Megan 

Angie recently obtained her PhD in School and Applied Child Psychology at Western University. She has worked with children, adolescents, and families across both school and clinical settings,including Marymount family support and Crisis Center, Mary J Wright Child and Youth Development clinic and the Waterloo Region District School Board. She completed her residency at EPS Family Health and the PsychoEd clinic, where the ladder specilizes is in ADHD assessment and she's currently completing her supervised practice at EPS Family Health and Wonderwide Psychology. Shayna Fox Lee obtained her master's degree from York University, where she lectured in the psychology department and is a doctoral candidate. She has served on the executive board and held an associate journal editorship for division 26 of the American Psychological Association. Shayna's clinical focus is on assessment of women and midlife diagnostics for ADHD and her academic research specializes in the development and verification of mindfulness intervention and the socio historical politics of therapeutic regulation. Shayna is part of the adult ADHD service at the PsychoEd clinic, where she provides psychometric and assessment services to adults and supervision to junior associates. So really excited to hear their presentation today on what it means to unmask ADHD in women, both understanding and allowing these individuals to be empowered and to really thrive. So we're really excited to hear from you guys today, and you can go ahead and take it away,

Angie 

beautiful. Thank you so much for that intro. Let me just share my screen here.

Megan 

yes, we can.

Beautiful, awesome. So thank you so much for joining our talk today on unmasking ADHD in women. Over the next hour, we'll really dive into the unique experience of having ADHD as a girl or a woman, kind of like in today's day and age.

Angie 

So both Shayna and I work and are affiliated with various places like you just heard. But we met while both working at the PsychoEd clinic, and we instantly bonded from there, and we're both just so excited to be speaking on this topic with you today. So we'll start with a super brief overview of ADHD, just to make sure we're kind of all on the same page. Then we'll get into barriers to identification in these girls and women, and what are some of the key reasons for the referral, once they do come to see us. We'll spend a good chunk of the time talking about the female ADHD experience and some of the associated features and kind of challenges that come with it. And then we'll end by going over some considerations for assessment and treatment when working with girls and women. And kind of sort of, what are the next steps, where do we kind of go from here? A couple things to just note up top is that we, as we were kind of going through the presentation, we realized that we really have, kind of like jam packed it with lots of content, because there's just so much to kind of talk about in this area. But we are going to be very mindful of time and make sure, hoping to get through all of it. We might speed through some things at the end, but we'll try to kind of keep an eye on the time. You'll also see that we've peppered in some quotes that kind of like, bring the experience of sort of what it's like to have ADHD as a girl or as a woman, kind of bring it to life. And these were included in a great article in The Attitude Magazine on ADHD and woman. So that's where they were kind of pulled from, and you'll see them sprinkled in throughout.  Alright. So let's jump in. Some are just kind of like almost fast facts. So ADHD is a common neuro developmental condition that's characterized by difficulties with attention, hyperactivity and impulsivity. In Canada, the prevalence rate is about 5-7% in children adolescents and 4-6% in adults. The sex differences in the prevalence of ADHD are pretty well documented. So I think like back in the day, it was something like maybe like 8 in 1 or 10 to 1 in terms of the ratio of boys to girls. Now it's kind of more like 2 or  3 to 1, but we kind of see that this almost evens out as we get into adulthood, where it kind of looks more like a one to one ratio. And I'll let Shayna kind of take it from here for a little bit.

Shayna 

Okay, great. Sorry. Now it's my job to actually be up to date on my on my slides. So to begin it's crucial to provide some context for where we're at as a society when it comes to experiences of ADHD in girls and women. And you can flip through. So ADHD is kind of having a cultural moment. As is often the case with various diagnostic categories, there's a feedback loop between the professional understanding and popular understandings of what various diagnoses mean, and this has become more prevalent since the advent of the Internet, which is providing more nuance about the range of ADHD symptomology. That's, you know, sort of blew out of the water that previously predominant stereotype about a little boy who overtly wasn't unable to regulate his own behavior and was like bouncing off the walls. And correspondingly, there's been a recent surge in science journalism about women being diagnosed with ADHD, particularly later in life, and and I have definitely seen this at our clinic. Women come to us, you know, in their 30s, plus I've had clients in their 70s. And while several explanations have been suggested for this trend by the journalists, an undeniably significant factor is the under recognition of ADHD symptoms in girlhood during childhood. So many girls throughout our lifespan who've experienced what we would now consider to be clear symptomology of ADHD in their younger years, due to the overly narrow scope of symptomological understanding, flew under the psi industry's radar and remained undiagnosed. So next slide, let me give you a brief overview about how we got to this place. Really, what we've discussed begs the question of, Why have so many girls been missed to begin I've got a caveat that's important about the differentiation between physiological understandings of biological sex and social processes and enactment thereof, which can be understood as gendering of individual experiences into imposed categories. So you'll notice that I verbed gender to represent that process of socialization. So for pragmatic purposes in this presentation, and because it reflects still sort of the predominant discourse in the field around ADHD. We are oversimplifying those experiences into the male and female dichotomy, but we encourage you to appreciate that this is ultimately an insufficient heuristic, given the reality of sex and gender variation. So I'm a psi historian, so you're getting the historical perspective in the side disciplines broadly diagnostic categories interact with social, cultural context, and the interpretation of them evolve with through time. Accordingly, this is particularly true in strongly multifactorial disorders such as ADHD. So in the early 20th century, symptoms like hyperactivity and distractibility, along with many other forms of psychological impairment, were predominantly moralized. A common term for Psy type services at that time was moral therapy. So what was perceived as personal shortcomings -  These were perceived as personal shortcomings rather than medical conditions per se. And in the social site and educational services, the onus of perceived character flaws, especially in children, tended to be attributed to poor discipline, lack of self control, and was associated with negligent or insufficient parenting or care provision. Moving through to the mid 20th century, this range of symptomology was increasingly medicalized, which was influenced by contextual forces like the world wars, the emergence of psychiatry and new formalization of diagnostics, such as the advent of the DSM and the expansion of the psycho pharmaceutical industry in the 1950s. Additionally, political movements, grassroots movements began to advocate for children's rights in a new way. You know, calling for more specialized educational services and increased attention was given to behaviors like hyperactivity. You know, it got codified beginning in 1968 with the second edition of the DSM as hyper kinetic reaction of childhood or adolescence, which was changed in 1980 with the third edition to ADD and then amended quickly in 87 to include the ADHD, due to the determination that there are no statistically significant differences between the inattentive and hyperactive presentations of the condition. Before that they had thought perhaps they were separate conditions that were interacting. Beginning in the 1990s the neurobiological explanation of ADHD took hold stronghold and led us to focus on brain structure, neurochemistry, genetics and the interaction with endocrine. The use of stimulants became more widespread, and ADHD diagnoses increased significantly. From the 2010s to the present, our current research is currently examining ADHD from a more socio culturally critical lens, critiquing simultaneously both what's perceived as over and under diagnosis of ADHD given respected populations and exploring alternate treatments. Um. So this is impacted by perception in the field, as I've indicated, and as well as broader cultural context. There is evidence to suggest that the broad discrepancy in the ratio of males to females in diagnosis with ADHD is due, in at least, I would consider large part to lack of recognition and or referral bias for females. So because people frequently experience and respond to the same behavior of males and females in different ways due to gender related behavioral expectations, there is a trickle down impact from research design to diagnostic standards, clinical practices and associated service provision, for example, academic accommodations. Relatedly, and this is important, because ADHD and most psychological research has primarily historically been focused on white middle class boys in North America,  until very recently. Studies have not systemically explored racialization and ADHD prevalence, and there's been few studies focusing on social economic status. However, children from lower socioeconomic backgrounds have been most often, most often been more likely to be diagnosed with ADHD, perhaps due to contributing factors such as environmental stressors involved in the poverty or reduced pathologization of behavior in the upper echelons. But unfortunately, the stat is contrasted by correspondingly low access to appropriate resources post diagnosis in SES vulnerable populations and similarly, non white populations face additional barriers to receiving ADHD diagnoses due to systemic racial biases in healthcare and education systems. Studies have shown that non white children are less likely to be diagnosed than white children, and when they are diagnosed, they may receive less adequate treatment or fewer prescriptions for stimulant medication. Racialized people are also more likely to be diagnosed later, which impacts their treatment outcomes. So there's similar, you know, we saw the female protection effect. You know, there's similar,

Shayna 

Okay, so now we have a good foundation for understanding why so many girls have been missed, especially throughout the child and teenage years. So how do they eventually get to our clinics? Well, many women are self referring. They're seeking an ADHD assessment, and they share a long history of a treat of treatment for secondary or associated comorbidities such as depression or anxiety. So while in therapy or medication, And not least increased pressure and expectations during midlife, transition periods, new responsibilities, women just often hit a wall, is the way that I describe it, in terms of the effectiveness of their self mitigation, compensatory stratagem. So what previously sufficed for their self management, there is slippage through the years and often, women come to us, burned out, overwhelmed, unsure you know of of what, how things can be reconfigured in their life to increase functionality,

Megan 

beautiful, like I could

literally listen to Shayna talk about this all day, like I get put in a trance while she talks.

Okay. So as you've talked about, women and girls are more likely to present as inattentive, as opposed to kind of hyperactive and impulsive, although many do experience some of those symptoms as well, it just might look like a little bit different compared to in boys and men, which we're going to get into in a moment. But first, I really wanted to spend some time walking us through how some of the inattentive symptoms can kind of show up and sometimes in these sort of subtler ways, since that marks kind of like the ADHD experience for so many of our females. So the first one here is, this is kind of like where there's, like, a little bit of a misnomer, because it's not a deficit in attention, but it's a deficit in attentional control, or attentional regulation, right? So it's not that we can't pay attention, it's just that we kind of have a hard time regulating it at times. And so here, it's easy for, you know, our girls to focus when things are really interesting and salient, but it kind of becomes harder to focus when things are a bit more boring or not salient. And maybe I'll let Shayna just take a minute to kind of talk a little bit about our interest based system.

Shayna 

Yeah, so in the field, we characterize the ADHD nervous system as the interest based nervous system. That's how we colloquialize it, and what we're discussing when we make that kind of phrase, is about differences in neuromodulation in response to perceived stimulation. So when the neuronormative body may mobilize in response to perceived importance or level of care. In ADHD, we see that there's a tendency to. obligation when it's further out in time.

Angie 

Yeah. Beautiful. How forgetfulness can kind of show up is it can be and sort of like day to day things right? Like, sometimes we'll forget to even, like, make the appointment that we know we need to make, or we might forget to, like, do an errand, run a chore, go to an appointment. But it can also show up in these different ways where it can be kind of harder to do, sort of like complex decision making, and that's because we might forget parts of the decision as we're kind of working through it, right? And so here it can be really helpful, like I do this all the time when I need to make important decisions is making, sort of like a mind map for myself, and kind of like writing things down and mapping them out so that I remember the key pieces that need to keep in mind in order to make, like the best decision for myself.

One other thing that I want to note here is that another common challenge for all individuals, I think, with ADHD, and even if you don't have ADHD, I think this kind of shows up for us. Is what we call perspective memory failures. So it's essentially forgetting to follow through on future intentions or plan tasks. As what this might look like is, let's say I'm going to my sisters later on in the day, in the morning, I might remember, okay, yeah, I borrowed that bowl from her last time. I need to bring it with me so I can return it to her. But then when the time comes to actually, like, leave the house and go to my sisters, I just totally forget to bring the bowl, and that's because I didn't remember it at the exact time that I needed to remember it. So then I might be at my sisters, or be like, as I'm walking to my sisters, and then it's almost like the sick, intrusive thought that goes through your head. We're like, oh my god, shoot, I totally forgot the bowl. And then that can be really annoying and frustrating, right? And depending on how kind of, like, critical I am of being of myself that day, it can lead to that kind of, like, feelings of guilt and shame and like, Oh my God, why can't I remember anything? What's wrong with me? Why doesn't my brain work and all of that, which is just so common, and I think the girls experience,

Angie 

do you want to spend a moment talking about kind of that strategy?

Shayna 

 These are like we had just discussed how this is a great example of the type of externalization strategies that can help us mitigate and manage this type of symptom. So because ADHD, you know, is a there's a biological deficit, like there's two layers of impairment, you know, there's some biological level, and then there's the interaction with societal expectations. But at the biological level, because we're not going to develop executive function, executive functions don't actually develop we have to provide external structure to accommodate that deficit. So a great example is this, if you're having issues with projective recall, what you want to do is ensure that the external trigger or reminder that you intend to provide for yourself. Oh, I know I'm not going to remember the bowl. I think even in the morning there's three hours, I better set a reminder. It's setting it appropriately as close to, or if you can, literally on top of what we call the point of performance, the POP. So I need to remember the bowl. Putting the sticker on the mirror when I'm brushing my teeth won't suffice. Putting it at my dresser to suffice. I want to stick it on the door, or I want to put it at 8:58 on my phone when I intend to leave at 9:00. So highest outcomes show getting reminders as salient to the potential impairment as possible, just generally, good approach across strategies.

perfect

In terms of like the the symptom around not listening when spoken to. So what this can look like is, you know, during a conversation, maybe she's like nodding along and responding appropriately again, kind of going back to what's expected of her from society, but then later, kind of realizes that she missed key details because her mind wandered and sort of like, actually doesn't really know what her friends were talking about, or maybe, you know, wasn't part of, like, the planning of something,

Angie 

And then, yeah, I'll get Shayna to talk to the teensy a little bit about this.

Shayna 

Sure. Yeah, I'm not going to give the full example, but I just want to indicate that this realm of impairment and time management has been in the discourse for a long time. One of the preeminent theorists in the 90s, Barkley, I'm forgetting his first name. I apologize for everyone. Called it future myopia. We now more colloquially know it as time blindness, or short a temporal short sightedness. There's disagreement in the literature about how fundamental to the experience of ADHD temporal variation, or, you know, issues with time management are but certainly it's a helpful metaphor to keep in mind that people experiencing these symptoms have a very tight circle of clarity around them, in terms that present proximal stimulation will always be louder and stickier no matter the importance of obligations further in the future or things that have to be recalled from the past, those will always be less perceivable to the person with ADHD than whatever's in their face in the current moment.

Angie 

Awesome,

How disorganization can show up is, you know, as sort of like the default CEO of the house. Women are often the ones who are doing things like meal planning. And so many of them talk about having a hard time with, like, all the different parts of meal planning, right? So deciding what they want to make that week, make sure that they have all the ingredients to cook the meal, following the recipes step by step, without, you know, missing important details and things like that.

In terms of sort of avoiding those tasks that are kind of like, require that sustained mental effort, or they're kind of boring things like, for example, filling out forms for their kids school can be really just kind of like exhausting, and so they'll sort of like, put it off into the last minute because of just how draining it feels. And then the last one here around kind of task initiation or completion avoidance, which we kind of know as procrastination,

And so during an ADHD assessment, you know, if this kind of comes up, like, you know, these issues around sort of task completion, it's helpful to kind of ask, right, like, what's behind all those projects that have been started but not completed?

Again, asking from a genuine sense of curiosity, right? Like, not a judgy way, because she's already experienced too much judgment throughout her life, but truly just getting curious about, kind of like, what's going on there for her. Okay, so this is one of those quotes from the the article that kind of ties into this. So they said, "I wish the world knew how severely inattentiveness can affect someone's life. For me, it meant the difference between having and not having a successful career. For a lot of women, it means they're forced to be financially dependent on a spouse and prone to suffering from the ADHD tax." And I think that this is important, because I think in society, sometimes we think that it's almost like the hyperactive, impulsive symptoms that are the ones that are most impairing, and they can be in certain ways, but we sort of like brush off. It's like, okay, so you can't really like focus sometimes you're kind of forgetful, like, big whoop, but it really can have significant consequences on a girl's life. So it's not to be sort of brushed aside and dismissed.

These next couple slides, they go over how hyperactive and impulsive symptoms can look a little bit different in girls, sometimes compared to boys and men. So the first one is how, when we kind of think about hyperactivity, I think we think about this in, like, a very physical sense, right? So again, it's kind of like always need to move around and getting up from our seat and climbing trees or whatnot in kids and in girls, how it can actually show up is what we call, like, hyper verbality. So this is them. The girls are, like, very chatty, right? And I feel like I see this come up so much in teacher comments on report cards, right? Where you're going to see kind of terms, like, you know, she's a chatter box or a social butterfly, you know, she loves to socialize and talk with her peers, but she needs to learn needs to learn like when it's appropriate and when it's not, things like that. The second one in terms of not thinking through the consequences. So one kind of significant kind of example of this is that, you know, girls with ADHD are more likely to get pregnant in their teen years compared to those without, and obviously that can affect your life in a massive way. And

in their minds, where there's a constant stream of thoughts and ideas and distractions that can feel really overwhelming.

And so one thing, again, because we can be so creative in how we kind of like deal with these things, is that, you know, one way she might cope is by now having, like, a lot of routine and structure in order to kind of reduce the chaos around her to kind of be able to cope with it in her mind.

Angie 

Along these same lines, maybe they have, like, a very, very tidy house. Everything has to be in its proper order, because the messiness can kind of like add to that messiness in her mind.

Shayna 

we didn't have this planned, but I just want to provide a synopsis of what you said, which is that if we consider the root of, you know, medicalized sense of hyperactivity, we're talking about a difference in nervous system function that's often perceived as an internal restlessness or agitation. And we so we need to parse apart, and kind of, as you said, Get under the surface of inhibition. So there's a self inhibition to external structures, rigid mitigation, range, and all of that can be evidence, right, diagnostic evidence versus just the overt behavior, uncontrolled behavior. So when we're looking at prevalence of controlling efforts, there is the different. You know, our current understanding of the difference between boys and girls when we're using assessment tools that are focused traditionally towards, you know, boy based assessment, it's good for us to supplement that with this consideration of what kinds of other evidence are we Collecting by ensuring we're doing considerate, nuanced assessment of women's experiences, of efforts to control their okay. Sorry, no,

Angie 

that was yeah, a very good point. So again, sort of a quote that kind of like highlights this experience is neurotypicals need to know that hyperactivity in women doesn't present as a stereotypical ADHD little boy who fidgets and runs in circles. Our hyperactivity is invisible. It's in our heads. My ADHD mind is like a la highway with high speed cars zooming here and there and everywhere, right? So I think that really kind of brings to life of like, what that can actually feel like in someone's head. Okay? And just a few more here. So there's a symptom around being kind of like a blabbermouth, not having a filter. And so how this can show up? As you know, these girls are called tactless or insensitive by their peers, and I think that the symptoms could be similar with boys, right? In terms of kind of like that, having no filter. But here, I think it can have maybe more significant social consequences for girls, again, because of how we're expected to behave in society, right? And so then that means that they can be more likely than their boys, than boys to be excluded or bullied because of these behaviors. And so, yeah, that can then have sort of again, like ripple effects down the line. Impulsivity might look like impulsive shopping or, you know, girls are more likely to engage in binging behavior compared to boys. And then the last one here around

Shayna 

So, you know, one of the items we'll ask is around, you know, do you have a hard time kind of like waiting, either like waiting in lines, or, you know, waiting your turn for things. And a lot of the time, maybe they'll say, like, Oh no, like, I'm fine with waiting. And then when you dig a little bit deeper, you'll find out that she almost like might plan her whole day so she doesn't have to wait in minds, right? So again, getting kind of creative where she'll know, sort of like when places are less busy or more busy, and then kind of like, schedule them accordingly. Okay, I think I'm just going to jump ahead and Shana, you can take it away on the hormonal front.  Okay, great. So you know, as indicated, in recent years, we've become more conscientious, conscientious of how hormonal fluctuations can significantly influence experience and presentation of ADHD and girls and women. So Most women experience large hormonal transitions through their monthly cycle, and we can see that the levels of estrogen and progesterone on this graph, I will note that most of the research has been focused on adulthood experiences in women with endocrine fluctuations. But puberty is a challenging and exciting moment in development that also we should not ignore. But so during reproduction, with pregnancy and postpartum experiences, estrogen levels increase during pregnancy, which can often bring temporary amelioration and relief from ADHD symptoms. And then, in contrast, during the postpartum moment, hormonal shifts can lead to significant emotional and cognitive challenges, often increasing ADHD symptomology and interacting with postpartum depression. So there can be kind of a whiplash effect during that time and then later in life, in perimenopause and menopause, declining estrogen levels often exacerbate a cognitive challenge, emotional dysregulation and memory dysfunction. And these symptoms can be feel really overwhelming, particularly for people who are undiagnosed or otherwise inadequately treated. So we frequently see perimenopause and menopause being the moment that midlife women decide to finally seek assistance. And you know, like, I'll hear one saying, like, after all these years, do I indeed, in fact, have a condition, and it's not just a character flaw. And so what's important here in terms of diagnostic assessment is because ADHD is a neurodevelopmental disorder, to the best of our knowledge, it does present throughout the lifespan. So you're wanting to make sure you're differentially ascertaining not just comorbidities, which are very common in women and ADHD folks of all genders, but also in terms of onset of presentation. We're really wanting to collate early life experiences, if there is significant increase of such symptoms post enduring perimenopause and menopause. That's complicated, because those experiences can mimic, reflect, or otherwise seem very similar to ADHD symptoms. So you just want to ensure that you're able to parse apart. Is it an exacerbation of something you've been experiencing it throughout your whole life, or is there an onset of something new that may conflate our diagnostic analysis?

Angie 

Beautiful. This is another quote that I think, kind of like highlights this nicely. "I just don't feel believed especially about how much my hormones and menstrual cycle deeply impact all of my symptoms. When I try to explain that my ADHD symptoms are more severe during the second half of the month, I've been told more by more than one doctor that they've never heard of anything like that", right, which I think is such a common experience for the girls that we see. Okay? So moving into kind of, what are some of the associated features that we often see show up in our girls and women with ADHD. So the first one being these difficulties with emotion regulation and kind of these, like ups and downs in their mood. So they might be a little bit more irritable. You know, their mood changes, they have lower frustration tolerance and things like that. And so they might experience kind of more frequent and rapid mood swings compared to their peers. And we've heard of some young women experiencing what they call kind of like zoomies. So it's like these brief bursts of intense energy that maybe lasts only like a couple hours, and it's almost like a super brief hypomanic episode. But it's like, not hypomania. And a lot of them kind of report that they can, that they kind of like, like this feeling, right? Because they can be super duper productive during that time, like get a lot of things done, especially if they maybe were kind of avoiding those tasks before, and then now it's like getting all of it done all at once. And so this might be a little bit annoying for the people around them, but in terms of their actual internal experience of that, it can actually be kind of pleasant. In terms of social challenges. We've touched on this a little bit, but these girls, they can definitely be more vulnerable to bullying, which can come in like all different, you know, ways where it's whether it's physical or social, relational or cyber bullying, they usually have fewer friends, they have a pattern of unstable relationships, and They're at greater risk for intimate partner violence. We also hear a lot of challenges around sleep, right? So a lot of clients, they have difficulty falling asleep, the report, kind of having a hard time turning off their minds, and that can become even more problematic when they're under greater stress, right? So if we think maybe about, you know, our moms with like, little kids, and they have so many things that they have to be kind of like thinking about all at once, then that can kind of keep them up at night, right, when they're kind of like planning the next day or or whatnot. Again, we've talked a little bit about comorbidities, right? So especially in terms of, like, internalizing issues like anxiety and depression. And here, it's really important, you know, again, in the assessment process, if things. I think depression is kind of coming up, you know, is it sort of like a primary concern, or is it kind of secondary to the ADHD, right? So sometimes I'll hear these girls, I'm thinking of one client where it's almost this, like, very predictable pattern. She's in university, so, like, every semester starts off great. She's excited about her courses. She's like, you know, going to the lectures, and then, like, about halfway through, and now it's like midterm season and assignments are due that it just kind of like all piles up on top of each other. There's lots of avoidance of the tasks, right? Hard time getting started, putting it off. And so then that kind of all comes to a head, and can really kind of like, then increase that anxiety. Then that usually kind of goes into a period of, like, low mood, maybe burnout, and then it kind of like ends and then sort of starts again the next semester, and then the summertime, no anxiety or low mood, and so, like, that's an example of it really being tied to, kind of those ADHD symptoms. And this last one here, I think, is so important, it can really affect our self esteem and self concept, right? So these girls, so many of the times they come in and like, you know, they feel like they're they're stupid, they feel hopeless. Research shows that they make fewer plans for their future because they're just not hopeful about it. I'm not really looking forward to it. And I heard this one staff that said, you know, by age 12, she's heard over 20,000 negative messages, right? So it's no wonder that her self esteem has taken a hit again a quote from that article, "the most misunderstood symptom to me, is invisible to others, and is the deep shame that I feel" again, hearing this from from so many of our girls.

Shayna 

yeah, so to supplement that, I really think there is an important component here, which I've sort of indicated to begin about assessment and treatment intervention, bedside manner, if you will, and conscientiousness, in terms of the impact on self concept that people with ADHD experience. And I want to complicate matters a little bit here, because I just want to ensure that people are not because we have this new insight about bio, sex differentiation, you know, within the field, that we don't over correct. So we've had this process where there was erasure of non white boy middle class experience that had overly narrow present in presentation of what we were assessing for that we don't want to now we've accommodated for a variation of experience that we don't want to stereotype or pigeon hole people according to genders. And I think you'll find that everyone you know that you interact with with this disorder presents some configuration right of diversity according to these associated features. So that, having been said, because there's so much negative messaging, we employ that language, what I would consider accessible language, in our assessment and intervention. So it's very useful tool to use words that people would have heard about their symptoms, chatter boxes we've seen blabber mouth Space Cadet lack, you know, not living up to your potential whatever laziness. You know, there's so many words, they're useful because they help people trigger their memory. And it's really important as we're trying to establish lifespan presentation. So especially when you're in midlife diagnostics, it's a long you know, it's a big task, recalling back through the decades. So it really helps to have those words. Unfortunately, there's two factors. One, those words tend to be pejorative, punitive, dismissive, belittling, you know, they they get internalized, you know, as essentially, what's a continuation of the moralization that we started with in the 1800s where I began. And then the other factor is that they are from the perception of an observer, and often an uninformed observer. I think this is an artifact of assessment being focused primarily on childhood initially. And so, because children are just developing that reflexive cognition where they can't self reflect, we were defer to adults perception of the children. But again, that can be, you know, that perception can amount to like sort of abusive perception of the person's experience. It's really important as clinicians to supplement that by bringing the knowledge back to the internal experience of the person having the symptoms. So we're going, Okay, here's a useful tool. How have you been perceived? But also, please, let's talk about what your experiences have been and what the impairment and negative impact of those have been. Off my soapbox.

Angie 

Beautiful, looking I know we have just about 10 minutes left, and so we're probably gonna have probably going to fly through these, these last slides, just in case it feels like we're going a little bit quicker. Okay, so here the United Kingdom ADHD partnership, they hosted a meeting of experts from around the world to basically discuss, sort of like, how ADHD shows up for girls, sort of across the lifespan. And. They put out an awesome paper. I think I have the reference on the next slide that kind of goes over all of these different areas. And this table, I think, provides a really nice visual of, kind of, what are the common problems or associated features that females experience, kind of again throughout their lifespan, so from childhood into adulthood. And so we'll touch on some of these just very quickly. When it comes to education, you know, from a young age, girls with ADHD are more likely to get in trouble in class, right? Maybe they're talking to their friend while the teacher's up at the front giving a lesson. So then they're more likely to get detentions. We've talked a little bit about academic difficulties that really stems from challenges with executive functioning. And then these girls are also more likely to kind of skip class, get suspended, drop out of school, which could then obviously have, you know, consequences on on their careers later in life, right, when it comes to employment and things like that. We've talked a little bit about, kind of the social realm. So these girls, they really do have more challenges, in their interpersonal relationships, right? So again, going back to some of their these symptoms, like impulsivity, right? So kind of speaking without a filter or emotional outbursts, it can lead to conflict, right, with peers or with their partners. And so then that can create kind of those feelings of guilt and shame, which can then make them want to kind of like withdraw and kind of isolate themselves, and so then to kind of cope with that social rejection and loneliness, these girls might turn to substance use at an earlier age, or they might engage in more high risk activities to try to find that sense of like connection and support somewhere, kind of thing. Moving on to the next slide, in terms of, kind of, just like the area of risk. So research shows that girls with ADHD are more likely to become sexually active at an earlier age and have greater number of sexual partners. Very talked about kind of they're more likely to become pregnant as teenagers. And one study found that girls with ADHD were four times more likely to have an unplanned pregnancy compared to their peers without ADHD. We talked a little bit about comorbidity. One that I just want to point out here is that in the teenage years, self harm and suicidality becomes more prominent. So again, one study looked into this, and they found that girls with ADHD, they're more likely to engage in non suicidal self injury as well as attempt suicide, compared to girls without ADHD. Okay, so I know that that might have painted a little bit of a bleak picture, but I think that is why it is so so important that these girls get the appropriate referrals for an assessment, and can then be connected with the appropriate treatments and supports, which is we're going to spend a little bit of time talking about in these last few minutes. This is basically just like a visual representation of kind of everything that came out of that sort of consensus meeting, and it'll be in the slide, so you can kind of take a look at it later and kind of have it as your resource. But I think it does sort of summarize, kind of the experience of having ADHD as a girl. Okay, so ending with some considerations for assessment and treatment when it comes to questionnaires, again, because back in the day, you know, all of the research was conducted on these boys that kind of influence then the development of the diagnostic criteria, as well as the assessment tools that we use. So it's definitely something to be keeping in mind kind of as we're assessing these girls. One thing you definitely want to double check when thinking about maybe which questionnaires to use in the assessment is whether they have female female norms. Right? We definitely want to choose the ones that have have female norms. I also included the SASI here. So that's the woman's ADHD self assessment symptom inventory, which can be a useful measure, because it was specifically designed for assessing ADHD symptoms in women. When it comes to the clinical interview, we want to be listening for, like, what we call soft signs of ADHD. So this could be like that sense of underachievement in academics, spending lots and lots of time to just kind of keep up and complete assignments, things like that. I think the self report aspect of the interview becomes like even more and more important as children get older, particularly for our girls, who usually present with more inattentive symptoms. That's kind of hard for other people to maybe pick up on that, and especially once you become super duper skilled at masking and has developed all these compensatory strategies, right then we really want to get into kind of like her internal experience. We've talked about the importance of exploring common, co occurring conditions as well. So I'll turn it to you, Shayna, to quickly chat about collateral information.

Shayna 

I mean, I think we've essentially covered this. We just want to keep a keen eye for the impact of self inhibition when we are collecting collateral data, you know, for a diagnosis. So normally, where data might be captured from overt behavior in school reports. You know, the types of self mitigation that girls are known to engage in are going to go completely missed, you know, not captured in that. So we need to, you know, as you've already said, self report becomes more important, and other forms of collateral should be taken into consideration, not just the traditional ones based on behavioral dysregulation.

Angie 

When it comes to considerations for treatment. So we know that early identification and treatment of ADHD are strongly recommended, and that's because the evidence tells us that timely intervention leads to long term functional benefits. So addressing ADHD early on can improve outcomes, just kind of like across the board. In terms of the gold standard, it is that multimodal treatment, right so medication and psychosocial intervention. Quick notes, on the medication side, there really aren't any differences in the medications that are used to treat ADHD in girls and boys. It's just that girls are more likely to start treatment and older age because they get referred at an older age for assessment treatment with ADHD medications not advised during pregnancy, although there is more research looking into this, to really get a better sense of, kind of like the the safety and kind of like the risks around it. We've talked about this, kind of as hormones change during key periods, it becomes even more important to kind of monitor our ADHD symptoms and look into our medication. On the psychosocial front, a key ingredient in all psychosocial interventions is that psycho education piece, right? So it's really important for both girls and women with ADHD and their families to understand how ADHD manifests in their lives, and this understanding can really help start the process of kind of de blaming, de shaming, normalizing and accepting, which is super important for the therapeutic process. I think in the interest of time, I'm probably just going to quickly speak to these just so we can wrap up here. There's kind of like we could think about as having two main types of psychosocial interventions, right? So those that kind of target the ADHD symptoms, and then those that kind of target the associated problems. So we won't get into this, but some of the ones that kind of target those symptoms directly are things like CBT mindfulness training or ADHD executive functioning coaching. In terms of the ones that target more associated problems, this could look like developing skills for CO occurring conditions like emotion regulation, anxiety and mood impulse control, things like that, improving our social skills and interpersonal relationships, improving self concept. Sex Education is very important for these girls, right? So kind of like that need for contraception and being safe. And then groups for adult women can be particularly, I think, empowering, right, where these women, they have, you know, a space where they can talk about challenges that come from motherhood or the workplace, like maybe, you know, being disorganized or even in the workplace, kind of being able to kind of accept that constructive criticism, which leads into this last quote here "the difficulty anxiety and misunderstanding that comes from rejection, sensitivity, dysphoria, I find it really challenging across all areas of my life. It causes me great difficulty in my workplace, as I find it really hard to take on constructive feedback, even though, rationally, I know it's not a biggie:.  Okay, why we made it so very quickly, I'm trying to think of, okay, just to kind of summarize briefly, I think where we're at right now is that, you know, we still have sort of like a long way to go, but I think we are making steps in the right direction, and in terms of, kind of like what we can continue doing to kind of like build on this momentum, I think number One is that we need to increase awareness, right? So by increasing awareness through talks like this, or, you know, giving different trainings within like healthcare and education, I think that that can then help with the recognition of how it might look different and the symptoms might look different in our girls and women. We definitely need more research in this area, especially looking kind of across the lifespan, and then it's important to continue creating programs that offer support to these girls, and building safe spaces like I know you've done such an amazing job at Flourish, doing that really allows individuals to feel heard and understood and connected. Thank you so much. I think maybe have time for a couple questions.

Hopefully. I think we have one question, maybe that we can or, yeah, squeeze in and then maybe any of the other ones we can send over if you want to answer them over email. So maybe Rob, if you want to go ahead and these questions in the chat, we can pop over in an email. Yeah, sure.

Rob 

Hi. Thank you so much for that presentation. I really, really appreciate it, and makes me think of a lot of the clients that I'm working with, and I'm like, Oh my gosh, this is like, just the lived experience is just bang on for a lot of the people that I've talked to. So like, thank you so much for making this accessible and relevant, which really, really appreciate. I know it's a huge conversation, and I'm kind of giving a bit of a reputation as that guy that asks about autism, but I feel like it is definitely worth talking about, because it comes up so often together. Do you have any resources about, like, how all of these things can interact with women who may also have autism or who might be maybe identified ADHD, they treat it, and then they start noticing, oh, wait a minute, there's these other things coming up too, like, what would you recommend around that? Resources, research, anything like that. I would love to know

Shayna 

that's a great go appreciate it, because we had such an animated conversation about this yesterday, right? It's just within the last decade or so that we have sort of revamped our understanding of the neuro divergence umbrella, and how various clusters of symptomologies can interact and be configured in individual experiences within it and so super recent and obviously that is then going to be interacting with the imposition of, you know, systemic level prejudice, societal expectations, you know, the gendering, the racializing, racializing, all of these things. And so I think I mean in terms of recommendations, just I keep saying key and I but being very vigilant about how we are just talking about differences in nervous system function. And that's not to I'm not trying to do the erasure of impairment, because obviously, we spent the last hour discussing the dire consequences of ignoring the potential

Rob 

impairment, shame of talking about, it's just a nervous system. It's not a character defect,

Shayna 

sure. So, like we've done this repair campaign of going, Look, we had major blind spots because of you know, inculcated inculcations About prejudices, let's not reinforce those prejudices into reified categories, but make sure that we're doing that equity building with the goal of increasing our understanding and assuming default, assuming individual diversity across all sort of, you know, box categorizations. So with women and you know, folks in vulnerable, vulnerable populations across the board, it's keeping an eye to the equity building, making sure we're not dropping the ball on that frame, and making sure that we're not imposing or foreclosing assumptions. So that was not directly towards autism spectrum, I apologize, but just being retaining the nuance, so that when you are seeing presentations of both kinds that we used to think were incommensurable, you're able to app, you know, perceive that, appraise that, and ensure that you can then mobilize what resources you have available to you.

Angie 

Thanks, Rob

Shayna 

essentially doing what you're already doing. I can tell Rob,

Megan W 

thank you guys so much. And we'll open up the chat questions if you guys want to pop in another question or so, and Angie and Shayna will email you those questions if you want to just provide a little answer that we can follow up over email with everybody. Thank you guys so much. This was just wonderful, and I appreciate you guys and your thoroughness for today's chat, and we will follow up with some of those questions shortly.

Angie 

Thank you so much, and thanks for everyone attending today and taking you know this hour out of their day at such a busy time of the year, we really appreciate it.