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10 CEUs Treating Locking In & Blocking Out: ADHD Adults

Section 20
Diagnostic Difficulties in Women with Adult ADHD

Question 20 | Test | Table of Contents | ADHD CEU Courses
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Attention deficit hyperactivity disorder (ADHD) is a neurobiological disorder affecting millions of individuals, limiting their potential, troubling their families, and interfering with many aspects of their lives. For girls and women, however, ADHD is often a hidden disorder, ignored or misdiagnosed, which causes them to suffer in silence. Without proper treatment, many females who have ADHD experience psychological and academic impairments. In addition, most report low self-esteem, impaired social relationships, and a general demoralization. Studies further suggest that adolescent females who have undiagnosed ADHD engage in "at risk" behaviors, such as promiscuity and substance abuse, at a greater rate than males. Lack of recognition of ADHD in females can be partly explained because their symptoms, such as forgetfulness, disorganization, low self-esteem, anxiety, and demoralization, are all considerably less overt than the disruptive behaviors typically seen among males. Furthermore, hyperactivity in females is more likely to manifest as hyper-talkativeness or emotional reactivity than excessive motor activity. Coexisting disorders seen in girls who have ADHD are also often different from those seen in boys: conduct disorder and oppositional defiant disorder are half as common in girls and are often the factors driving the referral for an evaluation in boys. Girls are more likely to internalize symptoms and become anxious, depressed, and socially withdrawn. And ADHD can lead to substance abuse disorders and sexual acting out as girls enter adolescence. Adolescent behaviors are not without repercussions. Women who have ADHD often report feelings of shame as they look back on their adolescence. Both girls and women who have ADHD report a sense of inadequacy as they struggle, unsuccessfully, to meet gender role expectations. These feelings may be experienced even as early as age 8 or 9. A female who has ADHD may exert a great deal of time and effort to maintain even a semblance of normalcy (Solden; Nadeau). She may appear to function well for many years, but at a great cost. The degree of her impairment often can only be determined when we take into account the degree of effort expended to perform well and compare it to the effort of others in her peer group to complete the same tasks. In certain instances, there seems to be an actual difference in the course of the disorder in females, which is based on the primary symptom of inattentiveness. Often it is not until the onset of puberty and the demands of middle school that girls who have inattentive type ADHD demonstrate impairment. Clinicians need to be aware that inattentive symptoms are difficult to identify.

A Complicated Diagnosis
ADHD, once properly diagnosed, is a very treatable condition. Outcomes can be improved with the use of medications, lifestyle adaptations, and accommodations, allowing individuals who have ADHD to lead a productive life and to reach realistic goals. But first clinicians must become aware of the various presentations of ADHD, especially among females. Diagnosis of ADHD may, however, be complicated because ADHD infrequently occurs in isolation and is often accompanied by a significant comorbidity. Biederman and colleagues have presented evidence indicating that the majority of persons who have ADHD have at least one and sometimes more than one additional psychiatric disorder. These disorders include depression, tics, Tourette’s syndrome, substance abuse, obsessive-compulsive disorder, anxiety disorders, and learning disabilities. It is, therefore, critical that the clinician be aware of the characteristics inherent in ADHD that mimic these conditions. All too often, and especially among females, a clinician is too quick to diagnose these coexisting condition as primary, thus missing the diagnosis of ADHD altogether. This situation often results in additional complications as the patient’s condition does not improve or relapses because the ADHD itself has not been untreated.

Research as well as clinical experience suggest that girls and women who have ADHD have high rates of coexisting anxiety and depression, and that it is these secondary conditions, rather than the underlying ADHD, that are most likely to be diagnosed. Factors contributing to this situation include a female tendency to internalize symptoms and become socially withdrawn, misinterpretation of symptoms of inattention as a different disorder altogether, and coexisting anxiety and depressive disorders that may mask underlying ADHD. ADHD affects millions of women, yet few receive the comprehensive treatment needed to alleviate the impact of its symptoms and to optimize functioning. The number of clinicians who have expertise in diagnosing ADHD in women is small. All too often, women who seek an evaluation for ADHD do not receive this diagnosis because their history does not fit the stereotypic ADHD patterns of young, hyperactive males. Clinicians who expect a report of poor academic functioning and behavioral problems in the elementary school years will overlook many, if not most, women who have ADHD. Clinicians who assume that ADHD occurs only in those who have never attended college or have failed to graduate from college can misinterpret signs of ADHD in highly intelligent women who may have earned a doctoral, law, or medical degree. Women who have primarily inattentive type ADHD who have a low arousal level may be diagnosed as having dysthymia, whereas women of the combined or hyperactive/impulsive type, who have a high energy level, impulsivity, and verbal aggression, may be diagnosed as having bipolar disorder. Although depression or bipolar disorder may be present in such women, coexisting with their ADHD, in many cases ADHD patterns in females are misinterpreted.

Common Symptoms of ADHD in Women
A study conducted by Stein and associates, using the Wender Utah Rating Scale (WURS), found that ADHD symptoms most reported by women were dysphoria, inattention, organization problems, and impulsive conduct. The largest factor extracted for females was dysphoria, described as a reactive moodiness rather than true depression with vegetative signs. Males in their study reported more conduct problems, learning problems, stress intolerance, attention problems, and poor social skills. Important differences were also found between male and female responses on self-ratings in a study conducted by Arcia and Conners. In that study, adult women had a poorer self concept and reported fewer assets and more problems than did their male counterparts. Rucklidge and Kaplan studied women who were not diagnosed as having ADHD until they were adults. Results indicated that these women were more likely to report depressive symptoms, stress, anxiety, and low self-esteem. In addition, they engaged in more emotion-oriented versus task-oriented coping than women who did not meet diagnostic criteria for ADHD. Similarly, in research published by Katz, Goldstein, and Geckle, women identified as having ADHD in adulthood were found to have a greater degree of psychological distress than their male counterparts. In addition, these women were rated as having more psychiatric symptoms but displayed more efficient cognitive strategies on neuropsychological measures. Alcohol and drug use disorders have been reported frequently in women who have ADHD; these problems often began at an early age (Wilens, Spencer, & Biederman). Women whose ADHD is not diagnosed are less able to be consistent parents, less able to manage their jobs and households, and at higher risk for divorce and single parenting (Nadeau). The stress resulting from these day-to-day struggles takes its toll over time and places these women at risk for diseases related to chronic stress, such as chronic fatigue syndrome and fibromyalgia (Rodin & Lithman). Consequently, the lack of appropriate identification and treatment of ADHD in women should be seen not only as a personal tragedy but also as a significant public health concern.

Treatment Differences in Females
Even if a woman is fortunate enough to be correctly diagnosed as having ADHD, treatment regimens are usually composed of recommendations established by those experienced in treating elementary school–aged boys. Hormonal fluctuations and the influence of estrogen on the brain are rarely considered, much less addressed. No wonder many adolescent girls and adult women treated for ADHD report only partial remission of symptoms. In addition, treatment methods that are effective for boys’ ADHD may not be for girls’ or women’s ADHD. For example, when boys’ symptoms worsen, increasing the dose of stimulant medication is often helpful, but clinical experience suggests that this approach frequently fails when applied to women who are in perimenopause or girls who are starting menstruation. Little is known about the interactions between hormones and the stimulant medications. Although ADHD symptoms respond to stimulant medication as well in females as in males (Spencer et al.; Wilens et al.; Spencer et al.), hormone levels during certain phases of the cycle may decrease their effectiveness. Cyclical variations of hormones (both estrogen and progesterone) during the menstrual cycle often must be considered in determining the proper dose of medication. Only two studies to date have looked at the effect of estrogen on the response to amphetamine and on the effect of amphetamine when administered during the follicular (before ovulation) versus the luteal (after ovulation) phase of the menstrual cycle (Justice & deWit). In the first study, 10 mg of amphetamine was administered to women during the early follicular phase of the menstrual cycle, with and without pretreatment with estradiol patches. The results indicated that the stimulating effects of amphetamine were increased with acute estradiol pretreatment. In the second study, the effects of 15 mg of amphetamine were assessed at two hormonally distinct phases of the menstrual cycle. During the follicular phase, the level of estrogen is low initially and then gradually rises. In the luteal phase, both estrogen and progesterone levels are high and decrease before menstruation. Results indicated that although there was no difference in these two groups before the study, the effects of the amphetamine dose were greater during the follicular phase than the luteal phase. Women reported feeling more "high," "energetic," and "intellectually efficient." The results demonstrated that during the follicular phase, but not the luteal phase, responses to amphetamines were related to estrogen levels. During the luteal phase, in the presence of progesterone, the effects of amphetamine were less pronounced. These findings suggest that estrogen may enhance the response to stimulant drugs in women but that this effect may be dampened or diminished by the presence of progesterone. It would seem then that some adolescent girls and adult women might require different stimulant dosages depending on the phase of their menstrual cycle, and increasing doses might be needed toward the end of the second half of the cycle, and perhaps into menstruation, or until estrogen levels are again established.

Clinical Issues and Summary
Females who have ADHD are an underrecognized, understudied, and insufficiently treated subgroup who need closer examination. For a woman who has ADHD, often her most painful challenge is a struggle with her own sense of inadequacy in fulfilling the roles she feels are expected of her by her family and by society. Girls are raised to "internalize"—to take in and "own" negative feedback, to apologize, to accommodate, and not to fight back—in short, to take the blame. Boys, however, are typically raised to "externalize"—to fight when attacked, to see the problem as outside them. These differences are described very tellingly in Sari Solden’s book, Women with ADHD (attention deficit disorder), in which she writes of "coming out of the ADHD closet" of shame and self-blame. Pharmacotherapy remains a crucial part of the treatment plan for ADHD. Such treatment should be undertaken as a collaborative effort between patient and practitioner with the physician guiding the use and management of medications proved to reduce ADHD symptoms. In addition to medication to reduce ADHD symptoms, women who have ADHD may need supports as part of a comprehensive treatment. These include psychotherapy, coaching, a professional organizer, career or marriage counselors, and support groups. When treating ADHD among adolescent girls and women, clinicians are challenged with disentangling symptoms of ADHD from associated coexisting anxiety, mood, and substance use disorders. It is important for the clinician to recognize that ADHD is a disorder rarely seen in isolation. Because young females who have ADHD frequently seek treatment for mood and/or anxiety disorders, they may really be struggling with long-standing untreated symptoms of ADHD and their sequelae. Females who have ADHD benefit from therapeutic management of ADHD as much as males, but certain differences need to be taken into consideration. Because girls who have ADHD have fewer behavioral problems, they need less "behavior management." Low self-esteem, shame, and demoralization secondary to undiagnosed ADHD may need to be addressed as may coexisting anxiety and depression. Effective treatment for girls’ ADHD will thus involve a multimodal approach that includes education, medication, psychosocial support, and educational placement. ADHD, once it is properly diagnosed, is a very treatable condition. Outcomes can be improved with medications, adaptations, and accommodations, thus allowing individuals to direct their life and reach realistic, achievable goals. But first clinicians must become aware of the various presentations of this disorder, which vary with gender and by stage of development. More specifically, clinicians need a set of revised criteria and guidelines that will lead to a comprehensive and accurate diagnosis.
- Quinn, Patricia O.; Treating adolescent girls and women with ADHD: Gender-Specific Issues; Journal of Clinical Psychology; May 2005, Vol. 61 Issue 5, p579

Personal Reflection Exercise #6
The preceding section contained information about diagnostic difficulties in women with adult ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article Reference:
Kofler, M. J., Harmon, S. L., Aduen, P. A., Day, T. N., Austin, K. E., Spiegel, J. A., Irwin, L., & Sarver, D. E. (2018). Neurocognitive and behavioral predictors of social problems in ADHD: A Bayesian framework. Neuropsychology, 32(3), 344–355.

Kofler, M. J., Sarver, D. E., Austin, K. E., Schaefer, H. S., Holland, E., Aduen, P. A., Wells, E. L., Soto, E. F., Irwin, L. N., Schatschneider, C., & Lonigan, C. J. (2018). Can working memory training work for ADHD? Development of central executive training and comparison with behavioral parent training. Journal of Consulting and Clinical Psychology, 86(12), 964–979.

Kofler, M. J., Singh, L. J., Soto, E. F., Chan, E. S. M., Miller, C. E., Harmon, S. L., & Spiegel, J. A. (2020). Working memory and short-term memory deficits in ADHD: A bifactor modeling approach. Neuropsychology, 34(6), 686–698.

According to Quinn, what is the key reason ADHD often goes unrecognized in females? Record the letter of the correct answer the Test.


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