Normally Active and Inattentive

I believe that many children with Predominantly Inattentive ADHD are normally active, that is, they have six or less of the hyperactive/impulsive symptoms. Many parents (and even physicians) get confused about the type of ADHD that their child has because they have a child that is predominantly inattentive but has two or three of the hyperactive or impulsive symptoms. The assumption is that all children with Predominantly Inattentive ADHD are dragging themselves about always looking fatigued, sluggish, drowsy, or slow. If a child is not sluggish the child is often diagnosed as having Combined type ADHD. I believe that this is a mistake because children who are not diagnosed correctly will not get a treatment plan that is tailored to their specific needs.

The normally active Predominantly Inattentive ADHD child may look something like this. A nine year boy sits in a classroom absorbed in something other than the classroom work. He is fidgeting with his button and all of a sudden leaves his seat to go check out that glimmering wall hanging. The temptation is to label that child a Combined type child with ADHD, because he has three of the hyperactive/impulsive symptoms and maybe all of the inattentive symptoms. If this boy has no other hyperactive or impulsive symptoms, he is not a combined type ADHD child or a Hyperactive ADHD type child. This is a normally active, Predominantly Inattentive ADHD child.

Children that have 6 or more of these Predominantly Inattentive symptoms:
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 have 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.

But less than 6 of these Hyperactive/Impulsive symptoms:
Fidget and squirm in their seats.

Talk nonstop.

Dash around, touching or playing with anything and everything in sight.

Have trouble sitting still during dinner, school, and story time.

Be constantly in motion.

Have difficulty doing quiet tasks or activities.

Be very impatient.

Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences.

Have difficulty waiting for things they want or waiting their turns in games.

Should be diagnosed as having Predominantly Inattentive ADHD.

They must have had these symptoms for over 6 months and have been observed with these symptoms in at least two different settings. There must not be another diagnosis which may account for the symptoms but the child.

A child with less than 6 of the hyperactive/impulsive symptoms is what I would call a normally active child. It is entirely possible for the Primarily Inattentive child to not have the symptoms of Sluggish Cognitive Tempo. They may, in fact, not be at all sluggish, slow, sleepy, or lethargic. People with Predominantly Inattentive ADHD do sometimes have a co-existing condition which is called Sluggish Cognitive Tempo and which does make the person appear fatigued and drowsy and cognitively slow but these people do not account for a majority of people with Predominantly Inattentive ADHD.

Normally active children can have Predominantly Inattentive ADHD. It is important that these Predominantly Inattentive children not be treated exactly like Hyperactive/Impulsive or Combined type children with ADHD because they are different. There is some very good evidence that the way these kids respond to medicines, the classroom interventions that work for these kids, and the adult outcomes for these children is considerably different than it is for children with Combined type and Hyperactive/Impulsive type ADHD.

The ADHD treatment regimen currently used for all children with ADHD may not be the most appropriate treatment regimen to choose for children with Predominantly Inattentive ADHD. In order to discover and test the most beneficial interventions for these children we must first insure that Predominantly Inattentive children are not incorrectly classified as Combined type or Hyperactive/Impulsive. Once we have accurately classified this subset of Predominantly Inattentive children, we can begin to fully explore how best to help them.


  1. Hi, you said "There is some very good evidence that the way these kids respond to medicines, the classroom interventions that work for these kids, and the adult outcomes for these children is considerably different than it is for children with Combined type and Hyperactive/Impulsive type ADHD." So what is the outcome for these children and how does it differ? Can you point me to a reference to read more? Thanks for sharing this. I think my son is Predominantly Inattentive, a little squirmy when seated at school and jumpy when standing in line, but I would not describe him as "constantly in motion". He can play quietly with legos and cars and trains for quite a long time, I don't think of him as "bouncing off the walls". But he is definitely not sluggish! He hasn't been diagnosed yet, but he has an appointment with the pediatrician next month and I will be asking for a referral then.

  2. Beth,

    Thanks for your questions. We need many more studies but this is what we know.

    From this paper by Russell Barkley, PHd, the psychologist that has done the most extensive work on this subtype. The link is this:

    All the references are at the end of the paper in the above link.

    The most interesting thing that Barkley reports in this paper are highlighted below.

    The PI type may be the true attention disorder while the other two types are simply different developmental stages of the same disorder, one that involves behavioral disinhibition that ultimately results in poor goal-directed persistence and defective resistance to distraction (Barkley, in press).

    If research continues to support such a distinction, it is quite likely that the diagnostic criteria for each should be separate, with a new list of inattentive symptoms created to more accurately reflect this qualitative distinction of the PI type from the other types. Certainly a different name for this new disorder would be needed (say, attention-deficit disorder) that distinguished it from ADHD (which might better be called behavioral inhibition disorder, or BID).

    ***And this new ADD would probably be removed from the metacategory of the disruptive behavior disorders as it seems to share little if any comorbidity with oppositional defiant or conduct disorders, as do the other types of ADHD (BID). **

    The treatments for these two disorders may prove to be different as well. This is already hinted at in several studies of stimulant medication with these subtypes.

    ******There, the PI type has shown a lower rate (prevalence) of positive response to medication (65 percent versus 92 percent), a smaller magnitude or degree of positive response when one is seen, with the most optimal dose being toward the lower end of the therapeutic range as compared to moderate or higher doses (Barkley and colleagues 1991). *******

    Should further research replicate these initial findings, it will indicate that

    *********stimulants may not be the medications of choice for the PI type of ADHD; their response is hauntingly familiar to that seen in normal children placed on stimulants************

    (Rapoport and colleagues). And while various behavioral or contingency management interventions may still be of assistance for the PI type, they are likely to be so for reasons that are different from why they are needed and helpful in the management of the HI or combined types.

    ********The cognitive behavioral therapies may even prove more useful for the PI type although they were of questionable efficacy for the HI or combined types (Abikoff; Diaz and Berk). ********


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