“Nothing but a dreamer” – ADHD and Women

“Nothing but a dreamer”-ADHD and Women

It’s quite hard when we look at all the statistics regarding ADHD especially ADHD and women, and find ourselves disagreeing with just about all the stats. If we look at the clinical records we hold at ADHD 360 we have women forming 49% of our patients. This is what we would expect, but it does fly in the face of research and past papers on the subject.

Are the papers out of date? Do we have a different sample size? Have things changed over time.

This paper discusses these matters, and also other issues surrounding women and ADHD. What we do know is that for far too long, females with ADHD were under-represented in treatment for ADHD and addressing this has been and is a goal of ADHD 360 since we formed.

We can recall with clarity how only 15 or so years ago, the nation’s experts were still convinced that ADHD was a childhood issue, so we can see the enormity of addressing the difficulties of gender bias and understand the challenges. Or do we?

‘Classic’ ADHD understanding would previously have us believe that ‘boys’ who misbehaved and were extremely naughty in school were the target group to assess and treat for ADHD. And it is perhaps here that we start to understand how girls, and then women, began to be left behind? This classically believed ‘myth’ led to two absolute wrongs for our society, that ADHD was for boys and that ADHD requires misbehaving. Of course, we know that ADHD is something for everyone, and is also not requiring misbehaviour.

The working pragmatism of these myth-based statements led to a plethora of poor practices, wasteful processes and inappropriate budget management. If we shift a scenario-based review of this, we see schools denying that a patient has ADHD as there is no misbehaviour, we see clinics having a gender bias to their work and we observe clinical processes that don’t actually recognise girls with ADHD.

We mentioned 15 years ago, and maybe just 10 years ago or so, we began to witness experts discussing the fact that ‘boys are hyperactive’ and ‘girls are dreamers at the back of the class’. More mythical nonsense. Can girls not behave, can boys not be the dreamer? Stereotyping in this was proved to be dangerous and we are still assessing many adults who were missed in school because of these myths.

Let’s set the record straight. ADHD effects women and men, girls and boys, females and males. In fact, we should go as far as recognising that transgender, gender neutral, non-binary and gender fluid whatever the label, ADHD doesn’t recognise these positions in human life. We can all have ADHD, in equal measure and our clinical caseload, from a population of over 2,000 supports this.

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Women as dreamers, sat in the back of the class couldn’t have ADHD.

Having dismissed the myth, lets look at the reality. The presence of hyperactivity is of course a ‘given’ for an ADHD diagnosis, the DSM5 makes that very clear. But of course, when we look for traditional explanations of hyperactivity, we look for fidgeting, walking instead of sitting. But what about looking at it differently, and looking for a hyperactive mind, more than merely looking for a hyperactive body? And hey presto there we find the dreamers, both boys and girls, men and women, and we challenge right now, right away the notion of girls and women being dreamers, and boys being naughty.

We have to fully understand that hyperactivity is present for people with ADHD, of the mind or the body, or both. A blend. It isn’t binary. And believe me, women with (or without) ADHD can be aggressive, can be physically hyperactive and can present exactly the same as any male patient.

Having therefore discussed the statistics of men-v-women in patient numbers and ratios and the apparent myths and mistakes that have led to previous disparity of service provision, let’s move the debate on a little, into women and their ADHD.

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XX not 1&0, it isn’t binary

What we all know about our female population is that women have different physiology to men. XX chromosomes, different body requirements, not least of which is the capability to bear children, never mind different pressures from society, we know women are different to men.

When we look around us, we may traditionally see women as copers, multi-taskers, competent human beings. Of course, we also should recognise the issues of being a women, a powerful male leader comparison may be seen as a stroppy women who is outspoken, a driven man may be a women that ignores her natural responsibilities, a grumpy man may be seen as just tired whereas a grumpy women could be seen as ‘moody’ and ‘pre-menstrual’.

And all of this locks itself firmly into the challenges of an accurate ADHD diagnosis. How do we assess tolerance for the norm? Do we norm reference against society to form a medical opinion of ‘difference?’ Do we separate out behavioural expectations for women from those for men? How do we ignore the prejudice of myths to ensure an accurate assessment?

We have to learn, study modern understanding, science and form new opinions.

And we should then set new standards, understand what a reality is and how we can work positively with new futures.

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A lack of ability to do the things that need doing

Women have periods, this natural occurrence in most women until the menopause affects life, lifestyle and behaviour. Wait a minute, are they not some of the prerequisites for an assessment for ADHD, behaviour, emotions, coping? Of course they are, and in the considerations of the assessment and treatment processes we need to fully comprehend, as discussed in our ‘3T’s paper – ADHD and the Menstrual Cycle’ , the continued, monthly effect of menstruation on female patients.

We work a lot with members of ADHD support groups and agencies across the world, and one of our frequent, and popular, partners is the American support association CHADD. They introduce the issues for women with ADHD with the following paragraph, which is quite interesting:

Some women seek treatment for ADHD because their lives are out of control―their finances may be in chaos; their paperwork and record-keeping are often poorly managed; they may struggle unsuccessfully to keep up with the demands of their jobs; and they may feel even less able to keep up with the daily tasks of meals, laundry and life management. Other women are more successful in hiding their ADHD, struggling valiantly to keep up with increasingly difficult demands by working into the night and spending their free time trying to “get organised.” But whether a woman’s life is clearly in chaos or whether she is able to hide her struggles, she often describes herself as feeling overwhelmed and exhausted.

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We know that women with ADHD suffer impairment in similar styles and types, with very similar outcomes to males with ADHD. Matters such as:

• dysphoria (unpleasant mood)
• major depression and
• anxiety disorders …

… are common, and these form what we refer to as the ‘Primary Care Revolving Door’.

The presentation to the GP with low mood, anxiety is often misunderstood, mainly because, going back to myths about ADHD, doctors are not looking for ADHD in female patients, and therefore it is not found. The mis-diagnosis is of depression, anxiety and dysphoria and we are not surprised that when patients don’t respond to the clinical diagnose as expected GPs remain confused. The adult patient in particular, that has not had their ADHD recognised, is not perhaps depressed, they are completely cheesed off with not understanding themselves, not being understood and having struggles far beyond those of peers, colleagues and families. We refer this as ‘Situational p****ed off-ness’ (SPO) and it is a ‘thing’!

We know clinically that a lot of our patients, and especially women present with SPO and despite being treated for depression and anxiety, to little positive effect, it is recognition and treatment of their ADHD that begins to unpick the mood, control the anxiety and ultimately make our patients happy.

We need to continue to research and focus on women with ADHD. We need to recognise that females remain underrepresented in the majority of clinical settings, and that women need more recognition. It is becoming increasingly clear that this is an emerging public health concern, that is misunderstood across the UK and beyond.