ADHD Inattentive in Children and Adolescents

ADHD is characterized by two main categories of symptoms:

• Inattention, which refers to difficulty paying attention to and carefully completing a given task, particularly in situations that require continued concentration or mental effort.
• Hyperactivity-impulsivity, which means having an unusually high level of activity and difficulty inhibiting impulses. Motor symptoms of hyperactivity become less obvious in adolescence compared to childhood, but difficulties persist with restlessness and impulsivity.

The Predominantly Inattentive Presentation of ADHD is diagnosed if the required number of symptoms of inattention, but not hyperactivity-impulsivity, have been present for the past six months:

• Often fails to give close attention to details or makes careless mistakes on schoolwork or other activities
• Often has difficulty holding attention on tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork or chores
• Often has difficulty with organization
• Often avoids or dislikes tasks that require continued mental effort
• Often loses necessary materials
• Is often easily distracted
• Is often forgetful in daily activities

In order to meet criteria for ADHD, Predominantly Inattentive Presentation, six or more of these symptoms must be present for children and adolescents up to age 16. Adolescents 17 and older must show five or more symptoms. These symptoms must be present for at least six months and be inappropriate for the child or adolescent’s developmental level. Additionally, the following conditions must be met:

• Several symptoms were present before age 12
• Several symptoms are present in two or more settings, such as at school, home, and in peer interactions
• Symptoms clearly interfere with or reduce the quality of the child’s school or social functioning
• Symptoms are not better explained by another psychiatric condition (for example, an anxiety or mood disorder) or occur only during the course of schizophrenia or another psychotic disorder

Children and adolescents with ADHD, Predominantly Inattentive Presentation may also show some symptoms of hyperactivity-impulsivity. However, children up to age 16 must have fewer than six hyperactivity-impulsivity symptoms and adolescents 17 and older must have fewer than five hyperactivity-impulsivity symptoms to meet criteria for the Predominantly Inattentive Presentation. Symptoms of hyperactivity-impulsivity include the following:

• Often fidgets with or taps hands or feet, or squirms in seat
• Often leaves seat in situations when remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate (adolescents may be limited to feeling restless)
• Often unable to play or take part in leisure activities quietly
• Is often "on the go" acting as if "driven by a motor"
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has trouble waiting his/her turn
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

ADHD is characterized by deficits in neurocognitive processes known as executive functions, which include processes that are important for regulating attention and behavior, such as attentional control, inhibitory control, cognitive flexibility, and planning. ADHD stems from multiple causes, including a strong genetic component. Genetics appears to be the principal cause of ADHD, likely accounting for up to approximately 75% of all cases. In a smaller percentage of cases, ADHD may arise from early brain injuries or other disruptions to brain development, such as pregnancy or birth complications. Research does not support the claim that ADHD is a result of food additives, preservatives, or sugar.

For preschool-aged children (4-5 years old):

First Line Treatments

• Evidence-based parent- and/or teacher-administered behavior therapy, implemented under the guidance of a behavior therapist, should be prescribed as the first-line treatment. Behavioral approaches, including behavioral parent training, classroom management, and peer interventions, and organizational interventions currently have the most research evidence for the treatment of children and adolescents with ADHD and are considered well-established treatments. In evidence-based behavioral approaches, professionally trained behavior therapists work directly with the parents and/or teachers to implement behavior interventions in the home and/or school settings. For children and adolescents with ADHD, Predominantly Inattentive Presentation, these interventions focus on improving planning, materials organization, time management, and homework management skills.

Second Line Treatments

• Methylphenidate may be prescribed if the behavior interventions do not yield significant improvement and there is continued moderate-to-severe disturbance in the child’s functioning.
• In areas in which evidence-based behavioral treatments are not available, the risks of starting medication at an early age must be weighed against the harm of delaying diagnosis and treatment.

For school-aged children and adolescents (6-18 years old):

First Line Treatments

• Treatment guidelines generally recommend the use of both FDA-approved medications for ADHD and evidence-based parent- and/or teacher-administered behavior therapy under the guidance of a behavior therapist.

• Stimulant medications have been demonstrated to reduce symptoms of ADHD, predominantly inattentive presentation, and improve attention span, focus, and task completion. Specific first-line medications for ADHD, predominantly inattentive presentation, in school-aged children and adolescents include:
• Methylphenidate
• dexmethylphenidate
• extended release dexmethylphenidate
• extended release methylphenidate
• methylphenidate hydrochloride
• Amphetamines
• mixed amphetamine salts
• extended release mixed amphetamine salts
• dextroamphetamine
• Lisdexamfetamine (extended release)

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Atomoxetine
• Extended release guanfacine
• Extended release clonidine
• The school environment, program, or placement should be part of any treatment plan.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments listed above, might be considered:

• Neurofeedback training
• Cognitive training

Healthcare professionals are encouraged to stress the value of a balanced diet, good nutrition, and regular exercise for children and adolescents with ADHD.

In addition, a reference for Natural ADHD substitutes can be here.