Already ten minutes late for her first appointment, Claire phoned from her car that she’d be in the office in five minutes. Fifteen minutes later, arriving flustered and embarrassed, she blurted “Oh my gosh, I left all the forms on my kitchen table, but I did fill them out” and “My insurance card? I’m sure I had it, I can call my husband, he has one, I think,” and “Could you please put money in the meter for me, I just realized I forgot and I have s-o-o-o many tickets…”
Claire came to see me about fatigue, but she also wanted to mention her concern about a possible yeast infection and her hormones and could she see the nutritionist too on this visit? She jiggled her knee constantly as she spoke, answered my questions mid-sentence, and changed the subject frequently.
Trying to address Claire’s multiple medical trajectories, I finally asked her–slowly, carefully–if she’d ever been diagnosed with attention deficit hyperactivity disorder (ADHD). “Funny you should mention ADHD,” she replied. “My best friend Sarah–she makes jewelry, sells it at art fairs, she’s got a website with pictures. What did you ask me again?”
Sarah, I soon learned, thought Claire had ADHD, but no, Claire had never been tested for it, and yes, she’d finished college, “so my ADHD can’t be that bad, though it did take me eight years to get my degree.”
I asked if she would take an online ADHD test with me. We took this one. “Well,” she laughed, “That’s the first time I’ve ever gotten a 100 on any test.”
Underdiagnosis in girls and women
Doctors can diagnose ADHD by observing the patient, asking some pertinent questions, and then walking her through the online test. If I’m in any doubt about my diagnosis, I refer patients to WholeHealth Chicago’s Dr. Janet Chandler, a psychologist who can do more extensive testing.
What doctors are learning is that there are far more adults–and especially women–with ADHD than anyone ever suspected. Until relatively recently, physicians were taught that ADHD was pretty much confined to boys and fairly easy to identify because of hyperactivity, inattentiveness, and easy distractibility. I remember being taught that the condition was rare in girls.
Current research on gender differences in ADHD confirm the disorder is underdiagnosed in both girls and women. Missed diagnoses or misdiagnosis might be due in large part to gender distinctions in how ADHD manifests itself. Women have fewer hyperactive-impulsive behaviors and more symptoms of inattentiveness, which are less disruptive in the classroom or workplace. Symptoms in girls and women tend to go unnoticed by family members, teachers, and coworkers, resulting in a gender-based physician referral bias.
Other issues cloud diagnosis
The presence of other psychiatric problems, most commonly anxiety and/or depression (whether occurring independently or as a consequence of untreated ADHD), can seriously complicate accurate diagnosis. Because ADHD symptoms are less obvious in women, a diagnosis of anxiety and/or depression is commonly made long before anyone even suggests ADHD testing.
One key researcher in this field, Patricia Quinn, MD, director of the National Center for Girls and Women with ADHD, has said “All too often, girls and women with the disorder are continuing to be diagnosed as anxious or depressed, while underlying ADHD is overlooked.” This can mean taking ineffective antidepressants and anti-anxiety medications for years without getting the anticipated positive response.
Another major factor that serves as a roadblock to proper ADHD diagnosis in girls and women is that they tend to develop better coping strategies than men. Women with ADHD live in a veritable snowstorm of sticky notes, memo books, and pushing the information they’re simply unable to remember onto their phones. Generally, an ADHD person’s workspace is chaotic (piles instead of files), and they go through life missing deadlines and appointments, forgetting overdue bills, procrastinating, and losing things like their keys and phones.
The price of their often-strenuous coping strategies is having to work extra hard to ensure that day-to-day functioning is not affected, but the effort to keep up can be physically and emotionally exhausting.
Dr. Quinn comments, “Very bright females can mitigate and mask their symptoms for many years until stressors exceed their ability to cope. These efforts come at a great cost to a woman’s self esteem and mental health.”
Missing the diagnosis in girls
A diagnosis may be missed in girls because elementary school teachers have been trained to spot hyperactivity in boys but not inattentiveness in girls. Years later, when a woman with ADHD needs to function on her own, she can refer herself to a psychologist for testing, but usually she’s already diagnosed herself with depression or anxiety.
Says Dr. Quinn: “Women often don’t know what’s wrong, and her complaints of being overwhelmed, depressed, or disorganized don’t always lead to a diagnosis of ADHD.” A woman with generalized anxiety can be seeing a psychologist or psychiatrist for years, making little progress despite refilling (inappropriate) meds repeatedly, and all the time neither patient nor therapist considers ADHD.
To make matters even more confusing, for many years doctors believed that a child with ADHD simply outgrew it–that medication could be discontinued during adolescence. This too turned out to be wrong. Children do become less hyperactive over time, but the inattention and distractibility continue unabated. Many affected adults struggle because their medication was wrongly discontinued.
Untreated men with ADHD have a real problem controlling impulsive behavior. It’s estimated that fully half of men in jail have some degree of ADHD.
Girls with ADHD grow up
Today we know that young girls can have the same ADHD symptoms as boys except for the hyperactivity. These girls are sitting quietly in class but their brains are like TV sets with a dozen channels going at once. The undiagnosed group from years ago eventually grew up and we now have an immense population of undiagnosed and untreated adult women. Experts believe 7 to 10% of the population (both sexes) probably have ADHD.
The result of this oversight? Millions of women 25 and older have been struggling through their lives impaired by their undiagnosed ADHD, and as a result they’ve experienced incredible challenges with learning.
People with ADHD endlessly hear, “You’re not living up to your potential.” They may fail to advance in their jobs (and many make frequent job changes), experience difficulties with relationships (“I always interrupted him”), and even with sex (“He could tell my mind was somewhere else when I said ‘Honey, did you know there’s a crack in the ceiling?’”).
Finally, a diagnosis
How a women are finally diagnosed with ADHD can occur in any of several ways:
- An alert psychologist or physician simply listens to her patient’s personal history along with her speech patterns (flipping from one topic to another, inattentiveness, finishing sentences, answering questions before they’re completed) and suggests ADHD testing.
- The child of an adult women with ADHD is diagnosed with ADHD and the woman recognizes she’s had the same symptoms herself.
- A friend remarks that she behaves like someone with ADHD and encourages her to take an online test.
- She’s read about ADHD herself and simply wants verification.
Most patients are relieved when they learn they have ADHD. “It’s explains so much!”
The most common way to confirm an ADHD diagnosis is to hear a patient’s own description of how she responded to medication. Like all sensible prescribing, the doctor should start with a low dose, only increasing it if needed. ADHD meds, such as Adderall and Ritalin, are designed to work fast, usually in less than an hour. A patient who takes an ADHD med for the first time will be almost immediately aware of some improvement in focus, concentration, and overall efficiency.
The phrase I hear most often in response to medication is some variation of “It’s like putting on a pair of glasses for your mind.” If a patient dislikes the way she feels on the drug, we advise her to be patient. It’s out of her body completely in a few hours.
Keeping in mind the meds for ADHD were designed for, and are mainly used by, children, both Ritalin and Adderall are extremely safe.
The sad irony of all this is that ADHD patients are often fiercely intelligent. Once they start on the drug, they’re frequently surprised by how easy learning is and how powerful memory can be. Many feel sad when they realize how different their lives might have been had someone recognized their ADHD when they were, say, seven years old.
Are there alternative treatments for ADHD other than medications? The answer is a hesitant “sometimes” for people with mild ADHD. Next week I’ll make some suggestions about using nutritional supplements and non-medical treatments like neurofeedback and even ADHD coaching via occupational therapy.
Be well,
David Edelberg, MD
In the article, there is a link for an ADD test, but the link isn’t working, Where can I find this test?
J
Thanks so much for letting us know! The link is updated, and here’s the survey that Dr. E uses frequently:
psychcentral.com/cgi-bin/addquiz.cgi
cliffmaurer
To your suggestion that ADHD is a “dubious” diagnosis, I submit to you the research evidence that not one or two, but 105 genes have been implicated in ADHD brain neurology. ADHD does not require treatment with stimulant medication (although that is certainly the fastest way to focused attention), and in fact has shown equally strong results with exercise and meditation. ADHD-specific coaching and Cognitive Behavioral Therapy (CBT) is also highly recommended. You do a disservice to those of us who live the ADHD every day and confirm once again that it is a poorly understood and often ridiculed disorder that has a higher suicide rate, higher rate of eating disorders and self harm and has been shown to shorter lifespan by an average of 13 years. Too bad there isn’t a test currently to show those “chemical imbalances” but it doesn’t mean ADHD brains don’t have pre-frontal cortex issues with executive function because of dopamine and norepinephrine deficiencies. Does Big Pharma benefit from ADHD treatment? You bet. But it’s because it took advantage of the opportunity for profit, not because ADHD is fictional.
Linda Roggli
I stumbled onto this site looking for integrative physicians. In you’re The Madness of Overmedication Madness case study you appropriately mention overmedication and how pharma controls the belief systems that most obedient traditional doctors adhere to (along with their compliant patients). Could ADHD, a “disease” of epidemic proportions that didn’t exist 40 years ago be somehow related to pharma manufactured narratives? In the NIMH’s Multisite Multimodal Treatment Study of Children with ADHD, the same study that child psychiatrists (at least those who know enough to even be aware of the study) cite as the “evidenced based” authority for providing meth based drugs that mimic cocaine to millions of children, became a long-term naturalized study. While the shorter-term results of the study was promising the long term results of continued use of these meth based drugs on kids were disastrous (for specifics on this study I encourage you to pick up a copy of Robert Whitaker’s ‘Anatomy of an Epidemic’). Apparently devastating people’s normal dopamine metabolism systems with drugs causes problems. Who’d a thunk it? Both Keith Conners and Leon Eisenberg gave what was essentially apologies for their roles in the ADHD epidemic in interviews shortly before their deaths. People no doubt suffer from different kinds of attention issues and there may indeed by a bio-chemical component to some of them, but “ADHD” is a dubious diagnosis at best, claiming yet another “chemical imbalance theory” which is never tested in patients before treatment is started. As your ‘The Madness of Overmedication’ case study implies, disease-mongering is part of pharma’s marketing plans and average doctors and gullible consumers watching TV advertisements are their marks. Ciba Geigy funded and was instrumental in launching CHADD which, like the pharma funded NAMI, was implied to be essentially a “peer support group”. Ciba had created Ritalin a few decades earlier, but sales were modest until ADD and ADHD was invented in the 80’s. If we were to go back in time 30 years ago and cynically ask ourselves, “What will companies do once they tap the pediatric market with these stimulant drugs?” I bet one of us would have come up with, “Create adult ADHD!” Hmmmmm? I guess I’ll keep looking for a new doc.
What is Informed Consent?
I agree, it’s nice to hear someone understand the exhaustion. I read an article in the Awake magazine about kids with ADHD. I was thinking to myself poor kids bouncing around, But no it said a lot times girls who are affected go undx. It described me to a T. I was 19 at the time and I just cried. It explained how I was all thru school. I was then in nursing school. Thinking I need to change career now . I didn’t thanks to a teacher who told me to just finish. I have tried to find alternatives for years, feeling that medication was a no go. I was always worried that because my mom is an alcoholic that it ran in the family and that meds would be a trap for me into a word of addition. I tried low carb high protein diet, i remember feeling the fog being lifted and thinking is this what the world is like for everyone else. It didn’t last long not sure why. But I’m 42 now and mentally and physically exhausted. I just started Rhondiola this week and it has seem to help. Calming and focus. But if there is more help out there I would really like it.
Denise S
Hi Lindsay
As you can see from your online research, this is a controversial topic. Ultimately your ob-gyne will be very much involved in the decision since they will want pregnancy, labor & delivery and baby to go smoothly. I think risks are dose related and reducing your dose will reduce risks
Dr E
In agreement…..so elated to have received my aaha moment. This was spot on for me. As a person struggling with this issue..I want to say, THANK YOU
Jackie
I was diagnosed as an adult about 5 years ago and being on adderall has been a life changer. One thing I worry about is having kids because I’m told that I can’t be on it while pregnant. I have a very demanding job and there is no way I could function pregnant without it. Is it safe to continue taking it during pregnancy? I’ve read mixed things things online
Lindsay
Dear Dr. E,
You never cease to amaze me. I received your e-newsletter this morning regarding Women and ADHD in my inbox, and about fell over and knew it was finally time to write you and provide an update. Time and time again, you have impacted my life, and I will always be grateful.
I feel compelled to share my experience over the course of the last 6 months. Your article has given me validation that I AM NOT CRAZY!
My anxiety hit an all time high over the course of the last 6 months…dealing with Todd and his health/mental health issues, family issues, my father-in-law diagnosed with an aggressive Alzheimer’s, increased chaos with 2 growing children who both suffer from diagnosed ADHD, and just a general sense that I was drowning with my daily tasks. My antidepressants just weren’t cutting it. I started therapy again for the 10th time. What was I doing wrong? Why couldn’t I keep it together??? The thought of unloading the dishwasher would put me over the edge. AND my non-existent sex drive from the increasing dose of anti-depressants was putting a wedge between my husband and me.
This last issue with my husband drove me to seek help from a local psychiatrist to see what I could do to decrease my antidepressants, change the brand, or figure out some other solution. So off I went to the psychiatrist (that also happens to treat my children). I told her my life story (similar to how you approach new patients…starting from the beginning). Unlike times in the past, I shared how I was put on antidepressants over and over again since I was 21 years old. I explained that I felt anxiety was my biggest issue. I described my endless strategies of trying to cope with my inability to stay on track over the years…having eternal hope that this next strategy would be the one to help me solve my disorganization, chronic procrastination, anxiety and lateness.
We even discussed my experience with becoming a new mother with my first child, and how I became overwhelmed and incapacitated with anxiety. I specifically remember comparing myself to my friends who recently had babies. How were they not overwhelmed? How were they coping so well? I couldn’t wait to escape back to work. Again, I was prescribed antidepressants and told I had depression.
I paid extra care to look at our family history and share this with her. It’s important to note that my daughter was diagnosed with ADHD 4 years ago (at age 8) and has been successfully treated with Adderall ever since. She’s a brilliant and kind little being. Soon enough our son was diagnosed with ADHD at the age of 7. His experience with medication hasn’t been as positive, but we’re hopeful that as he ages we will find the right one.
My maternal grandmother would be THE poster child for ADHD in women. She exhibited every single symptom…including losing every job due to her inability to control her impulsiveness. I see similar symptoms in my mom; however, she’s found many coping strategies to get her through the years. I am saddened to analyze my mom’s struggles through this new lens. I am certain that she could benefit from treatment.
Through the journey with our kids, I’ve read and read about ADHD, and in particular, its differences in women. I’ve learned how people self-medicate to cope with the overwhelming feelings and anxieties. I am scared to admit this, but I had begun to drink more than what I am comfortable admitting. In fact, this is the first time I am mentioning this to anyone beyond myself.
It was at this point during my visit that I asked my psychiatrist if she thought I might suffer from ADHD. She said that based on my history, familial history, and other symptoms that she thought I could benefit from medication. The best news was that she thought I could wean myself from my antidepressants over a period of time.
I started Adderall XR the next day. Within an hour, my world opened up, and my anxiety level went to almost zero. Never in my life have I felt this sense of calm and feelings of gratitude. I cried tears of joy and prayed that I would feel this way the next day. The next day came, and the medication worked again. I have been on the medication for almost 2 months now, and the BEST PART, I have stopped my antidepressant.
This has been one of the most cathartic writing experiences to date. Thank you for writing this article, thank you for always being a beacon of hope, thank you for always being ahead of your time, and thank you for believing in your patients’ stories. You are a gift.
With sincerest gratitude,
Anonymous
I think you wrote this article just for me. I’ve been struggling with everything you just described. When my 7 year old son was diagnosed with ADHD I immediately began to question whether I also have it. Now that I’ve read this, I’ll be seeking a diagnosis. This has affected my entire life in a negative way. Now I’m ready to live up to my full potential!
Thanks, Dr. E!!!!
Candice
DR. E,
I”m having trouble reading this, even with my cheaters on. Would you be open to a darker font?
Mary