Attention deficit hyperactivity disorder predominantly inattentive

"ADD" redirects here. For other uses, see ADD (disambiguation).

Attention deficit hyperactivity disorder predominantly inattentive (ADHD-PI) is one of the 2 of attention deficit hyperactivity disorder (ADHD). The term was formally changed in 1994 in the new Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-IV) to "ADHD predominantly inattentive" (ADHD-PI or ADHD-I), though the term attention deficit disorder is still widely used. ADHD-PI is similar to the other subtypes of ADHD in that it is characterized primarily by inattention, easy distractibility, disorganization, procrastination, and forgetfulness; where it differs is in lethargy/fatigue, and having fewer or no symptoms of hyperactivity or impulsiveness typical of the other ADHD subtypes. 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. Medications include two classes of drugs, stimulants and non-stimulants. Drugs for ADHD are divided into first-line medications and second-line medications. First-line medications include several of the stimulants, and tend to have a higher response rate and effect size than second-line medications. Although medication can help improve concentration, it does not cure ADHD and the symptoms will come back once the medication stops.

Differences from other ADHD subtypes

ADHD-I is similar to the other subtypes of ADHD in that it is characterized primarily by inattention, easy distractibility, disorganization, procrastination, and forgetfulness; where it differs is in lethargy - fatigue, and having fewer or no symptoms of hyperactivity or impulsiveness typical of the other ADHD subtypes. 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 ADD, 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 coping skills minimizing the frequency of inattentive or hyperactive behaviors. 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.

In the DSM-III, sluggishness, drowsiness, and daydreaming were listed as characteristics of ADD without hyperactivity. The symptoms were removed from the ADHD criteria in DSM-IV because, although those with ADHD were found to have these symptoms, this only occurred with the absence of hyperactive symptoms. These distinct symptoms were described as sluggish cognitive tempo (SCT).

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."

Some experts, such as Dr. Russell Barkley, have argued that ADD is exact same as ADHD that it should be regarded as a distinct disorder. However, Barkley currently maintains that the "other attention disorder" is sluggish cognitive tempo (SCT), that there are no meaningful "subtypes" of ADHD, and that the term ADD should no longer be used to avoid confusion. ADD is noted for the almost complete lack of conduct disorders and high-risk, thrill-seeking behavior, and additionally have higher rates of anxiety. Further research needs to be done to discover differences among those with attention disorders.

Symptoms

DSM-IV criteria

The DSM-IV allows for diagnosis of the predominantly inattentive subtype of ADHD (under code 314.00) if the individual presents six or more 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).

Examples of observed symptoms

Life Period	Example
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
	Excessive distractibility
	Forgetfulness
	Procrastination, inability to begin an activity
Adults	Often making careless mistakes when having to work on uninteresting or difficult projects
	Often having difficulty keeping attention during work; difficulty holding down a job for a significant amount of time
	Often having difficulty concentrating on conversations or losing concentration for brief moments while someone is talking
	Having trouble finishing projects; having many things "on the go" at the same time
	Often having difficulty organizing onesself for, or planning for the completion of tasks
	Avoiding or delaying starting projects that require a lot of thought, a lot of "mental effort"
	Often misplacing or having difficulty finding things at home or at work
	Keeping personal items in a disorganized state (sometimes keeping items that are old and therefore useless to the individual); keeping excessive "clutter" (in the home, car, etc.)
	Often distracted by activity or noise
	Often having problems remembering appointments or obligations
	Changing plans on a regular basis, to the inconvenience of others

Prevalence in children

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, until recently, professionals in the U.S. 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. Boys are seen as the prototypical ADHD child, therefore they are 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.

Treatment

Medications include two classes of drugs, stimulants and non-stimulants. Drugs for ADHD are divided into first-line medications and second-line medications. First-line medications include several of the stimulants, and tend to have a higher response rate and effect size than second-line medications. Some of the most common stimulants are Methylphenidate (Ritalin, Concerta), Adderall and Vyvanse. Second-line medications are usually anti-depressant medications such as Zoloft, Prozac, and Wellbutrin. These medications can help with fidgeting, inattentiveness, irritability, and trouble sleeping. Some of the symptoms the medications target are also found with ADD patients.

Although ADHD has most often been treated with medication there are questions as to the efficacy of these medications. Medications do not cure ADHD; they are used solely to treat the symptoms associated with this disorder. The symptoms will come back once the medication stops. Also, medication works better for some patients while it barely works for others.

Many studies have shown the use of psychostimulants to be an effective treatment for ADHD, as well as ADD, however these studies have shown a number of methodological flaws. Firstly they measure behaviour changes from the perspective of the parents, or teachers involved and assume that this change in behaviour is helping the child without ever consulting with the child. This has led to a questioning of who the medication is actually helping, and if the medication is being used simply to eliminate unwanted childhood behaviours rather than to actually help the child. Although most studies focus on children with ADHD the side effects and potential misuse of stimulant medications is identical for ADHD as many of the same medications are used (e.g. ritalin).

These studies have often failed to look at long-term efficacy and side effects. The psychostimulants used to treat ADHD normally start to lose efficacy after a very short period (often less than six weeks) and as this efficacy decreases the dosage given to the child must be increased, leading to a continuous cycle of more and more medication. These medications do work very quickly once administered and so may affect behaviour almost immediately, although this has again led to the idea that the medication may be getting used as a way to remove unwanted behaviours in a short-term situation.

Some have expressed concerns that educators may place undue pressure on students and their parents to use stimulant medication.

Along with medication, behavioral therapy is recommended to improve organizational skills, study techniques or social functioning.

Research

A study at the Mount Sinai AD/HD Center, supported by grants from the National Institutes of Health (NIH), will examine the use of functional Magnetic Resonance Imaging in identifying unique patterns of brain activation in children with ADD.

Strategies for parents of afflicted children

Parents are recommended to learn about this disorder to first be able to help themselves and then their children. Behavioral strategies are of great help; they include creating routines, getting organized, avoiding distractions, limiting choices, using goals and rewards, and ignoring behaviors.

Children with ADHD can be extremely disorganized. Parents should work with them to find specific places for everything and teach kids to use calendars and schedules. Parents are advised to get children into sports to help them build discipline, confidence, and improve their social skills. Physical activity boosts the brain’s dopamine, norepinephrine, and serotonin levels, and all these neurotransmitters affect focus and attention. Some sports may be too challenging and can add frustration. Parents should talk with their children about what activities and exercises most stimulate and satisfy them before signing them up for classes or sports.

Parents should establish close communication with the school to develop an education plan to address the child’s needs. Accommodations in school, such as extended time for tests or more frequent feedback from teachers, are beneficial for these individuals.

See also

• Adult attention-deficit disorder
• Auditory processing disorder
• Chemical imbalance theory
• Educational psychology
• Pediatric Attention Disorders Diagnostic Screener
• School psychology
• Sensory integration disorder
• Sluggish cognitive tempo
• Psychiatric diagnosis

External links

• http://whatisadd.net
• http://www.adda-sr.org/reading/Articles/mooreinattentive.htm
• http://www.addresources.org/?q=reading_material
• http://www.child-1st.com/new_site/index.html Educational materials specifically designed for children with ADD
• http://www.psychnet-uk.com/readers_articles/adhd_general.htm