It happened six months ago: I was sitting at the computer when suddenly I remembered that I’d arranged to make a phone call in another few minutes. I reached into my bag for the phone, but it was not there. I shifted the stack of papers next to the computer – nothing. I looked under the desk and stood on tiptoes to search the shelves. I opened drawers, moved chairs, removed cushions from the sofa, made a mess of a pile of drawings by the kids, scrounged around between the car seats. To no avail. I emailed my prospective interlocutor, saying I wouldn’t be able to talk and would have to reschedule, then I sat down, cursed myself and started to calculate the cost of a new phone.
And then the garbage can in the kitchen started to vibrate.
It was the first time I’d had to pull a cellular telephone out from among carrot peels and coffee grounds, but the fogginess that preceded that action is an old friend. Since childhood, I’ve been losing phones, purses, tickets, notebooks, coats. Getting ready to leave the house, leaving, returning because I’d forgotten something, leaving again. Starting to write an email, remembering that I wanted to check something on the internet, going to the refrigerator for an apple, returning to the computer and trying to remember why my Gmail was open. Every so often, I find myself in the stairwell, spreading out the contents of my bag on the floor in a hunt for the house key.
“Good thing you didn’t leave your head at home,” my sixth-grade homeroom teacher – when I was an outstanding student but struggled every day to remember what was supposed to be in my schoolbag – was fond of telling me.
For years, my sister claimed that I was suffering from attention deficit hyperactivity disorder, and I replied, “No way.” People with ADHD are energetic, jumpy, frenetic, whereas I generally feel like the sloth in “Zootropolis.” And then, last January, I came across an article about ADHD in women, and thousands of metaphorical fireworks exploded in my brain.
What I’ve discovered since then is that, because of a combination of anatomical, hormonal and social factors, attention deficit disorder in women often doesn’t include a hyperactive element. There’s a subgenre called “Inattentive ADHD Type,” which is apparently more common among girls and women. The widespread perception of ADHD is of a child who finds it difficult to sit still in the classroom, feels compelled to move around all the time and is highly disruptive. But girls with the disorder are often quiet and slow, while also finding it hard to concentrate, with a tendency to daydream and be messy.
A survey of articles on the subject in 2010 from the University of Canterbury, in New Zealand, found that, in contrast to boys, whose ADHD symptoms tend to be externalized (i.e., manifested by hyperactivity, an inability to sit quietly, aggressiveness), girls tend to have more internalized symptoms. When their energy level and interest in a particular subject dwindle, concentration becomes very difficult for these girls; they are unable to follow complicated instructions and tend to make careless errors in homework and on tests.
“What is involved here is actually a problem with the brain’s executive functions,” explains Lisa Grossman, an educational psychologist from Ra’anana, outside Tel Aviv, who specializes in treating adults with attention deficit problems, particularly women.
“That includes the ability to do what you want to do, from making a decision to implementing it, so a number of functions are involved: planning, executing an action, then following up on it. Regulation of emotions – all the negative thoughts, such as ‘I can’t,’ ‘I don’t feel like it’ – and the ability not to be impulsive and to be constantly in control of oneself, all these are affected. It’s as though there is no internal adult, or that it is weak and unassertive,” Grossman says.
According to the U.S. Centers for Disease Control and Prevention, boys are twice as likely as girls to be diagnosed with attention deficit disorders. In Israel, boys are 3 times more likely to be diagnosed, according to Ministry of Health data.This disparity often leads parents and teachers to think that ADHD is primarily “a boys’ thing.” (In a 2004 study conducted at the University of California, 550 teachers – 82 percent of the respondents – stated that ADHD is more prevalent among boys.)
However, more recently, as awareness of the existence of the condition among girls has increased, the gap with the boys is beginning to narrow. According to a study published in December 2015 in the Journal of Clinical Psychiatry, between 2003 and 2011 there was a 55-percent increase in diagnoses of ADHD among girls, as opposed to a 40-percent increase among boys. An analysis of prescriptions for drugs, conducted from 2008 to 2012 by a medical management company from a pool of 15 million Americans, found that the group showing the largest increase in the purchase of medicines that treat attention disorders was young women – apparently those who were not diagnosed in childhood. These data indicate that the gender gap in diagnosis is not due to the fact that the disorder is uncommon among girls, but because some other factor prevented a proper diagnosis. Israel’s Health Ministry is also aware of this anomaly: A response that I received from the ministry said that “under-diagnosis of girls is a possibility.”
Why are girls not diagnosed? The reason is that the symptoms they exhibit make it more difficult for teachers and parents to identify the disorder. (According to the California study, “40 percent of the teachers reported more difficulty in recognizing ADHD symptoms in girls, and 85 percent of teachers said that girls with ADHD are more likely to remain undiagnosed.”)
Sari Solden, an American psychotherapist and a pioneer in the field, offers a description in her book, “Women with Attention Deficit Disorder: Embrace Your Differences and Transform Your Life”. Imagine, she suggested, a primary-school class in the middle of doing math problems. One of the boys constantly interrupts the children with his outbursts, and the teacher sends him to the principal, who summons his parents for a talk. Sitting quietly next to him is a girl who is not causing a commotion, but is also unable to concentrate on her class work. Instead, she’s looking out the window and daydreaming. The disruptive boy will soon be tested by the school psychologist and diagnosed with ADHD; he will start to receive treatment and his condition will improve. The quiet, dreamy girl, who is not disruptive, will not be diagnosed – she will simply think of herself as stupid.
For years, studies were conducted on hyperactivity among boys, precisely because boys were the ones being diagnosed. Dr. Ellen Littman, an American clinical psychologist who wrote an article titled “The Secret Lives of Girls with ADHD,” estimates that only 1 percent of all research about the disorder focuses specifically on girls. The studies have thus created a bias in determining the criteria that define the condition, which has led to the under-diagnosis of girls.
For example, until 2013, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM, stated that to be eligible for a diagnosis of ADHD, an individual has to have begun displaying symptoms before the age of 7. However, in girls the disorder is very much influenced by hormone levels, particularly that of estrogen, and thus generally begins to present about the age of 12, when adolescence kicks in with sharp hormonal rises and falls.
Attention-challenged girls suffer more than boys in certain ways. For example, they find it difficult to understand social interaction, which tends to be verbal, rapid and highly nuanced. “Whether (girls ) are making up a game with Barbies or talking about someone -- usually the exchange is very fast-paced and there’s a lot of innuendo,” Littman told me in a telephone conversation. “A girl with Inattentive type won’t be able to process that quickly what’s going on, it will become more like noise to her after a few minutes and she will tend to withdraw to the sidelines, or lose interest. Often these girls are not wearing the coolest clothes, or they get food on themselves at lunch, or their hair is askew when everyone’s hair is perfect. These kinds of things will earn you rejection by girls pretty quickly.
For girls, Littman adds, peer acceptance is “really the way they define themselves. their inability to appropriately attend to other people’s responses leads to shame building up, and chipping away at their self esteem, so you end up with girls who are very depressed and anxious by the time they’re teenagers. When they see a doctor, they will get diagnosed for depression and anxiety”.
Social interaction problems persist into adulthood. A study published in the American Journal of Psychiatry in 2011, which examined 83 adults with and without ADD/ADHD, found that those who suffered from the disorders had difficulty managing their emotions and tended to outbursts of rage, frustration and impatience. Such behavior can hamper diagnosis, because emotional volatility at age 12 in girls is easily attributable to the onset of adolescence.
According to Littman, many girls choose to avoid complicated social interactions, and adult women and especially mothers are often burdened by unremitting guilt feelings.“It’s about being a mother and having to managing your own experience and emotional responses and then having relentless interaction with children, in which you don’t have downtime or time to regroup. They’re constantly feeling guilt -- I can’t believe I said that, I’m sorry I did that,” she explains, adding that men find it easier not to get involved in potentially explosive situations, like going to the supermarket with the children when either one or the other is tired and impatient, whereas with women, “there’s a sense that I should be able to handle this.”
According to the psychiatrist Dr. Yarden Levinsky, director of Resolution, a Tel Aviv-based institution for the psychological treatment of anxiety, depression and attention deficit problems among adults, “a smart girl who isn’t so attentive in class but manages to organize herself when it comes to taking exams, will be able to get along until a certain stage. But adult life is complex, and if she doesn’t learn how to cope with her difficulties, she will hit a glass ceiling.”
In school, he adds, girls can benefit from the existence of a binding timetable and a supportive network of teachers and parents. But when those structures disappear, things start to fall apart.
That’s what happened to Sari Solden, the American expert in attention deficit problems. As a girl, she was disorganized, had problems with math and her handwriting was messy, but she received support and was able to get by. In college, she compensated for the loss of the security net she had previously had with hard work. "She wrote out the textbooks for herself in order to memorize them, and in contrast to other girls, she struggled when she needed to figure out what to wear: “I had a problem with “girls” things,” she says.
This was on the eve of the women’s liberation movement: Everyone Solden knew got married in the summer after college. They woud set up house and have people over for dinner, with the fine china. Solden also got married, and she tried domesticity for a while, but found she wasn’t cut out for it. She particularly remembers how, for seder one year, she tried to make cherry Jell-o just like her mother used to: “I tried 10 ways to get the Jell-o out of the mold, but without success. For months afterward, our walls were covered with cherry juice stains.”
She adds, “I was so bad at being a housewife that I couldn’t do it any longer. I was saved from a life of conformity and superficiality.”
Solden went on to complete a master’s degree in clinical counseling, and in 1988, began to work in an organization that helped adults with learning disabilities. But there, too, chaos continued to reign. She spent hours in her small office, endlessly trying to organize the notes she took in meetings.
“But first I had to move the ticking clock in the room and stuff it into a drawer to muffle the sound,” she relates in her book. “Then I had to close the windows and turn up the fan to block out any extraneous sounds. Invariably, at the end of each day, still unorganized, I would stuff all my papers into my briefcase and take them home. I would put them with the other accumulated stuff in that little room downstairs and spend the evening, trying again in vain to organize them.”
Throughout this period, she kept an eye on the work of another psychologist in the same office who kept a perfectly organized notebook, who wrote down everything she needed, even while chatting with colleagues in the cafeteria.
During this period, as awareness began to develop about ADD in adults, Solden began to treat people with the disorder. She started to notice a pattern: men and women both described problems, but the women reported much more shame, embarrassment and a tendency to hide. Though the men she treated had the same problems, they didn’t allow the disorder to define them as human beings. “And men also receive far more help. The absentminded professor has a woman to help him get organized. Men can separate the chaos from the way they function, and succeed.” However, the women internalized cultural expectations -- that they have to function as the “chief coordinator” of their households -- and those traditional female functions were in immediate conflict with the disorder, resulting in a distortion of their sense of self. “When you grow up without understanding why you have to struggle so hard, you start to believe that you’re stupid,” says Solden, “Women know how to put on an act, but the price is high.”
This awareness was the wellspring of Solden’s ground-breaking book, published originally in 1995, and in an updated edition in 2012.
In recent years, it has been said that attention deficit disorders are being over-diagnosed. In Israel, for example, there are advantages to being defined as an ADHD sufferer: The diagnosis helps people get special dispensation when taking exams, access to medication, among other things.
Solden asserts that there is no over-diagnosis for women, that they are still under-diagnosed, or mistakenly diagnosed for depression. “There aren’t enough psychologists who specialize in women, so I get requests for help from all over the world.”
The women Ellen Littman sees in her clinic often spend a lifetime trying to create order in a chaotic world. “The coping mechanisms they develop are very effective but also prevent them from getting help,” she explains. “Most women who are successful with ADHD have an obsessive overlay -- they’re fighting the chaos in their minds all the time by checking that nothing is falling through the cracks. They become perfectionists and are their own worst critic -- if something gets messed up they blame themselves. To be that vigilant all the time is exhausting.” When women come in to her clinic, she says, she asks them if they’re overwhelmed - and often they burst into tears.
This seeming war of attrition that Littman is talking about sounds very familiar to me: the endless lists I compile in my head, the mornings when I lie in bed trying to enjoy another moment of quiet before venturing out and being subjected to a flood of requests – one sandwich with cheese, another with jam, and, mommy, don’t give me an apple, I want a peach, and I don’t want a sandwich, and mommy he kicked me, where’s my scarf, and what did I do with my bag? On the other hand, I ask Littman, isn’t this part of the normal life of a working mother? How do you know when it’s normal stress that you are feeling and when it indicates an organic problem?
Says Littman: “To think about everything you need to do, your kids need to do, everything that needs to be done at the house -- it’s not easy for anyone. But in the world of ADD, it takes so much focus and attention, that there’s no such thing as that relaxing and kicking back -- there’s always the sense of catching up, being overwhelmed and frantic. Another part of this is the shame, because it seems like other women are doing all this effortlessly, and the shame makes it so no one talks about it. Women are supposed to give help, not seek help.”
She adds that she once interviewed Ted Turner, the founder of CNN, who suffered from severe ADD but refused to take medication: “I asked him how he succeeded. ‘It’s very simple,’ he replied. ‘I have a fleet of people who follow me. If I say something, they write it down. If I need to turn left, they tell me to turn left. If I drop a note, they pick it up.’ If all women had someone to help them do what they find difficult because it’s boring, to their mind – such as laundry, or making sure there’s gas in the car – things would be a lot easier for them.”
The tide turns
For her part, Solden says she was met with disbelief on the part of the medical establishment when she first placed the problem of women with attention deficit issues on the public agenda, in the mid-1990s. Littman recalls that a speaker at a conference she attended during the same period claimed that women are “ADHD wannabes” and will never fit the disorder’s criteria. At present, though, the tide has turned: The web is filled with articles about women with the disorder, and NGOs dedicated to the subject have sprung up in the United States.
Solden herself occupies a place of honor in this flourishing subculture. Even Marie Kondo, the Japanese “organizing consultant” whose books about how to keep the house neat and get rid of clutter have sold millions of copies worldwide, cites Solden as a source of inspiration. In an interview with The New York Times, Kondo related that she came across Solden’s book when she was 19 and read in it about women who could not bring themselves to straighten up the house. The notion that a woman with ADD is somehow flawed, because she isn’t able to tidy up, left Kondo uneasy and led her to a new insight. “She realized that the work she was doing as a tidying consultant was far more psychological than it was practical. Tidying wasn’t just a function of your physical space; it was a function of your soul,” the Times article observed.
Solden, however, went in the opposite direction. She has become fond of chaos, and is a star attraction at conferences for women with ADD. In her book, she describes how the first such event she attended, in 1993, enabled her to understand that for years she had effectively been “in the closet”: “It wasn’t until I saw hundreds of people not in the closet, being themselves in front of others for the first time, that I realized how much time and energy is spent hiding, pretending and carefully monitoring one’s behavior. I especially enjoyed seeing women tearing through oversized, overstuffed purses, hunting furiously for something they needed and couldn’t find but without the usual embarrassment or self-consciousness. I stood in delighted wonder as I watched them throw things on the floor in search of that certain piece of paper or phone number they couldn’t find, talking fast, interrupting, laughing – finally finding people who could keep up with them.”
In August, in the wake of working on this article, I too finally went for a diagnosis. After listening respectfully to my story, the psychiatrist said it definitely sounded like ADD. I asked if he could he please give me a prescription for Ritalin – not for regular use, only for when I really need to concentrate, like when I’m writing an article. No problem, he said.
Since then, the Ritalin has remained in the medicine cabinet, unopened. I’ve had a few opportunities, but I still haven’t been able to make myself use it. Maybe it’s just fear of medicines, of the way pharmaceuticals will change me. But as of now, I am sticking to my regular mechanism of coping: checking my bag four times before I leave the house, and making tons of lists.