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ADHD & Women's health.

As Quita Remick puts it, her life was one drama after another. The bills went unpaid, she couldn't focus, she was always rushing. A tennis coach and player, she couldn't even keep her eye on the ball. Every bird that flew by, leaf that fluttered down or noise from the sidelines distracted her. Then a student's mother handed her a book. Called Driven to Distraction: Recognizing and Coping With Attention Deficit Disorder from Childhood Through Adulthood (Touchstone Publishers, 1995), it changed Ms. Remick's life.

"I was like, 'Oh my God, oh my God. This is me!'" the 38-year-old recalls of that time eight years ago. Now living in Washington, DC, and preparing to return to school to get her Masters in Business Administration, Ms. Remick openly talks about her diagnosis with Attention Deficit Hyperactivity Disorder (ADHD), a condition most often associated with school-age boys, not middle-aged women.

That association is changing, as the diagnosis in girls catches up with boys, and as more and more women learn that their disorganization, inability to focus, sense of perpetual chaos and social difficulties aren't due to some defect in their personality, but to a chemical dysfunction in their brain.

"Once the correct diagnosis is made, we can effectively change what is going on in these women's lives," says Patricia Quinn, MD, director of the National Center for Gender Issues and ADHD in Silver Spring, Maryland.

Difficulties with Diagnosis

Although the prevalence of ADHD in this country continues to be debated, recent research suggests it affects at least 7.5 percent of school-aged children and 4.5 percent of all adults. (1,2)

For years, it was believed those children were primarily boys, probably because most studies were conducted on children referred to ADHD clinics. Girls, because they were so underdiagnosed, weren't in the clinics, notes Stephen Hinshaw, PhD, professor of psychology at the University of California-Berkeley and the lead researcher of one of the largest studies ever conducted on girls with ADHD.

Girls often don't get diagnosed because ADHD can look quite different in females than in males, he says. Instead of hyperactive, girls with ADHD may be shy. Instead of failing in school, they may maintain good grades, albeit with tremendous effort. "A lot of parents say to me that their daughter is still doing okay academically, and I say, 'Yeah, but at what cost?'" notes Dr. Quinn. Girls generally look their teacher in the eye, even if they're not listening to what's being said, so it's hard to say a girl isn't paying attention. "They're not paying attention in school, and they're disorganized, but they're not causing trouble because they're not disruptive" like the boys, she notes. Hence, they're less likely to be referred for evaluation.

Still, some girls do fit the bill of the traditional ADHD kid, as Debra Calderon, 41, of Engleton, TX, knows all too well. Her daughter, Lauren, now 10, was first diagnosed with the disorder in first grade. "She was a relatively settled child, who could sit through a movie until age three, and then she could not sit still, talked incessantly and was unable to focus on things," recalls Ms. Calderon.

Overall, however, Dr. Quinn says, girls with the disorder are more likely to fall into the "predominantly inattentive" subtype of ADHD, rather than the "predominantly hyperactive-impulsive" type or a combination of the two.

When Dr. Hinshaw's team observed girls with ADHD in a summer camp he runs for them, they found the girls were often very shy, confused about what the teacher (or counselor) said, had problems understanding directions and difficulty reading social cues from their peers. In addition, those with the combined type showed significant disruption and even aggression, similar to behaviors observed in boys with ADHD. Intriguingly, both types showed marked problems with planning, goal-setting and self-organizing tasks. (34)

With more professionals becoming aware of male/female differences in the manifestation of ADHD in children, the disorder's gender gap is shrinking. "We used to say the ratio was about seven to one," says Robert Resnick, PhD, professor of psychology at Randolph-Macon College in Ashland, VA. "Now it's about three to one."

Still, the improved diagnosis in girls is a fairly recent phenomenon, which is why thousands of women are having the same kind of "Aha!" moment Ms.Remick had--an epiphany that often occurs when their own child is diagnosed with the condition.

Genetic Link Strong

That's because the genetic basis for ADHD is strong: most cases are inherited with a small percentage being due to environmental factors. In fact, ADHD is among the most recognized genetic-based disorders in psychiatry. (5) If one parent has ADHD, there's a 50 percent likelihood that her or his child will have the disorder, says David Goodman, MD, assistant professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine in Baltimore, MD.

Environmental causes of ADHD include prenatal and postnatal factors as well as delivery complications. Prenatal use of alcohol, tobacco and cocaine and delivery complications may alter brain development in the fetus/baby, resulting in the condition. Additionally, some postnatal problems, such as meningitis, encephalitis, chronic lead exposure or anemia during the first two years, or severe head trauma, can result in ADHD.

Brain Differences

For years, researchers relegated ADHD to a psychological problem despite the belief there had to be some brain abnormality involved. With the development of more sophisticated brain scanning techniques, they now know that people with ADHD have anatomical differences in their brains, as well as differences in the neurochemical function that controls mood, thoughts and impulses.

"We see certain areas (of the brain) that are smaller, or have structural abnormalities compared to those without ADHD," says Dr. Quinn. And, notes Dr. Hinshaw, who is in the midst of a study evaluating adolescent girls' brains with ADHD, "there is tantalizing evidence that the brains of girls with ADHD may be different than the brains of boys with ADHD."

Children with ADHD may also have differences in their brain wave activity. One study demonstrated that subjects with ADHD had slower brain waves than those without ADHD, but that the brain waves of girls with ADHD were just half as slow as boys'. (6)

Another biological component of ADHD has to do with levels of two key neurotransmitters in the brain, notes Dr. Quinn: dopamine and norepinephrine. Dopamine is involved with transmission of nerve impulses throughout the brain, and is the precursor to norepinephrine, thought to be essential in regulating impulse control, organization and attention. Those with ADHD generally have higher levels of a protein that alters the level of dopamine, resulting in a dopamine (and thus norepinephrine) deficiency. Medications like Concerta (methylphenidate HCI) and other stimulants work directly on this mechanism, making more dopamine available for the brain by blocking those proteins, while the newest ADHD drug, Stratrera (atomoxetine), works only on the norepinephrine pathway.

Growing Up With ADHD

Of course, if ADHD is related to physical changes in the brain, it stands to reason it's not something you "outgrow." Yet for decades, that's exactly what health care professionals believed happened. Dr. Resnick recalls seeing adolescents who had been diagnosed with ADHD as children, but taken off their medication once they hit puberty. "The only thing that changed in the child was that she was no longer eight; she was 16. But doctors thought that Ritalin wouldn't work in teenagers," he said. When he recommended the teens go back on medication, their behavior improved.

Now researchers know that ADHD may persist through the lifespan, with 80 percent of those diagnosed as children continuing to have the condition through adolescence, and up to 50 percent of these children having symptoms continue into adulthood. (7,8,9)

Diagnosing and treating adults is challenging. The diagnostic criteria, with its emphasis on school behavior and performance, were specifically designed for kids, not adults. Hyperactivity, for instance, tends to dissipate in adulthood, although mounting adult responsibilities may accentuate other impairments such as inattention.

Juggling the multiple demands society places on them is tough enough for most women today, but for women with ADHD, the struggle grows to nearly unimaginable dimensions. "I would lose things all the time, miss deadlines. Something as simple as writing a check for a bill and putting it in an envelope and getting it out the door on time was impossible for me," says Ms. Remick.

Women (and adolescent girls) with ADHD face special challenges. For instance, they're more likely to suffer from other mental health conditions, such as anxiety disorders, depression, eating and sleeping disorders and substance abuse, than males, says Dr. Quinn. She suspects that while some of these conditions co-exist with the ADHD, some, such as depression, may generate from the ADHD itself. For instance, girls and women with ADHD tend to blame themselves. "They say, 'this is my problem, my fault, nothing is ever going to be better for me,'" says Dr. Quinn. Whereas boys and men tend to externalize difficulties; for example, if they get a bad grade on a test, they blame it on the test. According to Dr. Quinn, girls' self-critical internalization wreaks havoc with their self-esteem, eventually leading to depression.

One of the few studies of ADHD in women found that women who weren't diagnosed until they were adults had developed a learned helplessness, and felt they had no control over their lives. (10) "They said they felt dumb and stupid," Dr. Quinn said.

Treatment Varies

For years, Lauren Calderon careened from one medication to another in search of help with her ADHD. Finally, the fourth grader ended up on a long-acting form of methylphenidate, Concerta, and the antidepressant Zoloft. The Zoloft helps with her obsessive-compulsive disorder, while the Concerta calms the ADHD.

"Everything is better," says her mother. "She's more focused, more settled. She's on the AIB honor roll consistently and maintained an 'excellent' or 'satisfactory' grade for behavior for the first time ever.

Stories like Lauren's are quite common, and one reason why diagnosing ADI-ID is so important. Left untreated, research shows that children with ADI-ID can suffer academically and experience behavioral, social and emotional problems through adulthood. (11) Yet a variety of treatments, including medication, behavior modification, cognitive behavioral therapy, lifestyle changes, and sometimes biofeedback, can make a tremendous difference.

The American Academy of Pediatrics recommends in its 2000 clinical practice guidelines on the treatment of the schoolage child with ADHD that: "The physician should recommend stimulant medication and/or behavior therapy as appropriate to improve target outcomes in children with ADHD."

The diagnosis itself, however, must be approached very carefully, cautions Dr. Hinshaw. "It can't be done during a routine office visit." An assessment of ADHD should involve, at the very least, comprehensive information from parents and teachers, usually in the form of standardized checklists; a thorough history, including a psychological evaluation of the child, to rule out the many factors that can mimic ADHD; and an extensive medical evaluation, to ensure that the child does not have a neurological condition (like a seizure disorder) that could be mistaken for ADHD. Cognitive and achievement testing also is important to assess if learning disorders are present. Involvement of a mental health professional with expertise in childhood behavioral and emotional problems in the assessment process may be recommended. Adults should check with the nearest large medical center, many of which now have ADHD centers.

Managing the Medication

Overall, about 50 percent of children and 13 percent of adults with ADHD are treated with medication, (12) usually with stimulants such as methylphenidate (Riralin and Concerta) and amphetamine (Dexedrine and Adderall). Adderall and Concerta are two long-acting forms of the drugs, with effects lasting eight and 12 hours respectively for a single dose. (13,14)

Although methylphenidate is perhaps one of the best-studied drugs available, with thousands of studies attesting to its longterm safety over the past 50 years, that hasn't stopped critics from raising alarms about the drug's long-term use on children's developing brains, particularly given research that finds the numbers of children taking the drug skyrocketing in recent years. (15) But several studies published in late 2002 find such worries baseless. One, in the Journal of the American Medical Association reported on a 10year study by the National Institute of Mental Health that found that while the brains of children and adolescents with ADHD are three to four percent smaller than those of children who don't have the disorder, medication is not the cause.

There has also been concern that long-term use of stimulants, which are chemically similar to cocaine, might lead to substance abuse, with one study showing a small correlation. The other 11 studies conducted on this issue found just the opposite, however: that children with ADHD medicated with stimulants were less likely to engage in substance abuse. (16) Two studies published in the January 2003 issue of Pediatrics, one that followed 146 children for 13 years, should put an end to the debate, with neither finding any greater risk of substance abuse in children who used stimulant medication to treat their ADHD. (17,18)

Another concern about stimulant medication has been whether it affects children's growth, with some earlier studies showing a correlation. A study presented at the American Psychiatric Association meeting in May 2002 on children who have used Concerta (a long-acting form of methyphenidate), for one year, however, found little difference in growth patterns between children taking the medication and those not taking it. (19) Most research findings also dispute any alleged connection between methylphenidate and tics, another concern, with one study finding that children with tics treated with the drug actually experience an improvement in their tics over time. (20)

In late 2002, the U.S. Food and Drug Administration approved Strattera, the first non-stimulant medication to treat ADHD . (21,22) Unlike stimulant medications, which work by a mechanism that inhibits the reuptake of two neurotransmitters (norepinephrine and dopamine) believed to play a role in ADHD, Strattera is classified as a "selective re-uptake inhibitor" and works only on blocking receptors in the brain that take in and dispose of norepinephrine. More long-term, comparative studies are needed to determine the efficacy and safety of Strattera, as compared with the proven efficacy of stimulant medications.

Research demonstrates that about 80 percent of children with ADHD who are treated with stimulant medications improve their functioning. (23) For those who don't respond to them, certain antidepressants, such as Wellbutrin (buproprion) and antihypertensives such as Clonidine (catapress), are commonly used as a second line of treatment, according to Dr. Resnick.

But no matter how successful medication is in treating ADHD, it should never be the only remedy. "One thing that's very important for girls and women is therapy to deal with the issues of self-esteem, depression and life issues that often occur with ADHD," says Dr. Quinn. Mothers and daughters who both have the disorder should especially consider counseling, as their relationship can become fraught with more than the typical challenges throughout adolescence, she says. Experts also recommend behavior modification for disruptive behaviors, and life skills coaching for dealing with the everyday challenges ADHD presents.

Resources

Children and Adults with Attention Deficit Hyperactivity Disorder

8181 Professional Place, Suite 201

Landover, MD 20785

1-800-233-4050

www.chadd.org

Provides information and support to those with ADHD and their families. Spanish and English resources at Web site.

National Center for Gender Issues and ADHD

1001 Spring Street, Suite 206

Silver Spring, MD 20910

1-888-238-8588

www.ncgiadd.org

Promotes awareness, advocacy and research on ADHD in women and girls; publishes. "ADDvance," magazine.

Attention Deficit Disorder Association

1788 Second Street, Suite 200

Highland Park, IL 60035

847-432-2332

www.add.org

Provides information and support for adults and young adults with ADHD; publishes "Focus," magazine.

Attention Deficit Information Network

58 Prince Street

Needham, MA 02492

617-455-9895

www.addinfonetwork.org

Provides up-to-date information on ADHD research and regional meetings.

Learning Disabilities Association of America

4156 Library Road

Pittsburgh, PA 15234

412-341-1515

www.ldanatl.org

Web site offers information on learning disabilities and related education issues.

References

(1.) Barbarest WJ, et al. How common is ADHD? Incidence in a population-based birth cohort in Rochester, Mins. Arch Pediatr Adolest Med. 2002 Mar; 156(3):217-24.

(2.) Incidence of 40110 in Adults, PCC Visuals, Nov 2002

(3.) Hinshow, S.P. (2002); Preadolescent girls with ADHO: I. Background characteristics, comorbidity, cognitive and social functioning, and parenting practices. Journal of Consulting and Clinical Psy-chology, 70, 1006-1096.

(4.) Hinshaw SP, et al. (2002). Preadolescent girls with ADHO. II. Neuropsychalogical performance in relation to subtypes and individual classification. Journal of Consulting and Clinical Psychology, 70, 1099-1111.

(5.) McGuffin P et al. 2001. Toward behavioral genomics. Science 291:1232-49

(6.) Kovatchev B, et al. A psychophysiologlcal marker of ADHO-defining the EEG consistency index. Appl Psychophysiol Biofeedback. 2001 Jun; 26(2):127-40.

(7.) Muguffin P, et al. 2001. Toward behavioral genomics. Science 291:1232-49

(8.) Barkley RA (1998). ADGD: A handbook f or diagnosis and treatment (2nd ed.). New York: Guilford Press.

(9.) Mannuzza S, Klein, RG. (1999). Adolescent and adult outcomes in ADHD. In HC Quay & AF Hogan (Eds.), Handbook of disruptive behavior disorders (pp. 279-204). New York: Plenum Press.

(10.) Rucklidge JJ, Kaplan 8J. (1997). Psychological functioning in women identified in adulthood with attention deficit/hyperactivity disorder. Journal of Attention Disorders, 2,167-176.

(11.) Impact Survey 2001, yew York University Child study Center.

(12.) www.Strottera.com

(13.) www.Concerta.net

(14.) www.rxlist.com

(15.) Zito JM, et al. Psychotropic proctice patterns for youth: a 10-year perspective. Arch Pediatr Adolesc Med. 2003 Jan; 157(1):17-25.

(16.) Barkley RA, et al. Does the treatment of ADHD with stimulants contribute to drog use/abuse? A 13-year prospective study. Pediatrirs. 2003 Jan; 111(1):97-109.

(17.) Wilens TE, et al. Does Stimulant Therapy of 40110 Beget LaterSubstance Abuse? A Meta-anolytic Review of the Literature. Pediatrics 2003 Ian; 111(1):179-85.

(18.) Barkley P.4, et al. Does the treatment of ADHO with stimulants contribute to drug use/abuse? A 13-year prospective study. Pediatrirs 2003 Jan; 111(1):97-109.

(19.) ADHD treatment with a once-daily formulation of methylphenidate: effect on growth and tics, European Neuropsychopharntacology 2002;12(Suppl 3):5413 (abstract). Presented at the 15th Congress of the European College of Neuropsychopharmacology, 2002 (poster)

(20.) Treatment of 40110 in children with tics: a rondomized controlled trial. Neurology. 2002 Feb 26; 58(4):527-36.

(21.) www.Strattera.com

(22.) FDA Talk Paper: FDA Approves Non-Stimulant 40110 Drug, Nov. 26, 2002, www.fda.gov

(23.) Journal of Attention Disorders (Special Issue) (2003). ADHD and methylpheoidate: 40 years' perspectives.

(24.) National Institutes of Health Consensus Panel on ADHD. National Institutes of Health consensus development conference statement: diagnosis and treatment of 40110. J Am Acad Child Adolesc Psychiatry. 2000; 30:182-193

(25.) Leibson CL, et al. Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder JAMA. 2001 Jan 3; 285(1):60-6.

(26.) Hankin, CS et al., The Burden of 40110. Drug Benefit Trends, Vol. 12, Issue 4: April 2001

(27.) Breen MJ, Barkley P.4. Child psychopathology and parenting stress in girls and boys having attention deficit disorder with hyperactivity. J Pediatr Psychol. 1908 Jun; 13(2):265-80.

(28.) Ibid.

(29.) Mash EJ, Johnston C. Parental perceptions of child behavior problems, parenting self-esteem, and mothers' reported stress in younger and older hyperactive and normal children. J Consult Clin Psychol. 1983 Feb; 51(1):86-99.; Baker DB, McCa K. Parenting stress in parents of children with attention-deficit hyperactivity disorder and parents of children with learning disabilities. J Child ram Stud. 1995;4:57-68

(30.) Hankin CS et al., The Burden of 40110. Drug Benefit Trends, Vol. 12, Issue 4: April 2001

(31.) Ibid.

(32.) Brown RT Pacini JN. Perceived family functioning, marital status, and depression in parents of boys with attention deficit disorder. J Learn Disabil. 1989 Nov; 22(9):581-7.

RELATED ARTICLE: ADHD's Wide-Ranging Impact

The effects of ADHD extend far beyond the classroom, often wreaking havoc on everything from school budgets to sibling relationships. In 1995, for instance, public schools spent more than $3 billion on students with ADHD, (24) while health care costs for children with the condition are twice those for children without the disorder. (25) Children with ADHO are four times as likely to fight with or engage in other negative behavior with their siblings. They also use more mental health services, have more frequent emergency department visits and higher rates of pedestrian, bicycle and driving accidents than children without ADHD. (26) All of which places extreme stress on their parents.

It doesn't matter if the child with ADHD is male or female; parenting either is equally stressful. (27) Overall, mothers of children with ADHD report significantly higher levels of parenting stress than mothers of children with other chronic disorders, and are more likely to become depressed.(28, 29, 30) Parents of children with ADHD are also more likely to have drinking problems than parents of children without the disorder, and experience increased absenteeism and decline in productivity in the workforce. (31)

Of course, this places tremendous strain on any marriage; so it's no wonder that parents of children with ADHD are three to five times more likely to become separated or divorced. (32) Patricia Quinn, MD, director of the National Center for Gender Issues and ADHD, notes "that doesn't even take into account the toll of undiagnosed ADHD cases, which is likely at least as high" as those diagnosed.

Books

Hallowell, Edward M., Ratey, John J., Recognizing and Coping With Attention Deficit Disorder from Childhood Through Adulthood, Touchstone Publishers, 1995.

Nadeau, Kathleen G., and Quinn, Patricia O., eds. Understanding Women with ADHD Advantage Books, 2002.

Solden, Sari. Women with Attention Deficit Disorders: Embracing Disorganization at Home and in the Workplace. Underwood Books, 1995.
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Title Annotation:attention-deficit hyperactivity disorder
Publication:National Women's Health Report
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Date:Feb 1, 2003
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