Understanding ADHD Combined Type

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There are three forms of attention deficit hyperactivity disorder (ADHD). These are:

  • Predominantly inattentive ADHD is characterized by problems regulating attention.
  • Predominantly hyperactive-impulsive ADHD is characterized by impulsive and hyperactive behavior.
  • Combined type ADHD is where both inattention and hyperactivity-impulsivity are present.

These different forms of ADHD used to be called ADHD subtypes.

Then, when the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in 2013, the term "subtype" was changed to "presentation." For example, a person could be diagnosed with attention deficit hyperactivity disorder, combined presentation.

Even though the official term is now presentation, many people still use the terms "subtypes" and "types." Occasionally, combined ADHD might be referred to as ADHD C.

How Is ADHD Combined Type Diagnosed?

All ADHD types are diagnosed in the same way. A detailed evaluation is carried out by an experienced health care professional. This clinician gathers information from a variety of sources including an interview with you (or your child), your medical history, family medical history, and your experiences in school. This assessment might also include intellectual screening, memory testing, attention and distraction tests, as well as an interview with your spouse.

If it is a child being assessed, the child’s parent will most likely be interviewed.

At the end of the evaluation, the clinician will determine if the criteria for ADHD outlined in the DSM-5 has been met. If it has, then a diagnosis of ADHD can be made. You or your child will be diagnosed with an ADHD presentation.

This will be either inattentive, hyperactive-impulsive, or combined ADHD.

The DSM lists nine symptoms for inattentive ADHD, and nine for hyperactive-impulsive presentation. To be diagnosed with combined ADHD:

  • A child needs to have six or more symptoms from both lists.
  • A person who is 17 years or older needs to have five or more symptoms from both lists.
  • The symptoms need to have been present for six months or longer.
  • The symptoms need to have been present before the age of 12 (although not necessarily diagnosed).
  • The symptoms should be noticeable in more than one setting, such as school and at home.
  • The symptoms need to affect the person’s ability to perform to his or her potential.
  • The symptoms cannot be caused by another condition.

Following is an adapted version of the 18 symptoms listed in the DSM.

Inattentive Symptoms

  • Often makes mistakes that appear careless, either at school or work. These mistakes occur because of problems paying attention to details.
  • Has difficulty maintaining attention on school, work, reading or fun activities.
  • Does not appear to listen during conversations, even one on one. Seems internally distracted, for example thinking about other things.
  • Following through on instructions is challenging. Finishing a task or homework from beginning to end is rare due to getting sidetracked or losing focus.
  • Tasks are avoided that involve mental effort for long periods of time like school work, work projects, or forms.
  • Frequently loses items, for example, textbooks, wallet, keys, glasses, and cell phones.
  • Can be easily distracted by external events.
  • Is forgetful while doing everyday activities like chores and errands.

Hyperactive-Impulsive Symptoms 

  • Being physically still is challenging. Will move feet and hands, and squirm.
  • Staying seated is hard. Will often get up and move around, even in situations where sitting down is socially expected, like a classroom or work environment.
  • Will run or climb at unsuitable times. Teenagers and adults might look physically still but experience internal restlessness.
  • Rarely participates in hobbies or play activities quietly.
  • Has lots of energy and is frequently described as "always on the go" or "driven by a motor."
  • Talks continually and might be known as a "chatterbox." This can result in problems at school and work.
  • Will answer questions before they have been fully asked. Interrupt others while they are talking.
  • Waiting for a turn is difficult, whether at play, in a line, or during a conversation.
  • Intrudes on other people’s activities and conversation.

Why Is It Important to Know What Type of ADHD I Have?

As with many topics, knowledge is power. The more you know about your condition and the type of ADHD you have, the more empowered you feel. This in turns means you can get the right treatment for your symptoms so they are well managed.

Knowing what ADHD presentation you have means you can distinguish between what is an ADHD symptom and what is part of your unique personality. Sometimes people struggle for years with an aspect of ADHD they think is just part of who they are, only to later find that it was related to ADHD and that treatment is available to help.

In addition to the practical benefits, there are psychological benefits to knowing how ADHD affects you. There is a lot of moral judgment around behaviors that result from having ADHD. For example, not being able to sit still in a meeting might be called "disrespectful." A person who makes what seems like careless mistakes at school may be labeled "unmotivated." Adults and children with ADHD often call themselves lazy or stupid, when they are neither. Understanding the subtleties of your ADHD type helps you to separate yourself from these negative comments and the shame and guilt that comes with them. This frees you to find a proactive solution instead.

Is It Worse to Have Combined Type Than Just One ADHD Type?

ADHD combined is the most common type of ADHD. It is also the most researched.

Having ADHD combined type does not automatically mean your ADHD is more severe compared to someone who is diagnosed with predominantly hyperactive type or predominantly inattentive type.

For example, a person who has predominantly hyperactivity-impulsivity might still experience some symptoms from the inattentive symptom list. However, he or she would not have the full five or six symptoms to be given a combined ADHD diagnosis. Being diagnosed with ADHD combined type means your symptoms are evenly distributed between the two types.

Anyone who is diagnosed with ADHD after May 2013 (when the DSM-5 was published) is told how severe his or her ADHD is. It could be mild (while still meeting the ADHD criteria), moderate, or severe. This rating is a more accurate way to know the severity of your condition, rather than judging it based on the type of ADHD you have.

Will I Always Have ADHD Combined Type?

When the DSM-5 was published, it replaced the term ADHD subtypes with ADHD presentations.  This change reflected the new understanding researchers have of ADHD. Rather than being a fixed and stagnant condition that could be neatly divided into subtypes, we now know that a person’s ADHD presentation and severity is more fluid and can change with age and the setting.

In his book Taking Charge of Adult ADHD, Dr. Russell Barkley writes that a predominantly hyperactive presentation could be an early developmental stage of combined ADHD. He states that the majority of people who are diagnosed with hyperactivity will develop sufficient symptoms related to attention regulation in 3 to 5 years. These new symptoms will be strong enough that these people will meet the requirements to be diagnosed with ADHD combined presentation.

We also know that as a person ages, their ADHD symptoms become more internal and less visible to observers. For example, a person who experienced hyperactivity as a child and found it hard to sit still, might be able to sit still when required as an adult but will feel internal restlessness and discomfort.

How Is Combined ADHD Treated?

If you or your child have combined ADHD, it is important to address both the inattentive and the hyperactive and impulsive symptoms.

While ADHD cannot be cured, it is possible to treat and manage symptoms successfully. As with all types of ADHD, the most effective treatment plan for combined ADHD is usually medication, plus behavioral treatments like therapy, accommodations, social skills, and lifestyle changes.

There are not specific ADHD medications that work best for certain types of ADHD. Instead, finding the right medication and dose is something that your doctor will be able to help with. You might try several different ADHD medications until you find one that helps your ADHD symptoms and has minimal side effects.

Sources:

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. 2013

Barkley R. ( 2010) Taking Charge of Adult ADHD, The Guilford Press 2010

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