NASET ADHD SERIES
Kristin Wilcox, PhD.
This issue of NASET’s ADHD series was written by Kristin Wilcox, Ph.D. Initially, ADHD was defined based on observations of hyperactive behavior in boys. Unfortunately, the perception of a child with ADHD – boys who are hyperactive, impulsive, fidgeting, blurting out answers in the classroom, and constantly talking – has changed little over the past several decades. Results from large population-based studies suggest the inattentive subtype of ADHD may be the most prevalent type, however, it continues to be underdiagnosed. Children with the inattentive subtype of ADHD fly under the radar at school and at home with symptoms of inattention, forgetfulness, and disorganization which are difficult to identify correctly as ADHD and can often be confused with other behavioral problems. Teacher and parent education is key to learning how to work with our children’s ADHD brains and will aid in earlier diagnosis of the inattentive subtype.
Abstract
Initially, ADHD was defined based on observations of hyperactive behavior in boys.
Unfortunately, the perception of a child with ADHD – boys who are hyperactive, impulsive, fidgeting, blurting out answers in the classroom, and constantly talking – has changed little over the past several decades. Results from large population-based studies suggest the inattentive subtype of ADHD may be the most prevalent type, however, it continues to be underdiagnosed.
Children with the inattentive subtype of ADHD fly under the radar at school and at home with symptoms of inattention, forgetfulness, and disorganization which are difficult to identify correctly as ADHD and can often be confused with other behavioral problems. Teacher and parent education is key to learning how to work with our children’s ADHD brains and will aid in earlier diagnosis of the inattentive subtype.
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“My brain is an overstuffed garbage can the lid doesn’t stay on and stuff is falling out all over the floor.” This is how my son describes what it is like to have ADHD. When my son was diagnosed, I thought I understood ADHD-it was diagnosed mostly in boys who were hyperactive, impulsive, fidgeting, blurting out answers in the classroom, and constantly talking. My son, who is diagnosed with the inattentive subtype of ADHD, has none of these behaviors.
Initially, ADHD was defined based on observations of hyperactive behavior in boys. Unfortunately, the perception of a child with ADHD has changed little over the past several decades. In their 2011 book Driven to Distraction noted psychiatrists Edward Hallowell and John Ratey describe the common view of ADHD as “stereotypical images of hyperactive little boys disrupting classrooms and turning life at home into chaos.” Boys are three times more likely to be diagnosed with ADHD due to the presence of hyperactive and impulsive behaviors compared to girls who predominantly display symptoms of inattention. However, there is more to ADHD than just hyperactive little boys.
Results from large population-based studies, a useful indicator of the prevalence of ADHD in the community, suggest the inattentive subtype of ADHD may be the most prevalent type. In children and adolescents evaluated based on parent and teacher questionnaires, and who met the Diagnostic and Statistical Manuel of Mental Disorders fourth edition (DSM IV, American Psychiatric Association, Fourth Edition, 1994) diagnostic criteria for ADHD, inattentive-type ADHD occurred at rates double those of the combined subtype. In addition, boys were twice as likely to be diagnosed with inattentive-type ADHD compared to girls. Willcutt (2012) reported the prevalence of the inattentive subtype of ADHD increases from 23% of preschool children with ADHD to 72% of adolescents with ADHD and remains the primary subtype in adults. In contrast, the prevalence of the combined subtype of ADHD declines in adolescents and adults. Thus, it is important to realize that students diagnosed with ADHD in elementary school who are hyperactive /impulsive will still have ADHD in high school, but it will present as the inattentive subtype.
Easily recognizable is the combined subtype of ADHD, where the child’s behaviors are disruptive and affect others. In contrast, children with the inattentive subtype of ADHD fly under the radar at school and at home with symptoms of inattention, forgetfulness, and disorganization. Knowledge of ADHD, including symptoms, behaviors, prognosis and treatment, varies across teachers (Mohr-Jennsen et al., 2019). Educators are most knowledgeable about the “hallmark” symptoms of ADHD like students fidgeting or squirming in their seat and being easily distracted by extraneous stimuli (Scuitto et al., 2016). However, a lack of focus in children with the inattentive subtype of ADHD may be due to boredom and under stimulation rather than inhibitory control (Diamond, 2005). Teachers with a greater understanding of ADHD recognize the benefit of behavioral and educational treatments and are more likely to help their students (Ohan et al., 2008). Thus, teacher education is important for understanding ADHD (Mohr-Jennsen et al., 2019), leading educators to play a critical role in identifying children with the inattentive subtype of ADHD.
According to the Centers for Disease Control 2017 report, 9 out of 10 children with ADHD received classroom accommodations in school. However, most children with ADHD are not in special education programs and their teachers may know little about ADHD behaviors. Dr. Michael Jellineck, Professor of Psychiatry and Pediatrics at Harvard Medical School has estimated children with ADHD could receive as many as 20,000 corrections for their behavior in school by the time they are 10 years old. Symptom like disorganization, forgetfulness, time-blindness, and behaviors like disappearing to the bathroom or nurse’s office during class to avoid a disliked task are difficult to identify correctly as the inattentive subtype of ADHD and can often be confused with other behavioral problems. My son has been pigeonholed by educators, coaches, and others as lazy, apathetic, and unintelligent because they didn’t understand his inattentive ADHD symptoms.
In the DSM V (American Psychiatric Association, Fifth Edition, 2013) the diagnostic criteria for ADHD were modified to identify the inattentive subtype with more accuracy. However, diagnosis of the inattentive subtype continues to be delayed until adolescence, or adulthood. My son was fortunate to be diagnosed in the third grade, at age 8. When he was in second grade my son’s teacher voiced her concern to me over some of his behaviors in the classroom (not completing work or disappearing from the classroom for extended periods of time). This teacher recognized my son’s, then undiagnosed, ADHD based on her experience with her own son who was diagnosed with inattentive-type ADHD. This led to my son receiving beneficial treatment and accommodations early on in school. Teachers who understood my son just didn’t need to work faster or try harder put him on the path to success, like his Algebra I teacher who gave him extra time on tests (this accommodation was not part of his 504 Plan at the time), knowing the limited class time made him feel anxious and overwhelmed; he continues to use this accommodation in college. Teacher education beyond the stereotypical symptoms of ADHD (e.g., hyperactivity, impulsivity, fidgeting) will aid in earlier diagnosis, and treatment for the inattentive subtype.
One challenge is the limited resources available for educators and parents on inattentive-type ADHD. There are essentially two categories of ADHD books, those discussing the combined subtype in boys, and those discussing the inattentive subtype in girls. As a parent, realizing the current literature falls short of discussing inattentive-type ADHD in boys, my son and I felt it was important to share our journey with his ADHD in our book Andrew’s Awesome Adventures with His ADHD Brain: Helping Children and Parents to Understand Inattentive-type ADHD (MSI Press, LLC, 2022). According to a Consumer Reports parent survey (2009) half of parents with ADHD children do not have a clear understanding of their child’s strengths and weaknesses, nor do they have a plan for managing their child’s behavioral problems. This statistic is even more troubling given the difficulty in diagnosing inattentive-type ADHD and the lack of resources for parents and educators.
ADHD is not a choice; our children do not want to be unfocused, forgetful, disorganized, socially awkward, or emotional. Often, children with ADHD are singled out for what they cannot do instead of for their extraordinary abilities. Independence, risk-taking, high energy, curiosity, humor, artistic, emotional, and argumentative are all traits identified in creative individuals, entrepreneurs and in children with the inattentive subtype of ADHD. Understanding and developing their strengths will go a long way towards building their self-confidence and success. For my son it was nurturing his passion for learning about anything related to space technology and space travel. His hyperfocus (the intense focus common in ADHD individuals) led him to become a national finalist in a NASA-sponsored contest, and to the small aerospace and aviation university where he is thriving as a freshman.
Teacher and parent education is key to learning how to work with our children’s ADHD brains and realizing that ADHD does not have to limit our children, but instead they can have limitless possibilities.
References
Albert, M., Rui, P., & Ashman, J.J. (2017). Physician office visits for attention-deficit/hyperactivity disorder in children and adolescents Aged 4–17 Years: United States, 2012–2013. National Center for Health Statistics. www.cdc.gov/nchs/products/ databriefs/db269.htm.
Consumer Reports Health News (2009, October 5). Managing a diagnosis of ADHDwww.consumerreports.org/media-room/press-releases/2009/10/consumer-reports-health-news-october-2009/.
Diamond, A. (2005). Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity). Developmental Psychopathology 17(3): 807–825.
Hallowell, E.M., & Ratey, J.J. (2011) Driven to distraction: Recognizing and coping with attention deficit disorder (Rev. ed.). Prescott, AZ: Anchor.
Jellineck, M.S. (2010, May 1) Don’t let ADHD crush children’s self-esteem.Clinical Psychiatry News. www.mdedge.com/psychiatry/article/23971/pediatrics/dont-let-adhd-crush-childrens-self-esteem.
Mohr-Jensen, C., Steen-Jensen, T., Bang Schnack, M., &Thingvad, H. (2019). What do primary and secondary school teachers kno about ADHD in children? Findings from a systematic review and a representative, nationwide sample of Danish teachers. Journal of Attention Disorders 23(3): 206-219.
Ohan, J. L., Cormier, N., Hepp, S. L., Visser, T. A. W., & Strain, M. C. (2008). Does knowledge about attention-deficit/hyperactivity disorder impact teachers’ reported behaviors and perceptions? School Psychology Quarterly, 23(3), 436–449.
Sciutto, M.J., Terjesen, M.D., Ku?erová, A., Michalová, Z., Schmiedeler, S., Antonopoulou, K., Shaker, N.Z., Lee, J., Lee, K., Drake, B., & Rossouw, J. (2016). Cross-national comparisons of teachers’ knowledge and misconceptions of ADHD. International Perspectives in Psychology 5(1): 34-50.
Willcutt, E.G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics 9: 490-499.
About the Author
Kristin Wilcox, author of the award-winning book “Andrew’s Awesome Adventures with His ADHD Brain”, has a Ph.D. in Pharmacology and over 20 years in academia as a behavioral pharmacologist studying drug abuse behavior and ADHD medications at Emory University and Johns Hopkins University School of Medicine. She has authored several manuscripts published in peer reviewed scientific journals and presented her research at international scientific meetings. Dr. Wilcox serves on the executive board of the Inattentive ADHD Coalition to increase awareness and understanding of the inattentive subtype of ADHD in children and adults. She lives in Maryland with her husband and two sons, one with inattentive-type ADHD.
