From job opportunities to personal income to marital relationships, there’s hardly an area in which American women haven’t made great strides in recent decades. But when it comes to getting diagnosed with and treated for ADHD, women still have a long way to go.
ADHD in Women
Women are as likely as men to have ADHD, and the latest research suggests that ADHD in women causes even greater emotional turmoil. Despite widespread improvements in the diagnosis and treatment of ADHD, some professionals still may harbor the belief that attention deficit hyperactivity disorder is something that primarily affects boys and men — not girls and women. Consequently, women with ADHD are more likely than men to go undiagnosed (or misdiagnosed), and less likely to receive appropriate treatment.
“ADHD is still presumed to be a male disorder,” says Fred Reimherr, M.D., director of the University of Utah Mood Disorders Clinic and the lead author of a recent study that found that ADHD has a disproportionate impact on women. “The women had a much more frequent history of having been diagnosed with other emotionally based psychiatric illnesses, such as a mood disorder or anxiety. I think those symptoms are often the things that a physician treating adults focuses on. A woman might come in presenting emotional symptoms, and the ADHD that’s underneath might be missed.”
Girls Versus Boys
Underdiagnosis of ADHD in women has its roots in childhood. Girls with ADHD tend to try harder than their male counterparts to compensate for and cover up symptoms. To keep up their grades, girls are often more willing to put in extra hours of studying and to ask their parents for help.
In addition, girls are more likely to be “people pleasers,” doing all they can to fit in — even when they know they are “different.”
Teachers are often the first to identify the signs of ADHD in children. Yet because some teachers still think of ADHD as a male disorder, they tend to suspect the disorder in boys but not girls. This is true whether girls exhibit the hyperactive (can’t sit still), the inattentive (daydreaming in a corner), or the combined version of the disorder.
“Most people have a misperception that ADHD is a disorder of hyperactive elementary school-aged boys,” says Patricia Quinn, M.D, a developmental pediatrician in Washington, D.C., and a leading expert in gender aspects of ADHD. “When they see behaviors in girls, even disruptive behaviors, the girls still go undiagnosed.”
Clinical psychologist Kathleen Nadeau, Ph.D., runs a private clinic in Silver Spring, Maryland, that specializes in the diagnosis and treatment of ADHD and learning disorders. She says that she sees many cases in which women come to suspect that they have ADHD after struggling for years to balance the responsibilities of a job, a home, and child rearing.
Some women come to suspect what’s at the root of their problems after seeing a report of ADHD in the media. Other women begin to suspect they have ADHD after a child of theirs has been diagnosed with the disorder.
In any case, many of the women who consult Nadeau do so only after months or years of frustration during which doctors were unable to provide relief for their problems.
“The most common diagnosis of a woman before she receives her ADHD diagnosis is depression,” says Nadeau. “So many women have come in to my office and said, ‘I’ve been in therapy for years and I’ve been diagnosed with anxiety and depression, but I am still having problems.’ It’s maddening, and it’s such a treatable disorder. There’s no excuse for that.”
According to Nadeau, many women go undiagnosed because the criteria doctors use to diagnose ADHD are outdated. For example, the criteria indicate that ADHD is to be considered as a potential diagnosis only if the patient has experienced significant symptoms from an early age. Yet, as doctors are starting to realize, many girls with ADHD “fly under the radar” during early years with the disorder.
One Mother’s Story
Rachael Hall, a 26-year-old mother of three from Sandy, Utah, spent years struggling with anxiety and depression — and never knew why. Whenever anything went wrong in her life, she overreacted.
Hall, a patient at Reimherr’s clinic, recalls falling apart during her honeymoon because she couldn’t decipher a set of driving directions: “I told my husband, ‘Why don’t you just leave me? I’m worthless.’ One little thing would just blow out of proportion. And then I would start to feel guilty afterward, and the more guilt I felt, the more depressed I got.”
The stresses of motherhood made things even worse for Hall. While she was expecting her third child, she broke down and was hospitalized for depression. Doctors prescribed an antidepressant. “It didn’t work at all,” she says. “It made it like I didn’t care. It took away everything. I didn’t feel happiness. I didn’t feel sorrow.”
After the birth of her daughter, Hall began experiencing frequent outbursts of anger. “One second I would be fine, and the next second I’d be a raging banshee,” she recalls. “I was so mean to the people I cared about. I couldn’t do it anymore.”
Hall thought she might be suffering from postpartum depression. But her obstetrician ruled that out, saying it was too long past her delivery date for that to be a possibility.
One day, Hall saw an ad for a mood disorders study at Reimherr’s clinic. She decided to enroll.
“I got frustrated at first,” she recalls. “I told my husband, ‘Well, I must be on a placebo, because it’s not working.’ Then as soon as I started into the second five weeks, I noticed a difference.”
She didn’t know it at the time, but during the second five weeks, she was taking the ADHD medication Concerta. The medication seemed to make her thinking “more logical.” She was less forgetful, less edgy. “I’m just generally in a better mood,” she says. “I feel happy. I don’t blow things out of proportion.”
Since continuing with treatment, Hall’s relationship with her family has improved, and she no longer feels awkward in social situations. “I’ve always been the hyperactive, talkative, center-of-attention type,” she says. “I’m a very friendly person, but to the point where I would embarrass myself. Now I’m able to be the center of attention and be funny and have people like me, but not to the point that I become obnoxious.”
Pressure to Perform
Nadeau says Hall’s experience is far from unique. “The pressure on women to be organized, self-controlled, to be the one who’s keeping everybody else organized, is a societal expectation that’s very deeply ingrained,” she says. “Women feel very much a failure if they can’t keep their house in order. There is a tremendous toll of having to keep up appearances, struggling, having embarrassing moments. Things like, ‘I forgot to pick my kids up after soccer practice, and they were the only ones left standing out there.’ It’s a very public failure, and women are often not forgiven for these types of things. With a man, they’ll say, ‘Oh he’s so busy, of course he forgot.’”
Quinn agrees, adding that the very fact that a woman senses that she is “different” from her peers is often difficult to bear.
“She may, for example, develop anxiety, demoralization, low self-esteem, and looks depressed,” says Quinn. “So she’s painfully aware. She really does suffer, but she suffers silently.”
Financial Costs and Missed Opportunities
As if emotional problems weren’t enough, ADHD may also bring significant financial costs.
“You’re constantly paying for your disorganization and forgetfulness,” says Nadeau. “You’re losing your glasses, so you have to buy a new pair. You get a parking ticket because you lost track of time and the meter ran out. Things like that may happen frequently in the life of someone with ADHD.”
Lyle Hawkins, a 59-year-old mother of three, long suspected that she had ADHD, but didn’t get diagnosed or treated until age 40. She regrets all those years of being misperceived as lazy and careless. But most of all, she laments lost opportunities. Hawkins married right out of high school, but she feels that she likely would have gone to college instead if she had been effectively diagnosed and treated in her early years.
“I was from a very educated family, where education was really important,” says Hawkins, a patient of Dr. Reimherr’s, who is also from Sandy, Utah. “But college would have been too stressful. When you have attention deficit, everybody’s on page 10 and you’re on page three.”
Hope for the Future
The medical community is waking up to the fact that ADHD is a big problem for girls and that the condition often persists into adulthood, says Nadeau. For now, she says, any woman who suspects she has ADHD should educate herself about the condition — and consult a mental-health professional who specializes in the field.
Quinn says a doctor’s credentials matter less than his or her understanding of, and experience with, treating ADHD in women.
“Many women find that their general practitioner, if he treats ADHD in older adolescents, can be helpful,” Quinn says. “Usually a psychiatrist or a therapist is the best equipped to diagnose the disorder in women.”
If a woman is feeling depressed, it makes sense for a doctor to diagnose her with depression and treat her for it. But if she has reason to believe that there is more to her problem (or if procrastination, time management problems, and forgetfulness persist, despite treatment for depression), it may also make sense to question the diagnosis — and to persist in questioning until she gets relief for her symptoms.
Should she switch doctors? Says Quinn, “She should switch if she is not being listened to, if her point of view is not being acknowledged or respected.”
Even when the diagnosis comes late in life, women know how to use their new awareness to their advantage. Lyle Hawkins, the 59-year-old mother of three, recognized many of her ADHD behaviors in her children. Not wanting them to go through the same thing, Hawkins made sure they got diagnosed — early. “If they had not had me for a mother,” she says, “they would have fallen through the cracks.”