What is late discovered ADHD? Beyond social media hype? Is an ADHD diagnosis worth it? Management of ADHD at Midlife.

60% of ADHD in neurodivergent women is late discovered.

94% of women with ADHD reported worsening symptoms at peri/menopause.

43% were diagnosed ages 41-50.

Late discovered ADHD can be a light bulb moment explaining a history misdiagnoses and gaslighting by the medical profession. It can be a wake-up-call as we reflect on what life might have been if we had we valued ourselves more. Lets be blunt, it's been very costly, not just financially but for some of us there is 8 years of decreased life expectancy! Slowly the realisation dawns. The harmful habits just to feel a moment of peace or comfort. The house moves, lack financial care or job after job...suceeding at first but quickly becoming bored or stressed. Then pernicious regret. A sinking sand of perfectionism...if only we coulda, shoulda, woulda.

In time it can lead to greater self-acceptance, less self-blame and to us finally addressing health disparities or seeking the support we've needed for decades.

What is ADHD?

ADHD didn't begin at peri-menopause, it's a neurodevelopmental condition begining in childhood. Symptoms exist on a spectrum, meaning they vary in type and severity, unique to each person. ADHD may result in you getting your tax returns in late but that's the case for millions of 'normies.' ADHD can also be life stopping. You feel like you are losing yourself and do not know where to turn.

There's a strong genetic component, 74% heritability. It appears to involve a combination of many genes each with small individual effect. This root cause is similar to seven other 'psychiatric' conditions perhaps explaining why it co-exists with other diagnoses.

It's through to be a structural and neurocircuitry issue of our brain. Part of the brain gets arrested at a particular period in time. For example, brain imaging studies show that individuals with ADHD may have smaller brain volumes in certain areas and reduced connectivity in white matter tracts connecting key brain regions. This may alter brain networks, such as the default mode network (DMN), involved in mind-wandering, daydreaming and task focus and dysfunctions in neurotransmitter systems, notably the dopamine and norepinephrine pathways. This affects the signaling pathways crucial for attention, emotion regulation, motivation, and executive control.

It's been linked to:

• Childhood development both within and outside of the womb. For example, premature birth, low birth weight and oxygen deprivation during or shortly after birth are linked to

• Environmental causes such as prenatal exposure to maternal smoking, alcohol use, lead and air pollution may disrupt brain development

• Exposure to adverse childhood experiences especially in ADHD in women. Increasing the number of ACEs experienced is associated with a higher risk of receiving an ADHD diagnosis

• ADHD expression has also been linked to inflamation, infection, gut microbiome, hipoxia, diet and stress.

Beyond social media hype

Social media has increased awareness of ADHD but...and it's a great big concerning BUT it's often not accurate, based on one persons personal journey and perception and this has real consequences. Lack of understanding continues to pathologise everyday human behaviour or ignores other explanations. There is an over simplification of a complex life disabling condition for the benefit of media engagement. Not only is this unethical its dangerous and wastes time. This is not unique to 'social media influencers' but I've notice this spread of misinformation from coaches and therapists. I've also witnessed Doctors (GP's) bias towards medicating, ignoring what I believe to be the core issue of the management of ADHD, the HPA axis. This is the engine of of neurodivergence but cannot we turned on or off with a pill. Therefore it's largely ignored by the medical and psychiatric profession.

Is an ADHD diagnosis worth it?

There is no specific ADHD diagnostic criteria for women at midlife.

Diagnosis is based on the Diagnostic Statistical Manual (DSM) a global bible of psychological conditions. The assessment is heavily reliant on self-report with a high correlation between a self diagnosis of ADHD and a psychiatric evaluation.

This suggest if you believe you have ADHD the professional diagnosis will tend to agree with you. If you believe you don't have ADHD the assessment will also align with you too.

The validity of the diagnostic appraisal is questionable, this means is it really doing what it's supposed to do?

However it's essential to have a psychiatric diagnosis if you want medical, financial or social support in the UK. Symptom severity (mild, moderate, or severe) and it's interference with daily functioning is the required outcome of a diagnosis.

It's helpful to understand the diagnostic process because is sheds more light on the nature of ADHD.

The DSM has been critised for pathologising natural human responses to trauma and other neurological experiences.

Recently the British Medical Journal (BMJ) reported that 100% of the DSM ADHD expert panel took undisclosed payments from pharmaceutical companies.

Both of these points call into question the efficacy of the DSM diagnostic criteria.

Firstly the potential bias of 'experts' given their big pharma under the table payments. This process lacks impartiality when it comes to ADHD indicator descriptions and what to include as the diagnositic criteria. This process determines treatment protocols, namely the drugs recommended for symptom management. Interestingly although emotional dysregulation is a very common and significant symptom and a key focus in understanding and managing adult ADHD. It is not a formal diagnostic criterion. Currently there are is no medical treatment that allows us to take a pill and turn the nervous system off or on, other than benzos and other nervous system suppressants.

Secondly, there are significant gender differences in symptomatic behaviour presentation of ADHD, this may be explained by other factors rather than ADHD. Increasing awareness of it's interactions with other biological processes, for example neuro-endocrine fluctuations of puberty, postpartum, perimenopause and menopause. This means normal daily, weekly, monthly changes will affect our symptoms depending on the sensitivity of our brain and nervous system. Whereas anti-depressants is often offered to midlife neurodivergent women, there is the realisation that they may have adverse affects (stimulating hormones) and other types of treament may help manage ADHD symptoms.

Women also take on more stress from carrying the brunt of emotional demands such as aging parents and supporting young adult children. We put others emotional needs before our own and typically mask our anger and resentment. This could be more of a lifestyle issue rather than pathologising reactions to normal life events.

The critical issue is the lack of research on ADHD in women and that our biology has been ignored. Our nervous system is regulated very differently from men.

Management of ADHD at Midlife

ADHD may not be cured just yet. Every woman will require a unique response to symptom management dependent on her neurological and endocrine systems and the existence of co-occuring conditions, many of which will also affect the autonomic nervous system. For example Endometriosis has such an effect and is thought to directly affect our blood pressure, digestion, breathing and heart rate. Which increases stress and inflamation and inturn may affect ADHD symptom expression.

There is emerging evidence that the HPA Axis is the engine of neurodivergence including ADHD. This is the foundation of our regulatory system including circadian rhytms, mood, inflamation and metabolism. In particular homeostatis it is harder to achieve and easier to lose in ADHD women. There is a complex interaction with our endocrine system, given the daily, weekly, monthly, seasonal, life time shifts. Neurodivergent women experience more sensitivity in their calibration.

Given the complexity of ADHD in women a coherent full body and lifestyle approach is recommended including:

• Structuring and consistent routines to provide stability and motivation. 

• Regular physical activity to improve focus and mood. 

• Adequate sleep a d regular bedtime routine

• Diet that stabilises blood sugar

• Supplements can help with specific symptoms, (be aware that some supplements can interact with ADHD and other medications), examples include:

  • Omega- fatty acids - can improve focus and cognitive skills

  •  Magnesium can manage hyperactivity, irritability and improve sleep

  •  Iron is essential for brain function and dopamine production

  •  B Vitamins Including B6, B9, and B12, support neurotransmitter production in the brain,

    Plays a role in brain function and may improve symptoms like impulsivity and hyperactivity. 

• Medication for ADHD tends to address the cognitive effects and the behavioural symptoms such as hyperactivity and restlessness. Stimulant and non-stimulant can improve cognitive functioning including focus, reduce impulsivity, and control hyperactivity. Around 70% of adults report improvements in symptoms, (no gender differences reported and no longer terms studies).If the medication works it can dramatically affect how we feel about ourselves and therefore reduce anxiety and improve emotional regulation. There is an increasing call from some in the medical profession to prescrible bio-idential hormones HRT to address ADHD symptoms at midlife. This may require specialised medical advice as HRT can affect co-existing conditions such as endometriosis (we are often outliers in the medical system given the number of co-occuring conditions.

• Co-regulation. This means ADHD women need to choose their community, as sensitive social creatures we are more susceptible to toxic human interaction and this will furthe dysregulate our nervous systems. A good womens circle has a strong facilitator!

• Finding ways to nurture and learn about our body is important but also rewiring our brain physically and psychologically. For example, rituals involving breathwork, mantra, prayer, chanting, drumming and singing not only feel good in the moment but also rewire our nervous system. Because ADHD thrives on novelty and new experiences, finding ways to enjoy this is important such as creative pursuits like art, crafting and drama. Likewise unless necessary avoiding experiences that are procedural and lack initiative or imagination, it drains our energy and does not play to our strengths.

Notes on HPA axis

To calibrate the HPA axis, or the hypothalamic-pituitary-adrenal axis, lifestyle changes include:

• Reducing chronic stress through meditation, yoga, and breathing exercises,

• Nutritious diet - micronutrients, adaptogens, and nervines, along with staying hydrated

• Moderate exercise

• Adequate sleep

• Practicing gratitude

• Accepting what you cannot control

• Setting and maintaining healthy boundaries

• Addressing underlying infections 

• Strong social connections.

• Mental health support systems to manage stress and emotional challenges. 

What is most important is having a consistent application of these healthy lifestyle practices to restore calibration on a daily basis, often it may be several times a day!

Medical approach to HPA axis regulation

There isn't a single "on/off" pill for HPA axis regulation because it's a complex, dynamic feedback system with long-term changes in gland functional mass, making it resistant to simple pharmaceutical fixes. Additionally, existing HPA-targeting drugs have shown poor efficacy and side effects, failing in chronic conditions like mood disorders due to compensatory changes in the glands that existing drugs do not address. 

The HPA axis is:

• A Dynamic System: The HPA axis is a system of interconnected glands (hypothalamus, pituitary, and adrenal glands) that form a sophisticated feedback loop.

• Functional Mass Changes: When the HPA axis is chronically activated by stress, the endocrine glands can change their functional mass, which means their physical size and activity level. These changes are not easily reversible by drugs that only affect hormone levels.

• Compensatory Mechanisms: The glands' functional mass changes can compensate for or override the effects of HPA-targeting drugs, leading to drug failure in chronic conditions. 

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Challenges with Existing HPA-Targeting Drugs

• High Failure Rate in Clinical Trials: Many drugs that aim to modulate the HPA axis have failed in clinical trials for mood disorders and other chronic conditions.

• Inconsistent Results: The efficacy of these drugs for conditions like major depressive disorder (MDD) remains uncertain.

• Adverse Effects: Some approaches, such as glucocorticoid antagonists, have led to significant side effects, including immune suppression and the potential for adrenal insufficiency if treatment is abruptly stopped. 

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Future Directions

• Targeting CRH: Mathematical modeling suggests that targeting corticotropin-releasing hormone (CRH) synthesis or its receptors could be more effective.

• Investigating Other Targets: Research is also exploring other potential targets, such as the vasopressin 1B (V1B) receptor.

• Identifying Biomarkers: There is a need for tests that can identify patients whose HPA axis is dysregulated in ways that would respond to specific treatments, leading to more personalized medicine.