ADHD (again) but this time re: "presents way differently in women"

Oct 13, 2008
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We've covered adult ADHD and testing in other recent threads, so perhaps we'll avoid retreading that ground.

More recently I've encountered two related phenomena that are new to me.

1. Therapists referring pts for "ADHD" and not in a "get the psych to say no" sort of way. Often I end up diagnosing the referred patient with an entirely different and usually pretty obvious diagnosis. I had two such pts yesterday with no apparent core impulsive or attentional issues and clearly mild ASD and significant anxiety.

2. Patients and referring therapists talking about how "ADHD presents way differently in women"--often when there's an obvious long standing mood disorder and history of high performance up until this year specifically.

I'm trying to be open minded and see if there's good reliable info about sex differences in ADHD. Maybe I'm actually missing something and not appropriately diagnosing more women with ADHD? I read this paper today which highlights what I think most of us were taught--hyperactivity is less common in girls. It then goes on to say that symptom severity may be milder in girls and there's more comorbid internalizing disorders--which is true of the female sex regardless of ADHD. They review the concept that internalizing disorders can be secondary to ADHD which I obviously believe in clear-cut untreated or incompletely treated ADHD from childhood cases.

I find it bothersome that they don't also mention how mood disorders can themselves cause inattention or difficulties with task completion, as if inattention is an independent trait and always means ADHD. It's also the biggest issue I'm having in that I'm getting referred women with excellent historical academic and work performance who are newly having difficulty staying on task this year trying to work from home and manage the kids simultaneously with a background context of pretty clear, long-standing mood/anxiety sx. Their therapists seem to be telling them that their anxiety or depression or whatever are signs of ADHD and not causes of inattention/task difficulty. They also aren't reviewing how disruptions in schedule, context, and added stress can further contribute.

Has anyone else come across this phenomenon of therapists concluding that any mood symptoms or minor isolated difficulty with task completion in their female patients are undiagnosed ADHD? Or that all procrastination is ADHD? There seem to be some more layperson-facing ADHD-interest websites (a lot of pts reference Additudes) and books ("So I'm not lazy etc.") that are promoting this concept, as well.

NB I haven't read the "lazy etc." book so I may be getting it confused with another one that some of my pts have mentioned.
 
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ExecutiveDysfunction

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We've covered adult ADHD and testing in other recent threads, so perhaps we'll avoid retreading that ground.

More recently I've encountered two related phenomena that are new to me.

1. Therapists referring pts for "ADHD" and not in a "get the psych to say no" sort of way. Often I end up diagnosing the referred patient with an entirely different and usually pretty obvious diagnosis. I had two such pts yesterday with no apparent core impulsive or attentional issues and clearly mild ASD and significant anxiety.

2. Patients and referring therapists talking about how "ADHD presents way differently in women"--often when there's an obvious long standing mood disorder and history of high performance up until this year specifically.

I'm trying to be open minded and see if there's good reliable info about sex differences in ADHD. Maybe I'm actually missing something and not appropriately diagnosing more women with ADHD? I read this paper today which highlights what I think most of us were taught--hyperactivity is less common in girls. It then goes on to say that symptom severity may be milder in girls and there's more comorbid internalizing disorders--which is true of the female sex regardless of ADHD. They review the concept that internalizing disorders can be secondary to ADHD which I obviously believe in clear-cut untreated or incompletely treated ADHD from childhood cases.

I find it bothersome that they don't also mention how mood disorders can themselves cause inattention or difficulties with task completion, as if inattention is an independent trait and always means ADHD. It's also the biggest issue I'm having in that I'm getting referred women with excellent historical academic and work performance who are newly having difficulty staying on task this year trying to work from home and manage the kids simultaneously with a background context of pretty clear, long-standing mood/anxiety sx. Their therapists seem to be telling them that their anxiety or depression or whatever are signs of ADHD and not causes of inattention/task difficulty. They also aren't reviewing how disruptions in schedule, context, and added stress can further contribute.

Has anyone else come across this phenomenon of therapists concluding that any mood symptoms or minor isolated difficulty with task completion in their female patients are undiagnosed ADHD? Or that all procrastination is ADHD? There seem to be some more layperson-facing ADHD-interest websites (a lot of pts reference Additudes) and books ("So I'm not lazy etc.") that are promoting this concept, as well.

NB I haven't read the "lazy etc." book so I may be getting it confused with another one that some of my pts have mentioned.

Interested in the topic (same with regard to ASD, although that’s for another thread I’m sure).

To answer your question of whether others have seen this. Yes, resounding yes. As a neuropsychologist, I have often seen this referral from midlevel medical providers and counselors. Although doctoral level staff are certainly not immune.

The issue definitely seemed to be with regard to sensitivity to presenting features and focusing on a facet of the presenting problem. I worked at a VA in the past, and I can’t tell you how many referrals were for adhd in people with no history, clearly exhibiting extreme anxiety symptoms secondary to obvious, uncomplicated textbook ptsd. Symptoms started after a particularly vicious battle, trouble focusing because of hypervigilance, etc. Like, idk treat the ptsd first and worry about “adhd” later, not the time for this.

We had a residential treatment program for women survivors of military sexual trauma, and many of those adhd referrals were at least complicated by longstanding symptoms predating military service secondary to early trauma/PD, but the same idea applies.

Don’t even get me started on the number of Bipolar diagnoses that, upon gathering of collateral from the diagnosing provider, were because of irritable mood (at baseline, no episodic nature) or mood swings (read as “sometimes they get mad/sad, sometimes they’re happy”).

So a slight digression, but at least to agree that you’re not alone. I suspect the subjective phenomenology and some of the presentation may differ, I’m not convinced that much of the real-world difference isn’t due to poor diagnosis and incorporation of personality traits/comorbid disorders into a “gendered” syndrome.
 
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When with a client who has ASD, we talk about the differences in attention that are related to "sticky attention" (difficulty shifting away from external stimuli, internal thoughts/dialogue, etc.). might present similarly to ADHD but is, in fact different (that's not to say someone might not have both, but just as a way of describing the differences in attention difficulties between the disorders when they may look similar).

OP mentioned "I find it bothersome that they don't also mention how mood disorders can themselves cause inattention or difficulties with task completion, as if inattention is an independent trait and always means ADHD" and yes, totally. I think that generally depression and anxiety should be considered and addressed first.

And also I think that if those have TRULY been addressed with full buy-in from the client, it's fair to consider ADHD as a question - high achievement in school doesn't necessarily mean ADHD isn't present also. Some bright folks may 1) have higher cognitive skills in general to lean on, 2) come up with some quite creative coping / accommodating strategies that work for them in that setting (and have accommodating teachers/parents even if they don't have a diagnosis or IEP) and may 3) put in more time to get the same amount of work done. and also maybe 4) get through ADHD related screwups or difficulties through good will of others willing to overlook some things just chalked up to part of the quirks/absentmindedness of an otherwise likeable person. I think think that it is possible that some people might get through most of life pretty well like this though they may be running a higher RPM underneath the surface and then when something else gets thrown into the picture - job change, new responsibility, etc., they were already putting in more time or cognitive effort or whatever, or maybe it is a situation where their usual coping strategies aren't easily generalized, and the wheels fall of the bus where the average person might have been able to adapt more easily. I hypothesize that people who fall into this bucket though would very easily be able to spout off different strategies that they used to get through school and strategies they currently use in their lives to accommodate for whatever their perceived difficulties are.

for whatever reason(s), some folks aren't willing to go the route of truly considering the anxiety route by putting time into skills and strategies to address that first, even though it's the more likely explanation many times. pursuing meds seems like an easier, quicker, more palatable approach than therapy to address anxiety and try to untangle that even if that's what they really need and it doesn't take a provider long to just put in a referral to psych.
 
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Merovinge

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I'm surprised that you are just now experiencing this. I have had lots of therapists who are not capable/trained/willing to do CBT for a very obvious anxiety disorder recommend psychiatric evaluation for psychostimulants beyond the cliché family's who simply want their kid to do better in school. The reality that ADHD has such a readily available treatment that works as well as it does is likely the big driver behind medical/psychology folks "discovering" the diagnosis. I assure you that if ADHD had treatments no better than Wellbutrin you would be seeing a tiny fraction of these referrals.

The gender differences in women are largely related to less hyperactivity, but frankly many parts of the system do a poor job with ADHD-IT for both genders. I've seen kids who felt they were "lazy" and families/schools that believe these are character flaws have life changing response to stimulant tx. I don't think any CAP are missing this, but given the bulk of referrals and diagnosis by schools/PCPs there is certainly a group being missed.
 
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clausewitz2

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I have also heard therapists say they don't do exposure-based treatments for anxiety because they feel like it's 'mean', which... isn't not crueler to withhold something very likely to work? Guess colluding with the anxiety is more comfortable for some clinicians than confronting it.

@singasongofjoy , do you have any citations or literature on sticky attention? I would love to know more and ASD/ADHD overlap/differential is one that has come up a lot recently in my practice.
 

birchswing

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I have also heard therapists say they don't do exposure-based treatments for anxiety because they feel like it's 'mean', which... isn't not crueler to withhold something very likely to work? Guess colluding with the anxiety is more comfortable for some clinicians than confronting it.

@singasongofjoy , do you have any citations or literature on sticky attention? I would love to know more and ASD/ADHD overlap/differential is one that has come up a lot recently in my practice.
Interoceptive or graded real life exposure?

I won't talk about my own experiences, but I'll say I have negative opinions of the former and positive about the latter.
 

whopper

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Not related but this reminds me of something from my 20s. I remember a college housemate. Nice girl, we were good friends, but we had a serious sexism problem between us that rubbed me the wrong way.

She was a very strong self-identified feminist. Great I got not problem with this, I even like it. So here's the problem. Any talk, any data showing that men in some way performed better on some metric, she'd get really really really mad connecting it to sexism. Of course almost everyone will agree men perform better on some metrics as a whole such as weight lifting, women perform better on others such as multi-tasking but individuals can't be judged on these generalities. Just the mere discussion of the metrics got her mad and she'd argue there's no difference at all between the sexes. (Hey if you brought up the physical genitalia are different she'd argue you're oversimplifying).

So lo and behold at the time the book Men are from Mars, Women are from Venus comes out and she thinks the book is just the next best thing since sliced-bread not connecting her hypocrisy, but because that book presented it in a fun and sexy manner she can't see it.

Also a friend of mine in my 20s was a huge womanizer. In fact later on I even ended our friendship because his womanizing was pathological, but in my early 20s it didn't mushroom to the pathological levels it did in his late 20s. When she found out a friend of mine was a womanizer she got into this critical judgment rant against me. Well its a few days later, he shows up, to our off-campus college house to hang out, and she's like "oh he's so hot!!!" looking at him with lovey dovey eyes.
 

clozareal

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That's interesting because 25% of my child panel are boys with ADHD which is consistent to the 2:1 male:female ratio reported in children. If they don't have ADHD symptoms before age 12, it cannot be ADHD per the DSM. I have several kids who have clear ADHD but have no distress or impairment because their parents are reminding them of all deadlines, sitting with them until they finish their work, and proofreading it for them so their grades are excellent despite doing worse on tests.

Diagnosing distractibility and inattention comes from looking for accompanying features: are they distracted becauase they're too worried about x, y, and x (GAD)? Are they inattentive because they don't care and are uninterested in lots of things they used to enjoy (MDD)? Are they distracted by voices in their head or too focused on delusional content (schizophrenia spectrum)? Are they distractible because they have a million thoughts and can't sleep and feel great because they're doing a lot more than they used to do in an episodic way (hypo/mania) or are they hyperactive, restless, and impulsive chronically (ADHD)? Did it start after a traumatic event (PTSD)?

There are also those who are clearly bright, had a lower severity of ADHD, and their environmental demands didn't exceed their capabilities until they go to college or even graduate/medical school. There are also those who don't have parents to advocate for them or teachers to recognize this and then don't get diagnosed despite having childhood report cards of "trouble following instructions, cannot sit in seat, doesn't listen, blurts out in class too much" with below average but passable grades.

I'm not aware of any studies talking about atypicalities in diagnostic criteria in female patients. Historically and socially, perhaps boys were expected to do better than girls in school and then start working before they turn 18 which may lead to the expectation that boys had more external obligations to be impaired from.

I haven't read too much about adult-onset ADHD although this paper and this paper seem to think it's a distinct clinical entity. Of course in any clinical examination, screening for co-morbidities is of the utmost importance. I tend to see in children more clear-cut ADHD without any mood or anxiety or substance use or other co-morbidities whereas in adults it's much more common. It would be classified as Other Specified ADHD in this case since they didn't have symptoms before age 12.
 
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I have also heard therapists say they don't do exposure-based treatments for anxiety because they feel like it's 'mean', which... isn't not crueler to withhold something very likely to work? Guess colluding with the anxiety is more comfortable for some clinicians than confronting it.

@singasongofjoy , do you have any citations or literature on sticky attention? I would love to know more and ASD/ADHD overlap/differential is one that has come up a lot recently in my practice.
It's not a feature I would use to differentiate the diagnosis, really- certainly not easy to measure (though on the BRIEF some of the attention items sort of address that). Rather, I use it as a way to explain to parents that what they are perceiving as ADHD-type inattention might not really be that- so they shouldn't be wedded to the ADHD diagnosis they've previously received- let's try teaching / engaging in ways that fit better with their cognitive/learning profile including using that idea of "sticky attention" to inform thinking about environment and teaching (how to incorporate interests, sensory differences, etc in a way that increases engagement and learning) so maybe we should try those things before they run to the PCP for the adderall. The conceptualization can also be helpful in decreasing parent frustration by helping them see that maybe their kid isn't engaging in purposeful selective ignoring of their parents, but rather they're not responding to you when you call their name sometimes because when their attention is being a bit sticky, it takes MORE to help them shift attention AWAY from something and on to something else than it does for the average kid - so maybe it's on you to recognize that and accommodate by getting their attention in a different way rather than blaming the kid for being defiant.

re: literature, Not readily available to copy-paste resources at the moment any more than a google search would pull up. But it did make me recall something from INSAR a few years ago - the study actually didn't find compelling overall differences supporting previous research in the area but rather that sticky attention was characteristic only in certain circumstances- which fits the descriptions I've heard from adults on the spectrum talking about their attention and working through developing strategies for them to use to help shift and re-engage their attention to the task at hand. It's so different / idiosyncratic from person to person- e.g., one person I am working with right now gets so stuck (and frustrated by getting stuck when she is trying to work etc) by certain kinds of angles/lines coming together in her visual field. I don't know how one would go about measuring what we are calling sticky attention and therefore I don't think it is useful for differential exactly (maybe if you have an adolescents or adult who can describe it as well as some of my folks have, but that would be rare I think). Nonetheless I think it is a useful concept. here's the abstract to the insar thing I just remembered, for what that is worth. 2017 International Meeting for Autism Research: ‘Sticky’ Attention in Children and Youth with Autism Spectrum Disorder: General Deficit or Task Dependent?.
 
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Ceke2002

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I find it bothersome that they don't also mention how mood disorders can themselves cause inattention or difficulties with task completion, as if inattention is an independent trait and always means ADHD. It's also the biggest issue I'm having in that I'm getting referred women with excellent historical academic and work performance who are newly having difficulty staying on task this year trying to work from home and manage the kids simultaneously with a background context of pretty clear, long-standing mood/anxiety sx. Their therapists seem to be telling them that their anxiety or depression or whatever are signs of ADHD and not causes of inattention/task difficulty. They also aren't reviewing how disruptions in schedule, context, and added stress can further contribute.

Has anyone else come across this phenomenon of therapists concluding that any mood symptoms or minor isolated difficulty with task completion in their female patients are undiagnosed ADHD? Or that all procrastination is ADHD?

This was one of the biggest frustrations for me in my, admittedly brief, foray into stimulant treatment for ADHD. Aside from the fact that in my case the benefits of medication did not out weigh the side effect profile, once I got the diagnosis (or re-diagnosis in my case, having already been diagnosed in childhood) as an adult suddenly everything was automatically equated with ADHD. Issues with concentration or distraction due to stress, anxiety, low mood, sleep deprivation, etc? None of that stuff matters, it's all ADHD all the time. Part of me did wonder if my treating Doctor at the time wasn't perhaps using it as a type of waste paper basket diagnosis in order to reduce the potential workload of a complex case down to a singular, simpler diagnosis.

In my experience as well difficulties with concentration and/or distractibility due to a mood or anxiety disorder, for example, is very different to difficulties with concentration et all due to ADHD. I don't think I could explain, or quantify, exactly what the difference is, but there is a difference.
 
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IMGer

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This was one of the biggest frustrations for me in my, admittedly brief, foray into stimulant treatment for ADHD. Aside from the fact that in my case the benefits of medication did not out weigh the side effect profile, once I got the diagnosis (or re-diagnosis in my case, having already been diagnosed in childhood) as an adult suddenly everything was automatically equated with ADHD. Issues with concentration or distraction due to stress, anxiety, low mood, sleep deprivation, etc? None of that stuff matters, it's all ADHD all the time. Part of me did wonder if my treating Doctor at the time wasn't perhaps using it as a type of waste paper basket diagnosis in order to reduce the potential workload of a complex case down to a singular, simpler diagnosis.

In my experience as well difficulties with concentration and/or distractibility due to a mood or anxiety disorder, for example, is very different to difficulties with concentration et all due to ADHD. I don't think I could explain, or quantify, exactly what the difference is, but there is a difference.
Give "Outside the Box: Rethinking ADD/ADHD in Children and Adults" a read, it's a great book by Dr. Thomas Brown. It will help conceptualize the nuances.

I think the emotions, anxiety, stresses absolutely play a part and a large number of patients, families, and clinicians would love to lump everything under a diagnosis, the eureka moment. But this is how most people would like life to turn out. Anxiety is crucial in ADHD, but it's not so strongly felt or prevalent as it is in GAD. The mere taste of it, whether conscious or unconscious can set off inattention/impulsivity. People with ADHD and their issues with executive function revolve around their limited perspective, limited working memory, and strong habituation/attitudes which were formed based on previous experiences. And because of their poor executive function, cannot recall in the moment and fall prey to their impulsive/inattentive tendencies. Exciting thoughts are ever so exciting, and if you string them together in a row for them, they'll get hypomanic almost. I find their default mode network to be working all the time (my own thought).
 
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