Types of ADHD: Hyperactive, Inattentive, and Combined
Attention deficit disorder was once diagnosed as ADD or ADHD, depending on the patient’s symptoms of
inattention or hyperactivity and impulsivity. Today, the condition is simply called ADHD — with one of three
sub-types.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) stipulates that all cases of attention
deficit are diagnosed as ADHD, with one of three different types: Primarily Hyperactive-Impulsive, Primarily
Inattentive, or Combined.
1. ADHD, Primarily Hyperactive-Impulsive type:
People with hyperactive ADHD feel the need for constant movement. They often fidget, squirm, and
struggle to stay seated. They appear to act as if “driven by a motor” and often talk and/or run around
excessively. They interrupt others, blurt out answers, and struggle with self-control. This is more common in
children and men.
2. ADHD, Primarily Inattentive type:
People with inattentive ADHD make careless mistakes because they have difficulty sustaining attention,
following detailed instructions, and organizing tasks and activities. They are forgetful, easily distracted by
external stimuli, and often lose things. This is more common in adults and girls and was formerly known as
ADD.
3. ADHD, Combined type:
People with combined-type ADHD demonstrate six or more symptoms of inattention, and six or more
symptoms of hyperactivity and impulsivity.
Medical professionals today further dene ADHD diagnoses by quantifying the severity as mild, moderate, or
severe, and by labelling the presentation.
How Is ADHD Diagnosed?
The DSM-V lists nine symptoms that suggest ADHD Primarily Inattentive, and nine that suggest ADHD
Primarily Hyperactive-Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six
of nine symptoms from one of the lists below, and if the symptoms have been noticeable for at least six
months in two or more settings — for example, at home and at school. What’s more, the symptoms must
interfere with the child’s functioning or development, and at least some of the symptoms must have been
apparent before age 12. Older teens and adults may need to demonstrate just five of these symptoms in
multiple settings.
Possible Symptoms of Attention Dysregulation:
• Difficulty regulating, switching and prioritizing attention, including over-focusing on stimulating
activities
• Easily distracted from the task at hand by noises or things going on around them
• Frequently looking around
• Difficulty staying focused on one activity
• Daydreaming
• Not focusing on speaker when spoken to
• Unable to remember verbal instructions
• Misinterpreting instructions
• Unable to pay attention to details
• Difficulty completing work without being reminded
• Losing things
• Difficulty organizing belongings and work
• Difficulty starting things
• Forgetting normal routines
Possible Symptoms of Hyperactivity:
• Fidgeting and squirming
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• Problems remaining seated
• Talking excessively and at inappropriate times
• Often running and climbing
• Standing instead of sitting at the table
• Unable to settle into a quiet activity
• Constantly on the go
• Frequently handling or touching objects and other people
Possible Symptoms of Impulsivity:
• Acting or reacting before considering consequences
• Butting into conversations
• Blurting out answers in the classroom
• Beginning work before instructions are given
• Disturbing others who are playing
• Grabbing others belongings
• Touching, grabbing hitting others
• Problems waiting for turn or standing in line
• Making impulsive decisions
Signs That May be Present in a Learning Environment
• Inattention
• Easily distracted
• Incomplete work
• Problems with getting homework done
• Problems bringing homework and necessary books home
• Difficulty remembering to hand work in
• Not able to produce the same amount and/or level of school work as others
• Need for repeated instructions
• Misinterpreting instruction and questions on assignments or tests
• Difficulty with handwriting
• Difficulty understanding what is read
• Careless errors
• Problems paying attention to details
• Problems with spelling and math
• Problems with sequencing
• Forgetting deadlines or difficulty completing work on time
• Problems with organizing larger assignments and projects
• Problems starting assignments
• Frequent daydreaming and presenting as spacey
• Excessive talking and interrupting others
• Blurting out answers
• Unable to sit still, constantly on the move
• Touching, pushing and grabbing others or things impulsively
• Interrupting others at play
• Problems dealing with frustration
• Tentative and unsure of trying new things and learning new skills
• Reluctant to volunteer answers or be called upon
• Does not make or keep friends easily
• Unable to change focus or start and stop activities
• Transitions or changes produce agitation or frustration
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Living in the Shadow of a Stereotype: New Facts About ADHD By Thomas Brown, Ph.D.
Findings from neuroscience, brain imaging, and clinical research have dramatically changed the old
understanding of ADHD as essentially a behaviour disorder. Experts now see ADHD as a developmental
impairment of the brain's self-management system, its executive functions. There are many other myths
about ADHD, as you will see. So, update your thinking about the condition with the facts.
New vs. Old Models
The new model of ADHD differs in many ways from the earlier model of this disorder as a cluster of
behaviour problems in young children. The new model is a paradigm shift for understanding ADHD. It
applies to children and adolescents and adults. It focuses on a wide range of self-management functions
linked to complex brain operations, and these are not limited to readily observable behaviours. But there
is substantial overlap between the old and new ADHD models.
On-and-Off Focus
Clinical data indicate that executive function impairments are situationally-variable; each person with ADHD
tends to have some specific activities or situations in which she has no difficulty in using executive
functions that are significantly impaired for her in most other situations. Typically, these are activities in
which the ADDer has a strong personal interest or about which he believes something unpleasant will
follow quickly if he does not do the task right now.
Signs in Childhood
Recent research has shown that many with ADHD function well during childhood and do not manifest any
significant symptoms until adolescence or later, when greater challenges to executive function are
encountered. Over the past decade research has shown that impairing symptoms of ADHD often persist
well into adulthood. However, studies have also shown that some individuals with ADHD during
childhood experience significant reductions in their impairments as they grow older.
High IQ and ADHD
Intelligence as measured by IQ tests has virtually no systematic relationship to the executive function
impairments described in the new model of ADHD. Studies have shown that even extremely high-IQ
children and adults can suffer impairments of ADHD. This causes them problems in deploying their strong
cognitive skills consistently and effectively in many life situations.
Emotional Connection
Recent research has shown the important role of emotions in ADHD. Some research has focused solely on
the problems in regulating emotions without sufficient inhibition. Research has also shown that a chronic
deficit in emotions that comprise motivation is an impairment for most individuals. This makes it hard for
them to arouse and sustain motivation for activities that don't give immediate and continuing reinforcement.
Mapping Deficits
Executive functions are complex and involve not only the prefrontal cortex, but many other components of
the brain. Individuals with ADHD have been shown to differ in the rate of maturation of specific areas of the
cortex, in the thickness of the cortical tissue, in characteristics of the parietal and cerebellar regions, as well
as in the basal ganglia, and in the white matter tracts that connect and provide critically important
communication between various regions of the brain.
Chemical Imbalance
Impairments of ADHD are not due to a global excess or lack of a specific chemical within or around the
brain. The primary problem is related to chemicals manufactured, released, and reloaded at the level of
synapses, the junctions between certain networks of neurons that manage the brain's management
system. Persons with ADHD tend not to release enough of these essential chemicals, or to release and
reload them too quickly. ADHD medication helps to improve this process.
The ADHD Gene
No single gene or genes have been identified as a cause of the impairments known as ADHD. Recent
research has identified two different groupings that together are associated with, though not definitively
causal of, ADHD. At this point, the complexity of the disorder is likely to be associated with multiple genes,
each of which, in itself, has only a small effect upon development of ADHD.
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ADHD and ODD
The incidence of oppositional defiant disorder (ODD) in children with ADHD ranges from 40 to 70%. The
higher rates are usually for persons with the combined type of ADHD. ODD is characterized by chronic
problems with negativistic, disobedient, defiant and/or hostile behaviour toward authority figures. Typically,
ODD is apparent at about 12 years of age and persists for about six years and then gradually remits. More
than 70% of kids diagnosed with ODD never develop Conduct Disorder. (US statistics)
ADHD and Autism
Research has demonstrated that many individuals with ADHD have significant traits related to Autistic
Spectrum Disorders, and that many persons diagnosed with disorders on the Autistic Spectrum also meet
criteria for ADHD. Studies have also shown that ADHD medications can be helpful in alleviating ADHD
impairments in individuals on the Autistic Spectrum. ADHD medications can also help those on the Autistic
Spectrum with ADHD to improve on some of their impairments.
Meds and Brain Changes
Studies and clinical trials have shown that ADHD medications give the following benefits to some children
and adults:
> improve working memory, classroom behaviour, the motivation to execute tasks, and to persist in solving
problems
> minimize boredom, distractibility when doing tasks, and emotional outbursts
> increase test performance, rates of graduation, and other achievements that can have lasting effects
> normalize structural abnormalities in specific brain regions
Meds for Different Ages
Fine-tuning the dose and timing of stimulants is important because the most effective dose depends on
how sensitive the patient's body is to that specific medication. Usually doctors start with a very low dose
and gradually increase it until an effective dose is found, significant adverse effects occur, or the maximum
recommended dose is reached. Some adolescents and adults need smaller doses than those taken
by children; some young children need larger doses than most of their peers.
Pre-schoolers and Meds
Research has shown that a majority of children aged 3 to 5 1/2 years with moderate to severe ADHD had
significant improvement in symptoms when treated with stimulants. Side effects are slightly more common
than is usually seen in older children, but still minimal. In 2012, the AAP recommended that children aged
four to five with significant ADHD impairments should be treated with behaviour therapy. If not effective
after nine months, stimulant medication is recommended.
Impulsive Forever?
Many with ADHD never manifest excessive levels of hyperactivity or impulsivity in childhood or beyond.
Among those who are more "hyper" and impulsive in childhood, a substantial percentage outgrow the
symptoms by middle childhood or early adolescence. But impairments in focusing and sustaining attention,
organizing tasks, managing emotions, and using working memory may persist and become problematic, as
the person enters adolescence and adulthood.
ADHD Is Different
ADHD differs from many other disorders in that it cross-cuts other disorders. The executive function
impairments that constitute ADHD underlie other disorders as well. Many learning and psychiatric disorders
could be compared to problems with a specific computer software package that, when not working well,
interferes with a few functions. ADHD might be compared to a problem in the computer's operating system
that is likely to interfere with the operation of many different programs.
Every Day with ADHD – Dealing with Challenging Behaviours
Plan ahead, instead of constantly reacting
While children with ADHD are very different from children on the Autistic spectrum, both groups are very
sensitive to their environment. Effective behaviour guidance will be largely aimed at setting up an
environment where the child with ADHD can experience success, while minimising some of the likely
sources of frustration and aggressive outbursts. Work to reduce the negative time and attention that the
child experiences.
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Be realistic, be ready, be fair and be firm
On a day-to-day basis, accept that the child is going to demand more time and attention. Routine tasks will
be an on-going challenge and it absolutely pays to walk away as much as possible from confrontations or
find ways to re-direct or approach the task differently.
“Fairness” means “a fair chance to learn and take part” as much as “all being treated the same.” There is
no need to justify (to other children or parents) that you treat children with different needs, differently.
Firm boundaries remain important though – especially around hitting, other aggressive or abusive
behaviour and damage to property.
Reach out to parents
Parents may have had a long history of struggle and stress, so they will often feel overwhelmed and
inadequate as parents, with frequent feelings of being judged and embarrassed in social situations. Their
defensiveness and difficulty with interaction with you as their child’s carer may be nothing to do with you
and everything to do with this experience.
Parents can also be tremendous sources of expertise in “what works” such as calming techniques or the
child’s special characteristics, quirks, interests and obsessions.
Start from strengths
Children with ADHD are likely to have frequent experiences of failure, giving up and being “useless”. So
one of the most important impacts we can have is to organise some opportunities for success based on the
child’s interests and/or strengths.
These positive activities will also give some options when “cooling off” or re-direction is needed and will
give the child the chance to be seen more positively by other children.
Small, sensible helper roles are very effective. When set tasks with clearly defined boundaries, they try
hard to meet expectations.
Giving instructions and explaining expectations
Make your communications as clear as possible. Give short instructions. Wait then repeat. Then ask the
child to repeat back. The child is likely to be quite black and white with language and meanings, so check in
on understanding. Never punish the child for being disorganised, it’s a part of the way he/she is. Calendars
and signs can be helpful aids to remind when, where, how.
Rules and expectations need clear explanation and repetition. Make this a routine part of an activity and
remind staff to spend a little one-to-one time with the child with ADHD before an activity starts, giving a
simple rules reminder.
When things go off track – escalating behaviour & discipline
Once the child is in the middle of being upset or an aggressive outburst, there are limited options but it’s not
the end of the world either. Respond with simple calm language “stop, now” and try re-directing with clear
task – “go to the couch and sit down” or “go get yourself a drink and wait by my desk”. Establish some
tasks that have a calming effect on the child such as cleaning, taking a message to another staff member
etc. There is no point trying to reason or discuss at this point.
Later it should be possible to talk with the child about the incident – listen and try to get a sense of how the
child saw things. This might help you to prevent a recurrence. Explain clearly what sort of behaviour would
have been more appropriate – remember the child might be quite unaware of even simple social cues and
expectations.
Consequences might be of limited value because the child might not be able to connect the consequence
to their misbehaviour. The child may be completely unaware of the impact the behaviour has had and why
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it was inappropriate. “Technically the child did not decide to break any rules. Before he could think about it
the action had occurred.” (Cooney)
As a follow up, take note of warning signs that behaviour is escalating (noise, movement, facials) and act
sooner. Look out for possible triggers, especially changes: including new staff, trips, different facilities,
unexpected social interactions. Think ahead about possible sources of frustration in an activity.
Work towards agreed “safety valves” that the child themselves can initiate e.g. if they are inclined to run
away, establish a specified safe place they can remove themselves to, rather than just running off at
random.
Using Visuals can cut down the need to use verbal reminders. Google images and Pinterest have lots of
great ideas to save you re-inventing the wheel!
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