ADHD: Combined Type

Children with ADHD combined type  (or combined presentation) may seem like they have the distractible mind of a butterfly in a beautiful meadow. One moment, they’re climbing all over the furniture, and the next, they’ve forgotten why they walked into the room in the first place. This is the daily reality of a child with combined ADHD.

In this article, we’ll do a deep dive into what makes combined ADHD unique, how it manifests in different settings, and what you can do to support your child.

What is ADHD Combined Type?

Combined type ADHD has symptoms of both inattention and hyperactivity-impulsivity. For someone to qualify for combined ADHD, they must have at least six symptoms of each type. Combined ADHD is the least common subtype [*].

This “all-in-one” variation of ADHD manifests through issues with concentration and executive functioning, alongside excessive energy and impulsive behavior.

ADHD Combined Type Symptoms

People with combined ADHD have symptoms of both inattentive and hyperactive-impulsive ADHD.

Inattentive symptoms include:

• Making careless mistakes because of difficulties paying attention
• Struggling to maintain attention in school or in social settings
• Not appearing to listen during conversations and seeming internally distracted
• Struggling to follow through with instructions or finish a task
• Avoiding tasks requiring significant mental effort
• Frequently losing or misplacing items
• Being easily distracted by external events
• Forgetting things when doing daily chores and errands

Symptoms of hyperactive-impulsive ADHD include:

• Struggling to stay seated and constantly needing to move around
• Running and climbing at unsuitable times
• Rarely participating in hobbies or social activities quietly
• Having lots of energy
• Talking continuously, which can result in problems at school
• Answering questions before they’ve been fully asked or interrupting others when they’re still talking
• Intruding on other people’s conversations and activities
• Struggling to wait their turn

ADHD Combined Type Causes & Risk Factors

There is no singular cause of combined ADHD, though it can result from genetic influences, neurobiological differences, and environmental factors. Studies show that the heritability of ADHD can be as high as 80% [*].

Environmental factors, such as familial aggression, childhood abuse, and psychosocial stressors, can also contribute to a child’s likelihood of developing combined ADHD [*].

Other potential risk factors include:

• Traumatic brain injuries
• Substance use during pregnancy
• Low birth rate or premature delivery

How is Combined Type ADHD Diagnosed?

Professionals diagnose combined ADHD by conducting a thorough medical examination to rule out other conditions. Then, they’ll observe symptoms of inattentiveness, impulsivity, or hyperactivity.

Sometimes, doctors will use rating scales to screen for ADHD. These rating scales can include 18 to 90 questions assessing the frequency of ADHD symptoms and behaviors. While not required, a doctor might also conduct the following additional tests in case of co-occurring learning disabilities or related issues:

• Intellectual screening
• Memory tests
• Attention/distraction tests

Doctors will also gather information from other sources, including family members, teachers, and the child themselves.

Treatment for Combined Type ADHD

The first-line treatment for children with combined type ADHD is a mix of behavioral interventions and stimulant medication (when appropriate). Stimulant medications increase brain chemicals that affect thinking and attention.

Parents need to consider whether their children have comorbid conditions, such as diabetes, depression, or anxiety. They often have a higher risk of experiencing side effects, which include:

• Lack of appetite
• Headaches
• Weight loss
• Trouble sleeping
• Chest pain
• Shortness of breath
• Palpitations

Combining medications with therapy can help children with ADHD better manage daily struggles, become more self-reliant, and reduce impulsive or harmful behaviors. Effective treatments include cognitive behavioral therapy (CBT), which introduces coping strategies to modify unwanted behaviors.

In cases where severe combined ADHD affects home life, families might consider undergoing family therapy. During these sessions, family members learn to manage the child’s symptoms. Family members also learn to communicate kindly and more effectively.

Support for Combined Type ADHD

Children with ADHD require structural support and a stable, loving home environment. How parents respond to their child’s ADHD can make things better. Here’s what you can do.

Talk about it and stay informed

Having combined ADHD shouldn’t be taboo. Instead, children should understand that having combined ADHD isn’t a “fault” or “shortcoming.” Here’s how you can stay informed.

• Together, learn as much as possible about the condition by reading books, attending workshops, or undergoing family therapy. Certain online and TV shows, such as Paris and Pups, focus on being relatable to children with ADHD.
• When talking about ADHD, use age-appropriate language and analogies that your child will understand. For example, you might say things like, “You know how a car’s engine might get too hot when it goes too fast? That’s a little bit like how your brain works sometimes! We just need to find ways to slow down together.”
• Work closely with your child’s teachers and counselors to create a more conducive and productive learning environment.

Help your child stay on task

Find ways to help your child stay on task or develop a predictable routine.

• If your child is a visual learner, use to-do lists for chores and a simple daily planner for homework. You can also use posters or leave sticky notes on their school supplies.
• For prolonged tasks, consider adopting the Pomodoro technique, which involves working for 25-minute intervals. As children become familiar with the Pomodoro technique, they avoid cognitive biases in time management and focus on what they can achieve in the moment.
• Factor in breaks for your child to get movement by doing a few jumping jacks or playing with a fidget toy.

Implement positive rewards and logical consequences

Provide simple rewards for good behavior to encourage your child to repeat it in the future.

• Reward your child with time for video games or a trip to the ice cream shop when they finish their homework or read a chapter of their book.
• Avoid overusing material rewards and regulate screen time appropriately.
• Implement logical consequences immediately. For instance, if the rule is to finish homework before watching TV, and your child refuses to finish their task, they miss out on watching their favorite show.

Give medicines safely

It’s normal for parents to worry about their child taking stimulant medicines, but when taken correctly and on schedule, they can be incredibly helpful for a child’s combined ADHD. Here are some tips for dispensing medicines safely and correctly.

• Always take medicines as instructed by your specialist. If you’re unsure about something, don’t hesitate to clarify with your child’s doctor.
• Keep medicines in a childproof container to prevent accidents. Never allow your child to self-medicate.
• If your child needs to take their medication during school hours, coordinate with the school nurse—don’t send your child to school with medication in their backpack.

Work with your child’s teachers

The work doesn’t stop when your child leaves home. School can be a challenging place for a child with ADHD to succeed, so it’s important to find ways to help.

• Consider special programs. Schools offer support for children with combined ADHD through Individualized Education Programs (IEPs) and 504 Plans. These classroom accommodations help children manage their ADHD in school settings by providing extra time on tests, equipping students with technology to support tasks, modifying the learning environment to reduce distractions, and supporting organization.
• Hold regular meetings with your child’s school counselor and teachers to understand where they’re improving and which aspects of their learning could use more attention.
• Provide your child’s teachers, nurses, and counselors with emergency contact information in case of an episode. Include their doctor’s information.

The Bottom Line

ADHD combined type can feel like an internal tug-of-war that leaves your child feeling lost and overwhelmed. Being patient, understanding, and accepting can put your child on the right path toward building self-confidence and becoming more resilient.

Looking for more ways to support your child? Explore our ADHD worksheets to find helpful tips and exercises.

Sources:

1. Ayano G, Tsegay L, Gizachew Y, et al. “Prevalence of attention deficit hyperactivity disorder in adults: Umbrella review of evidence generated across the globe.” Psychiatry Research, 2023.
2. Grimm O, Kranz TM, Reif A. “Genetics of ADHD: What Should the Clinician Know?” Current Psychiatry Reports, 2020.
3. Tistarelli N, Fagnani C, Troianiello M, Stazi MA, Adriani W. “The nature and nurture of ADHD and its comorbidities: A narrative review on twin studies.” Neuroscience & Biobehavioral Reviews, 2020.