ADD in children and the three types of ADHD

Many parents first search for ADD in children because their child does not fit the picture of ADHD they had in mind. Their son or daughter is not bouncing off the walls. They are quiet, drifting, forgetful, and falling behind. Others have the opposite worry: a child who cannot sit still for a moment. Both can be ADHD, and so can a mix of the two.

This guide explains the three ways ADHD can present in children, what the older term ADD means, and why the picture can change as your child grows.

ADD or ADHD: what is the difference?

ADD stands for attention deficit disorder. It is an older name that you will still hear from friends, teachers and sometimes in older books. People usually use it to mean ADHD without obvious hyperactivity.

Doctors in the UK now use ADHD, attention deficit hyperactivity disorder, as the single name for the condition, whatever form it takes. A child who might once have been told they had ADD would today be described as having ADHD with a mainly inattentive presentation. The "H" in the name does not mean every child with ADHD is hyperactive.

ADHD affects three areas: attention, activity levels and impulse control. Some children have difficulties with concentration only. Some are mainly hyperactive and impulsive. Many have difficulties in all three areas. That gives the three presentations below.

The three types of ADHD in children

Doctors often call these "presentations" rather than types, because they describe how ADHD shows itself in a child at a particular time, not a fixed category. Most children and young people with ADHD have signs of both inattention and hyperactivity-impulsivity, though some show only one.

Inattentive ADHD in children

This is the presentation people often mean when they say ADD. A child with mainly inattentive ADHD may:

• be easily distracted and drift off in class or during conversations
• seem not to listen, or find it hard to follow instructions with several steps
• make careless mistakes, or skip or misread questions
• lose things often, such as homework, water bottles and school jumpers
• forget everyday tasks, like brushing teeth or packing their bag
• start lots of things and finish very few
• struggle to organise their time, their belongings and their work

Because these children are rarely disruptive, their difficulties are easy to miss. They may be described as dreamy, lazy or "not trying", when they are trying very hard. The NHS notes that ADHD is thought to be recognised less often in girls, partly because girls more often have inattentive symptoms, which are harder to spot. Our guide to ADHD in girls looks at this in more detail.

Hyperactive child symptoms: the hyperactive-impulsive presentation

This is the picture most people recognise. A child with mainly hyperactive-impulsive ADHD may:

• fidget, tap their hands or feet, or squirm in their seat
• get up and move about when they are expected to sit still
• seem to have endless energy, as if driven by a motor
• talk a lot, and loudly
• find it very hard to wait their turn
• interrupt, or blurt out answers before the question is finished
• act without thinking, sometimes with little sense of danger

These children are often noticed early, especially at school. They can be told off a great deal, which wears down their confidence over time.

Combined ADHD symptoms

A child with combined ADHD has clear difficulties with attention and clear difficulties with hyperactivity and impulsivity. This is the most common presentation. In NICE's clinical summaries for GPs, the combined type is estimated to make up 50% to 75% of cases, the inattentive type 20% to 30%, and the hyperactive-impulsive type around 15%.

Is my child just a hyperactive child, or is it ADHD?

Almost every young child is distractible, impulsive and full of energy some of the time. The NHS points out that this is especially true of children under 5, and that tiredness, anxiety or stress can produce very similar behaviour. Attention usually improves with age, so what matters is how your child compares with others of the same age.

For a diagnosis, the signs need to:

• start in childhood, usually before the age of 12
• show up in more than one setting, usually at home and at school
• have been present for at least six months
• cause real difficulty with learning, friendships, safety or family life

That last point is the key one. A lively child who is learning, making friends and coping well does not need a label. A child whose energy or distraction is holding them back, day after day, deserves a proper look.

Mild and severe ADHD symptoms

ADHD is not all or nothing. NICE describes how its impact varies a great deal. Some children have symptoms in certain settings that cause difficulty in one or two areas, such as finishing schoolwork. Others have all three areas of difficulty, everywhere, affecting most of their day.

Severity is judged by impairment: how much the symptoms get in the way of your child's life. It is not decided by the type of ADHD. A child with inattentive ADHD can be just as affected as a child who is hyperactive, even if it looks quieter from the outside.

Can the type of ADHD change with age?

Yes. The presentation describes how ADHD looks now, and it often shifts as children grow. Over time, hyperactive and impulsive symptoms tend to ease, while inattentive symptoms tend to persist.

In practice, a seven year old who could not stay in their seat may become a teenager who sits still but feels restless inside, loses track of homework and struggles to organise revision. Some children's difficulties only become obvious when the demands on them rise, such as the move to secondary school. Our guide to ADHD in teenagers covers this stage.

This is one reason why the type matters less than the whole picture. Support should follow what your child finds hard at each stage, not a label given years earlier.

How doctors work out which presentation your child has

There is no blood test or brain scan for ADHD. A diagnosis comes from a careful clinical assessment, as NICE guidance sets out. That means talking with you and your child, gathering information from school, and looking at your child's development, health and day-to-day life.

At BZ Clinic, both doctors are consultant paediatricians, so they look at your child's general health as well as attention and behaviour. Every new assessment includes questionnaires from home and school, and a QbCheck, a computer-based test of attention, activity and impulsivity. The QbCheck is one part of the picture. It is never used on its own and it is not a pass or fail test.

Usually the doctor can give you a clear answer on the day, with recommendations for home and school. Those recommendations are shaped by how ADHD shows itself in your child, whether that is mainly concentration, mainly hyperactivity and impulsivity, or both.

What to do next

If you recognise your child in this guide, you do not need to work out their type yourself. Write down what you notice and when it happens, and ask school what they see. Then talk to your GP or the school's SENCO, or contact us about a private ADHD assessment for your child in West Byfleet, Surrey. No GP referral is needed.

For more on the early signs, read our guide to the signs of ADHD in children.

Questions parents ask