinical understanding or practice, and many clinicians continued to rely on outdated perceptions of ADHD until greater recognition developed in subsequent decades, particularly around the publication of the fifth edition, the DSM-5, in 2013.
Importantly, the DSM-5 also made significant changes to the criteria for adolescents and adults, including lowering the required symptom threshold from six to five for individuals aged 17 and older. This change better accounted for the fact that neurodevelopmental differences can change in how they manifest throughout the lifespan, and that adults have had many more years to learn to accommodate their own needs, develop compensatory strategies, or mask their symptoms.
Why ADHD has been Overlooked in Women
For women in particular, there are three main contributing factors to later diagnosis: historical gender bias in diagnostic criteria and clinical recognition, gendered behavioral expectations, and how girls are socialized. Regarding historical bias, much of the research informing our understanding of ADHD disproportionately focused on boys, particularly those with the most externally visible symptoms, which contributed to the stereotype of ADHD as primarily involving hyperactivity.
Additionally, there were researchers and clinicians who genuinely believed that women could not have ADHD and that it was a condition only found in boys. Consequently, many women who are adults now were overlooked or misdiagnosed with other mental health disorders, including anxiety and borderline personality disorder. Their ADHD symptoms were frequently attributed to personality traits, anxiety, or simply personal shortcomings. Since women are more likely to present with predominantly inattentive ADHD, their symptoms also frequently did not align with the stereotypical understanding of the condition.
Gendered Expectations and Masking
However, the behavioral and social expectations placed on women play a substantial role beyond differences in symptom presentation. Girls are “trained” very early in life to act a certain way, both consciously and unconsciously. They are often expected to be obedient, reliable, responsible, quiet, and organized, which can lead them to mask symptoms in order to either “behave correctly” or fit in socially with other girls.
Many women with ADHD report mirroring the behavior of their peers to learn what is considered “normal” and socially acceptable. They also describe putting extraordinary amounts of effort into their academic performance, only to have their difficulties dismissed because, “It can’t be that bad if you’re doing so well in school.” While men absolutely experience masking as well, gendered expectations can create additional pressures for women to conceal their symptoms in order to fit in socially.
The Cost of Masking Over Time
“Masking” refers to the act of concealing, suppressing, or compensating for symptoms, often regardless of the discomfort or distress doing so causes. Many adult women receiving diagnoses today have been masking for nearly their entire lives, and maintaining these behaviors can take a significant toll on their nervous systems. Masking often involves constantly playing a role while ignoring the cues their nervous systems are giving them in order to meet external expectations.
Importantly, this is frequently not a conscious process. Many people begin masking so early in life that it becomes an automatic response to social expectations, rather than a deliberate decision to conceal symptoms. For a child, it is often more a matter of “How do I fit in with my peers?” than consciously recognizing their symptoms and purposely covering them up. Masking over long periods of time, particularly decades, can contribute to intense burnout, chronic stress, and difficulty settling after stress or feeling overwhelmed.
It may also contribute to the development or worsening of other mental health conditions, such as depression, and can be associated with suicidal thoughts.
When Adult Responsibilities Overwhelm Existing Supports
The consequences of masking are only one reason adults seek ADHD evaluations later in life. Adults also face substantially greater demands on their executive functioning, an area where individuals with ADHD frequently experience difficulties. Executive functioning refers to the cognitive processes that allow us to plan, organize, manage time, regulate attention, remember information, initiate tasks, and adapt our behavior to meet goals. These processes affect nearly every aspect of daily life.
Children who receive more structure or unintentional support at home, such as a parent keeping track of time or making sure they remember to complete their homework, often find that transitioning into adulthood becomes significantly more difficult without those supports. College is one of the earliest points at which previously unrecognized ADHD can become apparent because it requires substantially more independent executive functioning without the structure of grade school.
Students are suddenly expected to independently manage their schedules, assignments, deadlines, and daily responsibilities, which can become an executive functioning nightmare.
Executive Functioning Difficulties are not a Lack of Effort
As a clinician, I have worked with quite a few college students who sought help with executive functioning difficulties. Some primarily needed support with organization and time management, while others were actively failing out of school because they couldn't get themselves to complete their work. Importantly, they couldn't, not that they simply didn't want to. Their difficulties were not necessarily a lack of motivation or effort, but rather an inability to consistently initiate or complete tasks despite wanting to do so.
However, these challenges are not exclusive to college students. Many adults across the lifespan encounter increasing responsibilities or circumstances that overwhelm their existing coping strategies, leading to significant difficulties and immense shame that eventually prompt them to seek treatment or evaluation.
Recognizing a Reason to Seek an Evaluation
Additionally, the increasing availability of accessible information about ADHD, alongside decreasing stigma surrounding mental health in general, has encouraged many adults to question whether their experiences are actually the result of being “lazy,” irresponsible, or unmotivated, or whether there may be an underlying explanation for the difficulties they have experienced throughout their lives. Often, it is only when these longstanding difficulties become increasingly disruptive, or when individuals recognize their experiences in accessible ADHD education, that they begin seeking a formal evaluation.
If these experiences sound familiar, seeking an evaluation can be a step toward understanding what is contributing to your difficulties and what support may fit your needs. Contact us to book a free consultation.
