Attention Magazine October 2022

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If you are a teacher, you likely have one or more students in your classroom who have the inattentive presentation of ADHD. By identifying these children and initiating help for them, you may change the course of their lives. You are well positioned for this detective work, because you see children in a structured environment where their impairments are more apparent. You are trained in normal child development and know what behaviors aren’t age-appropriate. You can spot behaviors that are outside the norm. This questionnaire—plus good information on ADHD—will help you find these children in your classroom and bring your concerns to their parents.

People often form opinions that are not based on facts. This article draws on research that might challenge opinions you have about ADHD, its causes, manifestations, and treatments. You may learn something that differs from what you have heard or believe about ADHD.

What is ADHD, and why be concerned?
ADHD is a chronic neurodevelopmental condition that is largely genetic in nature. Although each child’s brain is as unique as their fingerprints, children with ADHD have small variations in their brain chemistry and structure that differ from the neurotypical children in your classroom. Most children who have ADHD are born with it and will continue to have it throughout their lives. It does not result from poor parenting, although environmental factors can lessen or exacerbate its symptoms.

There are three presentations of ADHD: hyperactive-impulsive, combined, and inattentive. With the combined presentation, a child is hyperactive, impulsive, and distractible. Children with the hyperactive-impulsive and combined presentations are typically diagnosed by age seven, as disruptive children are noticed and get help.

Children with the inattentive presentation are usually not paying attention in class, but not causing a disturbance. They may be perceived as dreamy, introverted, and shy, but do not necessarily have any of those characteristics. If the child is committed to being a good student, he or she may never come to your attention.

If the child is quiet and gets good grades, is ADHD still a problem? Why be concerned if children with the inattentive presentation of ADHD have been, and continue to be, underdiagnosed?

Our best answers to these questions can be found when we listen to the stories of adults who were diagnosed at age 24, 45, 65, or even 85. Many tell us that they paid a price for the lack of understanding and treatment for their struggles. We know from research that looks at ADHD (including all types of ADHD, not just the predominantly inattentive presentation) that a substantial percentage of those diagnosed late in life will have adverse consequences.

They often say they experienced more failure than their peers. Fewer of them graduate from college, and if they do, it often took additional years. They have less successful professional lives and earned significantly less income. More of them have failed relationships. Their low self-esteem leads them to pair with anyone willing to be with them or their procrastination, forgetfulness, and tardiness drives their partners and friends away.

Although each child’s brain is as unique  as their fingerprints, children with ADHD have small variations in their brain chemistry and structure that differ from the neurotypical children in your classroom.

Studies show that undiagnosed ADHD is associated with poor health outcomes, including obesity, accidental injuries of all types, substance use, and comorbid psychiatric disorders. ADHD increases the risk of exposure to traumatic events and victimization and suicide attempts and completions. Their lifespan, on average, is twelve years less than those without ADHD. Early diagnosis and treatment of ADHD mitigates these dire outcomes.

What to look for
A student with the inattentive presentation of ADHD tends to be:

• easily pulled off course, forgetful, and inattentive
• disorganized mentally and physically, making careless mistakes, and not paying close attention to detail
• forgetful of one or more items when an assignment requires multiple items
• resistant to undertake tasks that are boring or require significant mental energy

They may have:

• difficulty organizing their work, setting priorities, planning out a strategy, and remembering to complete all required tasks
• difficulty organizing their things and are often sloppy
• trouble keeping track of their belongings and forgetting where they put them, in part because they rarely put things awa
• trouble holding multiple things in mind, which can make arithmetic calculation, reading, or abstract problem solving difficult

Think about how a person’s life is affected by these behaviors, which occur all day, every day, whether they are a child or an adult. How might these behaviors reduce their opportunities for success? Undiagnosed, they grow up with frequent criticism from parents and others who don’t understand their behaviors and get frustrated or angry. Here are some examples of what they may hear:

• “I’ve told you X times already. How do you not remember? It’s like you don’t care.”
• “You’re just being lazy. You need to do better. You aren’t trying!”
• “You never listen to me. You should have planned this out better.”
• “You lost XYZ again? Why can’t you just remember where you put it?”
• Anything that starts with “You should’ve…” or “If you had…” or “Why don’t you….”

Meanwhile, the belittling comments or the rolled eyes of coworkers, friends, and family members continue. The child or adult feels different without understanding why or how. Her self-esteem and self-confidence continue to suffer and often metastasize into the comorbid conditions of depression and anxiety.  Whatever dreams she had for her life slowly erode as, time after time, she underperforms.

Some individuals, however, go in the other direction and accept nothing less than perfection. They expend significant energy masking their deficits. They believe being perfect is the only way to be accepted. They exhaust themselves, struggling to keep their personal challenges and failures hidden from the world.

They make a good impression but lose touch with themselves and feel like a fraud. No one can see or know who they really are. Successful undiagnosed adults suffer from their striving, expending twice the effort to obtain a similar result. Their low self-esteem makes them believe they are worth less than others. Here are some quotes from adults diagnosed late in life:

“I have a very high IQ that was tested when I was in school, and I can compensate, but, as a consequence, I am burnt out, exhausted, tense and snappish. It’s like being a sprinter with a piano tied to my back who still competes in the race. Sure, I can do it, but I’m wrecked after I get to the finish line in a way that the other participants aren’t.”

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“I sometimes wonder how much faster I would be without the weights holding me down. I do my best not to think that way, but it is difficult not to wonder sometimes.”

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“I am at the point where I am trying not to be angry at how unfair it is that I have to have the metaphorical piano tied to me. It’s hard. My peers don’t see how hard I have to work to compensate and I hear all the time that everything ‘comes so easily’ to me. Oh, buddy. If you only knew.”

Believing they have abilities they aren’t using, without understanding why, is the tragedy of undiagnosed inattentive ADHD. Getting diagnosed is a relief: “Now I understand and can work to improve my life.” And a sorrow: “Now I understand and am sad my life has been less than it could have been.” Many say that having ADHD isn’t the problem. Not knowing they had ADHD was the problem.

“When I got my diagnosis, I was relieved and angry. Relieved because everything makes sense now, and angry because why not earlier? I was diagnosed at 33. Can you imagine how different my life would have been if I was diagnosed earlier?”

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“Getting diagnosed was like a weight off my shoulders, but I’m also super depressed because of what I could’ve been. I have a lot of trauma from childhood because of my undiagnosed ADHD. I spent years thinking I was lazy and hating myself.”

Like any medical condition, until you understand what you are dealing with, you flounder; but once your condition is known and understood, you can set a course correction.

Treatments for inattentive ADHD
Following a diagnosis of inattentive ADHD, for children in elementary and middle school, the American Academy of Pediatrics recommends FDA-approved medications along with parent training and behavioral classroom interventions. The course correction for adults includes medication and developing new habits and behaviors.

A statement issued in 2013 from the American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association highlighted the following:

“To help families make important decisions about treatment, the National Institute of Mental Health (NIMH) began a large treatment study in 1992 called the Multimodal Treatment Study of Children with ADHD (or the MTA study). Data from this 14-month study showed that stimulant medication is most effective in treating the symptoms of ADHD, as long as the dose is adjusted for each child to give the best response—either alone or in combination with behavioral therapy.

“The MTA study, along with many other large-scale treatment studies that have assessed the safety and effectiveness of ADHD medications, provides evidence that stimulant medication reduces hyperactivity and impulsivity, improves attention, and increases the ability to get along with others. For this reason, stimulant medications remain the medications of first choice for treating individuals with ADHD.”

Professor Philip Asherson of Kings College London says, “When you get the medication correct—the right medication and the right dose—what it’s actually doing is boosting the function of the brain. That’s why the medications are called stimulants. They enhance brain function. It seems that parts of the brain are not functioning as efficiently as they should and the medications enhance the efficiency of the brain. Medications enable those with ADHD to be better at doing things, and they give the child or adult more control and regulation.”

According to renowned ADHD expert Russell Barkley, numerous studies indicate that not only are stimulant medications safe for children, but that they are beneficial (neuroprotective) if started at an early age. Evidence based on more than thirty studies supports the notion that stimulant medications appear to promote brain development and that the ADHD brain may proximate that of neurotypical children with early and continued intake of stimulant medication.

NOW, LET’S GO BACK to those eight statements in the questionnaire that began this article to find out how well you scored. The correct answer to each item is False. Please feel free to share this article and questionnaire with your colleagues.

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Cynthia Hammer, MSW, is executive director of the Inattentive ADHD Coalition, a nonprofit with a mission that children with inattentive ADHD are diagnosed by age eight and adults with inattentive ADHD are readily and correctly diagnosed when they seek help. The website is www.iadhd.org.

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ADDITIONAL READING

The Adverse Health Outcomes, Economic Burden, and Public Health Implications of Unmanaged Attention Deficit Hyperactivity Disorder (ADHD): A Call to Action to Improve the Quality of Life and Life Expectancy of People with ADHD. Proceedings of CHADD’s ADHD Public Health Summit, Washington, DC. October 7, 2019. https://chadd.org/wp-content/uploads/2021/08/CHADD-Health-Outcomes-White-Paper_8-5-21-FINAL.pdf

Adele Diamond, Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit/hyperactivity disorder (with hyperactivity). Development and Psychopathology, Volume 17, Issue 3, September 2005.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1474811/?fbclid=IwAR3Ym7Sx4IPJ1FvY4e9QAs8NlxOFlol6yeOMqzZSnGezDlVVM5pzNmcaiA0

Russell Barkley, PhD. “ADHD and Life Expectancy: Treatment Matters More Than You Might Think,” in Attention, February 2019. https://chadd.org/attention-article/adhd-and-life-expectancy-treatment-matters-more-than-you-might-think/
Read about Dr. Barkley’s presentation at the 2018 Annual International Conference on ADHD (https://chadd.org/treatment-matters-adhd-and-life-expectancy/) and watch a video excerpt of his groundbreaking talk:  https://www.youtube.com/watch?v=HYq571cycqg.