Attention deficit hyperactivity disorder predominantly inattentive

Attention deficit hyperactivity disorder predominantly inattentive
Classification and external resources

Attention deficit hyperactivity disorder predominantly inattentive (ADHD-PI), formerly attention deficit disorder without hyperactivity,^[1] is one of the three presentations of attention deficit hyperactivity disorder (ADHD).^[2]

The term was formally changed in 1994 in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),^[3][4] to "ADHD predominantly inattentive" (ADHD-PI). The 'predominantly inattentive subtype' is similar to the other presentations of ADHD except that it is characterized primarily by problems with inattention or a deficit of sustained attention, such as procrastination, hesitation, and forgetfulness. It differs in having fewer or no typical symptoms of hyperactivity or impulsiveness. Lethargy and fatigue are sometimes reported, but ADHD-PI is a separate condition from the proposed cluster of symptoms known as sluggish cognitive tempo (SCT).

Classification

ADHD-PI is an attention-concentration deficit that has everything in common with other forms of ADHD except that it has fewer hyperactivity or impulsivity symptoms and has more directed attention fatigue symptoms.^[5]

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.

Signs and symptoms

DSM-5 criteria

The DSM-5 allows for diagnosis of the predominantly inattentive presentations 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.^[6]

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 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
	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 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 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
	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

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.^[7]

Pharmacological

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.^[8] They may have a better cardiovascular disease profile than methylphenidate and potentially better tolerated.^[9]

The fast-acting methylphenidate (Ritalin), is a dopamine reuptake inhibitor.^[10] 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.^[11]

The slow and long-acting nonstimulant 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.^[12] 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.^[13] 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;^{[14][15][16][17]} consequently, cholinergics such as galantamine or varenicline would be off label use for ADHD.^[18][19][20] New nicotinic cholinergic medications in development for ADHD are pozanicline,^[21][22] ABT-418,^[23] and ABT-894.^[24]

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 that requires extended focus, even if they thoroughly understand the topic. Children with ADHD may be at greater risk of academic failures and early withdrawal from school.^[25] 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.).^[26]

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.^[25]

Coping and age

It has been suggested^[5] 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.^[25] Some researchers have suggested that individuals with reduced or less overt hyperactivity symptoms should receive the ADHD-combined diagnosis. Hallowell and Ratey (2005) suggest^[27] 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."^[28]

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. 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.^[29] About five times more boys than girls are diagnosed with ADHD. Boys are seen as the prototypical ADHD child, therefore they are more often diagnosed with ADHD than girls.^[30] 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.

History

In 1980, the DSM-III changed the name of the condition from "hyperkinetic reaction of childhood" to "attention deficit disorder" (ADD). That happened because research by Virginia Douglas had suggested that the attention deficits were more important than the hyperactive behaviour for understanding the disorder. The new label also reflected the observation of clinicians that attention deficits could also exist without hyperactivity.

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.^[31]

References

1. Weiss, Lawrence G. (2005). WISC-IV clinical use and interpretation scientist-practitioner perspectives (1st ed.). Amsterdam: Elsevier Academic Press. p. 237. ISBN 9780125649315.
2. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington: American Psychiatric Publishing. pp. 59–65. ISBN 0890425558.
3. 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. doi:10.1097/00004583-199712000-00016. PMID 9401329.
4. 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. doi:10.1007/s12402-010-0045-8. PMC 3000907. PMID 21258430.
5. 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.
6. "Attention-Deficit/Hyperactivity Disorder". BehaveNet. Retrieved 17 April 2013.
7. "Attention deficit hyperactivity disorder". National Institute of Mental health. 2008. Archived from the original on 19 January 2013. Retrieved 9 January 2013.
8. 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. doi:10.3109/15622975.2011.603229. PMID 21906003.
9. 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. PMC 2518387. PMID 18728745.
10. 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. ISSN 1087-0547. PMID 12685517.
11. 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.
12. Simpson D, Plosker GL (2004). "Spotlight on atomoxetine in adults with attention-deficit hyperactivity disorder". CNS Drugs. 18 (6): 397–401. doi:10.2165/00023210-200418060-00011. PMID 15089111.
13. Messer, Tess (December 2009). "The Best Medicine for Inattentive ADHD". Primarily Inattentive ADHD (blog). Retrieved 25 December 2013.
14. 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. doi:10.1016/j.bcp.2007.07.002. PMC 2974320. PMID 17689498.
15. 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. doi:10.1016/S0165-0173(01)00044-3. PMID 11336780.
16. Levin ED, Simon BB (August 1998). "Nicotinic acetylcholine involvement in cognitive function in animals". Psychopharmacology. 138 (3–4): 217–30. doi:10.1007/s002130050667. PMID 9725745.
17. Demeter E, Sarter M (January 2013). "Leveraging the cortical cholinergic system to enhance attention". Neuropharmacology. 64: 294–304. doi:10.1016/j.neuropharm.2012.06.060. PMC 3445745. PMID 22796110.
18. Lehmann, Christine (21 November 2003). "ADHD Symptoms Respond To Cholinergic Drugs". Psychiatric News. 38 (22): 25. doi:10.1176/pn.38.22.0025.
19. Snyder, Bill (11 December 2009). "Genetics may explain three types of ADHD". Reporter: Vanderbilt University Medical Center's Weekly Newspaper.
20. 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. doi:10.1016/j.bbr.2006.09.015. PMID 17081628.
21. Apostol G, Abi-Saab W, Kratochvil CJ, Adler LA, Robieson WZ, Gault LM, Pritchett YL, Feifel D, Collins MA, Saltarelli MD (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. doi:10.1007/s00213-011-2393-2. PMID 21748252.
22. Rueter LE, Anderson DJ, Briggs CA, Donnelly-Roberts DL, Gintant GA, Gopalakrishnan M, Lin NH, Osinski MA, Reinhart GA, Buckley MJ, Martin RL, McDermott JS, Preusser LC, Seifert TR, Su Z, Cox BF, Decker MW, Sullivan JP (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. doi:10.1111/j.1527-3458.2004.tb00011.x. PMID 15179445.
23. Wilens TE, Biederman J, Spencer TJ, Bostic J, Prince J, Monuteaux MC, Soriano J, Fine C, Abrams A, Rater M, Polisner D (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. PMID 10588407.
24. Bain EE, Robieson W, Pritchett Y, Garimella T, Abi-Saab W, Apostol G, McGough JJ, Saltarelli MD (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. doi:10.1038/npp.2012.194. PMC 3547191. PMID 23032073.
25. 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.
26. 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.
27. 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.
28. Lane, Brittany Ann (2003). The differential neuropsychological/cognitive profiles of ADHD presentations: A meta-analysis (PhD Thesis). University of Northern Colorado. OCLC 56479200.
29. 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.
30. 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. doi:10.1037/a0026582. PMID 22201328.
31. Wheeler, Jennifer; Carlson, Caryn (3 July 1996). "Attention Deficit Disorder without Hyperactivity (ADHD, Predominantly Inattentive Type)". KidSource Online. Retrieved 30 June 2016.