Picture a fifth-grade classroom. One little boy will not sit still. He constantly interrupts the teacher and gets out of his chair during the lesson. Meanwhile, a little girl sits in the back row and gazes out the window. Ensnared in a daydream, she also has missed the lesson.

Eventually, the school’s counselor is likely to send the boy for evaluation, and his family will begin working with his learning needs. The girl, on the other hand, is likely to be passed on to sixth grade with low academic marks and even lower self-esteem. Both children have attention-deficit/hyperactivity disorder (ADHD), but because it is the boy’s behavior that presents as a “problem,” only he will receive treatment.

Wilma Fellman, a retired licensed professional counselor in West Bloomfield, Mich., and longtime American Counseling Association member, knows this scenario personally. She says she only “woke up” to her own diagnosis during the process of securing help for her son with ADHD 28 years ago. “The specialists decided to look into the parents’ backgrounds, and his father didn’t demonstrate any of the characteristics, but I was the poster child,” Fellman says. “There I was, 30 years old and suddenly putting things together that didn’t make sense to me when I was much younger. I live inside an ADHD body, so I know it’s real. I know the struggle. I also know it’s overdiagnosed and often a catchphrase, but it’s also underdiagnosed, particularly in women, because they don’t cause a problem.”

Kathleen Nadeau, an author, clinical psychologist and director of the Chesapeake ADHD Center in Silver Spring, Md., points to training deficiencies in the mental health field. “We’re so overtrained by the media and by social assumptions that [attention-deficit disorder] has to do with hyperactivity and with tremendously obvious distractibility. We only associate it with kids — [generally] kids who didn’t do well in school — and we associate it with boys. It’s not that women present atypically, [but] I think there’s really inadequate training for psychologists, social workers, counselors and psychiatrists about what adult ADHD looks like.”

Nadeau offers the example of a family she counseled recently. The daughter, who was in first grade, was “utterly charming” despite interrupting Nadeau’s interview. Both of her parents also had ADHD yet presented quite differently from each other. “Dad is bouncing all over the place. It was clear he had some kind of minor business crisis on his hands, but he didn’t want to leave the session,” Nadeau says. “Then there was his wife [who exhibited] much greater self-control but was describing her office as utter chaos. She said, ’I know where everything is, but I tell my boss that if I don’t see everything, I lose track.’ That’s her ADHD.”

The most common complaint Nadeau hears from women with ADHD is that they are overwhelmed with life: kids, house, work, bills, etc. “Many women can identify the point at which the drowning began,” Nadeau says. “[They might say] ’I worked really hard in college and was successful, but my apartment was always a wreck.’ They usually note a point at which the flood came overhead — maybe the second baby was born or they moved into a house with a larger mortgage. They have tremendous problems with lateness, with distractibility. They say, ’I work all day, every day, and I could not tell you what I accomplished.’ The reason she can’t is she lives her life in reactive mode, with no plan or organization.”

Delayed diagnoses

Women with ADHD are often misdiagnosed and sometimes medicated for other disorders, which can lead to a deep dissatisfaction with the mental health field and an increased sense of isolation, says Ellen Littman, an ADHD specialist in Mt. Kisco, N.Y., who has written extensively on the topic. “Almost all of the women I see have been bouncing around the mental health field for some time, having been misdiagnosed, often on a trial of Zoloft or Prozac. They’ve seen a little relief, but nothing significant.”

ADHD is rarely the first thought when a female client presents with symptoms such as exhaustion, trouble concentrating and feeling different from other people. “It’s missed almost all the time,” Littman says, “so by the time you find a woman in her 40s, struggling on her own for all this time, there are so many other problems that she’s developed as a result. It really impairs her life, and she feels alone.”

Raising awareness in the mental health field is paramount, says Littman, who adds that clinicians need to be sensitive to the history of struggle that each client carries. “It’s astounding the statements that psychopharmacologists make to women who are in such a vulnerable position … but finding a woman psychiatrist who understands all those factors is a needle-in-a-haystack experience,” she says. “Women will come in and say the medication and therapy is helping a little, but with years of being told, ’There’s nothing wrong with you. Just try harder,’ they’re not good at advocating for themselves when they go to a psychiatrist. And that becomes another cycle perpetuating low self-esteem. You have to create a safe environment where women feel all of their issues are being validated.”

Nadeau advises counselors to listen closely to their clients and carefully consider whether certain symptoms might be connected with ADHD. “It’s really important to help counselors understand that women with ADHD are very likely to have anxiety and depression [at the same time],” Nadeau stresses. “If you think about it, having ADHD is anxiety-provoking. If I’m running late, if I just got something in the mail, these things ratchet up the anxiety. What is rare is for [adult] ADHD to exist without a coexisting condition. So often the anxiety or depression is very readily diagnosed. All mental health professionals know how to diagnose that. [But with ADHD], sometimes it’s like peeling the layers of the onion.”

There are more than 14 typical ADHD symptoms, Fellman notes. “The tricky part is that almost no one has them all. The combination that Female A may have is 1, 3, 7 and 9, while Female B has 2, 6, 11 and 14, and the two don’t operate at all alike. Once counselors realize [ADHD] doesn’t follow the rules, then they are starting from the right place.”

Littman agrees. “In high school, [these clients with undiagnosed ADHD] didn’t fit in anywhere but soon discovered either through substances or through sex that these were ways to be accepted and to bridge the gap that they were not able to bridge another way. They may have had trouble connecting to others, but with those [behaviors] you get blanket acceptance. You find people in their 20s drinking or smoking pot all the time, doing things to slow their brains down. It’s very rare that they don’t have self-medicating behaviors.”

“There are also usually addictive behaviors,” she continues. “They often start with nail-biting, then food becomes the legal addictive item for girls. It’s unusual to find these clients without some sort of eating disorder.”

A counselor’s attitude can exacerbate the problems of women with ADHD. “A lot of therapists who are trained more analytically don’t really buy the whole diagnosis,” Littman says. They assume that “if there are problems, it must be something you are doing to sabotage yourself by repeating unhealthy behaviors and patterns. That confirms the person’s feeling that she is somehow a loser getting in the way of her own achievement.”

Great expectations

Cultural expectations about female behavior also make it difficult for women with ADHD to thrive. “Usually, girls and women have the additional issue of the sociocultural role of what a female is supposed to be: organized, together, socially adept and good at cooperative activities,” Littman says. “These women are not feeling good at any of those things. They may just tell the therapist they feel different or that they don’t know how to connect. … She strives to compensate and will do anything to [fit] the appropriate sociocultural role, and she is increasingly overwhelmed.”

Littman has found that women with undiagnosed ADHD experience difficult symptoms that may push them toward counseling during certain life stages. “The first [stage] is when they go to college, leaving home and the extreme structure that’s been imposed by a parent or two where everything was figured out for them — laundry, food, etc. Then they go and try to take on those roles themselves and try to fill in a blank slate of a day for themselves. The first year of college for most kids with ADHD is almost universally a disaster: sleeping, partying, drinking.

“If they’re able to get through that piece of it, then you get to the second [stage]. … Life becomes more difficult when you have a significant other [and you’re] trying to accommodate their needs when you’re not even sure of your own. Girls and women tend to focus on what the other person’s needs are, and their own needs are not addressed, not articulated. They cope like that for a while, but when you get into them having a house or an apartment, the difference is exponential.

“The final frontier, if you haven’t seen the client yet, is going to be the second child. There’s just no way [the client with undiagnosed ADHD] can manage. She’s hiding the chaos, but it’s everywhere. It can’t all be done. It’s more likely she will be diagnosed then, but the damage [has already been] done in terms of her self-esteem.”

Nadeau echoes this sentiment. “One of the gender differences is that very often in a workplace setting, women are more likely to be assigned a job that involves organizing other people — the essence of being an ’admin person.’ That’s exactly what’s so hard for these women. Even if a woman doesn’t have that kind of a job, much of the family expects her to be the one to figure out what’s for dinner, when is soccer practice and did you get the gifts for the birthday? So they begin to feel they’re just bad at being a female. Even though a man might be impacted in the same way, the world isn’t expecting him to manage his family in addition to doing his job.”

Career myths

In the 28 years since her own informal ADHD diagnosis, Fellman’s counseling career has focused on helping adults find meaningful work, with an emphasis on ADHD support. “I live and breathe the topic. In fact, I’m in graduate school again going for my doctorate because I’m not finished yet,” she says. Her research is focusing on the validity of Myers-Briggs Type Indicator results for women with ADHD and how the test, and other ADHD stereotypes, might lead counselors to reach inaccurate conclusions about their clients.

“I don’t think most counselors understand [ADHD],” Fellman says. “When you have a woman who goes to a counselor for career development guidance and the counselor has very passing knowledge of what ADHD is, they often use the myths that are associated with ADHD to guide this person. The myths are that everybody with ADHD is jumpy and can’t sit still, so just find them a job or career that has to do with moving around. That isn’t necessarily true. There are an awful lot of women with ADHD who are hyper-focusers. They can sit in one place for days if they are intensely interested. I have had dozens of accountants who are successful and who have ADHD.”

“Another myth is that all people with ADHD are creative and should probably follow that kind of career path,” she continues. “That isn’t true. Some are creative and others are not — just like the rest of the population. A counselor might believe that all women with ADHD are creative, so you [end up with] a client who feels badly for not completing what she should, then you add another negative feeling because she’s not creative enough either.”

“Not all women with ADHD should be entrepreneurs and work for themselves,” Fellman says. “For some, that’s a magic combo; for others, the kiss of death. They try to wear all hats and just can’t do it all. If organizational skills or time management are issues, they feel badly and say, ’I’m supposed to be a good entrepreneur. Why can’t I pull this off?’ Then the counselor is guiding the person into creative, entrepreneurial careers: ’Be your own boss! Find a job that moves around a lot!’ If this doesn’t sound like the client, it’s the last straw, and she says, ’I just don’t fit anywhere. I still don’t fit the diagnosis.’”

Treatment options

Sometimes, simply being diagnosed with ADHD is a tremendous relief for women who have struggled for years with no frame of reference for their experiences. “Psychoeducation teaches them that [ADHD is about] brain chemistry and genetics,” Littman says. “It’s useful to look at [family] history and realize that mom or dad had ADHD, too. [It’s finally] understanding the stories about the family’s ’black sheep,’ or alcoholic, or person who struggled in school or the one who always changed jobs. It just wasn’t named ADHD in those generations.”

Treatment itself becomes about reframing. “It’s not bad wiring. It’s just different from the linear thinkers of the world,” Littman says. “There’s a way to get people to embrace the way they think rather than constantly denigrating it. Reframing is everything. It’s the lens you see everything through, and it leads to feeling more hopeful.” Littman adds that counselors should change the focus of conversation from what the client can’t handle to becoming more confident in redefining what is really important.

Medication is Littman’s final intervention, but she acknowledges that ADHD requires a multimodal treatment process. “It starts with psychoeducation, reframing, getting supports, changing your caseload, learning shortcuts, and then comes medication,” she says.

Nadeau believes in getting the whole family on board during treatment. She recalls encouraging one client to manage her ADHD in part by adding household help. “But then her mother questioned the expense and said, ’How can you tell me finances are tight when you are doing that?’ That’s par for the course, whether it’s a spouse saying. ’Everybody else’s spouse can handle this, why can’t you?’ or something else more critical.”

“The ideal, of course, is to help women with ADHD recognize their strengths and have it become more reciprocal,” Nadeau adds. Educating the family about the condition’s true impact can assist in creating an ADHD-friendly home environment that supports needed lifestyle changes for the client such as getting good rest, exercising regularly and maintaining household routines. Nadeau also recommends that clients find outside support groups, limit exposure to people who don’t understand ADHD, schedule intentional alone time and delegate as many household tasks as possible.

Being encouraged to simplify one’s life is key, Nadeau says. “One of the strongest messages to get across to counselors is that the most destructive thing about living with ADHD is the barrage of criticism you get from others and the imagined criticism that you heap on yourself.”

Stacy Notaras Murphy is a licensed professional counselor practicing in Washington, D.C. To contact her, visit therapygeorgetown.com.

Letters to the editor: ct@counseling.org