Portal de Periódicos da CAPES

Attention deficit hyperactivity disorder in women and girls

2022; Wiley; Volume: 26; Issue: 4 Linguagem: Inglês

10.1002/pnp.771

1931-227X

Joy Ogden,

Maternal Mental Health During Pregnancy and Postpartum

Attention deficit hyperactivity disorder (ADHD) was first recognised as a valid condition in the UK in 2000, but not officially recognised as an adult condition until 2008, when the first National Institute for Health and Care Excellence (NICE) published its report on it.1 It is a neurodevelopmental disorder that is one of the most widespread childhood disorders today and is disproportionately diagnosed in boys rather than girls. This is generally agreed to be because boys’ hyperactive behaviour tends to be more overtly disruptive, while girls more often mask their hyperactive impulses, which some research papers say may contribute to lower rates of referral for ADHD assessment and support and lead to long delays for diagnosis.2, 3 Tracy Dickens, Director of Therapeutic Services at the ADHD Foundation, started working there ten years ago but was not diagnosed with the condition herself until January 2021. She says: ‘Interestingly, in the job interview I can remember Tony said, “why here, why ADHD?” and I said, “Well, all my kids have the same issues, as kids with ADHD do, but they haven't got ADHD”’. But the more I have understood and learnt, the more we, as a family, identified that this had been the elephant in the room, so – one at a time – three of my four kids lined up, were screened, had QB tests, were assessed and diagnosed between the ages of late 20s and early 30s. I looked in the mirror and thought, ‘That's what's been going on for me, all my life’ and it really helped me contextualise my experience, I suppose. She says: ‘I was always somebody who had about five part-time jobs on the go, I'd be studying part-time and spinning lots of plates. In those days I didn't think I was doing it for any other reason than that I was a person who was just interested in things and had lots of energy. I've never slept well, all my life, I just thought that was me.’ Alongside teaching in a secondary school, she qualified as a counsellor and therapist, then no longer needed school holidays and wanted ‘to do a job that means something to me’ so she went to work at the ADHD Foundation. Her own diagnosis made a big difference, she says: ‘A lot of adults go through life thinking they're either deficient in some way, or work two or three times as hard just to attain the same level.’ Professor Amanda Kirby is chair of the ADHD Foundation, a qualified GP, who worked in adult psychiatry and stress management but changed her career when her second child was diagnosed with dyspraxia, aged three years. She has first-hand lived experience of neurodiversity, seeing herself as neurodivergent (though not officially diagnosed) also as a parent of neurodivergent children and grandchildren. She says when her child was diagnosed all developmental disorders were regarded as disorders of childhood and did not include adults until relatively recently. She adds: ‘With ADHD we recognised that over time, as you grow, not surprisingly, we will present differently. So, from the overt hyperactivity of a child jumping up and running around, to – like me now – fiddling in my chair. But it wasn't really thought about and that's why adolescents, adults and girls were not considered.’ Professor Kirby says the impact on the life of somebody diagnosed as an adult depends on whether they have a good support structure around them, with people to help and provide guidance with planning and organisation. She adds: ‘But we know about one in three people who are in prison have ADHD and their support structure might not be so good, and all that cumulative adversity on top of ADHD can have a really difficult impact. If nobody's helping you and you haven't been identified, you're more likely to have secondary consequences of ADHD – living more chaotic lives, mixing with people where your impulsivity might get you into trouble – using drugs sometimes to dampen down.’ For women to combat the gender difference in diagnosis, she says: ‘Greater awareness comes from getting more women leaders of all sectors of society to come forward and say, “This is me, I've got ADHD”. And it's important to gain insight from different people about their struggles with accessing help and support. But we need to make sure the services are there – they are patchy across the UK for adults and often there are long waiting lists. ‘I think we're just starting to understand dealing with females with ADHD and I think training teachers to recognise girls early is important, because they're not usually disruptive and get missed. There's definitely a bias about what ADHD looks like – people are looking through a male lens, so that's why girls are getting missed.’ Professor Kirby believes that the ‘attention deficit’ is a misnomer, saying that it's attention surfeit and people with ADHD are hyperfocusing on things of high interest but losing focus on boring and tedious things. Dr Samantha Hiew, former cancer researcher and leading neurodiversity speaker, was diagnosed with ADHD aged 40 years after the birth of her second child. Following a family bereavement, her husband had to leave her alone with two children, one around three months old, and she found herself overwhelmed by the situation without his usual support. She grew up in Malaysia and when she was at school, she coped with it by working doubly hard. She went on to do a BA, a masters degree and won the Malaysian Prime Minister's scholarship, with which she completed a PhD in cancer research from University College, London. At 30 years of age, she grew bored with science and changed careers. Now 41 years old, she says: ‘I've worked in 16 work sectors, done lots of different types of work in different industries because I'm a serial job-hopper, which I was doing way before anyone said the work was multi-potentialised or multi-hyphenate.’ Having been diagnosed with ADHD was life changing, she says: ‘I wanted to make a film so I spoke to so many people who had done amazing work and it's so inspiring just to find successful people talking about ADHD from an empowering angle. It gave me lots of hope; also made me feel I belonged and I didn't chastise myself as much.’ Forging a new identity as a neurodivergent, with a new perception of its challenges and possible positive aspects, she founded ADHD Girls, an organisation to help women with ADHD to access employment and empower them with the skills to thrive in life. She also provides training for companies and says: ‘I've got corporate clients who want to increase ADHD awareness and a lot of people come to me for the ‘women with ADHD’ angle and to find how to help women in the menopausal/perimenopausal stage in the workplace, also neurodiversity. Professor Nandini Chakraborty is a consultant in early intervention in psychosis at Leicester Partnership NHS Trust and the Associate Dean for Equivalence at the Royal College of Psychiatry. She says in her first degree in psychiatry between 1998 to 2001 in Calcutta, she was taught that ADHD is the diagnosis for children, who grew out of it, then heard about adult ADHD for the first time when she started training in the UK around 2003/4. Professor Chakraborty says she became convinced of adult ADHD's existence when, as a relatively inexperienced psychiatrist in around 2008, she interviewed a woman in her clinic who had ‘gathered all kinds of diagnoses – borderline, antisocial personality disorder – with drug abuse in the background and a criminal record’. The woman described her school life as constantly losing things, forgetting her homework, constantly being told off for being distracted and as an adult losing credit cards, disorganisation, constant chaos. Professor Chakraborty says: ‘When I took her history she was so clear cut, it was one of those light-bulb moments. It had all the hallmarks of ADHD, which I thought explained all her other problems and traits, rather than personality disorder. And many people with ADHD tell us that drug use seems to have a slightly calming effect.’ For people who recognise the symptoms and seek a diagnosis for their children, their first port of call might be the school's educational psychologist, or for themselves, a GP who can refer to the proper secondary mental health services. But the services are ‘hugely under-resourced’, she says, with her own ADHD clinic experiencing waiting lists of almost a year now. Professor Chakraborty calls on general adult psychiatrists to be aware of ADHD, to learn about and gain confidence in prescribing for it. She says: ‘It should not just be left to an ADHD specialist. Many of my patients came to me for a first episode psychosis, not primarily for ADHD, and if I had left them to be treated by the ADHD clinic they'd be waiting for a year/18 months for an assessment and medication. So, I am trained in doing the assessment, I do re-assessments, I discuss it with a colleague with more experience in ADHD and start the medication myself. There isn't a specific ADHD qualification, so a general adult psychiatrist can very well start the medication and I think we have the responsibility as a professional community to be more aware of the condition.’