2 Overlooked Signs of ADHD

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Believed to have first been formally recognized in 1798 by Scottish physician Sir Alexander Crichton (Lange et al., 2010), ADHD needs little introduction in modern times. The condition has gone on to be one of the most over-diagnosed and undiagnosed disorders (e.g., Ginsberg et al., 2014; Ford-Jones, 2015; Chung et al., 2019; Kazda et al., 2021).

Anyone working in mental health care or pediatrics knows it is easy, at first glance, for other psychiatric conditions to be mistaken for ADHD (i.e., DSM-5). This is often the result of careless history-taking and/or kneejerk diagnosis based on one symptom, as I discussed in "One Symptom Isn't Enough."

Surely you're familiar with cases of a fidgety boy who can't focus and gets irritable who is quickly assigned an ADHD diagnosis, only to discover stimulant medication exacerbated the symptoms. Upon closer evaluation, it is discovered he has a very worried thought process, naturally leading to the "ADHD" presentation, and it was anxiety all along.

Conversely, ADHD can also be entirely missed. As some researchers (e.g., Madsen et al., 2018; Chung et al., 2019; Abdenour et al., 2022; Chronis-Tescano, 2022) have discovered, this is typically correlated to gender and ethnicity. For example, boys tend to be impulsive and restless, drawing fast attention to something awry. Conversely, girls tend to exhibit more inattention, therefore, perhaps being seen as simply "spacey," or assumptions are made that they have a learning disability. Cross-culturally "...tolerance for certain behaviors varies between cultural groups and that, in the specific case of ADHD, the attitudes of parents and relatives, clinicians, and even society at large can influence the diagnosis...of ADHD" (Gomez-Benito, 2019).

Regardless of demographics, it's also possible that chief symptoms have an atypical presentation and thus fly under the radar. The following two items are alternative presentations of the core symptoms of restlessness, poor impulse control, and lack of focus I have encountered over the years.

Two Atypical Presentations of Core ADHD Symptoms

1. Hyperfocus.

"How can she have ADHD?" asked Sam's mother (composite example), "She gets so focused on making her models and playing her guitar. Even some school subjects like science. It's like she gets in a groove. Isn't ADHD where there's no focus?"

Sam, age 12, was being evaluated after getting into trouble at school, where she shoved a teacher who made her discontinue an art project when the bell rang. Her mother said that since age four, Sam could get very irritable if removed from something of interest. They thought she was simply enthusiastic about certain interests.

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After assessing for a developmental history congruent with autism, which can also present intense fixation, it was clear Sam wasn't autistic.

Throughout the interviews, her mother shared information about her being absent-minded about where she left things and seeming fidgety when unoccupied, the latter being obvious in Sam's interview.

Further, her mother noticed an air of impatience about Sam, like an urgency to get on to the next thing. She figured Sam was perhaps just a temperamental girl. These details led me to wonder about ADHD; Sam presented what ADHD specialists refer to as a hyper-focused subtype (e.g., Ayers-Glassey, et al., 2021; Drake Institute, 2023).

While the stereotypical ADHD presentation likely conjures images of constantly shifting attention, the attention deficit in those with a proclivity for hyper-focus is that they have trouble shifting attention. It should be noted that this is not the same as a child with ADHD who becomes consumed with video gaming, which holds their attention due to fast-paced, new stimulation.

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2. A sense of urgency to complete activities.

As we saw with Sam, a sense of urgency to complete a task in order to get on to the next may also belie ADHD. Though not restless in a "crawling the walls" fashion as popular culture might depict ADHD, it is a more productive restlessness, as if the individual found a way to contain that energy more constructively. Despite often rushing, it doesn't mean the person cannot do a thorough job. Chances are, though, they are already in their head about the next thing to do while working on the current matter as if to maintain momentum.

It should be noted that this trait can also be present in people with generalized anxiety disorder (GAD) or hypomania. In GAD, however, the constant activity is a distraction from worry. Further, worried thought processes will be obvious upon getting to know the patient. There will be muscle tension, edginess, insomnia, irritability, and a lack of focus due to a mill of worried thoughts. In hypomania, it will only surface periodically when the person is in the throes of a hypomanic episode.

For someone with ADHD, it's a baseline trait and may seem as if keeping productively in motion is an end unto itself and, upon evaluation, be discovered to be accompanied by other ADHD symptoms. This doesn't mean ADHD and other disorders with similar symptoms can't co-occur.

Careful clinical attention must be paid to the differentiation process for accurate care. Pharmacologically, if someone suffers from both GAD and ADHD, for instance, stimulant medications might exacerbate the picture. Psychotherapeutically, though ADHD and GAD ostensibly have similar symptoms, it is not enough to address one and not the other. Such a patient is hit doubly hard, as both conditions engender trouble with restlessness and attention. Reducing the worried thoughts driving the GAD, at the least, will reduce edginess and engender better sleep, which is known to positively affect those with ADHD (e.g., Weiss et al., 2015; Surman & Walsh, 2021).

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care from an individual’s provider or formal supervision if you’re a practitioner or student.

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