ADD vs. ADHD, and Women vs. Men

An extra chapter was written for Thom's Complete Guide to ADHD, but was left out of the printed edition. The chapter is re-produced here.

In men, we various ruling passions find, in women, two almost divide the kind; Those only fix’d, they first or last obey, The love of pleasure, and the love of sway.
-Pope, Epistle to a Lady

Earlier in this book, I offered a complete and detailed psychological and neurological explanation for the driving mechanism behind ADHD. (All other theories I know of only address one or the other, and are thus incomplete.) In quick summary, I showed why and how those who think ADHD is a “top down” problem, such as a failure of cognition, inhibition, or even poor parenting, are totally and utterly wrong. Certainly there are differences among people in our ability to think and learn, our ability to inhibit behaviors ranging from eating to sex, and in the way we were raised. These variations play a small role in how ADHD is expressed, but are not at the core of ADHD behavior, as any person with ADHD can tell you.

The core mechanism, the driving force behind ADHD, is that need that Maslow overlooked when he assembled his hierarchy of human needs: the need to know one is alive. As mentioned, because of genetically determined differences in the set-point of the thalamus, which controls how “in touch” we each are with the sensory world, some of us are born knowing we are alive and never questioning it because lights are bright, sounds are loud, and touch is vivid. Others of us, however, feel the constant need to reach out for stimulus that will verify our aliveness, proving to us that we are really here and now and fully alive.

In her book Women With ADD, psychotherapist Sari Solden points out that women with ADD are often “daydreamers,” who drift through life paying only partial attention. They’re usually not diagnosed as having ADHD because the eruptive or externally impulsive behaviors so commonly identified with ADHD are not showing. This is the face of what’s come to be differentiated from ADHD, known popularly as “ADD without the hyperactivity.” It seems that most of the time boys and men are diagnosed with ADHD, and girls and women are more often diagnosed with ADD “without hyperactivity.”

There are also, of course, females who have the “typical boy” type of ADHD: outgoing, expressive, aggressive, and impulsive, and males who are the “typical girl” type of ADD-quiet and withdrawn, but constantly off in their own little dream world. But they seem to represent a minority, something on the order of around 20 percent in each case.

So why is it that we have these two “types” of ADD (with and without hyperactivity), and why is it that hyperactive ADHD is more prevalent among boys and daydreaming ADD more prevalent among girls?

The approach/withdrawal continuum provides one possible answer to help explain these two types of ADD. According to Dr. Robert Ornsteen (Roots of the Self), this continuum is a function of whether a person is primarily dominated by their left or right brain hemisphere. When a person is a born left-hemisphere approacher, they’ll exhibit their ADD in an external and expressive way. They’ll lurch toward things they want, move from thing to thing, person to person, and have a life filled with wild variety and activity.

A right-hemisphere avoider, however, will act out their ADD differently. Although they have the same internal “need for aliveness,” they’re prevented by their right hemisphere from expressing their impulsivity in the external world and in an external fashion. As a result, instead of interrupting others they interrupt themselves. Their daydreams and unwanted thoughts constantly interrupt their own stream of attention. They find that they can’t pay attention in class, can’t keep up with conversation, and are constantly losing things.

One reason we see the two types expressed largely through gender lines is because in our society men are mostly approachers and women are more likely to be avoiders.

Scientists hypothesize a genetic/evolutionary basis for at least a part of this. Anthropologists and social scientists point out that across the animal kingdom the male imperative is to sow its genetic material as far and wide as possible, whereas the female imperative is to be cautious and careful on behalf of the young who are incapable of fending for themselves. While a male can theoretically impregnate hundreds of females in the course of a year (and with many species, does), in most species a female can only become impregnated once. Translated into the human species, this could lead to a natural tendency for men to be outer-directed approachers, and for women to be inner-directed avoiders. That there are men who are avoiders and women who are approachers shows us the tremendous variety and adaptability of the human species, and may even, in itself, be some sort of ancestral/genetic adaptation.

Another reason why we see such a gender split probably has to do with how our society is organized. According to our most primal cultural stories, men should be out in the world conquering, changing, and transforming things, while women should be barefoot, pregnant, and quietly at home. If that sounds like an extreme statement, consider the stories that ground our culture. I remember well when our oldest daughter was about four years old and I was reading her the story of Cinderella. Halfway through the story, I got a creepy, shocked realization: The “good girl” in the story was quiet, demure, and did what she was told. The “bad and ugly” girls in the story were out in the world trying to get what they wanted. And the prize was a man!

The simple fact is that no matter how egalitarian we think we are as parents, our culture itself, from fairy tales to TV shows to advertising (probably the biggest offender) promulgates the stereotype of males as outer-directed “doers” and women as passive, quiet, and demure. At an early age, our children figure this out. Those little girls (and a small percentage of little boys) who are born with their thalamus set so they need regular stimulation to satisfy their “need for aliveness” discover that when they act that need out in the world, they get slapped down. “Be quiet,” they’re told, or, “Act like a lady.”

But the need for aliveness is still there, and, being a primal need, will find a way to be satisfied. So instead of producing external stimulation by running, jumping, fighting, interrupting, or acting out, these little girls (and a small percentage of little boys) learn how to stimulate themselves in their own heads.

If this sounds esoteric, stop an remember the last really good movie you watched or book you read. Did you laugh or cry? Did your heart race? Yet the stimulation producing those physiological responses was entirely internal - it was all in your head. You were simply reading words on a page and creating an imagined world inside, or watching images flickering on a screen and giving them reality in your own mind.

So this majority of girls and minority of boys with a strong “need for aliveness” find they can satisfy that need internally. They create worlds of fantasy and imagination to explore while the teacher is droning on about something boring. They carry on wild, non-stop conversations in their own heads, providing them with a ready source of internal stimulation and distraction. They’re interrupting every bit as much as their hyperactive peers, but it’s invisible on the outside because they’re interrupting themselves. Instead of seeming hyperactive (which they are, inside), they appear to be in a daze, off in a dream, their head in the clouds.

But it’s the same root cause to both ADHD and ADD: the need for aliveness. What we’re seeing is simply two different ways of getting that need filled. Boys are encouraged by our culture to be physical to meet that need, and carry around testosterone that further aggravates the situation. Girls are encouraged by our culture to be mental/internal/emotional to meet that need, and carry hormonal and biological imperatives to be less aggressive then men.

The proof that in both cases what we have is the need for aliveness (rather than neurochemical imbalances, brain damage, frontal lobe dysfunction, cognitive impairment, failure of inhibition, or any of the other theories to explain ADHD) is that the symptoms of both ADD and ADHD are relieved by the same thing: stimulation.

When dreamy types or hyperactive types are put into a classroom with a Robin Williams-like teacher, they can both suddenly learn and pay attention: their need for aliveness is met. When boys or girls with ADD or ADHD are given stimulant drugs, the hyperactive ones calm down externally and the dreamy ones report that their “internal conversation” quiets down: by turning up their sensory volume control, the stimulant drugs are chemically meeting their need for aliveness.

Thus, we can understand what we’ve been seeing and knew intuitively to be true: ADD and ADHD are simply two faces of one in the same thing: an unmet need for aliveness.

The above text is an unpublished chapter and (c) Copyright Thom Hartmann. It may not be reproduced in any form whatever, without the express permission of the author.

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