A chat with Kathleen Nadeau, PhD
KATHLEEN NADEAU, PhD,director of the Chesapeake ADHD Center of Maryland, has been in clinical practice for more than thirty years. An internationally recognized authority on ADHD, she has served on CHADD’s professional advisory board. She is the cofounder of the National Center for Gender Issues in ADHD, a nonprofit organization dedicated to public education and professional training about the needs of girls and women with ADHD. Her areas of special interest include gifted adolescents and adults with ADHD; career issues related to ADHD; postsecondary students with ADHD; women and girls with ADHD; and writers, entrepreneurs, and artists who struggle with ADHD.
Nadeau has been a pioneer in writing and lecturing about girls and women with ADHD. She coauthored two ground-breaking books,Understanding Girls with ADHD (Advantage, 2000) andUnderstanding Women with ADHD (Advantage, 2002), and coeditedGender Issues and ADHD (Advantage, 2002) for professionals. She has appeared on the Today Show and the Morning Showand is featured in the video ADD from the Inside Out, which was broadcast on PBS.
My daughter has inattentive ADHD. I understand that it is one of the least diagnosed types and there is not much information. What do you know of this type and is there any new information?
Inattentive ADHD is much better known and recognized now than in the past. Although it often affects girls, there are also many boys with inattentive type. Kids with inattentive type respond to medication just as do hyperactive kids, but they typically need different treatment in the classroom. Girls with inattentive type ADHD, for example, respond better to encouragement than to criticism and are often overwhelmed in competitive situations.
My thirteen-year-old daughter is in eighth grade. She began her menstrual periods just this past September. She is bombing out this semester and we will get a 504 for her. No learning disabilities are involved. Is this a common occurrence at this particular age and stage? It’s never been this bad for this long.
Yes, this is a very typical time for ADHD symptoms to increase—it is the result of hormonal fluctuations that girls experience. As estrogen levels rise and fall, ADHD symptoms rise and fall along with them. In extreme cases, it may be helpful to put a girl on low-dose birth control to stabilize hormone levels a bit.
Middle school is also a very challenging time for students with ADHD. The demand for organization and time management suddenly increases, and lots of skills need to be developed. It can be very helpful to work with a coach to begin to develop daily time management and organizational skills.
We are in constant conflict trying to get our daughter to do her homework and chores.
Homework is typically a big issue—not just for girls. And the solution isn't the same for every child. Some girls do best when they have company while they work—for example, sitting at the kitchen table with a parent nearby.
Many parents find that it helps to simply sit at the same table as a child doing homework, even if you're not interacting with them. It helps keep them focused. Homework in a bedroom is fraught with temptations these days—the Internet, instant messaging, and Facebook. Often, it helps to break up homework into short "bites"—getting some done before dinner and some more done after dinner.
It's hard getting my seventeen-year-old daughter to do any chores and homework without an argument. She does do her homework, but it's always a struggle, with lots of procrastination and late nights. Somehow her grades are good enough and she will be going to college next year. We have tried taking away computer time. Nothing seems to faze her.
Adolescent conflicts tend to intensify during high school. It's important to avoid yelling and arguments and to simply have rules in place that motivate her to get her chores and homework done. Her grades are good enough for college, even without doing homework? Sometimes this kind of resistance is a mask for depression. When "nothing fazes" an adolescent, it may be time for counseling or therapy to see what's going on.
Her medication is probably wearing off earlier in the evening when it's time to settle down to do homework. So, when she works, she's not really on medication. Procrastination and late nights are basically a form of "self-medication"—noradrenalin increases as stress increases—and this helps the brain to focus. Many high school students have done well with the methylphenidate transdermal patch, which can last all evening. You just need to take the patch off an hour or so before bedtime—that way you're on medication when you need it to study.
It's also important to think about whether she is really ready to go away to college after high school. I advise some parents that unless a student shows some signs of better self-regulation while at home, they're almost sure to "crash and burn" if they go away to college and have even less structure and support than they have at home. Going away to college is increasingly unaffordable for parents and high school grads shouldn't assume they have the "right" to go away unless they show that they are ready for the responsibility that goes along with the freedom. I work with far too many students who have dropped out of college.
Is it common for a girl with ADHD to have sleep disorders? What would be the approach?
Yes, sleep disorders are common for nearly all teens with ADHD (and adults as well). Typically, it's hard to wind down and fall asleep at a reasonable hour, and this is compounded when homework still needs to be done. It's most difficult in high school when school starts so early. One girl I worked with needed her school day to begin second period so that she could get more sleep, and I was actually able to arrange it.
Check with her pediatrician about possible interventions. It's super important to stay away from TV or computers for the last hour before bedtime. Recent research has demonstrated that light in the blue range emitted by electronic screens tends to wake up the brain. Regular, daily aerobic exercise can also help improve sleep patterns.
Caffeine intake needs to be monitored—and be sure that medication is not taken too late in the day. Establish a bedtime routine that includes taking a hot shower or bath, then getting in bed and reading quietly, and then turning lights out at a regular time. This can all be helpful.
Do you have any advice for those instances when ADHD is coupled with depression?
ADHD is very commonly found with depression. This seems to increase as girls enter adolescence. The two conditions can be treated together—check with her pediatrician or psychiatrist about possible medications. It's important that both conditions are addressed. Sometimes the depression is really a reaction to the frustrations of living with ADHD and not a true depression. ADHD-focused psychotherapy can help to sort this out. Anxiety is also very common in adolescents with ADHD.
My daughter is not diagnosed with ADHD. However, since I have been diagnosed with ADHD, I am seeing in her many of the same symptoms I had as a child. I have had her tested in school; there are signs of the condition, but she masks it very well there. How can I find the best medical provider for her, one that might be an advocate for her in the future?
This is true of many girls, especially bright ones. You would do well to work with an ADHD therapist who can explain ADHD issues to both of you. Typically, the ADHD patterns become more obvious as the demands of school, work, and life increase so that they become increasingly difficult to manage. She'll do better if she knows this and knows what to do if she begins to have difficulty managing daily demands. And managing without treatment can really take a toll—even if the efforts are successful.
What is the best recommendation when medication does not work? My daughter has tried both the stimulants and the nonstimulants and she is still not helped.
There are lots of other things to try. Daily aerobic exercise can have a powerful effect on brain chemistry—read Spark: The Revolutionary New Science of Exercise and the Brain by John Ratey, MD (Little Brown, 2008) for more on this. Diet can play an important role—low sugar and starch, along with protein at every meal, helps to stabilize blood sugar. Lots of structure and support—from parents, tutors, or coaches—can help, as can managing daily demands so that they are not so overwhelming. ADHD responds very well to a regular, predictable, structured daily environment.
Are social skills classes effective for girls with ADHD and ODD? My seven-year-old daughter has taken several social skills classes, yet she does not have many invites for playdates and parties.
Research suggests that the skills learned in social skills groups often don't translate into real life situations. Girls as young as your daughter may do best in one-on-one situations where the playmate can be selected as a good match. Many girls with social skills issues do better with younger playmates. It's important not to get focused on "popularity," and to focus more on helping her to develop one or two close friends and playmates. Some girls do better playing with boys, as there is less competition and criticism.
How do you stay encouraging when everything is a struggle?
That's a great question without an easy answer. Having raised a daughter with ADHD myself, I know how challenging the emotional rollercoaster can be. It's so important to reserve some part of each day for non-conflictual interaction—time to spend without reminding, nagging, correcting, or challenging your child; time to do something relaxed and enjoyable for a few moments. The more positive "deposits" you make in the relationship bank, the easier it is to get through the hard times. If you're feeling burnt out, it may be high time to bring in other supports.