Combined presentation ADHD

Combined presentation ADHD, previously known as Combined Type ADHD, is one of the three presentations (or subtypes) of Attention Deficit Hyperactivity Disorder (ADHD) identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The other two presentations are Predominantly Inattentive Presentation and Predominantly Hyperactive-Impulsive Presentation. The combined presentation is characterized by symptoms of both inattention and hyperactivity-impulsivity that are persistent and impairing, occurring in more than one setting (e.g., at home, school, or work).

Characteristics

Individuals with the combined presentation of ADHD display a mixture of inattentive and hyperactive-impulsive symptoms. Key characteristics include:

Inattention: Difficulty sustaining attention, making careless mistakes, not seeming to listen when spoken to directly, difficulty organizing tasks and activities, avoidance or dislike of tasks requiring sustained mental effort, losing things necessary for tasks or activities, easily distracted by extraneous stimuli, and forgetfulness in daily activities.
Hyperactivity: Fidgeting with or tapping hands or feet, or squirming in seat; leaving seat in situations when remaining seated is expected; running about or climbing in situations where it is inappropriate (in adolescents or adults, may be limited to feeling restless); being unable to play or engage in leisure activities quietly; being “on the go” or acting as if “driven by a motor”; talking excessively.
Impulsivity: Blurting out answers before questions have been completed, having difficulty waiting their turn, and interrupting or intruding on others (e.g., butting into conversations or games).

Diagnosis

The diagnosis of combined presentation ADHD requires a comprehensive evaluation that includes clinical interviews, and may also involve rating scales, observations, and potentially, neuropsychological testing. This evaluation aims to rule out other possible causes of symptoms, such as learning disorders or emotional disturbances, and to determine that the symptoms are not better explained by another mental disorder. The DSM-5 specifies that several symptoms should be present before the age of 12, be present in two or more settings (e.g., at home and school), and significantly impair social, academic, or occupational functioning.

Treatment

Treatment for combined presentation ADHD often involves a multimodal approach, including:

Medication: Stimulant medications (e.g., methylphenidate or amphetamines) are the most commonly prescribed and are effective in reducing symptoms for many individuals. Non-stimulant medications, such as atomoxetine, guanfacine, or clonidine, may also be used, particularly if stimulant medications are not effective or cause significant side effects.
Behavioral Therapy: Strategies may include behavior modification techniques, organizational skills training, and social skills training. For children, parent training in behavior management techniques is often recommended.
Psychoeducation: Educating the individual and family about ADHD and its management.
Accommodations: At school or work, accommodations might include extra time on tests, a quiet room for work, or organizational aids.

The choice of treatment depends on the individual’s specific symptoms, age, and the presence of any coexisting conditions. Effective management often requires adjustments over time and collaboration among healthcare providers, parents, educators, and the individual with ADHD.