Many with ADHD Are Not Hyper

For decades the primary marker used to identify individuals with ADHD impairments was hyperactivity. Children who were very obviously hyperactive were considered candidates for evaluation for ADHD, especially if they were being disruptive or making trouble for their teachers. ADHD diagnosis was not even considered for those who were not hyperactive and not disruptive in school. An elementary-school janitor described this as he came seeking evaluation for his ten-year-old daughter:

I could always spot the kids with the hyper. They were the ones always sent out to sit in the hall because they were making too much trouble in class. Some of them were actually pretty funny in their antics. Usually these were the same kids who would be running down the hall with the teacher calling after them to slow down and walk quietly. They were the ones on the playground who were always getting into arguments and fights with other kids or the last ones to come back in after lunch or recess.

It was never the kids who kept the rules who got picked as having ADD and it was never the quiet kids or the girls. That's why I never thought ADD could be my daughter's problem. She's always been kind of quiet and a little shy. Never made any trouble in class. Teachers have always liked her and said she was really bright. She loves to read and to learn. She's got insatiable curiosity and lots of good ideas, but she's not getting her work done and her grades have been dropping more every year. She's losing interest in school.

Many clinicians and educators still identify ADHD as the janitor described. As a result, many with ADHD, especially girls, are overlooked. Joseph Biederman (2002) studied the role of gender in diagnosis of ADHD. He found that although girls and boys with ADHD have similar patterns of severity with the problem, ten boys are referred to clinics for treatment of ADHD for every one girl referred. Community samples show a different gender ratio: three boys have ADHD for every one girl who has the disorder.

In contrast, during adulthood the rates of referral for ADHD are more balanced between women and men. Biederman (2004) suggested a reason: adults usually self-refer for ADHD evaluation because of problems they recognize in themselves, whereas children and adolescents are usually referred for evaluation by parents or teachers—adults who are more likely to identify those with obvious behavior problems.

Though their problems may not be so obvious, girls with ADHD can suffer significant problems. Stephen Hinshaw (2002a, 2002b) compared a large group of girls with ADHD to other girls of the same age and social status. He found that girls with ADHD had much more trouble according to several measures: cognitive tasks, academic performance, getting along with peers, and ratings of emotional problems, social isolation, and behavior problems. Biederman (1999) studied a large group of girls six to eighteen years old with ADHD and compared them to boys with ADHD.

He found that the girls with ADHD had problems in home and school that were just as serious as those of boys with the disorder. The primary difference between the two groups was how much trouble they made for other people. Serious behavior problems, such as oppositional defiant disorder and conduct disorder (explained in detail in Chapter 8), were twice as common among boys with ADHD. This 50 percent lower rate of disruptive behavioral problems in the girls with ADHD is probably the most important reason that girls are less often recognized as having this disorder.

But it is not only girls whose impairments are often overlooked. Many boys and men have ADD symptoms that go unrecognized because they are not boisterous troublemakers. This problem of delayed recognition or total failure to recognize ADHD in individuals who are not disruptive continues because many clinicians, educators, and persons in the general public still assume that attentional problems of ADHD are significant only when linked with hyperactivity.

This continuing mistaken assumption is not surprising, given that the very name of the disorder continues to hold the two terms together. The official DSM-IV label for the disorder is "attention-deficit/hyperactivity disorder," followed by a comma and the name of the subtype. For those whose ADHD impairments do not include significant problems with hy-peractivity, this system results in a diagnostic label that says essentially "attention-deficit hyperactivity disorder, without significant hyperactivity," a rather clumsy and confusing label that perpetuates the overemphasis on behavioral problems.

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