Dr Lotta Borg Skoglund “ADHD in Females  The Perfect Storm?” These are my disclosures,   and you can, of course, view them in more  detail when you get the PowerPoints after   the presentation. This is also another conflict  of interest or maybe more of a shoutout that   I would like to make you aware of my  book, “ADHD Girls to Women.” It’s a   comprehensive overview of the research so  far, also written together with my patients,   a lot of females with ADHD and of their life  stories. It’s a book very, very close to my heart. But today, we’re going to talk about four  different themes, four different focus the agenda   today. Some kind of background and about hormones  and about the brain, and I will go quite fast over   these two areas to focus mainly on ADHD in females  and then, the take home message after the talk.   I will hope you will enjoy it and that you can  also perhaps access the slides if it’s too fast. So, why female ADHD? Well, when I wrote this  book in Swedish four years ago, I realised   that the interest, in Sweden, anyway, was huge  and it seemed like it was in other countries,   as well, because it’s been actually translated  now into four or five different languages.   And it’s coming in November in English, so  I’m very, very happy and proud about that. But what about ADHD? Well, why focus on  ADHD? Well, I think this quote from the   French Philosopher, Albert Camus, kind of,  sums it up really well and especially when   we talk about ADHD in girls and women. He says  that “Most people do not understand that some   people use enormous amount of energy just to be  normal. And on that, kind of, theme, I think so   many of the women that I meet actually speak and  that was actually what made me write this book. So, why don’t you see me? Well, Susan Young  wrote an international consensus paper,   together with other authors, on female ADHD.  She says, “Many of these girls, they feel like   life is an uphill struggle, that “I’m trying  to find myself, to be accepted and to fit in,   to – that I camouflaged, and I cover up  my impairments with bravado and I don’t   get detected.” So, what I need here, I will be –  life skills, critical reasoning, problem-solving,   coping strategies, and what should we do if we  don’t attack, if we don’t find the girls?” Well,   we have to try anyway, because we can’t  leave them hanging. We already know way   too much about how this ends, and this is  what this talk is also going to be about. And why did I get interested in this topic? Well,  it’s actually a lunch that I had with a colleague,   a Gynaecologist of – colleague of mine, called  Helena Kopp Kallner, also my – I call her my   fellow ‘research wife’ in our research group,  GODDESS ADHD. And we were talking about a group   of females that Helena met in her practice, in  youth clinics and in the gynaecology clinics and   that – when she talked about them, about this  frustration about a group of women that did not   really listen to what she had to say. They did not  adhere to her treatment and she said, “It’s like   they don’t even want to listen. It’s like they  – what – they almost want to hurt themselves,   and they say that they don’t tolerate hormones and  that they tol – don’t tolerate the contraceptives   that I prescribe. And I just don’t believe  them because everyone knows that, you know,   you don’t get depressed by hormone  contraceptives. That’s just a myth.” And I was listening to Helena, and  I thought this sounds a lot like   the women that I meet in my ADHD clinic. So,  we were discussing back and forth, and we said,   “We need to put these, kind of, myths and  these questions that our patients and the   girls and the women that we meet actually  tell us to a test.” So, this is a lot about   the research that I’m going to present to you  today and what our research is actually about. So, same-same but different. Well, ADHD is the  same diagnosis in girls and boys and females   and in males, but the symptom display can be  different. Sometimes we have to view more of   the impairment than the behaviour when we look,  at least at the younger girls. There are also   biological differences, that’s hormones, we’re  going to talk about that soon, and different,   actually, social expectations of girls and  boys and of females and males. We’re going   to talk about – a little bit about that, as  well. And we have to realise that half of   our population does not just imagine that things  are in their head, certain times of the month   or certain periods in life, that hormones do  affect a lot of our mental health and actually,   also, our everyday functioning. And due  to the limited knowledge about this,   girls and women keep being un  or misdiagnosed for a long time. So, the thing that Helena and I realised  when we started talking about this group of   girls and young women that we meet, her in her  women clinic and me in my psychiatric ADHD clinic,   we thought that if we can help these women  because they struggle so much and they never   seem to fit in anywhere in the healthcare system  and they search and search and search for what’s   wrong with them, if we can help them, we  can actually prevent them – prevent a lot   of the negative outcomes associated with  undetected or actually diagnosed ADHD in   girls and women. We can affect and influence  mental health outcomes in generations to come,   because this is not just a matter of that  particular young woman. This psychosocial   negative outcomes is actually transmitted across  generations. So, I think here I have actually   found the most important area of research  in psychiatry, but of course, I’m biased. So, we want to – I want you to meet, actually,  Lou, Anja, Mia and Ella. We’re going to use them   as example for ADHD in different stages of  life. But first, ADHD. That’s a, kind of,   a controversial diagnosis, in Sweden,  anyway. Why is that? Well, it’s very   prevalent. From 2-3% in older adults, two up to  9% in children and adolescents. It’s persistent,   50-75% of children fulfilling  the diagnostic criteria will   keep having impairments as adults. It’s  pervasive across generations, as well,   so 80% of the liability or the heritability  around ADHD is explained by genetic factors,   and it’s problematic. We look at 30-80% of adult  people with ADHD, fulfilling at least one other   comorbid disorder, and both psychiatric and  somatic disorders. And ADHD is associated with   an eight-13 years reduced life expectancy if you  don’t get the diagnosis and the correct treatment. So, Helena and I founded our research group. We  call ourself, very humbly, the ‘GODDESS ADHD’   and it stands for “Gender-informed research  to Overcome Diagnostic Delay & Emotional   dysregulation through Self-awareness and  Self-efficacy in female ADHD.” And we are   a multidisciplinary collaboration looking for  more collaborations. So, please reach out to   us if you are interested in this field. We think  that females are especially well adapted or – and   well suited to actually collaborate in  research that – so, it is a fun group. What have we done so far? Well, we have shown  and – that female ADHD is associated with   multimorbidity, healthcare – increased healthcare  utilisation and polypharmacy. Sexual risk-taking,   challenges in reproductive counselling, five  times increased risk for depression following   hormonal contraceptive use, six times increased  risk for giving birth when you are still just a   teenager yourself, or a kid yourself. Risk  pregnancies, smoking duration pregnancy,   prematurity, postpartum depression, comorbid  anxiety and borderline disorders and this   diagnostic delay of four years. So, this is  what we have done so far, and we are just   getting started. This is us and we have, also,  onboard, Professor Lisa Berlin Thorell from   Karolinska Institutet and our extremely talented  Postdoc Researchers, Niklas, Darko and Hedvig. But now, I would like to introduce you to Lou,  Anja, Mia and Ella, and we can call this a   clinical phenotyping. And I will introduce to you,  also, the notion of digital phenotyping later on   in this talk. But Lou, and I think you know of Lou  if you have and you know a girl with ADHD or if   you work with ADHD. She’s eight-years-old,  she’s very shy and compliant in school,   but when she comes home, literally meltdowns on  her parents, on her siblings. She also has this   feeling of it – and struggling very much socially.  She al – she often feels rejected, she often feels   like her peers are not letting her into their  community and their – what they’re talking   about. She suffers a lot from a general anxiety,  a bit of an OCD is developing, and her mother is   really psy – anxious about that now, and she’s  – has had difficulty sleeping since she was an   infant. She often complains about stomach ache and  headaches and she has a really low self-esteem. So, then, Anja. She’s 19-years-old. She comes  to my practice because she is very risk-taking.   She has had a lot of abortions already, a  lot of conflicts at home, worried parents,   doesn’t’ feel that they reach her. She  also ends up in a lot of conflicts with   her peers. There’s been a lot of bullying going  around Anja, actually. She suffers from anxiety,   depression and actually, eating disorders.  A lot of somatic complaints as well, pain,   a lot of fatigue and she’s also a low, low  self-esteem. It’s not apparent, actually, always,   to the people who meet her because she comes  across, like, very self-confident, but she’s not. And then we have Mia. She is 47-years-old. She’s  always assigned the role of the Project Manager   at work because she is so – she has her ‘shit  together’ as she says. However, at home, she feels   like she’s failing as a parent, she’s failing as  a partner, she’s no social life, she has a lot   of burnout, and she’s started, actually, the last  couple of years to use alcohol when she comes home   from work to wind down and to self-medicate.  Also, a lot of somatic issues, IBS, PMDS,   fibromyalgia, also, a very, very low self-esteem,  although she is such a good girl at work. And Ella, she’s 73-years-old. She has struggled  with academic underachievement and a non-existing   social network her entire life. She  always feels excluded and she has very,   very limited contact with her kids and  her grandchildren. Suffered from anxiety,   depression, lone – oops – loneliness her entire  life and now she’s very worried that she is   developing dementia. She has metabolic  syndrome and type 2 diabetes and also,   struggled with substance use disorders across  her life and also, very low self-esteem. So, all of these women, different part of their  life, they’re – are talking about what I used to   call the ‘broken record syndrome’. They know  that they are struggling with stuff, and they   know what they should do, but they just can’t do  it. And we have to agree, I guess, that ADHD’s   a serious condition with a good prognosis, but  there are so little research and almost no tool   for female specific challenges. And as we talked  about before, without the diagnosis, without the   proper treatment, eight-13 years of reduced  life expectancy due to ADHD and comorbidity. So, I would like to introduce to you  a concept that I call, very cheesy,   7’ because ADHD doesn’t take naps, it  doesn’t take holidays, it doesn’t take vacations,   it doesn’t even take lunch. So, this is how  I talk to my patients about how – what ADHD   is and how it affects your life. And just to  have these, kind of, cheesy remembering rule   around our talks makes it possible, also, to get  back in the next session to see where are we and   are we going in the right direction? So, I will  just very quickly introduce you to ADHD 24:7,   the base, the ADHD phenotype or  the – and the life around ADHD. So, the first one, the 2 in the 24:7  model would be what everyone needs to be   able to talk about mental health. Doesn’t  matter, really, if you have ADHD or not,   because you need a tribe. You need a social  context where you feel like you can express   your needs and your emotions without being  judged and that someone knows you and cares   about you. And you need a purpose. Your life  has to have a purpose and a goal and you need   to – someone – something that is bigger than  yourself to set your goals towards. And a   feeling that you are contributing to a greater  good, something that is bigger than yourself. ADHD phenotype, what is that? Well,  that is what we can think about when we   think about neurodiversity and what  is actually the brain is struggling   with when you have ADHD. So, what ADHD  is, and for many women, in particular,   a problem of overviewing life. A Psychologist  would call it executive functioning,   central coherence, but I call it the control  tower in the airport. The organising, planning,   prioritising and getting started, finishing up  in time. That, kind of, frontal lobe functions   that people with ADHD struggle with so much. And  we also struggle with the internal volume button,   what Psychologists would say about –  call, perhaps, emotional regulation,   delay aversion, but what ADHD people may call  problems regulating the volume button in brain   areas involved in not only hyperactivity, but also  energy, appetite, sleep and emotions, of course. The next area in this four phenotype of ADHD, 4,  is the brain’s ability to filter out information,   perception, sensation, sensation overload. “To  live with a brain,” as someone of my patient said,   “is like living with a brain like a hard drive  without the virus filter. Everything just gets   in,” and also, everything from your own body.  So, your body and your surrounding keep sending   you cues all the time, and all this has to be  processed and you get really, really exhausted   and distracted. And the last part – area would be  to shift focus, and what the psychology, perhaps,   would call cognitive flexibility or metacognition,  but the ability to stop ruminating and the ability   to stop doing what you’re doing because you have  to do something else more important right now. And the 7 in that 24:7 model for ADHD would be  the seven lifestyle factors that is actually,   showed by research, associated with  the morbidity and the mortality of   ADHD. Strategies, skills for routines around  diet, exercise, sleep, stress and recovery,   emotions and relationships and different  kinds of addictions and the structure in life   to get your economic situation and your medical  situation under control. So, this is my 24:7   model that I wanted to introduce you to and  that I work with my patients and who seem to   actually like that. And it’s a very visualised  way of actually working with the everyday things   around ADHD that – keeping in mind that every  brain’s unique and that everyone’s ADHD is unique. So, then, we will just shortly go into  some facts about hormones and then,   we will dive into the area of ADHD in  females, specifically. Hormones, symptoms,   sexual health and pharmacological treatment  across the cycle and across the lifespan. So,   we will be talking about hormones, when it comes  to females, that are changing when we enter   puberty, and we are talking about PMS, PMDS, we’re  talking about special occasions like pregnancy and   postpartum, perimenopause and menopause. And  what hormones are we actually talking about? Well, we’re talking about oestrogens and there’s a  whole family of oestrogens involved in everything   from pregnancy to breast development, circulation  in your heart, your skeleton, your skin,   your mucosa, your libido, your sensation of  pain, memory, mood, sleep. A lot of things   that oestrogens are involved in. And we have  progesterone produced in the corpus luteum,   involved in also pregnancy and breast  development, the skeleton, again,   the blood pressure, the libido, PMS,  PMDS, emotional regulation and memory. And the problem is not the hormones per se,  but the thing would be that for females,   these hormones are fluctuating. And they are in a  certain hormonal status before puberty, and then   you have a cycle that you’re cycling the entire  menstrual cycle, where if we look at the menstrual   cycle in 24 days, that is the, kind of, average  menstrual cycle, you would have a phase just   when your menstruation starts, with increasing  oestrogen levels. Progesterone levels are still   low. Oestrogen levels will increase to prepare  the ovaries to release the egg at – on day 14   and ovulation. At that day, oestrogen levels are  peak and then will back down to a lower and stable   level for the rest of the menstrual cycle. Flo –  from day 14 to the next menstruation, progesterone   levels will steadily increase, creating an  entirely different hormonal situation for that   particular women. And if we don’t ask our patients  in what phase of their menstruation cycle they   are, we will, as we will see soon, have quite slim  chances of getting our medical decisions right. This is what it looks like for oestrogens  fluctuating across life. Starting in puberty,   oestrogen levels start increasing. During  menstruation, heavily fluctuating. Pregnancy,   huge boost of both oestrogen and progesterone  and then, again, cycling towards perimenopause   and menopause around age 51. And I will not have  time to go into all these studies, but I wanted,   anyway, to put them up here in the presentation  for you to read up on it if you’re interested. But   there are a lot of studies coming out now showing  that ovarian hormones, like progesterone and   oestrogen, actually shape lane – brain plasticity  during our reproductive years and we’ve not been   able to show that before. It’s mainly been shown  in animal studies. So, that’s really interesting. We want to understand the key areas where  oestrogen and progesterone receptors are affecting   the brain, different brain processes. And we want  to look at the frontal cortex, a very important   area for ADHD, where dopamine receptors are very  prevalent. We talk about control, inhibition,   organisation, planning and prioritising,  that are processes that are governed from   the frontal cortex. We’re also interested in the  hippocampus and the thalamus for arousal, memory,   body temperature and sleep, and the cerebellum  for motor co-ordination and for compulsions. So,   there are a lot of overlaps of the areas that  we are also interested in when it comes to ADHD. So, just to sum this up, mental health and  hormones. For Lou, Anja, Mia and Ella that   you just met, they all have increased risk to  develop stress, depression, anxiety, abuse,   binge eating, psychosis, mania and suicide in  certain phases of their hormonal lives. Still,   almost no-one asks them about their hormones  when they struggle with mental health issues   and when they seek our consultation for their  problems, and that is a huge problem when it   comes to female mental health and when  it comes to female ADHD, in particular. So, with this, kind of, short and very brief and  very fast overview of hormones and the background,   I would like to proceed into the main  area for this talk, “ADHD in Females:   From the Cradle to the Grave,” and a story  about Eddie and Anja. And a research study   done where Researchers wrote a vignette about  a boy called, we can call him Eddie, with ADHD,   and handed that story out to Teachers,  parents and healthcare professionals,   asking them why they thought that Eddie was  struggling so much. And perhaps not very   surprisingly, both the parents, healthcare  professionals and Teachers said that “Well,   probably Eddie has ADHD.” Okay, “Eddie  has ADHD. What should we do for Eddie,   then?” “Hmmm, yeah, maybe he should have  an assessment and maybe he should have,   like, eviben – evidence-based treatments.”  There is, like, a rationale for this, right? So, not very surprising up until then, but the  thing is where – when the Research Team edit   out just the name Eddie and exchanged it to Anja  instead. Handed it out again to a new population   of Teachers, parents and Researchers and asked  them, “Why do you think Anja is struggling so   much?” Remember, the exact same vignette. They  were very much more curious. They wanted to know   much more about Anja and her background and her  peers and her relationships within the family.   Okay, so it was really tough for us to pinpoint  what Anja’s problem was and then, again, asking,   “What should we do to help Anja, then?” Anja  was recommended speaking to, perhaps, the School   Curator or perhaps speaking with her peers or  talking to her mum. So, a lot of talking, but a   lot of time until someone actually suspected that  Anja could also have ADHD. The exact same story. I think we need to have that in our – in the  back of our head when we look at the research   and we – when we meet our patients today, to  be able to detect and to identify and properly   help the girls sooner. Because girls with ADHD, I,  usually, I call them the invisible children, but   they do have hyperactivity and impulsivity. It’s  – but they have a different symptom display. So,   their hyperactivity are more about the emotions  and their impulsivity may be more in a verbal   sense. They do have problems, even though they’re  not on our radar yet. They do express stress,   social exhaustion and academic failure  and they start very early in life to   develop a low self-esteem. Bullying, much  more common if you are a girl with ADHD. And of course, these small invisible girls, they  start and they try to handle their situation. They   look for explanations and they end up perhaps  overweight, struggling with eating disorders,   start smoking and using alcohol at a much earlier  age than their non-ADHD peers. And then puberty,   a period of extreme hormonal changes,  kickstarting the development for our female   characteristics. There are neurological changes  and there are social challenges and changes,   as well. A very transformative period, and these  small girls with ADHD, often then undetected,   they grow up to young women with ADHD. We talked  about the persistence of the diagnosis before. And ADHD and comorbidity, what do we know?  Well, we know that many girls and women are   undiagnosed and that we mis – or now that  we misunderstood their symptoms. That their   symptoms may change with age and that they use  a lot of compensatory strategies and masking.   Talking to females with ADHD, that is a core  theme in their life, trying to hide the secret   of them being deviant in – and trying to avoid  being exposed by others as being not normal,   and they develop the comorbidities. So, the  young women with ADHD, the theme there would   be comorbidity and risk-taking. They will  perhaps not seek up our help with – asking   us if they have ADHD, but rather, with  depression, anxiety and eating disorders.   They’re more susceptible to addiction and to  trauma and sexual risk-taking, teenage birth. And the problem is that the comorbidity chart  for them, it’s very messy and it’s hard for them,   as for us, as Clinicians, and for  parents, to disentangle what is   what. But this is the situation, and this  is actually not a very unusual patient,   having all these different comorbid conditions  during their adolescent and young adult life. So, we did a study, we call it ‘Time after Time’  and it’s just been accepted for publication in   JCPP, and we are looking at the diagnostic  delay in female ADHD. We know that females   were twice as likely to be diagnosed with  inattentive ADD and that this less disruptive   presentation of ADD – ADHD might be more difficult  for us, as Clinicians and parents and Teachers,   to detect. So, we looked at the age of ADHD  diagnosis or ADHD-index in a Swedish regional   healthcare register, aiming to establish age at  ADHD diagnosis in females and males and also,   looking at differences in comorbidity,  treatment or healthcare utilisation   around the ADHD-index for ADHD females, for  females without ADHD, and for ADHD males. And looking at our data, we can say that Anja,  she will get her ADHD diagnosis four years later   than Eddie. She will also have a high burden of  comorbidity and healthcare utilisation than Eddie,   and again, we will see the pattern of a  girl move around in the healthcare system,   not being recognised, being referred  to, or seeking out, different parts of   the healthcare system without being  properly identified and diagnosed. So, in our research group we started out at the  youth centres. I told you about this – how our   research interest came about. Meeting Helena Kopp  Kallner, who is a Gynaecologist and realising that   we actually saw the same patients. We saw the  same girls and adolescents. So, we thought that   youth centres might be a good place to detect  our ADHD girls and young women. So, we started   out with a study where we did interviews with  Midwives working at youth centres, and we heard,   or they told us, that they failed, they thought,  themselves, to offer timely and attractive   interventions for these – this group of women.  They didn’t know how to follow-up and to evaluate   their interventions and to plan and to know what  they were doing was actually working. So, they   doubted that the information that they delivered  to these girls, kind of, came through and they did   not really know how to consult them about proper  medication, contraceptives and other medications. The standard. They said that they did a lot of  things already when they identified that the   girl might have ADHD. So, they adapted  the room so it was less distracting,   and they can also have, like, flexible opening  hours for the females that – with ADHD that   had difficulty meeting appointments. But  what they wanted, they wanted much more,   and they thought that much more could be done, and  they told us that they wanted clear guidelines.   “How should we treat this? How should we make  sure that what we do is actually effective for   these women? We would like to have screening tools  at the youth centres to detect these women and   we want increased knowledge,” knowing that the  Midwives on youth – in youth centres are not –   they don’t feel that they’re properly trained  to detect and to support a female with ADHD. So, a very important and interesting study  to start off with, realising that there’s a   lot we can do right now just spreading the  knowledge about female ADHD to the people   that actually meet them in clinical practice.  And Anja told us that she couldn’t stand the   pill and that hormones made her ‘crazy’, and  that was a thing that Helena and I debated   about in the beginning of our research. So,  we wanted to check for that assumption. So,   the next study we did is a large National  Register-based study on ADHD and female   pregnancies, because we know that teenage  pregnancies is associated with long and   short-term adverse outcomes for both the  young mother and their – and her child. More specifically, the mother, she  risks low educational attainment,   being a single parent and being in increased  need of public assistance. And the child,   you can see that children to very young  mothers, they are at increased risk for   perinatal morbidity, mortality, low socioeconomic  status and quality of life when they grow up. And in Sweden and in the Sweden youth  centres, we have worked very efficiently   with these – with trying to reduce teenage  pregnancies due to these problems. And we   have numbers that decreased from about –  around 15% in the 1970s to around 2% today,   one of the lowest rates internationally.  So, very much to be proud of, but what   Helena and I was wondering, knowing these  group of females that we meet, we thought,   are we really reaching out or reaching all  females, and what about females with ADHD? So, we looked at this in a Swedish National  Register and we saw that the overall teenage   rate was about 3%, so about what we know  it will be, but it was way more common in   ADHD. Actually, about the rates where we were in  the 1970s, before we started working with these   questions, more specifically. And that Anja, in  this case, will have a sixfold increased risk of   becoming a teenaged mother compared to non-ADHD  peers. So, we do not seem to reach Anja and her   peers, and ADHD peers. “So, what could that  be due to?” we asked ourself in the next step.  So, we wanted to look at what Anja actually  said to us, that she felt that she got depressed   by using the pill and that she quit it due to  unacceptable side effects. And we know that Anja,   just because she has an ADHD diagnosis, is  an increased risk of developing depression   just due to her ADHD. And Helena is right, looking  at the science behind associations with hormonal   contraceptives and depression, we don’t see  that they increase the risk of depression in   the general population of females, but what  about Anja? What about young women with ADHD? So, we set out, again, in the National – in  a nationwide register-based study, to look   on hormonal contraceptives in women with ADHD and  without ADHD, and we found that Anja was actually   right. She was right and Helena was wrong, and  she do have three-five times increased risk of   being depressed using the standard hormonal  contraceptives prescribed in Swedish youth   centres, on top of an already increased risk for  anxiety and depression that we know about in ADHD. So, one of the studies we did, associated to this,  is also trying to advocate for the provision of   long-acting reversible contraceptives, like IUDs  and surgical – after surgical abortion. And we   think that that might be a safe and attractive  contraceptive for females that tend to not   tolerate or forget to take their pills. And we  see that we are already on our way in doing that,   but that there are much more that we can do,  and we think that we should actually advocate   that on a broader level because it’s a safe and  tolerable contraceptive for a female with ADHD. And when these women, they get – when they get  pregnant, they have risk pregnancies. So, in a   study from 2014, we were – we showed that smoking  during pregnancy and – is associated with a risk   for offspring ADHD. But when we adjust for genetic  factors, we can show that this association is   probably better explained by familial confounding,  by shared genetic factors, than the exposure of   smoking during pregnancy. With that said, smoking  during pregnancy is harmful for both mother and   child for so many other reasons. However, we  don’t think it’s the cause of childhood ADHD. More on risk pregnancies, ADHD and preterm birth.  We show in a study, a National Register study,   that we – females with ADHD have a higher  preterm risk, or risk for preterm birth,   compared to women without ADHD. And more  specifically, very preterm birth associated   with early spontaneous and medically induced birth  onsets, and that females with ADHD, following   pregnancy, are at increased risk for depression  and postpartum anxiety. Showing that we need more   knowledge and experience in maternal healthcare  to support these females at an early stage. And parenting. Being a parent with ADHD could be  tough. The heritability of neurodiversity is high,   so mothers with ADHD have a higher risk  of getting children with ADHD. And we know   from studies that mothers with ADHD, they  report a high parental-related stress. That   they more often report using a harsher and more  inconsistent parental style, although that they   do want to be the best and the most supportive  parent to their children, as anyone – parent   would be. They are more – have to depend on  increased need for welfare and social support   and they are less likely to adhere to parental  checkups. And they will more often feel that   they are criticised by others, adding to this low  self-esteem that we see in females of all ages,   and that the emotional dysregulation of ADHD is  one of the hardest thing to cope with as a parent,   because you feel that that affects  your child in a very negative way. So, multimorbidity, polypharmacy and increased  and excessive healthcare utilisation before   diagnosis is the rule, rather than the  exception, for young adult females with ADHD,   and early detection can impact mental  health in generations to come. Still,   standardised methods for predictable  hormonal fluctuation across female and   precision medicine and to tailor gender informed  interventions seems very far away today. And   this is something that we, in our research  group and many others, would like to change. So, just before we star – stop, some short, short  messages about what happens when Lou and Anja gets   into adulthood and become adult women with ADHD.  Looking at the research here, we have to highlight   the stress and the challenges in the reproductive  life, the parenthood, the relationships and the   work life of adult women with ADHD. And adult  women become ageing women with ADHD, and looking   at the research, we should have 2-3% of all women  over 60-years-old fulfilling the ADHD diagnosis.   Very, very few of them have gotten  an assessment or a proper diagnosis. They have the same difficulties, but life offers  new challenges. Maybe a partner has left or died.   Maybe retirement robs you of the structure you  had when you were – in your working life. And   reports show that these women, they live with  low self-esteem, feeling very lonely and the   7 life, the seven lifestyle factors, has  taken out its toll and physical and mental ill   health is common. However, the light in the tunnel  here is even though they have struggled an entire   life without proper diagnosis, getting  diagnosed, even if it’s later in life,   result in better quality of life and an  improved self-esteem and quality of life. So,   that is a very strong reason for also allowing  older females to get their ADHD diagnosis. So, the take homes. ADHD, females, hormones,  what’s the problem? Well, the problem that   we’ve been talking about today is that girls  and women with ADHD, they are at risk for   early sexual debut, sexual risk-tasking, sexually  transmitted diseases, exploitation, victimisation,   unwanted pregnancy, abortion, underage parenthood  and everything that follows that. The problem,   also, that women with psychiatric conditions are  often excluded from crim – clinical trials. So,   the knowledge of how hormonal factors  affect mental health, risk-taking,   medication and outcomes in females with ADHD,  is hugely lacking, but it’s getting better. We know that the interaction is  there about – with the ADHD symptoms   that may vary across the menstrual cycle. That  oestrogen do affect mood and emotions and that   dopamine is dysregulated in ADHD. And if  we continue to use the male norm instead   of start – thinking about gender informed  assessment and cyclic treatment strategies,   I think we risk missing out on a very, very  huge piece of the puzzle that we need here. So, the solution. Well, I don’t have the solution,  but I have some suggestions for the solution.   I think we have to find and support the girls  much earlier. We can’t leave them hanging there   and we can’t have a four-year diagnostic delay,  because during these four transformative years,   the girls, they develop a lot of comorbidities  and sinking self-esteem. We can do that, I think,   by improving knowledge in schools and primary  care, in youth centres and in every other places   where the girls keep turning up in our system.  We can target the reproductive counselling,   because we know that a lot of the girls with  ADHD, undiagnosed ADHD, and young women,   they will turn up in our youth centres. And we  can employ much more of the multidisciplinary   research and clinical work. We can also  talk about titrating ADHD medication,   since we know that oestrogen and dopamine  levels modulate each other’s effects. And cycling dosing, there is no research on  that yet, but since we know that oestrogen   affects ADHD symptoms and that dopamine is  moderated by oestrogen and that dopamine   is the central neurotransmitter that we are  trying to effect when we use ADHD medication,   there might be, now, theoretically  enough support to think or to, at least,   ask women how they are doing in different  parts of their cycle and let’s try to titrate   medication according to that. Might be that  you have too high dose in the first 14 days,   or that your dose is too low in the  post-ovulatory phase of your cycle. The implication. The early detection by focusing  on female specific displays to – oh, sorry – to   factor in the comorbidity, to factor in the  hormones and to focus on female display, early   comorbidity and predictive periods of hormonal  fluctuation and cyclic treatment strategies. So, what can you do to support girls  and women with ADHD, like Lou, Anja,   Mia and Ella? As a parent and a partner,  you can always listen very carefully,   and you have to listen sometimes  in between the lines of what   the girls and the young females are saying.  And you can also get interested in factoring   in the hormones. From a school and a workplace  position, we can also ask and talk, and we can   engage in practical problem-solving skills to be  part of bridging the gaps of knowledge. And us,   in healthcare, and the society as a whole, we can  be much more involved in the multi-professional   research standard of care and increase the  focus on biological and gender differences. So, Lou, Anja, Mia and Ella, we were talking about  the clinical phenotyping of their individual ADHD.   But what I am working on with my research group is  actually some kind of digital phenotyping. We’re   are engaging in the pilot now, where we employ  this 24:7 way of viewing ADHD to map out any –   every girl’s individual ADHD phenotype or profile,  and their seven deadly sins or lifestyle factors.   Building prediction models where you can actually  send messages to your future self in other periods   of your menstrual cycle, and develop, together  with a coach or with your healthcare professional,   productive and individualised life hacks  to handle your ADHD and your hormones. So, I’d just like to, again, promote my book.  I’m very proud of this book that I’ve written   together with my patients on how to live with  ADHD as a woman across the entire lifespan.   And to say thank you so much for listening and  for – if you want to, reach out to join and to   find new collaborations around female ADHD  across the lifespan. Thank you very much.