Women With ADHD: It Is an Explanation, Not
the Excuse Du Jour ppc_254
Roberta Waite, EdD, APRN, CNS-BC
PURPOSE. To call attention to attention deficit
hyperactivity disorder (ADHD) as a psychiatric
disorder that can limit women’s potential and
overall well-being.
CONCLUSION. ADHD, a legitimate
neurobiological disorder that is often hidden,
ignored, or misdiagnosed among women, causes
them to struggle in silence. Proper interventions
for women with ADHD that provide significant
attention to context mitigate challenges across
psychological, academic, occupational, and social
domains. This should amend the diagnosis du
jour concept, thereby supporting mechanisms to
improve early intervention and positive
outcomes.
PRACTICE IMPLICATIONS. Primary care
practitioners play a central role in recognition,
intervention, and recovery of women with
ADHD.
Search terms: ADHD, gender, multimodal
treatment, recovery, review, women
First Received February 24, 2009; Final Revision Received
September 17, 2009; Accepted for publication October 13, 2009.
182
doi: 10.1111/j.1744-6163.2010.00254.x
182..196
Roberta Waite, EdD, APRN, CNS-BC, is Assistant
Professor, Drexel University, Interdisciplinary Research
Unit, Philadelphia, Pennsylvania, USA.
A dult attention deficit/hyperactivity disorder
(ADHD), often characterized by the popular press as
being the diagnosis du jour, is a valid psychiatric dis-
order (Taylor & Keltner, 2002; Wender, Wolf, & Wass-
erstein, 2001). Over the past 3 decades, there has been
increasing recognition of the persistence of ADHD into
adulthood; however, it was once perceived to be exclu-
sively a childhood disorder. A recent American
national survey reported a 4.4% prevalence rate of
adult ADHD in the general population, representing
about nine million American adults (Kessler et al.,
2006). Secnik, Swensen, and Lage (2005) reported that
the resulting personal and socioeconomic costs for
these individuals are considerable—annual medical
costs of adults with ADHD are double those without
ADHD, and adults with ADHD miss significantly
more workdays. Moreover, the National Comorbidity
Survey Replication estimated lost work time at 35 days
per year, equivalent to $19.5 billion per year in lost
human capital (Kessler et al., 2005).
ADHD does not initially appear in adulthood. In
accordance to current guidelines, all valid diagnoses
of adult ADHD have a clear developmental history of
impairing symptoms dating back to childhood.
However, literature reports that ADHD is commonly
missed until adulthood for women, and the conse-
quences of ADHD symptoms can lead to limited func-
tional capabilities (Quinn, 2008). Given that women’s
symptoms are often hidden, ignored, or misdiagnosed,
some women with undiagnosed ADHD are reported
to struggle in silence (Quinn, 2005; Waite, 2007). This is
of concern to Faraone and Antshel (2008) who reported
that primary care providers (PCPs) are increasingly
being asked to make ADHD diagnoses. Faraone,
Spencer, and Montano (2004) examined the diagnostic
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
© 2010 Wiley Periodicals, Inc.
practices of primary care physicians in a medical
record review of 854 adults with persistent childhood-
onset ADHD. They discovered that, if no pediatric
ADHD diagnosis had been made, primary care physi-
cians did not consider making a diagnosis of ADHD in
adults.
Researchers have also identified the concern that
many PCPs do not have adequate knowledge of adult
ADHD (Managed Care Weekly, 2003; Valente, 2001).
PCPs, such as nurse practitioners (NPs) and physi-
cians, are at the forefront in providing comprehensive
care for patients with physical disorders and mental
comorbidities. Thus, they serve a critical role in screen-
ing for mental disorders that may require further
assessment by a specialist such as a psychiatric NP,
psychologist, psychiatrist, or licensed clinical social
worker. The World Health Organization recently rec-
ognized that adult ADHD should be of concern to
PCPs because it poses a substantial source of morbidity
in both primary care and psychiatric settings (Bieder-
man & Faraone, 2002).
The Diagnostic and Statistical Manual of Mental Disor-
ders (DSM-IV-TR; American Psychiatric Association
[APA], 2000) defines ADHD as “a persistent pattern of
inattention and/or hyperactivity-impulsivity that is
more frequently displayed and severe than is typically
observed in individuals at a comparable level of devel-
opment” (p. 85). However, an individual’s interpreta-
tion of what is normal at a comparable level of
development and criteria for hyperactive and impul-
sive behaviors is open to cultural interpretation.
Draguns (1973) reported that the attitudes, expecta-
tions, and prevailing patterns of adaptation within a
society determine if an individual’s behavior is viewed
as normal or abnormal. Thus, as American society
becomes increasingly diverse, health-care providers
need to increase their understanding of the influence
of culture on the ways that individuals, families, and
communities perceive behaviors. This is critical
because fundamental psychiatric constructs such as
“normality” and “pathology” have remained relatively
stagnant and have been limited to and based upon
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
acceptable majority population behaviors and stan-
dards for interaction. This is, in part, because of knowl-
edge deficits in the scientific literature, a literature that
notably serves as the basis of the conceptualization of
human behavior and experience, and on which mental
health professionals are often trained. Additionally,
these professionals must also be cognizant not to make
assumptions about ethnicity—that all ethnic groups
are monolithic in their belief systems.
The DSM-IV-TR notes that symptoms of inattention
and/or hyperactivity–impulsivity should be observ-
able before 7 years of age and should be observed
across a variety of situations, contacts, or environ-
ments. Health-care practitioners can make the diagno-
sis if (a) six of nine symptoms related to inattention are
present and have persisted for at least 6 months; or (b)
six of nine symptoms of hyperactivity and impulsivity
have persisted for an equal amount of time. In accor-
dance with the DSM-IV-TR criteria, inattention can
include varied factors including: (a) failing to give
attention to details; (b) being easily distracted or for-
getful; (c) seeming not to listen to or follow through on
instructions; (d) having trouble organizing tasks;
and/or (e) losing things (e.g., house keys, glasses,
homework). On the contrary, hyperactivity can be seen
as restlessness, aimlessly running about, having
trouble engaging in leisure activities, or talking inces-
santly. Impulsivity reflects behavior such as yelling out
answers spontaneously or interrupting and intruding
on others. Given this context, Wilens, Biederman, and
Spencer (2002) reported that the course of ADHD is
chronic, and a phasic course should suggest the differ-
ential diagnosis of an affective disorder.
DSM-IV-TR criteria do not provide guidance on
gender and cultural differences in the manifestation of
ADHD symptomatology. This is perhaps a reflection of
the fact that a majority of children in original DSM field
trials were young European American boys (Lahey
et al., 1994). Because of the narrow scope and lack of
gender specificity, girls and adult women are often at a
disadvantage and may be misdiagnosed (Taylor &
Keltner, 2002). Feminine subject position is not inher-
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Women With ADHD: It Is an Explanation, Not the Excuse Du Jour
ent but normative and is, therefore, culturally deter-
mined through the reiteration of norms and is
discursively constituted. Thus, when examining the
DSM, it is relevant to consider that culturally and his-
torically variable understandings of what it is to be a
man or a woman or what the terms “men” and
“women” mean are also affected by the major social
institutions through which we live our lives. Given the
vast differences that can exist in the manifestation of
symptoms for varied reasons, including the demands
often placed on women in society, more data are
required that examine ADHD across a wider
population base. Moreover, to attend to the meaning of
women’s experiences of ADHD within a sociopolitical
and cultural context is critical to prevent a sole reduc-
tion of women’s experience to a priori categories of
normality and abnormality. The aforementioned
factors elucidate why PCPs need to not only
become more knowledgeable about ADHD in
general, but specifically its manifestations for girls and
women.
Factors That Influence ADHD Diagnosis
Women and ADHD
Sadock and Sadock (2003) reported that inattention,
impulsivity, and hyperactivity are the “holy trinity” of
ADHD. Nadeau, Littman, and Quinn (1999) stated that
from early years “checklists commonly used by
schools, pediatricians, and psychologists to identify
children with ADHD continue to emphasize
hyperactive/impulsive behavior-patterns more typical
of boys” (p. 17). Given that symptoms of ADHD in the
DSM are focused on studies that primarily focused on
boys, mental health specialists may see ADHD symp-
toms in girls as atypical. Thus, socialized gendered
behaviors may be denied or alienated under pressures
of social forces and this may contribute to barriers to
treatment on the part of clinicians. It is critical for pro-
fessionals to develop adequate skills to effectively
assess and recognize ADHD among girls and women
184
and not mitigate them because they are not seen as a
serious enough concern that warrants intervention
(Quinn & Wigal, 2004; Waite, 2007).
Rutter, Caspi, and Moffitt (2003) and Quinn (2005)
indicated that gender difference in ADHD identifica-
tion has often been attributed to complex issues sur-
rounding neurobiological differences between men
and women, as well as methodological issues inter-
acting with socio-environmental influences. In addi-
tion, research has demonstrated consistently that
there is bias for gender differences for children who
exhibit aggression or hyperactivity without symp-
toms of inattention (Biederman et al., 2002, 2005).
Gender differences in the phenotypic expression
identify that girls with ADHD are less likely than
boys to
1. manifest a comorbid disruptive behavior disorder
(e.g., oppositional defiance or conduct disorder;
Quinn, 2005);
2. manifest a learning disability (Biederman et al.,
2002);
3. engage in rule-breaking or externalizing behaviors
(Abikoff et al., 2002), or demonstrate functional
impairments that impact involvement in extracur-
ricular activities (Biederman et al., 2002); and
4. demonstrate impairment on a number of behavioral
ratings (Newcorn et al., 2001), but may exhibit
higher levels of inattentiveness, internalizing symp-
toms, or comorbid conditions (e.g., separation
anxiety/generalized anxiety disorder, eating disor-
ders, and depression; Levy, Hay, Bennett, &
McStephen, 2005; Quinn, 2008), and social impair-
ment (Biederman et al., 2002; Gershon, 2002).
In comparison, the phenotypic expression of ADHD
with boys commonly includes:
1. higher levels of hyperactivity,
2. more conduct problems, and
3. greater levels of aggression and other externalizing
symptoms (Abikoff et al., 2002).
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
Because these symptoms are regarded as more disrup-
tive in a social environment (e.g., the classroom), boys
are frequently referred for assessment because of their
externalizing behavioral problems, while girls are at
lower risk for comorbid disruptive behavior disorders.
This can feed into the referral bias implicating boys
and also influencing underdiagnosis in girls
(Biederman et al., 2002, 2005).
The consequences of misdiagnosis or missed diag-
nosis are important because of the potential negative
impact on young women’s everyday lives, including:
(a) diminished self-image and self-esteem; (b) less-
developed or undeveloped interpersonal sensitivity
skills and awareness of relationship dynamics; (c)
decreased information processing skills, such as the
ability to retain important information and filter out
what is unnecessary; (d) inability to plan and organize
effectively without feeling overwhelmed; and (e)
increased emotional reactivity (Erk, 2000). All of these
factors can potentially influence maturity, career goals,
work personality, and work competence. Moreover,
women with ADHD who have been misdiagnosed
often receive unnecessary or inappropriate help, and
those who are ″missed″ in diagnosis do not get help at
all (Rucklidge, Brown, Crawford, & Kaplan, 2007). The
heavy social and personal impact of ADHD on women
further points to the importance of early identification
and treatment, calling for PCPs to be more competent
about this disorder.
The empirically derived diagnostic criteria for
ADHD as set forth in DSM-IV-TR represents a signifi-
cant advance over previous taxonomies; nevertheless,
a number of persistent problems have emerged with
clinical application of this diagnostic scheme. The
current diagnostic criteria for ADHD were developed
for children, and few are suitable for assessment and
diagnosis with adults. Problem areas in the criteria
include symptom descriptions, diagnostic threshold
cutoff, gender bias, an individual’s developmental
course, and age at onset. Appropriate diagnostic crite-
ria for adults may be added to the DSM-V; but, until
that time, clinicians should use modifications to the
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
current criteria. In addition, as researchers and practi-
tioners work to revise the DSM-IV-TR, recommenda-
tions are also needed for heterogeneity of subtypes
and influence of cultural and environmental contextual
considerations (Stefanatos & Baron, 2007). Given the
significant implications for women, it is important that
clinical practices and educational institutions, includ-
ing postsecondary settings, recognize the particular
needs of women learners and be alert to health-related
dynamics that may stem from ADHD symptoms.
Neurobiology
The exact cause of ADHD remains unknown;
however, most experts agree that ADHD is not a single
clinical disorder; rather, ADHD represents a group of
etiologically heterogeneous entities that share a group
of core symptoms (Biederman, 2005). Numerous
genetic studies have shown that children of parents
with ADHD also suffer more frequently from ADHD
themselves (Biederman, & Faraone, 2002; Chronis
et al., 2003; Khan & Faraone, 2006). Parents and siblings
of affected patients have a 2- to 8-fold risk of develop-
ing ADHD symptoms (Biederman & Faraone, 2002). A
meta-analysis of six twin studies revealed that 80% of
the variance of the clinical symptoms can be explained
in terms of genetic factors. Adopted siblings of ADHD
children have a lower risk than biological siblings, and
biological siblings perform more poorly than adopted
siblings in neuropsychological tests of sustained atten-
tion (Biederman & Faraone, 2002). These findings point
to the important role of genetic factors in the etiology
of ADHD symptoms.
Cerebral and functional imaging studies have also
demonstrated structural as well as neurochemical and
functional abnormalities in ADHD patients. For
example, researchers have reported reductions in total
brain volume, prefrontal brain (especially right-sided),
basal ganglia (especially the caudate nucleus), and the
cerebellum (especially the vermix; Biederman &
Faraone, 2002; Bush, Valera, & Seidman, 2005; Perlov
et al., 2007; Spencer, Biederman, & Mick, 2007). At a
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Women With ADHD: It Is an Explanation, Not the Excuse Du Jour
still deeper level, genes that lay down the blueprint for
manufacturing neurotransmitters are hypothesized to
contribute to ADHD symptoms. Individuals affected
with ADHD have at least one target gene, the dopam-
ine receptor D2 (DRD2) gene, which makes it difficult
for neurons to respond to dopamine (Blum et al., 2008).
This neurotransmitter is also involved in feelings of
pleasure and the regulation of attention. Other dopam-
inergic genes that have been implicated for ADHD
include the DRD4 receptor gene, the dopamine beta
hydroxylase (DbH) gene, and the dopamine trans-
porter genes as causative factors in ADHD (Biederman,
2005; Cook et al., 1995).
A further risk factor is chronic intrauterine nicotine
exposure (Biederman & Faraone, 2002), which is asso-
ciated with a 2- to 2.7-fold elevated risk for the later
development of ADHD (Banerjee, Middleton, &
Faraone, 2007). Other factors such as certain diets, lead
exposure, sugar and food additives, or metabolic dis-
eases such as cryptopyrroluria are also contentiously
debated as possible causes of ADHD (Biederman &
Faraone, 2002). Chronic familial conflicts, reduced
familial cohesion, and confrontation with parental
(especially maternal) psychopathology are more often
observed in families with members affected by ADHD
compared with control families (Biederman, 2005).
When thinking about the causes of ADHD, it is
important to distinguish the elements of causality (eti-
ology), mechanisms of action (pathogenesis), and clini-
cal picture (syndrome) from each other. Perlov et al.
(2007) reported that the capacity of attention control,
impulse control, and affect regulation are pathogeni-
cally closely associated with the fronto-striato-
thalamo-frontal feedback loop systems. However,
these are distributed through cerebral neuronal net-
works, and their function may be disturbed at various
sites for various reasons. For example, Perlov et al.
(2007) reported that this may occur from lesions of
greatly varying origins, such as perinatal asphyxia,
encephalitis, metabolic disorder, intoxication, and
febrile seizure. Lesions at various sites in the brain can
lead to a similar clinical deficit if an identical feedback
186
loop system is affected somewhere along its course
(Perlov et al., 2007). The function of these feedback
loops, however, may also be systematically compro-
mised (e.g., independently of individual lesions)
because of functional disorders of the adrenergic or
dopaminergic systems (Biederman & Faraone, 2002).
Because of the genetic component and the dopaminer-
gic and adrenergic substances on the core symptom of
attention control, it may readily be assumed that the
adrenergic and dopamine systems play a central patho-
genic role, at least in a large subgroup of patients
affected by ADHD Biederman & Faraone, 2002.
Against this background, there is much that argues
in favor of distinguishing between a primary and sec-
ondary ADHD from the etiologic perspective. A posi-
tive familial history and the lack of evidence of mild
cerebral dysfunctions tend to support a primary disor-
der of ADHD. Birth complications, inflammatory brain
diseases, intoxications, head traumas, or possibly a
familial history of convulsive disorder would suggest
a secondary ADHD diagnosis.
Associated Comorbidities/Differential Diagnosis
Over the past decade, research findings have noted
that women who were not diagnosed as having
ADHD until they were adults were more likely to
report depressive symptoms, stress, anxiety, low self-
esteem, eating disorders, alcohol and drug use disor-
ders, and sleep disorders (Hinshaw, Owens, Sami, &
Fargeon, 2006; Katz, Goldstein, & Geckle, 1998;
Quinn, 2008; Rucklidge & Kaplan, 1997). The lifetime
prevalence rates of major depression and bipolar dis-
order in women with ADHD have been estimated at
23% and 10%, respectively. Social phobia has been
estimated at 23% as the most prevalent anxiety disor-
der in women with ADHD, followed by generalized
anxiety disorder (16%), panic disorder (15%), agora-
phobia (9%), and obsessive-compulsive disorder (7%;
Biederman, Faraone, Monuteaux, Bober, & Cadogen,
2004). At the same time, some comorbidities are also
differential diagnoses, such as depressive disorder
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
with its impairments of concentration; however, it
can be distinguished from ADHD based on its usually
phasic course. Posttraumatic stress disorder (PTSD),
another differential diagnosis, must also be consid-
ered. Many PCPs do not realize that there is a high
degree of overlap between the symptoms of ADHD
and PTSD, including inattention, restlessness, irrita-
bility, and impulsivity (Weinstein, Staffelbach, &
Biaggio, 2000). For instance, inattention, one of the
prime symptoms of ADHD, may result from reexpe-
riencing trauma, hypervigilance, and/or avoidance of
stimuli as a result of trauma (Weinstein et al., 2000, as
cited in Rucklidge, Brown, Crawford, & Kaplan,
2006). Likewise, hyperarousal could be misconstrued
as hyperactivity (Glod & Teicher, 1996, as cited in
Rucklidge et al., 2006). It is critical to address these
symptoms, otherwise they may become chronic.
Importantly, the DSM-IV-TR neglects including
assessment for PTSD as a differential diagnosis when
evaluating patients for ADHD. What’s more, fre-
quently used assessment instruments to examine the
existence or lack of ADHD do not include questions
about trauma (Rucklidge et al., 2006).
Notwithstanding individual internal challenges that
women may endure when ADHD is not diagnosed
until later, Nadeau and Quinn (2002) reported that
these women are often less able to be consistent
parents, are less able to manage their jobs and house-
holds, and are at a higher risk for divorce and single
parenting. This can have significant downstream
effects for individuals that count on these women for
support in their day-to-day lives. Members of society
can often be complicit enforcing stereotypical gender
roles, and this further challenges women with ADHD
given the unrealistic demands placed upon them and
complex environmental demands (e.g., need to balance
families and careers, issues related to time manage-
ment, and encoding and manipulating information).
The stress resulting from day-to-day struggles can take
its toll over time, which can further threaten women’s
health for diseases related to chronic stress, such as
chronic fatigue syndrome and fibromyalgia (Rodin &
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
Lithman, 2002). Consequently, the lack of appropriate
identification and treatment of ADHD among women
should be seen not only as a personal tragedy, but also
as a significant public health concern.
Not an Excuse: Empowerment of Self and
Explaining Why Something Is Happening
Women will respond differently to their ADHD
diagnosis, and each has varied knowledge about the
disorder. When an accurate diagnosis is made,
changes in a woman’s life that could help her devel-
opment in ways that are meaningful to her (e.g.,
social, environmental, relational) should be consid-
ered. Because ADHD is seen as a disorder of doing
what one knows, if a woman is not informed, she
needs to educate herself about the disorder. Learning
about how ADHD affects her ability to get things
done can provide a woman with ADHD the power to
make informed choices. Empowering oneself and
putting thoughts and behaviors into actions that
reflect a woman’s positive image help to mitigate
excuses that may be disempowering. As Carol Meyer
(n.d.) stated, “acceptance is empowering.” That is,
women are more than their ADHD; each woman has
individual strengths and challenges on which to build
her future through the recovery process. Further-
more, this process is a nonlinear process of transfor-
mation by which people move from lower to higher
levels of fulfillment in the areas of hope, activity,
growth, orientation, satisfaction with social networks,
level of symptom interference, and personal sense of
safety (Granahan, 2008).
While symptoms of ADHD can present unique chal-
lenges, the diagnosis is not an escape from the conse-
quences of the events that result from unfavorable
behaviors and decision-making. Essentially, individu-
als who use excuses expect others to demonstrate
flexibility, change, and accommodations for them.
Unfortunately this approach to coping can promote an
unnecessary sense of powerlessness. All adults need to
function responsibly in the world; therefore, it is
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Women With ADHD: It Is an Explanation, Not the Excuse Du Jour
important for the person to strike a balance in life
activities, heighten self-awareness, and enact proactive
strategies to manage symptoms to promote overall
wellness (Ramsay, 2007).
Being able to explain and offer an understanding for
why something is occurring can promote “knowing”
what women can do about their issue(s). As such, the
onus of making changes and improvements rests with
the woman (i.e., accepting responsibility for her own
recovery, which in turn also offers hope for a better
future through a changed lifestyle) while she considers
the sociocultural and contextual dynamics of her life.
Multimodal Approach to ADHD
A multimodal approach to care—the combination of
diverse professional disciplines and interventions—is
a widely endorsed strategy and is a useful clinical
framework to manage adult ADHD symptoms effec-
tively (Attention Deficit Disorder Association, 2006;
Murphy, 2005). Multimodal approaches include a
process of recovery, pharmacotherapy, psychological
services, and psychosocial interventions. In combina-
tion, these approaches can facilitate improvement in
life outcomes.
Recovery: Self-Care and Symptom Management
Kelly and Gamble (2005) acknowledge that the
word “recovery” means different things to different
people; however, it is now commonly used in mental
health. Recovery in medicine has been seen as the
eradication of symptoms (i.e., cure) with no outstand-
ing reliance on or use of medication or health service
providers and no ongoing disability related to the con-
dition (Whitwell, 1999). However, the notion of recov-
ery in mental health is not about “cure” of a condition
of biological origin; it is about the recovery of the
whole person, the reclaiming of personhood, roles,
responsibilities, and self-knowledge. Anthony (1993)
suggested that recovery is the development of new
meaning and purpose as one grows beyond a mental
188
illness/disorder. Symptoms may still persist; however,
Repper and Perkins (2003) suggested that this does not
impede the subjective experience of recovery. Recov-
ery from mental distress is a complex process of
discovery that is as individual as each person who
embarks on it. It is a personally generated process, with
a set of positive outcomes set only by the person who
is embarking on the journey (Deegan, 2001).
Women with ADHD can and often do amazingly
well given the multifaceted challenges they face in
adult life. Recovery can further support some women’s
efforts with promotion of their well-being. Thus, if not
already in place, they can come to realize their desired
futures with clear identities, can make and keep close
relationships, and can get and keep meaningful work
throughout their adult lives (Farkas, 2007; Granahan,
2008). While recovery is not an intervention that
health-care providers can “do for a person,” services
identified through collaborative provider–patient part-
nerships can contribute to the outcomes and experi-
ence of recovery (e.g., well-being, self-esteem, valued
roles, symptom reduction, and empowerment). This
can be critically important because Rucklidge and
Kaplan (2000) reported that women with ADHD tend
to experience comorbid disabilities that span the neu-
rological, psychological, and social domains. This indi-
cates that effective practices may need to involve
planning and incorporate a rich and synergistic array
of approaches (e.g., nursing, medical, educational, psy-
chological, counseling, and rehabilitation) to help
young women with ADHD achieve satisfying and suc-
cessful personal and professional lives. Thus, single or
unidimensional interventions will probably be insuffi-
cient for making substantive gains.
In addition, Farkas, Anthony, and Cohen (1989)
purport that certain values are associated with
recovery-oriented services. These values include
person orientation, person involvement, self-
determination/choice, and growth potential (hope). A
person orientation emphasizes a person-first perspec-
tive, which conveys that people (i.e., health-care pro-
fessionals) are interested in him/her as a person and in
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
roles other than as “patient” (Weingarten, 1994). There-
fore, recovery-oriented services would encourage the
assessment and development of talents and strengths
of individuals, rather than narrowly focusing on defi-
cits. Furthermore, a focus on the person in recovery
guides services to promote access to resources and
environments outside the mental health system where
meaningful, socially valued roles can be attained,
rather than limiting individuals to less favorable con-
ditions often created by mental health service pro-
grams within our Western society (Farkas, 2007).
Majumder, Walls, and Fullmer (1998) maintained that,
when there is participation and partnership, individu-
als have an opportunity for meaningful involvement in
the planning and delivery of their services. This is seen
as a critical component of a quality management
system for any mental health service (Blackwell, Eilers,
& Robinson, 2000), as well as critical to the develop-
ment of a sense of empowerment (Deegan, 2001) and a
shift in self-identity.
Farkas (2007) stated that self-determination and self-
choice is the cornerstone of a recovery process. The
opportunity to choose one’s long-term goals, the
methods to be used to get to those goals, and the indi-
viduals or providers who will assist in the process are
all components of a service acknowledging this value.
Thus, medication compliance alone does not promote
the development of meaning and purpose in life. Fur-
thermore, placing a person in a facility, job, or a school
program, or prescribing medications without explor-
ing the person’s preferences, may achieve the immedi-
ate outcome of reducing symptoms or trying out a new
role in society. However, without promoting the indi-
vidual’s sense of self, empowerment, well-being, or
recovery, there may be the additional outcome of
dependence on professionals to take further steps.
Helping individuals take back their lives requires sup-
porting self-determination (Clearly & Dowling, 2009).
The last significant value espoused in recovery-
oriented services is hope. This goes beyond providing
services that promote activities focused on mainte-
nance or the prevention of relapse. It is important to
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
provide opportunities and support movement beyond
maintenance. Approaches that do not take this stance
are not recovery-oriented. Hope means remembering
that recovery can be a long-term process with many
successes, setbacks, and plateaus along the way
(Deegan, 2001; Farkas, 2007).
Pharmacotherapy
Pary et al. (2002) reported that pharmacotherapy is
the principal form of treatment for patients with
ADHD. Methylphenidate, amphetamines, and lisdex-
amfetamine are stimulants that are FDA-approved
(Antshel, Faraone, & Kunwar, 2008) for managing
adult ADHD. Atomoxetine is the first drug in the
emerging class of nonstimulants approved by the FDA
in the United States for the treatment of ADHD in
children, adolescent, and adult populations in 2002.
Stimulants and atomoxetine improve core symptoms
of hyperactivity, inattention, and impulsivity, includ-
ing poor attention span, distractibility, impulsive
behavior, hyperactivity, and restlessness, and improve
vigilance, cognition, reaction time, response inhibition,
and short-term memory (Adler et al., 2008; Connor,
2005; Hechtman, 2005). Stimulant medications are also
associated with fewer errors on a driving simulator in
teens and adults with ADHD (Barkley, Murphy,
O’Connell, & Connor, 2005). Barkley et al. (2005) also
conducted research that demonstrated that meth-
ylphenidate may have a beneficial effect on some
aspects of driving (e.g., less steering variability, slower
driving speed, greater use of turn signals, and fewer
impulsive responses).
In addition to the above medications, others have
also been identified as effective for managing ADHD
and are used as second-line agents (Taylor & Russo,
2000; Wilens et al., 2005). Bupropion is a second-line
agent for uncomplicated ADHD. Tricyclic antidepres-
sants are also used. Though they improve mood and
decrease hyperactivity, they do not improve concentra-
tion and cognitive tasks (Weiss & Hechtman, 1993).
Research data have shown that desipramine is effective
189
Women With ADHD: It Is an Explanation, Not the Excuse Du Jour
in the treatment of ADHD in adults (Spencer et al.,
2004), but it is less effective than stimulants. Clonidine
is an a2-adrenergic receptor agonist that has effect on
symptoms of hyperactivity and impulsivity, but not
those of inattention. Clonidine is considered to be a
second-line agent in the treatment of ADHD and may
be useful in some patients with comorbidity, particu-
larly in the treatment of patients with comorbid ADHD
and Tourette’s syndrome and other tic disorders (Rob-
ertson 2006; Wilens, 2006). Lastly, Guanfacine is effec-
tive treatment for symptoms of ADHD. It is especially
helpful for patients with liability for abuse of stimu-
lants. Biederman (2006) reports that Guanfacine is safe
and well tolerated in children and adults with ADHD.
Notwithstanding effective psychopharmacological
treatment of core ADHD symptoms, residual symp-
toms and long-lasting functional impairments persist
in many adult patients. Wender (1998) and Wilens et al.
(2002) reported that 20% to 50% of adults are consid-
ered non-responders to stimulants because of derisory
symptom reduction or inability to tolerate adverse
effects. Safren, Otto et al. (2005) reported that adult
responders often demonstrate a reduction in 50% or
less of the core ADHD symptoms, with a correlation
between symptoms and impairment reported to be
low with symptoms predicting less than 25% of the
variance in impairment (Gordon et al., 2006). Weiss,
Gadow, and Wasdell (2006) argued that more research
is needed on effectiveness variables (e.g., comorbidity,
functional impairment, substance abuse, and compli-
ance or treatment adherence) to evaluate the actual
clinical impact of the results from short-term psycho-
pharmacological trials. The importance of this is
further emphasized by the likelihood of an increased
number of adult patients with ADHD in psychiatry
because of increased recognition and awareness (Ash-
erson, Chen, Craddock, & Taylor, 2007).
Given that stimulant medication is an ineffective
treatment for approximately 30% of adults diagnosed
with ADHD, practitioners and researchers need to reex-
amine why this is occurring. With the vast overlap in
symptomatolgy with other mental health disorders,
190
misdiagnosis and comorbidities need to be reconsid-
ered. This is critical as many of these stimulants have
significant side effects that can be life threatening, par-
ticularly to populations already at higher risk for hyper-
tension and stroke. Thus, health providers need to
refine their skills continually, improve their assessment
process, and engage other interdisciplinary colleagues
in optimizing patient outcomes (Spencer, 2004).
Psychological Services
Psychological services are another critical cluster of
effective practices that help women with ADHD.
Sample strategies that can be used as interventions
include psychoeducation, cognitive behavioral therapy
(CBT), therapeutic counseling, coaching, self-
management skills training, environmental restructur-
ing, individual psychotherapy, family therapy, marital
or couple therapy, circles of support, and vocational
counseling. For example, psychoeducation can benefit
some women who have attributed their ADHD chal-
lenges to psychological or even moral deficiencies, or
who have used reactive aggression because they saw
themselves as victims in social situations. Education
about causative factors (e.g., the neurobiological roots
of ADHD symptoms) can help them place their expe-
riences into a personal context that can aid them in
viewing themselves more in terms of strengths to be
maximized, nondefensive skills to be learned, and
limitations to be minimized through altering social
expectations (Thurber, Heller, & Hinshaw, 2002).
Emphasizing task-oriented coping behavior, rather
than emotional-oriented coping behavior, can be an
effective compensatory mechanism (Rucklidge &
Kaplan, 1997). Three of the aforementioned interven-
tion strategies are discussed below (CBT, coaching, and
vocation education preparation).
CBT. CBT, originally developed as a treatment for
depression, has recently been modified for the treat-
ment of adult ADHD (McDermott, 2000; Ramsay &
Rostain, 2003; Rostain & Ramsay, 2006; Safren,
Perlman, Sprich, & Otto, 2005). CBT for adult ADHD
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
acknowledges its neurobiological underpinnings, thus
pointing out that ADHD is not caused by the result of
faulty or distorted thinking (Nigg, 2006). However,
neurobiological and neuropsychological inefficiencies
result in the downstream observable problems related
to cognitive and behavioral self-control.
Given that treatment goals are often formulated in
terms of specific behavioral objectives, the cognitive
modification component of CBT for adult ADHD is an
important one. Not only does executive dysfunction
contribute to difficulties with varied aspects of self-
management, adults with ADHD often have developed
pessimistic outlooks about themselves. Thus, this
results in negative assumptions about their abilities to
manage their affairs. Ramsay (2007) reported that in
some instances, these thoughts are not completely dis-
torted because individuals with ADHD can often cite
all-too-real examples of reasonable endeavors that
have not gone as planned, such as failing classes in
school, losing jobs, or not following through on prom-
ises made to significant others. However, the negative
conclusions drawn from these experiences can be over-
generalized and result in these adults discounting the
possibility that they can change. These thought pat-
terns can reduce the willingness of adults with ADHD
to experiment with new ways to handle challenging
situations and gradually wear away the sense of resil-
ience needed to make life changes.
Rostain and Ramsay (2006) reported that some
women with ADHD develop negative beliefs about
themselves and their world; therefore, CBT may be
useful for treating many of the cormorbid diagnoses
(e.g., anxiety, depression) and perceived functional
concerns (e.g., procrastination, poor time manage-
ment) that are often encountered when working with
this population. Barkley (2006) reported that a thera-
peutic model thought to be useful for adults with
ADHD focuses on training in methods of time man-
agement, organizational skills, communication skills,
decision-making, self-monitoring and reward, chang-
ing large tasks into smaller tasks, and changing faulty
cognitions and beliefs. To help ADHD patients exert
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
more control in their lives, cognitive and behavioral
interventions can provide promising outcomes in indi-
vidual well-being and should be considered through-
out ADHD treatment (Ramsay, 2007).
ADHD Coaching. Byron and Parker (2002) sug-
gested that individuals with ADHD may benefit from
ADHD coaching, another example, which assists indi-
viduals to: set goals, acknowledge strengths, and rec-
ognize limitations; develop reflective thinking; model
self-control strategies; and create strategies to be more
effective in their day-to-day lives. This is different from
traditional therapy in that therapy is about insight;
coaching is an approach that is pragmatic, behavioral,
results-oriented, and focuses on getting things done
(just do it; Favorite, 1995). Also, Ratey (2002) reported
that coaching focuses on what, how, and when—never
why, and it operates from a premise that the individual
is ready, willing, and able to work in a partnership
with the coach and rise to the challenge of creating a
better life.
Because many adults who have ADHD “fade” or
lose motivation and have trouble persisting in effort
over extended periods, a coach can help them stay on
course and complete the task at hand. This may require
ongoing support, encouragement, structure, account-
ability, and sometimes gentle, but firm, confrontation.
Importantly, acceptance that one has ADHD is neces-
sary for an optimal coaching experience (Murphy,
2005). Moreover, coaching includes frequent commu-
nication and a step-by-step approach to goal attain-
ment. This approach may contain many of the features
of vocational rehabilitation counseling that are effec-
tive in assisting people with disabilities to define, ini-
tiate, engage with, and ultimately, complete an
individualized plan for employment (Byron & Parker,
2002). Kelley, English, Schwallie-Giddis, and Jones
(2007) reported that coaching is an exemplary part of
treatment for women with ADHD to manage their
careers and personal lives. Maintaining employment
and achieving economic security can be significant
challenges facing women with attentional impairments
(Jans & Stoddard, 1999). The Institute for the Advance-
191
Women With ADHD: It Is an Explanation, Not the Excuse Du Jour
ment of ADHD Coaching (IAAC) developed core
competencies to identify the behavioral coaching pro-
ficiencies required to become a certified ADHD coach
(Kubbik, 2010). To learn more about ADHD coaching
from the IAAC explore their website at http://
www.adhdcoachinstitute.org/joom2/.
Vocational Education Preparation. Effective
employment transition practices can involve specific
strategies: pre-employment assessment; career guid-
ance and counseling; advocacy and networking; and
job development, placement, and follow-up/follow-
along services (Burgstahler, 2001). Women with ADHD
are diverse, not only in terms of degrees of severity
and functional concerns presented by their attentional
impairments, but also by contextual factors, such as
ethnicity, socioeconomic status, and individual factors
such as aptitudes and interests. Because all of these
factors can limit or facilitate a woman’s career devel-
opment, counselors working with women with ADHD
should learn as much as possible about them when
beginning career counseling and planning (Szyman-
ski, Hershenson, Enright, & Ettinger, 1996). Ochs and
Roessler (2001) stressed the importance of implement-
ing a variety of career development experiences in
school, home, and community for young women with
attentional impairments. Direct learning experiences,
such as volunteer work or job shadowing, can facilitate
young women’s self-efficacy beliefs and career out-
come expectations (Kelley & Schwallie-Giddis, 2002).
Kelley et al. (2007) stated that during job-finding
and job-keeping activities, employment specialists can
assist young women with ADHD by (a) networking
with state Vocational Rehabilitation agencies or the
National Job Accommodation Network, (b) teaching
them how to recognize and then articulate reasonable
job accommodation requests to employers, and (c)
stressing the importance of using time-management
skills in daily work tasks. An employment specialist
plays a critical and central role, not only in providing
pointers on where and how to go for help, but also in
helping women become more self-aware of career
realities. Therefore, follow-along job coaches may be
192
more helpful than a single follow-up session after a
woman with ADHD is employed.
Conclusion
ADHD should not be disparaged as a diagnosis du
jour with the implication that it is a transient cultural
phenomenon used as an “excuse” for women who may
be challenged with their functional capabilities. These
perceptions also need to consider sociocultural norms.
For women, particularly, when diagnosis is given later
in life, ADHD is a disorder that often is not seen in
isolation (Quinn, 2008). Manifestations of ADHD and
coexisting disorders that affect women may be differ-
ent from those seen in men with ADHD; therefore,
both genders require a careful assessment. The emerg-
ing picture of higher rates of comorbidities, particu-
larly depression and eating disorders, associated with
ADHD in women only underscores the psychological
challenges that women with ADHD may experience as
they struggle with society’s gender role norms.
Knowing more critically how women with ADHD suc-
cessfully fulfill role responsibilities illuminated by
societal barriers (e.g., race and class) needs to be exam-
ined. The interplay of these conditions needs to be
more closely investigated to more accurately paint the
clinical picture of ADHD in young and adult women
(Quinn, 2008).
After clinicians disentangle women’s ADHD symp-
toms from associated coexisting conditions, multimo-
dal treatment programs are a requisite to address these
conditions’ complex natures in order to optimize out-
comes for those recovering from one or more mental
diagnoses (Waite, 2007). Though stimulants are used as
the first line of defense to treat ADHD in adulthood
and have been found to be effective in reducing ADHD
symptoms, it is equally important to address the other
psychiatric and psychosocial concerns that are com-
plicit in limiting women’s abilities.
That is, the ADHD symptoms women experience
likely have been present in some form since child-
hood, making ADHD an inseparable part of how they
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
experience and know the world. Therefore, it is nec-
essary to provide basic education about the neurobi-
ology of ADHD and how it translates into some of
the common functional concerns that women with
ADHD experience, such as disorganization and for-
getfulness. With knowledge and support about
ADHD, women can reevaluate life’s recurring diffi-
culties, understanding that they can result from a set
of neurobiologically driven behaviors that can be
modified, rather than attribute these difficulties to
poor character or laziness. Moreover, understanding
how sociopolitical and environmental contexts shape
women’s mental health is requisite. This reevaluation
can provide an important shift in perspective for
many women with ADHD and, thus, open up new
hope for the prospect of change (Rucklidge & Kaplan,
1997).
Because most literature and extant research has
been oriented toward European American boys and
men, future research must take into account concerns
focused on women from a lifespan perspective. For
example, do multiple diagnoses (e.g., depression,
anxiety) in women with ADHD represent fallout
from years of undiagnosed ADHD difficulties, or are
they true coexisting conditions? Are disordered
eating patterns found primarily in women only
recently associated with ADHD because research has
focused for too long on male-only populations—the
result of impulsive symptoms, lower levels of self-
acceptance, or a combination of these and other
factors? How do wider influences (such as commu-
nity, environment, culture, economic, and policy)
affect health for women with ADHD? What is the cor-
relation between hormones (e.g., estrogen) and
ADHD in women? What are the cardiovascular risks
in women who are taking an ADHD medication? This
is critically important given the current gender dis-
parities in mortality related to heart attacks and the
cardiovascular risks from stimulants often used to
treat ADHD. One can only speculate what else will
emerge as clinicians continue to conduct research that
involves women with ADHD.
Perspectives in Psychiatric Care Vol. 46, No. 3, July 2010
Author contact: rlw26@drexel.edu, with a copy to the Editor:
gpearson@uchc.edu
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