ADHD (Attention-Deficit/Hyperactivity Disorder) is a complex neurodevelopmental condition that presents in different ways depending on the individual. Recognising that ADHD manifests differently in different people, the American Psychiatric Association’s DSM-5 categorises ADHD into three sub-types: Predominantly Inattentive Presentation, Predominantly Hyperactive-Impulsive Presentation, and Combined Presentation (APA, 2013). Understanding these sub-types allows for more accurate diagnosis and treatment, which can improve the quality of life for those affected.
1. Predominantly Inattentive Presentation (ADHD-I)
Predominantly Inattentive Presentation is characterised primarily by symptoms of inattention without significant hyperactivity or impulsivity. Individuals with this sub-type often struggle with focus.
Key Symptoms
- Difficulty sustaining attention in tasks or activities, especially those that require prolonged mental effort.
- Prone to forgetfulness in daily activities, such as missing appointments or misplacing items.
- Disorganisation, leading to struggles in managing schedules or handling multi-step instructions.
- Avoidance of subjectively ‘boring’ tasks: They may avoid tasks that do not stimulate their minds with innate interest (Willcutt et al., 2012; Young et al., 2020).
2. Predominantly Hyperactive-Impulsive Presentation (ADHD-HI)
Predominantly Hyperactive-Impulsive Presentation involves significant hyperactivity and impulsivity, with fewer symptoms of inattention. This presentation tends to be more noticeable, as it often includes behaviours that disrupt social and academic settings.
Key Symptoms
- Constant fidgeting or moving, including restlessness with adults where the hyperactivity may have been internalised.
- Difficulty sitting still in situations where remaining seated is expected, such as during meetings.
- Excessive talking and interrupting others, sometimes speaking before thinking.
- Impulsive actions, such as making decisions without considering consequences, which may affect financial or social life (Posner et al., 2020; Faraone et al., 2015).
3. Combined Presentation (ADHD-C)
The Combined Presentation is the most common sub-type and includes both inattentive and hyperactive-impulsive symptoms. Those with this presentation often experience a broad range of challenges that can affect multiple areas of life, including work, school, and social relationships.
Key Symptoms
- Inattention: Difficulty with focus, frequent forgetfulness, and trouble with organisation.
- Hyperactivity: Restlessness, fidgeting, and excessive talking.
- Impulsivity: Tendency to interrupt others and act without thinking (APA, 2013; Nigg, 2013).
Differential Diagnosis and Importance of Recognising Sub-Types
Identifying the specific sub-type of ADHD is important for creating an effective treatment plan. Each sub-type may respond differently to certain interventions. For example, those with predominantly inattentive symptoms may benefit more from strategies to improve focus and organisation, while those with hyperactive-impulsive symptoms may need support managing impulsivity and restlessness (Stein et al., 2021).
Summary
Understanding the sub-types of ADHD is essential for recognising its diverse manifestations and providing tailored support. Recognising whether someone has Predominantly Inattentive, Predominantly Hyperactive-Impulsive, or Combined Presentation helps in creating specific interventions that cater to individual strengths and challenges, thereby enhancing overall quality of life.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Faraone, S. V., Biederman, J., Spencer, T., Mick, E., Murray, K., Petty, C., … & Wilens, T. (2015). Diagnosing adult attention deficit hyperactivity disorder: Are late-onset and subthreshold diagnoses valid? American Journal of Psychiatry, 163(11), 1770-1775.
Nigg, J. T. (2013). Attention-deficit/hyperactivity disorder and adverse health outcomes. Clinical Psychology Review, 33(2), 215-228.
Posner, J., Polanczyk, G. V., & Sonuga-Barke, E. J. (2020). Attention-deficit hyperactivity disorder. The Lancet, 395(10222), 450-462.
Stein, M. A., Weiss, M., & Hagan, J. F. (2021). Attention-Deficit/Hyperactivity Disorder: New Practical Guidelines for Diagnosis and Treatment. JAMA Pediatrics, 175(8), 807-808.
Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., & Pennington, B. F. (2012). Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review. Biological Psychiatry, 57(11), 1336-1346.
Young, S., Hollingdale, J., Absoud, M., Bolton, P., Branney, P., Colley, W., … & Woodhouse, E. (2020). Guidance for identifying and managing ADHD in children and young people: The UK ADHD Partnership Guide. Journal of Psychopharmacology, 34(5), 456-482.