The Quiet Side of ADHD: How Inattentive Symptoms Get Missed

Is it ADHD, or just a normal part of being a kid, a busy adult or a stressed student? The line isn't always obvious. For ADHD Awareness Month, Shiby Abraham, M.D., FAPA, a board-certified child and adolescent psychiatrist, psychiatry residency program director and director of medical education at Catholic Health's St. Catherine of Siena Hospital in Smithtown, New York, spoke with The Educated Patient about common misconceptions surrounding attention-deficit/hyperactivity disorder (ADHD) and why the inattentive presentation is so often missed. This is the first of a two-part interview.

What's the biggest misconception you see about what counts as "real" ADHD versus everyday distraction?

Shiby Abraham, M.D., FAPA: One of the biggest misconceptions is that every child who is hyperactive, especially boys or younger children, automatically has ADHD because they can’t sit still or focus. This may not always be the case. We have to look at the child’s developmental level and what is appropriate for their age. Children can naturally be energetic [and] active and have difficulty sitting still depending on their age and stage of development. That is different from ADHD, where the symptoms are persistent and are interfering with the child’s functioning at school, at home or in other areas of their life. So sometimes we can be too quick to say that a child has ADHD when it may be a normal behavior pattern for their developmental stage. An ADHD evaluation should also look at other possible explanations rather than assuming that the behavior is automatically ADHD.

Another thing to look out for is anxiety. Anxiety can sometimes look like ADHD because a child may have difficulty concentrating, seem restless, or have trouble focusing because they are worried or overwhelmed. Anxiety can also occur at the same time as ADHD, so it is important to look at both instead of assuming one diagnosis explains everything.

The same idea applies to bipolar disorder, especially when looking at adults. There can be some overlap between ADHD and bipolar disorder, such as distractibility, impulsivity, increased activity and racing thoughts. However, bipolar disorder is generally more episodic, while ADHD symptoms tend to be more chronic and long-standing. This is why looking at the person’s history and the pattern of symptoms over time is important. Someone with bipolar disorder could potentially be misdiagnosed with ADHD if the broader mood symptoms and history are not recognized. ADHD and bipolar disorder can also occur together, so it is not always one or the other.

If a person had no significant academic or attention problems during childhood, high school or college and then develops new difficulties with focus or concentration in adulthood, it is important to consider other possible explanations rather than assuming ADHD. These may include mood disorders such as depression, anxiety disorders, sleep problems, substance or medication effects, and medical conditions that can affect cognition or attention. ADHD symptoms are expected to have been present during childhood, even if the condition was not formally diagnosed until adulthood.

At the same time, ADHD can also be underdiagnosed. Sometimes people are simply described as being multitaskers, easily distracted, forgetful or unable to concentrate, and it can be brushed off as everyday behavior. Stress and anxiety can certainly make anyone distracted or affect their concentration. However, if the difficulty with attention and concentration has been chronic, has been present over a long period of time, and is interfering with functioning at school, work, or in relationships, then it may be worth evaluating for ADHD rather than simply assuming it is normal everyday distraction

Why does the inattentive presentation of ADHD get missed or diagnosed later, especially in girls and adults?

SA: Inattentive presentation of ADHD without the hyperactive component is often missed or diagnosed later because these children may not create the same type of disruption in the classroom. Hyperactive or impulsive ADHD tends to be more noticeable because the child may disrupt the classroom or have behavioral difficulties and therefore gets more attention. The child with inattentive symptoms, on the other hand, may be seen as “daydreaming,” “lazy” or simply not trying, when in reality they may have ADHD and have a genuine difficulty sustaining attention and staying focused.

This can be especially important in girls, as girls are more likely to present with predominantly inattentive symptoms and may be less likely to show the disruptive or hyperactive behaviors that bring attention to ADHD. As a result, their symptoms may be missed or brushed off as simply “daydreaming” or being quiet.

Hence, if a child's grades are low, it is important to clarify with the child, parents and teachers why the grades are low. Is it because the child cannot sustain attention and is easily distracted because of ADHD? Is the child bored because they are academically advanced and therefore need a more challenging environment rather than an ADHD diagnosis? Is there a learning disability that is making it difficult for the child to understand or grasp the academic material? Or could there be another emotional, environmental, or medical factor contributing to the difficulty?

Similar questions apply in college and in the workplace. In general, the quieter child without obvious hyperactivity may be missed and labeled, when they may have significant academic potential but are struggling because of untreated ADHD. With the correct diagnosis and appropriate treatment and accommodations when indicated, they may be able to function much closer to their actual potential. This can include accommodations such as additional time or a quieter testing environment when clinically and educationally appropriate.

When ADHD is missed earlier in life, the difficulties can become more apparent as academic and occupational demands increase. A child who was able to compensate in elementary or high school may struggle much more in college, where there is less external structure and greater demands for independent organization and sustained attention. Similarly, difficulties with attention, organization, and executive functioning can affect occupational functioning in adulthood and, in some cases, contribute to problems maintaining employment.

In addition, ADHD symptoms can change over time. Someone who was initially diagnosed with ADHD, combined presentation, may have fewer hyperactive or impulsive symptoms as they get older, while inattentive symptoms can persist and continue to affect academic, social or occupational functioning.