Children who have ADHD present predominantly with symptoms of inattention, hyperactivity, and impulsivity, or a combination of these symptoms. The disorder has had numerous names over the last several decades: minimal brain damage, minimal brain dysfunction, hyperkinetic reaction of childhood, attention- deficit disorder with or without hyperactivity, and, since 1987, attention- deficit/hyperactivity disorder (ADHD).
Symptom lists that are used for the diagnosis of ADHD are split into inattentive and hyperactive- impulsive criteria. If an individual has six or more symptoms from both lists, he or she would be diagnosed with ADHD, combined presentation. If an individual has six or more symptoms in one list but not the other, he or she would be considered to have ADHD, predominantly inattentive or ADHD, predominantly hyperactive- impulsive form.
Symptoms of inattentive ADHD include poor attention to details, difficulty sustaining attention, not seeming to listen when spoken to, failure to finish tasks, disorganization, avoidance of work that requires sustained mental effort, a tendency to lose things, significant distractibility, and forgetfulness. Symptoms of the hyperactive-impulsive form include frequent fidgeting, difficulty remaining seated, running and climbing excessively (or restlessness in adolescents and adults), difficulty playing quietly, frequently being on the go, talking excessively, blurting out answers to questions before the questions are completed, difficulty waiting one’s turn, and interrupting and intruding on others’ activities.
Manifestations of ADHD in the Classroom
ADHD is a commonly occurring mental health disorder affecting many students. Children and adolescents who are hyperactive and impulsive are easy for teachers to identify as having classroom difficulties. They tend to be boys (there is a 3:1 ratio of males to females in this group, compared with the 2:1 or less in the nonhyperactive group), and they may become impatient, frustrated, and disruptive. The symptoms of students who exhibit a combination of hyperactivity, impulsivity, and distractibility are often most pronounced in the classroom where they are required to sit still for extended periods of time, focusing on a specific task. These students are very noticeable to teachers, as they tend to fidget, have difficulty remaining seated, appear to be unfocused, and, at times, may be disruptive. They may act without thinking, and their impulsivity may cause them to make significant errors in their schoolwork and to have significant difficulties with behavioral control. They may have difficulty being quiet in the classroom and may become bored easily.
ADHD may manifest in a student rushing through schoolwork, having difficulty paying attention to details in class, and appearing not to be listening to the teacher. Tasks are often left unfinished, and the student may be very disorganized and forgetful. The student’s desk may appear chaotic and the student may have difficulty finding class assignments. It may be very difficult for students who have ADHD to keep track of assignments that are due, and to pace themselves to study for tests, complete homework, and to allot the time necessary for various schoolwork demands.
Some children who have ADHD, combined type or hyperactive/impulsive type, become less hyperactive as they grow older, but continue to have symptoms of distractibility, poor attention span, disorganization, and other symptoms of inattention. Thus, a high school student who has ADHD may appear to be work avoidant and oppositional to following through on assignments when, in fact, he or she may be having great difficulty attending to the work, organizing written work, and so on.
Another group, the predominantly inattentive students, is easy to miss. While they are not disruptive they often have poor study skills, are inattentive in the classroom, are disorganized, and tend to achieve at a level significantly below their potential. They are often seen as being lazy, lacking motivation to do schoolwork, and simply being poor students. This is especially true for girls and young women, and their peers may describe them as scatter-brained, spaced out, flaky, ditsy, or social butterflies who lack interest in schoolwork, finding it boring. Meanwhile, their underlying difficulties in remaining focused and on task go unrecognized. Their ADHD is frequently not diagnosed, and they, their families, and their teachers are often unaware that they suffer from a treatable disability. Hyperactive and impulsive children and adolescents comprise the majority of those diagnosed by mental health professionals, but the nonhyperactive ones with ADHD may comprise an equally large number of students.
Jenny is a 14-year-old ninth grade student who has been having increasing difficulty mastering her school assignments. She is a bright student and was able to succeed in the past when school demands were less intense. She has been having problems organizing her work assignments in order to finish papers, be prepared for tests, and keep up with school demands. She has become increasingly frustrated, and her school counselor has wondered whether she is depressed. She was seen in psychiatric consultation. Her parents noted that she has never been disruptive or hyperactive, but has a long history of difficulty focusing, distractibility, and disorganization. She was diagnosed with ADHD and responded well to a combination of medication treatment and skills training for study skills and organizational skills.
Although the combined form of ADHD in males (inattentive and hyperactive/impulsive symptoms) is the most common form seen in clinics, the inattentive, nonhyperactive type often seen in females is frequently underidentified. What red flags are present in predominantly inattentive ADHD that educators can be on the lookout for in students who have this problem? Looking back, were there students with whom you have worked who, in retrospect, had evidence of predominantly inattentive ADHD? What would you do differently now, in working with students who have this profile?
William Dikel, MD, is a child and adolescent psychiatrist who consults with educators nationwide, in settings varying from general education classrooms to self-contained special education programs for severely emotionally disturbed students.
This post is an excerpt from William Dikel’s new book, Student Mental Health: A Guide For Teachers, School and District Leaders, School Psychologists and Nurses, Social Workers, Counselors, and Parents (W. W. Norton).