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ADHD in Women by Tara Hayes

She’s a neatly coiffed professional, driven and successful; a middle-aged woman still under the roof and thumb of her mother; a teenage drug addict angry at the world; or a 20-something with a condo and a firm grip on her job. She could fit the profile of any number of women who are making their way through life accompanied by a label, and the condition known as ADHD.

WHAT IS ADHD?

ADHD (attention deficit/hyperactivity disorder) is a neurobiological condition, having to do with the brain and nervous system. “That means it’s a medical problem,” not a psychological one, stresses Dr. Ted Mandelkorn, one of the preeminent medical doctors treating ADHD kids and adults in the Northwest.

ADHD is the revised term for ADD — attention deficit disorder — to encompass the hyperactive symptoms it can produce. However, many people still refer to the disorder as ADD. The label aside, it’s about much more than lack of attention; ADHD interferes with a person’s executive function: the use of short-term memory, the ability to plan and to organize.

There are a lot of analogies for ADHD. It’s like not having enough filing cabinets in the brain, like squinting to see without glasses, or like listening to a static-filled radio station. People with ADHD have trouble filtering what’s happening now, pulling up information about the past, and projecting into the future.

While researchers have yet to pin down the definitive causes, studies show that the factors contributing to ADHD include brain anatomy (a disturbance in the areas of the brain that control the executive functions); genetics (there’s a better than 50 percent chance that people with ADHD inherited it from their parents and that they will pass it on to their children); and brain chemistry (people with ADHD have trouble with the chemicals that send messages through the brain). Estimates for the number of people with ADHD vary widely. Dr. Patricia Quinn, a developmental pediatrician in Washington, D.C. and a pioneer in the study of women with ADHD, estimates that the disorder affects 8 to 12 percent of the general population. But it’s not always easily identifiable. “Some are high-energy, and others are laid back, look really flaky,” says Cynthia Hammer, former director of the national nonprofit organization Attention Deficit Disorder Resources and a local ADHD coach who has the disorder herself. The symptoms are chronic, but often inconsistent. Yet it’s clear that, as a part of brain function, ADHD continues throughout the lifespan; there is little evidence to indicate it goes away when people grow up.

The misleading thing about ADHD is that the symptoms — impulsivity, hyperactivity and distractibility — are things that all people experience. Everyone has periods of disorganization, stress or forgetfulness. The difference with ADHD is that these periods occur too frequently, in a pattern that lasts over a lifetime. The behaviors may be obvious, but the underlying cause is invisible.

WHAT DOES ADHD IN WOMEN LOOK LIKE?

That women present their ADHD differently — from boys, men, and girls — is well-documented anecdotally, but little researched. Part of it is not a mystery, says Dr. Kathleen Nadeau, a psychologist and director of the Chesapeake ADHD Center of Maryland. Adults are engaged in different activities than children, so they present differently. Well-established gender differences, such as women generally being more socially and verbally adept, change the ADHD picture.

Though they have the same ADHD symptoms and underlying brain issues, women manifest them differently than do boys, men and girls. For example, the H in ADHD, for hyperactivity, is the symptom people most commonly associate with ADHD, imagining little boys running crazed around a classroom. That way of manifesting the symptom doesn’t apply to most women. This difference in how the symptoms manifest is what has kept women from being diagnosed for such a long time.

Women tend to have either inattentive or combined (hyperactive and inattentive) types of ADHD. A woman with the inattentive type of ADHD is often quite shy and prone to anxiety and depression, says Dr. Nadeau. She’ll tell you she has very few friends and will talk about self-esteem issues. From the outside there is very little indication of an interior struggle.

Conversely, a woman with the combined type of ADHD tends to do well socially. She is energetic but may have lots of nervous energy, get bored easily and have lots of unfinished projects.

On first meeting, Carolyn James is a friendly woman, one who seems at ease with herself and others, dresses with flair and speaks with animation. She has been diagnosed with ADHD and several other disorders, including a learning disability. She says she has few friends, and can’t seem to keep a job, ever clean her house or get anyplace on time. She lives in her mother’s house with her two adolescent sons. James says she had to learn to make eye contact with people, and still feels misunderstood and shut out of many social aspects of life.

Diane Smith* had a happy childhood, one in which she was athletic, joined in with the boys in her neighborhood, and got kudos in school for her ability to jump from one subject to another. She was even allowed to move about the classroom during lessons. As an adult, Smith developed coping mechanisms for her excess energy, hiding her hands under meeting tables while flipping a pen or snapping a rubber band to help her stay focused. But there was always a knot in her stomach.

Many women develop coping mechanisms for their ADHD symptoms, straining to keep control, but find they eventually give out under mounting pressures. When ADHD women come to see Dr. Nadeau, one of the things she most often hears is, “I feel overwhelmed.” The men she sees rarely say that, and instead focus on their careers and lack of job satisfaction. ADHD women often feel they simply can’t keep up with the demands of daily life and, in turn, feel ashamed and inadequate.

ADHD women are the “truly desperate housewives” says Dr. Quinn. In fact, being a stay-at-home mom can be difficult for a woman with ADHD; there’s no structure to help order her day. Dr. Quinn gives the example of two women, both with big life stressors — jobs, spouses and kids. But take away those stressors (a free weekend with both kids and husband out of town) and it’s the ADHD woman who still won’t manage to finish her paperwork or clean the closet she meant to tackle.

Don Baker is a Seattle psychotherapist who counsels people with ADHD and sees how often people with the disorder are told to “just get over it.” “That’s true for men,” he says, “but women really get hammered with it.” Women take this message and tend to blame themselves for their chronic disorganization, tardiness and forgetfulness, even after a diagnosis.

People with ADHD are also often told to just try harder. “What girls and women do is they try harder all the time,” says Dr. Mandelkorn. Life rewards them with more responsibility, spouses, families, full-time jobs. That little girl with ADHD grows up to be a woman with ADHD, always pushing, and setting up for a crash. She may not show it, and she may work extra hard to compensate, but it’s there, and eventually it catches up with her.

A DIFFERENT DIAGNOSIS

As a pediatrician, Dr. Quinn saw some of her female patients struggling to make the transitions through high school and college. Girls who were good students had trouble managing their lives once the supports of childhood were removed.

She also saw mothers with ADHD children who didn’t follow through on the recommendations for their kids. “There’s nothing worse than an ADD untreated mother with and ADD child,” says Mandelkorn. With its strong genetic link, a woman’s first inkling of what she has been struggling with may come when her child is diagnosed with ADHD.

Kids get referred when their behavior bothers adults, says Dr. Mandelkorn, and girls aren’t as outwardly bothersome. In her practice Dr. Nadeau saw that as the existence of adult ADHD was publicized, and mothers saw their children being evaluated, they’d say “Oh my god, that’s me.” Women started self-reporting. “They know what is going on in their heads, and they want help.”

There are times in life when a woman’s symptoms may be more severe than at others. Hormones, estrogen in particular, influence ADHD symptoms. Girls often don’t present symptoms before the age of seven (previously a standard diagnostic measurement). Instead, their problems tend to stand out when they hit puberty, and symptoms are worse at premenstrual times.

For adult women, as estrogen decreases with age and, eventually, menopause, individuals who could cope before suddenly can’t. Perhaps this is part of what happened to Carolyn James, who had a more or less steady working history for 20 years, doing a lot of secretarial work, until about 10 years ago, she says, when things just started to fall apart. Now in the throes of menopause, she has an even harder time remembering things and making it through her day.

Many ADHD women are first diagnosed with something else, like depression or anxiety, both secondary problems that result from internalizing ADHD symptoms. But the source, the ADHD, isn’t identified or treated. James was told for eight years that her main problem was low self-esteem. She received no treatment for ADHD until after a second diagnosis. Most of the women life coach Mimi Handlin sees have already been in therapy, often for years. For many women, their condition is very obvious to themselves, says Dr. Mandelkorn, but not to the outside world. And they work hard to keep it that way.

“I won’t be surprised,” says Dr. Nadeau, “if in 10 to 15 years from now we decide that ADHD is a disorder that equally affects [both genders].” For the moment though, says Dr. Quinn, “women with ADHD stay in the closet a very long time.”

FACTORS INFLUENCING SUCCESS & FAILURE

There is no one type of ADHD woman. People can fall anywhere along a broad spectrum, and one’s lifestyle and life choices have a lot to do with success. ADHD symptoms can be mitigated or agitated by environment, other mental health issues, and upbringing.

Dr. Quinn herself has ADHD. She was always very active and piled on the activities, but she wasn’t diagnosed until medical school, when she found she was still inside studying when her colleagues had finished and gone out to socialize. She would read but wasn’t focusing on what she was reading, and had to go over material repeatedly. Her diagnosis informed her future life decisions.

While diagnosis is a first step, acceptance of that diagnosis is key. Ashley Bahner got her diagnosis in first grade. She’s now 25, with a full-time job she’s proud of. She had a hard time accepting her ADHD until she was through her teenage years. “I didn’t learn to take the time to learn how it affected my life, to make it work with rather than against me. So many people don’t want it or don’t want to deal with it.” That changed when she went to college, and she was on her own. She made the decision to figure out how to work with her ADHD. “Otherwise, my life was going to be really hard, and it didn’t have to be,” she says.

Other disorders, either secondary or coexistent, also complicate the picture: Depression, anxiety, obsessive compulsive disorder, learning disabilities and drug abuse, to name a few, can be layered with ADHD. Some of the women Don Baker works with have these compound issues, and it makes treatment harder. “Even if they’re taking meds, they are really challenged. That means they don’t get out of bed, don’t work, are on disability. If they do get a job they lose their job because of outbursts or inconsistent work.”

The different roles that environment and biology play could be seen in the different experiences Smith had compared to those of her “very ADD” daughter. As a child, and without a diagnosis, Smith was surrounded by adults who lauded her differences. Later, she watched her own child ostracized at school for having ADHD. In fact, it was only when her daughter hit puberty and really started struggling, refusing to take her prescribed medication, then turning to illegal stimulants, that Smith thought to get evaluated herself. She hoped to better understand what was happening with her child.

“It’s been sheer hell,” Smith says of her daughter’s experience. She longs for her daughter’s success. She can see her potential. “She has a high energy level. If she harnesses it, it would be extremely powerful. [But] the ADD just makes it that much harder.” ADHD makes life harder and the normal stepping stones of life more difficult to navigate.

OKAY, SO WHAT NOW?

For a woman who thinks she might have ADHD, the most important thing is to go to a health care provider who is familiar with the disorder. A psychologist, a developmental pediatrician or other health care provider experienced with ADHD will conduct a thorough interview and evaluation.

Stimulant medications help many people with ADHD. Smith powered through life with a constant knot in her stomach, an eternal sense of unease. She’s been taking medication for four years now, and it works for her. “The most striking difference was that I didn’t have that pit in my stomach. I always had that. It went away.” Without the medication, she says, she thinks she would be ill by now. She sleeps better and feels calmer, more settled and able to handle the stresses in her life.

But not everyone with ADHD wants to take or can even be helped by medication. James felt little positive effect from the prescription drugs she tried. Bahner now takes a very low dose and hopes to wean herself off of it over time. Education is a major part of treatment — finding out exactly what it is a woman needs to help her cope, seeking out support groups, reading the research. Enough sleep, exercise and adequate nutrition all play a role in reducing ADHD symptoms. Some women turn to alternative therapies like body movement, acupuncture and biofeedback.

For women whose lives are closing in around them, it can be overwhelming. James, for one, doesn’t have the resources to seek private care and she’s frustrated with the mental health care system in which different providers “don’t talk to each other.” Nancy Holm, one of the first life coaches in the Seattle area to specialize in ADHD, says that it’s hard when those people who are least equipped to manage a team of caregivers are required to do so in order to receive the most effective treatment.

A phrase popular in the field of ADHD is “pills don’t make skills.” It means that once diagnosed, a grown woman who may be getting treated for the chemical deficiency portion of ADHD can now control her focus, but she may have missed significant social, organizational and other building blocks along the way.

Yet a diagnosis is a chance to address those issues. Life coaching can be a way to get some positive feedback, a source of both unconditional acceptance and accountability. This accountability, from an external source, is particularly important for people with ADHD; their brains don’t easily perform that internal monitoring function. Coaching can also provide an opportunity for people to slow down and talk with someone knowledgeable about how to build in the structure they need for their lives, but simply don’t know how.

ADHD is not easy — not easy to live with, to diagnose or to pinpoint in the brain. But, suggests Dr. Nadeau, if ADHD were entirely negative, it would have been selected out of the population. We live in a very ADHD-unfriendly time, she says. “I think we’ll come to think of it as a type of brain, rather than a disability,” and an understanding that we, and our brains, all come with a particular set of assets and liabilities.

Tara Hayes is a frequent contributor to Seattle Woman.

RESOURCES FOR ADHD

BOOKS
Delivered from Distraction, by Edward M. Hallowell, M.D. and John J. Ratey, M.D.
Understanding Women with AD/HD, edited by Kathleen G. Nadeau, Ph.D. and Patricia O. Quinn, M.D.
Women with Attention Deficit Disorder, by Sari Solden
Journeys through ADDulthood, by Sari Solden
You Mean I’m Not Lazy, Stupid or Crazy?!, by Kate Kelly and Peggy Ramundo

WEB SITES
Children and Adults with Attention Deficit/ Hyperactivity Disorder (CHADD) (links to local chapter) - www.chadd.org
Attention Deficit Disorder Association (ADDA) - www.add.org
Chesapeake ADHD Center of Maryland, Kathleen G. Nadeau, Director - www.chesapeakeadd.com
ADDvance magazine for women - www.addvance.com
The National Center for Girls and Women with ADHD - www.ncgiadd.org
ADD Resources (in Tacoma) - www.addresources.org
Pete Quily - www.addcoach4u.com (Vancouver coach, has good links to research)

©2008 Caliope Publishing Company