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Inattentive AD/HD: Overlooked and Undertreated?

Inattentive AD/HD interferes with learning and friendships, yet it often goes undiagnosed. Learn what signs and symptoms to watch for -- and how to get help.

By Mary V. Solanto, Ph.D. and CHADD

When Ethan brought home his first fourth-grade report card, he knew his parents would not be pleased. In addition to grades that ranged between B and D, the teacher had commented, just as his third grade teacher had, "If Ethan would just focus on his work and try harder, he could do so much better!"

Lack of concentration and apparent lack of effort are hallmarks of the Inattentive subtype of AD/HD. The Predominantly Inattentive type (IN) of AD/HD - without hyperactivity or impulsivity - has been known as a disorder since 1994. Unlike children with the more commonly recognized "Combined" (CB - inattentive, hyperactive and impulsive) form of the disorder, children with IN are not behaviorally disruptive and typically are not difficult for parents or teachers to manage. Children with IN may appear to be underactive, sluggish or daydreamers, but their problems with attention are just as severe as those with CB-type AD/HD. Instead of working on their math problems, they might be gazing into space. When the teacher calls on them, they may have no idea of what is being discussed. Since they don't absorb new information well or produce the same caliber of work as their classmates, children with IN may be mislabeled as "slow learners" or "learning disabled"- often on the basis of group-administered tests where they had difficulty concentrating. They often just quietly underachieve with no one fully aware of their true potential.

In addition to their academic difficulties, children with IN often have very significant social problems. Their classmates see them as "tuned-out," or not "with it," and they are more likely to be ignored and friendless.

One recent study suggests that the social problems of children with the IN and CB subtypes of AD/HD may have different causes and different results. (Maedgen & Carlson, 2000). Children with the CB type tend to annoy others with their provocative, intrusive and sometimes aggressive behavior. As a result, these children are more likely to be socially rejected. When asked directly, however, these children with CB are able to state clearly and accurately how they should and should not behave with other children. In the heat of the moment, however, they are unable to exercise the behavioral self-control to follow through. Children with IN, however, were more likely to lack the knowledge of social skills. This may include knowing how to handle such everyday social interactions such as joining a group of children already at play, resolving a dispute or initiating a friendship. In part, these difficulties may be due to a failure to pay attention to the social nuances - the nonverbal cues or "body language" - which are an important part of social communication.

A Prevalent and Impairing Condition

Survey studies suggest that the IN form of AD/HD may be at least as common in schools as the better-known CB type. In these large-scale studies, hundreds of teachers were each asked to rate all the children in their classes on a checklist of behaviors reflecting the three core symptoms of AD/HD: inattention, hyperactivity and impulsivity.

The survey data also showed an interesting distribution between the sexes. Whereas the CB type is about four times more common among boys than girls, the IN type is more evenly distributed between the sexes with a boy:girl ratio closer to 2:1. In fact, if a girl has AD/HD, she is more likely to have the IN type. (Wolraich, Hannah, Pinnock, Baumgaertel, & Brown, 1996).

In the survey studies, teachers were also asked to rate how "impaired" students were in the three most important areas of functioning in school: academic, social and behavioral. The percentages of children rated by teachers as being "impaired" are shown below for the three currently recognized subtypes of AD/HD: IN, CB, and Predominantly Hyperactive-Impulsive (HI).

Percent of children rated by teachers as being "impaired"
Academic 76% 82% 23%
Social 59% 82% 53%
Behavioral 58% 90% 80%


These findings showed that a high percentage of children with IN were suffering academic difficulties - in fact, the percentage almost equaled that for the CB type. Sizeable percentages also had behavioral and social difficulties.

Despite the serious difficulties that children with IN experience, relatively few are identified or referred for treatment. Children with IN also account for up to 25 percent of all children with AD/HD who are seen at mental health centers. One likely reason is that since they are quieter and far less disruptive than children with CB, they are less likely to create headaches for teachers or parents, and therefore more likely to be overlooked.

Another important finding emerging from the survey studies was that the IN type of AD/HD may have a later age of onset than the other types. Although all subtypes must have an onset by age seven in order to meet current DSM-IV criteria for AD/HD, these more recent studies suggest that many cases of IN type may not actually become apparent until age nine, and that impairment may not be significant until age 11. (Applegate et al., 1997).

Copyright © 2002 CHADD. All Rights Reserved. For more information visit CHADD

Comments from readers

"I am 19 years old and i was diagnosed with severe ADHD-IN when i was 14. My parents however, did not tell me this until i was graduating from high school in a very academically rigorous program with really good grades. I feel that if given the right motivation anyone can overcome their disorder and get their stuff done. My motivation was that my parents spent time and money on me and my education, time and money that they did not have, and i knew that i would be extremely unhappy and guilty if i they did all that for nothing. So when it came down to it i did what needed to be done and bucked up. I feel as if america today is becoming a coward nation with more and more people pushing off responsibility on something else when really like in the case of ADHD you need to roll up your sleeves take the reigns and get your shit straight. Yes it will be hard but i've seen many of my friends become drones and change drastically to become something not nearly as beautiful as they were! before. I think that America needs to pony up and stop using the excuses for every damn inconvenient thing that makes it hard for them to work. I can just as easily do the harder calculus problems as any other person and focusing on it might be more difficult in nature but that's just the way it is."
"I'm a 17 year old girl and believe I have inattentive ADHD. I've always gotten grades ranging from A to F (but mostly around D or F, depending on my level of interest in the subject), and my teachers have always commented on my my lack of attention or commitment. It feels awful because I try, with no affect. I simply can't help but 'daydream' or forget my homework. I'm also a procrastinator..something about thinking about one particular thing for a long time makes me dread it, like homework. Another thing is that I'm somewhat socially impaired.. I've always felt behind my classmates on that front, and I've always been lonely. Upon discovering that this type of ADHD exists, I feel wronged because no one in my life has ever recognized it in me (I understand however that it's hard to recognize because we're better behaved than hyperactive kids thus less conspicuous); instead I've gotten negative feedback all my life for things I can't help. I don't want to take medication becau! se I actually like the way I think. I just don't like the consequences of it."
"Hello everyone! My son was diagnosed with adhd when he was 5 1/2 years old. His kindergarten teacher gently suggested some testing, but I had always had a 'feeling', if that makes any sense. His father and I were very adament that he NOT be on medication (his father was put on it as a child and had bad side affects) so we tried different techniques and behavior charts ... with no success. My swwet little boy was turning into someone that I didn't know. He was moody and mean and very depressed. I finally decided to just TRY the medication and if we didn't like it, to stop. Well, I have to tell you.... we saw a dramatic difference within about 2 hours after he took it! He wasn't moody or agressive anymore and was just... happy. He's now 7 years old and after trying a few different dosages we have settled on the ADHD patch. It was too difficult for him to swallow pills and the patch has had less side affects on him. I have to say, I NEVER though that I would be one of 'those' ! parents who 'medicates' their child... but you know what, my son is happy, he is making friends, he is self confidant... and that's all I've ever wanted for him. I hope this helps some of you out. You are NOT alone. We are all bonded by our love for our children and our drive to help the succeed. God bless."
"Thank God I saw this article!!! AFTER YEARS OF MY SON'S TEACHERS TELLING ME HE WASN'T PAYING ATTENTION IN CLASS AND HIM GETTING IN TROUBLE AT HOME FOR EITHER COMPLETELY FORGETTING WHAT I TOLD HIM, OR HAD SHOWN HIM JUST SECONDS BEFORE. After 11 years of this ( I have raised him alone since 2yrs old), I am finally resigned to start him on medication. My regret is that I didn't start him sooner. He has had problems making friends and good grades, and I don't want him to end up uneducated and alone. I Pray that I am doing the right thing. Is there anyone out there that knows what happens on the'other side' of the medication? I feel so alone. I know my son does too."
"In elementary school and throughout middle school I was given the comments on my report card as being inattentive. Otherwise, my behaviour was fine and I did get along well with others. Even though I always had the comments from teachers as being inattentive nothing was ever done about it. I wasn't concerned because, the word inattentive did not sound like a bad word. Maybe, they should say this child does not pay attention as opposed to this child is inattentive. "
"So what is or some of the suggested treatment of Inattentive AD/HD? What are my options? Thanks for any help."
"Excellent information. Thank you for sharing this information."
"Thank you for such a great article. Paticularly you touched on the area of social interaction problem, which is sometimes not mentioned in IN AD articles. My son is having difficulties making friends and your article FINALLY gave me some understanding as to why this is happening. I've observed my son silently sitting on the sidelines while other kids play in a group. He might possibly be interpeting it as children not wanting to play with him, when really it's him not knowing how to join in. "
"Do you have any sugestions for me I have a boy in 6 grade.That can't remenber anything forgets homework or don't finsh it. I have a daughter that is in 4 grade and is failing and can't seem to stay focus and finsh her work and is very spacie. I do NOT want tham to take Meds. They all have bad side affectes and I am not willing to take that chance. Thank you Tammy"