ADHD predominantly inattentive

ADHD predominantly inattentive (ADHD-PI or ADHD-I) is one of the three subtypes of Attention-deficit hyperactivity disorder (ADHD). While ADHD-PI is sometimes still called "attention deficit disorder" (ADD) by the general public, these older terms were formally changed in 1994 in the new Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).

Differences from other ADHD subtypes
ADHD-PI is different from the other subtypes of ADHD in that it is characterized primarily by inattention, easy distractibility, disorganization, procrastination, forgetfulness, and lethargy - fatigue, but with 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 ADHD-PI 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 ADHD-PI, and may provide them with frequent and erroneous negative feedback (e.g. "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 ADHD. The symptoms were removed from the ADHD criteria in DSM-IV because, although those with ADHD-PI 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, argue that ADHD-PI is so different from the other ADHD subtypes that it should be regarded as a distinct disorder. ADHD-PI is noted for the almost complete lack of conduct disorders and high-risk, thrill-seeking behavior. Further research needs to be done to discover differences among those with attention disorders.

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.
 * Often mixes up peoples' names or forgets them for short periods of time.

An ADHD-PI 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).

Prevalence
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 USA used a much broader definition of the term ADHD.

As a result, up to 10% of children in the USA 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. 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
Recent studies indicate that medications approved by the U.S. Food and Drug Administration (FDA) in the treatment of ADHD tend to work well in individuals with the predominantly inattentive type. These 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), 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 ADHD-PI patients.

Although medication can help improve concentration, it does not cure ADHD-I and the symptoms will come back once the medication stops. Moreover, medication works better for some patients while it barely works for others.

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

Research
A recently funded 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 ADHD-PI.

Strategies
Parents are recommended to learn about this disorder in order to first be able to help themselves and then their children.

Behavioral strategies are of great help and they include creating routines, getting organized, avoiding distractions (television, video and computer games especially on weekdays during homework), limiting choices, using goals and rewards, ignoring behaviors.

Since children with ADHD can be extremely disorganized, parents should work with children to find specific places for everything and teach kids to use calendars and schedules. Parents are also 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 substances affect focus and attention. However, some sports may be too challenging and would add frustration. Parents should talk to their children about what kinds of sports or exercise most stimulate and satisfy them before signing them up for classes or enrolling them in a given team sport.

It is very important to establish close communication with the school in order to develop an educational plan to address the child’s needs. Accommodations in school such as extended time for tests or more frequent feedback from teachers are also beneficial for these individuals.