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