When Denise Difede's daughter Alexandra entered Grade 4, she started to struggle badly in school. “This was a wonderfully bright little girl who had been reading books in senior kindergarten by herself. Then she began dreaming in class and not paying attention. She was getting frustrated and started banging her head on the wall,&" says Denise, who had also found it difficult to sit and listen through an entire class as a young girl.

Her family doctor referred them to a child psychiatrist in Toronto, who diagnosed Alexandra with attention-deficit/hyperactivity disorder (ADHD) and treated her with Ritalin. “The response we saw within 48 hours was phenomenal,&" says Denise. “You could see the light going on. She was able to sit still and participate in the learning. By the end of the school year it was like a miracle. She was able to catch up on schoolwork that she had missed, and she developed friends and gained confidence in herself.&"

After her two younger sons were diagnosed with ADHD in 2004, Denise began to suspect that she might have the disorder, too. “I had seen so much of me in Alexandra as a girl. In school I knew what I was learning, but my marks didn't reflect my level of knowledge.&"

Difficulty focusing
In June 2006, Denise attended an ADHD conference in Toronto. When Ross Greene, a clinical psychologist at Massachusetts General Hospital in Boston and the author of The Explosive Child (HarperCollins, 2005), talked about a treatment plan for kids, her attention wandered even though he was an animated speaker. She resolved to listen harder when another international expert, Kathleen Nadeau, a clinical psychologist at Chesapeake ADHD Center of Maryland in Washington, D.C., spoke about ADHD patterns in girls and women.

“She is a wonderful speaker,&" says Denise. “I forced myself to keep my attention on her. I didn't realize until then how difficult it was for me to focus.&" Denise's attention had wandered at other times, but she thought that was fairly normal. She noticed her lack of focus this time because despite her great interest in the talks, she couldn't focus well.

A common disorder
As Denise listened to Nadeau describe the symptoms of ADHD in women, she says, “I felt she was talking about me. It was like a slap in the face. That's when I decided to get tested.&" At age 44, Denise was diagnosed with ADHD. She began treatment with Adderall XR, a stimulant medication, and worked with an ADHD specialist.

ADHD is considered a common disorder in Canada. Historically, experts believed that ADHD was a childhood disorder, and that it mainly affected boys. They were wrong on both counts. Long-term studies have shown that about two-thirds of children with ADHD continue to have symptoms that affect their relationships, work and health as adults. As well, research indicates that while boys are more frequently diagnosed with ADHD than girls, it is as prevalent among women as men. “The ratio for children is four boys to one girl, but for adults it's one to one,&" says Dr. Lily Hechtman, a psychiatrist and director of ADHD research at McGill University Health Centre in Montreal and the Montreal Children's Hospital.

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Treatment makes a huge difference
Denise, an administrative assistant, is typical of most women with ADHD. As a girl, she was inattentive and dreamy in class, but not disruptive or hyperactive, so her symptoms were overlooked and she wasn't tested for the condition. “In childhood, girls with ADHD tend not to be totally disruptive and their symptoms aren't picked up,” says Hechtman. “As young adults, they may drop out of university or have difficulties at work. Because they go undiagnosed, they don't reach their full potential.”

The good news is that once diagnosed and properly treated, adults with ADHD can maximize their abilities and lead happy lives. “Adults are the most rewarding patients to work with,” says Hechtman, who directs a research clinic for adults with ADHD. “They are highly motivated, and for them, treatment makes a huge difference.”

Several differences
Adult ADHD differs from the childhood condition in several ways. The core symptoms of ADHD are inattention, hyperactivity and impulsivity. Professionals recognize three major subtypes: predominantly inattentive, predominantly hyperactive/impulsive and the combined type (a combination of the three core symptoms). In childhood, boys tend to be more hyperactive and girls more inattentive (though both genders may have the combined subtype).

As teens become adults, hyperactivity and impulsivity diminish, but problems with attention continue and may become more debilitating as the organizational demands of daily living increase. “Through the life cycle the main features of ADHD change, but by adulthood 75 per cent have the inattentive type,” says Dr. Atilla Turgay, director of the ADHD Clinic, Training and Research Institute at The Scarborough Hospital in Toronto.

Problems with attention make it hard for adults with ADHD to start a task and stick to it, or change their focus as needed. This leads to difficulties with organization and time management. For women who have to organize their families as well as themselves, and who work outside the home, too, this can be particularly difficult, says Hechtman.

Importance of diagnosis
Adult ADHD is also frequently associated with other psychiatric disorders known as comorbidities (one or more disorders coexisting with the main disorder). “About 80 to 90 per cent of adults with ADHD have comorbidities,” says
Dr. Margaret Weiss, a psychiatrist, director of the B.C. provincial ADHD program and head of an ADHD clinic at the Children's and Women's Health Centre in Vancouver.

Not being diagnosed in childhood has huge consequences for women: poor self-esteem, substance abuse and dropping out of school. “Comorbidities are prevalent in both men and women, but secondary anxiety and depression are seen more often in women. It's very frustrating and anxiety-provoking when you can't seem to do things that other people can do,” she says.

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"They missed the diagnosis"
Like many women with ADHD, 42-year-old Lori McCoy* suffered from another psychiatric disorder, low-grade depression. As a child she was bright but struggled in school.

“Hyperactivity was the focus then. Inattention wasn't looked at, so they missed the diagnosis,” she says. In 1999, when Lori's five-year-old son was diagnosed with ADHD, she attended a parent support group of the Calgary chapter of CH.A.D.D. (Children and Adults with Attention Deficit Disorder). “I was not a big fan of group situations, but going to that meeting was the best thing I have ever done.”

As Lori learned more about ADHD, she began to wonder whether the condition might explain some of the difficulties she had experienced in school, at work, in her marriage and with depression.

She called the psychologist who had seen her son. “I need some help. I've either been reading too much or my eyes have opened up,” said Lori, who proceeded to do 20 hours of testing.

How is ADHD diagnosed in adults?
The process usually involves a clinical interview that includes screening tests to see if you qualify for assessment; the assessment includes other tests and the use of rating scales to assess current symptoms. Also, information from parents, siblings, old report cards and your own recollections are used to determine if you had ADHD symptoms as a child.

The hallmark symptoms of adult ADHD, identified by Edward Hallowell and John Ratey, authors of Driven to Distraction (Touchstone, 1995), include: a sense of underachievement; difficulty getting organized; chronic procrastination; many projects going simultaneously and trouble with follow-through; a frequent search for high stimulation; intolerance of boredom; easy distractibility; trouble focusing attention; and a tendency to tune out in the middle of a conversation. (It's important to rule out medical causes, such as hyperthyroidism, which may cause ADHD-like symptoms.) If you had chronic symptoms as a child or have them as an adult, the final step is to determine if they are having a significant negative impact on your life today.

If you suspect that you or someone in your family has ADHD, ask your family doctor for a referral to a psychologist or psychiatrist experienced in treating adults with ADHD.

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Looking back
In Lori's case, teacher's comments on old report cards were particularly revealing. Her Grade 3 teacher wrote: “Interpreting what has been read or instructed orally tends to need attention. Paying attention, reading carefully and asking questions when in doubt will greatly benefit Lori. Careful attention must be given in reading written assignments over.” Her Grade 6 teacher wrote: “Lori tries hard, but works too quickly at times before she has mastered a new concept.”

Lori was diagnosed with ADHD as the primary disorder, and low-grade depression and a reading disability as associated disorders. Her experience as an inattentive but not hyperactive girl, and an adult who showed symptoms of depression, illustrates why ADHD is often missed or misdiagnosed in girls and women.

“In adults, the more common presenting symptoms are not ADHD symptoms but anxiety and depression,” says Dr. Umesh Jain, who holds a PhD in psychiatry and is chair of the Canadian ADHD Resource Alliance in Toronto. “As you get older, you carry more life burden with you. That life is accumulating a lot of negative noise. Not reaching your potential and having lots of screw-ups affects your self-esteem.”

"It was like listening to a thousand radio stations going off in your head"
Prior to her ADHD diagnosis in 2002, Lori had taken the antidepressant Prozac and undergone psychotherapy for several years, but she was still depressed. “I felt dopey, like I was a zombie. I felt as if I were walking around in someone else's body watching her life go on.”

After Lori was diagnosed, and treated with Wellbutrin, an antidepressant medication that's effective for people with ADHD and secondary depression, her ability to focus and her work performance, marriage and mood improved dramatically. “It was like being reanimated,” says Lori, describing how she felt after taking Wellbutrin. “It became easier for me to concentrate. It was like listening to a thousand radio stations going off in your head and then toning that down to a hundred stations, which makes a huge difference. You're listening to a hundred at the same time, but it's less noise.”

Treatment
Successful treatment of ADHD for adults usually involves three key components: psycho-education; medication; and behavioural interventions (such as skills training, therapy or coaching), which help clients make significant lifestyle changes. Adults diagnosed with ADHD find it remarkably therapeutic to learn more about the disorder (a process called psycho-education) and understand how their own particular symptoms have prevented them from realizing their potential at different stages of life. “The most powerful resource is gaining good enough knowledge about the disorder,” says Turgay.

Medication often makes it easier for patients to act upon that self-knowledge and benefit from nondrug treatments to learn new skills, develop more effective habits, set meaningful personal goals and fulfill them.

Developing effective habits
Lori's psycho-education began at her first CH.A.D.D. meeting, where she learned about ADHD by talking to other parents of kids with the disorder. Once she was diagnosed and treated, Lori saw the problems she had experienced in school, at work and in her marriage with fresh eyes. Looking back on a letter of reprimand that she received as a bank secretary, Lori understood why the boring, repetitive nature of the job had been such a poor fit.

Lori fared much better in recent years working in a distribution warehouse, doing a wide variety of tasks. Like many people with ADHD, she is energetic and creative. By learning organizational skills and developing more effective habits, Lori was able to channel her energy and tap into ideas to succeed on the job. “I worked my way up to become a supervisor. I am much better at multitasking now. I have the ability to stay on task, and I've learned how to spend the right amount of time on each task to get it all done,” she says.

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Feeling positive
Lori is paying more attention to her marriage as well. She used to be so disorganized that bills were lost and wouldn't get paid. “Now I leave the mail on the kitchen table so that we both see it.” A more fundamental problem was her failure to communicate with her husband. She didn't take the time to listen or have meaningful discussions, but would impulsively make biting comments. “If one partner is inattentive, that's big. Things would build up and the relationship became so fractured. We just weren't talking. Now there is more talking going on about things that are important -- and not just bills. We work on strategies together instead of playing the blame game. We spend time on us.”

Today Lori feels positive about the changes she has made since being diagnosed with ADHD. She has developed better coping skills not only through psychotherapy but also by gaining and exchanging knowledge with others through CH.A.A.D., where she has served on the executive and helped organize a resource fair. “Instead of working with a coach, my extensive involvement with CH.A.A.D. has helped me. I'm also able to work on the coaching by trying to be a coach for my son.” As a result, her quality of life and mood are greatly improved. “I have fewer days when things are spinning out of control. I have more days when I get out of bed and feel energized, when life is productive and joyful,” she says.

A sense of control
Denise Difede also feels a greater sense of control in her life since she was diagnosed and treated for ADHD. “Because I've learned about ADHD and how it can affect me, I can change what I don't like. Before I was flying by the seat of my pants. Now I make sure a project is started and completed well ahead of the deadline, rather than leaving it until the last minute. If I'm organizing an event, the details are arranged ahead of time, so there is no last-minute scrambling.” As for her home life, Denise says, “I can now make it to all my kids' appointments and activities, whereas before I would forget to write them down and miss some. Now I've got more purpose, focus and drive.”

Although Denise wishes her inattentive symptoms had been picked up and understood when she was a girl, she advises other women who suspect they have the condition that it's not too late to act. “If you think you might have ADHD and see those traits in yourself, get help. It has made all the difference for me. I am more together. I feel more confident, more in focus and more in tune with myself.”

For more information
To learn more about the assessment and treatment of ADHD in adults, visit the Canadian ADHD Resource Alliance's excellent website. You can also find useful information on medications and possible side- effects in the practice guidelines section.

To find a support group or get online support, visit the Centre for ADD/ADHD Advocacy, Canada. You can also contact CH.A.D.D. Canada, a volunteer organization with chapters in British Columbia, Alberta and Saskatchewan dedicated to bettering the lives of those with or affected by ADHD. Visit the site for links to the chapter nearest you. (You may not have to be diagnosed first; a support group may be able to help you find specialists to see for diagnosis and assessment.)

ADDvance, featuring international experts Kathleen Nadeau and Dr. Patricia Quinn, has a special section to meet the needs of girls and women with ADHD.

* Name has been changed.

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