Changing Focus: ADHD in Women

Picture a twelve-year-old girl. She’s always losing her homework. Whenever she starts a project she ends up with a half-cleaned room, an almost-done math assignment, only the first part of a book report, and a notebook filled with incomplete drawings. She doesn’t always remember to text her friends back and slowly they stop texting her. Her teachers frequently comment that she would do well if she would “apply herself,” but she can’t seem to get her head out of the clouds. Her parents wonder why she does not seem to hear what they say during dinner. School doesn’t interest her, and she doesn’t understand why other people can do well while she struggles. As she gets older, she finds methods to make sure she doesn’t fall behind in school, but it’s a constant struggle to balance these with her personal relationships. She is more likely than others to develop depression, anxiety, or even a substance abuse disorder due to stress. It is often hard for her to prioritize tasks or make decisions because she doesn’t always have a voice in her head telling her “Finish your work!” like others do. Instead, sometimes the voice in her head will tell her something outlandish, like “Research saltwater aquariums and then buy two hundred dollars’ worth of fish and equipment!” A dynamic like this extending through someone’s life can cause personal trouble, but there is more to the situation than its consequences. This woman is not careless, but instead demonstrates symptoms of attention deficit and hyperactivity disorder, or ADHD.

ADHD has a massive impact on the daily lives of many women. A common misconception, however, is that ADHD is a male-dominated condition and does not impact many women or persist into adulthood in women. This idea is being debunked with a new understanding that girls and women do experience this disorder at rates similar to boys and men, and around 64% of them continue to struggle with ADHD into adulthood [1]. Males and females often show vastly different symptoms, making it harder for females with ADHD to receive a timely and life-changing diagnosis, if they are diagnosed at all [2]. When ADHD in women is noticed, it’s often stigmatized and almost universally misunderstood. Part of this confusion comes from the various expressions of ADHD in different people and at different ages.

On a basic level, there are three distinct kinds of ADHD: hyperactive (ADHD-H), inattentive (ADHD-I), and combined (ADHD-C), which shows both inattentive and hyperactive traits. People with ADHD-I present symptoms that include frequent careless mistakes, not being able to finish tasks, forgetting important events and projects, and not speaking when spoken to. They may daydream as a way to escape boredom or interrupt conversations with unrelated comments. Conversely, people who have ADHD-H may move around inappropriately, talk excessively, are unable to wait their turn, fidget, and interrupt conversations. These actions match the diagnostic criteria governed by the fifth revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Unlike most of the other DSM-5 criteria for diagnosing mental disorders, these criteria were formulated to diagnose children, and they don’t always capture the nuances and struggles that adults with ADHD experience [2]. Beyond that, many adults with ADHD have comorbid disorders like substance abuse, depression, borderline personality disorder, or generalized anxiety disorder [7, 8]. These conditions have symptoms that frequently overlap with problems created by ADHD, like an unstable personal life, forgetfulness, anxiety, and volatile emotions. Doctors might see the anxiety caused by not remembering important events, or depression from difficulties forming appropriate social bonds, and treat those issues without recognizing that, depending on the cause, the underlying factor may be ADHD.

The complex etiology of ADHD leaves many researchers not knowing where to start or what to focus on. Many of them choose to corroborate older studies that focus on men and boys or simply base their research off of older male-focused studies because these groups have more evidence to inform their work [3]. Even in animal research, historically, male animals were nearly exclusively used in models of ADHD. This creates a gap in research pertaining to women. Because of this gap and the subsequent research emphasis on boys and men with ADHD, women with the disorder often go through their childhoods and much of their adult lives without a diagnosis to explain their symptoms. Our direct understandings of diagnosing ADHD and the long-term impact of ADHD focus mainly on men, making it difficult to apply to women who have a very different set of neurological causes and cultural expectations tied to the disorder. The gendered difference in expression requires better screening methods, more research, and increased societal awareness for women and girls with ADHD to prevent devastating social and emotional repercussions.

There are especially pervasive social problems around recognizing and diagnosing school-age girls who have ADHD [4]. Literature is conflicted on whether or not women are more likely to have the less-diagnosed ADHD-I, but this may be a barrier to treatment since people with ADHD-H or -C are more likely to be diagnosed at a young age and are therefore overrepresented in studies. Unfortunately, this means we know much more about people with ADHD-H and –C than those with ADHD-I who have subtler symptoms. Furthermore, societal expectations for girls to be quieter and less rowdy or disruptive during class may create a dynamic that stifles common ADHD-H or -C symptoms in young girls. The impact of different types of ADHD on teachers’ decisions to refer students to doctors was tested by researchers with the NHS Trust in the United Kingdom. Using a sample of 169 out of 186 elementary schools, researchers sent questionnaires containing vignettes of children with either ADHD-I or -C for teachers to read. The vignettes described behaviors common to each type of ADHD and emphasized the problems the hypothetical students had with making satisfactory progress in school. They found that teachers were equally likely to recognize ADHD-C and -I in male and female populations in laboratory settings. However, they recommended boys, more so than girls, with ADHD-I receive medical treatment in their classrooms outside of the experiment. In other words, although they knew the potential educational and social repercussions for both ADHD-I and -C, teachers did not recommend treatment for both types when they appeared in girls, as opposed to higher treatment recommendation rates for their male peers. Current studies of diagnosed children suggest that most elementary-age girls who are diagnosed with ADHD present ADHD-I, possibly because of social norms stifling expression of the other subtypes. Boys, especially those with ADHD-H or -C, are more disruptive to class because of the visibility of their symptoms [4]. This leads to a lack of correct diagnosis and treatment, especially in school-age children, perpetuating the idea of ADHD as a predominantly male disorder and discouraging women from seeking specific treatment later in life. This difference in symptoms is partially explained by neurological differences between men and women with ADHD.

Although most symptoms are common between men and women, brain differences point to a less known and critical difference in the neurological causes of ADHD in men versus women. According to a study conducted at the University of Wollongong with a sample of 16 men and 16 women with ADHD diagnosed in childhood and a sex-matched control group, men with ADHD have significantly reduced beta and increased theta brain waves when compared to gender-, age-, and IQ-matched pairs [5]. Beta waves facilitate active thinking and the ability to resist movement. Theta waves allow for increased short-term memory and the ability to process and respond to stimuli. This increased ability to process and respond tends to be associated with the inability to filter through stimuli: everything receives the same importance and emotional investment, whether it be planning for an important work meeting or choosing a tropical fish in a pet store. The differences in brain waves help to explain the hyperactivity shown in men with ADHD [5]. Men might be more prone to become interested in many different things rapidly or do things without thinking them through. This is a sharp contrast to women with ADHD, who on average have statistically insignificant differences in brain waves to a matched control group of women with the same ages and IQs [6]. However, they show significantly lower arousal. In this context, arousal refers to the gain of stimulation and satisfaction from daily activities. Women with ADHD have lower arousal levels, which was measured by their skin’s electrical conductance, than matched controls. Practically, this means they experience less enjoyment and satisfaction from normal activities. A lack of “arousal” from daily life could mean that the immediate gratification of a video game outweighs cleaning, and scrolling through Instagram or shopping on Amazon is more interesting than homework. Most people do find video games, shopping, or social media more fun than cleaning or work, but the problem comes when someone with ADHD cannot mentally prioritize the mundane, but necessary, tasks of living. This helps explain the tendency of women with ADHD to “check out” of day-to-day life as many of them may find it boring or unstimulating.

The variability in symptoms and, consequently, diagnosis also has an effect on long-term outcomes for women and men. Women with ADHD carry the disorder into adulthood between 44% and 62% of the time, based on self-reports of issues in the context of medical treatment, but these numbers do not include undiagnosed people or patients with fewer than five out of the nine diagnosable criteria—not enough to reach a full diagnosis. Comorbidities are most dangerous when the patient does not receive treatment for the underlying condition of ADHD. There is a long list of potential comorbidities, most of which have been observed separately in multiple studies. Common risks include increased liability for anxiety disorders, personality disorders such as borderline personality disorder and schizophrenia, bipolar disorder, and rejection-sensitive dysphoria [7, 8]. Outside of the mental health realm, there is an increased risk of sexually transmitted infections and single parenthood and a decreased likelihood of graduating high school and college [9, 10]. These do not always happen because of ADHD, and they do not happen to all people who have the disorder, but there is a greater incidence especially with untreated ADHD. If a woman in particular has many of these conditions along with any symptoms of ADHD, there is a high chance that she suffers from some form of this disorder. It might be helpful for her to have an appointment with a psychiatrist, because even if it does not lead to a diagnosis of ADHD, it could unearth one of the comorbid disorders, which could then be treated as a first-line of defense. Although these conditions are often treatable, they have massive repercussions for those who suffer from them, even with proper interventions. This includes a higher mortality rate, especially for women who have ADHD as well as comorbid disorders, and people who were diagnosed in adulthood [11]. This demonstrates the gendered barrier to appropriate treatment resulting from the stigma around female mental health and the overriding belief that ADHD is predominantly a male disorder.

To dispel this stigma around women with ADHD, medical journals and medical schools need to reframe the disorder as something that presents in many different forms and often persists into adulthood [1]. Schools should implement a more rigorous screening program for at-risk children, which would help children gain the therapy and treatment to develop socially, emotionally, and academically with their classmates. Addressing problems that come with impulsivity and poor decision-making skills may decrease the risk for certain comorbid disorders, like anxiety and depression, in adolescence and adulthood. The real and devastating effects of this neurological and psychological disorder are often swept away with an insistence that if patients simply “worked harder” or “focused more,” they would not be in their situations. Common social expectations of women (with or without ADHD) to perform as domestic partners, coupled with careers and the stressors of everyday life, can be overwhelming to the point of reducing their ability to do well in any of these areas [1]. We need to dispel the idea that women and girls are not susceptible to ADHD, and that ADHD-I is less damaging than more visible subtypes. Improving evidence-based diagnostics and treatments, regardless of gender, would likely lead to a higher instance of ADHD diagnosis in women, allowing them to access appropriate care before they begin to suffer from the negative effects associated with the disorder. This, partnered with breaking down mental health stigmas and traditional female social roles, would give women with ADHD a fighting chance at succeeding in the same environments as their peers, male or female.

References

  1. Guelzow, B. T., Loya, F., & Hinshaw, S. P. (2016). How Persistent is ADHD into Adulthood? Informant Report and Diagnostic Thresholds in a Female Sample. Journal of Abnormal Child Psychology, 45(2), 301-312. doi:10.1007/s10802-016-0174-4
  2. Waite, R. (2007). Women and attention deficit disorders: A great burden overlooked. Journal of the American Academy of Nurse Practitioners, 19(3), 116-125. doi:10.1111/j.1745-7599.2006.00203.x
  3. Valera, E. M., Brown, A., Biederman, J., Faraone, S. V., Makris, N., Monuteaux, M. C., . . . Seidman, L. J. (2010). Sex Differences in the Functional Neuroanatomy of Working Memory in Adults With ADHD. American Journal of Psychiatry, 167(1), 86-94. doi:10.1176/appi.ajp.2009.09020249
  4. Moldavsky, M., Groenewald, C., Owen, V., & Sayal, K. (2012). Teachers’ recognition of children with ADHD: Role of subtype and gender. Child and Adolescent Mental Health, 18(1), 18-23. doi:10.1111/j.1475-3588.2012.00653.x
  5. Dupuy, F. E., Clarke, A. R., Barry, R. J., Mccarthy, R., & Selikowitz, M. (2016). Women are different to men: EEG differences in DSM-5 Adult Attention-Deficit/Hyperactivity Disorder. International Journal of Psychophysiology, 108, 6. doi:10.1016/j.ijpsycho.2016.07.018
  6. Hermens, D. F., Williams, L. M., Lazzaro, I., Whitmont, S., Melkonian, D., & Gordon, E. (2004). Sex differences in adult ADHD: A double dissociation in brain activity and autonomic arousal. Biological Psychology, 66(3), 221-233. doi:10.1016/j.biopsycho.2003.10.006
  7. Solberg, B. S., Halmøy, A., & Engeland, A. (2017). Gender differences in psychiatric comorbidity: A population-based study of 40 000 adults with attention deficit hyperactivity disorder. Acta Psychiatrica Scandinavica, 137(3), 176-186. doi:10.1111/acps.12845
  8. Cortese, S., Faraone, S. V., Bernardi, S., Wang, S., & Blanco, C. (2016). Gender Differences in Adult Attention-Deficit/Hyperactivity Disorder. The Journal of Clinical Psychiatry, 77(04). doi:10.4088/jcp.14m09630
  9. Chen, M., Hsu, J., & Huang, K. (2018). Sexually Transmitted Infection Among Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder: A Nationwide Longitudinal Study. Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 48-53. doi:10.1016/j.jaac.2017.09.438
  10. Ahmad, S., Hinshaw, S. P., & Owens, E. (2016). 41.2 Adult Functional And Psychiatric Outcomes Among Women With Childhood Attention-Deficit/hyperactivity Disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10). doi:10.1016/j.jaac.2016.07.361
  11. Dalsgaard, S., Dr, Ostergaard, S., Dr, Leckman, J., PhD, Mortensen, P., PhD, & Pedersen, M., MSc. (2016). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: A nationwide cohort study. The Lancet. doi:https://doi.org/10.1016/S0140-6736(14)61684-6

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