hi everyone my name is Annie Rogers and on behalf of the attitude team I'd like to welcome you to today's ADHD expert presentation titled the emotional lives of girls with ADHD leading today's presentation is Dr L Borg scogland Dr skogland is an author keynote speaker and entrepreneur from Sweden her specialty is in Psychiatry addiction and family medicine with a spef specific focus on ADHD she currently holds a position as associate profess professor at Upsala University in the department of Women's and Children's Health she also leads the pioneering research group goddess ADHD and is author of a wonderful new book called ADHD girls to women in today's webinar we're going to discuss emotional disregulation big emotions can manif EST as Tantrums meltdowns even as self harm in young girls with ADHD or it can be hidden some girls May mask their symptoms and their feelings of anxiety and depression they may also struggle socially saying they just don't fit in young girls need caregivers who understand the special challenges they face and that is why we are here so to begin we'd like to do a little bit of a level set by asking asking you some uh a few short poll questions we'd like to know for those in our live audience um has your child been evaluated for ADHD um please let us know the status of that and then to follow up um if they have but they were not diagnosed with ADHD do you think that including emotional disregulation in the diagnostic criteria would have changed your child's diagnos nois this is your opinion whether you think it would if your child was diagnosed with ADHD we're curious whether they were screened for any comorbidities um so specifically we mean co-occurring conditions like eating disorders um uh depression anxiety anything along those lines so while you do that um I will point out that um you can find answers to Common webinar questions about slides transcripts and certificate certificates of attendance by clicking on the FAQ tab of your webinar screen and if you support the work we're doing here at attitude to strengthen the ADHD Community we encourage you to visit attitudemag docomond you can click on the magazine tab of your screen to learn more and I would be remiss not to mention that attitude has an ebook titled women with ADHD that offers some additional supplemental guidance on hormonal changes ADHD subtypes finding a doctor who will take your symptoms seriously um you'll learn why science has paid very little attention to female ADHD and how you can benefit from a diagnosis at any age okay without any further Ado please welcome me in um in welcoming Dr L Borg thank you so much um Dr skogland for joining us and leading this really important discussion today thank you so much for the opportunity to talk about the emotional lives of girls H and when young women with ADHD I'm a huge attitude fun so it's a a real honor for me to to be um presenting here today and when I started writing this book I looked forward to dive into the pool of knowledge about female lady HD but um I soon realized that you're not supposed to dive in such shallow Waters uh and that was really frustrating for me since the end of the pool dealing with prepubertal boys with ADHD is so huge and deep right so this is what we're going to talk about today um but I would like you to first meet Annie um Annie is 19 years old and she and her parents have some critical questions uh to us about the emotional lives of girls and young women and I think we will have some answers for her after this webinar um first of all Annie wonders if her ADHD brain is wired differently and her parents wonder how emotional disregulation PMS pmdd Rd RSD hormones and mood disorders are associated with ADHD they also want to know what girls and women like Annie risk if we keep missing their specific challenges and what Annie and her parents can do themselves to improve her physical mental and sexual health and quality of life so really good questions hopefully we will be able to answer at least some of them and let me see uh but let's start by uh reviewing what problems we may face then if if we continue to view ADHD from the male Norm um the the thing is that when presented with a case of a boy with ADHD I can call him Andy we as parents teachers healthc Care Professionals are quite uh fast to identify his problems as caused by ADHD and suggest evidence-based treatment for him if we change nothing about this vignette but the name Andy for Annie however we tend to think quite different so then we will focus much more on Annie's relationships of why she is so Desperately Seeking attention and have you seen the quite provocative content on her Tik Tok account maybe she's been traumatized somehow maybe she's been sexually abused well instead of thinking about ADHD we start looking uh for psychosocial causes to Annie's problems and Annie will probably be offered to talk to someone about her problems maybe a consultant in school or a family treatment by the social services and if or other when in Annie's case uh she doesn't um get helped by that she will probably be offered anti-depressants and perhaps something for anxiety perhaps something for Sleep Disorders or even mood stabilizer for her emotional instability before we even consider ADHD in her case so I'm exaggerating to make a point of course but looking at our research data this is not as far from the truth as you would wish in fact in our most recent study uh we found that boys got a head start of about four years in respect to diagnosis and treatment um with uh instead um females were typically missed during the formative years of childhood and adolesence so we looked at them five years before and five years after they got their ADHD diagnosis and females consistently had a higher risk for physical and psychiatric comorbidity and self harm they were more often prescribed sedatives anxiolytics anticho drugs or even opioids and they showed up absolutely everywhere in the Health Care system and in our so Social Services often due to mood disorders or Consequences of emotional disregulation unfortunately um we are just uh uh still so used to look at ADHD from the perspective of the disruptive boys but Annie just as Andy has ADHD and and this is how Annie would describe her ADHD life because she feel that she is different and there's always been something different about her something that is just slight slly off but not enough for others to see and validate that rather um others try to normalize everyone feels like this everyone thinks this this is uh difficult everyone struggles H with this sometimes and and Annie just feels that there's something different but she can't really find the words for it and she also feels that her brains fails her that she's stupid and when she needs to concentrate her thoughts just slips away or stops uh and when she in should relax her Minds start working like crazy to solve world peace or what happens after you die and think about those kind of stuff and she feels really hopeless because she can't control her emotions or her energy levels and she's realized that if she uh is going to to pass school or or manage life she will have to be so disciplined and so controlled she'll have to control what she eats when she exercise when to study how she is with friends and age 19 there's just not that much spontaneity left in her life her perfectionistic Tendencies are turning into a OCD or dtic prison for her and from the perspective of me as a clinician and a researcher uh I know that just by fulfilling the criteria for these four letters ad D HD you will live about 10 years shorter than a person of the same age sex and socioeconomic status and many of these years are lost due to the cability and in undetected and untreated ADHD the good thing though the light in the tunnel is that almost all of these years can be saved if we find and identify and proper properly treat uh women uh with ADHD uh in time so girls uh with ADHD um they they do exist and and given how serious un or misdiagnosed ADHD can be um the fact that girls with ADHD fly under our radar is a serious problem and research shows that girls with ADHD show fewer externalizing symptoms and more often get the add uh diagnosis however these girls exist and they do struggle without being recognized and they experience social and academic challenges and and they keep it together outside of home because girls on a group level at an earlier age than boys realize what's expected of them in Social settings so they mask and they compensate but that drains them of energy and the meltdowns and the Tantrums that they get uh in the safe environment of home or in safe relationships actually hurt their relationships and their self-esteem very much so um as ADHD uh most often doesn't um uh you you most often doesn't grow out of your ADHD these girls that fly under our radar will grow up and enter puberty a period that is very intense um uh biologically socially and existentially and both both uh with the uh changes going through the body and um and the social uh situations H and now we see these women and young women everywhere because they struggle with their emotions they show up in health care for depression anxiety Eating Disorders injuries or in Social Services because of trauma or victimization and the Paradox occur that we miss them again so because of uh as in the case of Andy and Annie we get the causality back backwards and we blame Annie's struggles on trauma or bullying or peer rejection or depression instead of considering that it may be might be her very ADHD that puts her at risk for depression trauma or social failure so this is really important when we talk about uh what comes first and how we need a very differentiated view when we look at the problems of young women with ADHD and before Annie came uh to me and before I met her she was diagnosed and treated for at least 10 different conditions this is a really messy picture both for Annie and for me right and and uh you can wonder if everyone before me just had missed the core of Annie's problem her ADHD or that we may have seen the same struggles or her struggles or her problems the same way but framed it uh differently and laying the puzzle of Annie's diagnosis ADHD borderline anxiety bipolar eating disorder autism among other diagnosis that she she's had in her young life we will find that in the overlap in the intersection of these uh diagnosis lies emotional disregulation so clearly the emotional line lives of girls with ADHD is a big deal and emotional disregulation is more the rule than the exception in ADHD uh and our emotions are important for us as humans we use them to communicate our needs to others and struggling in by with recognizing and regulating your emotions is a huge handicap in life and it's important to try even though the the picture the an Annie's picture of her comorbidity is really messy it is important to try to disentangle emotional disregulation in ADHD from other distinct comorbid conditions such as depression anxiety bipolar disorder or borderline personality disorder since they um are more common uh in individuals with ADHD and also they may need specific treatment outside of the ADHD treatment uh and then we also have the downstream consequences of of living with ADHD such as the increased risk for peer rejection the shame and the stigma associated with having a behavioral diagnosis that increase the risk of course to develop depression social anxiety and rejection sensitivity dysphoria RSD so obviously there are quite uh different and complex mechanisms underlying this overlap between ADHD mood disorders and emotions and a a um way of looking at the science behind this overlap of ADHD and emotional disregulation uh that resonates very well with the testimonies that I hear in my clinical practice is developed by my friend and research colleague PR Petrovic he and his colleague savier Castellano describe emotional disregulation in ADHD and boardline personality disorder as difficulties in two similar but not entirely overlapping topd down brain regulating mechanisms so in this uh model ADHD is viewed as difficulties in regulating more cool or executive attention while borderline um and the difficulties associated with borderline represent difficulties in controlling more hot or emotional circuits in the brain so in this way of looking at it ADHD and borderline becomes like sister conditions similar but not identical processes and petrich and Castellanos they argue that uh we may talk about an emotional subtype of ADHD located just in between ADHD and borderline personality disorder and that that might help us actually also Target and tailor interventions and treatments uh directly to a specific individual but we we have to make the picture even Messier unfortunately for us as girls and women because we have to also factor in the fluctuating hormones across the entire reproductive female lifespan so estrogen and progesterone will be produced in the ovaries among other places in the body uh and they easily uh pass through the blood brain barrier and access um our brains and there are hormonal receptors in literally all brain regions that are in involved in emotional regulation indicating that hormones are very much involved in how we feel and how we function so this is um really important and and again not uh sufficiently taken uh into consideration uh and the risk again um that we miss when we use research and clinical experience based on prepubertal boys that do not uh have not entered uh puberty yet and uh once they enter uh puberty will not um exhibit these monthly um fluctuations uh of of quite dramatic changes of of estrogen and progesterone levels um so firstly we know that these predictable periods of changing hormonal levels create vulnerable periods across the entire female life or the entire female reproductive life anyway so in our re Search Group we have actually targeted these uh vulnerable periods in in a women in the women's uh and girls lives and done studies uh specifically in youth centers in maternal health care and in women's clinics and these studies they show that for example teenage pregnancies and teenage births are six times more common in girls and women with ADHD H and we know that giving birth to a child in a very uh in very early stage in your life will affect both you your and your young child's psychosocial development across the your entire life so this is something that we wish that girls and and women young women with ADHD also are allowed to plan uh when they are um when they are founding their their families um and ADHD girls and women are actually five times more likely to experience depression following the traditional prescribed oral contraceptives um and we also have shown that 20% of pregnant women with ADHD will develop postpartum depression and anxiety following birth and that women with ADHD more often suffer from pain and stress related conditions during their P menopausal year so across the entire female lifespan there are vulnerable periods associated with fluctuations in estrogen and progesterone levels and again I I guess I will have to stress this a lot of times during this lecture but um 99% of the research is done on males uh or even prepuberal uh boys um where this is absolutely not taken into consideration so from puberty to menopause naturally cycling females will experience quite dramatic fluctuations of circulating sex hormones affecting both how we feel and how we function let's say we have like a cycle of 28 uh days um a u normal and regular um uh length of a menstrual cycle then day 1 to 14 or the follicular phase will be about the body preparing to release or perhaps also receive a fertilized egg this is why estrogen levels would rise to a maximum Peak at day 14 triggering this ovulation and research actually shows that risk-taking behaviors may increase not necessarily due to negative uh feelings but due to positive emotions uh uh during this time of the menstrual cycle however uh as often uh is the case in in young females with ADHD if the result of even though positive impulsive behavior is drinking alcohol taking drugs having risky sex driving irresponsibly or shopping impulsively the consequences might might be just as serious uh right H and also since estrogen and dopamine May potentiate each other uh side effects of ADHD medication that affects dopamine levels May further increase the risk-taking behavior so if you have an ADHD profile that is defined mostly by impulsivity and hyperactivity this part of the menstrual cycle may actually be the most difficult part of the month for you and then following day 14 estrogen level Falls quite steeply stabilizing on a uh level on a lower level during day 15 to 28 the Lal phase then instead progesterone levels will start Rising creating an entirely different hormonal environment where women generally report more symptoms of depression anxiety rejection sensitivity dysphoria sleeping problems cognitive difficulties with the memories Etc so if your ADHD profile is defined mostly by low energy levels and iety then the period around the higher estrogen level might offer a welcome energy and mood boost but you may instead suffer tremendously with pmdd PMS in the later part of your lutal face and this just sheds light on how important it is to not just um use the one size fits uh all regime that we do when we use the maale as the norm for ADHD and in fact females um uh have shown to have an increased risk with everything from stress depression anxiety to relapsing into binge eating addiction suicidal ideation and psychosis in the lual phase and there is also even though a very limited research at this point indicating that women with ADHD are at increased risk for just experiencing pmdd postpartum depression and worse climacteric symptoms but again we talk about this and we hear this a lot in our clinical uh practice and in our everyday life talking to each other H so we might think that there is a lot of research on these topics out there but it's not um and the the problem is that the research that is there um showing that there are vulnerable uh faces in a woman's life for for both ADHD and and non-adhd women still almost no one um me included um in the clinic asks us about hormones when we seek counseling for mental health issues and this is again a huge um lack um and problem that that we are facing as women where we actually risk not um getting the correct um medical advice and support so so um in essence female ADHD emotions and hormones can create the perfect storm for girls and uh young women with ADHD and uh unfortunately there's there almost no there's almost no research uh validating girls and women's experiences here so at this point uh I'm afraid to say that it's really up to us as girls women parents clinicians to try to figure out how this is all tied together for every single unique girl and woman and it might sound like that is a huge um job uh for me as a clinician but it's not and because it's really interesting and it's really rewarding so I really urge all of you um either if you are a clinician or if you are a girl or woman yourself or a parent uh to a girl to to Really uh lean in to this knowledge about how hormones affect uh our Aid to symptoms and our mental health uh and this is also why um our research group always use patient and public involvement and co-create both our research questions and uh the self-care tools that we develop such as L life that I'm going to show you uh um soon um and to to this end we have developed a model that we call ADHD 247 uh and this is to capture like The Wider perspective of the ADHD life for both children and adults um because ADHD doesn't go to bed it doesn't take lunch breaks or vacation it goes on 247 and it affects every aspect of your life and to get the correct support uh you need to speak the same language and to be able to communicate both your difficulties your problems your strengths uh and also your needs to your doctors or to your nurses or to the teachers in your child uh School so I will just quickly walk you through the uh two four and seven of our model and um try to explain why we think this is a good way to start when when we build the common uh language and the common knowledge about um girls and women with ADHD um so we start out with a holistic view of as humans and we argue that we all regardless of we have we have ADHD or not actually have some basic needs um uh if we are supposed to live a good and healthy life so first of all we need um to we need a a social Community where we safely can communicate what we think what we feel and what we need without being judged um many girls uh with ADHD that I talk to does not feel that school provide a protective uh or inclusive tribe for them quite the opposite uh um in fact and unfortunately uh and and also um except having this social Community we also need a calling where we feel that what we do contribute to something that is Meaningful for something some someone more than than just me uh and we also need to feel competent to handle the challenges that we face um in life and again so many of the girls that I meet doesn't uh um feel that there is very much meaning with anything in their lives at the moment school being unfortunately again no exception and it's really hard to motivate yourself uh and to uh motivate yourself when you have ADHD who is a motivational disorder uh um at large to motivate yourself then to go to school and to participate in this when you don't see the purpose of it all and I and we think um and we have discussed it uh at length um with our patient panels and and um uh our um lead patient users um that if we ignore these two like basic areas of life our support and our interventions risk being uh at best useful and at worst actually harmful for people so this is a very important basis for what we do and then uh we have the four in our 2 47 model and and an important aspect then of building the emotional intelligence in ADHD is to understand how your ADHD brain is wired and how it deals with information from the outside world and from your body so by uh talking about how all brains are different um have strengths and challenges and by using metaphors for different complex brain processes such as Central coherence top- down regulation meta cognition and cognitive flexibility for example we allow even younger kids to understand why some things like for example emotional self-regulation may be so much more difficult for me than for my peers so um the four most important areas of concern here then um and that stands out in our research are your brain's control tower so this is your ability to overview um um what you need to plan prioritize organize execute in your everyday life um and imagine that your brain is like a huge airport with planes coming in from the entire world uh every minute taking off uh every minute and everything needs to be coordinated to the very second to avoid like crazy or disasterous accidents and then imagine that you don't have anyone working in the control tower of your airport you have to manage everything manually and just an ordinary day in school will require enormous amounts of energy so this is the first important area that we have to discuss with our girls um the next uh area will be to uh the the brain's volume button um so your ability to regulate and moderate not only um your activity levels but everything from your energy levels appetite to your emotions so imagine that your volume button gets stuck at zero it's impossible to get anything done and everyone around you just say but do it you'll feel so much better afterwards and then imagine how this volume button stuck at zero without you knowing how or why just ramps up to 100 and it's impossible to stop eating it's impossible to quit gaming or to wind down and go to sleep um so that was the the other the the second area that we need to discuss with our ADHD girls that we need to actually um have the have a common language for the third area here would be our brain's virus filter or your ability to filter out irrelevant information from the outside world and from your own body so then imagine that every microscopic stimuli comes through into your brain and requires process speed in your brain in your brain's hard drive it's everything from how the clouds feel on your body your ball mement uh smells from outside everything competes for your attention and that is something also that girls and and women can describe quite vividly how extremely tired they get in Social um situations not because they don't appreciate the social situations because they cannot handle the influx of uh competing stimuli and then the fourth um area would be your brain's gearbox or your ability to shift out of negative ruminating thoughts H or to try something new when the things that you do actually don't work anymore so then imagine that you keep getting stuck in Loops of negative toxic thoughts and even though you know that it would be really good to try to view things in a lighter perspective and that these clouds really or or thoughts really cloud your mind and poison your relationships you just can't think past them or stop their toxic influence on your mental state and that is also something that is uh common for for female with ADHD to describe and that we have to have a common language for and then moving uh to the next uh last part of the 24 ADHD 247 model then um is uh our seven lifestyle factors that caus so much of the risk for both mental and PSY uh um psychiatric comorbidity in ADHD but also that carries great possibility of improving our emotional intelligence and build emotional resilience if we can find healthy routines uh and we can do them with moderation but it's no secret and research clearly shows that the 8 HD bra brain find it so much harder than neurotypical brains to set up and keep healthy routines for diet exercise sleep and workload in school or at work uh also it's so more much more difficult to regulate your emotions and get uh you you much more easily much more easily get addicted to nicotine alcohol drugs and gambling uh or have problems with gaming shopping or social media and as we grow up and as our children gets more and more independent we also are expected to manage and structure Our Lives independently to pay our bills to remember to take our medication uh or to meet appointments and deadlines without our parents or Partners having to remind us all the time uh and these areas these seven life areas uh are um stand out in our research and and also in other research as um carrier of so much of the cability load and the decreased quality of life uh load for both males and females and the the problem here unfortunately um having ADHD you will live in a world uh designed for the 95% of the neurotypical people and you isk getting a lot of well-meaning um but quite useless um or even actually harmful advice um for how you should manage life and why life it keeps being so difficult for you so my favorite B advice then would be uh since I have a background in addiction medicine uh would probably be oh you seem so tense and stressed out you know live a little have a drink and relax or uh why not on the topic of of the emotional lives of girls with ADHD if you feel angry you need to stand up for yourself and say that that's really really bad advice when so much of the emotional lives of girls revolves around social struggles and rejection sensitivity so this we need to uh focus on um better advice to try to build our emotional intelligence um and so how can we help then girls and young women with ADHD to develop their emotional intelligence uh well uh in our research based on this uh patient and public involvement and our co-creative development of the Digital support support tool for women let life we have identified some key areas for female ADHD so first of all many ADHD girls and their parents feel abandoned by Health Care um and they feel left with a at best an incomplete toolbox many women also um specifically say that their ADHD problems stems from difficulties in regulating emotions and energy levels and many feel that they somehow have to choose between strategies based on medication uh and health care or self-care self-help or skills training or that medication for some reason doesn't work properly or uh that both side effects and effects are inconsistent and hard to understand perhaps due to hormonal fluctuations uh and to build um the emotional intelligence and resilience we focus on some key ingredients that are adapted from CBT DBT motivational interviewing and mindfulness uh because if you have masked or mimicked in order to feel normal your entire life your self-awareness is probably quite underdeveloped and you might may feel very overwhelmed by questions um like what do you feel or what do you want me to do or what do you need so when um monitoring uh instead of focusing on how you feel focusing on how you are doing uh you might start by monitoring how you do on the different lifestyle factors that we talked about in our 247 model for example that might be a good start for understanding your emotions and what triggers them um it can be everything from hormones to rebound effects of medication or a bad night's sleep right um and then when you uh keep track of what works and um what you have to struggle with you can also send messages to your future self before upcoming PMS days instead of having others like parents pointing out to you when are misbehaving or when you're are um probably having a a bad day and this might be especially then empowering for teenagers and collecting also your own real life information about yourself will also armor you with objective and personal data allowing your Health Care Professionals a better basis for their medical decision- making uh and as we said there are almost all no research on this topic so we have to provide the information for the healthcare professionals we have to provide how the information on how hormones for example influence how we feel and how we are doing um and our emotional intelligence is built in interaction with others um that we feel safe uh with and respected by so that is why techniques from motivational interviewing for example like uh active and non-judging non-judging listening and reflecting is really crucial so instead of coming up with suggestions and solu iions try to just uh reflect back what your child is telling you um to be heard and uh to be listened to is really empowering and it builds emotional selfefficacy so finally uh we have identified some key concept where the common language uh of the ADHD 247 model may help us to come through to other important adults in our children's lives so you you want to make sure that your daughter's school for example has sufficient understanding of her unique challenges and by explaining her difficulties using the metaphors that we use in the 247 model may help the teachers and School staff to see beyond this compliant and Silent little girl that keeps it together in the class just to explode when she comes home or does really well in school but is so drained of energy that she just has to go straight home after school H in miss out on all the social important social life that the other girls share so use your our metaphors here or invent your owns but the important thing is to start to uh quite early in life talk to your child about how emotions and lifestyle factors are tied together um so don't forget talk about how in Period of hormonal changes for example or other stressors we have to be extra careful with our body balance and make sure to eat healthy to have a good sleep routine uh and to exercise regularly to build our emotional resilience and also that it's not cheating but really really smart to start building a a really diverse toolbox to handle your emotion in different parts of your life and um reaction sensitivity dysphoria or RSD is is characterized by extremely painful emotional responses to real or imagine criticism or rejection from others and it's really common uh in in ADHD and it can become a self-fulfilling prophecy uh so I would just like to tell you a little story or little um um result from a research study actually who who shows the the power of um uh teaching girls with emotional disregulation to give them time to not react uh on Instinct but to uh try to reapa what they are seeing and what they are experiencing in different situations because if someone shows you a picture of a woman crying and ask you uh to guess what she's feeling you'll probably say that she looks sad right but if you don't hear that she just met her son who's been traveling in Asia for a year you might perceive her reaction quite differently right so this reinter uh reinterpretation influences our em uh emotional brain processes uh something that we actually make use of when we develop our emotional intelligence um and um a key to better emotional intelligence is to recognize when your brain is more easily triggered perhaps using uh or during PMS H and to work actively to reappraise your perception and emotion and refrain from acting until you feel emotionally anchored and finally um how do we build emotional uh resilience in our children well first of all we want to make sure to optimize the things that we can actually influence um some research suggest that uh stimulant medication May improve um emotional de circulation with others show less um promising effect the the things that we don't know and we have anecdotal evidence pointing to differences in medication effect across the menstrual cycle and since dopamine and estrogen May moderate each other's effect this is a a valid hypothesis H and that could lead to both over and under stimulating stimulation of the medication depending on the hormonal status that we talked about earlier here um and also if your child suffers from distinct comorbidity she may need treatment for that also because it's not certain that ADHD treatment will take care of symptoms of anxiety depression or bipolar disorder second of all um we have mindfulness so part of building emotional resilience is finding ways to stop the emotional impulsivity and buy yourself time to reflect and choose a way to react where you can some that you can live with even though the the emotion will pass so so uh even though there is not much evidence for the effectiveness of mindfulness based practices in ADHD in younger children it's often used in DBT treatment for older adolescence with emotional disregulation and again it's almost never either or uh you don't have to choose medication or to meditate your way out of ADHD but rather try to introduce this aspect of reflecting on your body balance and recognizing your emotions and talk to your child about that and then finally moderation so uh if you and your daughter are anything like the many girls with ADHD and women that I know moderation is probably not your middle name um but then um my experience however is that even very young children can visualize the volume button in the ADHD 247 model and uh working towards moderation in all aspects will build actually emotional resilience so try to be creative uh maybe you can do a chickin race uh of how uh long long you can go um without entering the uh volume buttons danger zone how long you can stand doing things uh in the activity level between 40 and 60 uh or um how you can take yourself out of the danger zones and uh really really important also uh when we talk about the emotional lives of uh girls and women is to understand that they have probably uh if they are un uh or misdiagnosed build up a life with perfectionism stigma and shame around themselves and their behavior so to identify the downstream psychological consequences of living with undiagnosed or untreated ADHD is really important uh many of these girls and women young women they have developed a harsh and naviga of choir of Voices playing on auto repeat day and night voices of self-doubt not doing things good enough letting yourself or others down or being a failure or an impostor so this is why we have to uh work empowering and compassionate uh and try to exchange the vicious choir um by a pass compassionate choir and self-awareness and knowledge uh that emotions are made from perceptions interceptions and previous experience is key here uh and knowing that as long as you don't act on your emotions they can't hurt you again self-discipline might sound uh contra-intuitive um when it comes to fighting perfectionism but the truth is that setting empathic boundaries for yourself um and for others uh for example asking for a timeout uh in a heated discussion before it turns into a conflict you buy yourself time uh and you show yourself uh and others uh that you can stay in control and you take respons responsibility for the for the situation and you stay accountable my circling back then afterwards uh when the temperature is cooled off and then self-compassion and necessary components to heal and to move away from degrading self-image and to build uh healthier relationships to yourself and to to other maybe uh um enjoy a gratitude practice every evening or when you drive your kid to to work so before we we round up do we have the information now to answer Annie and her parents questions do you remember the questions um first of all they asked Annie asked us if her her brain was wired differently and I think we can say yes but also that all brains are different uh so we will ask her to be curious about her own ADHD profile um then they asked us her parents uh how it all would tie together and we could say that yes emotional disregulation is the core feature of ADHD especially in females and hormones affect brain processes uh that is crucial to regulate uh behaviors they also asked us what we risk uh when clinicians don't understand that girls present differently and we can say that this is a great question because early detection and adequate support is crucial to prevent multim Mobility poly Pharmacy and extensive Healthcare utilization associated with female ADHD and finally they wanted to have tips and tools to navigate and we say that yes there are a lot of uh tools out there but it's really important that you are aware uh uh of your own ADHD profile and that communicate your own needs uh to others uh and that you arm yourself with your own objective real life data uh for safe shared decision making with your healthc Care Professionals for example and then I would just like to say again thank you so much um for uh the opportunity to talk and to you uh today uh and looking back at the time that has passed since I first became interested in the emotional lives of girls and women I feel very fortunate um that the literature and the interest is growing and that me and my research group is standing uh on the shoulders of some true heroes in our eyes so we hope to be part of the um movement uh forward and to be able to be part also of the uh increased knowledge and support for females with ADHD and um sorry uh if you um um want to read more about girls and women there is a discount offer from my uh publisher Jessica Kingsley publishing um and if you're curious about letter life our co-creator digital tool for females you can you're very welcome to visit uh and we will allow you direct access uh to the app uh for free uh and please follow me and others advocating and raising awareness for female ADHD on social media I'm on Instagram Facebook and Linkedin and almost on Tik Tok now not uh according to my kids but uh uh I I feel very confident that I will be on Tik Tok uh in just a while H and this quote um to round up from the French philosopher and author Albert Kami I think it sums up so very much of what girls and women with ADHD tell us about their lives so thank you so much for listening and hopefully I will um be able to take some questions now yes oh Dr scogin that was an incredible master class in um ADHD in women and I want to congratulate everyone who's listening because I think at this point our audience probably knows more about ADHD and women than many of the medical professionals who they see um I can say I say that little bit fliply but it's actually true um unfortunately that is true um I wish that it was not the case but but again we have to um we have to educate ourselves and we have to Le the way I think yes yes so thank you for for helping us do that I'm going to do a quick recap on the poll question that we asked um at the outset of the presentation today we asked about those um the percentage that that had been evaluated um and that was uh 74% had been evaluated and diagnosed um their children and and 21% um had not now among those children who had been diagnosed with ADHD I'll point out that only 42% were screened for comorbid disorders like anxiety and depression um I I probably don't even need to ask this question but Dr scogland um should that number not be 100% oh definitely it it needs to be 100% otherwise you haven't really done your work properly I'm I I I guess I will H get a lot of of angry colleagues when I say this but but um the comorbidity is the rule rather than the exception and sometimes you get the misperception that uh ADHD in females is a light version of ADHD in mail and nothing could be further from the truth actually and our dat and others uh research groups focusing actually on females show that so we have to be prepared that when you have a a girl or a woman with ADHD you should be prepared for anxiety depression Eating Disorders um self harm even uh more even more serious than uh actually for the boys right and and someone wrote in just now to say is it is it standard for children to get tested um for all of those in an ADHD diagnosis um I think it's it's really imperative for caregivers to to insist yeah I think it is and and um it is it looks very differently in different countries uh and even in a small country like Sweden uh it looks very differently in different uh settings so we have to advocate for this as parents H and as patients uh to make sure that we get the full picture because it's we need the full picture that's why that's why the ADHD 247 model we need this full picture to move forward otherwise we risk actually um um driving off course and and doing things wasting time and and um resources um that is very serious both for us and for the for the Health Care System actually absolutely and you mentioned this um several times in your presentation but I think it's worth repeating that um girls in particular are prone to masking their symptoms and and sometimes that may look like perfectionism um it may look like procrastination um even a lack of motivation but it really is um critical to for the clinician to understand that the signs and symptoms will look different yeah um in girls and and of of ADHD but also you know those comorbid like anxiety in particular I'm thinking yeah and we have to be curious and clever uh when we ask about this um because having masked um and and having mimicked and having done this uh your your entire life or your you know your entire life from being a girl uh to a young woman it's not certain that you have the words or that you have the Expressions to to actually explain what you are going through and what you are suffering from so um we have to be um very re receptive um and actually also look um on the full picture of of um how how this girl is is doing and overwhelmed H would be one of kind of the core um words like the slogan I would say for for um overwhelmed and overflooded that will will be so many of the girls that I see talk uh about that in uh different words uh and uh on different themes and I have to say this this Dov tales with something I heard um I I mentioned that the attitude team attended a a conference for ADHD this last weekend and one of the the leaders in the field um Dr Dr Anthony rosain said you know he questioned why is it that ADHD is diagnosed on the basis of impairment but other conditions are diagnosed on the basis of suffering or distress and to me me this was like such a light bulb moment that wouldn't we all say that that our you know this emotional distress um that we're describing here um is is is indeed impairing right um that's good yeah it's a good point um and I think we should be both H I think we need to look at both the impairment because it's a lifelong for for many um individuals and then uh the suffering uh of course um and and then um again when you when you get the uh adequate support uh it doesn't need to be um an impairment for for for all people also right so so that that's it's a really interesting um uh diagnosis that we are fortunately interested in I think yes and to that point um you mentioned you know a lot of the um risks associated with ADHD umic specifically in girls and and several people asking whether um there's research suggesting that um medication use for ADHD does help to reduce those risks so things like um this sexual promiscuity car accidents um you know you you name it um yeah there is there is a lot of research actually showing that medication can be helpful uh to reduce a lot of the adverse outcomes associated with ADHD again what we have to remember is that maybe uh we have um uh samples that include uh enough women um but the what what is h what I'm almost 100% certain of is that we do not know if these women are uh or what part of their menstrual cycle they are or if they're also um taking oral contraceptives so we don't know about their hormonal status for example uh when we look at the outcomes so again the the research is flawed in that sense even though it's getting better because we also have female samples now so we have a sample that has actually perhaps even 5050 females and but but then we forget that sometimes we forget why we actually add females um into the research studies and and that is because we are like sub two different subtypes of the same species and we have to consider uh the hormonal aspects I think uh specifically when we when we consider ADHD because hormones have uh a lot of cognitive effects absolutely um such an important reminder we we received a lot of questions today about whether again there's research on the impact of contraception um birth control and in adolescent girls with ADHD um and you know we know that the comorbidity with um pmdd is so high is there any research um one way or the other yeah so we did one study where we showed that uh women with ADHD are five times more likely to develop depression following hormonal oral contraceptives however what we saw that there was no difference between progesterone uh pills only or combined pills so we don't think that it is the absolute level of hormones that is important but rather that females with ADHD due to their ADHD might forget to take their pills or take their more IR regularly so there will be fluctuations again so and that is something that we see and that we are going to follow up in in future studies that we think that it's not the horm hormones per se or the actual hormonal levels but when hormones change that is is um especially bad for neurodiverse uh um women uh and girls so in and that's also what we see uh during the LIF span right that in periods where hormonal hormones are fluctuating or changing in puberty uh after um after birth uh postpartum and in per menopause across almost 10 years across Pam menopause when hormones again uh I I usually say when once you finally start understanding your hormones then they start changing again no so so it's it's a huge part of life uh where our hormones are actually unpredictable to us um and I know we're we're we're out of time but I have to throw in one last question because it's just so pertinent here and that is you know we've been hearing a lot at attitude about very new thinking regarding the um ADHD medication use and how it may be adjusted to accommodate sort of the hormonal monthly cycle um is there any research that you know of that's going on and do you see this as something that we will probably see more of in the coming years the recognition that your dosage um may need to to change definitely uh so there is a very limited research there's only uh to my knowledge one uh observational study just published by Sandra koi and her research group uh however this is something that we see in our Clinic uh all the time and that is uh that I um usually I work a lot um with cyclic dosing so so that is definitely something that we will see more but also is something that we need to research more thoroughly so we are doing our research group are doing a lot of studies on this hopefully uh you will see them published in a year or so because research take time but uh while waiting for research you should ask your clinician what do you know about this um can we educate ourselves together can we see how this is playing out for me in my hormonal um life so so don't wait for us researchers but but hope for us because we will uh we will uh come with the evidence um in a while but it takes some time so just uh start educating yourself and make sure that you know how hormones affect you Dr scogin I cannot tell you how much we appreciate this session it really was um just mind-blowing um I I really really appreciate your contributions not only to the attitude Community but to this whole field of you know understanding and being able to help um better women with ADHD so thank you from the attitude team thank again thank you for for having me it's um it's a huge honor thank you and thank you to everyone who attended here today um please know that you will re uh receive a replay uh link for this video as well as a copy of the slides and we encourage you to share both of them with your treatment team um and we hope that you will join us as well for another attitude webinar in the future our next one is on living with ADHD in your 20s so please join us again sign up at attitudemag docomo so you don't miss a thing and we will see you again soon