I may be dating myself with the reference, but for a moment I ask us all to draw upon our collective memory and resurrect the dulcet tones of a sisterhood of nuns in an Abbey in long ago Austria, home of The Sound of Music. The nuns, replete in black and white habits, sing of Poor Maria. She is the heroine of an exciting tale of love and daring escape, both entertaining and endearing as enshrined by Rogers and Hammerstein for generations, and yet throughout the film a whole chorus of nuns sings not about her epic tale, but about their own perennial quest to understand her. Maria the enigma. How do you solve a problem like Maria?
With the disclaimer that as a mental health clinician I would never suggest that Maria herself is a problem, what if we took a closer look at her life and concerns? As the movie opens, we witness Maria singing and dancing, full of passion and joy and purpose. She is alive and electric, expressive and talented, the balloon only deflating as she realizes that she is once again late for mass and has broken the rules by singing on her own. Maria desperately desires to fit in with the nuns, to belong, and yet something holds her back. Those around Maria describe her as “unpredictable as the weather, as flighty as a feather, wild, a wil-o’-the-wisp, a headache, a clown,” and state that she is as hard to pin down as “a cloud” or “a wave upon the sand.” (Wise, 1965). Confused but longing to help, the mother superior sends her to care for a large family of children and their widowed father. Things start out well, yet half way through the film Maria ends up back at the Abbey, scared and confused.
Let’s imagine that when she returns to the Abbey, Maria seeks out mental health care. As she sits down during her first session, head in hands and close to tears, she verbalizes, “What is wrong with me? Why can I never seem to do the things that come so easily to those around me? Why do I begin things with such excitement and then cannot seem to stay the course? Why is it so hard for me to believe that I could actually belong?”
There are many ways we could begin to address those concerns as we partner in the therapeutic experience. We could work with the seeming anxiety related to her current relationships. We could start with the stated feelings of inferiority. We could shift course and double down on task management and daily routines. But would any of these directions actually answer the questions she brings? What if there was one string we could tug on that would connect all of the concerns both internal and external that weigh on dear Maria? What if Maria, in fact has Attention Deficit Hyperactivity Disorder (ADHD)?
When we think of ADHD we often conjure up an image of an eight-year-old boy who has trouble sitting still in class, often drawing attention until a diagnosis is made and resources are employed. The reality is that ADHD often presents differently for women and girls. While girls can display external hyperactivity, more often than not they experience internal symptoms related to attention (Attoe & Clime, 2023; Glaser Holthe & Langvik, 2017; Nussbaum, 2012).
If there is hyperactivity in a female child, it often presents in ways that are not readily attributable to ADHD such as “hyper-talkativeness, high arousal, fidgeting, flight of thoughts, internal restlessness, and emotional reactivity” (Glaser-Holthe & Langvik, 2017, p. 2). Because of this, the hyperactivity is often attributed to “emotional difficulties, disciplinary problems, and learning and attention difficulties, rather than symptoms of ADHD” (Glaser-Holthe & Langvik, 2017, p. 2). These girls are often confused as to why the things they are doing bother others and why they cannot seem to control the behaviors that others find unacceptable. This primarily internal experience of ADHD is one of the reasons that girls are diagnosed much later than boys (Attoe & Clime, 2023; Nussbaum, 2012) if they are diagnosed at all.
When symptomology goes undiagnosed for years, the messaging can begin to turn inward. Many of these women have grown up wondering from a young age why things feel harder. Like Maria, they wonder why it takes so much energy to start a task. Why is it so difficult to maintain friendships? When there is no conclusive answer, the assumption is often made that something is wrong with them, or that they are not doing it right. If only they could find the right hack or bullet journal it would get better. They decide that maybe they are just not trying hard enough and bathe themselves in shame. Women with late diagnosed ADHD have consistently lower levels of self-esteem than that of peers and consistent misdiagnosis of other mental health concerns, such as anxiety and depression (Glaser-Holthe & Langvik, 2017).
With all of this in mind, you may be asking, where is the hope? As a clinician I find great hope in current levels of interest in the ways ADHD presents in the female experience. The more we educate ourselves about the symptoms and real-life experiences of women with ADHD, the better we will be at catching it not only early, but effectively.
For someone managing ADHD, simply knowing that there is a reason for their constellation of struggles can be liberating. One of the first steps towards recovery is the practice of self-compassion as outlined by Kristen Neff (Neff, 2015). Acknowledging the differences that come with ADHD and turning towards these differences with compassion and acceptance allows us to begin a journey of working with rather than against a client’s unique brain and its needs.
For instance, the ADHD brain often exhibits a lower level of dopamine production than other brains, thus the seeming inability to approach or complete tasks that the individual finds boring or mundane. Part of the therapeutic process is helping the client identify the points at which they get stuck in their daily and weekly routines and find ways to leverage dopamine producing strategies to move through those tasks.
If we go back to the example of Maria, we could suggest that singing through a task, or staggering a boring component of a task with one of her “favorite things”, might be just enough of a boost to get her to the other side of the mundane (Wise, 1965). Some strategies and resourcing can be highly unique to the individual client. Others may be quite similar for many people, such as the utilization of timers, or the externalization of details such as calendar and order of operations for tasks with brightly colored sticky notes. The bottom line is that a unique brain requires unique solutions, and the process requires a good deal of self-acceptance and compassion.
If Maria’s example familiar to you and you would like to know more about how ADHD might present for you or someone you care for, and what resources are available, please contact me at sbooth@springtreecounseling.com. I’d be glad to help.
To learn more about Stephanie, please visit her bio page. She is currently accepting new clients and sees clients in person in Evanston and virtually via telehealth.