Sometimes it’s possible for a child to be so good, to work so hard, that years pass with a problem going unseen and undiagnosed. This happens frequently with girls who have ADHD without the H, or Attention Deficit Hyperactivity Disorder, without the hyperactivity.

 Maddy, who came to me when she was 13, was a wonderful kid — bright, outgoing, and well-behaved, and so conscientious that no one ever suspected that she had a problem.

Her grades were excellent. No one realized that it took her twice as long to do her work as it did the other kids in her class. She never complained, and never seemed to wonder why her friends had so much free time. Since she first entered kindergarten she just compensated and compensated. Her parents had asked teachers why Maddy had so much homework, but no one realized that Maddy was making a heroic effort.

The crack in the facade came when Maddy entered eighth grade. The material she had to study was much more complex, the homework more demanding, and tests contained more items to complete. With so much more asked of her, working extra-hard was no longer the viable solution.

Maddy’s grades started dropping and her parents noticed that she began referring to herself as stupid. In math she seemed to give up entirely. For the first time in her life, she stopped turning in assignments and got D’s on tests. When her parents asked her what was wrong, her behavior was sullen. Just as her good behavior had masked her problem before, her bad behavior hid it as well. Maddy’s parents, worried about depression or even the possibility of drug use, which Maddy angrily denied, had her visit a psychologist.

Fortunately, the psychologist referred Maddy to RNBC, where we did a thorough assessment. Her biggest challenge turned out to be attention. There are different kinds of attention we test for. Does a child have sustained attention or do her thoughts drift? Can a child successfully refocus attention when necessary, or do her thoughts continue to dwell on the preceding activity? What about selective attention, which is the ability to choose between different stimuli and pay attention to the one that matters.

As it turns out, Maddy’s issues were with selective attention. If the teacher was explaining what a polynomial was, and a bakery truck pulled up outside the window and the child next to her was breathing oddly, it was the polynomials that would lose out and the wheezy breath or the Wonder Bread that remained in her memory.

As we worked out a treatment plan, which involved carefully calibrated medication and sessions with an expert on executive function who helped Maddy with organizational skills, Maddy regained her good nature. “It’s such a relief to know what’s happening,” she said. “All of a sudden, I just couldn’t do the work and I didn’t know why.”

“I was worried about Maddy’s grades,” her mom said, “but after a while, that was the least of it. I could see my child changing—she was angry and upset all the time—and I couldn’t do anything about it. Knowing what the problem is makes all the difference in the world.”