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Categories: Cover, 2013, February
Understanding and Meeting the Needs of Women with ADHD
by Kari Dossett, LCSW
RESEARCH SHOWS THAT ADHD IS CAUSED BY NEUROBIOLOGICAL FACTORS. This brain-based disorder may manifest in generally recognized core symptoms including inattentiveness, distractibility, disorganization, impulsivity and hyper-motor activity or restlessness. Clinicians use specific diagnostic criteria to assess and diagnose ADHD. As we learn more about the disorder, there is growing recognition that different people manifest symptoms in different ways. Some individuals deal with greater levels of hyperactivity or restlessness, while others struggle more with severe, chronic disorganization.
What factors cause these differences? It is becoming more evident that the severity and types of symptoms may be based on numerous factors, including genetics, biology, or environmental insults. One area of increased interest is the study of how gender differences manifest in people with ADHD. As more research emerges, we are seeing some stark variances in symptoms exhibited by males with ADHD and females with ADHD.
Those of us focused on ADHD are a passionate lot. We constantly seek ways to diagnose, effectively treat, and support those living with its challenges. As an adult with ADHD, a parent of a young adult daughter with ADHD, and a professional who works with people who have ADHD, I certainly fit in this category. This has been my passion for over a decade.
It is exciting to see more research on girls and women with ADHD. We are beginning to look at the impact of brain-based hormonal fluctuations and genetics, in addition to societal influences and expectations. The evidence is showing what many of us already suspected: There is significantly greater impairment and a higher risk of negative outcomes for girls and women with ADHD.
Understanding the female brain
Why are we seeing these differences? Emerging evidence supports the theory of biologically based differences in the male and female brain.
In The Female Brain, Louann Brizendine, MD, discusses genetic variances as catalysts for different cognitive perceptions, emotional reactions, and behaviors. Research is pinpointing real differences in neurotransmission of synapses, along with different levels of pruning, or changes, during biological growth and development of the sexes. Of course, many parents and professionals have observed and noted these behaviors for generations. Boys in general tend to be more active and physically aggressive overall, for example. They also tend to be more task-oriented and less verbal.
Although some might argue that solely sociological factors and influences cause these differing behaviors, Brizendine assigns responsibility to neurological processes. Discussing communication by gender, for example, she states that girls and women tend to communicate much like a “superhighway” with many twists, turns, and overlaps, whereas males tend to communicate in a more linear fashion, much like a “two-lane road.”
Although ADHD is not her focus, and in fact is not even mentioned in her book, this mainstream point is clear. Male and female brains ARE different biologically, from the time the egg is fertilized until death. I would venture this is not a surprise to most of us.
So, what does this mean as we continue to research females with ADHD? Because the needs of the female with ADHD are different, we must share this research and biological evidence with medical professionals, mental health providers, parents, and educators.
Countless girls and women struggle more than necessary due to lack of information. They and their families live day to day thinking their neurobiologically based behaviors are willful choices that reflect laziness, lack of motivation, low intelligence, or even character defects.
I know this firsthand, having lived with these judgments from myself and others throughout my life. But it was not until my daughter began to struggle socially as a young child that I began my quest to understand these issues as they related to her development.
A voracious reader, I quickly became aware of the wonderful pioneering work of Patricia Quinn, Kathleen Nadeau, and Sari Solden. Their writings, emerging websites, and chat forums focusing on females with ADHD were invaluable. They served to affirm ADHD is real in girls and women. Yet, there was still a sense of isolation. It seemed no one else was discussing it unless it was online.
I began to seek out professional and educational support, such as psychoeducational testing. My daughter has dyslexia, for which she received appropriate, science-based remediation. Yet, since many of the symptoms mimicked ADHD, time after time there were no answers regarding treatment or support for her continuing challenges.
Some of the mental health professionals we consulted, even those claiming to be ADHD experts, were clearly uneducated on the disorder as it affects girls and women. There was no indication of depression or anxiety, my daughter was receiving support at school and doing well, and thus there were “no problems” in their opinions.
I began to see more and more red flags that concerned me, however. My sweet daughter got along great with many older individuals, such as teachers, and was wonderful with younger kids. She had multiple real-life skills, a strong work ethic, accumulated hundreds of hours of community work, and was a wonderful artist and singer. Yet, she was continually dealing with friendship issues. She might have a good friend for a short time, but would invariably say or do something that would alienate her. Often we didn’t know exactly what the infraction was; she would just be shut out or excluded once again.
Many times the rejection seemed almost unbearable. Although she never completely gave up her efforts to fit in with other girls, she could never quite successfully navigate the complex female relationships and the “mean girl” minefields.
I continued to explore ADHD and search for support. If ADHD was discussed in the literature in relation to females, the focus was typically on the inattentive type. The little girl or young lady who is lost in her own internal restlessness. The quiet, “perfect student” who is typically not a behavior problem. The girl who is invisible, and who will typically not be diagnosed until at least her teen years, if she’s lucky. That clearly was not my child. It also, frankly, was not me or even my mother.
Overlooked or mislabeled
It is important to understand the differences between the types of ADHD as we know them now and how primarily inattentive girls are often overlooked. They tend to exhibit what could be called internalized, adaptive, compensatory habits. They work all night long to finish assignments their peers get done by 10 PM. They may be anxious, struggling with excessive worry, strategizing how they will get by or even be “perfect.” They are often their own worst critics. Others may not see their struggles to keep up with peers and expectations.
Treatment is crucial for these females as they can be significantly impaired by their inattentive-type ADHD across all domains of their lives. These women tend to be diagnosed, if at all, much later in life than those with combined-type ADHD.
Ironically, girls with combined-type ADHD are also overlooked by those in their lives. But I must clarify—they are not overlooked at all. How could they be? They are often loud, disorganized, and emotionally reactive, displaying hyperactivity and impulsivity. They are not overlooked, just mislabeled as tomboys, troublemakers, or wild girls. They may be misdiagnosed with other psychiatric illnesses.
Although not immune to mood or anxiety disorders, these females are at great risk for a different type of impairment than inattentive females. They tend to externalize their behaviors and suffer socially. These girls don’t sit quietly. They show the world around them their neurobiological deficits daily. As young girls, females with combined-type ADHD are more likely to be bossy or demanding. They may have problems picking up social cues and filtering their comments, hence alienating their peers. They are at risk to suffer damaging peer rejection early on. According to psychologist Stephen Hinshaw, girls with these traits tend to be less popular among their peers. This can be confusing and quite damaging to these girls emotionally, yet they may not show it. Remember, these girls tend to externalize. They may just get louder, more demanding, or reactive, thus continuing the cycle of alienation.
Due to this likelihood of being unidentified or ineffectively treated, symptoms and challenges may continue into adolescence and adulthood. Research shows that sixty to seventy percent of individuals with ADHD carry their diagnosis into adulthood. Remembering that females are underdiagnosed, it is safe to say this number may be conservative in relation to females with combined ADHD.
Girls and women with ADHD may be impulsive and restless, yet they are often naive in their thinking. They tend to be too trusting of others, while also struggling with a sense of not belonging. This puts them at greater risk for becoming involved in risky behaviors at earlier ages than their peers, including early sexual activity with multiple partners, a greater likelihood of teen pregnancies, early experimentation with substances, and immersion in criminal activity. Emotionally, girls and women with ADHD tend to be hyper-reactive as well, at times having “meltdowns” due to low frustration and stress tolerance.
Russell Barkley and other ADHD experts think individuals with ADHD exhibit, on average, thirty percent less emotional maturity and brain growth than their chronological peers. This neurobiological deficit magnifies the aforementioned emotional reactions in females, along with the impulsivity and other symptoms. It is, in a sense, a double whammy.
In addition, individuals with ADHD often have challenges with self-perception. They don’t see themselves as others do and may experience what is called “magical” or “illusionary” thinking. The girl with combined-type ADHD may firmly believe things are going better than they actually are.
This magical thinking is not simplistic or harmless optimism; it is serious misperception of behaviors and performance. This can lead to boastful verbalizations that may alienate peers and others, along with greater risk-taking, or even feeling invincible. If a girl has coexisting learning disorders or perceptual differences, she may live with greater overall functional impairment, while having less insight into her own symptoms or illness.
Discerning and embracing differences
Many clinicians who assess girls or women with ADHD will look at a description of behaviors that may include running away, issues with anger and emotional reactivity, sexual promiscuity or serial romantic relationships, substance abuse, eating disorders or other compulsive behaviors and subsequently make a diagnosis unrelated to ADHD. It is not uncommon to see girls or women with combined-type ADHD diagnosed with depression, bipolar disorder, anxiety disorder, or borderline personality disorder.
The level of incidence, let alone potential impairment, of ADHD to girls and women is not well known, even by those in the mental health or medical professions. Research shows more females are affected than once believed, even if they are not identified until later in life. The neurobiological deficits reach across all domains and developmental stages of a female’s life, potentially impacting higher education, social relationships, finances, health, career, and parenting.
As these girls grow into women, they will be expected to meet their own and society’s demands. These include furthering their education or some type of career training. Success requires self-reliance, high frustration tolerance, autonomy and organizational skills—all areas that present difficulties. The woman with ADHD is expected to identify her own areas of weakness and seek out support. This, of course, presents a significant challenge to the young woman who may be easily distracted, impulsive, and has difficulties with insight and self-awareness.
Perhaps she is on the job for the first time. The demands of today’s workplace are greater than ever, with many people responsible for increasingly heavy workloads. This situation can be overwhelming and highly stressful, feeding into ADHD’s challenges. As a therapist, I have seen many women struggle with their jobs. Those with combined-type ADHD tend to be verbally intrusive or want to “help” too much. This may create problems with coworker relationships, or worse. They may say the wrong thing, or become emotional in front of the boss, perhaps getting overlooked for advancement, or even let go. This can be especially problematic. Educational challenges may have also limited their job choices as well.
When women who have ADHD become mothers, they face some of the toughest challenges of all. By definition, the job of mother plays to areas of weakness in women with ADHD and is in contrast to every support typically recommended to this population. There is no set schedule or instruction manual, yet there are many expectations of what a “good mother” does. They are expected to not only have a productive daily routine, but to initiate it themselves each and every day. Mothers with ADHD may experience problems with shame, guilt, and a profound feeling of isolation.
The increasing research on females with ADHD is exciting, yet it is still in its infancy. We owe it to these women to get the word out and to educate them and others on the facts. I hope that someday soon we, as advocates and professionals, can truthfully say…”Yes, you have ADHD. Yes, it IS different for you. Yes, we can help you.”
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