The many faces of ADHD

When Emma P.’s* oldest son was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), it wasn’t a surprise.


“It was very obvious quite early on. When he was two-and-a-half, three, he had boundless energy,” says Emma. “He could go to a park for four hours, then go for a big bike ride and then still be bouncing off the walls.”


Classroom disruptions, the inability to sit still, difficulty relating to peers. Even his kindergarten teachers suggested he see a doctor for an assessment. Sure enough, after a thorough round of evaluations by a psychologist, he was diagnosed with ADHD and Oppositional Defiant Disorder.


Emma’s eldest son ticks most boxes on the ADHD stereotype checklist. But she says her youngest son is shy, quiet and withdrawn and was only diagnosed with ADHD in Grade 4 — a year after a learning disability diagnosis.


If not for his learning disability, his attention problems might have remained undiscovered, she said.


Just like any mental health issue, stereotypes and stigma permeate public perceptions of ADHD, but symptoms can actually vary widely, says Dr. Judy Van Stralen, an Ottawa pediatrician who specializes in ADHD treatment and research.


“There are really many faces of ADHD,” says Van Stralen, who is the medical director at the Center for Pediatric Excellence. “Girls may be missed more because they won’t be as disruptive — the daydreamer. They may be more internally distracted, not being as disruptive in their behaviour, they may be under the radar.”


No ADHD symptoms belong to a single gender, Van Stralen adds. Girls can be disruptive, boys can also be quiet daydreamers. It used to be thought of as only a childhood illness, but no longer. Adult presentations of ADHD even out across genders, Van Stralen says. Adults tend to be less hyperactive and impulsive, but their attention problems don’t go away.


“It’s not necessary to have hyperactivity and impulsivity to have clinically impaired attention issues,” Van Stralen says. What’s more, it’s also possible for a single person to have ADHD, be academically “gifted” and have learning disabilities all at the same time. 


That can lead sometimes to missed diagnoses and real problems for patients.


“If you don’t treat everything, it’s difficult to get functional improvement,” says Van Stralen.


It can also be confusing for parents. Sarah L. said her son was testing in the 98th percentile for language when he was finally assessed and diagnosed with ADHD in Grade 2. 


“He was doing really well academically,” she said. Her son, without any prior exposure to any language other than English, had managed to become fluent in French in kindergarten and was having no problems reading. But his inability to sit still and listen in class lead to conflicts with his teachers and friction with other kids.


Stigma around ADHD is so severe that Emma said it’s strained her relationship with her mother-in law, friends and even led an Uber driver to scold and lecture her on a trip home from her son’s doctor’s office. Sarah says she’s very nervous talking about the fact that her son takes medication to help him with his symptoms, even though it has provided clear benefits to him academically, in addition to the extra support measures and accommodations provided by her son’s school.


“People feel really comfortable telling you what they think about whether your kid should be taking medication, or whether ADHD is a real diagnosis, or if it’s over-diagnosed. They can be so insensitive. It’s exhausting listening to it over and over,” said Cindy C., whose younger daughter has autism spectrum disorder as well as ADHD. “Nobody says don’t take insulin if you have diabetes. Insulin helps. Nobody says don’t wear glasses if you have eye problems.” 


Cindy’s daughter, like Emma’s boys and Sarah’s son, takes a medication and receives a variety of accommodations at school to help with focus and learning. The difference has been like night and day, she says. Getting a diagnosis allowed her to share the information with the school, get an individualized education program drafted and get her child extra help.


“I recommend parents work with a psychologist or other mental health worker to help with skill development. I always say that pills don’t teach skills,” says Van Stralen. But what medication can do, she says, is help a child focus long enough to learn study and organization skills from teachers and parents.


“In children, the evidence supports teaching the parents strategies to manage the children’s behaviours and teach their children skills,” she says. “It is important to teach executive function skills; my experience is that a good tutor can be helpful for this.”






Some types of school accommodations for kids with ADHD


Body breaks – teachers allow the child to get up, walk around, or exercise to release tension and stress. Some schools have special rooms with trampolines, crafts and other activities to help kids burn off energy and feel more secure.


Chromebooks to help with note taking


Chunking – breaking long assignments or lessons into smaller chunks


Extra time to complete tests and assignments


Noise reduction earphones


Help with note taking and keeping track of homework