ADHD

Manhattan Adult Attention Deficit Disorder Support Group

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Information For Adults With Add/Adhd

ADD/ADHD In The News:

Newsday, 4/2/02

SOME RESEARCHERS BELIEVE GIRLS & WOMEN HAVE BEEN OVERLOOKED

by Kelly Field

Nancy Ratey first sensed that something was wrong in graduate school, when she had to tie her foot to the desk in order to stay seated long enough to study.

She went to a psychologist, and, at the age of almost 30, was diagnosed with attention deficit hyperactivity disorder.

"I guess it hadn't been a liability until graduate school," said Ratey, who earned a master's degree from Harvard after adopting better time-management and organizational strategies and beginning medication. "That was when it became clear that it wasn't just a matter of willpower."

Ratey, co-author of "Coaching College Students with AD/HD" and head of the national Attention Deficit Disorder Association, is one of a growing number of women being diagnosed with a disorder traditionally associated with rambunctious little boys. Though males are still identified at a much higher rate than females, more and more women are receiving help with symptoms of inattention, impulsiveness and, sometimes, hyperactivity, say clinical psychologist Kathleen Nadeau and developmental pediatrician Patricia Quinn, co-authors of two just released books "Gender Issues and AD/HD" and "Understanding Women with AD/HD."

For some, "the true extent of their difficulties" becomes apparent only when they leave home for college or a job or to get married, said Sari Solden, author of "Women with Attention Deficit Disorder" and "Journeys through ADDulthood." "Then they hit a wall, unable to continue to compensate or cope," she said.

A nonprofit support group called CHADD, Children and Adults with Attention-Deficit/Hyperactivity Disorder, now estimates that up to 70 percent of children diagnosed with ADHD will continue to experience some symptoms in adulthood. In women, these most often include disorganization, distractibility and inattention. Women, as well as girls, may feel over stimulated, overloaded and overwhelmed.

"We now know that it can be as full-blown and debilitating in adults," said Quinn, who with Nadeau also co-edits and co-publishes a magazine, ADDvance.

Though recent studies suggest that ADHD may be more common in females than previously believed, no reliable statistics on the incidence among females have been compiled. This is largely because there have been only two major epidemiological studies of mental illness conducted to date, done in the late 1980s and early '90s, according to Rayford Kytle, spokesman for the National Institute of Mental Health.

One of these -- the National Comorbidity Study -- is being replicated on a larger scale worldwide: 10,000 children and 20,000 adults are participating in the United States, and 250,000 people are participating at sites around the world, according to Ronald Kessler, a professor of Health Care Policy at Harvard Medical School and the director of the U.S. site. The study is expected to establish more accurate rates for ADHD.

"In the last few years, people have become more sensitive to the fact that there are adults with impulse control problems," Kessler said. The increasing diagnosis of women began with the publication in the 1990s of two groundbreaking books on adults with ADHD: "Driven to Distraction" (1994) and "You Mean I'm Not Lazy, Stupid or Crazy?!" (1995), said Jane Brewster, a Virginia psychotherapist. These books popularized the notion of adult ADHD, prompting many adults to refer
themselves for evaluation.

"People will have an 'ah-ha' experience after reading an article or a book," said Joseph Scardapane, executive director of the Psychological Evaluation, Research and Counseling Clinic at Hofstra University.

"They'll say, 'Gee, that sounds like me.'"

There also has been a growing awareness of the existence of ADHD in girls. Michigan psychotherapist Terry Matlen, vice president of the Attention Deficit Disorder Association, said she recognized symptoms in herself only after her daughter was diagnosed.

"It turned on a lightbulb for me," said Matlen, who was diagnosed at age 41. "My whole life has changed."

Matlen was so empowered by her newfound self-awareness that she shifted her clinical focus from emotionally disturbed children to adults with ADHD to "help others achieve a breakthrough, like I did."

Treatments can include medications, either stimulants or antidepressants, depending on specific symptoms; aid in time-management and organization strategies; and short-term psychotherapy.

Psychologists say one reason today's women have gone undiagnosed is that females are more likely to exhibit the inattentive - and not the hyperactive - form of the disorder. They say dreamy and withdrawn girls are more likely to be overlooked by teachers than hyperactive boys, who are more disruptive in class. Quinn and Nadeau refer to this as the "squeaky wheel syndrome."

"Teachers will send in the boys because they are driving them nuts," said Molly Perkins Hauck, a Maryland psychologist. "The girls get referred by their parents because they're not focusing on their schoolwork."

Because these girls are "not wiggling around in their seats, teachers sometimes see them as unmotivated or lazy," said Anne Kaplan of Maryland, who has ADHD and also has a son and two daughters with the disorder.

"People see [attention] as a choice rather than a deficit," said Beth Kaplanek of Huntington, immediate past president of CHADD and a former nurse and mother of two sons with ADHD, "but they're missing the lens to filter out distraction." She said that children with the inattentive subtype often have troubles with organizing, prioritizing and goal-setting -- so-called "executive functioning" skills.

Carol Margaritis, clinic director at the Lindamond-Bell clinic in Roslyn, said more boys than girls are referred to her for testing and treatment -- largely because "girls don't get picked up as easily in the classroom."

Several studies support this argument. One, a New Zealand study by University of Otago Professor Rob McGee titled, "Are Girls With Problems of Attention Under recognized?" found that girls without "management" problems often weren't referred by their teachers.

Girls also may "stay in the closet longer" because they work hard to conceal their attention deficits and please their teachers, Nadeau said. "Good grades and satisfactory teacher reports in school cannot rule out ADHD in females," she said.

Meanwhile, hyperactive girls, identified more often than inattentive girls, also are more criticized, Nadeau said.

"People tend to think 'boys will be boys,' but girls should be young ladies," she said.

Some researchers contend that diagnostic criteria are skewed toward identifying males. They point to the fact that the criteria were established on the basis of studies of boys.

"There are some girls who are not diagnosed because they do not meet DSM-IV-R [Diagnostic and Statistical Manual, Revised] criteria," said Jeneva Ohad, a University of British Columbia researcher who co-authored a study that found that all but one of the diagnostic criteria -- "fails to complete tasks" -- were rated as being more descriptive of boys than girls.

According to the National Institute of Mental Health, ADHD affects between two and three times more boys than girls. Yet studies have focused on males, with the ratio of male to female subjects as high as 9 to 1.

"The vast, vast majority of studies have been done on boys," said Deborah Weisbrot, director of Child Outpatient Services at Stony Brook University Hospital's Division of Child and Adolescent Psychiatry. Other studies have shown that girls tend to develop the disorder later in life, another factor that may disadvantage them in diagnosis.

DSM-IV criteria require that symptoms appear before the age of 7, a standard that Quinn and Nadeau suggest be adjusted to include ages up to 13. They also suggest that a diagnosis take into consideration "associated features" such as moodiness, bossiness, stubbornness, demoralization, mild depression and poor self-esteem.

Solden said the DSM-IV needs criteria that "more clearly describe the inner experience of ADHD -- the felt experience, the more subtle aspects of the cognitive difficulties."

Brewster, the Virginia psychotherapist, said psychologists "may understand conceptually that it exists in girls, but they don't know how to diagnose it.

"I took my daughter to a well-respected neurologist, and he said, 'It doesn't show up, she doesn't have ADHD,'" said Brewster, whose son has been diagnosed. "Meanwhile, my child is suffering, and I know why."

"The guidelines are too rigid," agreed Matlen, who endorses the idea of alternative criteria for adults, as well.

Others argue that what is needed is not alternative diagnostic criteria, but better public education. Hofstra's Scardapane said that sensitizing the public about the ways ADHD manifests in girls would be the best way to redress any potential underdiagnosis. He said that qualified psychologists should be able to identify inattentive girls given a complete and thorough markup with existing criteria.

"If you know the diagnosis well, you are going to identify it," he said. "What we need is in-service training in schools so that teachers can be aware of the possibility of inattention in girls."

Ken Gadow, a professor of psychiatry and researcher at SUNY Stony Brook, said he would "support the notion that separate diagnostic criteria be investigated," but he warned of the potential of shifting from underdiagnosis to over diagnosis.

"Everyone wants to be sure that girls get the services they need, but I'm equally concerned that we don't over diagnose girls because of some statistical inequality in prevalence rates," he said. "It is likely this disorder is just more common in males."

Some psychologists say that ADHD can be particularly hard for women because they lack the professional and personal supports that many men possess. Expected to be supporters, rather than supported, women with ADHD can become overwhelmed by the competing organizational demands of work and home, they say.

"Women have this Martha Stewart mentality, this fantasy that other women do everything perfectly," Nadeau said. "We're talking about the impossible expectations that women lay on themselves."

"Homemaker," she added, "is the ADHD job from hell."

Ratey said her male clients are "trying to spend more time with their significant other," while her female clients are "trying to deal more with managing work and home."

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