Ellen Littman brings attention to women with ADHD

More than twenty years ago, based on what she was seeing in her own practice, Ellen Littman, PhDopens in new window, a Mt. Kisko, New York, clinical psychologist, realized that girls as well as boys have attention-deficit hyperactivity disorder (ADHD). The belief at the time was that the condition affected only boys. 

Since then, Littman has been instrumental in increasing the public's understanding of ADHD — and the chances that girls and women with this often debilitating condition will get help. 

But more practitioners need to get training in how to identify and help girls and women with ADHD, says Littman, co-author of the groundbreaking 1999 book "Understanding Girls with ADHD: How They Feel and Why They Do What They Doopens in new window", now in its second edition. 

Women often come to therapy for ADHD for the first time as adults, perhaps badly damaged from a lifetime of trying and failing to live up to society's feminine ideal of an organized, well turned-out problem-solver, Littman says. 

"A central aspect for women and girls with ADHD is shame, a very dangerous thing, very undermining to self-esteem. But if they stick with it [therapy], their sense of self improves dramatically," Littman says. 

ADHDopens in new window is a common, chronic neurobehavioral condition that often appears first in childhood, with symptoms that include inattention, hyperactivity and impulsivity. Left untreated, it can interfere with functioning and development. The acronym ADD, for attention-deficit disorder, was also used at one time, but only ADHD is used now, even though many affected individuals are not hyperactive. More than 8% of American children ages 2 to 17 have been diagnosed with ADHD according to a studyopens in new window based on the 2016 National Survey of Children's Health. 

Girls were not included in the early diagnosis of ADHD because they typically don't show the disruptive behaviors that are part of the classic constellation of symptoms for boys, Littman says. Even now, a diagnosis is more common for boys, but Littman says the growing number of adult women diagnosedopens in new window with the condition suggests that ADHD is probably distributed more or less equally between the genders. 

A hyperactive boy may be diagnosed by age seven, but girls are much more likely to fall into the "inattentive" category of ADHD, which is harder for teachers and other observers to peg. Estrogen is an important trigger in girls, so they may not begin to exhibit signs of the disorder before puberty, says Littman, who is not a researcher herself but "a careful consumer" of neuroscience. 

"There's nothing different about ADHD in boys and girls, but there are real gender differences that exacerbate the symptoms," she says. 

Children with ADHD can lag behind other kids by three to four years developmentally, and that delay can be compounded if they don't get treatment, she says. 

"Women with ADHD can find themselves up to 10 years behind their peers in their developmental trajectories," in terms of employment, education and independence, Littman says. 

In neurotypical people, maturity reflects lessons learned from mistakes made along the way, but the ADHD brain assesses experience differently, Littman says. She gives the example of a child who eats ice cream, goes on a carnival ride and then throws up from motion sickness. A typical child will shy away from that unfortunate sequence of events in the future, but someone with ADHD could repeat the scenario a number of times before realizing it's a bad idea. 

"A feature of the ADHD brain is that it holds on to high-stimulation experience. What that child remembers is, 'That roller coaster was amazing!' They don't remember that they threw up later," Littman says. 

Drugs like methylphenidate (Ritalin), for example, are often prescribed for ADHD, but Littman believes a combination of therapeutic approaches — psychoeducation, reframing and cognitive behavioral therapy — can help a patient develop strategies for dealing with the condition. "You can't change your brain wiring, but you can reframe your experience," she says. In terms of diagnosis, Littman would like to see tools developed that would measure not behavior but "impairment," to pick up the more "subtle experiences women have of ADHD." 

One bright spot in the picture is that some individuals with the condition wind up doing amazing things; thinking outside the box comes naturally to people with ADHD. 

"There are strengths and weaknesses that come with the package. People with ADHD can put things together in unusual ways, and are often creative thinkers," Littman says. While they don't typically thrive in an office setting, some become successful entrepreneurs or creatives. Ideally, they'll find a life partner who is structured and detail-oriented. "They're never going to be great in that department themselves," she says. 

Littman grew up in Westchester County, New York. She says she knew from childhood that she wanted to be a psychologist. However, after college at Brown University in Providence, Rhode Island, she worked as a science writer, before enrolling in her late 20s in the clinical psychology doctoral program at Long Island University in New York. 

Her dissertation was on reaction time in people with Wilson's Disease, a condition caused by a lack of copper in the brain that in the past was diagnosed as a cognitive disability. Littman showedopens in new window that people with the condition were cognitively fine, but had motor deficits; everything slowed down for them. It was another example of a situation where people were misunderstood. 

"I guess that's my theme," she says. 

Once established in her own practice, working for the most part with markedly intelligent people, Littman began to notice that a number of girls, teens and women she worked with didn't seem to be fully aware of what was going on around them — they were dreamy, anxious, shy, depressed. 

"They weren't hyperactive; they were inattentive. No one was looking for that presentation" of ADHD. Most clinicians didn't understand how to interpret what they were seeing, Littman says. 

At a conference she attended in the 1990s, she was disturbed to hear the keynote speaker call girls “ADHD wannabes." She went to the microphone and challenged the statement, recounting what she'd seen in her practice. "It was more than I had ever said aloud to thousands of people," she recalls. Out in the lobby, Littman feared she had committed career suicide. Instead, Patricia Quinn, MDopens in new window, and Kathleen Nadeau, PhDopens in new window, who also work with ADHD, approached to ask if she would write a book with them, which became "Understanding Girls with ADHD". 

"It was based on our clinical experience; there was no research on girls and ADHD at the time," Littman says. "But over the years, research has been done that supports everything in our book."