The descriptive phrases infiltrate the slang of our language: “space cadet,” “air head,” “out-of-the-loop,” and “couch potato.” The stereotypes of the “absent-minded professor” who forgets to wear shoes to lectures or the “clueless student” who spends class time staring out the window are comic stock characters in movies, books, and anecdotes. Despite this general cultural familiarity, specific knowledge concerning what was once called “ADD without hyperactivity” has been elusive and limited, but for those people who live with the consequences of the condition, the destructive effects are both concrete and pervasive.
Long considered as merely a subtype of Attention Deficit Hyperactivity Disorder (ADHD), this inattentive version of ADD has gradually gained recognition as a distinctive diagnosis. The most recent edition of the Diagnostic and Statistical Manual (1994) of the American Psychiatric Association distinguishes three categories of Attention-Deficit/ Hyperactivity Disorder: the predominantly hyperactive-impulsive type, the predominantly inattentive type, and the combined type. While each of these groups present different behavioral features, they seem to have very similar tragic effects, such as emotional problems, poor self-awareness and self-esteem, and difficulties with time management and organization. Both groups experience problems performing tasks at school and work.
Ironically, the “low key” nature of inattentiveness may well have made it a more insidious force for personal disaster than the highly visible and dramatic hyperactive variation; these individuals simply attract less notice within classrooms and families. Described as “dismissed and undiagnosed dreamers” by learning disabilities specialist Paula Stanford, inattentive ADDers are usually diagnosed later in life than their hyper counterparts; in fact, many of them may never be diagnosed at all and spend their lives floundering and repeatedly failing to meet expectations.
Inattentive students don’t annoy adults or behave in a volatile manner. They don’t wiggle in their seats and disrupt students sitting around them. Indeed, they may even appear to maintain concentration by staring fixedly at a textbook or a lecturer for periods of time, but this apparent “focus” may mask a wandering mental state. As Stanford notes, “It’s hard to see distractibility.”
People…expect to see a child in the back of the class “bouncing off the wall.” This example child is always talking and can never concentrate on anything put in front of him. This child was never an example of me….I was not hyperactive; I just could not concentrate, memorize or work on something that did not interest me. (Excerpt from an essay by an inattentive ADD adult client of Brainworks.)
The subtle and often ignored behavior patterns of inattentive ADDers include lethargy, slow processing and retrieval of information, and social apathy. They tend to direct negative feelings inwardly rather than outwardly, to become anxious and depressed rather than aggressive and openly defiant. Instead of challenging authority figures in direct confrontations, they may tend to adopt a type of “passive manipulation” which leads to their becoming perpetual victims, repeatedly rescued by family members, friends, and teachers.
During my elementary years, without realizing it, I learned how to manipulate my teachers into letting me turn my homework or other assignments in late…phrases like “Well, I guess, turn it in tomorrow,” were frequent. Even with my ability to manipulate teachers, I still heard, “Why can’t you do this? Why don’t you concentrate? It’s not that hard….You can’t see past the end of your nose.”
Other ADD experts have pointed out that social bias may have an impact on how inattentive disorders are detected and treated. In the first place, our culture and educational systems tend to punish activity and reward passivity. Paula Stanford comments, “If people are quiet and non-assertive, we tend to say they are ‘nice’ people and be proud of them.” The quiet student lost amid daydreams in the middle of the room may not be handing in homework consistently and may be capable of making better test grades than low C’s and D’s, yet this same underachieving student will often receive “excellent” conduct ratings!
However, the most striking feature concerning inattentive ADDers may fall within the realm of “gender issues.” For decades, ADD was defined in terms of being a hyperactivity disorder which primarily affected young males, and referral ratios of boys to girls for the condition have been estimated as being as high as 10 to 1.
In recent years, the definition of the condition and the disproportionate referral ratio have been challenged by numerous researchers. As Dr. Russell Barkley of the University of Massachusetts Medical Center points out in the April 1996 edition of The ADHD Report, the view that boys are more likely to be ADD than girls may be based on “an assumption that the criteria for diagnosing…were developed using some gender-free or gender-neutral procedure which is hardly the case.” In other words, if the descriptive symptoms for ADD were drawn from observations of predominantly male behaviors, then males will tend to be identified more than females as fitting the descriptions. Some researchers believe if inattentive characteristics are included in the diagnostic criteria, the ratio would reflect a 50/50 rather than a 10 to 1 ratio.
ADD expert Kate Kelly observes, “Little girls with ADD tend to be less physically active than ADD boys. They may receive less punishment and disapproval than their male counterparts but often become lost in the shuffle. Their symptoms are so subtle that no one identifies their problems.”
As difficult as it is to identify ADD inattentiveness, developing adequate management and treatment procedures may be even more difficult. With hyperactive individuals, management often involves redirecting restlessness into more productive channels or learning to control obviously overblown behaviors. The problems of “hypers” are clearly identifiable, and their active personalities can serve as “spark plugs” for making change. The energy they expend may be scattered and not consistently maintained over time, but they are generally enthusiastic about trying new methods or making “trial runs” with coping strategies. They often have a fierce desire for independence which serves as a powerful motivator for obtaining jobs or career training in a field of high interest. Many seem to be “natural-born performers” who are attracted to creative pursuits such as art, writing, music, or drama; at some point in their academic careers, they may be enrolled in gifted programs. At times, their fast paced minds and temperaments lead to flashes of brilliance and insight.
Managing the symptoms of inattentive ADDers presents a different set of challenges, often more frustrating and less clearly defined. The essence of inattentive ADD is passivity, so coping strategies must first activate these students to take charge of their lives. Although these individuals will also experience difficulties maintaining effort, their first problem is getting started at all!
In school situations, inattentive ADDers seldom participate in extra curricular activities or join clubs. While they seem to have an easier time making friends than their hyperactive counterparts, these friendships are often grounded in the idea that the inattentive person will “go along” with whatever is proposed by peers. They are “agreeable” by nature, but this same “wishy-washy” attitude can eventually cause peers to lose respect for the inattentive ADDer who won’t “stand up and be counted.” Moreover, the inattentive ADDer often has problems communicating with authority figures, such as teachers and coaches. Because they seem unable to ask questions, participate actively in discussions, or to advocate for themselves, their grades tend to run from mediocre to poor. They drift through the day, moving from classroom to classroom, making very little impression as they travel.
Furthermore, ADD inattentives usually are not motivated by a desire for independence, and they may end up continuing to reside “in the family nest” longer than their peers or non-ADD siblings. This dependency may stem from the inattentive’s inability to aggressively advance themselves in term of jobs and career training; however, their entrenched helplessness may have unwittingly been reinforced by a lifetime of “rescue missions” by well-meaning parents. At an early age, the rescue pattern seems harmless enough: Suzy forgot to take her lunch to school, so Dad leaves work to bring money to her school. Or, Billy didn’t realize his oral report on volcanoes (assigned weeks earlier) is due the next day, so Mom stays up all night looking through the “V” volume of the encyclopedia for information while Billy copies facts on note cards¬– until his hand gets tired and Dad takes over!
This pattern of dependency usually develops slowly over a long period of time, and parents may delude themselves by believing “as soon as my child becomes a teenager, she/he will be more responsible.” During the teen years, the belief switches to “as soon as he/she graduates” or “as soon as she/he gets a good job.” What is difficult to accept is the fact that although the child’s situations may change, the dependency behavior will not change of its own accord. Without specific training in areas such as goal-setting, money management, and communication skills, inattentive ADDers may never learn to function as adults successfully and will end up “bouncing back home” throughout the course of their lives.
In addition, clinical reports indicate that medication therapy for inattentive ADDers may follow different guidelines than those established for hyperactive ADDers. For example, standard doses of stimulant medicines commonly prescribed for hyperactivity may not be as effective for inattentive individuals; sometimes these people respond better to anti-depressant and anti-anxiety medications. Some physicians have reported positive results for inattentive patients from a combination of lower dosages of stimulants and anti-depressants. For many of the ADD inattentive clients attending Brainworks, establishing an effective medication schedule can be a complicated and time-consuming process, one requiring observations, evaluations, and much “fine tuning.”
Inattentive ADDers have long constituted an overlooked segment of our educational system, and while it is true that they attract little notice as they “suffer in silence,” they suffer nonetheless. As parents and educators become more adept at identifying these daydreamers, the challenge becomes to develop effective management techniques which address the distinctive needs and situations of these individuals who are the “lost souls” of our society.
- Barkley, Russell. “Gender is Already Implicit in the Diagnosis of ADHD: Shouldn’t It be Explicit?” The ADHD Report, April 1996.
- Kelly, Kate and Peggy Ramundo. You Mean I’m Not Lazy, Stupid Or Crazy? Cincinnati, Tyrell & Jerem Press, 1993.
- Stanford, Paula. “Dismissed and Undiagnosed Dreamers: Solutions to Female LD/ADD Issues.” Presentation at the 33rd Annual State Conference of the Learning Disabilities Association of Texas, Austin, November, 1997.
Reprint from Brainworks Newsletter, Spring 1998, Vol. 11, No. 2