Looking back, it was always there:

The nearly missed deadlines, the mental disarray, the effort needed to achieve . . . anything. Lisa Joy Tuttle got good grades, but only she knew what it took.

"I always felt a lot of stress," she said. "I had to work hard to keep up."

With just one year left in college, the facade of capability finally cracked. She quit full-time studies, trying out different lines of work - sales, contract writing, food - while finishing school at night. With less pressure, she slowly found her way, completing graduate school and finding success as a psychotherapist and then as a life coach.

It would be years before the nature of her struggles was given a name: ADHD.

Tuttle, who lives in Wynnewood, was diagnosed with attention deficit hyperactivity disorder shortly before turning 50.

"It was amazing," said Tuttle. "It was like a light went on."

As well-known as ADHD has become, particularly for children, experts say it is too often undetected or overlooked in girls and even more so in women. They may get diagnosed later, if at all.

According to the Centers for Disease Control and Prevention, ADHD is one of the most common neurobehavioral disorders of childhood, and it frequently lasts into adulthood. Some experts believe it can start there.

A 2011 federal survey estimated 11 percent of all school-age children had been diagnosed, up from 9.5 percent four years earlier. ADHD is more than twice as common in high school boys - one in five - than in girls.

But the estimate of one out of 11 girls may mask its real extent.

Experts say females' behavior often doesn't fit the standard profile, which is based on hyperactive boys, typically white.

Patricia Quinn, a developmental pediatrician and author of several books on ADHD in females, calls it "a hidden disorder" because it doesn't look like what's expected.

Quinn, who has ADHD herself, said the condition originally was thought to be a boys' ailment.

The female version often is not hyperactive and may be accompanied by anxiety and depression. Those are more easily recognized, Quinn said, sometimes leaving underlying ADHD undetected and untreated.

Girls also try hard to meet expectations and may not admit having trouble keeping up, she said, delaying a diagnosis. Adults may have fewer - but more severe - symptoms.

Karin Richards, kinesiology department chair at University of the Sciences in Philadelphia, has a history as an academic achiever. But that's not how she thought of herself growing up.

" 'I must be stupider than anyone else. I have to work harder,' " Richards remembered thinking.

The professor, now 46, was working on her doctorate and in therapy for anxiety when she learned a year ago that ADHD was behind her difficulties.

"It was a relief, but there was a little bit of anger, too," Richards said. "My life could have been so much easier."

Cognitive therapy and exercise, including karate, helped.

"I've shared with a couple of students and they say, 'I have ADHD, but I don't want to let anyone know,' " Richards said. "They're so embarrassed to admit it. They won't get extra help."

The American Psychiatric Association recognizes three types or presentations of ADHD - inattentive, hyperactive-impulsive, and a combined set of symptoms.

Females, more prone to internalizing, often fall into the inattentive type - easily distracted, difficulty with time management, misplacing things.

Educators may view them as negative female stereotypes like "space cadet" or "airhead." If they don't present behavior problems, they may be overlooked.

Even "hyper" girls express it differently than boys. While a boy may be physical - unable to stay seated in class - a girl is more likely to talk excessively, veer between emotional extremes, or shop obsessively.

Kelly Cavanagh, a nurse and mother of five in Malvern, was a tomboy growing up - not unusual for ADHD girls with hyperactive tendencies. She struggled in middle school with depression, social anxiety, and low self-esteem. Burned out from trying to keep up with her studies, she took a year off after high school.

Her firstborn, now 26, was around 7 when a teacher mentioned ADHD. Cavanagh started reading about it. She thought back to her father's impulsiveness - how he loved to race cars, how he'd jump from job to job as a young man. The disorder can run in families, and she saw herself in the books, too. When she was diagnosed, a lot started to make sense.

"Before it was like trying to box a ghost," said Cavanagh, 50, a coordinator of the Chester County-Main Line chapter of CHADD (Children and Adults with ADHD). "It's exhausting because you're swinging, but you can't land a punch."

Her three oldest children have all been diagnosed (and each took a gap year before college).

When undiagnosed, females with ADHD tend to hold on to perceived failings, building them into poor self-image and learned helplessness, sometimes accompanied by self-injury or suicidal thoughts. One study linked ADHD in females to increased likelihood of being a victim of domestic violence.

Anthony Rostain, medical director of the University of Pennsylvania's Adult ADHD Treatment and Research Program, said these girls tend to experience more rejection. Some have eating disorders such as bulimia and "self-medicating behaviors" such as smoking and overeating.

Both genders engage in risky behavior: Boys tend to drink too much and drive too fast; girls may be promiscuous.

"Unwanted pregnancies and STDs are a big problem," Rostain said.

So are unrealized dreams and unfulfilled potential.

"There is a lost generation of women who have not been diagnosed," said Michelle Frank, a clinical psychologist.

With their brains' compromised executive function, these women may have a harder time balancing work and family.

"They hide from their authentic selves and try to fit into a box," Frank said.

That needn't be the case.

About 80 percent of people with ADHD can get help from prescription medication such as stimulants, Frank said. "ADHD-informed therapy" along with coaching can aid in successfully managing the disorder. Proper nutrition and exercise help.

For some, ADHD can also be a source of creative strength; they see things outside the box.

Megan Hayden was diagnosed in elementary school. She got treatment, but had few mentors for managing her condition.

Now 31, Hayden has created "Process This," a program that brings students with disabilities, including ADHD, together with adults who have been where they are.

The South Philadelphia resident admits there are times she'd rather not have ADHD.

But it is a part of who she is.

"I don't want to be good at the mundane things," she said. "I like the way my brain works."

Lisa Tuttle, too, has found ways the disorder can be a source for good. In the five years since her diagnosis she has expanded her coaching practice to include helping adults with ADHD.

"We can thrive and succeed as long we learn how to self-manage," said Tuttle. And yes, she said, it can be learned.

What can I do?

Attention deficit hyperactivity disorder can be tricky to diagnose and frustrating to manage, especially for adults.

Books: Dr. Patricia Quinn has written several guides for women and girls.

Web: Try ADD.org and CHADD.org.

Treatment: Seek out psychiatrists (for medication) and therapists with ADHD experience.

rgiordano@phillynews.com
215-854-2391
@ritagiordano