Attention deficit hyperactivity disorder predominantly inattentive

Short description: Neurodevelopmental disorder

Attention deficit hyperactivity disorder predominantly inattentive

Other names| Attention deficit disorder (ADD) (without hyperactivity) (outdated)[1][2]
Specialty| Psychiatry
Medication|

* Stimulants (methylphenidate, amphetamine)
* non-stimulants (atomoxetine, viloxazine)
* alpha-2a agonists (guanfacine XR, clonidine XR)

Attention deficit hyperactivity disorder, predominantly inattentive presentation (ADHD-PI or ADHD-I),[3] is one of the three recognized presentations of attention deficit hyperactivity disorder (ADHD).[4]

Historically, ADHD was not divided into presentations. Between 1987 and 1994, during the publication of the DSM-III-R, the disorder was classified as a single entity without subtypes. In the DSM-5, these subtypes were replaced with “presentations,” reflecting that an individual’s symptom profile can change over time.

The predominantly inattentive presentation is characterized primarily by symptoms of inattention—such as difficulty sustaining attention, procrastination, hesitation in task initiation, and frequent forgetfulness. Unlike the hyperactive-impulsive and combined presentations, individuals with ADHD-PI exhibit fewer or no symptoms of hyperactivity and impulsivity. Lethargy and fatigue may be reported, but ADHD-PI is distinct from cognitive disengagement syndrome (CDS), a separate construct characterized by sluggish cognitive tempo.[5]

## Contents

* 1 Classification
* 2 Signs and symptoms
* 2.1 DSM-5 criteria
* 3 Treatment
* 3.1 Medication
* 4 Prognosis
* 4.1 Self-esteem
* 4.2 Coping and age
* 4.3 Comparisons between subtypes
* 5 Epidemiology
* 6 History
* 7 References

## Classification

ADHD-PI is a presentation of ADHD in which symptoms of inattention predominate, while symptoms of hyperactivity or impulsivity are less prominent or absent. Individuals often exhibit directed attention fatigue and may appear internally distracted rather than outwardly hyperactive.[6]

## Signs and symptoms

### DSM-5 criteria

The DSM-5 allows for diagnosis of the predominantly inattentive presentations of ADHD (ICD-10 code F90.0) 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.[7]

An ADHD 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 schizophrenia or another psychotic disorder, and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder).[8]

Life period  | Examples of observed symptoms

|

Children  | Failing to pay close attention to details or making careless mistakes when doing schoolwork 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, such as completing homework
Adults  | Procrastination; delaying or avoiding starting projects that require vigilant mental effort
Difficulty sustaining concentration in 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 are simultaneously on the go
Forgetting to complete tasks and details after temporarily switching 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
Changing 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
Compulsive behavior as compensation or coping mechanism for a perseverance deficit
Difficulty transitioning to new task or activity due to compulsive behavior
Higher rate of vigilant concentration fatigue after inhibiting many distractions from greater effort required

## Treatment

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.[9]

### Medication

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 bind to the trace amine associated receptor and triggers the release of dopamine into the synaptic cleft.[10] They may have a better cardiovascular disease profile than methylphenidate and potentially better tolerated.[11]

The fast-acting methylphenidate (well known under the trade name Ritalin) is a dopamine reuptake inhibitor.[12] In the short term, methylphenidate is well tolerated. However, long-term studies have not been conducted in adults, and concerns about long-term effects like increases in blood pressure have not been established.[13]

The slow and long-acting nonstimulant atomoxetine (Strattera), is primarily a norepinephrine reuptake inhibitor and, to a lesser extent, a dopamine reuptake inhibitor.[14] It is sometimes prescribed in adults who do not get enough vigilant concentration response from mixed amphetamine salts (Adderall) or get too many side effects.[15][unreliable medical source] It is also approved for ADHD by the US Food and Drug Administration.

The use of cholinergic adjunctive medications is uncommon and their clinical effects are poorly researched;[16][17][18][unreliable medical source][19] consequently, cholinergics such as galantamine or varenicline would be off label use for ADHD.[20][21][22] New nicotinic cholinergic medications in development for ADHD are pozanicline,[23][non-primary source needed][24] ABT-418,[25][non-primary source needed][26] and ABT-894.[27][non-primary source needed]

## Prognosis

### Self-esteem

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 assignments that require extended focus, even if they thoroughly understand the topic. Children with ADHD-PI may be at greater risk of academic failures and early withdrawal from school.[28] Teachers and parents may make incorrect assumptions about the behaviors 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.).[29]

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, mood disorders, and substance abuse.[28]

### Coping and age

It has been suggested[6] 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.[28] Some researchers have suggested that individuals with reduced or less overt hyperactivity symptoms should receive the ADHD-combined diagnosis. Hallowell and Ratey (2005) suggest[30] that the manifestation of hyperactivity simply changes with adolescence and adulthood, becoming a more generalized restlessness or tendency to fidget.

### Comparisons between subtypes

A meta-analysis of 37 studies on cognitive differences between those presenting ADHD-Predominantly Inattentive presentations and ADHD-Combined type found that "the ADHD-C presenting performed better than the ADHD-PI presenting in the areas of processing speed, attention, performance IQ, memory, and fluency. The ADHD-PI presenting performed better than the ADHD-C group on measures of flexibility, working memory, visual/spatial ability, non-verbal IQ, motor ability, and language. Both the ADHD-C and ADHD-PI 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-PI presenting did not differ on measures of sustained attention."[31]

## Epidemiology

It is difficult to say exactly how many children or adults 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.[32] This meant up to 10% of children in the U.S. were described as having ADHD. Current estimates suggest that ADHD is present internationally in about 7.2% of children.[33] ADHD is diagnosed around 5 times more often in boys than girls. Reasons for this disparity are debated, but likely involve both biological and social/diagnostic factors.[34][non-primary source needed] Some theorize this may be because of the particular ways they express their difficulties. Boys and girls both have attention problems, but due to differences in gender and symptoms, boys may come off as more active in their symptoms and therefore seem harder to manage.[35] 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, due to 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.

## History

In 1980, the DSM-III changed the name of the condition from "hyperkinetic reaction of childhood" to "attention deficit disorder" (ADD), as research by Virginia Douglas had suggested deficits in attention and impulse control were more important than hyperactive behavior for understanding the disorder. The new label also reflected the observation of clinicians that attention deficits could also exist without hyperactivity. Deficits in sustained attention or vigilance could separate the disorder from other psychiatric disorders.

For the first time, two subtypes were introduced: ADD with hyperactivity (ADD+H) and ADD without hyperactivity (ADD-H). While the ADD+H category was fairly consistent with previous definitions, the latter subtype represented essentially a new category. Thus, almost everything that is known about the predominantly inattentive subtype is based on research conducted since 1980. Those diagnosed with ADD-H were distinguished as more prone to daydreaming and developing lethargic and hypoactive behaviors in academic settings. In 1987, revisions to DSM renamed the disorder to "attention deficit hyperactivity disorder" (ADHD). The DSM combined the symptoms lists for inattentive, impulsivity, and hyperactivity into a single list.[36][37]

## References

1. ↑ "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. December 1997. doi:10.1097/00004583-199712000-00016. PMID 9401329. http://business.highbeam.com/5884/article-1G1-20383058/correspondence-between-dsmiiir-and-dsmiv-attentiondeficithyperactivity.
2. ↑ "The history of attention deficit hyperactivity disorder". Attention Deficit and Hyperactivity Disorders 2 (4): 241–55. December 2010. doi:10.1007/s12402-010-0045-8. PMID 21258430.
3. ↑ Weiss, Lawrence G. (2005). WISC-IV clinical use and interpretation scientist-practitioner perspectives (1st ed.). Amsterdam: Elsevier Academic Press. p. 237. ISBN 9780125649315. https://books.google.com/books?id=Eg9U9e_ICr8C&pg=PA237.
4. ↑ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 59–65. ISBN 978-0890425558. https://archive.org/details/diagnosticstatis0005unse/page/59.
5. ↑ Becker, Stephen P.; Willcutt, Erik G.; Leopold, Daniel R.; Fredrick, Joseph W.; Smith, Zoe R.; Jacobson, Lisa A.; Burns, G. Leonard; Mayes, Susan D. et al. (June 2023). "Report of a Work Group on Sluggish Cognitive Tempo: Key Research Directions and a Consensus Change in Terminology to Cognitive Disengagement Syndrome (CDS)". Journal of the American Academy of Child and Adolescent Psychiatry 62 (6): 629–645. doi:10.1016/j.jaac.2022.07.821. ISSN 0890-8567. PMID 36007816.
6. ↑ 6.0 6.1 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. ISBN 1-55798-663-0. http://www.maginationpress.com/4416630.html.
7. ↑ "Attention-Deficit/Hyperactivity Disorder". http://behavenet.com/attention-deficithyperactivity-disorder.
8. ↑ Drechsler, Renate; Brem, Silvia; Brandeis, Daniel; Grünblatt, Edna; Berger, Gregor; Walitza, Susanne (October 2020). "ADHD: Current Concepts and Treatments in Children and Adolescents". Neuropediatrics 51 (5): 315–335. doi:10.1055/s-0040-1701658. ISSN 0174-304X. PMID 32559806.
9. ↑ "Attention deficit hyperactivity disorder". National Institute of Mental health. 2008. https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-what-you-need-to-know.
10. ↑ "Pharmacological treatment of adult ADHD in Europe". The World Journal of Biological Psychiatry 12 (Suppl 1): 89–94. September 2011. doi:10.3109/15622975.2011.603229. PMID 21906003.
11. ↑ "Treatment of adults with attention-deficit/hyperactivity disorder". Neuropsychiatric Disease and Treatment 4 (2): 389–403. April 2008. doi:10.2147/ndt.s6985. PMID 18728745.
12. ↑ Volkow, N. D.; Fowler, J. S.; Wang, G.; Ding, Y.; Gatley, S. J. (1 January 2002). "Mechanism of action of methylphenidate: insights from PET imaging studies". Journal of Attention Disorders 6 (Suppl 1): S31–43. doi:10.1177/070674370200601s05. ISSN 1087-0547. PMID 12685517.
13. ↑ Godfrey J (March 2009). "Safety of therapeutic methylphenidate in adults: a systematic review of the evidence". Journal of Psychopharmacology 23 (2): 194–205. doi:10.1177/0269881108089809. PMID 18515459.
14. ↑ "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs 18 (6): 397–401. 2004. doi:10.2165/00023210-200418060-00011. PMID 15089111.
15. ↑ Messer, Tess (December 2009). "The Best Medicine for Inattentive ADHD". http://www.primarilyinattentiveadd.com/2009/12/best-medicine-for-inattentive-adhd.html.
16. ↑ "Neuronal nicotinic receptor agonists for the treatment of attention-deficit/hyperactivity disorder: focus on cognition". Biochemical Pharmacology 74 (8): 1212–23. October 2007. doi:10.1016/j.bcp.2007.07.002. PMID 17689498.
17. ↑ "The cognitive neuroscience of sustained attention: where top-down meets bottom-up". Brain Research Reviews 35 (2): 146–60. April 2001. doi:10.1016/S0165-0173(01)00044-3. PMID 11336780.
18. ↑ "Nicotinic acetylcholine involvement in cognitive function in animals". Psychopharmacology 138 (3–4): 217–30. August 1998. doi:10.1007/s002130050667. PMID 9725745.
19. ↑ "Leveraging the cortical cholinergic system to enhance attention". Neuropharmacology 64 (1): 294–304. January 2013. doi:10.1016/j.neuropharm.2012.06.060. PMID 22796110.
20. ↑ Lehmann, Christine (21 November 2003). "ADHD Symptoms Respond To Cholinergic Drugs". Psychiatric News 38 (22): 25. doi:10.1176/pn.38.22.0025.
21. ↑ Snyder, Bill (11 December 2009). "Genetics may explain three types of ADHD". http://www.mc.vanderbilt.edu:8080/reporter/index.html?ID=7947.
22. ↑ "Central nicotinic cholinergic systems: a role in the cognitive dysfunction in attention-deficit/hyperactivity disorder?". Behavioural Brain Research 175 (2): 201–11. December 2006. doi:10.1016/j.bbr.2006.09.015. PMID 17081628.
23. ↑ "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. February 2012. doi:10.1007/s00213-011-2393-2. PMID 21748252.
24. ↑ "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. 2004. doi:10.1111/j.1527-3458.2004.tb00011.x. PMID 15179445.
25. ↑ "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. December 1999. doi:10.1176/ajp.156.12.1931. PMID 10588407. http://ajp.psychiatryonline.org/article.aspx?volume=156&page=1931.
26. ↑ Childress, Ann; Sallee, Floyd R (2014-09-06). "Pozanicline for the treatment of attention-deficit/hyperactivity disorder". Expert Opinion on Investigational Drugs 23 (11): 1585–1593. doi:10.1517/13543784.2014.956078. ISSN 1354-3784. PMID 25196198. http://dx.doi.org/10.1517/13543784.2014.956078.
27. ↑ "A randomized, double-blind, placebo-controlled phase 2 study of α4β2 agonist ABT-894 in adults with ADHD". Neuropsychopharmacology 38 (3): 405–13. February 2013. doi:10.1038/npp.2012.194. PMID 23032073.
28. ↑ 28.0 28.1 28.2 Triolo, Santo (1998). Attention Deficit Hyperactivity Disorder in Adulthood: A Practitioner's Handbook. Philadelphia, PA: Brunner-Routledge. pp. 65–69. ISBN 0-87630-890-6.
29. ↑ Kelly, Kate; 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. ISBN 0-7432-6448-7. http://www.simonsays.com/content/book.cfm?tab=1&pid=506364.
30. ↑ Hallowell, Edward M.; Ratey, John J. (2005). Delivered from Distraction: Getting the Most out of Life with Attention Deficit Disorder. New York: Ballantine Books. pp. 253–5. ISBN 0-345-44231-8.
31. ↑ Lane, Brittany Ann (2003). The differential neuropsychological/cognitive profiles of ADHD presentations: A meta-analysis (PhD Thesis). University of Northern Colorado. OCLC 56479200.
32. ↑ Lange, Klaus W.; Reichl, Susanne; Lange, Katharina M.; Tucha, Lara; Tucha, Oliver (2010). "The history of attention deficit hyperactivity disorder". Attention Deficit and Hyperactivity Disorders 2 (4): 241–255. doi:10.1007/s12402-010-0045-8. ISSN 1866-6116. PMID 21258430.
33. ↑ Thomas, Rae; Sanders, Sharon; Doust, Jenny; Beller, Elaine; Glasziou, Paul (2015-04-01). "Prevalence of Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-analysis". Pediatrics 135 (4): e994–e1001. doi:10.1542/peds.2014-3482. ISSN 0031-4005. PMID 25733754.
34. ↑ "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. February 2012. doi:10.1037/a0026582. PMID 22201328.
35. ↑ Skogli, Erik Winther; Teicher, Martin H; Andersen, Per Normann; Hovik, Kjell Tore; Øie, Merete (2013-11-09). "ADHD in girls and boys – gender differences in co-existing symptoms and executive function measures". BMC Psychiatry 13 (1): 298. doi:10.1186/1471-244x-13-298. ISSN 1471-244X. PMID 24206839.
36. ↑ Barkley, Russell A., ed (2015). Attention-deficit hyperactivity disorder: a handbook for diagnosis and treatment (Fourth ed.). New York: The Guilford Press. ISBN 978-1-4625-1772-5.
37. ↑ Wheeler, Jennifer; Carlson, Caryn (3 July 1996). "Attention Deficit Disorder without Hyperactivity (ADHD, Predominantly Inattentive Type)". http://www.kidsource.com/LDA-CA/ADD_WO.html.

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Attention deficit hyperactivity disorder (F90, 314)

Main articles|

* History of ADHD
* ADHD in adults
* ADHD controversies
* ADHD management
* Social construct theory of ADHD
* ADHD coaching
* Epidemiology of ADHD
* Diet and ADHD

* Major characteristics: Attention
* Hyperactivity
* Impulsivity

Sub-types|

* ADHD predominantly inattentive (ADHD-I, formerly ADD)
* ADHD predominantly hyperactive (ADHD-H, formerly ADHD)
* ADHD combined type (ADHD-C)

Medications|

Stimulants:

* Methylphenidate (Ritalin, Concerta, and others)
* Dexmethylphenidate (Focalin, Focalin XR)
* Amphetamine (Evekeo, Adderall, Adzenys XR, Dyanavel XR)
* Dextroamphetamine (Dexedrine, Zenzedi, ProCentra, and others)
* Lisdexamfetamine (Vyvanse)

Non-stimulant:

* Atomoxetine (Strattera)
* Guanfacine (Tenex (off-label), Intuniv)
* Clonidine (Catapres (off-label), Kapvay)

Related or outdated topics|

* Deferred gratification
* Auditory processing disorder
* Deficits in attention, motor control and perception
* Developmental coordination disorder
* Low arousal theory
* Sluggish cognitive tempo
* Sensory processing disorder
* Hunter vs. farmer hypothesis

* Category

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Amphetamine

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and
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* Mydayis

|

Levoamphetamine|

N/A

Dextroamphetamine|

* Dexedrine
* ProCentra
* Zenzedi

Lisdexamfetamine|

* Vyvanse

Neuropharmacology|

| Biomolecular targets|

* TAAR1 (full agonist)
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|

Inhibited transporters|

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* VMAT1
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* EAAT3
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Active metabolites|

* 4-Hydroxyamphetamine
* 4-Hydroxynorephedrine
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* ADHD
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