Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood diagnosis. In 2015–2016, about 10% of children and adolescents were diagnosed and treated for ADHD. The diagnosis is based on a collection of symptoms that are frequent and severe enough to impair a child’s ability to function. Within that group of symptoms are different patterns or “presentations” of ADHD. People often differentiate ADD (without hyperactivity) from ADHD (with hyperactivity), but this distinction was dropped in 1994.
When a child or teen presents to me with symptoms of inattention, but not hyperactivity or behavioral impulsivity, patients and families are often surprised when they receive a diagnosis of ADHD. Parents and/or children/teens rightfully wonder why we would include “hyperactivity” in their diagnosis if that doesn’t describe them at all. The reasons for this awkwardly worded label are based on scientific research about ADHD that shows the two patterns to be much more similar than they are different.
Starting in 1994 with the publication of the Diagnostic and Statistical Manual 4th Edition (DSM IV), the ADD diagnosis has been discontinued. Rather, the diagnostic term has become ADHD, divided into three different types:
- Predominantly inattentive
- Predominantly hyperactive/impulsive
- Combination
In the most recent DSM, DSM 5, these distinctions have become even less clear-cut, and we refer to ADHD as having a current presentation of inattentive, hyperactive/impulsive, or combination.
A major reason for this evolution grew out of research showing that impulsivity — problems with the “stop” or “off” systems in the brain — is part of the big picture of ADHD, even when someone is not physically impulsive. For example, we often think about kids who are inattentive but not hyperactive as daydreamers, and we frame this as “difficulty maintaining focus.” However, “off” switch disruptions are part of inattention. Kids with ADHD are unable to turn off their attention to one thing (the ever present squirrel in the window) and shift their attention to the teacher’s words and actions. Other ADHD symptoms include not paying attention to details and making careless mistakes by misreading or mishearing instructions. These are also impulsivity challenges — trying to squash the impulse to attend to something shiny or more interesting rather than to maintain focus on what the teacher is saying or on the reading in front of them.
Another part of shifting our language away from strict categories of inattentive or impulsive is that treatments do not seem to have different effects based on the subtype of ADHD. That suggests the existence of common underlying brain signaling problems in all types of ADHD that respond to similar types of interventions.
A further component of the change in thinking about “types” of ADHD to “presentations” of ADHD at any given time is because people often present differently at different points in time. One of the most common shifts is very hyperactive, physically impulsive young children who seem to mature out of those symptoms into a primarily “busy brain” presentation, which looks more inattentive than hyperactive/impulsive.
Diagnostic terms are only important because they help us to identify and understand a problem we are trying to solve and to develop an effective treatment plan for that problem. The evolving semantics of the DSM are not really important except in helping us communicate and making sure that we (physicians and other providers) are using language that makes sense to our patients and their families. Unfortunately, when a term’s meaning evolves, it may lead to more confusion than clarity, as in the case of ADD and ADHD. Just remember that if a doctor is speaking in language that doesn’t make sense (or seems not to apply to you) don’t hesitate to speak up and ask about it.
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