should start at the time of diagnosis. The diagnostic evaluation can have
a powerful effect on the girl and her family. Sometimes, the emotional
circumstances get you their full attention. Other times they may be
overwhelmed and you may need to repeat the information later—when emotions
have cooled. If you are lucky and the girl is diagnosed at a young age,
you have a chance to mitigate the possible later consequences of AD/HD.
This girl may be at increased risk for depression, substance abuse, and
unwanted pregnancy. In this article the term AD/HD refers to both combined
type AD/HD and also to inattentive type AD/HD (The latter is often called
young girls with AD/HD
I tell the parents that
they need to start sex education early, and maintain an open dialogue with
their daughter about her romantic relationships. I ask the parents about
their own practices regarding alcohol and drugs. It is important that they
model responsible attitudes toward intoxicating substances. If their
daughter is going to be on medication, I talk to them about
differentiating prescribed medication from illegal drugs. I explain to the
girl the importance of never sharing her pills or using them the wrong
way. A kid may impulsively and (in their mind generously) give a pill to
an inattentive classmate end up expelled. Parents should never react to
misbehavior by saying, “Did you take your pill?”
During the diagnostic
interview, I have generally taken a history of family psychiatric
difficulties. If there is a family history of depression, bipolar disorder
or other illnesses, I go over the early warning signs with parents. This
is not predicting disaster; it is empowering them with extra knowledge.
Sometimes families want to
see what the medication does before adding psychosocial interventions. If
so, I still spend time educating them about educational, coaching and
Books or tapes are an
important part of educating the girl and her family, particularly if she
has a stereotype of AD/HD being a “hyper bad boy” disorder. Some girls
just love to learn more and will devour books on the subject. They may
become creative and come up with unique solutions to their differences.
Others might do better with audiotapes or having a parent read to them.
Girls with AD/HD are less likely to be troublemakers, so parents need to
become more active educational advocates.
Social acceptance is
especially important to most girls in our society. Because inattentive or
impulsive girls may have trouble reading social cues, they are often
unpopular. This can have a devastating effect on self esteem. I refer
parents to Fred Frankel’s book Good Friends Are Hard to Find. I
have middle and high school girls read How Rude! Parents and women
with AD/HD do well with What Does Everybody Else Know That I Don’t?
Sometimes school guidance counselors will have small “Friendship Groups”
that help kids who have trouble fitting in. The success of these groups
depends on not just the skill of the counselor but the mix of the group. A
shy inattentive girl might not fit in with a group of undersocialized
acting out peers. Girls often do well in therapy groups with other girls,
but it can often be difficult to find such a group in your area. A parent
may take the initiative to form a club around one of her daughter’s
interests. Some girls may do well with kids a year or two younger. A
popular, impulsive girl with AD/HD can be just as big a worry. If she
falls in with other impulsive kids, she may take dangerous risks.
If I am prescribing
medication, I prefer close medication monitoring. Studies have shown that
many people are dissatisfied with how a medication works and simply stop
it. Some girls and women are not assertive enough to complain about side
effects. I am specific about who will dispense the medication. Because
disorganization often runs in families, I encourage the use of the weekly
pill box. I also suggest that adults keep a couple of emergency doses in a
purse or glove compartment in case they discover, part way to school or
work that they have forgotten the medication. Longer-acting stimulants
have decreased the need for the embarrassment of the “play date”
Treating AD/HD during Adolescence
Although boys and some
girls get less hyperactive with adolescence, there may be a subset of
girls who show more irritability and activity when they enter puberty.
They may show more inattention and emotional instability in the
premenstrual phase. I feel that it is a good idea to track this for
several cycles before determining that it is related to the menstrual
cycle. AN SSRI, such as fluoxetine or paroxetine, given the week before
menses may be helpful. However this regimen can be difficult to
arrange—especially if the girl has irregular menses. Sometimes, we may
give the SSRI all month. In other cases, BCP may help both in regulating
the menses and in decreasing PMS. I like Vinnie’s Giant Roller Coaster
Period Chart & Journal Sticker Book. It is a humorous way to help
girls keep track of their periods and deal with PMS and cramps.
Adult Women with AD/HD
Women often get diagnosed
after they have brought in a child for treatment. Because I treat both
children and adults, I treat a lot of “matched sets.” It is not
unusual to start out with one child and end up treating several family
members. In my experience, it is often the most difficult to get the
father in for treatment. Adult women are more likely to volunteer for
treatment than are adult men. It’s not just AD/HD. Ask an optometrist
about who is first to come in for reading glasses. They see men who are
holding the book at arm’s length before they come for an eye exam.
Women are more likely to internalize: to blame themselves
and to become depressed. Inattentive or impulsive girls often feel that
“something” is wrong with them. Feelings of shame and guilt can layer
themselves in to a young woman’s personality as she grows up. When a woman
is first diagnosed with AD/HD, she may feel relief and a temporary
euphoria. She now has a name for her guilty secret. But a diagnosis does
not change an ingrained personality style. After the diagnosis comes the
real work. She must gain an in-depth understanding of how the AD/HD
affects her own unique strengths and weaknesses.
Many girls and women with AD/HD have co-morbid psychiatric
disorders. In women, I particularly look for depression, anxiety bipolar
disorder and substance abuse. I often do an in-office drug screen on
adolescents and adults who come in for an evaluation for AD/HD. Women are
more likely to hide their alcohol abuse. I try to get them to see the
substance abuse not as a personal flaw but just something they did to self
medicate that has gotten out of control. I like to refer them to 12 step
groups and group therapy. They might do well with a sponsor who also has
AD/HD. I am cautious about prescribing stimulants until the woman is in an
abstinence program. I would also be cautious about using Strattera, the
new non-stimulant AD/HD medication in those who smoke marijuana.
I encourage women to read about AD/HD. However, more and
more women come to the diagnostic session already having read books.
Women often bear more of the responsibility for maintaining
the household and raising the children. We expect the homemaker to provide
organization and structure for the rest of the family members. Office jobs
often have specific schedules and clear job descriptions. The home is much
less structured. Tasks may not have a clear beginning or end. Traditional
female careers may also involve responsibilities for keeping other people
organized. When I was considering a career in health care, my mother, a
former nurse, told me that I would be better off as a doctor because
nurses would help me keep organized. Secretaries and office managers,
traditionally female jobs, keep their bosses organized.
Some women may feel overwhelmed at the sheer number of
tasks in the home. It may be difficult to break down and prioritize tasks.
A woman with difficulty maintaining divided attention may blow up when her
children start asking for things while she is trying to fix dinner. She
may have difficulty providing the structure her children need to help
contain their own ADD. A woman prone to impulsive temper outbursts may
have difficulty disciplining her children. Occasionally this impulsivity
can lead to excessive punishment and even child abuse. If she has insight
into her impulsive tendencies, she and her family can plan to have “time
out” periods when arguments become heated.
If the woman has children with AD/HD or other special
needs, this can add to the demands and the domestic disorganization. Women
with AD/HD can make wonderful dynamic mothers. However, the larger the
number of children, the more sources of distraction. If I diagnose an
adolescent or a young woman, we might discuss limiting family size.
Stimulants are generally the first line medications for
individuals with AD/HD. Some women are elated that they can finally focus
but they still have problems with prioritization. Now that they can focus
better, they try to do a lot more, and end up sleeping less. The stimulant
enables them to “get away” with the sleep deprivation. However in a few
weeks or months, it catches up to them. They get depressed or irritable
and may chalk it up to medication side effects. They may also want to push
the dose of the stimulant too high.
Since women are at greater risk for anxiety and mood
disorders, I may medicate for both. However, some mood stabilizers make it
harder to focus, and if the antidepressant dose is too high, it may cause
apathy. It is important to be systematic and to track the effects of each
medication. Hormonal cycles may influence both attention and moods. It is
useful to track this over several cycles. The data on hormones and
attention is an area that is being studied. It is a difficult area of
study because of the variability of hormonal phases in women and the
hormones’ tendency to affect multiple organ systems. The hormone changes
of perimenopause may affect concentration and mood. More research is
needed in this area.
Unlike men, girls and women can get pregnant. This is a
consideration when prescribing medication, particularly for individuals
who tend to be impulsive. It is a good idea to review whether the
individual is sexually active and whether she uses birth control. I bring
this up at regular intervals. If a woman who takes medication for AD/HD
wants to become pregnant, here is what she should ideally do: Before she
starts trying to become pregnant, she should review her life circumstances
and make sure that she is in a relatively stable situation with social
support and sufficient financial resources to maintain a growing family.
She should consult with the physician who is prescribing her medication
and discuss her desire to become pregnant. She should review the risks of
her particular medications with her psychiatrist and with her
obstetrician. If many cases, she should work with her doctors towards a
trial off medications.
That is the ideal situation. Some women--particularly those
with good insight and a supportive partner--may actually do this. However,
sometimes the physician gets a call from a patient who is taking AD/HD
medications and has discovered that she is pregnant. If this occurs, the
patient should make an appointment as soon as possible to discuss her
options. This situation calls for collaboration between the psychiatrist,
the obstetrician and the patient.
If it is determined that she really needs medication during
pregnancy, some medications may be less risky than others. Women with mild
to moderate AD/HD and women who are able to arrange a less demanding
schedule during pregnancy might do well to try to stay off medications
during pregnancy. However women with severe AD/HD or who must work a
demanding job, may still need medication. Methylphenidate is a Class C
drug so we are cautious about suing it during pregnancy. There is some
data on the use of the tricyclic antidepressants in pregnancy. Another
option is Bupropion, a Class B medication. Clonidine (Catapress) is not as
effective for inattention but may be useful for women with impulsivity. We
are fairly comfortable using some of the SSRI medications during
pregnancy. The SSRI medications are not specific for AD/HD but can help
with depression and irritability. Sometimes an intensification of therapy
and an effort to reduce life stresses, can enable the woman to do without
medications during the pregnancy.
Medications and sexual performance: Some of the medications
used to treat AD/HD can either increased or, decrease sexual desire or
performance. Women should be aware of this in advance since they may be
reluctant to bring this up on their own.
Individual psychotherapy: This is useful for the woman who
has labored under years of feeling inferior and different. It can help
them identify maladaptive patterns related to the AD/HD and find better
ways of coping. Types of therapy may include insight oriented, cognitive
and behavioral therapy.
Couples and family therapy: AD/HD can put a major strain on
a marriage. People with AD/HD may have difficulty staying in
relationships. Sometimes we may start out simply by educating the spouse.
He may need to understand that the woman’s inattention of forgetfulness is
not an intentional affront. This type of education can collapse if the
spouse feels that the woman is trying to use AD/HD as an excuse. Extended
couples therapy may help the couple learn the difference between an
explanation and an excuse. It may help the non-AD/HD spouse learn to give
supportive structure without being controlling. If both members of the
couple have AD/HD. The therapist may need to help them arrange for outside
sources of structure and support.
Group therapy may be useful for social skills issues and
for helping the woman build a system of support. If the woman is able to
make suggestions that help other group members, she may begin to feel a
sense of competence. Psychodrama may be helpful for the woman who does not
like to sit still in a chair for the whole therapy hour.
12 Step Groups are useful for women who are involved
directly or indirectly in substance abuse. These meetings help foster a
sense of shared community and help the individual deal with issues of
blame and responsibility. Women in early recovery often do well in all
women's AA or NA groups.
Coaching: This is distinct from psychotherapy. A coach
talks to the woman daily, at regular intervals and helps her define and
clarify her goals. The coach also helps her prioritize. Since coaching is
not regulated, it is important to make sure that the coach is trained and
has experience. A mentor, a sympathetic teacher or a friend can partially
help in this area.
Planners and technological aids: I am a big believer in the
use of a day planner. Unfortunately, many people start out
enthusiastically but then trail off within a month. I like to refer people
to the Franklin Covey Seminar that has them spend a whole day learning how
to set up the planner and then has follow up to help encourage the
continued use of the planner. Women with organizational difficulty or
learning disabilities may benefit from the use of a computer, timers, and
writing aids such as Dragon Naturally Speaking or Inspiration.
Home Organization: There are people who will come in and
help a woman de-junk her home. This is not the same as a cleaning service,
although a cleaning service is also a good idea.
Assertiveness Training: This can be formal or informal. The
woman with AD/HD needs to learn to advocate for herself. She needs to be
firm about asking for what she needs.
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County Psychiatric Associates
Offices in Monkton and Lutherville, Maryland