When psychologist Stephen P. Hinshaw, PhD, published two studies on attention deficit hyperactivity disorder (ADHD) in girls last October, psychologist Kathleen Nadeau, PhD, was excited that women with ADHD were finally starting to receive the attention that the researchers had been waiting for.
"Hinshaw is one of the first to study the girls themselves," Nadeau says of the lead author's paper, published in the Journal of Consulting and Clinical Psychology (Vol. 70, No. 5). "Most of the few previous studies have focused on comparing girls to boys, using boys' ADHD symptoms as the marker against which girls should be measured."
For Nadeau, Hinshaw's research confirmed what he had observed clinically for years: "that girls experience significant difficulties that are often overlooked because their ADHD symptoms bear little resemblance to those of boys." It was also a sign for her to push herself even harder to raise awareness of the needs of women with this disorder. Through advocacy and innovative research and writing, Nadeau and a small group of psychologists are fighting to move women's ADHD issues from the fringes of research to center stage.
"Historically, ADHD research has focused almost exclusively on hyperactive children, and only in the last six or seven years has any research focused on ADHD in adults," says Nadeau, an expert on the disorder in women and director from Chesapeake Psychological Services. of Maryland in Silver Spring. "And recognition of women [with the disorder] has been further delayed."
According to Nadeau, this delay in recognition by girls and women is due to current diagnostic criteria, which remain more appropriate for men than women, and parental and teacher referral patterns, stimulated by more male ADHD behaviors. obvious and problematic. Some deny that the disorder exists in women, or in anyone else.
Researcher and educational therapist Jane Adelizzi, PhD, theorizes that researchers have largely overlooked women with ADHD because hyperactivity is generally absent in girls, who often have attention deficit disorder (ADD), the inattentive type of ADHD. But for advocates, the bottom line is this: Girls with undiagnosed ADHD are likely to carry their problems into adulthood, and if left untreated, their lives often fall apart.
"Girls with untreated ADHD are at risk for chronic low self-esteem, poor achievement, anxiety, depression, teen pregnancy, early smoking during middle and high school," says Nadeau.
As adults, they are at risk of "divorce, financial crises, single parenting of a child with ADHD, never finishing college, underemployment, substance abuse, eating disorders, and constant stress due to difficulty managing the demands of daily life, that spill over into the struggles of their children, 50% of whom probably also have ADHD," adds Nadeau.
"Girls with ADHD remain an enigma—often overlooked, misunderstood, and hotly debated," says Ellen Littman, PhD, one of the first psychologists and researchers to focus on gender differences in ADHD and in advocate for a reexamination of how the disorder is defined.
Littman theorizes that girls with ADHD are not identified and helped early in their lives because male patterns of ADHD have been overrepresented in the literature. "As with all diversity issues, the danger is in assuming that these more typical patterns characterize all children with ADHD," says Littman, who runs a clinical practice in Mount Kisco, New York. "So while there seems to be a great deal of information out there about ADHD, we may be under the false feeling that we know more about girls' experience with ADHD than we really do."
More research on gender issues in ADHD is needed for a number of reasons, says Julia J. Rucklidge, PhD, an assistant professor of psychology at the University of Canterbury in Christchurch, New Zealand, who has studied ADHD in Canadian women. "We can't make assumptions that what applies to men will apply to women—women have different hormonal influences to begin with, which can greatly affect their behavior." Also, Rucklidge says, women are socialized differently and therefore tend to express themselves differently and are more susceptible to issues like depression or anxiety, which again influence behavior. This suggests that ADHD "will manifest and express itself differently in women," she says. "But only research can tell us that definitively. Until then, these are assumptions we make."
the mom factor
Many women are in their 30s and 40s before they are diagnosed with ADHD. “One of the most common ways for a woman to be diagnosed is for one of her children to be diagnosed. She starts educating herself and recognizes characteristics in herself,” says Nadeau. "These women [usually] are going to be older," because boys are usually diagnosed with ADHD in high school.
Women with ADHD often have tremendous time management challenges, chronic disorganization, feelings of stress and overwhelm, difficulties with money management, children or siblings with ADHD, and a history of anxiety and depression, says Nadeau, who didn't acknowledge her. . she has ADHD through middle age and has a daughter and brother with the condition.
The disorder is typically treated with a combination of stimulant medication and ADHD-focused psychotherapy, "that is very structured, goal-oriented, and uses a lot of 'coaching' techniques as well as standard psychotherapy techniques," Nadeau says. "Women, more than men with ADHD, struggle with low self-esteem, and this should be the main focus of therapy," she adds.
Many of the women who come to neuropsychologist Mitchell Clionsky, PhD, for ADHD testing fit the typical profile. A 42-year-old patient diagnosed with ADD was referred by a psychiatrist who was treating her for depression. Her marriage was in trouble and she had low self-esteem, says Clionsky, co-founder of the ADD Center of Western Massachusetts in Springfield. Since childhood, the patient thought that she was lazy and irresponsible because she did not finish the things that she started. A "very smart woman," she completed a few years of college and "probably would have gone further if her problem had been identified earlier," she says.
The tragedy is that "these are people who are significantly underperforming and [who] end up going down the path of depression, mostly as a result of failure in life," Clionsky says. "It's like they're running the race of life with lead weights around their ankles."
Some psychologists are building the literature on ADHD among women. Julia Rucklidge began studying the field while pursuing her PhD in psychology at the University of Calgary in Alberta, Canada. "When I started in 1995, there was very little research in the adult population [and] maybe one or two studies looking specifically at women with ADD," she says.
Rucklidge, with her colleague Bonnie Kaplan, PhD, studied 102 women between the ages of 26 and 59, with an average age of 41. Half of the women surveyed had ADHD and half did not. All of the women in the study had a child with ADHD, so all of the subjects could relate to the stressors involved in raising a child with the disorder.
Rucklidge's findings, published in the Journal of Attention Disorders (Vol. 2, No. 3) and Journal of Clinical Psychology (Vol. 56, No. 6), shed light on the experiences of women diagnosed in later life:
Women with ADHD were more likely to have a "learned helplessness style" of responding to negative situations than women without the disorder and tended to blame themselves when bad things happened.
Women with ADHD likely believed they couldn't control the outcomes of life events, creating a vicious cycle, Rucklidge reports. "A woman with ADHD is less likely to push herself to finish challenging tasks because of the belief that she is powerless to change the negative outcome. By giving up, she further reinforces the belief that she is powerless to accomplish things in life." . she says.
Women with ADHD were also more likely to report a history of depression and anxiety. They were also more frequently in psychological treatment and received more prescriptions for psychotropic medications than women without ADHD.
Jane Adelizzi's research explored an underexplored area of ADHD: its similarity to post-traumatic stress disorder (PTSD). Three of her studies looked at women diagnosed with attention and learning problems who also had PTSD symptoms as a result of classroom trauma, which she defines as a significantly unpleasant or stressful external event that occurs within the confines of an educational setting. which is psychological. nature.
"As a result of classroom trauma over the years, some women develop a set of symptoms that are recognizable - by some professionals - as post-traumatic stress symptoms," reports Adelizzi, coordinator of the Adult Center, Program for the Promotion of the Learning at Curry College in Milton, Massachusetts. "These symptoms are also similar, very similar, to ADHD behaviors and symptoms."
It's not always clear which comes first—PTSD symptoms, ADHD symptoms, or trauma, Adelizzi says. But, she argues, these women's ADHD symptoms cannot be avoided without examining the coexisting panic and anxiety that can be triggered many years later, if, for example, they decide to go back to school.
In addition to driving more research on gender issues, these psychologists use a variety of forums to raise awareness of ADHD in women. With pediatrician Patricia Quinn, MD, Nadeau recently founded theNational Center for Gender Issues and ADHD(NCGI) to promote awareness and research on the disorder in women. Nadeau and Quinn also developed Advantage Books, an ADHD specialty publisher, and co-edited several volumes on ADHD issues in girls and women (see Further Reading). Nadeau is also editor of ADDvance Online News, NCGI's monthly electronic newsletter.
"We're doing cutting-edge advocacy," says Nadeau, who has lectured on the subject nationally, as well as in Norway, Japan, Puerto Rico and Germany, and has discussed the issue in popular media, including in " Today" on NBC. Show."
Networking is also a crucial part of Nadeau's advocacy work. She has formed alliances with national ADHD groups, including the Association for Attention Deficit Disorder and Children and Adults with Attention Deficit Hyperactivity Disorder.
Since the 1990s, Adelizzi has led support groups for women with ADD, and other learning disabilities, trying to get into college. She also teaches seminars and has developed two certification programs for professionals who work with women with attention disorders and others. She and she continues to study these women, most recently observing how they express their emotions through art.
In addition, Littman and Nadeau are pushing for changes to the next edition of the Diagnostic and Statistical Manual of Mental Disorders.
"I hope that psychologists, especially those who specialize in adult ADD issues, will play an active role in advocating for more appropriate diagnostic criteria, for adults and especially for women, before the DSM-V is published," Nadeau says. "I hope these issues are addressed at the [next] APA convention in an open way: many people's lives are at stake."