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Why ADHD instead of ADD? / Why predominantly hyperactive-impulsive instead of predominantly-impulsive?

Why ADHD instead of ADD? / Why predominantly hyperactive-impulsive instead of predominantly-impulsive?



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The types of Attention deficit hyperactivity disorder are:

  1. predominantly inattentive

  2. predominantly hyperactive-impulsive

  3. combined

Not sure I understand. People with ADHD are hyperactive because of the H in ADHD. So what's the point of the word "hyperactive" being in both "predominantly hyperactive-impulsive" and "Attention deficit hyperactivity disorder" ? Why not just say predominantly impulsive or attention deficit disorder?


Edit to justify this question not being a duplicate:

I think one of the terms unnecessarily uses the word "hyperactive":

  1. ADHD

  2. predominantly hyperactive-impulsive

Why do we use hyperactive twice? Why not

  1. ADD has 3 types: predominantly inattentive, predominantly hyperactive-impulsive, combined

or

  1. ADHD has 3 types: predominantly inattentive, predominantly impulsive, combined?

ADHD used to be called just ADD in DSM-III (released in 1980), with the subtypes ADD/H (ADD with hyperactivity) and ADD/WO (ADD without hyperactivity). However, by 1987 when DSM-III-R was published, it turned out there was not enough empirical evidence to support the multidimensional view of ADD from DSM-III, so DSM-III-R adopted a unidimensional view, which was reflected in the name change to ADHD. This change was not without criticism, and it turned out that the criticism was well founded, because by the time DSM-IV came about (it was published in 1994), enough empirical evidence had accumulated for the multidimensional view, however the dimension space was refined into inattention and hyperactivity-impulsivity, and allowed for a combined type as well. From empirical research it turned out that the DSM-III diagnoses of ADD/WO and ADD/H correspond fairly closely with the DSM-IV diagnoses of ADHD predominantly inattentive type and combined type, respectively (cf. Morgan et al.)

Now for the terminology, the proper name howadays is attention-deficit/hyperactivity disorder (i.e. with the slash), which correctly reflects the equal importance of the two dimensions (from DSM-IV and 5) in the name. If you want to be really nitpicky, the proper, unambiguous abbreviation of this name should be something like {AD/H/AD+H}D or ADD/HD/AD+HD, though of course nobody writes it like that for reasons of parsimony.

If you propose to say that "ADD has 3 types: predominantly inattentive [… ]" you're still semantically repeating inattentive which means attention deficit, so I don't get the parsimony you propose at 1 as it asymmetrical, i.e. you're still repeating something in the first subtype from the title name even though you avoid it for the 2nd subtype.

As for proposal 2 "ADHD has 3 types: predominantly inattentive, predominantly impulsive", you're now calling the hyperactive-impulsive just impulsive. This is more a matter of how do you want to call the hyperactivity-impulsivity subtype. There is probably not enough empirical evidence to to have 3 dimensions (inattention, hyperactivity and impulsivity) for ADHD, nevertheless DSM-IV distinguished between the latter two for reasons not entirely clear to me, but which I suspect are a matter of calling a spade a spade:

Hyperactivity: (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often “on the go” or often acts as if “driven by a motor” (f) often talks excessively

Impulsivity: (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games)

For diagnostic purposes these two are combined, i.e you need 6 of any of these for hyperactive-impulsive diagnosis. Nevertheless it seems somewhat awkward to say that someone who has difficulty awaiting his/her turn is hyperactive rather than impulsive. There may be more history behind this sub-subheading split without diagnostic consequences; the DSM is designed by a committee so there may have been more to it, but I wasn't able to find out. What seems obvious is that lifting hyperactive rather than impulsive to the disorder name is appropriate given that most criteria for the subtype are of the hyperactive kind. Calling it "attention-deficit/hyperactive-impulsive disorder" seems really a mouthful.

It turns out there's at least one 2005 paper that partially agrees with your criticism though:

Not only is “ADHD without hyperactivity” (ADHD of the predominantly inattentive type) an awkward locution, but it also tries to squeeze ADD into a box in which it does not belong. The term ADHD should be reserved for when hyperactivity is present (as the term implies), regardless of whether inattention is also present.

As it's evident in the above, abbreviations don't capture alternatives. So ADHD is hard to read as {AD|H}D. Nevertheless the DSM-5 committees were not convinced and the name remained what it is. Although some changes were made to the ADHD diagnosis the DSM-5:

The retention of the ADHD symptom domains and 18 core symptoms likely reflects a judgment that the DSM-IV definition of ADHD has largely withstood the test of time.

However

The change in nomenclature from “subtypes” in DSM-IV to “presentations” in DSM-5 reflects increasing evidence that symptoms are often fluid within individuals across their lifespan rather than stable traits. DSM-IV ADHD subtypes change across development due to the heterotypic continuity of symptom trajectories over time. For example, since inattention is relatively stable across development while hyperactivity/impulsivity often wane with age, many children diagnosed with ADHD, Combined eventually transition to ADHD, Predominantly Inattentive [… ]. The “presentation” terminology better reflects that the symptom profile represents the person's current symptomatology, which may change over time. The “type” terminology implied more stable, trait-like characteristics.


You are partly right. In older patients, there is usually just attention deficit without hyperactivity.

Hyperactivity is term which describe behavior, and attention is the word which describes cognitive processes.

These processes are not the same although they depend on each other because neurotransmitter dopamine.

http://www.dsm5.org/documents/adhd%20fact%20sheet.pdf

EDIT: Control of impulses and hyper-activity are in behavioral domain. hyper means "a lot of" activity". Because of this reasons hyperactivity is diagnosed: - appears to be always on the go - excessively talks - has severe difficulty waiting for their turn - squirms in their seat, taps their hands or feet, or fidgets - gets up from a seat when remaining seated is expected - runs around or climbs in inappropriate situations - is unable to quietly play or take part in leisure activities - blurts out an answer before a question has been finished - intrudes on and interrupts others constantly


Bibliography

american psychiatric association. (1994). diagnostic andstatistical manual of mental disorders, 4th edition. washington, dc: american psychiatric press.

barkley, r. a. (1998). attention deficit hyperactivity disorder: a handbook for diagnosis and treatment, 2nd edition. new york: guilford.

carlson, e. a. jacobvitz, d. and sroufe, l. a. (1995). "adevelopmental investigation of inattentiveness and hyperactivity." child development 66:37–54.

degrandpre, r., and hinshaw, s. p. (2000). "attention-deficit hyperactivity disorder: psychiatric problem or american cop-out?" cerebrum 2:12–38.

hinshaw, s. p. (1999). "psychosocial intervention forchildhood adhd: etiologic and developmental themes, comorbidity, and integration with pharmacotherapy." in rochester symposium on developmental psychopathology, vol. 9: developmental approaches to prevention and intervention, ed. d. ciccehetti and s. l. toth. rochester, ny: university of rochester press.

hinshaw, s. p. owens, e. b. wells, k. c. kraemer, h. c.abikoff, h. b. arnold, l. e. conners, c. k. elliott, g. greenhill, l. l. hechtman, l. hoza, b. jensen, p. s. march, j. s. newcorn, j. pelham, w. e. swanson, j. m. vitiello, b. and wigal, t. (2000). "family processes and treatment outcome in the mta: negative/ineffective parenting practices in relation to multimodal treatment." journal of abnormal child psychology 28:555–568.

hinshaw, s. p., and park, t. (1999). "research issues andproblems: toward a more definitive science of disruptive behavior disorders." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

hinshaw, s. p. zupan, b. a. simmel, c. nigg, j. t. andmelnick, s. m. (1997). "peer status in boys with and without attention-deficit hyperactivity disorder: predictions from overt and covert antisocial behavior, social isolation, and authoritative parenting beliefs." child development 64:880–896.

johnston, c., and mash, e. j. (2001). "families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research." clinical child and family psychology review 4:183–207.

mannuzza, s., and klein, r. g. (1999). "adolescent andadult outcomes in attention-deficit/hyperactivity disorder." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

patterson, g. r. reid, j. and dishion, t. (1992). antisocial boys. eugene, or: castalia.

pelham, w. e. wheeler, t. and chronis, a. (1998). "empirically supported psychosocial treatments for adhd." journal of clinical child psychology 27:189–204.

simmel, c. brooks, d. barth, r. p. and hinshaw, s. p.(2001). "externalizing symptomatology among adoptive youth: prevalence and preadoption risk factors." journal of abnormal child psychology 29:57–69.

tannock, r. (1998). "attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research." journal of child psychology and psychiatry 39:65–99.


Symptoms and Diagnosis of ADHD

Deciding if a child has ADHD is a process with several steps. This page gives you an overview of how ADHD is diagnosed. There is no single test to diagnose ADHD, and many other problems, like sleep disorders, anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

If you are concerned about whether a child might have ADHD, the first step is to talk with a healthcare provider to find out if the symptoms fit the diagnosis. The diagnosis can be made by a mental health professional, like a psychologist or psychiatrist, or by a primary care provider, like a pediatrician.

The American Academy of Pediatrics (AAP) recommends that healthcare providers ask parents, teachers, and other adults who care for the child about the child&rsquos behavior in different settings, like at home, school, or with peers. Read more about the recommendations.

The healthcare provider should also determine whether the child has another condition that can either explain the symptoms better, or that occurs at the same time as ADHD. Read more about other concerns and conditions.

How is ADHD diagnosed?

Healthcare providers use the guidelines in the American Psychiatric Association&rsquos Diagnostic and Statistical Manual, Fifth edition (DSM-5) 1 , to help diagnose ADHD. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities can also help determine how many children have ADHD, and how public health is impacted by this condition.

Here are the criteria in shortened form. Please note that they are presented just for your information. Only trained healthcare providers can diagnose or treat ADHD.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity&ndashimpulsivity that interferes with functioning or development:

  1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    • Often has trouble holding attention on tasks or play activities.
    • Often does not seem to listen when spoken to directly.
    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
    • Often has trouble organizing tasks and activities.
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    • Is often easily distracted
    • Is often forgetful in daily activities.
  2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person&rsquos developmental level:
    • Often fidgets with or taps hands or feet, or squirms in seat.
    • Often leaves seat in situations when remaining seated is expected.
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    • Often unable to play or take part in leisure activities quietly.
    • Is often &ldquoon the go&rdquo acting as if &ldquodriven by a motor&rdquo.
    • Often talks excessively.
    • Often blurts out an answer before a question has been completed.
    • Often has trouble waiting their turn.
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  • Several symptoms are present in two or more settings, (such as at home, school or work with friends or relatives in other activities).
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
  • The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
  • Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
  • Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
  • Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.

Diagnosing ADHD in Adults

ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 years or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the National Resource Center on ADHD external icon and the National Institutes of Mental Health external icon .

Reference

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.


Changes in the Definition of ADHD in DSM-5: Subtle but Important

While there were earlier descriptions of children with high levels of activity and impulsivity [1], what is now called Attention-Deficit/Hyperactivity Disorder (ADHD) first appeared in the second edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1968 [2]. In DSM-II, the disorder was termed Hyperkinetic Reaction of Childhood, which as the name implies focused primarily on symptoms of excessive motor activity. With the publication of the DSM-III [3] in 1980, the disorder was markedly re-conceptualized with a focus on problems with attention, impulsivity and hyperactivity, and was renamed Attention Deficit Disorder (with and without Hyperactivity). The term Attention Deficit/Hyperactivity Disorder (ADHD) was introduced in DSM-III-R [4], with the controversial elimination of ADD without Hyperactivity. With the publication of the DSM- IV [5], the term ADHD was retained along with the introduction of three specific subtypes (predominantly Inattentive, predominantly Hyperactive-Impulsive, and Combined), defined by the presence of excessive symptoms of inattention and/or hyperactivity-impulsivity.

The recent release of DSM-5 [6] is the latest update to ADHD nosology. The DSM-5 revisions include modifications to each of the ADHD diagnostic criteria (A-E), a terminological change in the ADHD subtype nosology, and the addition of two ADHD modifiers. Criterion A (ADHD symptoms) are unchanged from DSM-IV except for additional examples of how symptoms may manifest in adolescence and adulthood, and a reduction from six to five in the minimum number of symptoms in either symptom domain required for older adolescents and adults. Criterion B (age of onset) changed from onset of symptoms and impairments before age 7 to onset of symptoms before age 12. Criterion C (pervasiveness) was changed from evidence of impairment to evidence of symptoms in two or more settings. Criterion D (impairment) now requires that functional impairments only need to “reduce the quality of social, academic or occupational functioning” instead of requiring that they be 𠇌linically significant.” Criterion E (exclusionary conditions) no longer includes Autism Spectrum Disorder as an exclusionary diagnosis. Regarding nosology, the DSM-IV ADHD “types” are now referred to as “presentations.” Finally, modifiers were added so that the severity of the disorder (i.e., mild, moderate, or severe) can be specified and the disorder can be coded as “in partial remission” if full diagnostic criteria are not currently met.

Overall, the revisions to ADHD in DSM-5 are less dramatic than updates to earlier DSMs. Importantly, the DSM-5 ADHD and Disruptive Behavior Disorders Workgroup decided neither to modify the core ADHD symptom domains (i.e., Inattention and Hyperactivity/Impulsivity) nor to revise the 18 core symptoms, aside from adding example behaviors to better define some of the symptoms for older adolescents and adults. The retention of the ADHD symptom domains and 18 core symptoms likely reflects a judgment that the DSM-IV definition of ADHD has largely withstood the test of time. DSM-IV ADHD criteria have proven to be quite effective at reliably identifying a population of individuals who have significant impairments across a wide range of outcomes (e.g., academic, interpersonal, occupational, personal, substance use, driving, etc. [7, 8]). Moreover, individuals identified by DSM-IV ADHD criteria appear to have distinct neuropsychological profiles [9, 10] identifiable neurobiological signatures (e.g., abnormalities in frontal-striatal circuitry [11, 12]) and unique genetic correlates [13]. By retaining a similar ADHD phenotype as defined in DSM-IV, the DSM-5 workgroup ensured that the voluminous body of DSM-IV defined ADHD research accumulated over the past 2 decades will largely generalize to the new, yet highly similar, DSM-5 ADHD phenotype.

Although more subtle than changes in prior DSMs, the changes to ADHD in DSM-5 are important and reflect our increased knowledge about the nature of ADHD. In particular, it has become increasingly evident that the DSM-IV symptom domain thresholds (i.e., 6 of 9 symptoms per symptom domain), while appropriate for young children, are not effective for identifying adolescents and adults experiencing ADHD-related impairment. Prior to DSM-5, some researchers used lower symptom thresholds to define adolescent and/or adult ADHD samples (e.g., [14]), in discord with DSM-IV many clinicians did likewise or relied on the poorly-defined ADHD Not Otherwise Specified. Research suggests that a lower symptom number threshold more accurately identifies those 17 and older who experience impairments warranting intervention [15].

Similarly, research has shown no meaningful differences in functioning, response to treatment, or outcomes in individuals who display ADHD symptoms prior to age 7 versus those who first display symptoms at an older age [16]. Both research and clinical experience indicates some ADHD patient groups (e.g., those with high intelligence, with predominantly inattentive symptoms, or in a highly structured environment) may not experience significant impairment until expectations for self- management increase in late elementary or middle school. For those individuals whose ADHD is not identified until adulthood, they often have difficulty recalling at what age they first experienced impairments, as the inherent memory problems often associated with ADHD make recall of childhood details difficult. The change to an age of onset of 12, while albeit still rather arbitrary, may reduce some of these diagnostic issues.

The change in nomenclature from “subtypes” in DSM-IV to “presentations” in DSM-5 reflects increasing evidence that symptoms are often fluid within individuals across their lifespan rather than stable traits. DSM-IV ADHD subtypes change across development due to the heterotypic continuity of symptom trajectories over time. For example, since inattention is relatively stable across development while hyperactivity/impulsivity often wane with age, many children diagnosed with ADHD, Combined eventually transition to ADHD, Predominantly Inattentive [17]. The “presentation” terminology better reflects that the symptom profile represents the person’s current symptomatology, which may change over time. The “type” terminology implied more stable, trait-like characteristics. Finally, modifying Criteria E to allow a diagnosis of ADHD comorbid with ASD is consistent with research indicating that children with ASD can also have ADHD [18].

Besides aligning the ADHD criteria with the current state of knowledge, the modifications in DSM-5 have the potential to make the ADHD diagnosis more reliable. In particular, the switch from requiring evidence of impairing symptoms to just symptoms for both the pervasiveness and age of onset criteria likely improves their reliability. Symptoms tend to be more easily quantified and observed. There are numerous established measures of ADHD symptoms, whereas impairments tend to be more qualitative and subjective for which we have fewer reliable measures. However, since ADHD symptoms can exist in the absence of impairment, whereas impairments in the absence of symptoms are unlikely, focusing on symptoms without impairments may increase the number of children who meet both age of onset and pervasiveness criteria. In addition, the modification of the definition of impairment from “significant” to “interfere with, reduce the quality of…” is also a more liberal and more inclusive requirement. So, while the new DSM-5 ADHD criteria may result in a more reliable set of criteria, ADHD prevalence rates may increase.

A couple of issues were unfortunately not addressed in the revisions to ADHD in DSM-5. First, there is an increasing, if not universal, acceptance that ADHD, like many psychopathologies, is a dimensional disorder [19]. That is, inattention and hyperactivity/impulsivity are behavioral traits that naturally occur on a continuum, much like intelligence. In this view, diagnostic thresholds used to define �normal behavior” are artificial, though useful in identifying individuals who experience significant impairment in their daily functioning. DSM-5 continues to place everyone meeting diagnostic criteria into a single category which doesn’t capture the dimensionality of underlying constructs. While DSM-5 does allow for a severity classification (mild, moderate, or severe), these can be applied based on either number of symptoms or magnitude of impairment. Given that both symptom counts and functional impairment can, and often do, vary across domains and across settings, it is likely that severity classifications will be unreliable and will vary considerably across diagnosticians. Preferably, some form of indication of level of global functioning might most accurately indicate severity of the disorder. The WHO Disability Assessment Scale (WHODAS) has been added to DSM-5, and is somewhat akin to indicating global functioning except it assesses the impact of the patient’s entire diagnostic profile on global functioning. Future revisions should consider other nosological devices to indicate both the dimensionality of the disorder and the impact of each specific disorder (e.g., ADHD) on overall functioning. Perhaps overall clinical global impressions [20], as used to assess severity of impairment in ADHD clinical trials, could be considered.

Finally, while some changes, as noted above, were made to make the ADHD criteria more applicable to older adolescents and adults, the DSM-5 ADHD diagnostic structure fails to reflect established developmental trajectories. In particular, the “Predominantly Inattentive Presentation” includes both children who, at a younger age, met criteria for 𠇌ombined presentation” as well as those who have always had few, if any, Hyperactive/Impulsive symptoms. Pre-release correspondence from the Workgroup suggested that an “Inattentive Restrictive Type” was considered for children with consistently low numbers of hyperactive/impulsive symptoms. It is possible that segmenting out this sub-population of children with ADHD may have both addressed heterogeneity within the ADHD Predominantly Inattentive presentation and spurred research into whether specific symptom trajectories are associated with prognosis, neurobiological correlates, comorbidity patterns, etc. Hopefully, future revisions will reconsider such sub-classifications, or other strategies for capturing developmental changes over time.


Background

Attention deficit/hyperactivity disorder (ADHD) is characterized by a combination of age-inappropriate levels of inattention, impulsive behavior and hyperactivity. Symptoms must become apparent before the age of 12 years and cause significant impairments in more than one setting, e.g., at school or work, or with family and peers [1]. The diagnostic and statistical manual of mental disorders (DSM V [1]) distinguishes three subtypes of ADHD, the predominantly inattentive type (IA), the predominantly hyperactive/impulsive type (HI) and the combined type (C). Children of the IA type show more than six out of the nine relevant symptoms specified as inattentive behavior and less than six out of the nine relevant symptoms specified as hyperactive/impulsive behavior. The predominantly HI type is characterized by more than six HI symptoms and less than six IA symptoms, whereas children of the C type show more than six symptoms in both areas. Although ADHD was long regarded solely as a childhood disorder, it is now agreed that the disorder persists into adulthood (e.g., [2, 3]), and even into old age [4, 5]. Estimations of adulthood ADHD’s prevalence rates range from 2.5 to 5% [6�], slightly smaller than those reported for children and youths that range from 5.0 to 7.1% [13, 14].

Assessment of ADHD using ratings and tests

Most diagnostic guidelines (e.g., [15�]) require that ADHD be assessed and diagnosed by relying on information provided via a variety of methods (e.g., clinical interviews, observations and ratings) and collected from multiple sources (e.g., parents and teachers). However, using subjective measures always incorporates the risk of informant biases [18] and clinicians are often confronted with great inconsistencies between ratings obtained from different sources [19, 20]. Although the discrepancies between different informants can be of clinical relevance [21], the use of objective measures in addition to subjective ratings might yield valuable information facilitating the diagnosis of ADHD. In the present study, we therefore aimed to investigate the role of objective measures when trying to distinguish between individuals with ADHD and controls. We also aimed to investigate how objective measures are related to subjective measures by investigating how well we could discriminate between ADHD and controls when using the combination of these two types of measures. The combination of objective and subjective measures may provide additional information than objective measures alone as it has been argued that tests and ratings may capture at least partly different constructs [22, 23] and should not be used interchangeably. Toplak and colleagues [23] argue that one important difference between ratings and tests is that the former measure typical performance (i.e., how an individual normally performs), whereas tests usually capture optimal performance (i.e., how well an individual performs under relatively optimal conditions). Thus, objective measures assess performance free of influences of the different situations. However, this study primarily investigated whether only objective measures would be sufficient to develop a statistical model as the bias and inter-operator error inherent in subjective measures are not well suited to developing a robust and objective classifier. Whilst the value of including subjective measures in a classifier alongside objective measures has been explored, developing an objective statistical method using only subjective data would not be expected to produce a robust classifier that would generalize to corresponding data acquired by other operators.

The relative importance of individual variables towards a diagnosis of ADHD is an issue that has not been empirically examined, at least not in studies employing statistical methods that can handle numerous variables to make an objective prediction. Similarly, few studies focus on objective measurements of ADHD symptom levels rather than constructs (such as executive functioning deficits) that are known to be associated with ADHD.

Objective measures

Test battery of attention

In Germany, where this study was conducted, a frequently used neuropsychological test is the test battery of attention for adolescents and adults (TAP [24]) or for children aged 6� (KiTAP [25]). The various subtests enable the assessment of aspects of two of the three core symptoms of ADHD, namely inattention and impulsivity. A detailed description of the tasks is provided in the method section. One study using the TAP in a sample of children with ADHD and healthy controls demonstrated that two test measures (reaction time variability of the Go/NoGo task, number of errors of the reaction change task) were needed to classify 90% of the children correctly [26]. Drechsler et al. [27] detected significant group differences between children with and without ADHD in four of the KiTAP’s six subtests. Nevertheless, they did not recommend using it for diagnostic purposes due to its weak specificity. Another study on the psychometric properties of the KiTAP reported values for split-half reliability of .55–.96 for children aged 8� [25] and .32–.72 for children aged 6𠄷 years [28]. The psychometric properties of the TAP/KiTAP are thus not fully satisfactory, and norm references are missing for some age groups. An alternative is the Quantified Behavior Test, a neuropsychological test becoming increasingly important in ADHD diagnostics.

The Quantified Behavior Test

The Quantified Behavior Test for children aged 6� (QbTest 6� [29]) and the Quantified Behavior Test Plus for subjects 12 years and older (Qb+ © [30]) are computerized neuropsychological tests that assess the three core symptoms of ADHD using a continuous performance test (CPT). One great advantage of these tests is that in addition to providing estimates of the participant’s performance (e.g., omission and commission errors), they also measure head movements via a motion tracking system. For example, the system generates measures of the time the subject has moved more than 1਌m/s, as well as the distance they traveled during the test or the surface covered through their movements. Reh et al. [31] reported promising results determining the QbTest 6�’s factorial and discriminant validity with a three-factor solution corresponding to the three areas of ADHD impairment. These explained 76% of the total variance and reliability estimates ranging from α = .60 (impulsivity) to α = .95 (hyperactivity) for these factors. Findings have been less consistent regarding the QbTest 6�’s convergent and discriminant validity. One study exhibited significant differences between children with ADHD, their siblings, and healthy controls, and the authors identified the factor of hyperactivity as a possible “intermediate phenotype” [32]. Hult et al. [33] examined the diagnostic validity of the QbTest 6� applying ROC curves in a clinical sample of children diagnosed with ADHD and a clinical control group of individuals with primarily autism spectrum disorder, observing moderate sensitivity (47�%) and specificity values (72�%). In a third study, multi-trait, multi-method analyses comparing self- and observer ratings (Conners 3 rating scales) with objective measures provided support for the convergent validity of the QbTest 6� especially for the variables assessing inattention, but discriminant validity was not supported [34]. However, discrimination analyses based on the QbTest 6� also achieved 73.8% accuracy in predicting whether a child had an ADHD diagnosis (all subtypes) or not with the variables measuring activity revealing the greatest impact. There are studies of the Qb+ © , the version used for adolescents and adults, demonstrating high sensitivity (86%) and specificity (83%) when trying to differentiate between subjects with and without ADHD [35, 36]. However, sensitivity dropped substantially when trying to differentiate between individuals with ADHD and other clinical groups such as bipolar II disorder (36%) or borderline personality disorder (41% [35]). However, in another study, with a large sample of patients that came in for ADHD assessment, we were able to differentiate patients for which an ADHD diagnosis was confirmed (66% of 773 subjects) versus patients that had symptoms of inattention, impulsivity or hyperactivity due to other disorders (34% of 773 subjects). All individuals performed the QbTest, the objective measure also used in this study. Of those individuals predicted not to have an ADHD diagnosis based on the QbTest, 67% actually had no diagnosis of those individuals predicted to have an ADHD diagnosis, 79% actually had a diagnosis. In the whole sample, the correct classification rate was 76.4%, sensitivity was 90%, and specificity was just 45% [37]. Another study reported satisfactory overall classification rates (87.8% correctly identified ADHD patients), but lower correct prediction rates regarding the area under the curve (AUC) range for sensitivity (36.5�.5%) and specificity (80�% [38]). Hirsch and Christiansen [37] verified the three factorial structure of the Qb+ © and provided support for convergent validity using multi-trait, multi-method analyses, but the discriminant validity of this instrument was only partially supported. The measure of impulsivity has been shown to be the least sensitive symptom with regard to discriminating between adults with and without ADHD as well as between patients with ADHD or other psychiatric disorders [35, 36, 39].

Aim of the present study

In summary, there are several studies reporting promising results regarding the ability of the QbTest 6� and the Qb+ © to differentiate between patients with and without ADHD. Nevertheless, findings are inconsistent, and often suggest using neuropsychological tests only as an additional resource within a comprehensive assessment strategy incorporating a variety of methods [27]. In the clinical community there is a high controversy about the usefulness of objective measures for diagnostic purposes as problems regarding sensitivity, specificity and ecological validity have been reported [40]. In light of the evidence that ratings and tests seem to assess partly different constructs, objective and subjective measures could be seen as complementing each other. The diagnostic value of objective tests becomes all the more important when the potential risks of subjective measures are taken into account, informant bias being the most important thereof. There is lack of studies evaluating the differential contributions of objective and subjective measures for correctly classifying ADHD. Whilst the study investigates the relative contribution of subjective measures in a classifier, the diagnostic accuracy using objective measurements only is considered more generalisable due to the inherent inter-operator variability in subjective measures. In contrast to most previous studies using neuropsychological measures and ratings to differentiate between patients with ADHD and healthy controls, we used machine learning rather than discriminant function analysis or logistic regression analysis. The advantage of the former is that it is data-driven and less sensitive to outliers [41]. Furthermore, it is a multivariate approach, as it does not rely on summary scores, but considers every single item. The risk of losing information is therefore reduced [41]. More specifically, the present study used support vector machine (SVM). This machine-learning approach is known to be very robust and capable of translating well in studies using imaging data [42]. However, it has been predominantly implemented in studies using neuroimaging data to diagnostically classify clinical populations [43, 44] and not in studies using standard clinical assessments as recommended by the various ADHD diagnostic guidelines outlined above.

The first aim of this study was thus to investigate the accuracy of employing only variables from the objective measures to reveal their specific potential contribution free from the potential confound of subjective measures. We further aimed to investigate how objective measures are related to subjective measures by investigating how well we could discriminate between ADHD and controls when using the combination of these two types of measures. In contrast to previous research, we used a machine-learning technique (SVM) to analyze the data.


Three types of ADHD: What are the differences?

ADHD stands for attention deficit hyperactivity disorder and is also sometimes referred to as ADD, generally when the person with the disorder does not display symptoms of hyperactivity.

Although there are several different predominant clusters of symptoms that people can experience, the diagnosis is still ADHD.

ADHD is one of the most common health disorders affecting children. It is estimated that around 11 percent of children aged between 4 and 17 in the United States have ADHD, which equates to around 6.4 million children. However, adults can also have ADHD.

This article will explain the three different types of ADHD.

Share on Pinterest ADHD is estimated to affect more than 10 percent of children in the U.S., making it one of the most common health disorders children face.

ADHD is often first identified in school-aged children. A key sign is when their behavior becomes disruptive, and they show signs of:

ADHD is more common among boys than girls.

There are three main types of ADHD, which differ according to the symptoms that present most commonly. The three types are:

  • ADHD, combined presentation: This is the most common type of ADHD. The person will show impulsive and hyperactive behavior, as well as getting distracted easily and struggling to maintain attention.
  • ADHD, predominantly impulsive/hyperactive: This is the least common type. The person will show signs of hyperactivity and the need to move constantly, as well as displaying impulsive behavior. They do not show signs of getting distracted or inattention.
  • ADHD, predominantly inattentive: People with this type of ADHD do not exhibit signs of hyperactivity or impulsivity. Instead, the person will get distracted easily and find it difficult to pay attention.

The predominantly inattentive type is the one often referred to as ADD (standing for attention deficit disorder) as the term does not contain the word “hyperactivity.”

The disorder was described as ADD before the word ‘hyperactivity’ was added in 1987. Essentially, ADD is now an outdated way to refer to ADHD.

It was once believed that children with ADHD outgrew the disorder during adolescence because hyperactivity is often reduced as children become teenagers.

However, adults can also have ADHD and often they do not even realize that they have it. While it is true that hyperactivity is less of an issue in adults with ADHD, often other symptoms can get worse. These include:

While most people diagnosed with ADHD as adults recall having similar problems as a child, it is not always the case, and it is possible that the symptoms have developed later in life.


Symptoms of ADHD Inattentive Subtype

It’s usually easy to spot children with combined ADHD in a classroom setting: They may blurt out answers, fidget constantly, and have a hard time staying in one place. Students with ADHD inattentive type are harder to spot. Instead of drawing attention, they may sit quietly at their desks, staring out the window. Often, these children appear to be performing beneath their potential. They’re smart, but they struggle with organization and distraction, so homework isn’t always completed or turned in on time.

Adults who have the inattentive form of ADHD exhibit similar symptoms: They’re easily distracted, frequently forgetful, and often disorganized.

In order to diagnose ADHD predominantly inattentive subtype, doctors must identify five (in children) or six (in adults) of these symptoms:

Doesn’t pay close attention to details or makes careless mistakes

Has difficulty staying focused on tasks or activities

Doesn’t appear to listen (seems distracted during conversations)

Frequently does not follow through on chores, assignments or tasks

Struggles with organization

Forgets daily tasks, such as returning calls or keeping appointments

Anxiety and learning disorders are also common in people with inattentive ADHD.


Inattentive Type ADHD

ADHD is generally twice as prevalent among boys than girls. However, inattentive type ADHD is more common in girls. It is also more prevalent in older children and adults.

People with this type of ADHD have symptoms stemming from not being able to focus properly. Unlike with impulsive/hyperactive ADHD, people with this type do not show any signs of hyperactivity or impulsivity. Instead, the main symptoms of this type are:

  • Being easily distracted
  • Reluctance to do tasks that require sustained mental effort, like schoolwork
  • Fixation on activities that don't require sustained mental effort, like television
  • Forgetfulness
  • Trouble with organization
  • Often makes careless errors

They didn't always call it ADHD, though, and used terms like:

  • Brain-injured
  • Brain-damaged child
  • Hyperkinetic impulse disorder
  • Hyperexcitability syndrome
  • Clumsy child syndrome
  • Hyperactive child syndrome
  • Hyperkinetic reaction of childhood
  • Minimal brain dysfunction
  • Organic brain disease
  • Nervous child
  • Attention deficit disorder

It has been known as ADHD since 1987 and is further divided into three subtypes: inattentive type, hyperactive/impulsive type, and the combined type.


How to Help a Child With the Condition

If your child is diagnosed, their doctor may prescribe medication to make them more able to concentrate, suggest therapy, or use a small device to help stimulate the part of the brain believed to be responsible for ADHD. This recently FDA-approved device, called the Monarch external Trigeminal Nerve Stimulation (eTNS) System, can be prescribed for patients 7 to 12 years old who are not already taking ADHD medication.

Continued

A combination of medicine and therapy is the most common approach.

Behavior therapy also teaches you some parenting tactics, such as:

  • Set up a system of rewards for good behavior.
  • Withhold privileges or take away rewards to deal with unwanted behavior.

Continued

Parents, teachers, and counselors can use these methods to help children with inattentive ADHD stay on track:

  • Make to-do lists. Create lists of homework and household chores, and post them in places where your child can easily see them.
  • "Bite-size" projects. Break down projects and requests into small tasks. Instead of saying, "Do your homework," you might say, "Finish your math sheet. Then read one chapter of your English book. Finally, write one paragraph describing what you read."
  • Give clear instructions. Make them simple and easy to understand.
  • Organize. Make sure your child's clothes and schoolwork are always in the same place and easy to find.
  • Get into a routine. A sense of order helps inattentive children stay focused. Follow the same schedule every day -- “get dressed, brush your teeth, eat breakfast, put on your coat.” Post the schedule in a central place, such as the kitchen or main hallway of your house.
  • Cut down on distractions. Turn off the TV, computer, radio, and video games as much as possible at home. Ask the teacher to seat your child away from the windows and doors in class.
  • Give rewards. Everyone likes praise for a job well-done. When the homework is finished on time, or the bedroom gets picked up, let your child know you noticed. You might offer to take them on a trip to the zoo or go out for frozen yogurt.

Continued

Your child spends much of their time in school, so you’ll need to be in touch with their teacher to keep tabs on how they are doing in class. Together, you can come up with different ways to help your child. The school can make accommodations to better serve your child’s needs. Talk to the principal.

When a child has the treatment, tools, and support they need, they will be able to focus and accomplish their goals.

Sources

National Institute of Mental Health: "Attention Deficit Hyperactivity Disorder (ADHD)."

Nemours Foundation: "What Is ADHD?"

Bope, E.T., and Kellerman, R.D. Conn's Current Therapy 2012, 1st edition, Saunders Elsevier, 2011.

UpToDate: "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis."


Symptoms of ADHD Inattentive Subtype

It’s usually easy to spot children with combined ADHD in a classroom setting: They may blurt out answers, fidget constantly, and have a hard time staying in one place. Students with ADHD inattentive type are harder to spot. Instead of drawing attention, they may sit quietly at their desks, staring out the window. Often, these children appear to be performing beneath their potential. They’re smart, but they struggle with organization and distraction, so homework isn’t always completed or turned in on time.

Adults who have the inattentive form of ADHD exhibit similar symptoms: They’re easily distracted, frequently forgetful, and often disorganized.

In order to diagnose ADHD predominantly inattentive subtype, doctors must identify five (in children) or six (in adults) of these symptoms:

Doesn’t pay close attention to details or makes careless mistakes

Has difficulty staying focused on tasks or activities

Doesn’t appear to listen (seems distracted during conversations)

Frequently does not follow through on chores, assignments or tasks

Struggles with organization

Forgets daily tasks, such as returning calls or keeping appointments

Anxiety and learning disorders are also common in people with inattentive ADHD.


Changes in the Definition of ADHD in DSM-5: Subtle but Important

While there were earlier descriptions of children with high levels of activity and impulsivity [1], what is now called Attention-Deficit/Hyperactivity Disorder (ADHD) first appeared in the second edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1968 [2]. In DSM-II, the disorder was termed Hyperkinetic Reaction of Childhood, which as the name implies focused primarily on symptoms of excessive motor activity. With the publication of the DSM-III [3] in 1980, the disorder was markedly re-conceptualized with a focus on problems with attention, impulsivity and hyperactivity, and was renamed Attention Deficit Disorder (with and without Hyperactivity). The term Attention Deficit/Hyperactivity Disorder (ADHD) was introduced in DSM-III-R [4], with the controversial elimination of ADD without Hyperactivity. With the publication of the DSM- IV [5], the term ADHD was retained along with the introduction of three specific subtypes (predominantly Inattentive, predominantly Hyperactive-Impulsive, and Combined), defined by the presence of excessive symptoms of inattention and/or hyperactivity-impulsivity.

The recent release of DSM-5 [6] is the latest update to ADHD nosology. The DSM-5 revisions include modifications to each of the ADHD diagnostic criteria (A-E), a terminological change in the ADHD subtype nosology, and the addition of two ADHD modifiers. Criterion A (ADHD symptoms) are unchanged from DSM-IV except for additional examples of how symptoms may manifest in adolescence and adulthood, and a reduction from six to five in the minimum number of symptoms in either symptom domain required for older adolescents and adults. Criterion B (age of onset) changed from onset of symptoms and impairments before age 7 to onset of symptoms before age 12. Criterion C (pervasiveness) was changed from evidence of impairment to evidence of symptoms in two or more settings. Criterion D (impairment) now requires that functional impairments only need to “reduce the quality of social, academic or occupational functioning” instead of requiring that they be 𠇌linically significant.” Criterion E (exclusionary conditions) no longer includes Autism Spectrum Disorder as an exclusionary diagnosis. Regarding nosology, the DSM-IV ADHD “types” are now referred to as “presentations.” Finally, modifiers were added so that the severity of the disorder (i.e., mild, moderate, or severe) can be specified and the disorder can be coded as “in partial remission” if full diagnostic criteria are not currently met.

Overall, the revisions to ADHD in DSM-5 are less dramatic than updates to earlier DSMs. Importantly, the DSM-5 ADHD and Disruptive Behavior Disorders Workgroup decided neither to modify the core ADHD symptom domains (i.e., Inattention and Hyperactivity/Impulsivity) nor to revise the 18 core symptoms, aside from adding example behaviors to better define some of the symptoms for older adolescents and adults. The retention of the ADHD symptom domains and 18 core symptoms likely reflects a judgment that the DSM-IV definition of ADHD has largely withstood the test of time. DSM-IV ADHD criteria have proven to be quite effective at reliably identifying a population of individuals who have significant impairments across a wide range of outcomes (e.g., academic, interpersonal, occupational, personal, substance use, driving, etc. [7, 8]). Moreover, individuals identified by DSM-IV ADHD criteria appear to have distinct neuropsychological profiles [9, 10] identifiable neurobiological signatures (e.g., abnormalities in frontal-striatal circuitry [11, 12]) and unique genetic correlates [13]. By retaining a similar ADHD phenotype as defined in DSM-IV, the DSM-5 workgroup ensured that the voluminous body of DSM-IV defined ADHD research accumulated over the past 2 decades will largely generalize to the new, yet highly similar, DSM-5 ADHD phenotype.

Although more subtle than changes in prior DSMs, the changes to ADHD in DSM-5 are important and reflect our increased knowledge about the nature of ADHD. In particular, it has become increasingly evident that the DSM-IV symptom domain thresholds (i.e., 6 of 9 symptoms per symptom domain), while appropriate for young children, are not effective for identifying adolescents and adults experiencing ADHD-related impairment. Prior to DSM-5, some researchers used lower symptom thresholds to define adolescent and/or adult ADHD samples (e.g., [14]), in discord with DSM-IV many clinicians did likewise or relied on the poorly-defined ADHD Not Otherwise Specified. Research suggests that a lower symptom number threshold more accurately identifies those 17 and older who experience impairments warranting intervention [15].

Similarly, research has shown no meaningful differences in functioning, response to treatment, or outcomes in individuals who display ADHD symptoms prior to age 7 versus those who first display symptoms at an older age [16]. Both research and clinical experience indicates some ADHD patient groups (e.g., those with high intelligence, with predominantly inattentive symptoms, or in a highly structured environment) may not experience significant impairment until expectations for self- management increase in late elementary or middle school. For those individuals whose ADHD is not identified until adulthood, they often have difficulty recalling at what age they first experienced impairments, as the inherent memory problems often associated with ADHD make recall of childhood details difficult. The change to an age of onset of 12, while albeit still rather arbitrary, may reduce some of these diagnostic issues.

The change in nomenclature from “subtypes” in DSM-IV to “presentations” in DSM-5 reflects increasing evidence that symptoms are often fluid within individuals across their lifespan rather than stable traits. DSM-IV ADHD subtypes change across development due to the heterotypic continuity of symptom trajectories over time. For example, since inattention is relatively stable across development while hyperactivity/impulsivity often wane with age, many children diagnosed with ADHD, Combined eventually transition to ADHD, Predominantly Inattentive [17]. The “presentation” terminology better reflects that the symptom profile represents the person’s current symptomatology, which may change over time. The “type” terminology implied more stable, trait-like characteristics. Finally, modifying Criteria E to allow a diagnosis of ADHD comorbid with ASD is consistent with research indicating that children with ASD can also have ADHD [18].

Besides aligning the ADHD criteria with the current state of knowledge, the modifications in DSM-5 have the potential to make the ADHD diagnosis more reliable. In particular, the switch from requiring evidence of impairing symptoms to just symptoms for both the pervasiveness and age of onset criteria likely improves their reliability. Symptoms tend to be more easily quantified and observed. There are numerous established measures of ADHD symptoms, whereas impairments tend to be more qualitative and subjective for which we have fewer reliable measures. However, since ADHD symptoms can exist in the absence of impairment, whereas impairments in the absence of symptoms are unlikely, focusing on symptoms without impairments may increase the number of children who meet both age of onset and pervasiveness criteria. In addition, the modification of the definition of impairment from “significant” to “interfere with, reduce the quality of…” is also a more liberal and more inclusive requirement. So, while the new DSM-5 ADHD criteria may result in a more reliable set of criteria, ADHD prevalence rates may increase.

A couple of issues were unfortunately not addressed in the revisions to ADHD in DSM-5. First, there is an increasing, if not universal, acceptance that ADHD, like many psychopathologies, is a dimensional disorder [19]. That is, inattention and hyperactivity/impulsivity are behavioral traits that naturally occur on a continuum, much like intelligence. In this view, diagnostic thresholds used to define �normal behavior” are artificial, though useful in identifying individuals who experience significant impairment in their daily functioning. DSM-5 continues to place everyone meeting diagnostic criteria into a single category which doesn’t capture the dimensionality of underlying constructs. While DSM-5 does allow for a severity classification (mild, moderate, or severe), these can be applied based on either number of symptoms or magnitude of impairment. Given that both symptom counts and functional impairment can, and often do, vary across domains and across settings, it is likely that severity classifications will be unreliable and will vary considerably across diagnosticians. Preferably, some form of indication of level of global functioning might most accurately indicate severity of the disorder. The WHO Disability Assessment Scale (WHODAS) has been added to DSM-5, and is somewhat akin to indicating global functioning except it assesses the impact of the patient’s entire diagnostic profile on global functioning. Future revisions should consider other nosological devices to indicate both the dimensionality of the disorder and the impact of each specific disorder (e.g., ADHD) on overall functioning. Perhaps overall clinical global impressions [20], as used to assess severity of impairment in ADHD clinical trials, could be considered.

Finally, while some changes, as noted above, were made to make the ADHD criteria more applicable to older adolescents and adults, the DSM-5 ADHD diagnostic structure fails to reflect established developmental trajectories. In particular, the “Predominantly Inattentive Presentation” includes both children who, at a younger age, met criteria for 𠇌ombined presentation” as well as those who have always had few, if any, Hyperactive/Impulsive symptoms. Pre-release correspondence from the Workgroup suggested that an “Inattentive Restrictive Type” was considered for children with consistently low numbers of hyperactive/impulsive symptoms. It is possible that segmenting out this sub-population of children with ADHD may have both addressed heterogeneity within the ADHD Predominantly Inattentive presentation and spurred research into whether specific symptom trajectories are associated with prognosis, neurobiological correlates, comorbidity patterns, etc. Hopefully, future revisions will reconsider such sub-classifications, or other strategies for capturing developmental changes over time.


Bibliography

american psychiatric association. (1994). diagnostic andstatistical manual of mental disorders, 4th edition. washington, dc: american psychiatric press.

barkley, r. a. (1998). attention deficit hyperactivity disorder: a handbook for diagnosis and treatment, 2nd edition. new york: guilford.

carlson, e. a. jacobvitz, d. and sroufe, l. a. (1995). "adevelopmental investigation of inattentiveness and hyperactivity." child development 66:37–54.

degrandpre, r., and hinshaw, s. p. (2000). "attention-deficit hyperactivity disorder: psychiatric problem or american cop-out?" cerebrum 2:12–38.

hinshaw, s. p. (1999). "psychosocial intervention forchildhood adhd: etiologic and developmental themes, comorbidity, and integration with pharmacotherapy." in rochester symposium on developmental psychopathology, vol. 9: developmental approaches to prevention and intervention, ed. d. ciccehetti and s. l. toth. rochester, ny: university of rochester press.

hinshaw, s. p. owens, e. b. wells, k. c. kraemer, h. c.abikoff, h. b. arnold, l. e. conners, c. k. elliott, g. greenhill, l. l. hechtman, l. hoza, b. jensen, p. s. march, j. s. newcorn, j. pelham, w. e. swanson, j. m. vitiello, b. and wigal, t. (2000). "family processes and treatment outcome in the mta: negative/ineffective parenting practices in relation to multimodal treatment." journal of abnormal child psychology 28:555–568.

hinshaw, s. p., and park, t. (1999). "research issues andproblems: toward a more definitive science of disruptive behavior disorders." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

hinshaw, s. p. zupan, b. a. simmel, c. nigg, j. t. andmelnick, s. m. (1997). "peer status in boys with and without attention-deficit hyperactivity disorder: predictions from overt and covert antisocial behavior, social isolation, and authoritative parenting beliefs." child development 64:880–896.

johnston, c., and mash, e. j. (2001). "families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research." clinical child and family psychology review 4:183–207.

mannuzza, s., and klein, r. g. (1999). "adolescent andadult outcomes in attention-deficit/hyperactivity disorder." in handbook of disruptive behavior disorders, ed. h. c. quay and a. e. hogan. new york: plenum.

patterson, g. r. reid, j. and dishion, t. (1992). antisocial boys. eugene, or: castalia.

pelham, w. e. wheeler, t. and chronis, a. (1998). "empirically supported psychosocial treatments for adhd." journal of clinical child psychology 27:189–204.

simmel, c. brooks, d. barth, r. p. and hinshaw, s. p.(2001). "externalizing symptomatology among adoptive youth: prevalence and preadoption risk factors." journal of abnormal child psychology 29:57–69.

tannock, r. (1998). "attention deficit hyperactivity disorder: advances in cognitive, neurobiological, and genetic research." journal of child psychology and psychiatry 39:65–99.


Three types of ADHD: What are the differences?

ADHD stands for attention deficit hyperactivity disorder and is also sometimes referred to as ADD, generally when the person with the disorder does not display symptoms of hyperactivity.

Although there are several different predominant clusters of symptoms that people can experience, the diagnosis is still ADHD.

ADHD is one of the most common health disorders affecting children. It is estimated that around 11 percent of children aged between 4 and 17 in the United States have ADHD, which equates to around 6.4 million children. However, adults can also have ADHD.

This article will explain the three different types of ADHD.

Share on Pinterest ADHD is estimated to affect more than 10 percent of children in the U.S., making it one of the most common health disorders children face.

ADHD is often first identified in school-aged children. A key sign is when their behavior becomes disruptive, and they show signs of:

ADHD is more common among boys than girls.

There are three main types of ADHD, which differ according to the symptoms that present most commonly. The three types are:

  • ADHD, combined presentation: This is the most common type of ADHD. The person will show impulsive and hyperactive behavior, as well as getting distracted easily and struggling to maintain attention.
  • ADHD, predominantly impulsive/hyperactive: This is the least common type. The person will show signs of hyperactivity and the need to move constantly, as well as displaying impulsive behavior. They do not show signs of getting distracted or inattention.
  • ADHD, predominantly inattentive: People with this type of ADHD do not exhibit signs of hyperactivity or impulsivity. Instead, the person will get distracted easily and find it difficult to pay attention.

The predominantly inattentive type is the one often referred to as ADD (standing for attention deficit disorder) as the term does not contain the word “hyperactivity.”

The disorder was described as ADD before the word ‘hyperactivity’ was added in 1987. Essentially, ADD is now an outdated way to refer to ADHD.

It was once believed that children with ADHD outgrew the disorder during adolescence because hyperactivity is often reduced as children become teenagers.

However, adults can also have ADHD and often they do not even realize that they have it. While it is true that hyperactivity is less of an issue in adults with ADHD, often other symptoms can get worse. These include:

While most people diagnosed with ADHD as adults recall having similar problems as a child, it is not always the case, and it is possible that the symptoms have developed later in life.


How to Help a Child With the Condition

If your child is diagnosed, their doctor may prescribe medication to make them more able to concentrate, suggest therapy, or use a small device to help stimulate the part of the brain believed to be responsible for ADHD. This recently FDA-approved device, called the Monarch external Trigeminal Nerve Stimulation (eTNS) System, can be prescribed for patients 7 to 12 years old who are not already taking ADHD medication.

Continued

A combination of medicine and therapy is the most common approach.

Behavior therapy also teaches you some parenting tactics, such as:

  • Set up a system of rewards for good behavior.
  • Withhold privileges or take away rewards to deal with unwanted behavior.

Continued

Parents, teachers, and counselors can use these methods to help children with inattentive ADHD stay on track:

  • Make to-do lists. Create lists of homework and household chores, and post them in places where your child can easily see them.
  • "Bite-size" projects. Break down projects and requests into small tasks. Instead of saying, "Do your homework," you might say, "Finish your math sheet. Then read one chapter of your English book. Finally, write one paragraph describing what you read."
  • Give clear instructions. Make them simple and easy to understand.
  • Organize. Make sure your child's clothes and schoolwork are always in the same place and easy to find.
  • Get into a routine. A sense of order helps inattentive children stay focused. Follow the same schedule every day -- “get dressed, brush your teeth, eat breakfast, put on your coat.” Post the schedule in a central place, such as the kitchen or main hallway of your house.
  • Cut down on distractions. Turn off the TV, computer, radio, and video games as much as possible at home. Ask the teacher to seat your child away from the windows and doors in class.
  • Give rewards. Everyone likes praise for a job well-done. When the homework is finished on time, or the bedroom gets picked up, let your child know you noticed. You might offer to take them on a trip to the zoo or go out for frozen yogurt.

Continued

Your child spends much of their time in school, so you’ll need to be in touch with their teacher to keep tabs on how they are doing in class. Together, you can come up with different ways to help your child. The school can make accommodations to better serve your child’s needs. Talk to the principal.

When a child has the treatment, tools, and support they need, they will be able to focus and accomplish their goals.

Sources

National Institute of Mental Health: "Attention Deficit Hyperactivity Disorder (ADHD)."

Nemours Foundation: "What Is ADHD?"

Bope, E.T., and Kellerman, R.D. Conn's Current Therapy 2012, 1st edition, Saunders Elsevier, 2011.

UpToDate: "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis."


Symptoms and Diagnosis of ADHD

Deciding if a child has ADHD is a process with several steps. This page gives you an overview of how ADHD is diagnosed. There is no single test to diagnose ADHD, and many other problems, like sleep disorders, anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

If you are concerned about whether a child might have ADHD, the first step is to talk with a healthcare provider to find out if the symptoms fit the diagnosis. The diagnosis can be made by a mental health professional, like a psychologist or psychiatrist, or by a primary care provider, like a pediatrician.

The American Academy of Pediatrics (AAP) recommends that healthcare providers ask parents, teachers, and other adults who care for the child about the child&rsquos behavior in different settings, like at home, school, or with peers. Read more about the recommendations.

The healthcare provider should also determine whether the child has another condition that can either explain the symptoms better, or that occurs at the same time as ADHD. Read more about other concerns and conditions.

How is ADHD diagnosed?

Healthcare providers use the guidelines in the American Psychiatric Association&rsquos Diagnostic and Statistical Manual, Fifth edition (DSM-5) 1 , to help diagnose ADHD. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities can also help determine how many children have ADHD, and how public health is impacted by this condition.

Here are the criteria in shortened form. Please note that they are presented just for your information. Only trained healthcare providers can diagnose or treat ADHD.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity&ndashimpulsivity that interferes with functioning or development:

  1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    • Often has trouble holding attention on tasks or play activities.
    • Often does not seem to listen when spoken to directly.
    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
    • Often has trouble organizing tasks and activities.
    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    • Is often easily distracted
    • Is often forgetful in daily activities.
  2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person&rsquos developmental level:
    • Often fidgets with or taps hands or feet, or squirms in seat.
    • Often leaves seat in situations when remaining seated is expected.
    • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    • Often unable to play or take part in leisure activities quietly.
    • Is often &ldquoon the go&rdquo acting as if &ldquodriven by a motor&rdquo.
    • Often talks excessively.
    • Often blurts out an answer before a question has been completed.
    • Often has trouble waiting their turn.
    • Often interrupts or intrudes on others (e.g., butts into conversations or games)
In addition, the following conditions must be met:
  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  • Several symptoms are present in two or more settings, (such as at home, school or work with friends or relatives in other activities).
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
  • The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
  • Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
  • Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
  • Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.

Diagnosing ADHD in Adults

ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 years or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

For more information about diagnosis and treatment throughout the lifespan, please visit the websites of the National Resource Center on ADHD external icon and the National Institutes of Mental Health external icon .

Reference

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.


They didn't always call it ADHD, though, and used terms like:

  • Brain-injured
  • Brain-damaged child
  • Hyperkinetic impulse disorder
  • Hyperexcitability syndrome
  • Clumsy child syndrome
  • Hyperactive child syndrome
  • Hyperkinetic reaction of childhood
  • Minimal brain dysfunction
  • Organic brain disease
  • Nervous child
  • Attention deficit disorder

It has been known as ADHD since 1987 and is further divided into three subtypes: inattentive type, hyperactive/impulsive type, and the combined type.


Inattentive Type ADHD

ADHD is generally twice as prevalent among boys than girls. However, inattentive type ADHD is more common in girls. It is also more prevalent in older children and adults.

People with this type of ADHD have symptoms stemming from not being able to focus properly. Unlike with impulsive/hyperactive ADHD, people with this type do not show any signs of hyperactivity or impulsivity. Instead, the main symptoms of this type are:

  • Being easily distracted
  • Reluctance to do tasks that require sustained mental effort, like schoolwork
  • Fixation on activities that don't require sustained mental effort, like television
  • Forgetfulness
  • Trouble with organization
  • Often makes careless errors

Background

Attention deficit/hyperactivity disorder (ADHD) is characterized by a combination of age-inappropriate levels of inattention, impulsive behavior and hyperactivity. Symptoms must become apparent before the age of 12 years and cause significant impairments in more than one setting, e.g., at school or work, or with family and peers [1]. The diagnostic and statistical manual of mental disorders (DSM V [1]) distinguishes three subtypes of ADHD, the predominantly inattentive type (IA), the predominantly hyperactive/impulsive type (HI) and the combined type (C). Children of the IA type show more than six out of the nine relevant symptoms specified as inattentive behavior and less than six out of the nine relevant symptoms specified as hyperactive/impulsive behavior. The predominantly HI type is characterized by more than six HI symptoms and less than six IA symptoms, whereas children of the C type show more than six symptoms in both areas. Although ADHD was long regarded solely as a childhood disorder, it is now agreed that the disorder persists into adulthood (e.g., [2, 3]), and even into old age [4, 5]. Estimations of adulthood ADHD’s prevalence rates range from 2.5 to 5% [6�], slightly smaller than those reported for children and youths that range from 5.0 to 7.1% [13, 14].

Assessment of ADHD using ratings and tests

Most diagnostic guidelines (e.g., [15�]) require that ADHD be assessed and diagnosed by relying on information provided via a variety of methods (e.g., clinical interviews, observations and ratings) and collected from multiple sources (e.g., parents and teachers). However, using subjective measures always incorporates the risk of informant biases [18] and clinicians are often confronted with great inconsistencies between ratings obtained from different sources [19, 20]. Although the discrepancies between different informants can be of clinical relevance [21], the use of objective measures in addition to subjective ratings might yield valuable information facilitating the diagnosis of ADHD. In the present study, we therefore aimed to investigate the role of objective measures when trying to distinguish between individuals with ADHD and controls. We also aimed to investigate how objective measures are related to subjective measures by investigating how well we could discriminate between ADHD and controls when using the combination of these two types of measures. The combination of objective and subjective measures may provide additional information than objective measures alone as it has been argued that tests and ratings may capture at least partly different constructs [22, 23] and should not be used interchangeably. Toplak and colleagues [23] argue that one important difference between ratings and tests is that the former measure typical performance (i.e., how an individual normally performs), whereas tests usually capture optimal performance (i.e., how well an individual performs under relatively optimal conditions). Thus, objective measures assess performance free of influences of the different situations. However, this study primarily investigated whether only objective measures would be sufficient to develop a statistical model as the bias and inter-operator error inherent in subjective measures are not well suited to developing a robust and objective classifier. Whilst the value of including subjective measures in a classifier alongside objective measures has been explored, developing an objective statistical method using only subjective data would not be expected to produce a robust classifier that would generalize to corresponding data acquired by other operators.

The relative importance of individual variables towards a diagnosis of ADHD is an issue that has not been empirically examined, at least not in studies employing statistical methods that can handle numerous variables to make an objective prediction. Similarly, few studies focus on objective measurements of ADHD symptom levels rather than constructs (such as executive functioning deficits) that are known to be associated with ADHD.

Objective measures

Test battery of attention

In Germany, where this study was conducted, a frequently used neuropsychological test is the test battery of attention for adolescents and adults (TAP [24]) or for children aged 6� (KiTAP [25]). The various subtests enable the assessment of aspects of two of the three core symptoms of ADHD, namely inattention and impulsivity. A detailed description of the tasks is provided in the method section. One study using the TAP in a sample of children with ADHD and healthy controls demonstrated that two test measures (reaction time variability of the Go/NoGo task, number of errors of the reaction change task) were needed to classify 90% of the children correctly [26]. Drechsler et al. [27] detected significant group differences between children with and without ADHD in four of the KiTAP’s six subtests. Nevertheless, they did not recommend using it for diagnostic purposes due to its weak specificity. Another study on the psychometric properties of the KiTAP reported values for split-half reliability of .55–.96 for children aged 8� [25] and .32–.72 for children aged 6𠄷 years [28]. The psychometric properties of the TAP/KiTAP are thus not fully satisfactory, and norm references are missing for some age groups. An alternative is the Quantified Behavior Test, a neuropsychological test becoming increasingly important in ADHD diagnostics.

The Quantified Behavior Test

The Quantified Behavior Test for children aged 6� (QbTest 6� [29]) and the Quantified Behavior Test Plus for subjects 12 years and older (Qb+ © [30]) are computerized neuropsychological tests that assess the three core symptoms of ADHD using a continuous performance test (CPT). One great advantage of these tests is that in addition to providing estimates of the participant’s performance (e.g., omission and commission errors), they also measure head movements via a motion tracking system. For example, the system generates measures of the time the subject has moved more than 1਌m/s, as well as the distance they traveled during the test or the surface covered through their movements. Reh et al. [31] reported promising results determining the QbTest 6�’s factorial and discriminant validity with a three-factor solution corresponding to the three areas of ADHD impairment. These explained 76% of the total variance and reliability estimates ranging from α = .60 (impulsivity) to α = .95 (hyperactivity) for these factors. Findings have been less consistent regarding the QbTest 6�’s convergent and discriminant validity. One study exhibited significant differences between children with ADHD, their siblings, and healthy controls, and the authors identified the factor of hyperactivity as a possible “intermediate phenotype” [32]. Hult et al. [33] examined the diagnostic validity of the QbTest 6� applying ROC curves in a clinical sample of children diagnosed with ADHD and a clinical control group of individuals with primarily autism spectrum disorder, observing moderate sensitivity (47�%) and specificity values (72�%). In a third study, multi-trait, multi-method analyses comparing self- and observer ratings (Conners 3 rating scales) with objective measures provided support for the convergent validity of the QbTest 6� especially for the variables assessing inattention, but discriminant validity was not supported [34]. However, discrimination analyses based on the QbTest 6� also achieved 73.8% accuracy in predicting whether a child had an ADHD diagnosis (all subtypes) or not with the variables measuring activity revealing the greatest impact. There are studies of the Qb+ © , the version used for adolescents and adults, demonstrating high sensitivity (86%) and specificity (83%) when trying to differentiate between subjects with and without ADHD [35, 36]. However, sensitivity dropped substantially when trying to differentiate between individuals with ADHD and other clinical groups such as bipolar II disorder (36%) or borderline personality disorder (41% [35]). However, in another study, with a large sample of patients that came in for ADHD assessment, we were able to differentiate patients for which an ADHD diagnosis was confirmed (66% of 773 subjects) versus patients that had symptoms of inattention, impulsivity or hyperactivity due to other disorders (34% of 773 subjects). All individuals performed the QbTest, the objective measure also used in this study. Of those individuals predicted not to have an ADHD diagnosis based on the QbTest, 67% actually had no diagnosis of those individuals predicted to have an ADHD diagnosis, 79% actually had a diagnosis. In the whole sample, the correct classification rate was 76.4%, sensitivity was 90%, and specificity was just 45% [37]. Another study reported satisfactory overall classification rates (87.8% correctly identified ADHD patients), but lower correct prediction rates regarding the area under the curve (AUC) range for sensitivity (36.5�.5%) and specificity (80�% [38]). Hirsch and Christiansen [37] verified the three factorial structure of the Qb+ © and provided support for convergent validity using multi-trait, multi-method analyses, but the discriminant validity of this instrument was only partially supported. The measure of impulsivity has been shown to be the least sensitive symptom with regard to discriminating between adults with and without ADHD as well as between patients with ADHD or other psychiatric disorders [35, 36, 39].

Aim of the present study

In summary, there are several studies reporting promising results regarding the ability of the QbTest 6� and the Qb+ © to differentiate between patients with and without ADHD. Nevertheless, findings are inconsistent, and often suggest using neuropsychological tests only as an additional resource within a comprehensive assessment strategy incorporating a variety of methods [27]. In the clinical community there is a high controversy about the usefulness of objective measures for diagnostic purposes as problems regarding sensitivity, specificity and ecological validity have been reported [40]. In light of the evidence that ratings and tests seem to assess partly different constructs, objective and subjective measures could be seen as complementing each other. The diagnostic value of objective tests becomes all the more important when the potential risks of subjective measures are taken into account, informant bias being the most important thereof. There is lack of studies evaluating the differential contributions of objective and subjective measures for correctly classifying ADHD. Whilst the study investigates the relative contribution of subjective measures in a classifier, the diagnostic accuracy using objective measurements only is considered more generalisable due to the inherent inter-operator variability in subjective measures. In contrast to most previous studies using neuropsychological measures and ratings to differentiate between patients with ADHD and healthy controls, we used machine learning rather than discriminant function analysis or logistic regression analysis. The advantage of the former is that it is data-driven and less sensitive to outliers [41]. Furthermore, it is a multivariate approach, as it does not rely on summary scores, but considers every single item. The risk of losing information is therefore reduced [41]. More specifically, the present study used support vector machine (SVM). This machine-learning approach is known to be very robust and capable of translating well in studies using imaging data [42]. However, it has been predominantly implemented in studies using neuroimaging data to diagnostically classify clinical populations [43, 44] and not in studies using standard clinical assessments as recommended by the various ADHD diagnostic guidelines outlined above.

The first aim of this study was thus to investigate the accuracy of employing only variables from the objective measures to reveal their specific potential contribution free from the potential confound of subjective measures. We further aimed to investigate how objective measures are related to subjective measures by investigating how well we could discriminate between ADHD and controls when using the combination of these two types of measures. In contrast to previous research, we used a machine-learning technique (SVM) to analyze the data.


Watch the video: The Brain and Learning - ADHDADD - Attention (August 2022).