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.
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 the women, in consultation with her psychiatrist and her obstetrician, determine 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 using 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 sometimes use some of the SSRI medication ssuch as fluoxetine (Prozac) 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 manage 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.