Feature

When psychologist Stephen P. Hinshaw, PhD, published two studies on attention-deficit hyperactivity disorder (ADHD) in girls last October, psychologist Kathleen Nadeau, PhD, was heartened that females with ADHD were finally beginning to receive long overdue attention from researchers.

"Hinshaw is one of the first to study girls themselves," says Nadeau of the lead author's work, published in the Journal of Consulting and Clinical Psychology (Vol. 70, No. 5). "Most of the few prior studies have focused on comparing girls to boys--using boys' ADHD symptoms as the marker against which girls should be measured."

For Nadeau, Hinshaw's research was vindication for what she had observed clinically for years: "that girls experience significant struggles that are often overlooked because their ADHD symptoms bear little resemblance to those of boys." It was also a signal for her to push even harder to raise the awareness of the needs of women with the disorder. Through advocacy and groundbreaking research and writing, Nadeau and a small group of psychologists are fighting to bring the issues of ADHD in women from the fringes of research to center stage.

"Historically, research on ADHD has focused almost exclusively on hyperactive little boys, and only in the past six or seven years has any research focused on adult ADHD," says Nadeau, an expert on the disorder in women and director of Chesapeake Psychological Services of Maryland in Silver Spring. "And the recognition of females [with the disorder] has lagged even further behind."

According to Nadeau, this lagging recognition of girls and women is due to current diagnostic criteria--which remain more appropriate for males than females--and to parent and teacher referral patterns, spurred by the more obvious and more problematic male ADHD behaviors. Some deny that the disorder exists in females--or in anyone at all.

Researcher and educational therapist Jane Adelizzi, PhD, theorizes that females with ADHD have been largely neglected by researchers because hyperactivity is usually missing in girls, who typically have attention deficit disorder (ADD), the inattentive type of ADHD. But for advocates, the bottom line is this: Girls with undiagnosed ADHD will most likely carry their problems into adulthood, and left untreated, their lives often fall apart.

"Girls with untreated ADHD are at risk for chronic low self-esteem, underachievement, anxiety, depression, teen pregnancy, early smoking during middle school and high school," says Nadeau.

As adults, they're at risk for "divorce, financial crises, single-parenting a child with ADHD, never completing college, underemployment, substance abuse, eating disorders and constant stress due to difficulty in managing the demands of daily life--which overflow into the difficulties of their children, 50 percent of whom are likely to have ADHD as well," Nadeau adds.

"Girls with ADHD remain an enigma--often overlooked, misunderstood and hotly debated," says Ellen Littman, PhD, one of the first psychologists and researchers to focus on gender differences in ADHD and to advocate for a re examination of how the disorder is defined.

Littman theorizes that girls with ADHD aren't identified and helped earlier in their lives because male ADHD patterns have been over-represented in the literature. "As with all diversity issues, the danger lies in assuming that these more typical patterns characterize all children with ADHD," says Littman, who runs a clinical practice in Mount Kisco, N.Y. "Therefore, while there appears to be an abundance of information available on ADHD, we may have a false sense that we know more about the experience of girls with ADHD than we really do."

More research on gender issues in ADHD is needed for several reasons, says Julia J. Rucklidge, PhD, assistant psychology professor at the University of Canterbury in Christchurch, New Zealand, who has studied ADHD in Canadian women. "We can't make assumptions that what applies to males will apply to females--females have different hormonal influences to start with that can greatly affect their behavior." Also, Rucklidge says, females are socialized differently and therefore tend to express themselves in a different manner, and are more susceptible to such problems as depression or anxiety that again influence behavior. This suggests that ADHD "will manifest and express itself differently in females," she says. "But only research can tell us this definitively. Until then, these are assumptions that we make."

The mommy factor

Many women are in their late 30s or early 40s before they are diagnosed with ADHD. "One of the most common pathways to a woman being diagnosed is that one of her children is diagnosed. She begins to educate herself and recognizes traits in herself," says Nadeau. "These women are [usually] going to be older," because children are typically diagnosed with ADHD in mid-to-late elementary school.

Women with ADHD typically present with tremendous time management challenges, chronic disorganization, longstanding feelings of stress and being overwhelmed, difficulties with money management, children or siblings with ADHD, and a history of anxiety and depression, says Nadeau, who didn't recognize her own ADHD until middle age and has a daughter and a brother with the condition.

The disorder is typically treated with a combination of stimulant medication and ADHD-focused psychotherapy, "which is very structured, goal-oriented, and uses many 'coaching' techniques, as well as standard psychotherapy techniques," says Nadeau. "Women more than men with ADHD struggle with low self-esteem, and this needs to be a major focus of therapy," she adds.

Many of the women who come to clinical and neuropsychologist Mitchell Clionsky, PhD, for ADHD testing fit the typical profile. One 42-year-old patient he diagnosed with ADD was referred by a psychiatrist treating her for depression. Her marriage was troubled, and she had low self-esteem, says Clionsky, the cofounder of the ADD Center of Western Massachusetts in Springfield. Since childhood, the patient had thought she was lazy and irresponsible because she didn't complete things she started. A "very bright woman," she completed a few years of college, and "probably would have gone farther had her problem been identified sooner," he says.

The tragedy is "these are people significantly underachieving and [who] end up going the depression route, mostly the result of life failure," Clionsky says. "It's like they're running life's race with lead weights on their ankles."

Pioneering research

Some psychologists are building up the literature on ADHD among women. Julia Rucklidge began studying the area while working on her doctorate in psychology at the University of Calgary in Alberta, Canada. "When I started in 1995, there was very little research in the adult population [and] maybe one or two studies looking specifically at women with ADD," she says.

Rucklidge, with colleague Bonnie Kaplan, PhD, studied 102 women ages 26 to 59, with a mean age of 41. Half of the women interviewed had ADHD and half did not. All of the women in the study had a child with ADHD--therefore all subjects could relate to the stressors involved in parenting a child with the disorder.

Rucklidge's findings, published in the Journal of Attention Disorders (Vol. 2, No. 3) and the Journal of Clinical Psychology (Vol. 56, No. 6), shed light on the experiences of women diagnosed in adulthood:

  • Women with ADHD were more likely to have a "learned helpless style" of responding to negative situations than were women without the disorder and tended to blame themselves when bad things happened.

  • Women with ADHD were likely to believe that they couldn't control the outcomes of life events, resulting in a vicious cycle, reports Rucklidge. "A woman with ADHD is less likely to make efforts to finish challenging tasks due to her belief that she has no power to change the negative outcome. By giving up, she further reinforces the belief that she is unable to accomplish things in life," she says.

  • Women with ADHD were also more likely to report a history of depression and anxiety. They had also been in psychological treatment more often and had received more prescriptions for psychotropic medications than had women without ADHD.

Jane Adelizzi's research explored a rarely mined area of ADHD: its similarity to post-traumatic stress disorder (PTSD). Three of her studies looked at women diagnosed with attention and learning problems who also showed PTSD symptoms as a result of experiencing classroom trauma--which she defines as a significantly unpleasant external event or stressor occurring within the confines of an educational environment that is of a psychological nature.

"As a result of classroom trauma over a span of years, some women develop a set of symptoms that are recognizable--by some professionals--as post-traumatic stress symptoms," reports Adelizzi, coordinator of the Adult Center, Program for the Advancement of Learning at Curry College in Milton, Mass. "These symptoms are also similar--too similar--to ADHD behaviors and symptoms."

It's not always clear which comes first, the post-traumatic stress symptoms, the ADHD symptoms or the trauma, says Adelizzi. But, she argues, these women's ADHD symptoms can't be helped without looking into the coexisting panic and anxiety that can be triggered many years later--if, for example, they decide to return to school.

'Cutting-edge advocacy'

In addition to pushing for more studies on gender issues, these psychologists use a range of forums to raise awareness of ADHD in women. With pediatrician Patricia Quinn, MD, Nadeau recently founded the National Center for Gender Issues and ADHD (NCGI) to promote awareness and research on the disorder in females. Nadeau and Quinn also developed Advantage Books, an ADHD specialty press, and have co-edited several volumes on ADHD issues in girls and women (see Further Reading). Nadeau is also editor of ADDvance Online News, NCGI's monthly e-newsletter.

"We're doing cutting-edge advocacy," says Nadeau, who has lectured on the issue nationally as well as in Norway, Japan, Puerto Rico and Germany, and has discussed the topic in the popular media, including on NBC's "Today Show."

Networking is also a crucial part of Nadeau's advocacy work. She's formed alliances with national ADHD groups, including the Attention Deficit Disorder Association and Children and Adults with Attention-Deficit/Hyperactivity Disorder.

Since the 1990s, Adelizzi has been running support groups for women with ADD--and other learning disabilities--who are attempting college. She also gives seminars and has developed two certificate programs for professionals who work with women with attentional and other disorders. And she's continuing to study these women--most recently looking at how they express their emotions through art.

In addition, Littman and Nadeau are pushing for changes to be made to the next edition of the Diagnostic and Statistical Manual for Mental Disorders.

"I hope that psychologists, especially those who specialize in adult ADD issues, will play an active role in advocating for more appropriate diagnostic criteria--for adults, and especially for women--before DSM-V comes out," says Nadeau. "I hope that such issues are dealt with at the [next] APA convention in a vocal fashion--the lives of many people are at stake."

Further reading

  • Adelizzi, J.U. (1998). Shades of trauma. Plymouth, MA: Jones River Press.

  • Beiderman, J., Farone, S., Mick, E., et al. (1999). Clinical correlates of ADHD in females: Findings from a large group of girls ascertained from pediatric and psychiatric referral sources. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 996-975.

  • Hinshaw, S.P. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices, Journal of Consulting and Clinical Psychology, 70(5), 1086-1098.

  • Hinshaw, S.P., Carte, E.T., Sami, T., et al. (2002). Preadolescent girls with attention-deficit/hyperactivity disorder: II. Neuropsychological performance in relation to subtypes and individual classification. Journal of Consulting and Clinical Psychology, 70(5), 1099-1111.

  • Nadeau, K.G., & Quinn, P.O. (Eds.) (2002). Gender issues and AD/HD: Research, diagnosis, and treatment. Silver Spring, MD: Advantage Books.

  • Nadeau, K.G., & Quinn, P.O. (Eds.) (2002). Understanding women with AD/HD. Silver Spring, MD: Advantage Books.

  • Resnick, R.J. (2000). The hidden disorder: A clinician's guide to attention deficit hyperactivity disorder in adults. Washington, DC: American Psychological Association.

  • Rucklidge, J.J., & Kaplan, B.J. (2000). Attributions and perceptions of childhood in women with AD/HD symptomatology. Journal of Clinical Psychology, 56(6), 711-722.

  • Rucklidge, J.J., & Kaplan, B.J. (1997). Psychological functioning in women identified in adulthood with attention-deficit/hyperactivity disorder. Journal of Attention Disorders, 2(3), 167-176.