Attention deficit hyperactivity disorder predominantly inattentive
Attention deficit hyperactivity disorder predominantly inattentive (ADHD-PI), also called attention deficit disorder (ADD), is one of the two types of hyperactivity or impulsiveness. Lethargy/fatigue is sometimes reported but ADHD-PI is a separate condition from the proposed cluster of symptoms known as Sluggish cognitive tempo.
The three most popular ADHD medications in order are Amphetamine mixed salts for dopamine and norepinephrine basically balanced, Methylphenidate for a dopamine emphasis, and Atomoxetine for a norepinephrine emphasis.
- Classification 1
Signs and symptoms 2
- DSM-5 criteria 2.1
- Pharmacological 3.1
- Prognosis 4
- Epidemiology 5
- History 6
- References 7
- External links 8
ADHD-Predominantly Inattentive is an Attention Concentration Deficit that has everything in common with ADHD except that it has fewer hyperactivity or impulsivity symptoms and has more directed attention fatigue symptoms.
Different countries have used different ways of diagnosing ADHD-PI. In the United Kingdom, diagnosis is based on quite a narrow set of symptoms, and about 0.5–1% of children are thought to have attention or hyperactivity problems. The United States used a much broader definition of the term ADHD. As a result, up to 10% of children in the U.S. were described as having ADHD. Current estimates suggest that ADHD is present throughout the world in about 1–5% of the population. About five times more boys than girls are diagnosed with ADHD.
Signs and symptoms
The DSM-5 allows for diagnosis of the predominantly inattentive subtype of ADHD (code 314.00) if the individual presents six or more (five for adults) of the following symptoms of inattention for at least six months to a point that is disruptive and inappropriate for developmental level:
- Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
- Often has trouble keeping attention on tasks or play activities.
- Often does not seem to listen when spoken to directly.
- Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
- Often has trouble organizing activities.
- Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period (such as schoolwork or homework).
- Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
- Is often easily distracted.
- Is often forgetful in daily activities.
An ADD diagnosis is contingent upon the symptoms of impairment presenting themselves in two or more settings (e.g., at school or work and at home). There must also be clear evidence of clinically significant impairment in social, academic, or occupational functioning. Lastly, the symptoms must not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder).
|Life Period||Examples of Observed Symptoms|
|Children||Failing to pay close attention to details or making careless mistakes when doing school-work or other activities|
|Trouble keeping attention focused during play or tasks|
|Appearing not to listen when spoken to (often being accused of "daydreaming")|
|Failing to follow instructions or finish tasks|
|Avoiding tasks that require a high amount of longer-term mental effort and organization, such as school projects|
|Frequently losing items required to facilitate tasks or activities, such as school supplies|
|Procrastination, inability to begin an activity, such as completing homework|
|Adults||Procrastination; delaying or avoiding starting projects that require vigilant mental effort|
|Difficulty sustaining concentration on conversations or briefly losing attention on someone speaking|
|Hesitation to sustain concentration in planning and organizing for the completion of tasks|
|Hesitative responses, doubt, and delayed execution due to inattention remembering information|
|Difficulty finishing projects or completing assignments because many tasks simultaneously on the go|
|Forgetting to complete tasks and details after temporary switches to more stimulating tasks|
|Difficulty finding misplaced tools after task switching due to bypassing adequate memory storage|
|Sustained information processing is slower than others causing information gaps that inhibit execution|
|Problems remembering appointments, obligations, or instructions|
|Difficulty learning new projects when concentration deficits cause desire to multitask or daydream|
|Distracted from persevering during work; difficulty holding onto a job for a significant amount of time|
|Change plans to the inconvenience of others due to forgetting or not fully aware of the bigger scenario|
|Maintaining excessive personal items such as storing old items of diminished usefulness|
|Obsessive behavior as compensation or coping mechanism for a perseverance deficit|
|Difficulty transitioning to new task or activity due to obsessive behavior|
|Higher rate of vigilant concentration fatigue after inhibiting many distractions from greater effort required|
Although ADHD has most often been treated with medication, medications do not cure ADHD. They are used solely to treat the symptoms associated with this disorder and the symptoms will come back once the medication stops.
Stimulants are typically formulated in fast and slow-acting as well as short and long-acting formulations. The fast-acting amphetamine mixed salts (Adderall) and its derivatives, with short and long-acting formulations produce reuptake inhibition of dopamine and norepinephrine and also increase the release of these neurotransmitters into the synaptic cleft. They may have a better cardiovascular disease profile than methylphenidate and potentially better tolerated.
The fast-acting methylphenidate (Ritalin), with short and long-acting formulations produce dopamine, and to a lesser extent, norepinephrine reuptake inhibition. In the short term, methylphenidate is well tolerated. However, long term studies have not been conducted in adults and concerns about increases in blood pressure have not been established.
The slow and long-acting stimulant atomoxetine (Strattera), is primarily a norepinephrine reuptake inhibitor and, to a lesser extent, a dopamine reuptake inhibitor. It may be more effective for those with predominantly inattentive concentration. It is sometimes prescribed in adults who do not get enough vigilant concentration response from mixed amphetamine salts (Adderall) or get too much side effect. It is also approved for ADHD by the US Food and Drug Administration.
Alternative or adjunctive therapies of Histaminergic and Cholinergic medications are much less common and researched. Histamine promoting medications to reduce sedation such as Modafinil and Acetylcholine promoting to sustain concentration such as Galantamine or Varenicline would be off label use for ADHD. New nicotinic cholinergic medications in development for ADHD are Pozanicline, ABT-418, and ABT-894.
In some cases, children who enjoy learning may develop a sense of fear when faced with structured or planned work, especially long or group-based that requires extended focus, even if they thoroughly understand the topic. Children with ADD may be at greater risk of academic failures and early withdrawal from school. Teachers and parents may make incorrect assumptions about the behaviours and attitudes of a child with ADHD-PI, and may provide them with frequent and erroneous negative feedback (e.g. "careless", "you're irresponsible", "you're immature", "you're lazy", "you don't care/show any effort", "you just aren't trying", etc.).
The inattentive children may realize on some level that they are somehow different internally from their peers. However, they are also likely to accept and internalize the continuous negative feedback, creating a negative self-image that becomes self-reinforcing. If these children progress into adulthood undiagnosed or untreated, their inattentiveness, ongoing frustrations, and poor self-image frequently create numerous and severe problems maintaining healthy relationships, succeeding in postsecondary schooling, or succeeding in the workplace. These problems can compound frustrations and low self-esteem, and will often lead to the development of secondary pathologies including anxiety disorders, sexual promiscuity, mood disorders, and substance abuse.
It has been suggested that some of the symptoms of ADHD present in childhood appear to be less overt in adulthood. This is likely due to an adult's ability to make cognitive adjustments and develop compensating or coping skills to minimize the impact of inattentive or hyperactive symptoms. However, the core problems of ADHD do not disappear with age. Some researchers have suggested that individuals with reduced or less overt hyperactivity symptoms should receive the ADHD-combined diagnosis. Hallowell and Ratey (2005) suggest that the manifestation of hyperactivity simply changes with adolescence and adulthood, becoming a more generalized restlessness or tendency to fidget.
A meta-analysis of 37 studies on cognitive differences between those with ADHD-Inattentive type and ADHD-Combined type found that "the ADHD/C subtype performed better than the ADHD/I subtype in the areas of processing speed, attention, performance IQ, memory, and fluency. The ADHD/I subtype performed better than the ADHD/C group on measures of flexibility, working memory, visual/spatial ability, motor ability, and language. Both the ADHD/C and ADHD/I groups were found to perform more poorly than the control group on measures of inhibition, however, there was no difference found between the two groups. Furthermore the ADHD/C and ADHD/I subtypes did not differ on measures of sustained attention."
It is difficult to say exactly how many children worldwide have ADHD because different countries have used different ways of diagnosing it, while some do not diagnose it at all. In the UK, diagnosis is based on quite a narrow set of symptoms, and about 0.5–1% of children are thought to have attention or hyperactivity problems. In comparison, professionals in the U.S. used a much broader definition of the term ADHD until recently. This meant up to 10% of children in the U.S. were described as having ADHD. Current estimates suggest that ADHD is present throughout the world in about 1–5% of the population. About five times more boys than girls are diagnosed with ADHD. Boys are seen as the prototypical ADHD child, therefore they are more often overdiagnosed with ADHD than girls. This may be partly because of the particular ways they express their difficulties. Boys and girls both have attention problems, but boys are more likely to be overactive and difficult to manage. Children from all cultures and social groups are diagnosed with ADHD. However, children from certain backgrounds may be particularly likely to be diagnosed with ADHD, because of different expectations about how they should behave. It is therefore important to ensure that a child's cultural background is understood and taken into account as part of the assessment.
In the DSM-III, sluggishness, drowsiness, and daydreaming were listed as characteristics of ADD without hyperactivity. These symptoms were removed from the ADHD criteria in DSM-IV even though many of those with ADHD were found to have these symptoms along with hyperactive symptoms. These distinct symptoms in the absence of hyperactivity though were described in a separate category called sluggish cognitive tempo.
- Biederman J, Faraone SV, Weber W, Russell RL, Rater M, Park KS (December 1997). "Correspondence between DSM-III-R and DSM-IV attention-deficit/hyperactivity disorder". Journal of the American Academy of Child and Adolescent Psychiatry 36 (12): 1682–7.
- Lange KW, Reichl S, Lange KM, Tucha L, Tucha O (December 2010). "The history of attention deficit hyperactivity disorder". Attention Deficit and Hyperactivity Disorders 2 (4): 241–55.
- Quinn, Patricia (1994). ADD and the College Student: A Guide for High School and College Students with Attention Deficit Disorder. New York, NY: Magination Press. pp. 2–3.
- "Attention-Deficit/Hyperactivity Disorder". BehaveNet. Retrieved 17 April 2013.
- "Attention deficit hyperactivity disorder". National Institute of Mental health. Retrieved 9 January 2013.
- Retz W, Retz-Junginger P, Thome J, Rösler M (September 2011). "Pharmacological treatment of adult ADHD in Europe". The World Journal of Biological Psychiatry 12 (Suppl 1): 89–94.
- Kolar D, Keller A, Golfinopoulos M, Cumyn L, Syer C, Hechtman L (April 2008). "Treatment of adults with attention-deficit/hyperactivity disorder". Neuropsychiatric Disease and Treatment 4 (2): 389–403.
- Godfrey J (March 2009). "Safety of therapeutic methylphenidate in adults: a systematic review of the evidence". Journal of Psychopharmacology 23 (2): 194–205.
- Simpson D, Plosker GL (2004). "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs 18 (6): 397–401.
- "Primarily Inattentive ADD: The Best Medicine for Inattentive ADHD". Primarily Inattentive ADHD. Retrieved 25 December 2013.
- Wilens TE, Decker MW (October 2007). "Neuronal nicotinic receptor agonists for the treatment of attention-deficit/hyperactivity disorder: focus on cognition". Biochemical Pharmacology 74 (8): 1212–23.
- Sarter M, Givens B, Bruno JP (April 2001). "The cognitive neuroscience of sustained attention: where top-down meets bottom-up". Brain Research Reviews 35 (2): 146–60.
- Levin ED, Simon BB (August 1998). "Nicotinic acetylcholine involvement in cognitive function in animals". Psychopharmacology 138 (3-4): 217–30.
- Demeter E, Sarter M (January 2013). "Leveraging the cortical cholinergic system to enhance attention". Neuropharmacology 64: 294–304.
- Potter AS, Newhouse PA, Bucci DJ (December 2006). "Central nicotinic cholinergic systems: a role in the cognitive dysfunction in attention-deficit/hyperactivity disorder?". Behavioural Brain Research 175 (2): 201–11.
- Apostol G, Abi-Saab W, Kratochvil CJ, et al. (February 2012). "Efficacy and safety of the novel α₄β₂ neuronal nicotinic receptor partial agonist ABT-089 in adults with attention-deficit/hyperactivity disorder: a randomized, double-blind, placebo-controlled crossover study". Psychopharmacology 219 (3): 715–25.
- Rueter LE, Anderson DJ, Briggs CA, et al. (2004). "ABT-089: pharmacological properties of a neuronal nicotinic acetylcholine receptor agonist for the potential treatment of cognitive disorders". CNS Drug Reviews 10 (2): 167–82.
- Wilens TE, Biederman J, Spencer TJ, et al. (December 1999). "A pilot controlled clinical trial of ABT-418, a cholinergic agonist, in the treatment of adults with attention deficit hyperactivity disorder". The American Journal of Psychiatry 156 (12): 1931–7.
- Bain EE, Robieson W, Pritchett Y, et al. (February 2013). "A randomized, double-blind, placebo-controlled phase 2 study of α4β2 agonist ABT-894 in adults with ADHD". Neuropsychopharmacology 38 (3): 405–13.
- Triolo, Santo (1998). Attention Deficit Hyperactivity Disorder in Adulthood: A Practitioner's Handbook. Philadelphia, PA: Brunner-Routledge. pp. 65–69.
- Ramundo, Peggy (2006). You Mean I'm Not Lazy, Stupid or Crazy?! The Classic Self-Help Book For Adults with Attention Deficit Disorder. New York, NY: Scribner. pp. 11–12.
- Lane, Brittany Ann (2003). The differential neuropsychological/cognitive profiles of ADHD subtypes: A meta-analysis (PhD Thesis). University of Northern Colorado.
- Bruchmüller K, Margraf J, Schneider S (February 2012). "Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis". Journal of Consulting and Clinical Psychology 80 (1): 128–38.