Why ADD has Disappeared as a Diagnosis, and the Subtypes of ADHD

For a very long time, Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD) were considered separate but related diagnoses. The major distinguisher between the two was the ‘H’ for hyperactivity, which was indicated for those who had trouble sitting still and showed more physical symptoms, like having an over-abundance of energy. In the most recent release of the Diagnostic and Statistical Manual of Mental Health Disorders (also known as DSM-V), however, these diagnoses were combined into just one disorder, ADHD, with corresponding subtypes to distinguish between the different presentations. Ultimately the differences between ADD and ADHD were significant enough for them to warrant different diagnoses. The trouble actually came with presentations that were somehow both or neither presentation, such as racing thoughts (which qualify as hyperactive) but not a lot of physical hyperactivity, which is a more common presentation in girls. Thus the diagnoses were combined and are now viewed as almost a spectrum, with a variety of symptoms possible that add up to a specific subtype of ADHD.

There are three presentations acknowledged for ADHD: Hyperactive, Inattentive, and Combined type. The hyperactive presentation is more what typical ADHD was originally, while ADD was re-labelled as Inattentive. The Combined type is what brought these two diagnoses together.

The Hyperactive subtype is characterized by the more stereotypical form of hyperactivity. This includes struggling with impulse control, being unable to sit still, acting out of turn, rapid and loud speech, and fidgeting. This presentation is the easiest to identify because of its tendency to manifest in disruptive classroom behavior, particularly in young children. As children with hyperactive ADHD grow older, their impulse control improves (although is generally still significantly less than their neurotypical peers) and thus they may not have as many instances of being disruptive outright, but will often still struggle with not talking during class, acting impulsively, and sitting still for long periods of time. They are also capable of hyperfocus, a state in which they are extremely absorbed in one activity for an abnormally long amount of time. This is usually something that they’re interested in, but can also be a suddenly diverting detail. For example, playing one video game for so long that they forget to eat, drink, sleep, or go to the bathroom; another is cleaning one specific object while trying to do chores with an unusual intensity or attention to detail. 

The Inattentive subtype presents with distractibility as its primary symptom. Those with this form of ADHD struggle with following instructions (often because they can’t pay attention through the entire set of instructions), organization, forgetfulness, misplacing objects and being easily distracted by unimportant details or stimuli. This becomes more prevalent as they move into adolescence and are responsible for more things on their own, like remembering to do homework, organizing and preparing for a project or getting homework done on time, or struggling to complete a task because other potential tasks or activities keep distracting them or stealing their focus. The inattentive type is also prone to sudden hyperfocus, similar to hyperactive. 

The Combination subtype presents with a mix of the two sets of symptoms simultaneously. It is not enough, however, to present with just a few of each, but to qualify as Combined type, there must be a majority of both subtypes’ symptoms present. Surprisingly, despite the steep diagnostic criteria, Combined type is the most  commonly diagnosed subtype, with Inattentive being the least common. This is likely due to the fact that inattentive subtype has fewer easily identifiable symptoms from an onlooker’s perspective, and instead are primarily experienced in the internal world of the person. 

While ADHD can be confusing in it’s many presentations, much of the experiences at its core are similar from person to person, and important to address. A person with ADHD that is left untreated (meaning without either therapeutic intervention or medication) is highly likely to develop anxiety or depression as a result of the chronic discomfort it can cause. Because ADHD is a developmental disorder, there is no ‘cure’ or getting rid of it, or developing skills that would eliminate the symptoms. Instead, treatment often focuses on learning about one’s own experience and working with the strengths of the mind rather than trying to force the brain to lean on its weaknesses.