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Section 19
The Internalizing Dimension in Children with ADHD- Inattentive Type

Question 19 | Test | Table of Contents

Clinical and factor-analytic data can provide credence for viewing ADHD-PI (predominately inattentive type) as falling along an internalizing dimension of symptoms (Barkley; Berry, Shaywitz, & Shaywitz; Hynd et al.; Lahey et al.; Lahey, Schaughency, Frame, & Strauss). Clinical studies of children reliably diagnosed with ADHD-Pl have suggested that these children differ in meaningful or significant ways, including different psychopathologies or comorbidities found to be more associated with ADHD-PI than ADHD-PHI  (predominately hyperactive-impulsive type) (Goodyear & Hynd; Hynd et al.; Marshall, Hynd, Handwerk, & Hall). Goodyear and Hynd performed an extensive review of the research literature that contrasted 256 individuals who had ADHD with hyperactivity and 177 individuals who had ADHD without hyperactivity, 125 individuals in a clinic control group, and 97 individuals in a control group. For practitioners, this research is important because it lead the way to establishing the neuropsychological and behavioral distinctiveness of ADHD-PHI and ADHD-Pl. For example, results of this study indicated that the evidence preponderated in the direction of ADHD-Pl being more of an attentional, cognitive, anxious type disorder (e.g., internalizing dimension) in contrast to ADHD­PHI being an attentional, behavioral, and impulsive disorder (e.g., externalizing dimension). It is, therefore, reasonable to assume that clients with ADHD-PHI and ADHD-Pl have unique and differential behaviors. Moreover, these subtypes can be profiled or considered as falling on different dimensions or means of expression--inner versus external manifestation.

Casting ADHD-PI in terms of an internalizing dimension should increase the probability that the disorder can be differentially or more reliably diagnosed. This implies that more appropriate treatment regimes matched to the internal dimension can be devised and implemented. Therefore, it could be useful for therapists to study or assess the internalizing dimension and the corresponding behaviors that are often occurring within the framework of ADHD-PI more carefully. For example, ADHD-PHI has been viewed as occupying the externalizing dimension of behavior due mainly to its broad band of externalizing or overt problems (e.g., hyperactivity, aggression, conduct disorders), which are atypical in the majority of accurately diagnosed cases of ADHD-PI. Internalizing behaviors represent an intriguing and problematic area for therapists or practitioners because they can be more difficult to detect, assess, and classify with symptoms often mingled together (Merrill). W. M. Reynolds referred to internalizing behaviors as often being thought of as hidden or private disorders or illnesses. Therefore, the assessment of the internalizing dimension or emotional and behavioral problems can be ambiguous by nature. Therapists should be aware that the internalizing dimension often makes problems invisible or subtle in their initial appearance. For example, they are sometimes seemingly inert in their early stages of development. However, therapists should remember that internalized aspects of ADHD-PI usually have an evolving developmental course and that strong evidence seems to be emerging (e.g., in the neurobiological, neurobehavioral literature; Quinn) suggesting that many forms of these internalizing aspects are likely to be related to genetics and brain metabolism or the brain’s neurochemistry.

Apparently, many of the problematic behaviors that fall on the internalizing dimension are often found in the clinical subtype of ADHD-PI. Counseling practitioners need to seriously consider the distinctive clinical presentation of ADHD-PI that has resulted or emerged from numerous clinical behavioral studies (Goodyear & Hynd). For example, Barkley and Barkley, DuPaul, and McMurray reported the following characteristics of persons with ADHD-PI: (a) They performed much worse on tests that involved perceptual-motor speed or eye-hand coordination where automaticity or speed was a factor; (b) they made more mistakes on tests where memory was the principal factor; (c) they had more difficulty recalling learned material (e.g., academic) with the passage of time; and (d) they have, in general, more difficulty with the speed that their brain can process or accommodate and organize incoming information (e.g., from parents, teachers, and peers). Moreover, children with ADHD-PI often seem to wander through their daily lives missing essential cues or instructions that could improve their existence; are more prone to misinterpreting oral or written instructions; do not mentally filter out the meaningful parts of information from the unimportant; and usually do not benefit from warnings supplied to them by parents, teachers, and peers about what may happen, particularly in the future, if they persist in their present course of action or behavior. Although caution is urged in interpreting or correlating the dimensions (e.g., internalizing, externalizing) with the ADHD subtypes, therapists should be aware that these behavioral distinctions have been confirmed with clinical samples using multivariate findings. For example, according to Quay, the following are principal characteristics of ADHD found in 165 multivariate studies: (a) poor concentration, (b) short attention span, (c) inattentive and distractible, (d) daydreaming, (e) clumsy or poor concentration, (f) preoccupied or stares into space, (g) passive or easily led, (h) fidgety or restless, (i) fails to finish tasks or lack of perseverance, (j) sluggish or lazy, (k) impulsive, (l) lacks interest or easily bored, (m) drowsy, and (n) hyperactive. Although hyperactivity, as a behavior trait, appears on the externalizing dimension, Quay believed it was not always primary or central to the disorder and considered that the other characteristics or behaviors could often be more reflective (e.g., underactive physically, sluggish mental tempo) of the condition. For example, it may not define or be characteristic of the majority of the ADHD cases. In fact, behaviors that are characteristic of underactivity or inattention can often be prominent features of the disorder (Merrill). This is not to suggest that the externalizing dimension is not valid for the DSM (APA) subtypes of ADHD (e.g., particularly the ADHD-PHI subtype); however, Quay’s pioneering work subsumes many of the characteristics or symptoms of ADHD-PI that are noted in the DSM. For example, in the DSM, six of the following symptoms of inattention are required to make a diagnosis of ADHD-PI: (a) often fails to give close attention to details, (b) often has difficulty sustaining attention, (c) often does not seem to listen when spoken to directly, (d) often does not follow through on instructions, (e) often has difficulty organizing tasks or activities, (f) often avoids or is reluctant to engage in tasks that require sustained mental effort, (g) often loses things, (h) is often distracted by extraneous stimuli, and (i) is often forgetful in daily activities.
The parallel between the findings of Quay and many of the symptoms or characteristics of ADHD-PI contained in the DSM (APA) seem to support Quay’s concern or contention that hyperactivity may not be the determining factor or central to the disorder (discussed earlier in this article). Moreover, many ADHD symptoms or behaviors are more reflective of motor underactivity, sluggish cognitive tempo or cognitive dysfunction (e.g., which are internally or neurologically occurring conditions; Brown; Nadeau; Sandier).

Furthermore, the following principal characteristics were derived by Quay from 216 multivariate studies along the internalizing dimension of anxiety-withdrawal-dysphoria (e.g., fear of an uncertain future, sadness about the loss of one’s power to influence the course of events): (a) anxious or tense, (b) shy or timid, (c) sad or depressed, (d) feels inferior or worthless, (e) self-conscious or easily embarrassed, (f) lacks initiative or self-confidence, (g) easily frustrated or confused, (h) cries frequently, (i) aloof, and (j) worries. Finally, Lahey and Carlson, in their review of the literature to determine the validity of the category of ADHD-PI, presented taxometric evidence (e.g., from the technique of cluster analysis; Lahey et al.) that symptoms with consistent unique loadings on the inattention-disorganization dimension or factor were the following: (a) difficulty organizing tasks, (b) difficulty finishing tasks, (c) difficulty following through on instructions, (d) often loses things, (e) easily distracted (teachers were the respondents), (f) does not seem to listen (teachers were the respondents), (g) difficulty concentrating or sustaining attention (teachers were the respondents), and needs a lot of supervision (teachers were the respondents). It is important for therapists to be cognizant or aware that these symptoms or characteristics identified by Quay and Lahey and Carlson are often cited or discussed by researchers as being characteristics or descriptors of children diagnosed with ADI-ID without hyperactivity or ADHD-PI (Barkley; Brown; Copeland & Love; Erk; Goodyear& Hynd; Jordan; Lerneretal). The research or evidence presented in this framework should prompt practicing therapists to consider ADHD-PI as occurring primarily on the internalizing dimension and as potentially the more impaired or severely affected diagnostic subtype.
- Erk, Robert R; Five Frameworks for Increasing Understanding and Effective Treatment of Attention Deficit/Hyperactivity Disorder: Predominately Inattentive Type; Journal of Counseling & Development; Fall2000, Vol. 78 Issue 4, p389

Personal Reflection Exercise #5
The preceding section contained information about the internalizing dimension in children with ADHD- predominately inattentive type.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
The Impact of Internalizing Symptoms on Impairment for
Children With ADHD: A Strength-Based Perspective

- Bethune, S. C., Rogers, M. A., Smith, D., Whitley, J., Hone, M., & McBrearty, N. (2023). The Impact of Internalizing Symptoms on Impairment for Children With ADHD: A Strength-Based Perspective. Journal of attention disorders, 27(1), 26–37. https://doi.org/10.1177/10870547221115874


Peer-Reviewed Journal Article References:
Shahidullah, J. D., Carlson, J. S., Haggerty, D., & Lancaster, B. M. (2018). Integrated care models for ADHD in children and adolescents: A systematic review. Families, Systems, & Health, 36(2), 233–247.

Smith, Z. R., Eadeh, H.-M., Breaux, R. P., & Langberg, J. M. (2019). Sleepy, sluggish, worried, or down? The distinction between self-reported sluggish cognitive tempo, daytime sleepiness, and internalizing symptoms in youth with attention-deficit/hyperactivity disorder. Psychological Assessment, 31(3), 365–375.

Stanton, K., Forbes, M. K., & Zimmerman, M. (2018). Distinct dimensions defining the Adult ADHD Self-Report Scale: Implications for assessing inattentive and hyperactive/impulsive symptoms. Psychological Assessment, 30(12), 1549–1559.

Tannoia, D. P., & Lease, A. M. (2021). The relation of inattention and hyperactivity-impulsivity to peer dislike: An examination of potential mediators. School Psychology.

Weyers, L., Zemp, M., & Alpers, G. W. (2019). Impaired interparental relationships in families of children with attention-deficit/hyperactivity disorder (ADHD): A meta-analysis. Zeitschrift für Psychologie, 227(1), 31–41.

QUESTION 19
According to Erk, which subtype of ADHD should be considered the most impaired? To select and enter your answer go to Test.

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