Rethinking ADHD in Women: A Body-Aware Model for Executive Function and Cognitive Regulation

By Sarah Shore, M.S.

Traditional models of ADHD have emphasized deficits in attention, inhibition, and working memory, often conceptualized as static neurocognitive impairments. However, emerging research in affective neuroscience, embodied cognition, and self-regulation suggests a more dynamic picture: that ADHD reflects a difficulty in synchronizing cognitive control systems with the body’s arousal and regulation states. This paper explores the specific implications of this model for women, who are both underdiagnosed and underserved in ADHD research. Drawing from current findings in executive function theory, interoceptive neuroscience, and gendered masking behaviors, this paper argues that sustainable change requires interventions addressing the state-dependent nature of attention and activation, rather than cognitive strategies alone.

The Limits of the Traditional Framework

The conventional understanding of ADHD remains heavily influenced by neurocognitive deficit models developed primarily through research on boys and men (Barkley, 1997; Castellanos & Proal, 2012). These frameworks describe ADHD as an impairment in the prefrontal cortex’s executive control networks—those responsible for planning, working memory, and inhibition. While this framing captures key neuropsychological findings, it fails to explain several persistent phenomena:

The inconsistency of performance (rather than its absolute deficit) in individuals with ADHD.
The variability of symptom expression based on emotional and environmental context.
The disproportionate experience of overwhelm, fatigue, and anxiety among women with ADHD, even when they appear high-functioning.

In other words, ADHD does not simply involve “less” executive control—it involves a control system that fluctuates in efficiency depending on physiological and contextual conditions. The result is what Brown (2005) described as “situational variability of attention,” where activation depends on emotional salience or interest rather than task importance.

Women, in particular, experience this inconsistency acutely. Many report feeling that they “can’t start” tasks even when motivated, or that they swing between hyperfocus and paralysis. These patterns are not anomalies—they are the natural expression of a nervous system that must be in a certain state before cognitive control becomes possible.

State-Dependent Executive Function

Research in cognitive neuroscience increasingly supports the view that executive function is state-dependent—that is, its efficacy is mediated by autonomic regulation and emotional arousal (Arnsten, 2009; McEwen & Morrison, 2013). The prefrontal cortex, which governs planning and inhibition, functions optimally within a narrow window of physiological arousal (Yerkes & Dodson, 1908). When arousal is too low, motivation and initiation falter; when it is too high, anxiety and cognitive interference emerge.

For individuals with ADHD, maintaining this optimal window is more difficult due to altered catecholamine signaling (Volkow et al., 2009). Stimulant medications modulate this system pharmacologically, but behavioral and environmental interventions can target it through regulatory mechanisms—including movement, breathwork, sensory input, and emotional attunement.

The implications are profound: most behavioral interventions fail not because they are conceptually flawed, but because they assume the individual is already within a regulated physiological state. Cognitive strategies such as planning, time blocking, or cognitive reframing depend on access to prefrontal resources that are offline when the nervous system is dysregulated.

Why Traditional Strategies Fail Women

Most strategies taught to women with ADHD—organization systems, productivity tools, accountability structures—rely on sustained executive engagement. But for many women, especially those carrying chronic stress loads, caregiving responsibilities, and social perfectionism, the body is rarely in the calm-alert state required for those strategies to function.

Women also tend to mask symptoms more effectively, often developing overcontrolled behaviors (Ramtekkar et al., 2010). This masking comes at the expense of self-regulation: behind the facade of competence, physiological stress levels remain elevated, impairing working memory and cognitive flexibility (Liston et al., 2009).

Moreover, female hormonal fluctuations affect dopamine transmission and cortical excitability (Becker et al., 2021), compounding difficulties with focus and motivation. Thus, women’s challenges with ADHD are not simply “executive function issues” but reflect a complex interplay between physiology, stress reactivity, and social adaptation.

When an individual’s body is in a defensive or depleted state, no amount of cognitive instruction will activate the system. This explains why so many women describe cycles of “knowing what to do but not being able to do it.” The failure is not in comprehension, but in state regulation.

A Body-Aware Model of Executive Function

A body-aware framework for ADHD reframes executive dysfunction as a problem of integration—how physiological regulation and cognitive control synchronize to produce coherent behavior. Within this framework, interventions target both the top-down (cognitive) and bottom-up (physiological) processes that shape executive performance.

Physiological Regulation before Cognitive Control

Executive systems depend on the body’s capacity for regulation. Grounding techniques, controlled breathing, and brief physical activation can restore prefrontal access by modulating vagal tone and shifting arousal within the optimal performance range (Thayer & Lane, 2000).

Contextual Scaffolding

Environmental predictability and sensory design significantly influence attentional stability. Research shows that structured environments reduce decision fatigue and stabilize neural oscillations related to working memory (Cowan, 2017). For women balancing multiple roles, micro-structural routines (rather than rigid schedules) provide cognitive relief and emotional containment.

Dynamic Self-Monitoring

Effective regulation involves metacognitive awareness of internal states—what neuropsychology calls “interoceptive accuracy” (Craig, 2009). Training women to notice physiological cues (e.g., restlessness, numbness, overwhelm) allows earlier intervention and self-regulation before executive systems collapse.

Emotion-Cognition Integration

Rather than suppressing emotion, adaptive strategies integrate emotional data into executive decision-making. Emotional salience—when leveraged intentionally—can serve as a natural activation cue. This requires teaching women to reinterpret emotional intensity as a signal rather than a threat, facilitating motivation without dysregulation.

Implications for Practice

The integration of physiological regulation and executive function training represents a paradigm shift in ADHD support for women. Practically, it means moving away from purely cognitive coaching models toward multimodal approaches that include:

Real-time state tracking (interoceptive awareness and heart rate variability).
Task initiation protocols that begin with physiological activation rather than task analysis.
Regulation-first coaching sessions where body-based grounding precedes cognitive planning.
Adaptive accountability systems that account for fluctuating state and hormonal variables.

By acknowledging that activation precedes cognition, interventions can finally align with how ADHD brains actually operate in real-world conditions.

Conclusion

Women with ADHD do not fail because they lack motivation or knowledge—they struggle because the systems designed to help them ignore the role of physiological regulation. ADHD is best understood not as a static disorder of attention, but as a dynamic challenge of synchronization between body and executive function.

When regulation is prioritized, strategies that once failed begin to work. Attention stabilizes, planning becomes possible, and emotional reactivity softens. The path forward lies in bridging neuroscience and lived experience, offering women not just tools, but a new model of self-understanding that honors both their cognitive brilliance and their physiological complexity.

References (selected for conceptual accuracy)

Arnsten, A. F. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10(6), 410–422.
Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121(1), 65–94.
Becker, J. B., McClellan, M., & Reed, B. G. (2021). Sex differences, gender, and addiction. Journal of Neuroscience Research, 99(1), 3–17.
Brown, T. E. (2005). Attention Deficit Disorder: The Unfocused Mind in Children and Adults. Yale University Press.
Craig, A. D. (2009). How do you feel—now? The anterior insula and human awareness. Nature Reviews Neuroscience, 10(1), 59–70.
McEwen, B. S., & Morrison, J. H. (2013). The brain on stress: Vulnerability and plasticity of the prefrontal cortex over the life course. Neuron, 79(1), 16–29.
Ramtekkar, U. P. et al. (2010). Sex and age differences in ADHD symptoms and diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 49(3), 217–228.
Thayer, J. F., & Lane, R. D. (2000). A model of neurovisceral integration in emotion regulation and dysregulation. Journal of Affective Disorders, 61(3), 201–216.
Volkow, N. D. et al. (2009). Motivation deficit in ADHD is associated with dysfunction of the dopamine reward pathway. Molecular Psychiatry, 14(9), 927–939.