ADHD, ADD, or Something Else?

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By Dr. Allison Kawa

Attention issues in children and adolescents are like a fever: they tell you something is going on but not exactly what. This is one reason why people are sometimes misdiagnosed with attentional disorders. Adding to the confusion are the actual terms that we use to talk about these attention problems. What exactly is ADHD and how is it different from ADD? Could inattention simply represent laziness or a lack of motivation? If it isn’t an attentional disorder, then what the heck is it? Let’s break this down, shall we?

Why ADHD is a Confusing Term

ADHD stands for Attention-Deficit/Hyperactivity Disorder, a long and confusing name for a cognitive profile that we don’t really understand all that well. The first part of this diagnosis, “Attention-Deficit,” suggests that attention is binary—either you have it or you don’t. Well, that’s not exactly how attention works. Attention occurs on a spectrum, with the most focused person on the planet at one end, and the least focused person on the planet at the other end. Most of us have an attentional capacity that falls somewhere in the middle of these two extremes. However, when there is a neurocognitive disorder in a person’s attention system, their attention actually swings between the two ends of the spectrum to an extreme degree. 

For most of us, paying attention to boring things is hard. For an ADHDer, paying attention to boring things is nearly impossible. This isn’t because of a character flaw such as laziness. Rather, it is a neurological deficit in the way the brain responds to chemical signals called neurotransmitters. Similarly, most of us find it easy to focus on things that we find interesting. An ADHDer might actually hyperfocus on things they like to such an extent that it is hard to interrupt them and they have difficulty transitioning away from preferred activities. When we talk about ADHD, we actually are talking about dysregulation in the attention system that causes extreme attention and extreme inattention rather than a lack of attention as the name implies.

Now for the second part of the diagnosis: “Hyperactivity Disorder.” Upon hearing this, you might (rationally in my humble opinion) assume that to be diagnosed with ADHD, one must be hyperactive. This is incorrect! Some ADHDers absolutely will be hyperactive and struggle to sit still, fidget constantly, or be in constant movement; this is the prototypical “ants in your pants” ADHDer. They may also have problems with impulsivity, including interrupting, talking too much, calling out in class, and being unable to wait. But not everyone with ADHD has these hyperactive-impulsive symptoms, and those that do have them can experience them in differing combinations or to different degrees. The hyperactive-impulsive symptoms also tend to diminish as children mature into teenagers and adults, so a child might appear to “grow out” of ADHD over time. 

Wait! What about ADD?

Remember that some ADHDers do not have hyperactive-impulsive symptoms, while others are hyperactive and impulsive without significant inattention. To capture these differences, we classify individuals diagnosed with ADHD into three subgroups: Predominantly Inattentive, Predominantly Hyperactive-Impulsive, and Combined Presentation. The manual that we use to operationally define disorders (so that we make sure that the professionals are all using terms consistently) is currently in its fifth edition. Between edition three and edition four, the term Attention Deficit Disorder (ADD) was changed to Attention-Deficit/Hyperactivity Disorder (ADHD). That’s literally the difference between ADD and ADHD: which book you used. However, most people who say “ADD” are talking about the Predominantly Inattentive subtype of ADHD.

A Peek Behind the Diagnostic Curtain

Since providers are working all over the world, it is important that we are on the same page when researching and communicating about different diagnoses. The DSM 5 diagnostic manual defines diagnoses based on lists of symptoms. If a person has a certain number of symptoms from the list, then they meet the diagnostic criteria and are “officially” diagnosed with ADHD. If this sounds arbitrary to you, that is because it is. In order to be diagnosed with ADHD, a person must have six symptoms from the list. That means that an extremely impulsive person who has minimal hyperactivity but a lot of inattention symptoms might not necessarily tick enough boxes in the Hyperactive-Impulsive column to meet criteria for Combined Presentation. We would diagnose them with ADHD- Predominantly Inattentive Presentation, which would miss an important part of this particular person’s symptom constellation. All I can say is that it is a work in progress and people are complex, nuanced, and so much more than a label.

Severity Ratings and Their Relationship to Stressors

To recap, ADD changed to ADHD a few decades ago, but people still use both terms. There are three types of ADHD, but they are assigned in a sort of arbitrary way that some people might find confusing. We also give a severity rating when making the diagnosis: mild, moderate, or severe. This is, in all honesty, pretty subjective depending on who is doing the diagnosing. Further, there are a massive number of factors that can make ADHD symptoms look better or worse. For example, if a student is not in an appropriate school setting and there are no supports, there is a very good chance that the severity rating will fall in the moderate to severe range. However, this same student might have mild symptoms at summer camp where there are fewer academic demands and more time to play and run. Likewise, anxiety and depression will absolutely contribute to an increase in ADHD symptoms severity. No one focuses their best when they are emotionally stressed. 

Anxiety and depression in particular are slippery when considering ADHD. In addition to problems with attention and distractibility, ADHDers have weaknesses in executive functioning. This is a broad term capturing high-level cognitive abilities such as organization, time management, planning, the ability to prioritize, and the ability to monitor oneself. Regulating one’s feelings is an important executive function that is often underdeveloped for ADHDers. This can create a chicken-or-egg conundrum because ADHD-related executive functioning problems will result in poor emotional regulation. This, in turn, can lead to anxiety or depression. However, anxiety and depression can exacerbate ADHD symptoms. This is where many people get stuck in a negative cycle and spiral into severe episodes of anxiety or depression.

What About the Fever Analogy?

Earlier in this blog, I wrote that attention problems are not specific to ADHD. This means that a person stuck in the feedback loop of anxiety or depression leading to bad concentration leading to poor performance leading to more anxiety or depression might actually have terrific concentration once the psychiatric symptoms are cleared. Trauma can also cause symptoms that look much like ADHD. This is particularly important when there was trauma in infancy or early childhood, because it actually changes the architecture of the brain, but typical ADHD treatments might not be effective. So how can we tell what’s what? The answer is to do a very careful and thorough evaluation that includes a comprehensive look at emotional functioning and personality development. In order to treat a person appropriately, it is important to know exactly what is being treated!

Another thing that makes ADHD a tricky diagnosis is that people with various processing and learning differences can appear inattentive. For instance, problems with attention can signal a central auditory processing disorder, a language processing disorder, or a visual processing disorder. People with learning differences such as dyslexia often appear inattentive because the reading demands are simply inappropriate for them. Finally, some people who are intellectually Gifted may seem inattentive because they can become intensely absorbed in their interests, and they can have something called overexcitabilities (more on this in another blog). Not only can any or all of these issues mimic ADHD, but they can co-occur with ADHD. It is extremely common for ADHDers also to be diagnosed with a psychiatric, processing, or learning disorder. Some researchers estimate that 80% of ADHDers will have something else going on that is causing a meaningful problem for them. The only way to know what else might be affected is to measure it. 

ADHD Can Be a Superpower

There are some obvious downsides to having ADHD. It is hard to pay attention in class or at work, organization and planning feel like monumental challenges, and sitting still or waiting feel like torture. Then there’s the anxiety, guilt, and shame that goes along with letting yourself or other people down sometimes. However, there are some upsides to having ADHD that are important to recognize, celebrate, and nurture. Many ADHDers notice things other people don’t necessarily notice. This helps them to be creative, out-of-the-box thinkers and excellent problem-solvers. These people are paying attention to little things that might escape the focus of the rest of us, and they can use that to their advantage. Also, remember the concept of hyperfocus? When an ADHDer finds an area of study or work that they are passionate about, nothing can stop them. Work situations that might seem horrendously stressful (like being an ER doctor) to a neurotypical can be exhilarating, perfect fits for an ADHDer who thrives on novelty and a fast pace.

Global estimates of the prevalence of ADHD are about 10%. That means that worldwide, one in ten people meets diagnostic criteria for ADHD. As a Los Angeles-based provider, I would estimate that the prevalence is much, much higher in my community. This is because the combination of inventive, engaging, out-of-the-box thinking plus hyperfocus is a recipe to be wildly successful in creative industries. Once we understand a person’s unique pattern of strengths and stretches, we can help to “aim” their ADHD superpower so they can achieve their heart’s desires. 

I Want to Know More!

If you want to know more about ADHD, you’re in good company! Our understanding is constantly evolving. One resource that I find very user-friendly is The site is a great source for the latest updates and research on diagnosis and treatments for attention disorders. 

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