At its core, inattentive ADHD is a developmental impairment of executive functioning and self-regulation, explains Thomas E. Brown, Ph.D. A foremost expert in the field, Brown clarifies that kids with inattentive ADHD can–and do—pay attention when they’re motivated. They’re only motivated, however, by particular tasks that excite or interest them (a favorite sport, an engaging game, etc.) or when they feel “under the gun” or fearful of negative consequences (“If I don’t turn in my paper by Thursday, I’ll lose my scholarship”).
To the untrained eye, inattentive ADHD can look like a willpower problem. But the answer isn’t to demand that these kids just try harder; it’s to understand that the tasks they struggle to complete—the ones that cause them to procrastinate, make careless mistakes, shut down, or become excessively anxious—implicate a broad spectrum of executive functions that are weak and lagging in kids with ADHD.
Many parents, teachers, pediatricians and psychiatrists miss a diagnosis of inattentive ADHD because they’re looking for the wrong symptoms.
They’re focused on kids who cannot pay attention to anything, instead of kids with poor executive functioning skills who can focus intently on certain things but not at all on others.
Missed Clues
Inattentive ADHD may also be missed because smart, creative kids are able to compensate for their weaknesses. As demands increase, however, the nature of the work and the host of administrative functions they need to complete overwhelm their poor executive functions.
Whether it’s at school, with homework, or on the job, as kids get older, there are more things they need to do. For example, they need to remember to bring the right things to school (books, binders, pens and pencils, gym clothes, lunch, musical instrument, etc.); to read and understand extensive, complex, and often boring required assignments; and to complete multi-step, long-term projects from start to finish.
As the EF requirements increase, teachers and parents see these kids struggling to keep up, and the kids themselves realize they need additional support. That may prompt an evaluation for kids who previously were able to get by.
Diagnosing Inattentive ADHD
When trying to identify kids with inattentive ADHD, Brown recommends looking for those who “cannot focus on important non-preferred tasks,” especially boring or overly challenging activities (homework, laundry, room cleaning, driving safely, etc.) and those who do especially well under do-or-die circumstances.
Brown emphasizes that many clinicians, including psychiatrists and psychologists, have not had refined training in ADHD. He, therefore, advises parents to seek out specialists in ADHD who are familiar with its various presentations, including what it looks like at different ages, how it manifests itself in daily functioning, and how it is impacted by co-existing conditions such as depression, anxiety, learning disabilities, bi-polar disorder, and substance abuse, which may require unique treatments.
An evaluation for inattentive ADHD takes considerable time and requires enough conversation for a professional to develop a clear, detailed picture of the child.
In addition to intensive interviews, Brown suggests using rating scales from multiple perspectives, including teachers, parents, siblings and, for children over eight years old, their own perception of how they’re doing. Scales focus on the severity of particular behaviors, inquire about difficulties kids encounter in specific contexts, and ask for particular examples (e.g., Do you think you worry more than your peers? Do you struggle to remember what you read for assignments?).
Finally, Brown does not endorse neuropsychological evaluations, which he finds neither necessary nor helpful in assessing ADHD. He maintains that the battery of EF tests administered by a neuropsychologist in an office setting is an inaccurate tool for evaluating various activities of daily living, which is the crux of ADHD.
Even if your child focuses intently on areas of interest, they may still have inattentive ADHD if they persistently exhibit six or more of the following behaviors:
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
Resource: The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5)
This article is based on an ADDitude webinar, Inattentive ADHD: Why ADD is Misdiagnosed and Best Way to Treat it, by Thomas E. Brown, Ph.D., a clinical psychologist, author, and Director of the Brown Clinic for Attention and Related Disorders, and Ryan Kennedy, DNP, a Nurse Practitioner and Associate Director of the Brown Clinic, www.BrownADHDClinic.com. Eve Kessler, Esq., a former criminal appellate attorney, is Executive Director of SPED*NET Wilton (CT), www.spednetwilton.org, and a Contributing Editor of SmartKids.
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