Not Much News for Defining Sluggish Cognitive Tempo

Not Much News for Defining Sluggish Cognitive Tempo 

If Sluggish Cognitive Tempo (SCT) is to get a "place at the table" in the DSM V (the diagnostic manual that psychiatrists use to diagnose mental health conditions) a complete and accurate definition and description of the symptoms are necessary.

A group of researchers has developed a 14 point scale of SCT symptoms that aim to distinguish SCT from ADHD and from Inattentive ADHD.

A study, just published, in the Journal of Abnormal Child Psychology has tested this scale and identified three distinct traits that correspond with SCT and/or Inattentive ADHD symptoms and a trait, that when it is present, significantly impair individuals with SCT above and beyond the impairments related to sluggishness or inattentiveness.

The three traits are Sleepy/Sluggish, Slow/Daydreamy, and Low Initiation/Persistence.   The low initiaion/persistence scale contributes to significantly greater academic impairment but I would argue, as I did in the post on ADHD being a persistence deficit, that  this trait can be found in everyone with a diagnosis of ADHD regardless of subtype.

I hate to be a kill joy but I honestly do not see how a study that tells us that people with Sluggish Cognitive Tempo are more sluggish or more sleepy (or that a lack of persistence contribute to greater academic impairment) adds much to our knowledge of SCT.

The abstract is below.


J Abnorm Child Psychol. 2012 May 8.
Factor Structure of a Sluggish Cognitive Tempo Scale in Clinically-Referred Children.
Jacobson LA, Murphy-Bowman SC, Pritchard AE, Tart-Zelvin A, Zabel TA, Mahone EM.


Abstract

"Sluggish cognitive tempo" (SCT) is a construct hypothesized to describe a constellation of behaviors that includes daydreaming, lethargy, drowsiness, difficulty sustaining attention, and underactivity. Although the construct has been inconsistently defined, measures of SCT have shown associations with symptoms of attention-deficit/hyperactivity disorder (ADHD), particularly inattention. Thus, better characterization of SCT symptoms may help to better predict specific areas of functional difficulty in children with ADHD. The present study examined psychometric characteristics of a recently developed 14-item scale of SCT (Penny et al., Psychological Assessment 21:380-389, 2009), completed by teachers on children referred for outpatient neuropsychological assessment. Exploratory factor analysis identified three factors in the clinical sample: Sleepy/Sluggish, Slow/Daydreamy, and Low Initiation/Persistence. Additionally, SCT symptoms, especially those loading on the Sleepy/Sluggish and Slow/Daydreamy factors, correlated more strongly with inattentive than with hyperactive/impulsive symptoms, while Low Initiation/Persistence symptoms added significant unique variance (over and above symptoms of inattention) to the predictions of impairment in academic progress.

Inattentive ADD Symptoms - Free ADD Test and Self Assessment

This free Inattentive ADD test or Inattentive ADHD self assessment is to be used as a quick check for the symptoms that are diagnostic for Inattentive ADHD. Patients and parents concerned about a diagnosis of ADHD in themselves or their children should seek a complete ADHD evaluation by a licensed  medical provider.

Inattentive ADD Test/Inattentive ADHD Self Assessment Check the Inattentive ADHD symptoms that are considered to be a significant problem at the present time: Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities Often has difficulty sustaining attention in tasks or play activity Often easily distracted Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions) Often has difficulty organizing tasks and activities Often does not seem to listen when spoken to directly Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Often looses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools) Often easily distracted by extraneous stimuli Often forgetful in daily activities If a person has six or more of these symptoms, which have been present for at least 6 months and that are present both at school/work and at home, the person is considered to fulfill the criteria for a diagnosis of  the Inattentive Subtype of ADHD If  a considerable number of hyperactivity and Impulsive symptoms* are also present along with the above symptoms then the patient is considered to have Combined type ADHD (ADHD-C). If only Hyperactivity and Impulsive symptoms are present without the above symptoms then the person is thought to have the Hyperactive/Impulsive subtype of ADHD (ADHD-H If fewer then six of the above symptoms are present then the person is thought to be without a diagnosis of ADHD. * The symptoms of Hyperactivity and Impulsive behavior include: Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, and story time Be constantly in motion Have difficulty doing quiet tasks or activities. Be very impatient Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences Have difficulty waiting for things they want or waiting their turns in games Often interrupt conversations or others' activities.

Inattentive ADHD Symptoms, Causes and Treatment, An Overview

Inattentive ADHD Symptoms, Causes, Rx Overview

This is the overview page for Primarily Inattentive ADD. Here you will find a broad view of the information known about Inattentive ADHD.

This overview discusses the symptom, treatment, and diagnostic differences between Inattentive ADHD and the other subtypes of ADHD.

Inattentive ADHD is one of the three subtypes of Attention Deficit Hyperactivity Disorder (ADHD).
Inattentive ADHD is sometimes referred to as ADD which is short for Attention Deficit Disorder. This subtype of ADHD is also called ADHD predominantly inattentive (ADHD-I, ADHD-PI).  I will use all these terms interchangeably.

Symptoms: 

ADD differs from the other two subtypes in several ways. The characteristic symptoms of the inattentive subtype are inattention, easy distractibility, disorganization, procrastination and forgetfulness.

About a third of people with the Inattentive subtype also have coexisting lethargy and fatigue and people with this variant of ADD are said to have Sluggish Cognitive Tempo or SCT.

People with ADD and Sluggish Cognitive Tempo have fewer or no symptoms of hyperactivity or impulsiveness and they are less likely to have a co-existing diagnosis of Oppositional Defiance Disorder or Conduct disorder. Hyperactivity and Impulsiveness are symptoms that are the hallmark of the other two subtypes of ADHD, the Combined type of ADHD referred to as ADHD-C and the Hyperactive/Impulsive subtype of ADHD which is referred to as ADHD-HI.

People with this condition have been shown in studies to perform more poorly in school than people with the other subtypes of ADHD but they are less likely to suffer the adverse life outcomes, such as substance abuse disorder or law enforcement problems, seen more commonly in people with the other two subtypes of ADHD.

Causes:

The cause of ADHD-PI is unknown but genetic influences are thought to play a major role. It is estimated that up to 70% of people with ADD have a relative with Inattentive ADD. Other factors that may play a causative roll in ADD and SCT include:

Dietary allergies-It is possible that certain people may have increased ADHD-PI symptoms after consuming certain foods or food dyes.

Environmental Factors and Toxins - pesticides and lead have both been implicated in causing increased symptoms.

Prematurity and Traumatic head injuries- may be related to an increased risk of symptoms.

Social Influences- maternal separation and other social factors are being studied to determine their role in causing this condition.


Testing:

ADHD questionnaires are standardly administered to diagnose this condition. These questionnaires consist of a series of symptoms questions where parents and teachers rate the severity of symptom sand the perceived degree of disability caused by each symptom.

Other diagnostic methods include computerized programs that measure attention, hyperactivity and impulsive behavior. The computerized test can give a more objective view of symptoms which is important because parent and teacher questionnaires responses can vary greatly and often do not agree on the severity of disabling characteristic of the ADHD symptom.

Treatment:

The appropriate dose of medication, which may be lower in the case of treating ADD than it is for the other subgroups of ADHD.

The following is a list of medications used to treat Inattention:

Dextroamphetamine (Adderall, Dexedrine,Vyvanse) - most commonly used stimulant treatment (along with methylphenidate) for all subtypes of this condition.

Methylphenidate (Ritalin, Concerta, Focalin, Daytrana,Metadate) - some people may have a genetic basis for NOT responding to methylphenidate.

Atomexitine (Strattera) - non-stimulant therapy.

Alpha-2A-Adrenoceptor Agonist (Intuniv, Clonidine) - especially useful for combined ADHD and Tourette's syndrome

Selective Serotonin Re-uptake Inhibitors (Paxil, Zoloft, Prozac) - useful for the treatment of associated depression or as a second line treatment for ADHD-PI when stimulants fail.

Try-cyclic Antidepressants (Norparmine,Tofranil) - also used for treating co-existing depression but the try-cyclics can have unpleasant side effects and must be used with extreme caution in children.

Bupropion (Wellbutrin) - Wellbutrin is a norepinephrine and dopamine reuptake inhibitor and is another second line treatment for the inattentive subtype.

Behavioral therapy is useful sometimes alone and sometimes combined with medication to better treat issues related to motivation, persistence, academic issues and social skill problems. Behavioral therapy may be more useful for ADHD-PI than it is for the other subtypes.

Lifestyle skills treatment generally addresses lifestyle issues such as diet, exercise and stress reduction.

ADHD Inattentive Classroom treatment methods include: Classroom management, parent support training and classroom accommodation.  Ebook: Ten Tips to Help ADHD I Students Succeed at School.

Additional useful treatment methods include:

Vitamin supplementation and ADHD optimized diet- to address potential deficiencies in protein,Omega-3 fatty acids, iron or zinc and to eliminate foods that can aggravate ADHD symptoms.

Behavioral therapy and Coaching.

Psychotherapy - to treat the problems that can co-exist with Inattentive ADHD such as anxiety, depression and social phobias.

Cognitive-behavioral therapy (CBT) - to address common areas of cognitive weaknesses.

ADHD Social skills training methods - to address the problems that result socially from the inattentive symptoms of ADHD-PI.

The symptoms and treatment for Inattentive ADHD are different from the symptoms and treatment of the other subtypes of ADHD. People with Inattentive ADHD and parents of children with ADHD must assure that an appropriate diagnosis of ADHD is made in order that this subtype of ADHD be appropriately managed.

ADHD, Sleep and Learning

At my house by Inattentive ADHD (ADHD-PI) son cannot sleep unless he is given Melatonin or exercises extensively and my Hyperactive/Impulsive (ADHD-HI) son who is on a thirteen hour stimulant (Vyvanse) sleeps like a baby (once the thirteen hours pass).  My ADHD-PI son has had much more consistent success at school since he started taking Melatonin for sleep and I attribute his improvements in learning to improved sleep

Many studies performed on sleep-deprived pilots and medical students have shown that cognitive performance, memory and learning decline dramatically in people who are sleep deprived. Researchers at the University of California, Berkeley, have been exploring the causes of the commonly known medical fact that sleeping well improves your ability to learn.

What the researcher in California have found is that different phases of sleep help the brain efficiently make rooms for new information and that the biphasic sleep schedule seen in people who sleep 'well' not only clears your mind and readies it for learning but that good sleep can actually make you smarter. 

According to Matthew Walker, the lead researcher in the University of California study, the more hours that a person stays awake, the more sluggish their mind will become and the less capable they will be at learning new material. Dr. Walker reports that "Sleep not only rights the wrong of prolonged wakefulness but, at a neurocognitive level, it moves you beyond where you were before you took a nap."

These findings have important implications for ADHD.  Sleep problems and ADHD go together like peanut butter and jelly and the learning difficulties seen in children and adolescents with ADHD are well known.  It is estimated that up to 50% of children and adolescents with ADHD will also have problems falling asleep, staying asleep, problems with night terrors, suffer from restless leg syndrome or will have problems with sleep apnea. 

In some individuals with ADHD, stimulant medication or other treatments for ADHD may worsen sleep problems while some people with ADHD have improved sleep after treatment for ADHD. As strange as this may seem, sleep improvement is sometimes even seen in some children and adolescents treated with stimulant medication.  Researchers are unsure if the neurological processes involved in both sleep and ADHD are what is disrupted in people with ADHD and if this is why treatments that target these processes may simultaneously improve both ADHD and sleep symptoms.

Sleep deprivation impairs our ability to learn and is a major problem in people with ADD and ADHD. Treating the sleep disturbances of ADHD can improve the symptoms of sluggishness, inattention, and memory problems seen in children diagnosed with Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder. 

Parents should be alerted to the fact that sleep problems that do not improve with treatment must be treated with melatonin or with other medications prescribed by a health care provider.  This is necessary in order that children and adolescents do not suffer further learning impairments as a result of sleep deprivation.

ADHD-PI and Impulsive or Not?

I recently received the registration material for the 22nd Annual International Conference of ADHD which is being sponsored by CHADD. I hope to attend the conference and while looking through the program I noticed that Russell Barkley, PhD will be giving the opening keynote address. Dr. Barkley is one of the most respected authorities on ADHD and the title of his keynote address is "The Importance of Emotion in Understanding and Managing ADHD."

Dr Barkley has been recently lecturing on the role on the anterior cingulate on impulse control in ADHD. Studies have shown that in people with Impulsive symptoms and ADHD the anterior cingulate fails to control emotions as it does in non-impulsive ADHD controls. This lack of activity in this part of the brain leads to aggression, increased displays of anger and frustration, excitability and impatience. Many of the poor outcomes associated with ADHD which include substance abuse, difficulty in maintaining relationships, social difficulties and conduct disorders can be attributed to this biological inability to control or inhibit emotions.

I have recently been thinking about impulse control and ADHD treatment and about a Consumer Report article that stated that while over 80% percent of parents of children with ADHD noticed an improvement in ADHD symptoms when their children were on medication, only slightly more than 50% were happy with the treatment. There are many reasons for parents to feel ambivalent about medicating their children but I believe that sometimes it is an absolute necessity to medicate and it boils down to a simple question. The question is, does the ADHD diagnosis includes impulsive behavior or not?

Animal models have shown that Ritalin positively engages the anterior cingulate and promotes impulse control. I have written in this post about why impulse control is where the 'rubber meets the road' in ADHD and why ADHD with an impulsive behavior component MUST be treated.

People with Predominantly Inattentive ADHD (ADHD-PI) often have fewer problems with impulse control. A Developmental Psychopathology study published in 2009 (please see abstract below) describes people with ADHD-PI as being, with respect to reflexively controlled inhibition (impulse control), considerably less impaired.

Dr. Ari Tuckman, another well known ADHD authority has proposed an integrative approach to ADHD therapy, an approach which includes Behavioral Therapy and ADHD coaching to completely treat ADHD. I completely agree with this and also believe that in individuals with ADHD-PI symptoms without behavioral impulsiveness, behavior and coaching interventions should be implemented and only after these interventions have failed should medication therapy be initiated.

Developmental Psychopathology. 2009 Spring;21(2):539-54.
Inhibitory deficits in children with attention-deficit/hyperactivity disorder: intentional versus automatic mechanisms of attention. Fillmore MT, Milich R, Lorch EP.

Placebo Treatment of Inattentive ADHD

I ran into this study the other day while I was reading up on something else that I found kind of amazing. The researchers of the study were trying to figure out the degree of placebo effect that you were going to get when you gave individuals with ADHD a new drug treatment.

The researchers used data gathered from a study on Strattera and determined that if you had never been given any drug treatment OR if you were predominantly inattentive, your response to a placebo was going to be pretty good.

It is important to gauge placebo effect when studying a new drug because if you give 10 people Strattera and ten people a sugar pill and the people on the Strattera report 40% fewer symptoms you might say, "Wow, this drug is fantastic, my patient is 40% better," until you realize that the people on the sugar pill (the placebo) also reported 40% fewer symptoms and the Strattera was no better than a placebo in reducing symptoms.

The researchers of the study found that if you were predominantly inattentive, or if you had never been treated with medicine for ADHD you were going to have 40% fewer Inattentive ADD symptoms when measured by the ADHD rating scale by simply taking a sugar pill. This was not true with people with combined type ADHD. They did not have a big response to the sugar pills. This was also not true of people who had previously been treated with stimulants.

This Inattentive ADHD finding reminds me a little of what Woody Allen has said about life. Ninety percent is just showing up. I believe that with Inattentive ADHD paying attention to the disease (just 'showing up' with a diagnosis) makes a good bit of difference. I believe that if you pay attention to inattentive kids, they do better. If you give them omega-3, vitamins, coffee, encouragement, respect, a mission or a task relevant to their lives... they do better.

Maybe all of these tactics help simply because of the placebo effect. Maybe they would do better if you just ask them to do better. I do not know but it makes sense to me that the first step to improving the symptoms of  Inattentive ADHD if the recognition of the problem and the formulation of a plan, any plan, that will address the inattention.

It may go without saying but it is also important to continuously remind the inattentive of what you are doing to encourage their focus and attention because if you do not set up a reminder system, those of us with Inattentive ADHD are like to forget.

Characteristics of Placebo Responders in Pediatric Clinical Trials of Attention-Deficit/Hyperactivity Disorder.

Newcorn JH, Sutton VK, Zhang S, Wilens T, Kratochvil C, Emslie GJ, D'Souza DN, Schuh LM, Allen AJ.

RESULTS: A subset analysis of patients completing 6 weeks of treatment (to eliminate the effects of early dropout) identified inattentive subtype and lack of previous stimulant experience as significant predictors of robust placebo response.

Journal of the American Academy of Child and Adolescent Psychiatry. 2009 Oct 23. 

School Help For the Inattentive ADHD Child

The (ADHD-I) Inattentive ADHD school child looks absent minded, disorganized, spacey, in their own world, out too lunch, uninterested, un-engaged, occasionally brilliant but usually uninvolved in the classroom. Teachers and parents are easily frustrated with individuals with ADHD Inattentive. Though these children are often very smart, they are dismissed by teachers who see them as lazy, immature, and disrespectful.

The symptoms described above are of a school child with ADHD Inattentive. With a few parent and classroom interventions, Inattentive ADHD can be managed. For the disorganization and distractibility of ADHD-I to be kept to a minimum, the parent, teacher and child must understand the diagnosis and form a team to battle the symptoms head on and with the goal being, the child's success.

The following is a list of interventions that have been proven to work and that are designed to minimize the poor outcomes that occur as a result of the symptoms of ADHD Inattentive.

Ensure that parents and child all know of all due assignments.

Have the child sit in the front of the class.

Establish good eye contact with the child frequently.

Watch that the child stays engaged.

Give directions concisely and positively. "Bring the book here, instead of "Why are you walking around with that book."

Teach and Practice how to take notes.

Inform parents about regular classroom schedule such as math quiz on Fridays, book report due every Tuesday, etc.

Weekly assignments should be given on Monday or on the Friday before they are due.

Set up a system of rewards and privileges for goal accomplishment.

Discipline with loss of privileges.

Give feedback quickly for both positive and negative behavior.

Keeping a regular schedule for meals, homework, screen time, etc.

Limit assumptions regarding appropriate behavior. Spell out what is expected.

Make a habit of putting belonging in the same location so they are easy to find.

Keep subject assignments in a designated folder or on a calendar,

Keep all necessary school supplies in one place.

Use color coding or folder tabs to keep assignments in order of subject and priority.

Check the assignment book or calendar weekly to make sure that assignments are completed and are on time.

Establish a child, parent, teacher team approach of 'United we stand, divided we fall', so that everyone is working together towards the same goal.

Individuals with Inattentive ADHD can perform incredibly well when these home and classroom interventions are in place. The structure, reinforcements, and feedback that these interventions provide for individuals with Inattentive ADHD result in greater school happiness and success.

Teaching Social Skills to Children with Inattentive ADHD or ADD

Children with Predominantly Inattentive ADHD (ADHD-PI, also known as ADD), have difficulty with social skills. These children tend to lack assertiveness and frequently have difficulties in social situations that require interactions with more than one person or with people that they do not know.   They sometimes have problems with a sluggish cognitive tempo which may awkwardly delay their response to social interactions These kids may also be perceived by their peers as being as self centered and egotistical because they can appear standoffish as a result of their inattentiveness.

The good news is assertiveness and social skills can be taught. Extensive research has been done of teaching social skills to children with ADHD.  Children with Combined type (ADHD-C) and Hyperactive Impulsive ADHD (ADHD-HI) need training in cooperation, self control, and empathy.  Children with ADHD-PI need help with assertiveness, appearing approachable, and simple communication.  Studies have shown that social skills' training is extremely effective in improving communication, assertiveness, empathy, and social interactions. More importantly these studies have shown long term benefits in improving the school experience of children with ADHD.

I found two studies that looked at social skills training in children with ADHD-PI.  It seems that children with ADHD-PI are helped more by social skills training programs that children with combined type ADHD or children with ADHD and co-morbid Oppositional Defiance Disorder.

The first study performed on 59 children at the Children's Hospital-Boston found that children with ADHD-PI were helped more with social skills training than were children with the combined type of ADHD.  The children received 8 weeks of social skills training after which; "Children with ADHD-I improved in assertion skills more than children with ADHD-C."

The second study is ongoing and is taking place in Berkley.  Researchers at the University of California are conducting a longitudinal study of children with ADHD-PI. They are using a tool called the Child Life and Attention Skills Program (CLAS) to teach ADHD-PI children and parents both attention skills and social skills. The researchers are still recruiting participants but the first set of results, published a few years ago, concluded that; "Children randomized to the Child Life and Attention Skills Program were reported to have significantly fewer inattention and sluggish cognitive tempo symptoms, and significantly improved social and organizational skills, relative to the control group."  If you happen to live in the San Francisco area, you can contact the Department of Psychiatry at UC Berkley here to participate in this study.

Children with ADHD are generally aware of social cues.  They do not need to be taught to 'read' people's reactions to them.  Being unaware of social cues is one of the hallmarks of children and adults with Asberger's syndrome but it is generally not a problem for children with ADHD.  Children with ADHD-C and ADHD-HI have difficulty with self control but are still aware of the social impression that they are making.  Children with ADHD-PI are often keelnly aware of their social awkwardness and tend to avoid situations that will cause them to be embarrassed.

The social skills training tools that have worked the best to train children with ADHD include exercises that break down complex social situations into smaller components and train, one at a time, each component of the social interaction.  Role playing games are helpful as is modeling which involves having the child watch a model exhibiting the desired behavior. 

Social skills' training is generally a family affair.   Parents, siblings, and other family members are encouraged to participate in the training, provide encouragement to the children in training, and to help reinforce the behaviors that are being trained.  I will discuss the specific exercises, role playing, and other tools that have proved useful in my next post.

In conclusion, social skills' training has proven to be extremely beneficial in improving the self confidence and school experience of children with ADHD.  This training may be especially useful to children with a diagnosis of ADHD-PI.

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More Information on Girls and Women with ADHD

For more information on girls with ADHD please check out  Attention, Girls!: A Guide to Learn All About Your Ad/Hd. This book is written especially for 12-18 year olds and is a terrific resource for girls with ADHD.

There is a wonderful series of books with a heroine named Phoebe Flower, a girl with Hyperactive Impulsive ADHD.  The social skill problems and anxiety issues that Phoebe suffers are similar to the social skill problems and worries of girls with ADHD Predominantly Inattentive (ADHD-PI).  We have some of these books in our library at school and my kids have enjoyed reading about Phoebe's adventures.

There are also several great web pages for women with ADHD.  Patricia Quinn, MD is the authority on ADHD in women and girls and her web page is here.    A support forum for women with ADHD can be found here.

A great book about women with ADHD is called Understanding Women with AD/HD by Kathleen Nadeau.  This book is a tremendous resource for women suffering from ADHD symptoms.

Boys and Girls with Inattentive ADHD, Are They Different

There are not a lot of studies that have looked at the gender differences in people with Predominantly Inattentive ADHD (ADHD-PI) but there are studies that have looked at other things and have coincidently stumbled upon some interesting findings with regards to differences between males and females with ADHD.

Boys and Girls with Inattentive ADHD are the same when it comes to their response to stimulant treatment and they are the same with regards to the difficulties that they have in social situations. Both boys and girls with ADHD-PI tend to be shy and overwhelmed by group dynamics. Boys and girls with ADHD-PI find it difficult to engage in normal school social exchanges as they do not do well with school group bantering, teasing, and playing. Boys and girls with Inattentive ADHD will do much better in a one on one situation and many will end up socially ostracized because of their inability to engage in normal social school dynamics.
Girls may have it a bit easier than boys in this regard as all girls are often more shy than boys. Boys are expected to be sporty, loud, and outgoing and boys with ADHD-PI are generally not involved in sports and are not loud or extroverted.

There are a few other gender differences that have been discovered in Individuals with ADHD-PI. Studies have found differences in females and males when they have looked:

1. Hormone Fluctuations and the Symptoms of ADHD.
2. Brain Development and the Symptoms of ADHD.
4. Executive Function Impairments and the Symptoms of ADHD.
5. Motor Activity.
6. Mood Disorders.
7. Referral Rates for Medical Treatment.

Hormone fluctuations and the symptoms of ADHD.

Women and adolescent girls will have hormone fluctuations that will worsen their ADHD symptoms. Innumerable studies have demonstrated that estrogen improves memory, cognitive function, memory, and mood. During the second half of a women’s menstrual cycle, after the onset of menstrual bleeding, estrogen levels are higher than they are prior to menstrual bleeding. Girls with ADHD-PI will have premenstrual worsening of ADHD symptoms because of the low level of estrogen. Women who are going through menopause will also experience worsening of their ADHD symptoms as a result of their decreasing estrogen levels.

Brain development and the symptoms of ADHD.
Boys and girls have different rates of brain development and maturity. Some researchers have suggested that the earlier brain maturation of girls is somehow protective for the development of all types of ADHD including inattentive ADHD. The implication may be that a brain that develops faster is at less risk for environmental damage or other biological processses that may in some way worsen the symptoms of ADHD. This may also explain our next topic which shows that girls seem to have less executive function impairments than boys.

Executive function impairments and the symptoms of ADHD.
One study concluded that while both boys and girls have neuropsychological problems related to executive function deficits, when girls and boys were compared on tasks such as arithmetic achievement, reading achievement, and freedom from distractibility, boys were significantly more impaired than girls on these measurements of executive functioning. Another study looked at executive functioning in boys and girls and found that girls with ADHD-PI scored better on the executive function tasks measured than boys did on these same tasks.

Motor Activity

Boys are more active than girls and boys with ADHD-PI are more active than girls with ADHD-PI. The consequence of this is that ADHD-PI boys are more likely to be labeled as combined type ADHD (ADHD-C) even though they are not at all hyperactive. Boys with ADHD-PI are more active than ADHD-PI girls but are not more active than boys who are not diagnosed with ADHD.

Mood Disorders

Girls with all forms of ADHD have lower self esteem than boys with ADHD. Girls also have higher rates of anxiety and depression and often face worsening anxiety and depression as a result of puberty and fluctuating estrogen levels. Stimulant therapy can worsen anxiety symptoms in both men and women with ADHD-PI and providers should be on the lookout for side effects such as worsening anxiety when treating girls with pre-existing anxiety and ADHD-PI.

Referral Rates for Medical Treatment

Girls are less likely to be referred for treatment than boys. Girls with ADHD-PI are prone to be seen as shy, unintelligent, or un-motivated. They are more likely to be diagnosed with depression or anxiety before they are diagnosed with ADHD.  They are often perceived by teachers and parents as unlikely to be helped by medical intervention and are therefore less likely to be referred for medical care and less likely to be expeditiously or promptly treated for their ADHD symptoms.

Males and Females with ADHD-PI are similar in some ways and different in others. They are similar in that they share the same ADHD symptoms, they have similar social problems and they are similar in their response to ADHD treatment. They are different with regards to hormone fluctuations, brain development, executive function impairments, motor activity, rate of mood disorders, and referral rates for medical treatment.

There have been only a few studies that have looked at gender differences within the ADHD-PI subtype. More studies are needed in order that we may adequately treat both boys and girls and men and women with Predominantly Inattentive ADHD.

Girls with ADHD. Depression is Treated Before ADHD is treated

Girls with ADHD are much more likely to be diagnosed and treated for depression than they are to be diagnosed and treated for ADHD. Recent evidence confirms that girls with ADHD are 5.4 times more likely to be diagnosed with major depression and three times more likely to be treated for depression before their ADHD symptoms are addressed or treated. Girls with ADHD also have a higher risk of substance abuse disorders and eating disorders than boys with ADHD.  According to a huge study done by the National Institutes of Health, "Boys had 2.1 times greater prevalence of attention-deficit/hyperactivity disorder than girls, girls had twofold higher rates of mood disorders than boys." There is an upside and a downside to these statistics.  I will give you the bad news first.

Girls with ADHD who are improperly diagnosed and treated will often be denied the classroom and lifestyle interventions that will immediately help them control their ADHD symptoms.  They will not be placed on appropriate medication and will often miss out on the appropriate medical interventions that would have controlled their ADHD symptoms.  This lack of medical care may only worsen their symptoms of depression, anxiety, and other co-morbidities.

The good news is that girls diagnosed and treated for depression will often see a reduction in their ADHD symptoms.  Studies indicate that when girls and women are treated with Cognitive Behavioral Therapy, girls without conduct problems benefit at a greater rate than boys, whereas boys with conduct problems will benefit from stimulants with behavioral therapy.  Girls often see great reductions in symptoms of ADHD with behavioral therapy alone.  This is terrific news.  

Currently, mood disorders in adolescents and children are often treated with behavioral therapy first and medication only as a second option.  This is, for all practical purposes, the opposite pattern that the treatment for ADHD follows.  

Girls with ADHD are more likely to be Predominantly Inattentive and more likely to have coexisting depression or anxiety.  They are less likely to be diagnosed with ADHD-PI and more likely to be diagnosed with anxiety and depression.  They will be referred for Cognitive Behavioral Therapy because of a diagnosis of depression or anxiety but this treatment will help their symptoms of ADHD-PI or for that matter any other ADHD symptoms that they may have.  

It would be better for these girls if their diagnosis reflected a full view of their ADHD problem.  This does not seem to be in our foreseeable future so we must take what we can get.  If a girl with ADHD manages to receive treatment and defies the beliefs by some parents and teachers that girls simply do not benefit from any treatment for their mood and attention problems, Cognitive Behavioral Therapy is a good first step.  It would be better if these girls arrived at their Cognitive Behavioral Therapy appointments with an accurate diagnosis but unfortunately, beggars can't be choosers.

Predominantly Inattentive ADHD and other ADHD In Girls

You can only truly appreciate how it is possible that girls and people with Predominantly Inattentive ADHD, ADHD-PI get ignored by the medical research community if you have lived with or have, in some other manner, thoroughly experienced the other subtypes of ADHD.  The reality is that the other subtypes are louder, more immediately in need of attention, and in general, at least at first blush, much more difficult to live with.

I do not say this to propose that those of us with ADHD-PI are better off than the other subtypes.  We are not, we have other problems.   I say this to give everyone an understanding of what we are up against.  Girls are at a disadvantage when it comes to being diagnosed with ADHD because they are more likely to have ADHD-PI but they are also at a disadvantage just because they are girls.  All Girls, regardless of the subtype, are viewed differently than boys with ADHD and they are less likely to be identified, diagnosed, or referred for treatment.

 I believe that there is a hierarchy of need that is taken into account when medical dollars are allocated for research.  It is appropriate that there are more research dollars allocated to Cancer and heart disease research than there are for say onychomycosis (nail fungus). 

My contention is that girls get less attention because the problems of ADHD-PI are 'quieter' than the problems of the other subtypes.  Girls are also thought to be less at risk for becoming a societal nuisance, than boys.  Girls with ADHD are perceived by teachers and parents differently than boys with the same symptoms and they get less attention and care for their ADHD problems because of this.

Girls suffer tremendously as a result of their symptoms of ADHD but their symptoms often go completely ignored.  Because, the majority of children with the hyperactive/Impulsive type of ADHD (ADHD-HI) and the combined type of ADHD (ADHD-C) are boys, the studies done on the trends, interventions, and outcomes for these types of ADHD has tended to include a predominance of boys.  To make matters even worse, girls with the combined or hyperactive/impulsive type of ADHD are often mislabeled as having some other condition other than ADHD and so are in turn, not treated appropriately.

Two interesting studies were performed a few months ago.  In one of these studies the researchers gave teachers written vignettes with a case study of a girl with symptoms of ADHD-PI and a case study of a girl with the symptoms of ADHD-C.  Different teachers received different vignettes and were then asked questions regarding the girl's diagnosis and the need for a medical referral.  Ninety-eight percent of the teachers recognized that there was a problem but they classified the girls as having emotional problems rather than ADHD symptom problems.   The combined type case study girl was identified as having ADHD by only 43% of teachers.  Eighty-six percent of teachers failed to identify the girls with ADHD-PI.  Eighty-five percent of teachers reported that medication would not be helpful for either case study girl.

In the second study 140 teachers  and 96 parents were given a vignette with a case study  of a child with ADHD symptoms.  Half the parents and teachers read the case vignettes with a boys names on them and the other half read the vignettes with a girls names on them.  The participants then rated their likeliness to seek or recommend further evaluation or treatment for the child in each vignette.  Parents and teachers were less likely to recommend services for girls than boys with ADHD symptoms.

The researcher of this second study had hypothesized that parents and teachers were not seeking evaluation and treatment for girls because the girls were less disruptive but this turned out to not be the case.  The differences in referral rates turned out to be related to the perception by parents and teachers that "learning assistance is less effective for girls than boys with ADHD." 

The findings from this second study should infuriate any woman reading this.  The bias by parents and teachers is so glaringly biased and unfortunate for girls with ADHD.  Girls with ADHD are likely to go without attention for years and will fall further and further behind in school.  Most girls will carry these symptoms into adulthood and are likely to have coexisting problems such as substance abuse and depression which will only be worsened by ignoring the symptoms of ADHD. 

We have got to do better by our girls.  Researchers are finally starting to research and understand the barrier to treating girls with ADHD.  There is much more work to be done but these studies are at least, a start.

Teacher Agreement on Symptom of Inattention and ADHD

There has been almost as much excitement in the ADHD community regarding a new study by Duke University researchers that has found that elementary school age students with ADHD may not have symptoms of ADHD when evaluated a year later as their has been in the general community to the Duke University basketball championship. The study can be found here.

The researchers asked the teachers of some ADHD students in first grade and some ADHD students in 4th grade to rate these students level of inattention. Twelve to fourteen months later, their current teachers again evaluated the students for inattention. The two teachers disagreed about the severity of the inattentive ADHD symptoms about 25%-50% of the time.

One of the authors of the study, which is entitled Teacher Ratings of Children's Inattentive Symptoms: Implications for the Assessment of ADHD, reported that, “ADHD is generally regarded as a chronic condition and it certainly persists over the long term for many children. However, our findings highlight that many children with significant attention difficulties during one grade do not show these problems at school the following year, even children who have been carefully diagnosed with ADHD.

The authors of the study reported that children diagnosed in school with ADHD might improve in a more organized classroom or in class with fewer disruptive classmates. They concluded that children should be evaluated yearly lest their ADHD symptoms have unknowingly improved and they be given medication or other remediation that is no longer necessary.

I should be ecstatic about this findings but I am not. The reason is this. We know from age-old studies that it is unlikely that any two teachers will agree on the severity of a child's ADHD symptoms. Parent and teacher agreement is even worse. In 30% to 50% of cases parent and teacher will not agree upon the ADHD symptoms of a child. A study done in 1987 reported that, ”The degree of agreement between parents and teacher for any dimension of child behavior is modest, often ranging between .30 and .50 (Achenbach, McConaughy, & Howell, 1987).

The authors of the study found clinically elevated ratings persisted for less than 50% of children and between 25% and 50% had ratings that declined to within the normative range when evaluated one year later by their new teachers.

My contention is that the Duke researchers would have seen these improved findings after 5 days or any minimal amount of time because the teacher disagreement is a constant and has nothing to do with a child's improvement and more to do with they teacher's idea of what is clinically significant ADHD inattention.

The philosophical implications of these finding are interesting in their own right. Currently if teacher and parent agree that the child has ADHD symptoms that are so severe that they are impairing learning, the child is started on medication or on some other ADHD treatment. If, as documented, two teachers disagree so consistently, we may want to consider a less arbitrary method of diagnosis than what we are currently using. It may make much more sense to rely more on less subjective ADHD tests such as Quotient™ ADHD System. There is information on that test here.

Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101, 213–232.

Normally Active and Inattentive

I believe that many children with Predominantly Inattentive ADHD are normally active, that is, they have six or less of the hyperactive/impulsive symptoms. Many parents (and even physicians) get confused about the type of ADHD that their child has because they have a child that is predominantly inattentive but has two or three of the hyperactive or impulsive symptoms. The assumption is that all children with Predominantly Inattentive ADHD are dragging themselves about always looking fatigued, sluggish, drowsy, or slow. If a child is not sluggish the child is often diagnosed as having Combined type ADHD. I believe that this is a mistake because children who are not diagnosed correctly will not get a treatment plan that is tailored to their specific needs.

The normally active Predominantly Inattentive ADHD child may look something like this. A nine year boy sits in a classroom absorbed in something other than the classroom work. He is fidgeting with his button and all of a sudden leaves his seat to go check out that glimmering wall hanging. The temptation is to label that child a Combined type child with ADHD, because he has three of the hyperactive/impulsive symptoms and maybe all of the inattentive symptoms. If this boy has no other hyperactive or impulsive symptoms, he is not a combined type ADHD child or a Hyperactive ADHD type child. This is a normally active, Predominantly Inattentive ADHD child.

Children that have 6 or more of these Predominantly Inattentive symptoms:
Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Often has trouble keeping attention on tasks or play activities.

Often does not seem to listen when spoken to directly.

Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

Often have trouble organizing activities.

Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period (such as schoolwork or homework).

Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

Is often easily distracted.

Is often forgetful in daily activities.

But less than 6 of these Hyperactive/Impulsive symptoms:
Fidget and squirm in their seats.

Talk nonstop.

Dash around, touching or playing with anything and everything in sight.

Have trouble sitting still during dinner, school, and story time.

Be constantly in motion.

Have difficulty doing quiet tasks or activities.

Be very impatient.

Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences.

Have difficulty waiting for things they want or waiting their turns in games.

Should be diagnosed as having Predominantly Inattentive ADHD.

They must have had these symptoms for over 6 months and have been observed with these symptoms in at least two different settings. There must not be another diagnosis which may account for the symptoms but the child.

A child with less than 6 of the hyperactive/impulsive symptoms is what I would call a normally active child. It is entirely possible for the Primarily Inattentive child to not have the symptoms of Sluggish Cognitive Tempo. They may, in fact, not be at all sluggish, slow, sleepy, or lethargic. People with Predominantly Inattentive ADHD do sometimes have a co-existing condition which is called Sluggish Cognitive Tempo and which does make the person appear fatigued and drowsy and cognitively slow but these people do not account for a majority of people with Predominantly Inattentive ADHD.

Normally active children can have Predominantly Inattentive ADHD. It is important that these Predominantly Inattentive children not be treated exactly like Hyperactive/Impulsive or Combined type children with ADHD because they are different. There is some very good evidence that the way these kids respond to medicines, the classroom interventions that work for these kids, and the adult outcomes for these children is considerably different than it is for children with Combined type and Hyperactive/Impulsive type ADHD.

The ADHD treatment regimen currently used for all children with ADHD may not be the most appropriate treatment regimen to choose for children with Predominantly Inattentive ADHD. In order to discover and test the most beneficial interventions for these children we must first insure that Predominantly Inattentive children are not incorrectly classified as Combined type or Hyperactive/Impulsive. Once we have accurately classified this subset of Predominantly Inattentive children, we can begin to fully explore how best to help them.

Is Inattentive ADHD Different from the Combined Type Of ADHD

At the heart of the debate over whether to give Primarily Inattentive ADHD it's own DSM-V category in the 2013 revised edition of the psychiatic diagnostic manual is the question of whether there is a substantial difference between this subtype and the other subtypes of ADHD.


Prominent researchers have argued that Predominantly Inattentive ADHD is just a continuum of other subtypes of ADHD.  They have proposed that the symptoms of the Primarily Inattentive subtype are nothing more than the symptoms of the ADHD Combined type missing a few hyperactive or impulsive symptoms.  They contend that Predominantly Inattentive ADHD is not substantially different from the other subtypes.  Other researchers have tried to lump Primarily Inattentive ADHD into the Sluggish Cognitive Tempo camp arguing that Primarily Inattentive ADHD is best described by the characteristic of slow cognitive processing.


A study done in Canada in September of 2009 tested 400 children with ADHD.  The researchers looked at Predominantly Inattentive children and children diagnosed as Combined type ADHD.  They documented the reported conduct disorders, treatment response to Ritalin, history of maternal smoking and alcohol consumption, history of maternal stress, genotypes, and birth weight in these children.


The study found that children with Combined type ADHD had a higher frequency of conduct disorders, a better response to Ritalin, a higher incidence of 5-HTT genotype, and more maternal stress during pregancy, when they were compared to Primarily Inattentive ADHD children.  These researchers reported that these findings pointed towards a separate biological process in children with Primarily Inattentive ADHD.


When studies are done today on ADHD, the subtypes are usually lumped together.  It is generally impossible to know how someone with Primarily Inattentive ADHD performed on the trial as compared to the rest of the ADHD group.  Studies done on primarily Inattentive ADHD children and adults are few and far between.


Providers treating individuals with Inattentive ADHD should be aware of the substantial characteristics differences of this subtype in order that appropriate treatment is provided, specific disorder related interventions are addressed, and  risk factor concerns are appropritately managed.

The question of whether Predominantly Inattentive ADHD is a separate disorder is important.  As long as Predominantly Inattentive ADHD is considered to be a ADHD Combined type with fewer hyperactive and impulsive symptoms, individuals with Primarily or Predominantly Inattentive ADHD will not be properly studied and this disorder will not be properly treated.

A Home of Their Own for the Predominantly Inattentive. New DSM V

The DSM or Diagnostic and Statistical Manual of Mental Disorders is a manual published by the American Psychiatric Association.  The manual is a tool used by researchers, insurance companies, and physicians to identify mental illnesses in both adults and children. 


The DSM  is currently undergoing revision.  The new manual is due out in 2013 and includes some potentially important changes for the Predominantly Inattentive category of ADHD.  Two of the proposed changes would give folks currently categorized and ADHD-PI, a home of their own sort of speak.


The primary purpose of the DSM is to provide professionals in the mental health community a written description of the characteristics and symptoms of every mental health condition.  The manual is necessary for there be consistency and agreement among providers and researchers regarding what defines a certain mental health condition.  The current DSM IV was published in 1994 and is considered the sacred book of psychiatric diagnosing.  It is used around the world to identify mental illness.

Having Inattentive ADD in its own category is a huge deal.  There has been very little research done on this sub-type of ADHD and this would change if the condition had a separate DSM code.  Research dollars and pharmaceutical study dollars are often doled out only if there is a corresponding DSM code.


I went onto the American Psychiatric Association webpage and this is what they are proposing.  There are essentially three options with regards to how the new manual will handle Inattention without hyperactivity or impulsiveness.


Option #1:  Use the existing definition and allow for up to 5 Hyperactive/Impulsive criteria in the definition of Predominantly Inattentive.

Option #2:  Make a 4th category in the general ADHD diagnosis called RPI (restrictive predominantly inattentive) which would be for folks with no more that 2 hyperactive/impulsive symptoms.

Option #3:  Make a totally new DSM diagnosis called Attention Deficit Disorder.  None of the diagnostic criteria for hyperactive or impulsive symptoms would be used to define this diagnosis.

Option one would lump many of the current ADHD-PI types into the combined type category, this is consistent with what Dr. Russell  Barkley supports.  He believes that most of the folks with ADHD-PI are really combined types that are missing just a few hyperactive or impulsive symptoms.  I totally disagree with this option.

Option two, (RPI), would be similar to what we have now except that individuals with predominantly inattentive symptoms would be clearly defined as having very few hyperactive impulsive (HI) symptoms.   I believe that folks with more than 3 HI symptoms are currently treated as combined ADHD types. So though they say that this would bring us to four subtypes, I believe that there still would be, in actual practice, only three.  The Hyperactive Impulsive type, the Combined type, and RPI type.  This option would better define the predominantly inattentive type and I would be fine with this.

Option three would get the "RPI" types out of the ADHD bag all together and give them a DSM diagnosis all of their own.  This is our best option as I believe that it would provide us with a unique code for research and treatment.

It has been said by a physician many times that getting the right treatment, always depends on having the right diagnosis.  There has been some pretty good evidence that the risk factors, co-morbididy, genetics, and treatment of individuals with predominantly inattentive ADHD are different than for the other subtypes of ADHD.  I think that giving the predominantly inattentive subtype its own DSM category would allow for more identification, study, and appropriate treatment of this condition.

Introverted and Inattentive

I have been blogging lately about the differential diagnosis for Inattentive ADHD and I thought it might be helpful to explore the symptoms of introversion to show how it is that parents and teachers may confuse introversion for inattentiveness.

Introverted people are not merely shy.  This is a misconception.  People who are introverted are fundamentally different with regards to how they interact with the world.  Whereas extroverted people gain energy from being around people.  Introverted people are energized by being alone.  Their energy is drained when they are around a large group and they enjoy spending time in their inner world exploring their own thoughts and feelings.  Being with people, even people they know well and like can be draining for an introvert who needs time to recharge by introspecting.  Introverts make up only about 33% of the general population and 60% of the gifted population.

When you read this definition it is obvious how individuals who are introverted could be seen as possibly Primarily Inattentive.  Researcher have explored the similarities in symptoms and have found a connection.  In the February 2010 issue of the Journal of Abnormal Psychology, researchers divided children with ADHD into 6 categories by asking parents to rate their children on scales for perfectionism, intovertion, extroversion, disagreeable, well adjusted, and poor self control.

Inattentive children scored disproportionally high on the introverted scale where as children with the ADHD combined type could be sub-divided into a groups that could be described as 'combined type with extroversion and disruptive conduct disorders" or "combined type with extroversion and no co-morbid disorders". The researchers felt that in many cases a "person centered personality approach may be one promisingway to capture homogenous subgroups within the ADHD population.

Whereas most inattentive ADHD children are introverted.  Most Introverted children are not inattentive.  Making this differential diagnosis distinction is imperative.  Knowing the personality traits of an ADHD individual can make the differential diagnosis fairly obvious.  Primarily Inattentive individuals have issues with disorganization, time management,  and task completion that are not issues for individuals who are just introverted.   The motivational difficulties are also not present in introverted individuals.

Inattentive ADHD individuals are similar in many ways and share the main characteristics of  all introverts.  What makes individuals with Primarily Inattentive ADHD different is the added difficulties with time management, organization, and task follow through and it is these other symptoms that make Primarily Inattentive Individuals unique.

Shy, Autistic, Anxious, or Inattentive ADHD. The Confusion.

 When you look at this DSM-IV list of symptoms of Inattentive ADHD it is easy to see how confusing it can be to diagnose a person with this subtype of ADHD.

A person must have six or more of the following symptoms of inattention have been present for at least 6 months, in at least two settings, to a point that is disruptive and inappropriate for developmental level:

1) Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2) Often has trouble keeping attention on tasks or play activities.

3) Often does not seem to listen when spoken to directly.

4) Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5) Often has trouble organizing activities.

6) Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7) Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8) Is often easily distracted.

9) Is often forgetful in daily activities

The problem with this list is that it may be useful for diagnosing adults but it is almost worthless for diagnosing children.  The reason is that the above list describes 90% of children.  Children, by the simple nature of being children, are distracted and inattentive. 

The equation is further complicated by the fact that parents and teachers have to agree.  Russell Barkley has reported that parents and teachers only agree that there is a hyperactivity, impulsivity, or inattentiveness problem in about 30-50% of all cases of ADHD.  I can guarantee you that for inattentive ADHD the incidence of agreement is even less.   The demands that are placed on children and at home are so different that a child that may be considered totally impaired by inattention by a teacher, may only seem mildly distracted to a parent.

The diagnosis becomes more complicated when you factor in the internalizing comorbidities that can accompany Inattentive ADHD such as anxiety and depression.  We all know that we can be disorganized, scattered, and off in our own world when we are depressed or anxious.  So is this anxiety or is this ADHD??  The truth is that the inattentive, anxious child is often still inattentive even when their anxiety is under control.  Yes they are more likely to be depressed or anxious but even after controlling for those symptoms, the inattention remains.

Inattentives can also appear shy or socially awkward.  The inattentive child is labeled as 'just shy' but in fact in situations when they are socially comfortable the Inattentive subtype is still distracted and spacey, in fact more so.  

There is also a considerable overlap between the symptoms of inattentive ADHD and Asberger's syndrome.  The Inattentive ADHD person sometime fails to make eye contact and is sometime socially inappropriate.  The difference is that the inattentive ADHD person is aware of the social norm and is distracted or disinterested in adhering to it, whereas the Asberger's person is unaware of the social norm.

People with Inattentive ADHD and slow cognitive tempo (SCT) may appear learning disabled and may be thought to be of low IQ.  A person who is dyslexic and inattentive may also be labeled as having a low IQ.  Striking a bull’s-eye on the diagnosis can be complicated when there are other mood, learning or cognitive issues mixed in with the inattentive ADHD.

The way I see inattentive ADHD is like this.  The person with Inattentive ADHD is most comfortable, and gains energy from being in the world going on in their mind.  That very interesting world, in their head,  can be distracting.  When I am thinking about something in my head, I am often disinterested and un-engaged with what is happening in the world outside my head.  

I see two treatment goals for those of us with inattentive ADHD.  The first is to find a way to make the inattentive's outside world interesting enough to stay in for a while, and second is to devise a set of treatment strategies, (medical and behavioral),  that will keep you on task and organized in the real world.