Combined ADHD Type: Symptoms, Causes, & Treatment

What is Combined ADHD?

Attention-deficit/hyperactivity disorder (ADHD) symptoms are typically divided into three types: inattentive ADHD, hyperactive-impulsive, and combined. Combined ADHD is when you have both inattentive and hyperactive-impulsive symptoms instead of predominantly one or the other. ADHD combined presentation may involve forgetfulness, inability to relax, disorganization, reacting emotionally, and acting without thinking first.²

The most recent data suggest that nearly 10% of children and 4.4% of adults have been diagnosed with ADHD, with combined presentation being the most common type.^3,4,5 Combined ADHD is more prevalent in males.⁶ While inattentive types predict academic problems and peer neglect, hyperactive-impulsive ADHD predicts aggression and peer rejection. Inattention typically appears later in life than hyperactivity symptoms, so hyperactivity-impulsivity may be the first to be noticed.⁷

How Is Combined Type Different From Other Types?

Combined ADHD only differs from the other types in that the diagnosis incorporates both sets of symptoms instead of being either inattentive or hyperactive-impulsive. Because of the combination of symptoms, combined ADHD is more easily recognized. Historically, the differences between the presentations were in severity rather than the type of symptoms, and the more severe cases were diagnosed as combined type. Today, the combination of symptoms does not equate to increased severity.

Causes of Combined ADHD

The direct cause of combined ADHD is not determined, but experts agree that it is likely a combination of nature and nurture. There is a two- to fourfold increased risk of developing ADHD among first-degree relatives, although the specific subtype is not specified.⁷ Sociological factors such as pace of life, quality of schooling, and family stress may also contribute.

Possible causes of combined ADHD include:

• Cigarette smoking and/or alcohol use during pregnancy
• Premature delivery or other pregnancy complications
• Pesticide exposures during pregnancy
• Maternal weight, health, and nutrition
• Low birth weight
• Low socioeconomic status⁷

Symptoms of Combined ADHD

The symptoms of combined type ADHD will vary in terms of which ones are present and how severe they are from one person to the next. Symptom presentation can even change over time within the same person. As children grow older, hyperactivity symptoms tend to diminish or become less obvious, and inattentive symptoms appear worse.⁷

Common inattentive symptoms include:

• Struggling to follow instructions
• Inability to persist at tasks or play activities
• Difficulty remembering rules
• Trouble following instructions
• Ineffectively resisting distractions
• Difficulty planning
• Disorganization
• Forgetfulness
• Being slower and less likely to return to an activity once interrupted

Common hyperactive-impulsive symptoms include:

• Fidgeting or squirming
• Difficulty staying seated
• Talking excessively
• Interrupting others’ activities
• Difficulty waiting for one’s turn
• Less able to delay gratification
• Running or climbing at inappropriate times
• Unable to participate quietly in leisure activities

Is Combined ADHD More Severe?

Combined ADHD is not inherently more severe than other presentations. The intensity of symptoms is distinct from the number and type of symptoms you experience. Whether your symptoms are mild, moderate, or severe will have more impact on functioning than the number of symptoms.

How is Combined ADHD Diagnosed?

A typical diagnostic process for combined type ADHD includes an initial screening evaluation, a more comprehensive, in-depth interview, rating scales, and occasional observation in your natural setting. Depending on the age at diagnosis, school records may also be reviewed. Unless your mental health professional requests additional documentation, you don’t have to do anything to prepare for the evaluation.

ADHD combined type can be diagnosed by a psychiatrist, psychologist, or primary-care physician. To receive a diagnosis of combined ADHD, at least six symptoms of both inattentive and hyperactive types, for a total of twelve or more, must be present for at least six months. Symptoms may present differently for a child than an adult but must have begun before age twelve.

A diagnostic process for Combined ADHD may include:

• Medical history review
• Psychological tests
• Parent and teacher reports
• Observation in your natural environment
• Family history review⁸

Treatment for Combined ADHD

Treatment for combined ADHD can improve symptoms by decreasing impulsivity and increasing attention. As with most mental health conditions, a combination of therapy and medications works best. Stimulants and non-stimulants work by adjusting certain chemical levels in your brain. They each have side effects and work with varying degrees of success, depending on the individual.

Treatment for Children & Adolescents

Combined ADHD is treated with both medication and behavioral therapy strategies. A comprehensive treatment plan will include suggestions for multiple settings, including home, school, and extracurricular social activities. Your child’s particular symptoms will influence what goes into a treatment plan. Treatment plans for children and adolescents often target issues in school, such as difficulty following directions and trouble sitting still during lessons.

A treatment plan for combined ADHD in children & adolescents may include:⁸

• Behavioral therapy: Behavioral therapy, including CBT for ADHD, involves teaching, practicing, monitoring, and reinforcing skills to enhance attention and motivation. Successful behavioral therapy for children and teens requires the cooperation of parents and teachers.
• Parent management training: Teaching parents how to reduce their stress and increase a sense of control helps keep their child’s ADHD symptoms at bay. Parent management training educates parents about ADHD, encourages them to model socially competent behavior, and to provide consistent rewards and consequences.
• Medication: Stimulant or non-stimulant medication may help manage a child’s behaviors and inattention. However, some ADHD medications increase anxiety, so it is important to ensure you find the right medication for your child.
• School-based interventions: Many children with combined type ADHD benefit from a team approach that includes their teacher and school counselor. A teacher implementing classroom management approaches with a child can promote increased attention span and motivation for socially positive behaviors.
• Executive skills training: Because children with combined ADHD suffer deficits in executive functioning, training in specific executive skills can increase their emotional regulation, resilience, sustained attention, ability to think before acting, persistence, organization, time management, and more.⁹

Treatment for Adults

Combined ADHD in adults is treated similarly to children and adolescents but with more of a focus on individual and work-based skills. An individual’s symptoms will help determine the specific goals of their treatment plan. A combination of medication and behavioral therapy is the most effective treatment. Medication alone does not lead to long-term positive outcomes, whereas behavioral therapy can help to sustain symptom management.¹⁰

A treatment plan for combined ADHD in adults may include:

• Behavioral Therapy: Behavioral therapy interventions focus on practical domains, which, if applied properly, lead to long-term benefits in daily life. Behavioral therapy for combined type ADHD has been shown to improve both inattentive and hyperactive-impulsive symptoms.¹⁰
• Medication: Prescription medication for adult ADHD could be stimulant or non-stimulant, and a thorough discussion with one’s doctor can help them to make the best choice for their needs.
• Social Skills Training: Learning behaviors to improve interpersonal relationships, such as maintaining personal space, starting and continuing a conversation, and setting boundaries, can address some impacts of combined presentation ADHD symptoms.⁸
• Natural Remedies: Natural remedies for ADHD can improve ADHD symptoms without the negative side effects that can occur with prescription medication.
• Mindfulness: Mindfulness training has been shown to improve attention and self-regulation, both of which are key factors in treating ADHD combined presentation.¹¹
• Adaptive technology: Leveraging technology, such as calendar and task management apps, can assist with organization and time management.
• Work accommodations: Collaborating with one’s employer to implement reasonable accommodations such as flexible work hours, regular check-ins, and assistive devices such as noise-canceling headphones to limit distractions.
• Healthy sleep schedule: Chronic sleep deprivation mimics symptoms of ADHD. Improving the quality and duration of sleep can lead to a significant reduction in symptoms.¹²

How to Find Professional Support for ADHD

When searching for a neurodiverse-affirming therapist to help with combined type ADHD, look for qualities such as someone trained in behavioral therapy. You may want to search using an online therapist directory, or if you prefer virtual therapy, try an online therapy platform to find a therapist specializing in ADHD treatment. If you want to try medication to manage your combined type ADHD symptoms, consider seeing a psychiatrist. Like with therapy, you can decide if you want a doctor who sees you in person or if you’d prefer online psychiatrist options.

In My Experience

In my experience, medication management, behavioral training, support from families, and a positive working client-therapist relationship are the most important factors in treating combined ADHD presentation. The more you are willing to engage in the process, try out recommendations suggested by your therapist, and give feedback on what does and does not work for you, the better the odds of successfully reducing ADHD symptoms.