If you have been diagnosed with ADHD, believe you might have it, or you are researching for a loved one with ADHD, you may be trying to educate yourself on the condition. It can be confusing to navigate the many symptoms and treatments associated with the three known subtypes of ADHD; hyperactive, inattentive, and combined. 

At Augmentive, we aim to provide holistic, tailored mental health support to everyone so they can live their life to the fullest, so if you have questions about combined type ADHD or its symptoms, we’re here to help. 

Proper identification of the subtype of ADHD is incredibly important when seeking a diagnosis and getting treatment. Here, we are taking a closer look at combined type ADHD; its signs and symptoms (depending on gender and age), how it is diagnosed, what a diagnosis of combined ADHD means, how it might progress, and how to manage this specific type of ADHD in daily life. 

What is ADHD? 

ADHD stands for attention-deficit hyperactivity disorder, and this is a type of neurodivergence which means there is a difference in how an individual’s brain is hard-wired when compared to neurotypical individuals.

There are three different types of ADHD:

1. Predominantly inattentive ADHD – this type causes mainly symptoms relating to regulating attention
2. Predominantly hyperactive/impulsive ADHD – this type causes mainly symptoms relating to impulsivity and hyperactive behaviour
3. Combined type ADHD – As the name suggests, this is a combination of both inattentive and hyperactive/impulsive types of ADHD

What is combined ADHD? 

Combined type ADHD might be referred to as simply combined ADHD, and it means an individual has ADHD with symptoms of both the inattentive subtype and the hyperactive/impulsive subtype. Someone with combined type ADHD may struggle with keeping their attention focused, being excessively hyperactive, and engaging in impulsive behaviours, resulting in challenges across various parts of their life. 

“There are a lot more symptoms present in combined ADHD. This may include the inability to sit still, increased impulsivity and the inability to pay attention to tasks. Because there is a larger range of significant symptoms, more compensating behaviours are required to manage behaviours and therefore the distress in impairment is higher.” - Dr Kapil Bakshi, Psychiatrist

Historically, ADHD was thought to present in two different ways, and so two different diagnoses were offered; attention deficit disorder and attention-deficit hyperactivity disorder. In 1994, the DSM IV was published, which combined both types into one disorder with three subtypes: predominantly inattentive, predominantly hyperactive, or combined.

Studies have found predominantly inattentive ADHD to be prevalent in around 18.3% of the total number of people with ADHD, and predominantly hyperactive/impulsive ADHD to be present in around 8.3% of people with ADHD. Combined type ADHD is estimated to be present in 70% of people with ADHD, so it is thought to be the most common presentation of the condition. A thorough understanding of its specific symptoms and treatments is therefore important for the majority of those with ADHD. 

What are the symptoms of combined ADHD? 

As mentioned, combined type ADHD is a combination of inattentive, hyperactive and impulsive behaviours, so the symptoms are essentially a mix of some from both subtypes. When identifying combined type ADHD it can help to understand what these behaviours might look like in everyday life. Some examples of each type of ADHD symptom include: 

Adults with combined ADHD

In adults, these symptoms may be most noticeable in a work setting, or in taking care of general life administrative tasks.

Inattentive:

• Having difficulty following through on tasks or assignments
• Losing important items regularly 
• Forgetting things like appointments or paying bills

Hyperactive / Impulsive:

• Talking nonstop
• Being impatient
• Interrupting or butting into other peoples’ conversations

Children with combined ADHD

In children, these symptoms may be most noticeable in a school setting, or among peer groups.

Inattentive:

• Struggling to follow instructions
• Appearing to not listen when spoken to
• Becoming easily distracted

Hyperactive / Impulsive:

• Fidgeting or squirming
• Being unable to remain seated for long periods
• Blurting out answers / having difficulty waiting their turn

According to the Centres for Disease Control and Prevention, someone with combined ADHD will usually display six or more of the above symptoms, and those symptoms will have been present for more than 6 months. 

It is important to remember that ADHD often presents differently in women and girls. Although both inattentive and hyperactive/impulsive types of ADHD can be present in females, and therefore combined type ADHD can also occur, females do tend to present with the inattentive subtype more often than hyperactive/impulsive subtypes. In adult women this may look like difficulty organising and completing tasks, forgetfulness, and difficulty following through on instructions. In adolescent women or children, this could look more like difficulties with peer relationships and schoolwork.

How is combined ADHD diagnosed?

According to the DSM-5, to diagnose combined type ADHD a child aged 16 years old or under must present with six or more of the symptoms from either the inattentive or hyperactive/impulsive subtypes for at least 6 months. These symptoms must also be inappropriate for their developmental level. In the case of those aged 17 or older, five symptoms or more must be present.

Inattentive symptoms:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
• Often has trouble holding attention on tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g. loses focus or becomes side-tracked)
• Often has trouble organising tasks and activities
• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)
• Often loses things necessary for tasks and activities (e.g. school materials, pencils, tools, wallets, keys, paperwork, glasses, etc.)
• Is often easily distracted
• Is often forgetful in daily activities

Hyperactive/impulsive symptoms:

• Often fidgets with or taps hands or feet, or squirms in their seat
• Often leaves their seat in situations when remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
• Often unable to play or take part in leisure activities quietly
• Is often “on the go” acting as if “driven by a motor”
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has trouble waiting their turn
• Often interrupts or intrudes on others (e.g. butts into conversations or games)

As well as the above criteria, an individual will have experienced:

• Several inattentive or hyperactive-impulsive symptoms before age 12 
• Several symptoms present in two or more settings (such as at home, school or work; with friends or relatives; in other activities)
• The symptoms interfere with, or reduce the quality of, social, school, or work functioning
• The symptoms not being better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder)
• The symptoms not only happening during the course of schizophrenia or another psychotic disorder

Why is it important to diagnose the specific type of ADHD?

Getting an accurate diagnosis of the specific type of ADHD you or your loved one has is key for receiving a tailored, bespoke treatment plan that addresses the symptoms you find most challenging.

Since each ADHD subtype leads to different symptoms, interventions should be tailored to the individual. For example, inattentive subtypes of ADHD may benefit from help to create strategies that focus on organisation and planning, while hyperactive/impulsive subtypes may benefit more from interventions that target impulse control. 

Receiving the correct diagnosis of combined type ADHD (if applicable to you) can have a positive impact on the outcome of your condition by leading to the correct combination of treatments, such as behavioural interventions, medications, and management tools. 

Misdiagnosis of any ADHD type has been thought to lead to ineffective interventions that negatively impact a person getting the support they need. Several factors have been found to influence the identification and diagnosis of ADHD subtypes, such as parents, teachers, healthcare workers and the immediate environment. More education is needed across the board on the different presentations of ADHD so more people can receive an accurate diagnosis early.

Failure to properly diagnose ADHD prevents the individual from receiving the support they need in order to achieve their full potential in school and work settings, and studies suggest that untreated behavioural issues can have significant sociocultural, employment and relationship impacts. 

The more you understand your own condition, the more empowered you can feel to take appropriate actions and have more control over your treatment. An accurate diagnosis of the type of ADHD you have is the first step in gaining more autonomy. 

How does combined ADHD progress?

Combined type ADHD often begins in childhood, and symptoms can continue into adulthood. The progression of this type of ADHD varies depending on the individual, but in many cases ADHD presentations and their severity are thought of as fluid, and can evolve depending on the age of the individual and the setting, i.e. from school to work settings. For example, hyperactive symptoms may lessen with age, whereas inattentive symptoms may begin to affect daily tasks and relationships when left unmanaged. 

It is important to keep in mind that having combined ADHD does not mean your ADHD is more severe in comparison with others who have predominantly inattentive or predominantly hyperactive/impulsive ADHD. It simply means your symptoms are a combination across both subtypes, and may evolve or progress in the same manner that others would. 

How is combined ADHD treated?

At Augmentive, we believe advice and support for those with ADHD should be bespoke and individualised, so that each person receives the care and support that will work best for their specific circumstances. Therefore, if you believe you may have combined type ADHD it is best to speak to a specialist who can listen to your unique experience and combination of symptoms, and recommend the best ways for you to work through the symptoms that cause you most distress. 

Treatments for all types of ADHD can include medication, and there are 5 types licensed for ADHD treatment in the UK; methylphenidate, lisdexamfetamine, dexamfetamine, atomoxetine and guanfacine. These medicines do not cure ADHD, but they can help individuals with the condition to focus more, be less impulsive, feel less anxious, and pay more attention. You can read more in our article: Your Guide to ADHD Medication in the UK.

Different types of ADHD medication are often recommended in varying doses for different subtypes of ADHD. For example, stimulants can help reduce the symptoms of combined ADHD as they are thought to help with hyperactivity, impulsivity and inattention. Your doctor or psychiatrist can prescribe the correct type of medication and dosage to help with your specific symptoms, which may be a stimulant or another type of medication such as a non-stimulant or an antidepressant. 

If you or your loved one has combined ADHD, treatments could involve a combination of medication and other therapies, such as:

• Psychoeducation: A therapy where the patient is encouraged to discuss ADHD and its effects with the aim of making sense of their condition and coping better.
• Behavioural therapy: A therapy which includes the whole support unit such as carers and teachers of those with the condition, and where rewards are used to encourage children to control their symptoms.
• Cognitive behavioural therapy (CBT): A talking therapy that can help people with ADHD manage the issues they face by changing the way they think and behave.

Often, a combination of medication and therapy is recommended by healthcare professionals, but if you are unsure which type of therapy may be best for you, our free 15 minute consultation could help you figure out the most relevant therapist to help you manage your combined type ADHD in daily life. 

How can combined ADHD be managed in daily life?

Combined type ADHD, along with other types of ADHD, cannot be cured. Treatment involves managing the symptoms in everyday life. With combined type ADHD you will have a mix of symptoms, so as above, your doctor or prescribing psychiatrist can help find the correct combination of treatments to help you. 

You may also find it helpful to implement systems and get assistance with specific areas of life, for example:

• Start using a calendar or planner to stay organised
• Make lists each day to stay focused on priority tasks 
• Set up a filing system so you can always find what you need 
• Use timers and reminders to stick to your schedule and honour commitments
• Write everything down to avoid forgetfulness
• Tackle tasks one at a time and abandon the multitasking mindset to avoid ADHD burnout 
• Ask for help with accountability from a partner or someone you trust, to help with managing important things like paying bills
• Avoid ADHD paralysis by regularly talking to a trusted friend or family member about what makes you feel overwhelmed 
• Exercise to relieve stress 
• Maintain good general health by getting plenty of sleep and eating a healthy diet 
• Take steps to tackle impulse spending, such as only taking cash out with you 
• If relevant, ask for help from a trusted friend, family member or ADHD specialist to discuss managing alcohol issues

Whether you’re feeling off-kilter or want to shake up your routine, our state-of-the-art mental wellbeing platform gives you quick and seamless access to world-class support on your terms, from a private adult ADHD assessment or AuDHD assessment, to help finding an ADHD specialist near you to support you on your journey.

If you have a question about mental health, like finding out if "ring of fire" ADHD is a real condition, we’re here to assist on your journey. Our free 15 minute consultation can guide you to the most relevant specialists to answer your questions and discuss next steps.

DISCLAIMER: The content published by Augmentive is not designed to treat, diagnose, cure, or prevent any disease or condition. Always consult your GP or a qualified healthcare provider with any questions regarding a medical condition and before starting any therapy, diet, exercise, or any other health-related programme.