Focus on Inattentive ADHD:

The Under-Diagnosed and

Under-Treated Subtype

January 10, 2022

Podcast #384

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 meet today’s expert speaker:
Mary V. Solanto, Ph.D.
Dr. Mary Solanto is professor of pediatrics and psychiatry at the
Hofstra/Northwell School of Medicine (Long Island, N.Y.). Prior to joining
Hofstra, she was Director of the ADHD Center at the Mount Sinai School
of Medicine and Associate Professor of Psychiatry at NYU. In 2017-
2018, Dr. Solanto was a Fulbright U.S. Scholar in the Netherlands,
where she conducted research on treatment of ADHD in college
students. Dr. Solanto’s research on the cognitive and behavioral
functioning of children and adults with ADHD, the effects of
psychostimulants, and the characteristics of subtypes of ADHD has
been supported by grants from NIMH, NICHD, and NINDS. She
developed a novel cognitive-behavioral intervention for adults with
ADHD, which was the focus of an NIMH-sponsored efficacy study
(American Journal of Psychiatry, 2010). The manual for therapists,
Cognitive-Behavioral Treatment of Adult ADHD: Targeting Executive
Dysfunction was published by Guilford Press (2011). The program was
recognized as the Innovative Program of the Year by CHADD (2011). Dr.
Solanto has served on study section/grant review panels for NIMH.
Currently, she is a member of the editorial boards of the Journal of
Attention Disorders, and the ADHD Report (Guilford Press), and serves
on the professional advisory boards of CHADD and APSARD.

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 ADHD Experts Podcast
Episode # 384

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 AD/HD in the DSM-V (2013)
◼ Three “Presentations” (“Subtypes” in DSM-IV)
◼ “Predominantly Inattentive” (PI)
◼ “Predominantly Hyperactive-Impulsive” (HI)
◼ “Combined” (CB)
◼ PI has at least 6 of 9 inattentive symptoms;
◼ 5 of 9 for adults and late adolescents
◼ Fewer than 5/6 hyperactive-impulsive
◼ HI has at least 6 of 9 hyperactive-impulsive symptoms
◼ 5 of 9 for adults and late adolescents
◼ Fewer than 5/6 of inattentive-symptoms
◼ CB has at least 6 of 9 of both sets of symptoms
◼ 5 of 9 for adults and late adolescents
 DSM-V - Inattentiveness
(6 of 9 required)
• Often fails to give close attention to details/careless errors
• Often has difficulty sustaining attention
• Often does not seem to listen
• Often fails to follow through/complete tasks
• Often has difficulty organizing tasks and activities
• Often avoids/dislikes tasks requiring sustained attention
• Often loses things necessary for tasks/activities
• Often easily distracted by extraneous stimuli
• Often forgetful in daily activities
 DSM-V Hyperactivity-Impulsivity
(6 of 9 required)
◼ Often fidgets with hands or feet or squirms in seat
◼ Often leaves seat in classroom or in other situations in which
remaining seated is expected
◼ Often runs about or climbs excessively in situations in which it is
inappropriate
◼ Often has difficulty playing or engaging in leisure activities
quietly
◼ Often “on the go” or often acts as if “driven by a motor”
◼ Often blurts out answers before questions have been completed
◼ Often has difficulty awaiting turn
◼ Often interrupts or intrudes on others (e.g. butts into
conversations or games)
 Other DSM-IV Criteria
A. Symptoms (previous) have persisted for at least 6
months to a degree that is maladaptive & inconsistent
with developmental level
B. Onset (some impairing symptoms) before age 7
C. Pervasive (symptoms both at home and at
school/work)
D. Clinically significant impairment
E. Symptoms do not occur exclusively during the course
of PDD, schizophrenia, or other psychotic disorder
and are not better accounted for by another mental disorder
(e.g., mood, anxiety, dissociative, or personality
disorder)
 Stability of Subtypes Over Time
◼ Lahey et al., 2005
◼ Archives of General Psychiatry, 62 (8), 896-902.
◼ Enrolled 118 preschoolers (4-6 yr) with ADHD
◼ Combined=83
◼ Predominantly Inattentive = 12

◼ Hyperactive-Impulsive=23

◼ Evaluated them annually over the next 8 years

(i.e., to age 12-14 yr)
 CB (N=83) PI (N=12) HI (n=23)

100
80
% ADHD

60
40
20
0
2 3 44 66 7 8
YearYear
of ofAssessment
Assessment
 CB (N=83) PI (N=12) HI (N=23)

100
% Different Subtype

80
60
40
20
0 2 3 4 6 7 8
2 3 Year
Year of
4of Assessment
Assessment
6 7 8
Impairment Associated with Inattention
vs. Hyperactivity-Impulsivity
◼ Inattention
◼ Executive Function
◼ Academic Underachievement

◼ Social Function – Shy/Passive

◼ Hyperactivity-Impulsivity
◼ Social Function – Intrusive/Disruptive
Willcutt, E. G., Nigg, J. T., Pennington, B. F., Solanto, M. V., Rohde, L. A.,
Tannock, R., . . . Lahey, B. B. (2012). J Abnorm Psychol, 121(4), 991-1010.
 Sluggish Cognitive Tempo
◼ Sluggish Cognitive Tempo (SCT) describes a
cluster of characteristics including:
◼ Hypoactivity, daydreaminess, lethargy, apathy.
◼ More common in PI than CB (?)
◼ Also occurs in individuals without ADHD
◼ Associated with increased executive dysfunction
in adults :
◼ Leikauf & Solanto, 2017, J Atten Disorders, 21(8).
◼ Responds to stimulant medication in adults:
◼ Adler, L.A. et al. 2021 , J Clin Psychiatry, 82(4).
 Prevalence: Gender X Subtype
CHILDREN COMBINED INATTENTIVE HYPERACT- TOTAL
(6-12 Yr) IMPULSIVE
Percent of 3.3% 5.1% 2.9% 11.4%
Pop.
Ratio of 3.6 TO 1.0 2.2 TO 1.0 2.3: TO 1.0
Male to Female

ADULTS COMBINED INATTENTIVE HYPERACT- TOTAL

19 YR + IMPULSIVE
Percent of Pop. 1.1% 2.4% 1.6% 5.1%
Ratio of 2 .0 TO 1.0 1.7 TO 1.0 1.4 TO 1.0 1.6 to 1.0
Male to Female

Willcutt, E. G. Et al (2012). The prevalence of DSM-IV ADHD: a meta-analytic review.

Neurotherapeutics, 9(3), 490-499.
 Treatment-Seeking Adults with ADHD:
Gender X Subtype

Solanto et al: (2019) The Prevalence of Adult-Onset ADHD, J Attention Disorders

 Comorbidity
◼ Other Disruptive Behavior Disorders
◼ Oppositional Defiant Disorder: CB>PI
◼ Conduct Disorder: CB>PI
◼ Alcohol and Substance Abuse: CB>PI
◼ Depression/Anxiety PI=CB
◼ Learning Disorders PI=CB

de la Pena, I. C., Pan, M. C., Thai, C. G., & Alisso, T. (2020).

Subtype/Presentation: Research Progress and Translational Studies.
Brain Sci, 10(5).
Comparisons between PI and CB
◼ Symptom Profile
◼ Gender distribution
◼ Comorbidity
◼ Cognitive/Executive Function
◼ Social Function
◼ Heritability
◼ Response to Treatment
 Cognitive/Executive Functions
◼ Greater deficit in CB subtype for:
◼ Inhibitory Control
◼ Emotional Dysregulation
◼ Greater deficit in PI subtype for :
◼ Processing Speed
◼ Visual-motor/visual search tasks
E.g., WISC: Coding and Symbol Search
◼ May include speed of Auditory Processing
◼ No CB-PI differences1/or Greater severity in CB2
◼ Attention: Orienting, Sustained, Distractibility, Reaction Time
◼ Memory: Verbal, Visual, Working
1Solanto,M. V., et al. (2007). Journal of Abnormal Child Psychology, 35(5), 729-744.
2Nikolas, M. A., & Nigg, J. T. (2013).. Neuropsychology, 27(1), 107-120.
 Social Characteristics
◼ PI: slow to respond: “in la-la land” “tuned-out”
◼ PI: Deficits in social knowledge vs.

CB: Deficits in social behavioral self-regulation

◼ PI more passive; CB more aggressive

◼ Sociometric Studies:
◼ PI more likely to be socially neglected
◼ CB more likely to be socially rejected

Maedgen, J. W. & Carlson, C. L. (2000). Journal of Clinical Child

Psychology, 29, 30-42.
 Social Skills Rating Scale
Teacher
P<.001 P<.001 P<.01
20
18
16
14
Raw Score

12 Combined
Combined
10 Inattentive
Inattentive
8 Comparison
Compariso
6 n
4
2
0
Cooperation Assertion Self-Control

Solanto, M. V., et al. (2009).. Journal of Attention Disorders, 13(1), 27-35

 Heritability/Familial Genetics
• Familial Aggregation of Disorder:
- 15-20% of mothers- 25-30% of fathers
• 40% of either parent
• Twin Studies of Heritability:
• Concordance Rate:
• 80% for identical twins; 35% for fraternal
• Heritability = 70-80%
- Shared Environment = 0-6% (Not significant)
- Unique Environment = 15-20%
• Both subtypes can occur in the same family
 Assessment and Diagnosis
Adults
◼ Screening Instrument:
◼ World Health Organization -brief screener
◼ Diagnostic Evaluation:
◼ Conners Adult ADHD Rating Scale (CAARS)
◼ History: Childhood and Adolescence
◼ Current Functioning and Impairment
◼ Educational, Social, Occupational
◼ Gender Differences
◼ Challenging in practice to differentiate PI from
disorders of Anxiety, Learning, Language, and ASD
 Response to Medication
Comparing PI and CB
◼ Stimulants
◼ In children – Variable results across studies
◼ PI responded best at lowest dose (Stein et al, 2003)
◼ No PI-CB differences (Solanto et al, 2009)

◼ PI: smaller improvements than CB even at lowest dose

(Beery, Quay, & Pelham, 2012)
◼ In adults –less well-studied. No differences between subtypes
shown in response to stims or non-stims
◼ TAKE HOME:
◼ Medication must be carefully titrated for each child.
 Response to Psychological Treatment
Comparing PI and CB
◼ Children
◼ No diffs in response to typical BT programs
◼ Behavioral Program uniquely for PI (Pfiffner)

◼ Adults:
◼ No Difference in Response to CBT for Executive
Dysfunction
CBT for Executive Dysfunction: Topics

◼ Getting Enough Sleep

◼ Time-Awareness and Scheduling
◼ Prioritization
◼ Organization
◼ Short- and Long-term Planning
◼ Mindfulness
◼ Home Exercise
The Two Most Helpful Strategies
“If it’s not in the planner it doesn’t exist”
Planner Use;
◼ Your roadmap for the day
◼ Without it, you will take a meandering route –
and may never get there at all

“If I’m having trouble starting, the first step is too big”
Chunking:
◼ The best strategy for overcoming procrastination
 Summary
◼ CB and PI are similar with respect to core inattentive
symptoms & associated impairment
◼ PI has less difficulty with behavioral self-
inhibition/self-control and emotional self-regulation
◼ PI has less comorbidity with externalizing disorders
(ODD, CD etc.); equal comorbidity with internalizing
◼ PI more likely to have slow processing speed and
features of SCT
◼ PI and CB have correspondingly different types of
social difficulties
◼ Children with PI/CB may differ in response to
stimulants, but not to BT or CBT in children or adults
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