All about an overlooked but impairing ADHD subtype: Inattentive Type ADHD
Inattentive ADHD is a lonely road. I remember listening to an expert--an M.D. with ADHD himself, and a well-known author on the subject--describe the classic ADHD kid: "They're like sports car engines with no brakes." Around the room, parents' heads nodded knowingly. All except mine.
After the talk, I approached the expert: "My son has inattentive type ADHD. So he's not really like a sports car with no brakes. He's more like..." I searched for the right vehicular metaphor: A stalling engine? No accelerator? A winged car that lifts itself clear off the road?
"A butterfly," said the speaker with a smile. And he was right.
The "butterfly brain"
Just as butterflies alight on plants briefly and then quickly, unpredictably flutter off, the inattentive type ADHD mind won't stay put. It may start out with the best intentions--do the math assignment, listen to the history lecture, fold clothes and put them away--but somehow, something gets in the way.
Often, it's something from within. External distractions--a conversation in the next room, a TV turned on, a quarter on the floor--can all derail attention, but with inattentive type, often the derailing comes from inside the brain itself. Daydreaming and "mind trips" force out whatever the inattentive person is supposed to be paying attention to. The inattentive ADHD mind can be very easily bored, although you'll rarely hear people with this subtype complaining of boredom. Why? They internalize their issues rather than sharing them with the world. And in many cases, they don't even realize they're bored with a subject at hand, because they've moved on to an entirely different one, without having made a conscious choice to do that.
This internal distractibility means that a quiet, organized space for work or homework -- while a good start -- is often not enough for an inattentive ADD person to get the job done. They're up against their own "butterly brain."
Just as butterflies move gently and silently, the inattentive ADD child or adult rarely disrupts anyone. Without hyperactive or impuslve behavior that affects others, inattentive ADD folks don't call attention to themselves, which is why they're often diagnosed later than those with other ADHD subtypes. The problem is, inattention can create just as big an academic, social and even safety risk as the better-known ADHD problems of hyperactivity and impulsivity.
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But that description doesn't sound like ADHD!
That's right; it doesn't...which is why experts like Russell Barkley, PhD, have suggested inattentive type ADHD might best be split out as its own disorder.
The fact is, inattentive ADHD almost looks like the opposite of hyperactive type or combined type ADHD. Where hyperactive or combined type folks tend to be overactive and disruptive, those with inattentive type are underactive, passive & withdrawn. It's hard to imagine more different types of people, yet they all currently fall under the same diagnostic "umbrella."
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Diagnosing inattentive type ADHD
For a long time, inattentive has been listed as a subtype of ADHD. While some experts advocated for separating out the inattentive type as its own condition, it appears from the just-released DSM V (the latest edition of the Diagnostic and Statistical Manual of Mental Disorders) that that didn't happen. What apparently did happen, according to this very short blurb, is that a new subtype was added, called "Inattentive Presentation (Restrictive)," for those who meet the criteria for predominantly inattentive ADHD but have no more than 2 of the hyperactivity-impulsivity symptoms. (My son would fit this "new" subtype, though I'm not sure what difference that makes.)
To be diagnosed with inattentive type ADHD, you need to demonstrate at least 6 of these symptoms (or 5, if you are an adult) from the DSM. You need to have shown symptoms before age 12 (was age 7 in the DSM IV, and personally I have mixed feelings about the increase to age 12); they must significantly impair your social, school or work functioning; and (this is important) the symptoms must be present in more than one setting -- e.g., school AND home or work AND home, not just school or just work or just home.
~ Lack of attention to detail; careless mistakes at school, work, activities
~ Trouble keeping attention on tasks or play activities
~ Seeming not to listen when directly spoken to
~ Failure to finish schoolwork, work responsibiltiies, chores, etc. -- NOT due to lack of understanding or to oppositional behavior
~ Trouble organizing activities
~ Avoidance of sustained mental effort (e.g., with schoolwork)
~ Frequent loss of items needed for tasks/activities
~ Easily distractible
~ Forgetful in day-to-day activities
With inattentive ADD, these symptoms aren't combined with hyperactivity or impulsive behavior. Also, the symptoms can't be better explained by another disorder such as PDD/autistic spectrum disorder, anxiety disorder, mood disorder, etc.
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DSM V criteria for ADHD, including Predominantly Inattentive type
An e-book by Tess Messer from the above YouTube clip. I haven't yet read it, so can't provide a specific recommendation, but it is so rare to find a book specifically on inattentive type ADHD that I figured this was worth pointing out.
Another targeted e-book, this time on inattentive ADHD in adults.
"Smart but scattered" sound familiar? Here, some well-reviewed advice on helping kids with executive functioning problems.
Foolers: Rule these out first!
Some other problems can mask as inattentive type ADHD, so it's important to rule them out first, as we did when our son (now 15) was younger. (A neuropsychologist evaluated our son for ADHD and was able to rule out anxiety disorders. But before that, we consulted with his pediatrician, 2 audiologists, and a neurologist specializing in seizure disorders to rule out the other potential "foolers." Phew!)
~ Chronic inadequate sleep can look just like ADHD. If the person in question is not getting 8 hours (ages 18 & up), 9 hours (ages 10-17), 10 hours (ages 5-10) or 12 hours (ages 3-5), don't even think of asking the doctor about ADHD. Ask instead how to help them meet their sleep needs. Getting more sleep can be a simple as turning off all electronics and lowering house lights an hour before bed, or getting more exercise during the day so you fall asleep faster. Sometimes, it requires a lifestyle change like cutting down extracurriculars and even homework. Work with the doctor to get there, and when you do, see if that makes a difference in inattentive symptoms.
~ Hypothyroidism, or an underactive thyroid gland, can create the sluggish or foggy demeanor often seen with inattentive ADD. A simple blood test will confirm or deny.
~ Absence seizures show up as staring spells that last a few seconds, sometimes (but not always) with fluttering eyelids and a nodding head. This is what our son's school nurse believed he was experiencing as a young child, but 2 EEGs ruled it out.
~ A hearing issue can make someone less responsive -- they're not answering 'cause they're not hearing the question, or not hearing it well. This is especially worth checking out for kids who've had chronic ear infections.
~ Central Auditory Processing Disorder (CAPD): This is an ear-brain coordination issue that makes it hard for kids to process what they've heard, especially if there's any kind of background noise (e.g., reality). An audiologist can evaluate for this, but not 'til around age 7.
~ Anxiety: This is a tough one. Anxiety can cause inattention, especially the "internalized" type that is characteristic of inattentive ADD. It's hard to focus when you're chronically anxious. So what looks like ADHD could be anxiety instead. On the other hand, a genuinely inattentive child who's getting chastised a lot for not paying attention, not keeping up, etc., can develop anxiety because of all this negative feedback and the bad feeling of being behind, or out of it. This kind of anxiety is "secondary" to his or her attention problems. How to tell the difference? This is why doctors get the big bucks. It's important to have a specialist sort this out, as treatment approaches may be different for primary than secondary anxiety.
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Do you know someone who has, or may have, inattentive ADHD?
If you have experience with inattentive ADHD, what has helped the most?
Processing speed problems
"Processing speed" is how quickly we react to incoming inforrmation, understand it, think about it, and respond to it. Processing speed and intelligence are two different things. A very bright person can be a slow processor of information. This problem can be mainly visual, mainly auditory, or both -- and it's commonly (though not always) seen with inattentive ADHD. Processing speed problems are hard to remediate, even with ADHD medication, so patience, understanding, and appropriate accommodations are important.
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Try the Time Timer
This visual timer is probably the most valuable tool we found in our inattentive ADHD struggle. When our son was young, we'd set it for each homework assignment, or even for each section of an assignment, and offer a small reward for completing on time. As he got older, he set his own time targets and rewards. We also began setting it for total time until dinner or bed, so that he could practice managing a block of time and see that the more quickly he finished his work, the more time would be left for play and relaxation. While this didn't--couldn't--erase his processing speed problems, it did help him build a sense of the passage of time and motivate him to stay as focused as possible. He now uses portable, standard digital timers for getting ready in the morning, etc., but for years the visual timer was the only kind that really helped.
Sluggish Cognitive Tempo
I admit, I have a hard time understanding how this newer descriptive term differs from the concept of slow processing, but basically, with Sluggish Cognitive Tempo, slow processing seems to fall into a broader profile of mental "sluggishness" or foginess. Lethargy, daydreaming, staring, and even sleepiness are seen with SCT, which is not to be confused with the old-school "slow" euphemism for intellectually impaired.
Researchers are still trying to figure out whether SCT is a subset of inattentive ADHD (in other words, a subtype of a subtype!), affecting 30 to 50% of inattentive ADHDers, or its own distinct condition.
Limited studies have shown kids with SCT are more at risk for anxiety symptoms, even disorders, and possibly depression. They can appear to lack motivation in everything from mundane tasks to maintaining friendships. Their minds tend to be "underaroused," but like the broader ADHD population they can get very engaged in an activity that stimulates them.
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Wikipedia writeup on sluggish cognitive tempo
About.com writeup on sluggish cognitive tempo
Summary of a study suggesting sluggish cognitive tempo is not a subtype of ADHD
Study abstract on sluggish cognitive tempo, ADHD & anxiety
ADD forum discussion on sluggish cognitive tempo
Problems with working memory
Some experts believe the core underlying problem in inattentive ADHD could be a deficit in working memory -- the "mental clipboard" we employ to store and use info within a very short period of time. Examples would be mental arithmetic, where we hold numbers in our brain long enough to add them and say or write the answer, or repeating a phone number we've just been given.
Our experience: When our son has just read from a textbook and is supposed to be answering questions but is stalled out or staring, it's hard to know whether he's having trouble retrieving & using what he's just read (working memory), processing the info (processing speed), or daydreaming.
Studies show that working memory problems are more commonly linked with inattention symtpoms of ADHD than with hyperactivity or impulsivity. Working memory problems also tend not to respond much to stimulant medications commonly used for ADHD. On the positive side, working memory "training" (including computerized methods) is showing some promise.
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Our family avoids untested "alternative" ADHD treatments for fear of short- and long-term side effects, but a moderate dose of fish oil can help ADHD symptoms and has long been recommended by doctors as a brain, mood & memory booster, with or without ADHD. The neurotoxin mercury is a concern with any fish product, so we use this brand, which is third-party tested for heavy metals. Older kids can swallow the slightly lemony Ultimate Omega capsules, while little ones like the tangerine-flavored gummies. Either way, purity is a priority.
Some experts say inattentive type ADHDers have fewer social difficulties than their peers with hyperactive or combined type, because they don't do disruptive things like blurting out answers in class; interrupting conversations; breaking rules in a game or activity; and generally being fidgety, grabby, impatient & loud.
Others say inattentive ADHDers are more at risk of long-term social problems because they tend to be (especially those with the "Sluggish Cognitive Tempo" profile) socially withdrawn, which makes it hard to form & maintain friendships. They also tend to be passive, which means that the "work" of a friendship may be carried more by the other person, which can get tiring and over time make the friendship seem less worthwhile. From a practical standpoint, it can also be frustrating to have a friend who constantly spaces out in conversation, forgets to take his/her turn in a game, etc.
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What can you do about inattentive ADD?
~ Cover the basics: Adequate sleep makes a world of difference, as does regular aerobic exercise. It's not an overstatement to say that both sleep and exercise function as medication for ADHD...without the side effects.
~ As with other ADHD subtypes, stimulant medications can help. Finding the right one can take time and usually involves trial and error. Most importantly, you need a good doctor--preferably a psychiatrist (or child/adolescent psychiatrist, for patients under 18) with plenty of experience in treating ADHD--to guide you through this process. Opinions differ on whether inattentive type ADHD responds as well to stimulants as the other subtypes, with some experts saying it doesn't. When it does respond, that often happens at lower doses of medication than with other ADHD subtypes. The "start low, go slow" (with dosage increases) idea is smart with any subtype, but perhaps especially with inattentive ADHD. Some inattentive ADHD folks will find nonstimulant medications helpful, either alone or in conjunction with stimulants.
~ Kids/teens who truly fit the diagnostic criteria for inattentive ADHD will need specialized help at school through a 504 plan, which provides for accommodations such as seating near teachers, extended test time and homework modification; and/or an Individualized Education Plan (IEP), which sets specific goals for the student, pairs these with appropriate services and supports, and states how progress toward goals will be measured. Most schools will require a formal ADHD diagnosis before developing a 504 and/or IEP with the student & family.
~ Behavioral techniques at school and home are almost always needed, even when medication is helpful, to help manage responsibilities. Teachers and parents should work together to help kids break tasks down into component parts, plan & execute each part, and celebrate successful completion. Over time, kids can take more and more responsibility for this planning and execution, but remember that as kids mature, school and life demands increase, so independence is a "moving target." Some with inattentive ADHD may need tutoring, coaching or other assistance well into adolescence and adulthood, or even indefinitely, as a) 1/4 to 2/3 of those with ADHD (depending on how strict a definition is used) will not outgrow it as adults, and b) inattention tends to be more persistent over time than hyperactivity and impulsivity, which often resolve through brain maturation.
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Even with an excellent child psychiatrist on board, four years of obvious symptoms, and a diagnosis we absolutely knew was correct, starting our son on ADHD medication at age 7 terrified me. A friend recommended this book, and it became an invaluable resource as we discussed options with the doctor. Having the Wilens book at home is like getting a "second opinion" on each option and helps immensely with risk-benefit analysis.
Are you, your spouse or your child diagnosed with inattentive ADHD? How have you managed it? What's helped, what hasn't? Please share your experience!