Navigating ADHD with Girls and Women - Episode 1

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Transcript

SPEAKER_00 0:00

Welcome to Mind and Medicine of a Sontera Podcast. I'm Tommy Batman, your host, and today we will be having Chesty Simmons Talbot. And she'll be talking with us about ADHD across the lifespan with girls and women. But before we begin, here are a few CME announcements. This episode is accredited for AMA PRA Category 1 credits for full accreditation, destination, and disclosure information. Please refer to the show notes. And now the show.

SPEAKER_01 0:36

Thank you for having me. I'm glad to be here.

SPEAKER_00 0:39

Absolutely. So you know, before we get started, I know we're talking about ADHD specifically with uh young women and uh throughout the lifespan. So women of all ages really. Um but before we get started, why don't you tell us about yourself?

SPEAKER_01 0:56

Well, I am um the on-site EAP counselor here at Centera Halifax Regional Hospital. Um I actually became really interested in ADHD with um the diagnosis with my daughter, um, and then navigating the whole um special education um program at school, had to do lots of research for that to actually get some accommodations. Um, and then in as people have come in into um for counseling, I've just noticed that there have been a lot of women who have um not been diagnosed but who present with lots of symptoms. So that just gave me an increased interest in um looking at ADHD in women, doing lots of research on my own, um, so that I'd have the information to give women because also there was not a lot of I didn't meet very many women who had been talked about with ADHD who knew very much about it, even and people who had been diagnosed hadn't been giving very great information. And just in helping um clients deal with the emotions that can go along with ADHD, um, supporting them around the executive functioning, I just thought, okay, having information to give folks, printed out information that I could give them to take home when they could read it when they had more time or more attention would be really helpful. Um that was a bit of a tangent. So um I am actually uh under supervision, working towards my um clinical license in social work, and um that's it.

SPEAKER_00 3:01

Very good. So, you know, as we're getting started, let's first, you know, when you say ADHD, you know, of course people have something usually have something specific in mind. And I'm I'm thinking of rampunctious young boys and people that just can't stop moving and all that stuff. But before we get into the differences between, you know, the male and female, you know, uh presentation of ADHD, what what is ADHD in general first? Like what is what's going on in the brain?

SPEAKER_01 3:29

Okay, so ADHD or attention deficit hyperactivity disorder, it's a neurodevelopmental disorder, it's um really commonly diagnosed in children. It does last through um into adulthood, it's genetic. Um, let's see, it really impacts exec executive functioning skills in the brain. Okay, so that's areas like attention, concentration, memory, motivation and effort, um, impulsivity, hyperactivity, organization, and social skills. Um, yeah, so you you are basically thinking about young hyperactive boys because that's where most of the research has been done.

SPEAKER_00 4:25

Yeah, they do have uh uh pretty big and disruptive behaviors, you know. So I think I guess it gets attention.

SPEAKER_01 4:33

Right, right, right, right. So just a little bit more about the um executive functioning. So um I guess you know, our brains don't stop growing until we're like 26, maybe up to 30. Um, that prefrontal cortex part where um we're making really good decisions. Um that part also helps a lot with the organization of thoughts and activities, um, us being able to manage time efficiently, um, prioritizing and completing tasks. So um ADHD impacts that area, you know, the um the just the executive functioning skills that are that are going on there. Um ADHD also can have a bit of a negative stigma, I guess maybe somewhat related to the um young boys, the idea of young boys running around and not being well managed, their behavior not being well managed. Um but actually I like to think of ADHD as I understand it, it it is a um it's sort of a superpower that has where you have to be mindful to give yourself the supports that you need.

SPEAKER_00 5:53

Yeah, and it seems like it, you know, in many ways it can be used as a survival thing. Um, you know, in crises, I've noticed a lot of folks with ADHD tend to really focus and they are able to handle complex and and very specific things. Um me saying that it seems like a survival thing, it is it more natural and and a very prevalent thing? Is it is it uh just something that is a I would say quote unquote normal condition within you know within the scope of humanity, um, you know, like is it 25%, 30% of people deal with uh what could be called ADHD, or what is the prevalence?

SPEAKER_01 6:31

Okay, so um let's see. So within the population itself, about adult population of Americans, 5.4% of uh men have an ADHD diagnosis, whereas about 3.2% of women have an ADHD diagnosis. Um generally um boys are identified and diagnosed about five years earlier than girls. Um I guess from the ages of three to 17, only about 6% of girls are diagnosed, and 13% of boys are diagnosed with ADHD. So I and also, you know, there has been an increase in information coming out and being more readily available. I think um some better education going on, so we're catching a few more people than we used to as well, you know. But um what you say about this survival being being able to um focus that hyper focus um aspect that can come along with ADHD, I think has been probably really helpful in um survival.

SPEAKER_00 8:00

I would say it's it's it's like maybe a holdover from the days where we really needed that sort of superpower, you know. Whereas now uh in the in the digital age, it may be a little bit uh uh a little bit disruptive at times uh for you know today's today's uh way of survival. Um so in on that note, you did note that there was a difference between uh male and female um diagnosis rates and in you know, of course, the presentation's different, uh which may account for it. Uh is there anything else that that may account for that difference uh um you know between male and female uh diagnosis rates?

SPEAKER_01 8:44

Yeah, well, there are a couple different reasons. So um because the research has been based on has historically been based on boys, that has led to the screeners, the um testing, the diagnostic criteria to be based primarily on the um behaviors of young boys, which girls are not. So it it presents differently in in girls. And so they have and also girls, um, girls with ADHD tend to do a lot of masking and overcompensating. Um generally speaking, um, girls tend to um be, they tend to want to be socially accepted. So a lot of the masking and the compensation efforts are driven by that. Um, so a lot of times girls develop coping skills that get them through, get them by. Maybe they um learn some social skills by watching the other girls. Um but it and it helps them get through the their current situations, but perhaps they're not the best coping skills. But what it ends up doing is they so they sort of fly under the radar, they aren't getting picked up. Teachers are often um some of the first people who may notice the symptoms of um ADHD in children, but because girls typically aren't hyperactive in the same way that boys are, um they get they aren't really noticed, if if that makes sense, you know. So they're getting they're they're getting they're getting by, um, and they are quieter and not as disruptive. Um and because uh our um thinking generally tends to think about young hyperactive boys when we think about ADHD, then some that that pushes girls away from being recognized as possibly having them and then being tested.

SPEAKER_00 11:07

Let's talk about that. Um you know, of course, if it's out of sight, you know, and it's not really causing a disruption to their you know normal daily life, you know, outwardly, especially when they're under the care of a parent or guardian who are the ones that would notice a disruption, um, you know, of course, it's not going to be seen. So let's get into the the kind of the details. What what are typical female presentations you know in youth and maybe later on in life? But let's stick with youth for right now of ADHD symptoms.

SPEAKER_01 11:41

Okay. So um I think girls with ADHD can often have be seen as or maybe labeled as spacey, daydreaming. There's a bigger core component of inattention there. Um, you know, like you might have girls who are struggling to focus because they are thinking of other things, they're looking out the window, um daydreaming. There's a lot of um oftentimes there's disorganization, like their um desks might be a mess, their bedrooms might be a mess. Um organization is not can often not be their forte. Um they may struggle to remember um all of the steps in in a particular routine. That that makes me think about um doing algebra, you know, when you get there and you have to remember all of the steps, and each step builds on the last step in order to arrive at the correct answer. So if you can't remember all of the steps while you are doing the math, which is quite a bit of juggling, um that can be hard, that can be difficult for um girls, and part of that is because of the effect that um ADHD has on working memory. Um let's see, so hyperactivity can exist in girls as well, but it just doesn't look like it does with boys. So with girls, hyperactivity might look like um being really talkle talkative, um a struggle with some inner restlessness, like maybe um I like to call them thought tornadoes where a thought starts and it just keeps going and going and going, um, rumination, um that sort of thing. Um so that's what some of the some of the symptoms. Another is some impulsivity, okay? So impulsivity with with females can sort of look like um maybe they like to drive fast. Um maybe they um speak and they're not thinking before they speak, you know, maybe you know, if something comes to their mind and there it is, it's out of their mouth, and they're and then they're left with, oh gosh, I wish I hadn't said that, if only I had thought about it before I said it, you know, that kind of thing. And it can really impact um that kind of thing can really impact um social relationships. And because um females tend to um utilize social relationships to um process their feelings and um for support, you know, when you have a hard time focusing or paying attention to it during a conversation, or you're saying things impulsively without thinking them through, those behaviors can negatively impact um your social relationships, which can be really, really difficult for girls as they're learning to make friends and through middle school as you're navigating that whole um social environment there, it can those girls can experience a lot of um social rejection, um, negative reflections of about themselves that can get internalized and really have a negative impact on their self-esteem and self-confidence. Um does that does that do it? That's pretty good. Yeah.

SPEAKER_00 15:56

Any other symptoms that are specific uh are more prevalent within uh um you know girls or young women?

SPEAKER_01 16:05

Well, um let's see, with that impulsivity, I think this is something that's really important and really important because for um to make sure that girls are being correctly diagnosed and caught early. So um some of the high risk behaviors um can be dangerous, you know, like I said, speeding or extreme sports, um, addictive behaviors is a high risk of addiction um with substance use, maybe gambling. Um earlier sexual activity. Um there's an increased risk of unwanted pregnancies for girls with ADHD, girls and women who are there's an increased wit risk of self-harm and um suicidality among girls and um women with ADHD. There might be some self-harm cutting, kicking at skin, um which all are have a negative impact on their mental health and um but also can again impact their negatively impact their social relationships, um leaving women, girls and women feeling really really isolated. Um there can be some hypersensitivity issues like um sensory overload, maybe maybe I'm sorry, go ahead. Um, maybe like being they don't like to be touched.

SPEAKER_00 17:53

Yeah.

SPEAKER_01 17:55

Uh-huh. I think we have a bit of a lag there.

SPEAKER_00 18:00

I can I could fix that on the on editing, but um, I'm finding something interesting here that you mentioned cutting, you mentioned, you know, uh all these other types of behavior, substance use, all these other comorbidities, but now I'm wondering, you know, are these things diagnosed as depression, anxiety, substance use rather than a problem with ADHD?

SPEAKER_01 18:23

Yeah, yes, I think that that is a um that commonly happens. Um oftentimes clinicians uh focusing more on um the comorbid conditions that can go along with um ADHD. And so if a girl or a woman is presenting with anxiety or depression, a diagnosis of anxiety and depression tend to be the first go-to versus considering that this might be a symptom of undiagnosed ADHD, if if that makes sense. So the the lack of research and great information about ADHD in girls and women leads us to um not having the best diagnostic criteria by which to judge whether or not this person, this female in front of me has ADHD, or if um if it's anxiety or depression, clinicians are usually more familiar with anxiety, depression. So they girls ended up, girls and women end up getting those diagnoses versus having ADHD as the primary diagnosis and seeing those other things as symptoms. So that can really impact um the treatment regimen. You know, if you are given antidepressants, but you actually have ADHD, that's not going to be very effective. If you have, if you're given um medication for ADHD, that may relieve help relieve some of the symptoms of AD ADHD, give you better control over it, which in itself might relieve anxiety and depression without having to have medication to treat it. Does that make sense in how that that comes about?

SPEAKER_00 20:28

Absolutely.

unknown 20:29

Yeah.

SPEAKER_00 20:30

Absolutely. And so, and yeah, and in the course of you know, research has shown that women are more often diagnosed with an anxiety disorder than men. And so it's easy as a clinician to go, something presenting as anxiety to go, well, uh a woman presenting with anxiety, probably easy to you know, easy diagnostic here, but um, you know, and there is a bias uh towards that perhaps. So so uh I I can see where anxiety is getting looked over when it and excuse me, uh ADHD is getting looked over when it could be uh uh uh that instead of anxiety or depression.

SPEAKER_01 21:07

Yeah, that's right. So if um if women tend to have more anxiety, if that's what this statistics say, and um doctors are given less education on what ADHD looks like in girls and women, and the diagnostic criteria is pretty much based on what it looks like in young boys. You can see that there's an there's a a lot that's ha going on that's acting as a barrier to women getting a correct diagnosis and the correct treatment. And um it's just really important that we fix this, that we get better research, that doctors or any clinician diagnoses. Is thinking about all of these things that create a barrier for women and girls to getting a correct and earlier diagnosis for um ADHD.

SPEAKER_00 22:16

So, you know, ADHD, as you mentioned, is genetic. It is a very biological thing. And, you know, allow me to dip my toe in potential controversy, but you know, with many boys, our um our natures, our hormones, um, you know, the chemicals flowing through our male bodies tend to make us more aggressive and you know, liking to play rough and assertion and all that sort of thing. Or assertiveness, not assertion. Jeez, know my vocabulary. Um, but with with um with girls and women, um, how does you know the biological condition known as ADHD interact with you know female hormones nature and puberty and and all that sort of stuff? What does it look like through that lifespan?

SPEAKER_01 23:09

Okay, so that's really important. Uh that's a really wonderful and important question. Um, and I think it also this also ties into um why girls and women may not be being diagnosed as well. So um estrogen is um a really important hormone for um females and um estrogen increases during puberty. Estrogen impacts dopamine in our brains. Um it it it helps dopamine get to where it needs to be. Um so when um girls go through puberty and then they're having um monthly menstrual cycles. So the um during the first part of that uh menstrual cycle, I think it would be called like day zero to 14. That is the follicular phase of menstruation and estrogen is higher and increasing. I think that um that during that time of menstruation with the increase in estrogen, women tend to be doing better. You know, they're able, their memory is better, they can think better, they're feeling better, um everything is better. Once you go through um it's from the second half of the second two weeks of that span, is the luteal phase, uh, estrogen is decreasing. And so women can start to um feel more anxiety, more depression, their memories can start to be to not work as well, they're struggling for um recall of words, um, their attention is is less, they're feeling a little more emotional, that emotional regulation piece is off. Um and not and that is happening because of the um the decrease in estrogen. Okay, so if a theme, if a girl who is going through puberty or a woman is is um approaching a clinician thinking they may have ADHD or maybe they don't know what's going on with them, if the clinician isn't mindful or knowledgeable about how hormones affect the presentation of ADHD symptoms in women, they may attribute those symptoms, presentation of symptoms to another condition. They may um they may even just write it off as, you know, like a woman being hormonal or whatever, but they are very likely to miss how estrogen and the um shifting levels of estrogen in the body throughout the menstrual cycle impacts uh ADHD symptoms. Okay, so the knowledge around hormones and its effect on ADHD is really, really, really important in order for um clinicians to be able to understand what they should be looking for, how things might look different from week to week or even day to day as hormonal shifts happen. I mean, it's it's really um something that needs a lot more research and um better education for clinicians. Okay, so that's that's puberty and menstruation. Then you get to um women going through perimenopause, and there you have that slow decrease in estrogen, which is um negatively impacting all of those executive functions that um go well when we have enough estrogen helping with um dopamine. Okay, um, so it's slowly come pulling away that estrogen is you know, memory is harder, um, verbal recall is harder, um, attention, um focus, um, sleep gets messed up. Then, you know, so paramenopause is the reduction in estrogen until you get to there's no estrogen production, and then that's what menopause is, and women actually just simply live the rest of their lives like that. So then you are really struggling with um the executive functions are really negatively impacted by that lack of estrogen. And this can be a time when women who um weren't diagnosed as girls, the absence of that estrogen so magnifies the symptoms of ADHD that suddenly they're like, what is going on? And so sometimes this is the time in their lives, many women's lives, when they're actually getting diagnosed because you know they can start to worry, you know, it do I have dementia? Is that what's happening, you know? But what's actually going on is that the estrogen is gone, it's not helping your brain, the dopamine in your brain anymore. So um now your ADHD symptoms are just really magnified. Um, and so there is evidence to show that hormone replacement therapy actually is really beneficial for women in this stage of their lives. Like it just it gives back some of that estrogen that helps the brain function, um, in addition to all of the other um areas within the woman's body that estrogen helps. But the um impact on ADHD is um significantly better with hormone replacement therapy. And I know that there has been, you know, that's another thing against women, like that 2004 women's health initiative study that was misinterpreted, and then women were no longer women were afraid that they were gonna get have strokes, breast cancer, all of these things. Doctors stopped offering HRT to women, women stopped asking for it, and so we had this whole section of generations of women who didn't have it, who might have had ADHD, who couldn't utilize HRT to help with ADHD's um management. So it's they're just obstacle after obstacle after after obstacle that women face in order to get a diagnosis and then treatment for ADHD.

SPEAKER_00 30:26

Very good. So I think we have to pause there and and and so what we're gonna do when we pick up next time is what what the um you know what the experience and uh uh diagnostic criteria and treatment uh for ADHD should be when someone walks into uh into that doctor's office uh and what will be the most helpful thing. So Chasty, thank you for coming on this part one, and then we will pick up for part two in just a moment.

SPEAKER_01 30:53

All right, thanks.

SPEAKER_00 30:55

Thank you for listening to Mind and Medicine Essentera podcast. As a reminder, please check the show notes for details on how to claim your continuing education credits, as well as any resources mentioned today. That's it for now, but keep an eye out for another episode and more evidence based education for healthcare providers on the go. Be well.