ADHD-C: Understanding Combined ADHD
ADHD-C, also known as combined type attention-deficit/hyperactivity disorder (ADHD) or combination ADHD, is a mixture of two major presentations of attention-deficit/hyperactivity disorder. In this article, we will use the terms “type” and “subtype’” interchangeably, but it is important to know that new changes in the DSM-V classify ADHD as just one disorder that presents itself in three distinct ways.
What is attention-deficit/hyperactivity disorder (ADHD)?
ADHD is a neurodevelopmental disorder that affects development, functioning, and cognitive control and can cause working memory deficits. It belongs to a group of externalizing disorders that also include conduct disorder and oppositional defiant disorder.
Though it’s tough to get an exact number due to underdiagnosis in some demographic groups and other potential factors such as misdiagnosis, up to 9.4% of children in the United States have been diagnosed with ADHD at some point in their lives, though symptom severity may vary. It is the most common neurodevelopmental disorder in children, but with that in mind, it’s crucial to state that ADHD does not only affect minors—children with ADHD, diagnosed or undiagnosed, can go on to become adults with continued ADHD symptoms.
ADHD subtypes
Stereotypes surrounding ADHD may make it seem as though ADHD always presents the same way, but the truth is that it can–and does–vary from person to person. These variations can be broken down into one of the below subtypes based on criteria outlined by the current DSM-V.
1. Hyperactive-impulsive type ADHD
The first presentation of ADHD that we will cover is not ADHD-C, but the most commonly known or represented version of the disorder, particularly in preschool children, hyperactive-impulsive ADHD (ADHD-HI).
If the child is 16 years old or under and seeking to be officially diagnosed by a professional, they must present at least six of the hyperactive and impulsive symptoms below. If someone is 17 or older, they must experience five or more hyperactive symptoms.
Fidgets (i.e., whole body, hands, feet), squirms in seat, or taps
Runs or climbs on things in situations when doing so is inappropriate
Often leaves seats in situations in which one is expected to stay seated
Has trouble playing with toys or taking part in activities quietly
Seems to be driven by a motor or constantly on the go
Often interrupts or intrudes on others
Has trouble waiting for their turn
Talks excessively
Blurts out answers
On top of the above nine symptoms, the following criteria must be met for diagnosis.
The symptoms have been present for at least six months and are not better characterized by another diagnosis, such as a mood disorder.
Many of the ADHD signs and symptoms that qualify the diagnosis were present before the age of 12.
These symptoms present in more than one setting, such as at home, school, during extracurricular activities, or at work.
The symptoms experienced because of ADHD reduce the quality of life in school, at home, or socially.
2. Inattentive type ADHD
The second type of ADHD recognized in the DSM-5 is inattentive ADHD (ADHD I). Like with hyperactive-impulsive ADHD, individuals must have experienced inattention symptoms for at least six months, and several of these symptoms must have been noticed before age 12. Additionally, the symptoms must be present in more than one area of life, and they must reduce the quality of life in school, work, relationships, etc.
To be diagnosed with predominantly inattentive type ADHD, children 16 and younger must present six or more symptoms, and those 17 and older must present five inattentive symptoms.
Unable to pay close attention or making careless mistakes
Difficulty focusing on tasks or playful activities
Not listening (or seeming not to listen) when spoken to
Difficulty following through on instructions/completing tasks
Trouble organizing tasks
Avoiding tasks that require extended periods of concentrated thinking
Frequently losing items
Easily distracted
Forgetful while completing everyday activities
3. Combined type ADHD
As mentioned above, those with ADHD combined type (ADHD-C) have inattention and hyperactivity-impulsivity symptoms. If individuals have been diagnosed with both ADHD types, they are considered part of the ADHD-combined type group.
Managing ADHD symptoms
No matter a person’s age, living with the hyperactive impulsive symptoms of ADHD-C can be challenging. Inattentive and combined types of ADHD may make it difficult to remain appropriately calm, be patient in situations, listen to others, and focus on tasks at hand.
Before you begin treatment or seek treatment for a loved one, it’s important to understand that ADHD-C is not the individual’s fault, nor are the symptoms of the condition. You should also recognize that while treatment may not dissolve symptoms, it can help those impacted by ADHD-C live with their symptoms and lead a happy and fulfilling life.
Treatment for ADHD-C, like treatment for other presentations of the disorder, might focus on various goals, including:
Reducing ADHD-C symptoms
Improving overall life functioning
Highlighting achievements and strengths
Increasing self-esteem
Navigating interpersonal relationships
If applicable, addressing co-occurring conditions (depression, anxiety, etc.)
Treatment of adults and children with ADHD can differ in some ways, but they do contain similar routes. Medication, therapy, and peer or social support options are often helpful for those who live with ADHD. For children who live with ADHD, part of the treatment program may involve education and training for parents.
According to the CDC and other expert sources, roughly 70-80% of those who live with ADHD benefit from medication. That said, behavioral therapy is suggested first for those under six years of age. Please consult with your prescribing doctor or primary care physician before considering any medication options.
The process of finding the right treatment plan, including the correct mix of therapy and medication, can take time. Here are some things you can do to support yourself or your child as you look for what works best for you:
Find people who understand
There are support groups for those who live with ADHD as well as support groups for those who have children living with ADHD. Even if those in these groups don’t have symptoms of both subtypes of ADHD, they can still offer support and understanding.
Ask for help from a loved one
When you have a to-do list and feel overwhelmed, are having a tough time initiating a task, or something else, don’t be afraid to ask for support. Oftentimes, having someone to accompany you while you work on a task can prove helpful. This is an action known as body doubling.
Double your time
Time management can be challenging for many people who live with ADHD-C. Some helpful steps include planning to leave early and setting alarms or other reminders accordingly. There are also a variety of time management apps specifically geared towards neurodivergent individuals.
Use technology to your advantage
If you have a smartphone, built-in apps may allow you to keep email tasks in one place, set phone reminders, and so on. You can also look for apps to help with making grocery lists, organizing doctors’ appointments, and storing passwords or other information that you don’t want to lose. There are apps made specifically for those who live with ADHD that you may wish to try.
Let yourself say “no”
Due to challenges related to time management, some people living with ADHD-C may unintentionally overbook themselves. By saying “no” to things that do not serve you, you free up your time for things that are actual priorities to you, and can provide yourself cushioning between tasks that can reduce stress. Practice taking a step back and thinking about your true threshold before you take something on. You might even practice saying something like, “Is it okay if I check my work schedule and let you know later on?” Be kind to yourself if you do forget or take too much on, as developing this habit can take time and is not always a linear process.
Find a therapeutic match
Many people living with ADHD benefit from therapy. When looking for a therapist, remember that not every therapist specializes in working with the same population, condition, or treatment. For example, someone experienced in adolescent psychiatry may be a good fit for a teen, and a therapist who specializes in adult ADHD may be better able to help adults find tools and systems that work for them as well as healthy ways to cope or self-soothe.
Embrace curiosity and self-compassion over judgment
Sometimes, it takes trial and error to find what works. We’re all different, and it can be tempting to judge or shame ourselves when what works for someone else does not work for us. If it’s a child we’re caring for, we may get worried or even frustrated when a particular strategy falls through. However, when something doesn’t work, it is simply a chance to gain information and better understand how the individual functions. Stay curious, use creativity, and don’t be afraid to try something new when you need to.
Get support for combined-type ADHD
Living with ADHD-C may mean it’s difficult to remember appointments, listen to those who are talking, and commit to showing up to a therapy session (or struggling to sit through one). Those symptoms, and others, may mean attending an in-person therapy appointment can be difficult or unappealing.
Online therapy allows you to attend appointments from anywhere you have a stable internet connection, which means it may be easier to fit therapy into your life. Additionally, when you enroll in an online therapy platform, you’ll usually be able to communicate with your therapist through messages as well, not just during your scheduled video or phone session.
A review of studies that looked at online treatment for ADHD suggests that online interventions can help improve individuals’ social functions. One of these studies examined the role of online cognitive behavioral therapy (CBT) in treating adult ADHD and found that this form of therapy is likely effective.
Takeaway
What is ADHD subtype C?
ADHD subtype C likely refers to the combined subtype (ADHD-C). The two others are the primarily hyperactive and impulsive subtype (ADHD-HI) and the primarily inattentive subtype (ADHD-PI). Those diagnosed with ADHD-C show symptoms of both other subtypes; they display at least some hyperactive or impulsive behaviors and some inattentive behaviors. Both ADHD-PI and ADHD-HI have nine separate diagnostic criteria. To be diagnosed with ADHD-C, a person must exhibit six of the nine criteria from both the ADHD-PI and ADHD-HI subtypes.
Is ADHD-C better than ADHD-PI?
Whether one form of ADHD is “better” than the other is a matter of personal interpretation. A person with a relatively mild presentation of ADHD-PI may fare better than a person with a severe presentation of ADHD-C, but the reverse could also likely be true. The ADHD subtypes only define the particular set of symptoms a patient presents with; they do not describe the impact that the symptoms have on the person’s life. The relative impact likely comes down to how well ADHD is managed.
What are the three types of ADHD?
There are three distinct subtypes of ADHD, summarized below:
- Predominantly Inattentive Presentation (ADHD-PI). Individuals struggle to stay organized, finish tasks, pay attention to details, or follow instructions. The person is likely easily distracted and forgets small details quickly.
- Predominantly Hyperactive-Impulsive Presentation (ADHD-HI). The person fidgets frequently, talks a lot, and may find it hard to stay still for long. They frequently feel restless and may make impulsive decisions. Waiting their turn, speaking at appropriate times during a conversation, and listening to directions is also challenging.
- Combined Presentation (ADHD-C). The individual displays symptoms of both the ADHD-PI and ADHD-HI subtypes.
What are ADHD-PI and ADHD-C?
ADHD-PI refers to the predominantly inattentive subtype of ADHD, characterized by difficulty paying attention, staying organized, or following instructions. It contrasts the predominantly hyperactive/impulsive subtype (ADHD-HI), which is characterized by fidgeting, excessive talking, difficulty staying still, and impulsive decision-making. ADHD-C, the combined subtype, is diagnosed when a person displays symptoms of both ADHD-HI and ADHD-PI.
What is high IQ ADHD?
“High IQ ADHD” is not a clinical diagnosis, nor does it represent a subtype of the condition. The term likely refers to the interaction between IQ and ADHD. There is some evidence to suggest that a high IQ can “mask” the symptoms of ADHD, creating a symptom profile that differs between those with standard and high IQs. Specifically, those with high IQs tend to do better on executive function tasks, like sorting, trail-making, and matching. Researchers believe that a higher degree of intellectual efficiency may compensate for deficits in executive function caused by ADHD.
At what age is ADHD hardest?
Evidence suggests that ADHD is typically the hardest between middle school and young adulthood. During that time, children and young adults experience significant demands on their focus, concentration, and organizational skills. They must control impulsivity and tolerate spending many hours per day in school. Once a child with ADHD reaches adulthood, they typically have additional skills and strategies they can use to help mitigate their symptoms and have likely received both psychotherapeutic and pharmacological treatment. Those who are undiagnosed are likely behind their ADHD peers who received treatment, but they probably gained skills through trial and error, even if they are unaware of their condition.
Do people with ADHD mentally age slower?
Evidence indicates that people with ADHD typically mature slower than their peers. Some estimates suggest that those with ADHD lag three to five years behind their peers in certain developmental areas. Neuroimaging studies indicate that about one-third of children diagnosed with ADHD will “catch up” to their peers during early adolescence, but the majority will experience symptoms into adulthood. Whether ADHD persists beyond that point is still poorly understood. Evidence suggests that many people enter a “sub-clinical” stage of ADHD where they experience symptoms that are more significant than the general population but not severe enough to warrant an ongoing diagnosis of ADHD.
What are the warning signs of ADHD?
ADHD can present differently from child to child, and a diagnosis of ADHD requires a comprehensive evaluation from a mental health professional. There are not any standardized early warning signs, and many experts are quick to caution parents from worrying too early. Many ADHD symptoms are similar to behavior that is typical in early childhood, and it is difficult to recognize ADHD in those younger than school age.
However, once children reach kindergarten, there are some warning signs to watch out for. Dr. Mark Mahone, director of the Department of Neuropsychology at the Kennedy Krieger Institute, recommends getting a child evaluated if they display any of the following signs:
- Dislikes or avoids activities requiring sustained attention for over a minute or two.
- Loses interest in an activity after engaging for only a few moments.
- Talks much more than other children the same age.
- Climbs on things, even when instructed not to.
- Nearly always restless and fidgets frequently. Can only stay seated for a few minutes.
- Is fearless to the point of getting into dangerous situations.
- Warms up to strangers too quickly.
- Frequently aggressive with playmates.
- Has been injured because of moving too fast or running in inappropriate areas.
Can ADHD get worse in old age?
The information surrounding the effects of ADHD is limited. Until recently, ADHD was considered a “childhood disorder,” and it was assumed that most people would grow out of the condition by the time they left young adulthood. Because of this, the bulk of ADHD research has been focused on children, with researchers only recently extending investigations to older adults. Preliminary evidence suggests that ADHD likely stabilizes in middle adulthood, but symptoms may worsen or reemerge in late adulthood. However, researchers are still working to understand how ADHD combines with other cognitive concerns that appear in old age, such as dementia or mild cognitive impairment.
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