treating Girls and Women with Attention Deficit Disorder

Young Girls

Adolescents

Adult Women

Medication

Psychosocial Treatments

Treatment

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

ADD.)

 

Treating

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

therapeutic options.

 

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”

medication dose.

 

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.

 

Treating

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.

Medication

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.

 

Psychosocial Treatments

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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Northern

County Psychiatric Associates

Offices in Monkton and Lutherville, Maryland 

 

 

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