Attention deficit hyperactivity disorder (ADHD) isn’t just for fidgety little boys anymore.
The number of young adult women taking medications for ADHD jumped by 85 percent between 2008 and 2012, according to a recent report by St. Louis-based Express Scripts, a pharmaceutical benefits company.
While children are still more likely to have ADHD, the rate of diagnosis is climbing faster in adults – up 53 percent in grownups versus 19 percent in kids over those four years.
The increase has been driven by rising awareness and recent changes to ADHD’s definition, which allows more adults to meet the diagnosis criteria.
Some suspect those definition changes largely benefit the companies that sell ADHD drugs, and are reporting multi-million dollar earnings. ADHD specialists say they better reflect how people, especially women, experience the condition.
ADHD is particularly challenging for women, because society expects them to work, as well as manage the household – picking the kids up at soccer practice, fixing dinner, and remembering tomorrow’s bake sale, said Ellen Littman, a clinical psychologist and author of several books on girls and women and ADHD.
“Women are taught that ‘you have to be able to do everything,’” said Littman, who has a private practice in Mount Kisco, NY, drawing roughly half her patients from nearby Fairfield County. “Women are not thinking ‘I might have underlying ADHD and that’s why it’s so hard for me.’ Women are ashamed.”
Melissa, a Norwalk resident in her 50s, said ADHD has derailed much of her adult life, including her education, her marriage, her career and her self-esteem. Like many adults with ADHD, she feels too embarrassed about her condition to want to be fully identified.
“I don’t tell a lot of people about it,” she said, in a telephone interview. “I’m afraid to.”
That weekday morning, Melissa was still upstairs in bed at 10:15, though she’s expected to arrive at her part-time job around 9. A stack of unpaid bills awaited her downstairs.
“You can’t really tell a lot of people what your problem is, because they don’t really understand,” she said.
Strewn across her bed, Melissa said, were books about anthropology, Native American life, gardens of Great Britain, Egyptology, the constellations, making mosaics and painting flowers. “I’m reading a little bit of everything and don’t really do anything with it.”
This inability to prioritize is typical of people with ADHD, who struggle with what experts call “executive function.”
ADHD is caused by “inefficient functioning of part of brain behind the forehead, the output of which is what they call executive cognitive functioning,” said Dr. Daniel F. Connor, chief of child psychiatry and a professor at the University of Connecticut School of Medicine in Farmington.
People with ADHD face constant challenges with executive functions – which include things like managing time, organizing a task, getting started, keeping track of multiple things at once, and seeing a project through to completion.
ADHD isn’t entirely negative, said Thomas E. Brown, the associate director of the Yale Clinic for Attention and Related Disorders.
“Everybody I’ve ever seen who has ADHD has a few things where they can focus very, very well,” he said, like playing video games, selling high-stake stocks, treating critically ill patients, or – in Melissa’s case – making crafts with kids.
That temporary focus makes it easy to confuse ADHD with a willpower problem, Brown said, “when it’s a problem with the dynamics of the chemistry of the brain. This is not about people who cannot behave.”
For Melissa, the real problems started when her kids got older and their lives weren’t providing structure for her own. Once they left for college, tensions that had been brewing for years with her super-organized husband, boiled over.
The therapist they went to see in the late 1990s was the first to suggest that the challenges Melissa had faced all her life could be explained by ADHD.
“I remember the day I got diagnosed and got the official paperwork,” Melissa said. “I broke down sobbing and I said, ‘It’s not my fault.’”
Even today, many girls with ADHD are missed because they’re not bouncing around the classroom like the typical boy with the condition.
Instead, they quietly underperform, receiving comments on report cards like the ones Melissa always got: “Isn’t trying hard enough.” “Underachiever.” “Really could do it if she tried.”
“That was with me the first 30 years of my life,” Melissa said, and “it makes you feel crummy.”
Littman said females tend to internalize their ADHD symptoms. They’re more anxious, depressed, complain of headaches, stomachaches, trouble sleeping, and eating issues. “Things that would not be associated with ADHD, unless someone is pretty familiar with what it looks like in girls,” she said.
The smarter the girl, the better she is able to compensate for her ADHD, Littman said, keeping it hidden until well into adulthood. Many of her clients end up with a diagnosis when their own kids are diagnosed, she said.
Last year, the latest edition of the Diagnostic Statistical Manual –the book psychiatrists and psychologists use to diagnose brain-based conditions – broadened the definition of ADHD. Earlier editions had said someone didn’t have ADHD unless their symptoms began before age 7, and required both children and adults to meet the same criteria for diagnosis.
But researchers realized that that definition excluded many adolescents and women. The hormones of puberty tend to magnify problems in girls, Littman said, making obvious what wasn’t obvious before. In the new definition, symptoms can appear up to age 12 to allow more girls to be diagnosed.
For boys, hyperactivity tends to diminish in puberty – which is why people used to assume that ADHD was something kids grew out of and adults didn’t have.
Research in recent years has shown that at least 30 percent of children with ADHD continue to have the condition as adults. That recognition led to the skyrocketing of diagnoses in adults, up from near zero two decades ago, Connor said. In the new definition, adults now need to meet most, but not all the same criteria as children.
Although boys are still diagnosed five times more often than girls, in young adults, ages 19-25, the diagnosis rates are pretty much the same regardless of gender, the Express Scripts and other research shows.
Diagnosis of ADHD remains tricky, with no biological test or number to consult on a chart. Before diagnosing someone with ADHD, specialists typically spend several hours with the person, getting a family history, talking with family members and making sure ADHD problems impair both work and home life.
“The kid at private school with a B average and they want an A average – that’s not how the disease presents,” that’s not ADHD, Connor said.
But it’s easy to see why some people are incorrectly diagnosed by pediatricians and general practitioners who aren’t as familiar with the signs of ADHD and only have 20 minutes to spend with each patient, he said.
According to Express Scripts, two-thirds of adults diagnosed with ADHD are given the label by their general practitioner, rather than a specialist.
Medication For Sale
Prescriptions for ADHD rose faster in 2012 than for other major medical conditions such as diabetes, asthma, and high blood pressure, Express Scripts reported.
There’s no question that misuse is up, too. One recent poll at an unnamed Ivy League college found that 18 percent of students admitted to using ADHD meds they weren’t prescribed. Other studies have found similar results.
But among people who actually have ADHD, abuse is rare, Brown said. For every person who misuses the drugs, “there are probably thousands who take these medicines quite safely,” he said.
Getting the dosage right can be tricky, though, especially for women, said Brown, who has a private practice in Hamden. Doctors don’t yet fully understand the role female hormones play in the condition or in drug response.
Adults may also need a different approach to medications than kids, he said. For the most part, children can come off their medications in the afternoon, after school hours are over and especially when homework is complete. But adults – who are managing a household, making sure dinner is made, the laundry is washed and that homework gets done – may need a prescription lasting far longer than a schoolchild’s 6-8 hours, Brown said.
Medications won’t fix everything, he said, but they can help people with ADHD focus longer than they do naturally – long enough to power through tasks that would be impossible otherwise, like homework or taxes or projects at work.
Melissa said ADHD medications help her to accomplish much more than she would otherwise. Her only regret, she said, is that she didn’t start them in time to have a better career or save her marriage.
Connor said people need to start thinking about ADHD – and its treatments – as they do asthma or diabetes. They wouldn’t tell a diabetic to simply control their blood sugar, an asthmatic that she’d be better off if she just breathed more deeply.
“People with ADHD are not efficient in living up to their potential,” he said. “But they still have that potential.”