ADHD Is Different for Women
The standard conception of the disorder is based on studies of “hyperactive young white boys.” For females, it comes on later, and has different symptoms.
When you live in total squalor—cookies in your pants drawer, pants in your cookies drawer, and nickels, dresses, old New Yorkers, and apple seeds in your bed—it’s hard to know where to look when you lose your keys. The other day, after two weeks of fruitless searching, I found my keys in the refrigerator on top of the roasted-garlic hummus. I can’t say I was surprised. I was surprised when my psychiatrist diagnosed me with ADHD two years ago, when I was a junior at Yale.
In editorials and in waiting rooms, concerns of too-liberal diagnoses and over-medication dominate our discussions of attention deficit hyperactivity disorder, or ADHD. The New York Times recently reported, with great alarm, the findings of a new Centers for Disease Control and Prevention study: 11 percent of school-age children have received an ADHD diagnosis, a 16 percent increase since 2007. And rising diagnoses mean rising treatments—drugs like Adderall and Ritalin are more accessible than ever, whether prescribed by a physician or purchased in a library. The consequences of misuse and abuse of these drugs are dangerous—sometimes fatal.
Yet also harmful are the consequences of ADHD untreated, an all-too-common story for women like me, who not only develop symptoms later in life but also have symptoms—disorganization and forgetfulness, for instance—that look different than those typically expressed in males. While the New York Times’ op-ed columnist Roger Cohen may claim that Adderall and other “smart” drugs “have become to college what steroids are to baseball,” these drugs have given me, a relatively unambitious young adult who does not need to cram for tests or club until 6 a.m., a more normal, settled life.
The idea that young adults, particularly women, actually have ADHD routinely evokes skepticism. As a fairly driven adult female who found the strength to sit through biology lectures and avoid major academic or social failures, I too was initially perplexed by my diagnosis. My peers were also confused, and rather certain my psychiatrist was misguided. “Of course you don’t have ADHD. You’re smart,” a friend told me, definitively, before switching to the far more compelling topic: medication. “So are you going to take Adderall and become super skinny?” “Are you going to sell it?” “Are you going to snort it?”
The answer to all of those questions was no. I would be taking Concerta, a relative of Ritalin. Dr. Ellen Littman, the author of Understanding Girls with ADHD, has studied high-IQ adults and adolescents with the disorder for more than 25 years. She attributes the under-diagnosis of girls and women—it is estimated that there are about 4 million who are not diagnosed, or half to three-quarters of all women with ADHD—and the misunderstandings that have ensued about the disorder as it manifests in females, to the early clinical studies of ADHD in the 1970s. “These studies were based on really hyperactive young white boys who were taken to clinics,” Littman says. “The diagnostic criteria were developed based on those studies. As a result, those criteria overrepresent the symptoms you see in young boys, making it difficult for girls to be diagnosed unless they behave like hyperactive boys.”
ADHD does not look the same in boys and girls. Women with the disorder tend to be less hyperactive and impulsive, more disorganized, scattered, forgetful, and introverted. “They’ve alternately been anxious or depressed for years,” Littman says. “It’s this sense of not being able to hold everything together.”
Further, while a decrease in symptoms at puberty is common for boys, the opposite is true for girls, whose symptoms intensify as estrogen increases in their system, thus complicating the general perception that ADHD is resolved by puberty. One of the criteria for ADHD long held by the Diagnostic and Statistical Manual, published by the American Psychiatric Association, is that symptoms appear by age 7. While this age is expected to change to 12 in the new DSM-5, symptoms may not emerge until college for many girls, when the organizing structure of home life—parents, rules, chores, and daily mandatory school—is eliminated, and as estrogen levels increase. “Symptoms may still be present in these girls early on,” says Dr. Pat Quinn, the co-founder of the National Center for Girls and Women with ADHD. “They just might not affect functioning until a girl is older.” Even if girls do outwardly express symptoms, they are less likely to receive a diagnosis. A 2009 study conducted by The University of Queensland found that girls displaying ADHD symptoms are less likely to be referred for mental-health services.
In “The Secret Lives of Girls with ADHD,” published in the December 2012 issue of Attention, Dr. Littman investigates the emotional cost of high-IQ girls with ADHD, particularly for those undiagnosed. Confused and ashamed by their struggles, girls will internalize their inability to meet social expectations. Sari Solden, a therapist and the author of Women and Attention Deficit Disorder, says, “For a long time, these girls see their trouble prioritizing, organizing, coordinating, and paying attention as character flaws. No one told them it’s neurobiological.”
Often, women who are finally diagnosed with ADHD in their 20s or beyond have been anxious or depressed for years. A recent study published in the Journal of Consulting and Clinical Psychology found that girls with ADHD have high rates of self-injury and suicide during their teenage years, bringing attention to the distinct severity of ADHD in females. In Pediatrics, a large population study found that the majority of adults with ADHD had at least one other psychiatric disorder, whether alcohol abuse, hypomanic episodes, or major depression. This poses a particular threat to females, for whom ADHD diagnoses tend to come later in life.
For the two decades prior to my diagnosis, I never would have suspected my symptoms were symptoms; rather, I considered these traits—my messiness, forgetfulness, trouble concentrating, important-document losing—to be embarrassing personal failings. Matters really deteriorated in college, when I was wrongfully allowed a room of my own, leaving me with no mother to check up on “that space between your bed and the wall,” where moldy teacups, money, and important documents would lie dormant. I maintained a room so cluttered that fire inspectors not only threatened to fine me $200 if I didn’t clean but insisted it was the messiest room they had ever seen (boys’ included!) in their 20 years of service. Throughout college, I would lose my ID and keys about five times a semester. I’d consistently show up for work three hours early or three hours late. I once misplaced my cellphone only to find it, weeks later, in a shoe.
“Often, if girls are smart or in supportive homes, symptoms are masked,” Solden says. “Because they’re not hyperactive or causing trouble for other people, they’re usually not diagnosed until they hit a wall, often at college, marriage, or pregnancy. A lot of things that are simple and routine to other people—like buying groceries, making dinner, keeping track of possessions, and responding to emails—do not become automatic to these women, which can be embarrassing and exhausting.”
As a recent college graduate cautiously negotiating adulthood in New York City, I am both embarrassed and exhausted by my struggles to keep track of objects and time. While the stakes have become significantly higher—credit cards, passports, and cameras have slipped through my fingers—medication has minimized the frequency of these incidents.
I can’t say that I know what part is ADHD, what part is me, or whether there’s a difference. I can say that ADHD medication (in conjunction with SSRIs) has granted me a base level of functionality; it has granted me the cognitive energy to sit at my jobs, to keep track of my schedule and most of my possessions, and to maintain a semblance of control over the quotidian, fairly standard tasks that had overwhelmed me—like doing laundry, or finding a sensible place to put my passport.
Medication is certainly not a cure-all, but when paired with the awareness granted by a diagnosis, it has rendered my symptoms more bearable—less unknown, less shameful. And while I’m certain I’ll continue to misplace and forget objects, I have discovered the virtues of a little self-love, a lot of self-forgiveness, and even using different drawers to store different things.
The drawer thing, though, is a work in progress. The next time I misplace my keys, the fridge will be the first place I look.