Addressing ADHD in Women: A Guide to Diagnosis and Treatment

Ashley Baker:
Welcome to NeuroFrontiers on ReachMD.  I’m psychiatric nurse practitioner Ashley Baker. And here with me today to discuss ADHD in girls and women is Dr. Kathleen Nadeau. Dr. Nadeau is the Founder and Clinical Director of the Chesapeake Center for ADHD Learning and Behavioral Health in Bethesda, Maryland. Dr. Nadeau, thanks for joining me today. 

Dr. Nadeau:
Thank you so much for inviting me. 

Ashley Baker:
Let’s dive right in, Dr. Nadeau. What would you see clinically in terms of symptoms that a woman might present in your office with that could be different than a man presenting with the same diagnosis?

Dr. Nadeau:
The most common word a woman uses when she comes into my office is “I am overwhelmed.” I’ve literally never had a man walk into my office and say, “I am overwhelmed.” And I think it has to do with that whole complex set of familial and societal expectations that are hard for any woman to live up to, and then us women with ADHD even more so are overwhelmed. So they just talk about “I feel like a failure;” “I feel like a bad mom;” “I feel like a bad homemaker;” “I feel like a bad friend because I’m always arriving late,” and “I’m forgetting to send birthday cards;” and “Oh my gosh, I was supposed to send something to the bake sale, and I didn’t have time to do it.” It’s just this “I’m failing at being a woman,” instead of having the confidence to push back and say, “This is ridiculous; nobody should be expected to do this.”

Ashley Baker:
Why else might girls and women be often underdiagnosed compared to men and likely, as a result, undertreated? Are there any other reasons or things that we’re missing, especially as providers?

Dr. Nadeau:
There are lots of reasons. I mean, another reason—and it just fits right into the whole picture of societal pressure on us—girls are much, much better and work much harder to mask their symptoms. I certainly didn’t know I had ADHD when I was growing up as a kid, and I was one of those anomalies. I was one of those girls that would never have been diagnosed because I loved school and I was a good student, but if you looked at me then through the eyes I have now and looking back at my report cards,  the teacher was criticizing me for always tipping my chair, always chewing on my pencil, and always waving my hand to be called on because I knew the answer. You know, just all kinds of things that were screaming ADHD, and yet I made straight A’s and so people would say, “Well, where is the disability?” And I think one of the things I’m really glad is now being talked about is changing the idea of disability to how we’re impacted emotionally by it. 

Ashley Baker:
So as a provider, if I had someone in my office, maybe a teenage girl, and she was presenting with some of the issues that we’ve talked about today, and in some ways that could sound a lot like anxiety. How can we educate our audience, our providers, and our students on how to make that differentiation in diagnosis compared to maybe depression or generalized anxiety versus “No, the root of this is ADHD”?  What else goes into it?

Dr. Nadeau:
Well, what I would say to that clinician—and I do get that question all the time of “Isn’t this just anxiety?” It isn’t just anxiety, but it is anxiety. In fact, it’s an extremely rare teenage girl with ADHD that is not anxious, but that is not looking below the surface to see what’s going on and what’s driving that anxiety. One of the things I often say is describing ADHD in adolescence is almost like describing adolescents on steroids. You could say, well, all teenage girls worry about their social standing and get upset if somebody is mean or doesn’t like them. But all teenage girls don’t live with the feeling of “I just don’t fit in. I never fit in. I’m always screwing up.” 

So one of the things I tell clinicians is look at the males in the family. They may not have diagnosed ADHD, but often these days they do.  It’s often the boys that are diagnosed. Because if there’s a girl in the family, there’s very likely to be a boy in the family with ADHD, so we need to look at it, not just only looking at the individual, but this is a very genetic familial disorder. And if nobody in the family on any generation shows any signs of ADHD, it’s probably not ADHD, but that’s almost never the case, so that’s one of the things that I tell clinicians. The other thing is that being anxious doesn’t make us messy; being anxious doesn’t make us lose track of the time or forget our jacket at school every other day, and so look at the other things beyond and underneath the anxiety. 

Ashley Baker:
For those just tuning in, you’re listening to NeuroFrontiers on ReachMD. I’m psychiatric nurse practitioner Ashley Baker, and I’m speaking with Dr. Kathleen Nadeau about how we can better identify and manage girls and women with ADHD. 

Now if we focus on treatments, Dr. Nadeau, are there different strategies for girls and women than boys and men with ADHD?

Dr. Nadeau:
Everyone with ADHD needs help with executive functioning issues, and what does that mean? It means we have difficulty with planning and prioritizing, staying organized, following through, and having all the materials that we need whenever we’re beginning an activity or project. I find that one of the most healing things that you can do is run a therapy group for peers because we haven’t had a group. We haven’t had a tribe. We’re the ones on the outside trying to get on the inside. And I have just seen wonderful things happen when you put five, six, seven teenage girls with ADHD in a room with each other, and suddenly, they’re finishing each other’s sentences, and they really do know what you’re going through. They really support each other. At every age, I think, women are so healed by being helped to find their tribe. 

Ashley Baker:
Before we end our discussion today, was there any take-home or really important message that you want our audience to remember and leave with?

Dr. Nadeau:
Well, I think that the biggest message I want to give is that ADHD has been trivialized, and I think that part of the problem is we keep sticking to those old inaccurate diagnostic criteria. ADHD in females is a serious issue if it’s not treated.  We’re at risk for unplanned pregnancies as teenagers. The rate of cigarette smoking is very high, and we know how lethal and unhealthy vaping or cigarette smoking is. The average age they found in a Harvard study that girls with ADHD start vaping or smoking is 11. And it’s clearly self-medication. They’re not diagnosed yet. And so the nicotine is sort of helping them feel more focused and alert. There are more psychiatric hospitalizations. Women with ADHD have very high rates of complex PTSD, and by that, I mean that they have felt wounded by microaggressions their entire life. They struggle with anxiety and with depression. Suicide attempts and suicides are all part and parcel of untreated ADHD in females, so it’s a serious disorder that, unfortunately, has been trivialized.

Ashley Baker:
With those final thoughts in mind, I’d like to thank my guest, Dr. Kathleen Nadeau, for joining me to discuss ADHD in women and girls. Dr. Nadeau, it was great speaking with you.

Dr. Nadeau:
Thank you so much for inviting me.

Ashley Baker:
For ReachMD, I’m Ashley Baker. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge.  Thanks for listening.