Sandra N. Crespo, LICSW, is Clinic Director at Columbia Mental Health’s North Bethesda location. As a licensed clinical social worker, professor, and neurodivergent leader, she brings both lived experience and clinical insight to her work. In this conversation, Sandra shares her thoughts on how ADHD shows up across gender and age, what treatment can look like, and what she hopes individuals living with ADHD understand.

ADHD is not a deficit—it’s an interest-based nervous system

Some people assume ADHD just means not paying attention. Is that true?

Sandra: I think that is one of the biggest misconceptions—that ADHD is just not paying attention, right? I think ADHD isn’t a lack of attention. It’s like an interest-based nervous system. People with ADHD pay attention to everything or nothing, depending on whether it sparks them. And it’s interesting—there’s a lot of conversation around the actual title of the diagnosis, where it focuses on a “deficit,” right? ADHD stands for attention-deficit hyperactivity disorder, whereas it’s more an issue of executive functioning and paying attention to too many things at once, which creates that paralysis in executive functioning. It certainly shows up differently in kids than it does in adults. But that’s how I would describe it—really more of an interest-based nervous system. It’s a very interesting way of looking at ADHD.

Treatment that adapts to the client

Do you treat both children and adults who have ADHD?

Yes. At Columbia Mental Health, we see the full lifespan. We see everyone from kids navigating school to adults juggling work and relationships and everything in between. It’s a true mix. What we have noticed (and I don’t want to call it a trend, but it has increased) is the number of adult women receiving late diagnoses of ADHD. That process, from the outside in, is a beautiful thing to see:

An individual comes in seeking more understanding of why they are the way they are, and a couple of months later they really have a grasp on the wiring of their brain and understand that they’re not broken.

And so it really depends—we curate treatment exactly to what the client needs.

What therapeutic approaches do you use for adults with ADHD?

Once we tailor the tools and approach to the individual, some of the things we bring to the table are knowledge around cognitive therapy. Cognitive-behavioral therapy (CBT) is one of them, and we also use REBT—rational emotive behavior therapy. ADHD brains tend to be very analytical, and an approach like REBT really centers the metacognitive process of their own ways of thinking—it’s kind of like teaching them to think about their thinking. How do you get to the source of either the overthinking or a thought that may not be based on evidence? What are your actual choices, and what control do you have in the situations you put yourself in? Those kinds of strategies tend to work well, along with a lot of psychoeducation around their ADHD diagnosis, infused with some lifestyle coaching.

For adults, ADHD treatment often doesn’t involve traditional therapeutic intervention as much as coaching. The therapy piece comes in because they’ve often been living with this brain for so long, and maybe it was identified but not treated, or not identified at all, and that can cause a lot of other co-occurring issues. We have adults who have developed anxiety or depression, to name two of the bigger ones, and that requires understanding and therapeutic intervention. Once someone gains an understanding of their ADHD—realizing you’re not broken, this is why you do the things you do—then we’ll say, “Okay, now let’s focus on your anxiety and learn how to regulate that with this new understanding. How is it impacting your depression?” That kind of supplemental knowledge is really, really helpful in their journey.

Meeting young clients where they are

How do you approach ADHD treatment for children?

Now, for youth, it’s really about playing to their strengths and interests. One therapist here is a certified art therapist, and she uses art—and not just painting, but art in many different forms. She uses music and play therapy and just infuses all of it into how that child works. Sometimes kids haven’t been exposed to these outlets, so initially they’ll reject it. She works with that engagement and building the buy-in.

Half the time, we use these creative modalities instead of traditional talk (narrative) therapy, because a lot of times for children (and even adolescents), narrative therapy isn’t helpful. The ADHD brain can be so dysregulated that their topics are all over the place, and they don’t always know what to focus on—sometimes they don’t even have the language to identify what they’re feeling at that age. Giving them different means of communication is helpful. We build treatment plans with all of that in mind.

How ADHD can be misunderstood in adult women

How does ADHD tend to affect adult women, and why do their symptoms often get overlooked?

When we’re talking specifically about adult women, they do get overlooked because their symptoms tend to be much more internalized. There’s a lot of chronic overthinking and emotional overwhelm, rather than the disruptive behavior we might expect when thinking about ADHD.

It’s not something that magically goes away in adulthood—it just shows up differently. At its core, ADHD is a dopamine deficiency, right?

As an adult woman with unidentified ADHD, when you finally get that information and understand your brain, it’s like a massive weight is lifted.

There’s a little bit of mourning there, but the understanding and clarity they get allows them to breathe for a second, because they’ve been up against this hierarchy of societal norms. They’ve had to “keep it together.”

It plays out in their relationships. Sometimes women find themselves stuck in a pattern of unhealthy relationships where they might confuse peace and healthy stability for boredom—because again, it goes back to that dopamine deficiency. Arguments and chaos can inadvertently provide that dopamine rush.

It’s hard as an adult, as a woman specifically, because you’re expected to keep it together. If you’re a mother, if you’re a professional—in all these roles you’re supposed to hold it together.

A child has permission to act out and people say, “Oh, they’re just young,” but as an adult woman, what’s your excuse? Why don’t you have it together? So when things finally do blow up—in whatever space, at home or work—it’s seen as, “You need to get help; you need to fix this,” because it isn’t okay. And the truth is, it isn’t okay only because you’re trying so hard to fit into this particular box that wasn’t made for you. You’re trying to figure it out without the right language, so you end up just acting how you feel.

There’s also a cultural lens. ADHD in women can show up differently in cultures where there’s a heavy expectation that the woman is the backbone of the household, and we’re taught not to ask for help—“don’t air your dirty laundry.” It becomes a very internalized, chaotic journey.

You end up feeling like you’re the only one experiencing these things, because you don’t allow yourself to ask for help or even to ask, “Hey, is anybody else drowning here? I can’t be the only one.”

There’s so much tied to the biology of being a woman, and to our emotional state, that we have to fight against. We’re constantly trying to prove that we are okay to do certain things, instead of being allowed to exist as we are. We are different, and it’s okay. It’s not good or bad—it’s just different.

You’re not broken—you’re wired differently

What advice do you have for someone who thinks they might have ADHD?

First, I want them to know: you’re not broken. A lot of times—and this was true in my own journey when I came face to face with my ADHD diagnosis—I felt like my brain was broken, like it just didn’t work right. Sometimes I wanted it to do something and it just wouldn’t, and I couldn’t explain why. And when I tried to explain my struggles, it sounded like I was making excuses. It wasn’t until I learned more about my brain that I realized I’m simply wired differently.

What I’d say to anyone wondering if they have ADHD is this: You’re not broken—you’re wired differently, creatively, intuitively, energetically. The 9-to-5 world we live in is us trying to fit into something that wasn’t designed for us. We have to find structures that flex with us and discover what our personal rhythm is. Our brain isn’t “lazy” or “wrong”—often we just experience time and focus in a different way (time blindness is a real thing for us). Your brain might be operating in a slightly different time zone, so to speak.

I really encourage anyone who has noticed ongoing challenges with focus, organization, or other patterns in their daily life to pause and take a look at those patterns. Look back at your history and identify if there are consistent signs. If there are, consider exploring the possibility of ADHD. Talk to a professional and try to understand how your brain works. That’s the biggest thing: understanding how you’re wired.

When you understand your brain, it gives you so much more grace for yourself.

Find ADHD support at Columbia Mental Health

If this has resonated with you know that you’re not alone and you’re not broken. Whether you’ve just begun to wonder about ADHD, or you’ve carried a silent weight for years, there is support. There’s language to explain what you’ve been experiencing. There are tools that can help you thrive not in spite of your differences, but because of them.

As Sandra reminds us, ADHD isn’t a failure of willpower, it’s a difference in wiring, in rhythm, in how we experience the world. And that difference can be a source of insight, creativity, and deep connection, when it’s understood and supported.

At Columbia Mental Health, we meet each client where they are. That means offering a range of approaches, from cognitive strategies and psychoeducation to art therapy and coaching. It means treating clients across the lifespan, across cultures, and across every stage of their diagnostic journey and it means holding space for complexity, grief, and growth, especially for those who’ve spent a lifetime trying to “hold it together.”