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Flying Under the Radar ADHD in Women

She rises in the middle of the night to provide food for her family… She plants a vineyard from her earnings… She girds her loins with strength and energizes her arms… Her children rise and commend her; her husband praises her, “Many daughters have performed valiantly, but you surpass them all!” (Mishlei 31)

Whenever Shoshana* hears her husband sing Eishes Chayil, the Woman of Valor, on Friday night before Kiddush, she fervently hopes that he will not think about the English translation of Shlomo Hamelech’s vivid words. That is because Shoshana rarely feels “energy in her arms” or “strength in her loins.” Shoshana has ADHD, and perhaps her story (a composite of several true stories) can shed some light on this often misunderstood condition.

Shoshana is a woman in her mid-30s who tends to misplace her belongings. When facing a deadline at work, she waits until the last minute. She is often late for appointments. Shoshana’s behaviors did not begin as an adult. As a child and teenager, her locker in school was a mess, her notes were jumbled, and even if she did her homework she would often forget it at home. The one thing she had going for her was that she was extremely bright. She was therefore able to maintain adequate grades in spite of her disorganization. She became accustomed to last-minute cramming, since she could not bring herself to study in an organized manner.

Shoshana’s behavior in school was not disruptive, but she often appeared to be daydreaming. Her failure to achieve top grades in spite of her obvious intelligence was seen as a sign of lack of ambition and underperformance. Since Shoshana’s grades were satisfactory and she was getting by, the school did not suspect that anything was “wrong” with her. At PTA, her parents were told that their daughter could do even better if she would only try a little harder. No one really understood the nature of her underperformance.

Although Shoshana managed to get through school, when she entered the work force, she upset her coworkers and superiors, who felt that she was not dependable. At home, her husband could not understand why the housework was so overwhelming for her even before any children were born. The one who was most mystified by Shoshana’s behavior was Shoshana herself. Why she couldn’t she pull herself together? Eventually, Shoshana developed low self-esteem and fell into depression.

In fact, Shoshana has ADHD (attention-deficit/hyperactivity disorder), but no one realized. Her discovery of her condition came through her son Reuven, an energetic and fun-loving boy who had a difficult time controlling his behavior in school. The school suggested that Reuven be evaluated. When Shoshana accompanied her son for his evaluation, the psychologist took a family history (since ADHD tends to run in families), and discovered that Shoshana and Reuven both had ADHD, just different types of ADHD.

Shoshana was puzzled. Never in her life had her behavior even remotely resemble that of her son. She was certainly not hyperactive! How was it possible that she had ADHD? Nevertheless, the fact that she now had a diagnosis gave her a certain measure of peace of mind. The mystery of her life was solved. Now she had to figure out how to use this knowledge for her benefit.

Shoshana’s story is more common than you would expect. It is not unusual for women to come in for an ADHD evaluation for the first time in adulthood, even though symptoms may have been present since their childhood.

Why are women and girls undiagnosed? The answer lies in understanding the different faces of ADHD. Although one of the primary traits of ADHD is an attention deficit, the presentation can be quite varied. Broadly speaking, ADHD is broken down into three basic types: the hyperactive and impulsive type, the inattentive type (formerly called ADD), and the combined type.

The hyperactive and impulsive type of ADHD has many of the following symptoms: fidgeting or tapping hands or feet, inability to remain seated, restlessness, inability to partake in leisure activities quietly, acting as if “driven by a motor,” talking excessively, blurting out an answer before a question has been completed, and having trouble waiting one’s turn.

The inattentive type has a different presentation of symptoms: failing to pay close attention to details, making careless mistakes in one’s work, difficulty in sustaining attention to tasks or play activities, seeming to not listen when spoken to directly, not following through on instructions, failing to finish one’s work or projects, having trouble organizing tasks and activities, reluctance to do tasks that require mental effort over a long period of time (such as schoolwork or homework), losing things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones), getting easily distracted, and being forgetful in daily activities.

If someone has some symptoms of inattention and some symptoms of hyperactivity/impulsivity, then he or she is considered to have the combined type.

For reasons most probably based on physiology, boys with ADHD tend to have symptoms of hyperactivity and impulsivity, whereas girls tend to have symptoms of inattention (although both types exist in both genders).

Now let us imagine ourselves analyzing the behavior of a girl who daydreams, stares out of the window, and has average grades. She is not disruptive. We might assume that she is just not as smart as some of her classmates. She is not swinging from the rafters, shooting spitballs, or engaging in the kinds of mischievous behaviors that boys are notorious for. It is quite easy to understand how such a girl can fall through the cracks and go through her much of her life without anyone picking up on her “covert” ADHD.

Even girls with symptoms of hyperactivity can fly under the radar. Unlike boys, they usually restrain themselves from blatantly disruptive behavior in school. Even though such a girl behaves in school (at least enough to avoid having her parents called), she may have great difficulty achieving academically due to her distractibility.

Highly intelligent girls with ADHD are the most difficult to spot. The brighter a girl with ADHD, the later her difficulties tend to emerge. Many girls with above-average IQ can keep it together academically. But the more demanding and complicated life becomes, the more their problems with concentration and organization are likely to impede them. She might outgrow her ADHD, but in about one-third of cases the condition lasts into adulthood.

Where does this leave us? Obviously, not all daydreaming girls have ADHD. But some do.  There are effective interventions for ADHD. For some people, behavioral therapy or ADHD coaching can provide them with the skills they need to manage their condition. Others might need medication (or a combination of medication and therapy). Certainly, going through life without a basic understanding of the nature of her difficulties is not the solution. As with most life issues, when we understand ourselves, we are more than halfway to the solution.

In conclusion, it must be pointed out that, although this article focuses on the difficulties faced by children and adults who have ADHD, people with ADHD are often extremely gifted and talented individuals, who excel in ways that are unattainable by supposedly “normal” people. (Who is truly normal, anyway?) But that will have to wait for another article.