The standard conception of the disorder is based on studies of "hyperactive young 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 fairly 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.
Dr. Ellen Littman, 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 around 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 over-represent 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-V, 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, cofounder 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 diagnoses.
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, from alcohol abuse to hypomanic episodes to 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, they 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.