Women Living with ADHD

Dr. Binder chose to present the life journey of women with ADHD using a case study of one patient. Rachell’s video- taped interview with Dr. Binder was a comprehensive testimony, on top of which evidence-based learnings were shared.

 

The session provided an opportunity to appreciate the real-life challenges of managing ADHD symptoms and their impact on relationships, work and sense of self; to understand the impact of hormones on women throughout the lifespan; to explore best practice in treating women with ADHD during Post-Menstrual Syndrome (PMS), pregnancy and peri-menopause; and to witness the work and reward of the therapeutic process in accepting one's own version of ADHD.

 

Rachell’s Profile:

 

• 45 years old, married, mother of 3
• Long term employment as Executive Assistant 
• Diagnosed with ADHD at age 36 after her daughter was treated for comorbid ADHD
• Treated with LA Amphetamine until 18 months previously
• Tried LA methylphenidate over the last year and felt “unmedicated”
• Impulsive behavior resulted


Psychiatric Assessment


• Completed ADHD screening tools:
      o ASPS, WURS, Barkley Current/Childhood self & other, WIFRS, JOR
• Mood described as good and stable, sleep intact, energy normal
• No Anxiety Dx — GAD, Social Anxiety, PD, OCD, PTSD
• No psychotic phenomena SUD: drinks socially, no illicit drugs, no caffeine
• Many would wonder about possible Bipolar D/O however as Rachelle describes...it is not



As Rachelle was describing her journey with ADHD, Dr. Binder presented current scientific knowledge backed by the literature:

 

Gender is a factor in ADHD1



1.ADHD symptoms may vary across menstrual cycle in response to hormone changes
2. Increase in ADHD symptoms in early follicular and post-ovulatory phases coincides with lower Dopamine (DA) levels
3. Implications for cyclical ADHD treatment strategies



Expert Consensus (2020) on Associated Features and Vulnerabilities2 :



1. Difficulties with emotional lability and emotional dysregulation may be more severe or common in girls and women with ADHD
2. Social problems may be particularly impairing
3. Girls with ADHD are vulnerable to bullying, including physical and social-relational bullying, and cyberbullying
4. Females with ADHD tend to become sexually active earlier than their peers and have an increased number of sexual partners. Rates of contraction of sexually transmitted infections and rates of teenage, early and unplanned pregnancies are elevated
5. Antisocial behavior may also be present in females with ADHD. The rate of ADHD among prisoners is similar for male and female offenders
6. Increased school dropout, academic under-achievement
7. Decreased self-esteem and self-concept
8. Increased rate of accidents

 

Findings from Canadian Women3

 

Canadian women aged 20-39 with ADHD:
• 3x the prevalence of insomnia, chronic pain, suicidal ideation, childhood sexual abuse, generalized anxiety disorder (GAD)
• 2x the prevalence of substance abuse, current smoking, depressive disorders, severe poverty, childhood physical abuse Suggest that women with ADHD are particularly vulnerable to early adversities, health and mental health problems

Exploring the impact of hormones on ADHD from puberty to pregnancy to menopause was an important part of Rachelle’s case study. Research from 2018 on ADHD & the menstrual cycle4 examined daily levels of reproductive hormones. It is the first study to suggest strong post-ovulatory worsening of ADHD. It found that lower estrogen with higher progesterone & testosterone predict next-day increase in ADHD symptoms and that effects of low estrogen are present only during periods of high progesterone & testosterone.

 

During Pregnancy: Women with ADHD May Be More Vulnerable to Decreased Cognition



In the perinatal period, ADHD symptoms may increase due to:



• Elevated prolactin levels associated with worse executive functions:
o Verbal memory and processing speed
• Increased prolactin negatively impacts DA and norepinephrine (NE)
• Sleep deprivation 
• Change in routines and structure
• Challenges associated with parenting a newborn



Treatment Considerations5,6 :



• More women entering reproductive years are being treated for ADHD
• No guidelines to inform treatment of ADHD during pregnancy and postpartum
     • Stimulants classified as 'Category C'
• In utero exposure to stimulants raises concerns regarding fetal growth
• Stimulants do not appear to be associated with major congenital malformations
• Weighing risks/benefits of treatment is crucial in determining use of psychotropic medications in pregnancy
• Infants born to mothers taking stimulants should be monitored for withdrawal symptoms
• Many women may stop ADHD medications during pregnancy and lactation with minimal negative impact
• Others experience significant impairment and severe consequences:

o Driving and motor vehicle accidents
o Occupational functioning
o Finances o Self-care - neonatal appointments, diet
o Relationships
o Substance use - Pregnant women with ADHD are more likely to smoke up to the third trimester



A systematic review and meta-analysis performed to evaluate the adverse maternal and neonatal outcomes associated with exposure to ADHD medication during pregnancy highlighted these findings7 :



• Controversy whether increased risk of adverse maternal and neonatal outcomes with ADHD medications
• ADHD medication use during pregnancy is associated with an increased risk of NICU admission
• Exposure to methylphenidate is marginally associated with an increased risk of cardiac malformation
• No evidence of an increased risk for other adverse maternal or neonatal outcomes was found

 

In summary, this a-typical session combined evidence-based learning with a focus on women and ADHD with a patient interview of a woman describing her journey living alongside ADHD. From diagnosis to treatment, it enabled learning about the challenges along the way. While managing marriage, motherhood and career, listeners learned how a woman rediscovers herself and the role ADHD plays in her daily life.

 

Presenter:


Dr. Sara K Binder works with adults struggling with mood, anxiety, ADHD and substance use disorders at the Psychiatric Adult Service (PAS), Foothills Medical Centre in Calgary, Alberta. Dr Binder is the Vice Chair of CADDRA and co-chair of the Education Committee. She is passionate about ADHD – both the clinical aspects but also in educating other healthcare professionals in managing ADHD in adults.

 

References

 

  1. Martel MM, Klump K, Nigg JT, Breedlove SM, Sisk CL. Potential hormonal mechanisms of attention-deficit/hyperactivity disorder and major depressive disorder: a new perspective. Horm Behav. 2009 Apr;55(4):465-79. doi: 10.1016/j.yhbeh.2009.02.004. Epub 2009 Mar 2. PMID: 19265696

  2. Young S, Adamo N, Ásgeirsdóttir BB, Branney P, Beckett M, Colley W, Cubbin S, Deeley Q, Farrag E, Gudjonsson G, Hill P, Hollingdale J, Kilic O, Lloyd T, Mason P, Paliokosta E, Perecherla S, Sedgwick J, Skirrow C, Tierney K, van Rensburg K, Woodhouse E. Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women. BMC Psychiatry. 2020 Aug 12;20(1):404. doi: 10.1186/s12888-020-02707-9. PMID: 32787804

  3. Fuller-Thomson E, Lewis DA, Agbeyaka SK. Attention-deficit/hyperactivity disorder casts a long shadow: findings from a population-based study of adult women with self-reported ADHD. Child Care Health Dev. 2016 Nov;42(6):918-927. doi: 10.1111/cch.12380. Epub 2016 Jul 20. PMID: 27439337.

  4. Roberts B, Eisenlohr-Moul T, Martel MM. Reproductive steroids and ADHD symptoms across the menstrual cycle. Psychoneuroendocrinology. 2018 Feb;88:105-114. doi: 10.1016/j.psyneuen.2017.11.015. Epub 2017 Nov 28. PMID: 29197795

  5. McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V, Green L, Gregoire A, Howard LM, Jones I, Khalifeh H, Lingford-Hughes A, McDonald E, Micali N, Pariante CM, Peters L, Roberts A, Smith NC, Taylor D, Wieck A, Yates LM, Young AH; endorsed by the British Association for Psychopharmacology. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. J Psychopharmacol. 2017 May;31(5):519-552. doi: 10.1177/0269881117699361. Epub 2017 Apr 25. PMID: 28440103.

  6. Freeman MP. ADHD and pregnancy. Am J Psychiatry. 2014 Jul;171(7):723-8. doi: 10.1176/appi.ajp.2013.13050680. PMID: 24980168.

  7. Jiang HY, Zhang X, Jiang CM, Fu HB. Maternal and neonatal outcomes after exposure to ADHD medication during pregnancy: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf. 2019 Mar;28(3):288-295. doi: 10.1002/pds.4716. Epub 2018 Dec 26. PMID: 30585374.