What Is Inattentive ADHD? Symptoms, Characteristics, Diagnostic Considerations
Formerly called ADD, inattentive ADHD is characterized by symptoms of disorganization, poor time management, faulty working memory, and a lack of focus — all signs commonly dismissed or misdiagnosed, particularly in girls and women. Here, learn about the distinctive characteristics that should guide clinicians’ diagnostic and treatment practices for inattentive ADHD.
What Is Inattentive ADHD?
Attention deficit disorder (ADD) is no longer a standalone diagnosis; its telltale symptoms of disorganization, poor time management, faulty working memory, and lack of focus, among others, are now categorized as attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation, in the DSM-5. In other words, inattentive type ADHD is the not-so-new name for ADD.
Individuals with inattentive type ADHD do not exhibit the stereotypical symptoms of ADHD — namely physical hyperactivity and impulsivity. Their executive dysfunction is easily blamed on carelessness or laziness, and their social struggles may be attributed to growing pains or character idiosyncrasies. All of this contributes to a chronic problem of underdiagnosis and inadequate treatment for inattentive type ADHD, particularly in girls and women.
Inattentive ADHD: Symptoms
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists nine core symptoms of ADHD, predominantly inattentive presentation:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
- Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines)
- Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
- Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
- Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
- Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
A child must exhibit at least six of these symptoms (and fewer than six symptoms of hyperactivity and/or impulsivity) to receive a diagnosis of inattentive ADHD. Adults and late adolescents must exhibit only five of the above symptoms (and fewer than five symptoms of hyperactivity and/or impulsivity). Symptoms of ADHD, predominantly hyperactive/impulsive type, include fidgeting, interrupting others, and acting “on the go,” among several others. (Click here to read about symptoms that are present in ADHD-combined presentation.)
Inattentive ADHD: Prevalence and Gender Disparities
Some research using population-based samples indicate that inattentive type ADHD is the most prevalent presentation of ADHD. According to a meta-analysis of 86 studies of children and adolescents, and 11 studies of adults, inattentive ADHD constitutes 21% of preschool ADHD cases, 45% of elementary school cases, and 72% of adolescent cases.1 It is also the most common presentation type in adults, making up about half of all ADHD cases across all demographics.1
The predominantly hyperactive/impulsive presentation of ADHD is relatively rare in clinical settings, especially after preschool. Hyperactive ADHD typically converts to the combined type over time, as attentional demands become more salient. The inattentive and combined presentations, while also subject to fluctuations, do not vary to the same degree.2
Missed or misdiagnosed symptoms of inattentive ADHD are an ongoing and well-documented problem for girls and women, in particular. Though females are more likely than males to be diagnosed with inattentive ADHD,3 men still outnumber women across all presentation types. The ratio gap, however, becomes smaller in adulthood4, possibly pointing to increased awareness of ADHD symptoms historically overlooked in girls.
Inattentive ADHD: Distinctive Characteristics and Presentation
The impairments and challenges associated with inattentive ADHD differ from those associated with other ADHD presentation types. The following distinctive characteristics exist across multiple domains, and they are confirmed by research and clinical observations.
Inattentive ADHD, Cognition, and Executive Function
- Slower processing speed. Inattentive ADHD is associated with relatively greater deficits in processing speed, as shown in research involving visual-motor and visual-search tasks such as matching a letter to a number or comparing symbols.5 This association is in line with research on sluggish cognitive tempo – a combination of characteristics and symptoms that include hypoactivity, “daydreaminess,” lethargy, and apathy – which has been linked to predominantly inattentive ADHD.6
- Greater inhibitory control. Compared to inattentive type ADHD, combined-type ADHD is associated with greater deficits in situation and on tasks that require inhibitory control – or the ability to stop before carrying out an action.5
- Stronger emotional regulation. Individuals with combined-type ADHD are at greater risk for disruptive outbursts, meltdowns, excessive reactions, and intense emotions than are individuals with inattentive ADHD alone.5
Inattentive ADHD and Social Characteristics
- Children with inattentive ADHD are more likely to be socially shy, passive, or withdrawn than are their combined-type counterparts, who are often described as impulsive, intrusive, and aggressive.3 7 Inattentive children also appear slower to respond to cognitive and social stimuli, while children with a combined presentation rapidly orient to stimuli.6
- Social knowledge vs. social performance: Individuals with inattentive ADHD are more likely to exhibit deficits in social knowledge (e.g., how to introduce themselves to strangers, make friends, join a group conversation, etc.) compared to individuals with combined-type ADHD. On the other hand, individuals with combined-type ADHD may exhibit greater deficits in social behavioral self-regulation (even if they know how they should behave), which impairs their ability to navigate through social settings.8
- Socially neglected vs. socially rejected: Sociometric studies in children suggest that inattentive ADHD is associated with social neglect and combined-type ADHD with social rejection.8 That is, children may be more likely to ignore their inattentive peers, possibly because of their perceived unresponsiveness or shyness; they may avoid interacting with combined-type peers who struggle to “play nicely” and follow rules or directions.
Inattentive ADHD and Comorbidities
- Inattentive ADHD is highly comorbid with internalizing disorders such as anxiety and mood disorders, and with learning disorders.3
- Disruptive behavior disorders such as oppositional defiant disorder (ODD) and conduct disorder (CD), as well as alcohol and substance abuse issues, are relatively more prevalent in individuals with combined-type ADHD.3
Inattentive ADHD: Diagnostic and Treatment Considerations
Inattentive ADHD Evaluation
Inattentive ADHD is challenging to identify in practice for a few reasons.
- Symptoms of inattention are rarely as “obvious” as the more visible symptoms of hyperactivity or impulsivity.
- Attention problems may present across various disorders, including anxiety, autism, mood disorders, and learning disorders. What’s more, these conditions often co-occur with ADHD.3
- Perceived gender differences bias evaluations. While the core symptoms of inattentive ADHD are the same across genders, symptom manifestations depend heavily on context, which often differs for females and males.
A comprehensive diagnostic evaluation for ADHD should include:
- A questionnaire rating an individual’s ADHD symptoms: The Conners’ Adult ADHD Rating Scale (CAARS) is a self-reported scale that yields a score with respect to how a patient compares to others in their gender and age group.
- Careful assessment of a patient’s current functioning and impairment across educational, social, occupational, and other spheres: Clinicians should consider the various ways difficulties may be expressed across males and females. (The gendered division of domestic labor, for example, continues to disproportionately affect women.9 Women with inattentive ADHD, therefore, may exhibit difficulties with household management that may not manifest in male patients.)
- An appreciation for how changes in responsibilities and expectations may reveal previously hidden ADHD symptoms: Clinicians should consider “inflection points,” or significant life events and changes, that may exacerbate and reveal ADHD symptoms not obvious before age 12, the latest age of onset indicated in the DSM-5. Many individuals develop coping mechanisms that help them function well until a major change, like college, marriage, or parenthood, stresses their executive functions to the breaking point. Beyond basic questions of inattention, clinicians should use specific manifestations as examples such as, “Do you/does your child tend to do things at the last minute?” and “Did you/your child always have a messy desk?”
- Differential diagnosis to consider comorbid conditions: It takes careful inquiry to identify the presence and boundaries of co-occurring disorders.
Inattentive ADHD and Medication Response
How do children with inattentive ADHD respond to stimulant medications? The research is inconclusive. In one study, children with inattentive ADHD were more likely than those with combined-type ADHD to respond optimally to lower doses of stimulant medication.10 Another report found no difference in response across the groups,11 and a more recent study showed that children with inattentive ADHD see smaller medication effect sizes than do children with combined-type ADHD across all doses.12 Parallel studies comparing medication response of the ADHD subtypes in adults have generally not been conducted.
Sluggish cognitive tempo, which is strongly associated with inattentive ADHD, also responds well to stimulant medication, according to a study on adults with ADHD.13
With all patients, prescribers must carefully titrate ADHD medication to achieve the greatest symptom improvement with the fewest side effects – a process that involves identifying and quantifying improvements and side effects over time.
Psychological Treatment for Inattentive ADHD
- Behavioral training (BT). There are no differences in response to typical BT programs across ADHD presentation types. The Child Life and Attention Skills (CLAS) Program, however, is a behavioral treatment specifically developed for children with inattentive ADHD.14
- Cognitive behavior therapy (CBT): Similarly, research shows no differences in response to CBT for executive dysfunction across ADHD presentation types in adults. The treatment, which imparts skills and strategies for planning, organization, time management, and more, improves ADHD symptoms.15 The program’s most helpful strategies include planner use and task chunking (breaking down large jobs into smaller steps) to help individuals overcome procrastination.
Inattentive ADHD: Conclusions
Though inattentive type ADHD is the most prevalent presentation type, it remains under-studied and undertreated — especially in women. Research has uncovered several key characteristics — namely, sluggish cognitive tempo, deficits in social knowledge, related comorbidities, and stimulant medication response in children — that can help clinicians better identify and treat inattentive ADHD in patients of all ages.
Inattentive ADHD: Next Steps
- Free Download: Inattentive ADHD, Explained
- Read: Inattention and the ADHD Brain
- Read: After the ADHD Diagnosis – Experts Answer Your Top 10 Questions
The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Focus on Inattentive ADHD: The Under-Diagnosed and Under-Treated Subtype” [Video Replay & Podcast #384] with Mary V. Solanto, Ph.D., which was broadcast live on January 10, 2022.
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