With some 9.4 percent of all children and 4.4 percent of adults in the U.S. diagnosed with attention-deficit hyperactivity disorder, you would think the signs of ADHD would be well known by now. And in many cases they are: Fidgety, squirmy, noisy, and rambunctious kids who have a hard time waiting for their turn; adults that can’t sit still through work and seem to jump first, think later. The reality: This is but a sliver of the disorder. A huge swatch of kids and adults who suffer from inattentive ADHD break the stereotype. Quiet, spacey, and withdrawn are ways to describe these folks. The symptoms differ, but they suffer from the same genetic psychiatric disorder — and similarly need the attention their rambunctious brethren are receiving.
ADHD with predominantly inattentive presentation, as it is officially called is marked by trouble focusing, forgetfulness, disorganization, and what may come across as being disinterest. Inattentive presentation is much more common in females than males, even though ADHD as a whole is diagnosed at least three times more often in boys than girls.
“It’s the girl who sits in the back of the classroom staring out the window and the teacher thinks she is not interested or not very bright,” says psychiatrist Ned Hallowell, M.D., author of the famous 1994 book Driven to Distraction. “If we ask her what it’s like to be in the classroom, she’ll say ‘fine’ because she’s almost never there [mentally]. She is serene and quiet and has no discipline problems.”
Because the symptoms of inattentive ADHD can be less outwardly apparent — and because they don’t jive with the conventional view of the disorder — kids with this presentation often fly under the radar, especially girls. Their symptoms are either missed altogether, misconstrued as a learning disability or other mental health issue, or brushed off as personality traits the child could control if they just tried harder. Regardless, without the proper diagnosis and intervention, these kids typically struggle through school, and many develop depression and anxiety. Then as adults, they often face financial and relationship problems and fail to reach their full career potential.
This is a tragedy, since most people with ADHD, no matter the presentation, are intelligent, driven, creative, and entirely capable of succeeding in life. They just need a little help to manage their disorder.
“I describe ADHD as having a Ferrari engine for a brain with bicycle brakes — it’s a very powerful brain but difficult to control,” Hallowell says. “But if managed properly, ADHD is a superpower. Most entrepreneurs have it. Nobel Prize and Pulitzer Prize winners have it. Self-made billionaires have it. I have it.”
When not managed properly, however, “ADHD can ruin your life,” Hallowell says. “Our prisons are full of undiagnosed and unmanaged ADHD, as are the halls of addiction and bankruptcy.”
To ensure that ADHD becomes an asset, not a liability, for your child, it’s important to pinpoint it as early as possible. The best thing parents can do, says Hallowell, is educate themselves on the disorder so they know the signs to watch for in their kids—and in themselves, since ADHD is genetic and often goes undiagnosed into adulthood, especially the inattentive presentation.
Three Facets of ADHD
Parents might remember attention-deficit disorder (ADD) being its own condition and wonder why kids who can’t focus but are not hyperactive or impulsive wouldn’t just be classified as that. Although people sometimes still use the term ADD, the American Psychiatric Association actually axed it in 1987, lumping ADD and ADHD together as a single condition: ADHD, with or without the hyperactivity-impulsivity component.
Then in 2013, the APA developed three different “presentations” of ADHD in order to classify people according to their main symptoms: ADHD with predominantly hyperactive-impulsive presentation, ADHD with predominantly inattentive presentation, and ADHD with combined presentation. Combined presentation simply means that a person meets the criteria for both inattentive and hyperactive-impulsive presentations.
“They made this change so that clinicians can say, ‘on this day, these symptoms were more prominent,’” says Russell Barkley, Ph.D., clinical professor of psychiatry at the Virginia Treatment Center for Children at Virginia Commonwealth University. “It’s still the same disorder, and [this distinction] doesn’t signify how ADHD will present over the course of your life. It’s possible to go through all three presentations in your lifetime.”
In fact, most people with ADHD do cycle through them, which is why the hyperactive-impulsive presentation and the combined presentation are much more common than the inattentive presentation. That said, among those who only ever show the inattentive presentation, the vast majority are female, many of whom miss out on an ADHD diagnosis altogether so they continue having difficulties in school and life.
When ADHD Symptoms Appear
Another reason why the hyperactive-impulsive presentation and combined presentations are more widely diagnosed is because their symptoms typically appear earlier in life. Hyperactivity frequently emerges during the preschool years, although mainly in boys. “Not many girls get the hyperactivity component,” says Hallowell. Hyperactivity, then, commonly declines with age, sometimes becoming milder, sometimes going away completely.
“Inattentive symptoms usually take a few more years to emerge and become impairing,” Barkley says. “When inattention does come to the fore, [those who were or still are hyperactive] move into combined presentation. Then when they get older, they may move into inattentive presentation.” That said, if a person is ever labeled with combined presentation, Barkley says that remains their official diagnosis for life.
For most kids, the inattentive symptoms usually appear around first grade. “Look for unexplained underachievement—a child not doing as well in school as their brainpower would have you expect,” Hallowell says. Yet it’s possible the signs won’t surface—or be noticeable enough for parents and teachers to catch—until middle school, high school or even later. “It can appear whenever the organizational demands of life exceed your ability to compensate,” Hallowell explains. “Sometimes that’s the first year of medical school, or when you have your first child and suddenly have way too much on your plate.”
But when kids are still kids, Hallowell says ADHD with inattentive presentation gets missed all the time, particularly in girls. “If the girl is diagnosed with anything, it is often that she is not very motivated or even not very smart,” he says. “She may be considered ‘sweet but stupid,’ which is just so unfortunate. It’s like she is nearsighted and never get eyeglasses. But once she does, she absolutely can thrive.”
Kids and adults with undiagnosed inattentive presentation may also be diagnosed with depression or anxiety. These determinations may be totally accurate, by the way—they just don’t capture the whole picture. “People with inattentive presentation are often are anxious because they’re always wondering how they will screw up next,” Hallowell says. “They become depressed because they are frustrated because they know they could be doing better.”
Diagnosing and Managing Inattentive ADHD
If you or your child’s teacher suspects they have ADHD with predominantly inattentive presentation (or any presentation), the first step is to share your concerns with their pediatrician or family medicine doctor. They can assess for ADHD, or they may refer you to a psychologist or psychiatrist. Practitioners might also might gather additional reports on the child’s symptoms from teachers and other caregivers to get a better picture of their behavior and help rule out other potential causes.
Doctors then use the APA’s rating scale, which lists nine symptoms of inattention and nine for hyperactivity-impulsivity, to screen for ADHD. To qualify for either presentation, the child must display six or more symptoms in the respective category (five anyone age 17 and up) for at least the last six months.
If a diagnosis is made, Hallowell says it’s important to talk to the child about it in the right way. “The critical first step is to take it out of deficit-disorder model,” he says. “I’ll say to a little girl, ‘you’re very lucky; you have an amazing brain. You are so creative and have such a vivid imagination and lots of new ideas. You just have trouble organizing them and handing your papers in on time, and you nod off when the teacher gets boring. This is a marker of talent, so we need you to unwrap your gift.’ Reframing it in that way makes a big difference.”
As for interventions, the American Academy of Pediatrics cautions against prescribing ADHD medications to children age six or younger. But for older kids and adults, several drugs have been shown to be effective, both stimulants such as Ritalin and nonstimulants like Straterra. Meds may not the right fit for your kid—that’s something you’ll discuss with the doctor.
Drugs aside, though, Hallowell says behavioral interventions that coach the child on organizational skills and helpful habits are a must. Depending on their age and specific needs, these may include regular visits with a therapist, either one-on-one or in a group setting; professional assistance at school; or parental guidance. “Sometimes coaching is a brief intervention, but some people may need it repeatedly throughout their lives,” Hallowell says. “Parents can do a lot to help young children stay organized, but as they grow older and no longer want Mom or Dad hovering over them, outside help can be especially beneficial.”
Physical exercise is also very helpful for kids with ADHD with inattentive presentation. “Especially specialized exercises that stimulate the cerebellum—anything that requires balance and coordination, such as skateboarding, skiing, surfing, or even just standing on a wobble board,” Hallowell says. “Nutritionally, these kids should stay away from sugar, additives, and junk food and take omega-3 fatty acids, such as fish oil, and vitamin D.”
If there’s a chance that your kid (or you, for that matter) may have this oft-overlooked presentation of ADHD, don’t wait any longer to see a doc. People with this disorder have a ton of potential that it would be a shame to squash.