Inattentive ADHD Treatment. What Do We Know?

I received a question from a reader who wanted to know more about what we know regarding treatment, risk factors, and other interventions for Predominantly Inattentive ADHD (ADHD-PI). I have posted this information in my response to her question but I wanted to put it in a regular post so that everyone could read it.

When my son did not respond well to Ritalin, I suspected that he was not that different from other children with Inattentive ADHD. I knew from living with my two children that the symptoms that my eldest son with ADHD-PI had were substantially different from the ADHD Hyperactive/Impulsive ADHD condition that my younger son was being treated for. I wanted to find out who had information on this subtype and on how these ADHD-PI kids responded to stimulants. I found that Russell Barkley had studied this subtype pretty extensively in the early 90s and I set out to read all that I could of his work on ADHD-Pi.

It was one of Dr. Barkley’s quotes in the paper that I cite below that was a huge motivator for me to try and learn as much as I could about treating children with Predominantly Inattentive ADHD. I think that you will be able to guess which of the quotes (in astericks) pushed me into action.

This was my response to the reader's question.

What we know about Predominantly Inattentive ADHD is mostly from the work done by Russell Barkley, PhD. I have read most of what Dr. Barkley has written about ADHD-PI. Unfortunately there have not been many recent studies done looking specifically at ADHD-PI and the research done in the 90s still applies today. The Russell Barkley summary article cited below answers many of the questions regarding behavioral therapy, stimulant therapy, and risk factors for ADHD-PI

This information is from a paper that Dr. Barkley wrote in 1996, entitled: Research Developments and Their Implications for Clinical Care of the ADHD Child. All the references cited can be found at the end of the paper.

The link to this paper can be found here:
http://www.psychiatrictimes.com/display/article/10168/1158321

I have excerpted and highlighted in astericks what I think are some of the most interesting things that Barkley reports on in this paper. (The asterisks are my notation.)

"The PI type may be the true attention disorder while the other two types are simply different developmental stages of the same disorder, one that involves behavioral disinhibition that ultimately results in poor goal-directed persistence and defective resistance to distraction (Barkley, in press).

If research continues to support such a distinction, it is quite likely that the diagnostic criteria for each should be separate, with a new list of inattentive symptoms created to more accurately reflect this qualitative distinction of the PI type from the other types. Certainly a different name for this new disorder would be needed (say, attention-deficit disorder) that distinguished it from ADHD (which might better be called behavioral inhibition disorder, or BID).

****And this new ADD would probably be removed from the metacategory of the disruptive behavior disorders as it seems to share little if any comorbidity with oppositional defiant or conduct disorders, as do the other types of ADHD (BID). ****

The treatments for these two disorders may prove to be different as well. This is already hinted at in several studies of stimulant medication with these subtypes.

****There, the PI type has shown a lower rate (prevalence) of positive response to medication (65 percent versus 92 percent), a smaller magnitude or degree of positive response when one is seen, with the most optimal dose being toward the lower end of the therapeutic range as compared to moderate or higher doses (Barkley and colleagues 1991). ****

Should further research replicate these initial findings, it will indicate that

****stimulants may not be the medications of choice for the PI type of ADHD; their response is hauntingly familiar to that seen in normal children placed on stimulants**** (Rapoport and colleagues).

And while various behavioral or contingency management interventions may still be of assistance for the PI type, they are likely to be so for reasons that are different from why they are needed and helpful in the management of the HI or combined types.

****The cognitive behavioral therapies may even prove more useful for the PI type although they were of questionable efficacy for the HI or combined types (Abikoff; Diaz and Berk)." ****

So can you guess which Russell Barkley quote (in astericks) got me so riled up that I set out to research this topic ad nauseam??