Attention-deficit/hyperactivity disorder (ADHD) affects individuals throughout their lives. Though people often associate it with childhood, ADHD can continue into adulthood, creating distinct challenges for those diagnosed and for the mental health professionals who assist them. Among the common forms of this disorder is ADHD, combined type (ICD-10: F90.2).

Therapists need to grasp the diagnostic criteria, clinical implications, and effective practices for treating ADHD, combined type. By expanding our understanding of this specific subtype, we can offer more precise and effective interventions that address the main symptoms and related challenges our clients experience. This article equips mental health professionals with the knowledge and strategies necessary to identify, document, and treat ADHD, combined type ethically and effectively.

Diagnostic Criteria and ICD-10 Context

The ICD-10 code F90.2 identifies ADHD, combined type, marked by both inattentive and hyperactive-impulsive symptoms. For a diagnosis, an individual must show at least six symptoms (or five for adults) from both the inattention and hyperactivity-impulsivity symptom lists. These symptoms must persist for at least six months, begin before age 12, and appear in two or more settings (e.g., home, school, work), causing significant difficulties in functioning.

ADHD, combined type differs from the inattentive type (F90.0), which primarily involves issues with focus, organization, and forgetfulness, and the hyperactive-impulsive type (F90.1), which is characterized by restlessness, impulsivity, and excessive talking. Recognizing these differences is important for accurate diagnosis and treatment planning.

Clinical Presentation Across the Lifespan

ADHD, combined type shows different symptoms at various stages of life, presenting unique challenges in childhood, adolescence, and adulthood.

In children, the most noticeable symptoms often include:

• Fidgeting and restlessness: Constantly moving, squirming in their seat, or having difficulty sitting still.
• Impulsivity: Acting without thinking, interrupting others, or struggling to wait their turn.
• Inattention: Difficulty sustaining focus in class, frequently losing items, or appearing not to listen.
• Peer conflicts: Struggling to follow rules in games or experiencing rejection due to impulsive behavior.

During adolescence, individuals with ADHD, combined type may experience changes such as:

• Academic underachievement: Struggling to keep up with increased demands for organization and time management.
• Risk-taking behavior: Engaging in impulsive, dangerous activities without considering consequences.
• Emotional reactivity: Experiencing intense mood swings, low frustration tolerance, or angry outbursts.

In adulthood, ADHD, combined type symptoms may become more internalized but still affect daily life:

• Disorganization: Struggling to manage household tasks, work responsibilities, or personal finances.
• Chronic lateness: Difficulty with time management, often running behind schedule or missing deadlines.
• Relationship strain: Experiencing conflict with partners due to forgetfulness, impulsivity, or emotional dysregulation.
• Task avoidance: Procrastinating on important projects, especially those that require sustained mental effort.

It's important to recognize that women and girls with ADHD, combined type are often underdiagnosed because their symptoms may be masked or internalized. They might work harder to manage challenges, leading to missed or delayed diagnosis and treatment.

Differential Diagnosis and Comorbidity Considerations

Diagnosing ADHD, combined type accurately involves a thorough assessment that takes into account possible differential diagnoses and co-occurring conditions. Many mental health disorders share symptoms with ADHD, so distinguishing between them is important for planning effective treatment.

Common differential diagnoses include:

• Anxiety disorders: Symptoms like restlessness, difficulty concentrating, and emotional dysregulation can resemble those of ADHD.
• Bipolar disorder: Impulsivity, hyperactivity, and emotional instability may look like ADHD, especially in young people.
• Oppositional Defiant Disorder (ODD): Defiance, argumentativeness, and trouble following rules can coexist with or be confused for ADHD.
• Trauma-related symptoms: Hypervigilance, impulsivity, and inattention due to trauma can overlap with ADHD symptoms.

ADHD, combined type often occurs alongside several mental health conditions, such as:

• Depression: People with ADHD face a higher risk of depression, which can worsen motivation, concentration, and emotional regulation issues.
• Learning disabilities: Specific challenges in reading, writing, or math frequently accompany ADHD, creating academic difficulties.
• Substance use disorders: Impulsivity and poor self-regulation linked to ADHD can lead to substance abuse problems.

Anxiety disorders are especially common, affecting 25-50% of those with ADHD. Anxiety can intensify ADHD symptoms and complicate treatment, necessitating a tailored approach that addresses both issues. A multidisciplinary treatment plan including medication, psychotherapy (like cognitive behavioral therapy), and lifestyle changes is often required for the best outcomes.

To ensure a precise diagnosis, it’s important to conduct a detailed intake history, use validated rating scales (such as ASRS, Vanderbilt), collect information from family members or teachers, and engage in clinical observation. Collaborating with other healthcare professionals, such as psychiatrists or neuropsychologists, can provide valuable insights and support comprehensive care for individuals with ADHD, combined type and coexisting conditions.

Treatment and Therapy Considerations

Medication often serves as the initial treatment for ADHD, combined type, but therapy plays a significant role in developing functional skills and strategies. A thorough treatment plan should combine medication management with evidence-based therapeutic interventions tailored to the individual's needs and age.

Psychoeducation forms a core part of therapy for ADHD, combined type, assisting clients and their families in understanding the disorder, its effects on daily life, and the importance of executive functioning skills. Through psychoeducation, therapists can help clients reframe their challenges, reduce self-blame, and foster a sense of empowerment.

Behavioral strategies are important for improving organization, time management, and planning skills. These may include:

• Establishing routines: Creating consistent daily structures to manage symptoms and boost productivity.
• Breaking down tasks: Dividing large projects into smaller, manageable steps to prevent overwhelm and enhance focus.
• Using visual aids: Incorporating checklists, calendars, and color-coding to support memory and organization.
• Minimizing distractions: Modifying the environment to reduce distractions and improve concentration.

Cognitive behavioral therapy (CBT) effectively addresses the emotional and self-esteem challenges often linked with ADHD, combined type. CBT helps clients identify and challenge negative thought patterns, develop coping strategies for impulsivity and emotional dysregulation, and build problem-solving skills.

Mindfulness and body-based interventions, such as deep breathing, progressive muscle relaxation, and meditation, can help individuals with ADHD, combined type manage impulsivity, restlessness, and stress. These practices promote self-awareness, emotional regulation, and a greater sense of calm.

For children and adolescents with ADHD, combined type, parent training and family therapy are essential components of treatment. These interventions assist parents in developing effective behavior management strategies, improving communication, and fostering a supportive home environment. Family work also addresses the impact of ADHD on sibling relationships and overall family dynamics.

Supporting Clients With ADHD in Therapy

When working with clients who have ADHD, combined type, creating a supportive, structured therapeutic environment that promotes skill-building and self-awareness is important. Therapy sessions should focus on goals, using visual cues, checklists, and routines to help clients remain focused and organized. These tools offer a clear framework for progress and accountability, which can be particularly helpful for those who struggle with attention and follow-through.

Normalizing the frustration and challenges that come with ADHD plays a vital role in therapy. Many individuals with ADHD, combined type experience shame or self-blame related to their symptoms, which can hinder progress and well-being. Therapists can help reduce this shame by:

• Validating experiences: Acknowledging the real difficulties that ADHD presents and emphasizing that challenges are not a personal failing.
• Reframing perspectives: Encouraging clients to view their symptoms as opportunities for growth and skill-building rather than inherent flaws.
• Celebrating successes: Recognizing and praising progress, no matter how small, to build self-esteem and motivation.

Accountability tools are another important component of effective ADHD therapy. These may include:

• Reminders: Setting up phone, email, or text reminders for appointments, deadlines, and important tasks.
• Habit stacking: Pairing new habits with established routines to make them more automatic and easier to remember.
• Self-monitoring worksheets: Using daily or weekly tracking sheets to monitor progress, identify patterns, and celebrate successes.

In addition to addressing challenges, encouraging a strengths-based approach to ADHD is valuable. Many individuals with ADHD, combined type possess unique qualities that can help them succeed, such as creativity, high energy, strong problem-solving skills, and the ability to hyperfocus on engaging tasks. Therapists can help clients identify and make use of these strengths by:

• Exploring interests: Discussing passions, hobbies, and areas of natural talent to uncover potential strengths.
• Applying strengths to challenges: Brainstorming ways to use identified strengths to overcome obstacles and achieve goals.
• Cultivating a growth mindset: Encouraging clients to view their ADHD as a source of unique abilities rather than a limitation.

Documentation and Ethical Use of F90.2

Accurate and ethical documentation is key when diagnosing and treating ADHD, combined type. Proper documentation should clearly show evidence of symptoms in the areas of inattention and hyperactivity-impulsivity, as well as the functional impairment these symptoms cause. It's important to note how long symptoms have lasted and their early onset, typically before age 12.

To avoid overdiagnosis or misdiagnosis, assign the F90.2 code only when the full diagnostic criteria are met. This includes having at least six symptoms (or five for adults) in both the inattention and hyperactivity-impulsivity areas, persisting for at least six months, and causing significant impairment in multiple settings. Diagnosing ADHD, combined type without fully meeting the criteria can lead to unnecessary stigma and inappropriate treatment.

When documenting the diagnosis, consider the following ethical principles:

• Beneficence: Ensure the diagnosis and treatment plan benefit the client, promoting their well-being and functioning.
• Non-maleficence: Avoid causing harm through misdiagnosis, overdiagnosis, or stigmatization.
• Justice: Provide fair access to diagnostic and treatment services, regardless of the client's background or circumstances.
• Respect for autonomy: Involve the client (and their family, when appropriate) in the diagnostic process and treatment decisions, respecting their right to informed consent.

Discuss the implications of the ADHD, combined type diagnosis with your clients, including its impact on treatment options, insurance coverage, and potential stigma. Help them view the diagnosis as a way to better understand their challenges and develop effective coping strategies, rather than as a label that defines them.

When medication is part of the treatment plan, work closely with the prescribing medical provider. Obtain necessary releases of information (ROIs) to facilitate communication and ensure a coordinated approach to care. Regular communication with the prescriber can help monitor the effectiveness and side effects of medication, as well as any changes in symptoms or functioning.

Ethical documentation and use of the F90.2 code also involve staying informed about the latest research and best practices in ADHD diagnosis and treatment. Engage in ongoing education and training to ensure that your approach aligns with the most current evidence and guidelines.

Key Takeaways

ADHD, combined type is a complex and often misunderstood condition that affects individuals across their lifespan. While it presents significant challenges, it's important to remember that ADHD is highly treatable with the right combination of support, strategies, and interventions.

As mental health professionals, our role involves looking beyond the diagnosis to see the entire person. This means shifting away from a pathologizing perspective and focusing on building resilience, adaptability, and empowerment in our clients with ADHD, combined type.

Key strategies for empowering clients with ADHD include:

• Finding the "right difficult": Encouraging clients to engage in activities that are challenging but not overwhelming, keeping their ADHD brain stimulated and motivated.
• Recognizing strengths and uniqueness: Helping clients identify and appreciate their unique abilities, such as creativity, innovation, and spontaneity.
• Creating routines and structure: Supporting clients in establishing daily routines and using tools like planners and apps to manage symptoms and reduce mental load.
• Breaking tasks into manageable steps: Guiding clients to divide large projects into smaller, less daunting tasks and set realistic goals for each step.
• Applying cognitive behavioral therapy (CBT): Working with clients to identify and change negative thought patterns, develop healthy coping strategies, and improve self-esteem.

Our aim as therapists is to help clients with ADHD, combined type thrive with their neurodivergence. With the right support, understanding, and tools, these individuals can lead fulfilling, successful lives and make valuable contributions to their communities.

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