https://www.youtube.com/watch?v=NvF74SgfERo

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Stephaine:
Hey, I'm Stephanie, and I make videos about ADHD and OCD. If you notice my eyes darting to the side of the screen in this video, it's because I can't record a video without first preparing a script, so I'm reading my receipts things. Last week, my brother and I had the opportunity to interview Dr. Russell Barkley, a prominent ADHD researcher and clinical professor of psychiatry at the Virginia Commonwealth University Medical Center. We had some questions for him about how ADHD affects women differently than men, and the conversation was pretty interesting. Adhd in girls and women has not been as extensively studied as it has been in boys and men, and the main reason for this is because women's role in society has historically been secondary to men's and this is really clear in the fields of medicine and psychiatry, where research on female experiences lags behind research on men's experiences. I feel the need to preface this segment of our interview with a content warning, as there's some discussion of traumatic experiences such as sexual assault, eating disorders and suicidality. There's also mention of gender roles in how the scientific community has historically ignored or neglected to study women because we weren't deemed to be critical(??). I want to emphasize that if you have experienced violence of any kind, including sexual assault, it is not your fault. It is the fault of the person who harmed you. Just because women with ADHD experience higher rates of victimization, that does not mean that you invite harm on yourself. This is Dr Barkley's position in this video. So while ADHD may put you at higher risk of experiencing harm, this is very different from placing the blame on your shoulders. So let's look at the studies in the few studies we do have that include female participants, the results are pretty staggering.

Stephaine:
Women with ADHD are at higher risk than the average female population to experience things like. Teen pregnancy, we are eight to 10 times more likely than women without ADHD to experience teen. We are also more likely to experience victimization. This includes sexual assault along with physical and sexual abuse. And eating disorders, women with ADHD are three point six times more likely than the average female to suffer from an eating disorder, with 15 to 20 percent of us qualifying for a diagnosis of an eating disorder. The real point here is not to claim that women are inherently more chaotic or tempestuous, but to focus on the fact that ADHD is impairment of executive functions like emotional regulation and impulse control can cause a great deal of harm to the individual to the extent to which these impairments interfere and negatively impact our daily lives and in our lives as women. The outside pressures of sexual objectification and gender and societal expectations make our harm more likely to manifest in ways like these. More research on ADHD in girls and women is currently underway. Some very interesting studies analyzing the role of hormonal cycles and pregnancy and how they might affect ADHD symptoms came out just last week. So while the bulk of ADHD studies are focused on boys and men, more data on women and our experiences is emerging year after year. And so Dr. Barkley gave us some high level insight into what that research has yielded to date. If you know of any interesting studies or if you have more questions, I'd love to hear your thoughts, so please leave them in the comments. Anyway, here's the segment of the interview

Stephaines Brother:
Before we do cut it, if we may. There was one more kind of big area of question that we

Dr. Barkley:
Can go a little longer if you want to or just a few questions

Stephaine:
Because you are full of questions.

Dr. Barkley:
Oh man, we got so off task. Let's handle those questions to make sure that our readers and our listeners really feel like, you know, they they had a place here. So let's do that. It was,

Stephaines Brother:
I guess, there may have been two, but so the first one that I would want to talk about is the women and ADHD. We had more than a few questions on that front. And then also, I guess, managing your manager in ADHD that when you work differently and you're constantly running into managers that are like, but I don't want to do that right, you're inconveniencing me by existing kind of how to manage that. But but I'd say, let's go to women in ADHD and then if we have time, we can do that and then I'll just have to save my willpower bit for another time. It doesn't deal with it on my own.

Dr. Barkley:
Ok, well, we'll come back again. Let's do it again later. Ok? Oh yeah. Yeah, that would be thrilling. Yeah, I'd love to. I'd love to. Your endpoint users are the very people that I really want to be talking to, not my colleagues. I've had enough of them, but I'm kidding. But you know what I'm saying? So, and I'm coming to the end of my life, so it doesn't matter anyway. I'm a full professor with tenure, so duh. You know, what are you going to do? You're going to send me back to Vietnam again. I mean, you know, I've already been there once. I'm not going back again. So what's the worst that can happen? You know, so yeah. So at this point, let's talk about the women because that's a great it's a great area. Let's understand that for much of the last 40 or 50 years and even beyond that. But in the modern era of research, which goes back to the 1960s when ADHD really blew up in the research journals and even more so today, I mean, you know, we have 1200 articles a month appearing in science journals on ADHD right now. So this is huge. But the point here is that for many years, women were under-recognized for a couple of reasons.

Dr. Barkley:
First of all, in children, the disorder is three times more common in boys than girls, right? So that was part of it. But a big part of it was the boys are more disruptive and aggressive than the girls tend to be, and nothing gets you referred to a psychiatrist or a pediatrician faster than being a pain in the ass. You know, really royal aggressive, obnoxious, emotional temper outburst individual. And that was the boys. The boys have more oppositional disorder. The girls have it, but not not to the extent that the boys do generally. We're talking about averages here, by the way, not individuals. So individuals are different. But but my point then is the girls weren't getting referred because they weren't as obnoxious and the girl's problems were more educational and social and to some extent, emotional, you know, kind of drama queens. But with the boys, I mean, they're out pounding people and they're reactively aggressive and they're yelling and they're defiant and, you know, and then they can't discipline their impulsive and, you know, they're running all over the place and climbing on things. So. So the boys are much more noticeable. But there's a third thing, by the way, and I know our listeners probably don't want to hear this, but there is research going back 50 years showing that at least in earlier decades, it probably doesn't apply so much now to current parents.

Dr. Barkley:
But in earlier times, when women were predominantly viewed as people who chose to be housewives, homemakers and so on. So if you want to go back to Victorian England and all the way up through World War Two, which is when it started to change. That said, it is easier to marry off your daughter than your son. And therefore, there was ample sociological research to show that a parent would refer a son for help faster than a daughter because that son needed to be independent, self-supporting. You can't just marry that guy off, whereas if you had a daughter back in the day, right, you could usually find somebody who would take care of her right through marriage or some other means, but. And I know that's offensive to modern women today, and I get that and things are changing and you have the better you have at least acknowledge. Yeah, yeah, yeah. Why are people in their 40s and 50s and 60s who are women? Why didn't they ever get diagnosed? Because back in the 50s, 60s and 70s, right, they were not a priority, right? So and the guys were,

Stephaines Brother:
And it seems like that implies that practitioners also that means they just got less practice with women. Right. That wasn't happening. There was less research happening. They would see them less. There were more practitioners who possibly had like just never seen a woman with ADHD and didn't consider it.

Dr. Barkley:
Yeah. And if they did, they called her depressed or they called her borderline personality or back in Freud's day, she was just a hysteric, you know?

Stephaine:
Yeah, but written off or often

Dr. Barkley:
Kind of sad. I mean, one of my rules was cruel. All right.

Stephaine:
So I agree, and especially I've done some reading and it mentions a lot. It comes up a lot that for women, we're often more frequently diagnosed with anxiety disorders instead of ADHD or depression. And whereas oftentimes anxiety and depression stem from the executive dysfunction that we're experiencing, so they treat that and that was the case with me very much. I have OCD as well as ADHD. But part of the reason that my psychiatrist is thinking I went under the radar for so long in ADHD is because OCD has a lot of symptoms that it can share in common and especially ADHD and other mental illnesses can present similar symptoms. So in terms of concentration, especially if that's what a lot of clinicians are looking for. Yeah. And the struggle then becomes, how do I differentiate what is causing these symptoms? Is it the OCD, for example, or is it root cause ADHD, which in my case, it stems from ADHD and OCD kind of developed later as a response?

Dr. Barkley:
Sure. Well, that that can happen. But let me let me go back to your anxiety depression. We now have ample longitudinal research showing that the longer you let ADHD go untreated, the greater the likelihood you will develop an anxiety disorder in conjunction with it. So in kids, it's about 15 to 20 percent qualify for an anxiety disorder. By the time you're 35, it's 45 to 50 percent of adults with ADHD, and every four years that number keeps going up. So there is. It probably has to do with the repeated failure experiences socially, educationally, occupationally. You know, at some point, you know, just just going into some new environment freaks you out because you have failed repeatedly. So we know that ADHD does cause the higher risk for anxiety. Now you can have anxiety independently of ADHD. Let's let's get that out of there. But but it's the same with depression as well, but it's more anxiety than depression. It's demoralization. I think that ADHD is leading to as much as or more so than.

Stephaine:
Absolutely.

Stephaines Brother:
Right the way, the way I thought of it....

Dr. Barkley:
There was a stagaging to it. So let me just correct something. If you have OCD, you're only slightly more likely to have ADHD. But if you have ADHD, excuse me, and I've reversed that. If you have ADHD, you're only a little more likely to get OCD two percent more, right? But if you have OCD, Adhd is 60 percent of those people, it's the first disorder to emerge because of the way the brain develops and because these are different hierarchies in the brain and it's the worst of the two disorders to have unless you're OCD is very, very severe, in which case you usually have Tourette syndrome along with it, not just OCD.

Dr. Barkley:
Because Tourette's and OCD are on the same spectrum of disorders, you know, goes OCD to tics, to vocal noises for Tourette's and so on. And they run in the same family, same genetic risks and so on. So, you know, we call that a one way comorbidity. If you have disorder X, you are much more likely to have ADHD. But if you have ADHD, you may not be more likely to have that. Other disorder just depends on on the sequencing there. It's the same with autism. About 20 percent of people with ADHD have autism symptoms. They're usually at the higher functioning end. But if you have autism, the figure is somewhere around 40 to 60 percent will have ADHD with their ASD. So we call those one way comorbidities, and the reason is the other disorder, in this case, OCD and autism and Tourette's are occurring at much lower brain levels. And when they develop, they echo up and affect things above them, like the executive system. Whereas if you have ADHD, your disorder is high up in the brain and that doesn't cause problems with the lower levels. So that's why ADHD doesn't create Tourette syndrome. But boy, if you have Tourette's that lower level basal ganglia, then it causes the other problem.

Stephaines Brother:
Thank you.That made a lot of sense

Dr. Barkley:
I know we've gotten way off task. Just so, you know,

Stephaine:
We did get a lot of questions

Dr. Barkley:
With ADHD, have another disorder. 50 percent of them have two other disorders. So ADHD alone is very uncommon. Only about one in seven people who come to a clinic are only ADHD. So part of our job, Scott is looking for the second and third disorder that are going together in this mix up or mash up of a person's life and not just attributing everything only to the ADHD, but the ADHD is the earliest starting of the disorders like anxiety, depression and the others. And so that's why we usually see it ahead of time.

Stephaine:
Has there been much research on the overlap of symptoms or the comorbidity of CPTSD with ADHD?

Dr. Barkley:
Yes, yes. And then I want to come back and finish the women's answer.

Stephaine:
Ok, sorry.

Dr. Barkley:
Very quickly, if you have ADHD, you are more likely to develop PTSD when you experience a traumatic event than as a typical person. We know that for soldiers serving in the military, we know that from children who are, you know, traumatized. So and that has to do with the fact that one of the executive functions is emotional self-control and self-regulation. And if that's not working well and you're traumatized, you're going to struggle much more than another person to deal with the PTSD downstream from that traumatic event. Now that said, once the PTSD is there, it brings in its own complicating problems and symptoms that we have to deal with. And unfortunately, ADHD makes you more likely to experience a traumatic event because of your risk taking, because of your impulsivity and your lack of conscientiousness. You're doing things that other people would have thought twice about, and as a result, you may well have traumatic brain injury. You may well enter the military three times more likely than a typical person would, because that's what adults with ADHD do. They're niche picking. They're trying to find places where they might succeed, and the military happens to be one of those. So now you've exposed yourself to traumatic events through warfare that other people might not have had. And then there's the driving and the car accidents and the risky sex, and the fact that women with ADHD are much more likely to be sexually victimized than men are because they are immature in the sense of their self-control.

Dr. Barkley:
They're impulsive they're risk taking and they drink. And as a result, you mix that all together and you are a set up to be abused by a sexual predator. And so hence a lot of ADHD girls report, having had either near close calls or, in fact, sexually traumatic events with other people. And they blame themselves in part, how could I have let myself get into that situation? But the lack of forethought, the lack of self-control, the excessive use of alcohol, and here we are. You know, so women with ADHD, they tend to have a little bit more of the inattention, a little bit less of the hyperactivity. It's not dramatically different. It is the same disorder, but the symptoms can be emphasized a little more in one than the other. But it's not qualitatively different, as some people have argued in trade books about women with ADHD, that is simply not true. Where they differ is that the girls often have a more severe form of the inattention, and that's because it takes more genes in your family. For a girl to show a genetic disorder like ADHD than it does a male, there's a lower threshold in males for psychiatric disorders to penetrate into that phenotype, into their life, whereas in females, at least currently and I don't want to make it sound definitive, but it looks like for a girl to manifest a disorder, there has to be a higher genetic loading in the relatives and more risk being in that family. Or she's also had experience.

Stephaines Brother:
So, oh, no, I'm losing Dr Barkley. I'm losing everybody. Oh, oh no.

Dr. Barkley:
Hazard, that has further 12 percent genetic and voice about 65 to 75 percent genetic boys acquire disorders faster than girls from being exposed to biologically hazardous events like prenatal alcohol exposure and, you know, lead poisoning and traumatic brain injury and so on. The male brain is a more fragile instrument than a female brain tends to be. So you know, those are minor scientific points. But it's interesting, though, to me, the real sex difference here is in the comorbidity of other disorders, but that's true of women in general. In the general population, women are more likely to have anxiety and depression. Men are more likely to have aggression to have antisocial behavior and substance use and just general risk taking behavior than are the girls. And so as a result, it's the second and third disorder and the types of impairments that go with them that separate the sexes. That doesn't mean that the girls don't do those other things. Girls with ADHD derive worse than typical women, but they're not as bad as the boys, right? And it's the same in other areas, too. Like crime and substance use. The girls aren't quite as bad as the boys, but they're worse than the other girls are. If we compare them to girls now, on the other hand, the girls are more likely to have social relationship problems, to have anxiety, to have depression, to marry later than others, and to find themselves more likely to have had a child while they're young or at least have gotten pregnant.

Dr. Barkley:
Adhd predisposes women to early childbearing. The men, too, but it's the woman who bears the brunt of that. So, for instance, in our studies, 32 to 40 percent of girls with ADHD have an adolescent pregnancy, whether they carry the term or not, by the way, that's 10 times the national average. So if you are staggering, well, it is. But it tells you that if you want to find ADHD, women go to a home for unwed pregnant girls, right? And you'll find a much higher rate of ADHD, the same with bulimia, the same with binge eating, the same with obesity. If you want to find these people, that's where they are. You know, they're trying to get control of of these addictions. So the difference to me is in comorbidity and in what domain of your life is is being impaired and because women may opt in and out of different roles in their life. Adhd disrupts the role you chose. So whether it's housewife, homemaker, mother, career woman or all of that, ADHD is going to perniciously affect those. But we generally find that women report more disruption of their social relationships, of their home, life, of their marriage, and less so in their occupation. Unless, of course, we look at career women and then it reverses, and then they talk about the detrimental effect on their career, more so than they talk about their home life.

Stephaine:
I'm smiling because this is the case with me. I social relationships are fine. My employment has always been fraught with kind of social difficulties in the workplace, not really understanding social politics, but also struggling to manage my executive dysfunction and to still kind of perform to the level that I want to. Yeah, yeah. I did have one more question about women wondering if there's been any research on the possible role that hormones could play

Dr. Barkley:
In the expression. Great. Great question. I mean, this is this is just happening literally this month.

Stephaine:
Oh, exciting.

Dr. Barkley:
That's that's a really good question, by the way. Let me just back up. I forgot to clarify. Adhd is three times more common in boys and girls. By the time you're a teenager, it's two to one. By the time you're an adult, it's one and a half to one. What the heck is going on here where the girls are catching up? We're not sure, but two studies indicate that women have a a double onset. Like the boys, they have an early onset. So it's half of the girls have an early onset, but there's a second wave of girls getting ADHD at menses, at puberty. So that answers your second question Is there something hormonal going on here? We think so. We think that girls who were marginal or may be sort of symptomatic but didn't really have the disorder can be pushed into the zone of having that disorder by the onset of their menses and those hormones. And that probably has to do with the fact that the frontal lobe seems to be very sensitive to female hormones. For some reason, we can go into evolutionary explanations another day for that. But but the point being is that we also see it at the end of life. So you could have been a high functioning career woman who had mild or borderline or marginal ADHD, and you hit 55 and you're coming in because now we're all losing working memory and you didn't have enough to lose.

Dr. Barkley:
And when you start to lose it, you cross that line into a diagnosisable disorder that was kind of marginal, and you can cope with it before you get there, so we see women coming in now at mid to late life as the first time they've ever come in asking for assistance. And so all of this, both the onset and the onset of menses related to hormonal changes in women is related to some extent to a woman's symptoms, including each month as she has her period. The two or three days before and after often have to be dealt with because of the effects it has on emotion regulation. And if you don't have a lot of emotion regulation, it can get a lot worse and the same with with working memory. So there's an expert who's writing an article for my newsletter right now on this very topic. And there were just, I think, one or two research papers and grants that have gone in to study this. So it is a much understudied area of women with ADHD that we need to take a closer look at because women may need to be managed somewhat differently, particularly around these phases of life than we would do for men or for women outside of those phases of life.

Dr. Barkley:
So, you know, that was a great Segway from, you know, women with ADHD over to the hormonal effects. But by the way, while we're at it, there was one question that I saw on the thread, which is, can you take these medicines during pregnancy of women with ADHD? We didn't know a lot about that until this past year, and the pharmaceutical companies always have on their labels do not use during pregnancy. That's to avoid liability. It's not because I have any evidence, it's because we don't have any evidence and they don't want to put themselves out there. So they're telling you not to use it. But the fact is, in clinical practice, we can't be so cavalier about that because not managing your ADHD brings on a whole suite of risks that we get rid of when you manage your disorder, you can die from this disorder. You can have car accidents, you can get hurt, you can get abused and victimized, you can lose your job, you can lose your marriage. You know, you can lose friends all over this if this isn't being managed well. And by the way, it also affects your parenting adversely. So, yeah, those are compelling reasons why we might want to roll the dice and treat a pregnant woman with ADHD while she's pregnant because we have to weigh what's the risk benefit here? Ok? I don't know what the drug is doing to the baby, but I sure as hell know what's going to happen if I take you off this medicine and you're just going to collapse in terms of your functional effectiveness and your risks are going to go way up.

Dr. Barkley:
There are great studies just out within the last month that show even in the months you're off your medication versus on your medication, the mortality rate goes through the roof. Wow. So it isn't just around accidental injuries. Yeah, yeah. I mean, that's how population based study out of the Scandinavian countries where of course, they have all these medical records they can access. And so they can compare people on the months they didn't renew their medicine to the months they did, as well as compare people with ADHD to non ADHD people. And what it shows is the medication puts your wrist back to normal. That doesn't mean there is no risk. Even normal people have a risk of a car accident, but it eliminates the risk for suicide. The risk for car accidents. The risk for accidental injury and mortality. And those are major things. So back to the pregnancy issue. That's what we as clinicians have to think about, which is worse here, an unknown effect on the child or a known effect on that mother now.

Dr. Barkley:
And people have to walk that through. If it was mild ADHD, we'd probably tell you to stop. If it was moderate to severe, we would say press on, you know. But now we do know we've had three huge population studies in the past year looking at this issue, and here's what it showed. First study showed there are no major physical abnormalities that we can detect in the offspring of women who stayed on medication versus those who didn't. So you're not going to have a malformed fetus or some major problem, right? Second study found there is no increase in psychiatric disorders in the offspring of women who took that medication versus those who did, I mean, there's a genetic risk, as you know. I mean, if a mom has ADHD, half of her kids are going to have it. But there is no increase in risk by taking the medicine during that time now. Subsequently, the two studies published in the last six months focused on smaller degrees of abnormalities and both of them found and by the way, they're only with methylphenidate. These studies were not done with the amphetamines like Vyvanse or Adderall. The reason for that is this drug is not available in many of those European countries. Only methylphenidate might be available in some of them, but in any case. And what they found is there's a very small increase in the likelihood of heart defects in the babies whose mothers took methylphenidate.

Dr. Barkley:
The increase in risk, although it's statistically significant because we're dealing with tens of thousands of people is in a clinical sense, only a minor uptick probably increases the risk by two or three percent that there's going to be a cardiac malformation. Ok, so so is there a risk? Yeah. Is it a great risk? No. Is it a risk that we might consider taking because it's only a two or three percent increase in risk versus the idea that you are going to suffer if you come off this medication horribly and we can't have that, those are the risk. So, you know, it's a complicated area that physicians really have to walk through. And unfortunately, most physicians don't know the data about this. And if they did, they might think more take a more nuanced approach to this instead of the blanket drug insert description. No drugs for you kind of like the soup Nazi on Seinfeld, you know, none for you. And we can't do that. I mean, there are risks on both sides here that have to be weighed in the balance. So, you know, bless the person for asking that question. That was a great question that really got to the current research that's just around over the past year or so.

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