The symptoms of ADHD vary according to age, from infancy to adulthood.
In infancy, early symptoms such as restlessness, increased activity and sleep problems may indicate an increased risk of ADHD.
Symptoms in infancy include distractibility, chaotic play behavior and motor problems.
In preschool age, ADHD-I can show anxious and withdrawn behavior, while hyperactive and impulsive behavior is already noticeable in ADHD-HI.
At school age, other ADHD symptoms are added, such as attention problems, learning difficulties, emotional and social problems.
In adolescence, ADHD can be associated with increased risk-taking behavior and addiction.
In adulthood, earlier hyperactivity decreases and inner restlessness becomes more visible. Affective comorbidities such as depression or anxiety disorders can also occur. ADHD can also first manifest itself in adulthood, particularly in women from their late 30s onwards.
Non-affected people also have individual ADHD symptoms. However, people with ADHD have significantly more ADHD symptoms than people without ADHD. However, the diagnosis is not only based on the presence of certain symptoms, but also on their intensity and long-term presence in various areas of life. It is important to distinguish ADHD from temporary stress or strain.
Many of the symptoms listed below are basically typical for children. Nevertheless, naming them is relevant, because the difference lies in the degree of occurrence, which in ADHD clearly exceeds that of peers. The mere occurrence of more severe symptoms compared to peers is not a compelling reason to make a diagnosis. Some children have developmental delays that disappear over time. Nevertheless, these should be observed at an early stage without pathologizing them so that timely intervention can be made if they become severe enough to require support or treatment. For preschool children, one of the most effective forms of treatment is training the parents to interact appropriately with the child and to develop an understanding of the child’s individual problems.
1. Symptom development of ADHD-HI (with hyperactivity) by age¶
1.1. Infancy - early symptoms of ADHD¶
One study was able to distinguish those with a high genetic risk of ADHD (older siblings or parents with ADHD) from those without a genetic risk of ADHD in children at 1 month of age based on behavior (primarily increased activity and impulsivity and more frequently reported behavior and temperament problems).
The following early symptoms in infants correlate with an increased risk of ADHD in later years:
- Restlessness, hypermotoric
- Restlessness((
- Approx. 60 % of children show extreme restlessness
- Restlessness at 6 months correlated with ADHD symptoms at 37 and 54 months, independent of the early symptom of shortened sleep duration
- Uninterrupted urge to move
- Inexhaustible energy
- No crawling, early walking
- Restless, unbalanced
- Playing time shortened
- Difficulties in establishing a calm waking state
- Sleep
- Unstable wake and sleep rhythm
- Superficial sleep, wide awake
- Short sleeper
- Normal sleepers before 18 months showed significantly fewer ADHD symptoms at 37 months than long-term short sleepers
- Regulatory problems (excessive crying, sleep or feeding problems) that were co-occurring (multiple) or persistent at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020) and overall behavioural problems (p = .001), especially more depressive (p = .012), somatic (p = .005), avoidant (p < .001) and antisocial personality problems (p = .006) than in children who never had regulatory problems. The risk of an ADHD diagnosis was increased (p = .017), especially of the hyperactive/impulsive subtype (p = .032). IQ was not correlated.
- Crying, screaming
- Particularly frequent, persistent and shrill crying
- Insatiable crying at times
- Regulatory problems (excessive crying, sleep or feeding problems) that were co-occurring (multiple) or persistent at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020) and overall behavioural problems (p = .001), especially more depressive (p = .012), somatic (p = .005), avoidant (p < .001) and antisocial personality problems (p = .006) than in children who never had regulatory problems. The risk of an ADHD diagnosis was increased (p = .017), especially of the hyperactive/impulsive subtype (p = .032). IQ was not correlated.
- Feeding problems
- Drinking problems
- Hot eater
- Frequent colic
- Regulatory problems (excessive crying, sleep or feeding problems) that were co-occurring (multiple) or persistent at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020) and overall behavioural problems (p = .001), especially more depressive (p = .012), somatic (p = .005), avoidant (p < .001) and antisocial personality problems (p = .006) than in children who never had regulatory problems. The risk of an ADHD diagnosis was increased (p = .017), especially of the hyperactive/impulsive subtype (p = .032). IQ was not correlated.
- Cleanliness education often delayed
- Language development often delayed
- Stroking is not enjoyed
- Frequent skin allergies
- Higher level of negative affect (already at the age of 3 months)
- The results for positive affect did not reach statistical significance
- Simultaneous observation of the progression of positive and negative emotionality can generate additional information
- Negative affect only correlated with ADHD symptoms in childhood if moderate, stable or low positive affect was present at the same time
1.2. Infant age (1 - 3 years)¶
- Distractibility
- Chaotic and destructive, less goal-oriented play behavior
- Sleep problems
- Sleep-through problems in toddlers 1 to 3 years old were a stronger predictor of later ADHD than sleep duration.
- Sleep disorders
- Regulatory problems (excessive crying, sleep or feeding problems) that were co-occurring (multiple) or persistent at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020) and overall behavioural problems (p = .001), especially more depressive (p = .012), somatic (p = .005), avoidant (p < .001) and antisocial personality problems (p = .006) than in children who never had regulatory problems. The risk of an ADHD diagnosis was increased (p = .017), especially of the hyperactive/impulsive subtype (p = .032). IQ was not correlated.
- Gross motor problems
- Often falls over his own legs
- Mouth motor skills noticeable
- Mouth is often open
- Drools easily
- Desire for violent movements
- Constantly on the move
- Sometimes very skillful motor skills
- Playing time shortened
- Changes employment frequently
- Does not finish the game
- Learning problems
- No learning gain through negative experiences
- Learns to dress with difficulty
- Language development delayed
- Conversion problems
- Adaptation problems
- Can’t wait
- Sensitivity changes
- Highly sensitive or hyposensitive to external stimuli
- Novelty Seeking
- Stimulation hunger
- Enormously curious
- Daring, increased risk of accidents
-
ADHD-HI specific:
- Group incompetence and disruptive behavior, outsider role
- Constant fidgeting and interrupting in the chair circle
- Strong urge to move leads to danger to self and others
- No awareness of danger
- Impulsiveness
-
Impulsivity at age 2 correlated with ADHD symptoms at age 3.
- Irritability
-
Significant irritability at 3 years of age was predictive of clinical diagnoses
- At the age of 6 years (depression, oppositional behavior disorder and functional impairment. Irritability also correlated with parental depression and anxiety)
- At age 9 (current and lifetime anxiety disorders at age nine, current and lifetime generalized anxiety disorder and current separation anxiety, depressive symptoms, disruptive behavior, major functional impairment, and use of outpatient treatment)
- Between the ages of 12 and 15 (internalizing and externalizing disorders in adolescence, anxiety and depressive symptoms as well as major functional impairments, in particular poorer peer relations, poorer physical health, use of antidepressants)
- Emotional dysregulation
- Aggression
- Increased aggression
- Little tyrant
- Destruction of games and toys
- Anger
- Frequent / uncontrollable fits of rage
- Affect spasms
- Affectively unstable, mostly pronounced defiant phase
-
ADHD-I specific:
- Remarkably calm and well-behaved
- Overanxious, clinging, very affectionate
- A meta-analysis found a predictive power of symptoms in the first 36 months for later ADHD in childhood:
- Activity level (k = 18) in infancy and toddlerhood correlated moderately with ADHD (ADHD-C only)
- Sustained attention correlated moderately negatively with ADHD (all subtypes)
- Negative emotionality correlated moderately with ADHD (all subtypes)
1.3. Preschool age (4 - 6 years)¶
1.3.1. ADHD-I at preschool age (without hyperactivity)¶
- Often anxious
- Often unsafe
- Learning difficulties
- Problems listening
- Slow comprehension
- Often believes he cannot cope with the task
- Slow language acquisition, confuses letters
- Gross motor skills
- Conspicuous oral motor skills
- Speaks indistinctly
- Does not like to paint or do handicrafts
- Motor problems
- Difficulties learning to swim
- Difficulties learning to ride a bike
- Balance problems
- Activities slowed down or too fast
- Fine motor skills impaired
- Withdrawn social behavior
- Often plays alone
- Little contact with children of the same age
- Withdrawal tendencies in groups
- Kindergarten
- Circle of chairs
- Gets bored quickly
- Often loses and forgets things
- Regulatory problems (excessive crying, sleep or feeding problems) that were co-occurring (multiple) or persistent at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020) and overall behavioural problems (p = .001), especially more depressive (p = .012), somatic (p = .005), avoidant (p < .001) and antisocial personality problems (p = .006) than in children who never had regulatory problems. The risk of an ADHD diagnosis was increased (p = .017), especially of the hyperactive/impulsive subtype (p = .032). IQ was not correlated.
1.3.2. ADHD at preschool age (with hyperactivity)¶
- Motor hyperactivity
- Motor restlessness
- Always on the move
- Impulsiveness
- Gets excited quickly and strongly
- Reacts spontaneously and rashly
- Asks a lot
- Often does not wait for answers
- Does not adhere to rules
- Often forgets rules again
- Grumbles quickly
- Attention problems
- Often only become apparent at an older age (school years)
- Cannot listen for long
- Forgets quickly
- Loses a lot
- Aggression
- Often as a comorbidity
- Especially in case of uncertainty
- Gross motor skills
- Conspicuous oral motor skills
- Language problems
- Speaks indistinctly
- Stammer
- Difficulties with some consonants
- Does not like to paint or do handicrafts
- Holds pens cramped
- Presses too hard
- Coloring or cutting out shapes makes it difficult
- Difficulties learning to swim
- Difficulties learning to ride a bike
- Balance problems
- Fine motor skills impaired
- Social behavior
- Strong sense of justice
- High ambition in sports and games
- Often wants to determine
- Eager for social services
- Quickly offended
- Impatience
- Wets more frequently
- More often during the day than at night
- Sleep
- Frequently falling asleep late
- Needs little sleep
- Executive function problems at preschool age
- Correlated with more externalizing and attention symptoms, but fewer internalizing symptoms at the age of 8 to 13 years
- Similar for an older age group
1.4. School years (6 to 15 years)¶
ADHD symptoms are now becoming fully apparent.
Sleep problems at the age of 8 to 9 years increased the risk of ADHD at the age of 10 to 11 years by 18 to 20%
1.4.1. ADHD-I at school age (without hyperactivity)¶
- Emotional problems
- Often anxious
- Often unsafe
- Dares to do nothing
- Rejection Sensitivity
- Easily offended
- Cries quickly
- Emotionally sensitive
- Poorly tolerates criticism
- Feels unloved
- Feels misunderstood
- Attention and learning difficulties
- Problems listening
- Easily distractible
- Forgets a lot
- Overhears a lot
- Unfocused
- Unless something is of particular interest
- Dreamy
- Slowly
- Inflexible thinking
- Takes a very long time to do homework
- Cannot do homework alone
- Gross and fine motor problems
- Writing problems
- Coloring unclean
- Speaks indistinctly
- Social behavior
- Is easily annoyed
- Can defend himself badly
- Delayed development of social maturity
- Gets bored quickly
- Often loses and forgets things
- Somatization tendencies
- Frequent headaches
- Frequent abdominal pain
1.4.2. ADHD-HI at school age (with hyperactivity)¶
- Social behavior
- Integration into the class group very difficult
- Aggression
- Hits frequently, is often beaten by others
- Risk behavior
- Can assess dangers poorly
- 85 % of accidents on the way to school
- Attention problems become recognizable for the first time
- From the age of 7 at the earliest
- Up to the age of 14, 15 years
- Motor hyperactivity
- Motor restlessness
- Always on the move
- Fidgets a lot
- Gross motor skills
- Impulsiveness
- Gets excited quickly and strongly
- Reacts spontaneously and rashly
- Interrupts others
- Answers before the question is finished
- Is often loud
- High sensitivity
- Is often sensitive to noise itself
- Attention problems
- Often only become apparent at an older age (school years)
- Cannot listen for long
- Forgets quickly
- Loses a lot
- Concentration span limited
- Frequently switches back and forth between tasks / activities
- Often paints on the side
- Difficulties starting homework
- Interrupts homework frequently
- Good powers of observation
- Notices a lot
- Can see through others well
- Learning problems
- Makes mistakes again and again
- Does not learn from mistakes
- Gross motor skills
- Conspicuous oral motor skills
- Language problems
- Speaks indistinctly
- Stammer
- Difficulties with some consonants
- Does not like to paint or do handicrafts
- Holds pens cramped
- Presses too hard
- Coloring or cutting out shapes makes it difficult
- Difficulties learning to swim
- Difficulties learning to ride a bike
- Balance problems
- Emotional dysregulation
- Rejection Sensitivity
- Quickly feels unfairly treated
- Social behavior
- Strong sense of justice
- Often wants to determine
- Gets on worse with peers than with younger or older people
- Collects useless things
- Sleep
1.5. Adolescence (from 15 years)¶
- Motor hyperactivity is reduced
- Inner and outer restlessness
- Impulsiveness and reduced attention remain
- Orientation towards socially marginalized groups
- Risk of developing an addiction
- Willingness to engage in high-risk behavior
- Frequent accidents
- Drop in performance under stress
- Organizational problems
- Low determination
- Spotty handwriting
1.6. Adulthood¶
- Barely any motor hyperactivity, instead inner restlessness, feeling driven
- Attention problems subside somewhat
- Emotional problems / affective comorbidities on the rise
- Depression
- Anxiety disorders
- Increased risk of addiction, Disorders in social behavior
- Anxiety symptoms, alcohol problems
- Criminal offenses
- Increased tendency to have accidents
- Worse professional position
2. Symptom frequency and symptom intensity in ADHD¶
ADHD is not diagnosed by the presence of a specific type of symptom that is exclusive to ADHD (categorical), but by the set of symptoms that can originate from ADHD and their intensity (dimensional).
- In a collection of symptoms presented by Barkley
- Non-affected people often experience 1 to 2 of the 18 symptoms on average, i.e. around 5 %
- On average, people with ADHD often have 12 of the 18 symptoms mentioned, i.e. around 66%.
- In the online test we designed ourselves ⇒ ADHD online tests
have
- According to their own assessment, people with ADHD who were not affected had an average of just under 8 out of 32 possible symptoms (25 %)
- Subjects with a confirmed ADHD diagnosis around 24 of the 32 possible symptoms (75 %)
- Hardly any person with ADHD has all the symptoms “often”, and it is barely possible to typify which symptoms occur more frequently together.
The symptoms must occur over a longer period of time and in several areas of life. They usually first become apparent before the age of 12. However, more and more cases of late onset ADHD are being recognized in which there were no sufficiently severe symptoms in adolescence to justify a diagnosis. This mainly affects women in their late 30s.
The fact that symptoms must persist for longer and in different areas of life serves to distinguish ADHD as a permanent disorder from symptoms of merely temporary (stress) exposure to temporary stressors.
3. Ethnic and cultural differences¶
When adults diagnose ADHD in children, the different ethnic and cultural backgrounds should be taken into account.
