What are the Symptoms of ADHD?

Core Symptoms of ADHD:

Dr. William Dodson is one of the leading contributors to the field of study of ADHD in all ages. He has superbly captured what he refers to as:

The three most defining traits of ADHD

Ones that shape perceptions, emotions, and motivation

The textbook symptoms of ADHD — inattention, hyperactivity, and impulsivity — fail to reflect several of its most powerful characteristics.

What does everyone with ADHD have in common, that people with ADHD don’t experience?

Three defining features of ADHD emerge that explain every aspect of the condition:

1. an interest-based nervous system
2. emotional hyperarousal
3. rejection sensitivity

1. Interest-based nervous system

Despite its name, ADHD doesn’t actually cause a deficit of attention. It actually causes inconsistent attention that is only activated under certain circumstances.

People with ADHD often say they “get in the zone” or “hit a groove.” These are all ways of describing a state of hyperfocus – intense concentration on a particular task, during which the individual feels she can accomplish anything. In fact, she may become so intently focused that the adult with ADD may lose all sense of how much time has passed.

This state is not activated by a teacher’s assignment, or a boss’s request. It is only created by a momentary sense of interest, competition, novelty, or urgency created by a do-or-die deadline.

The ADHD nervous system is interest-based, rather than importance- or priority-based.

Practitioners should ask, “Have you ever been able to get engaged and stay engaged?” Then, “Once you’re engaged, have you ever found something you couldn’t do?”

Anyone with ADHD will answer along these lines: “I have always been able to do anything I wanted so long as I could get engaged through interest, challenge, novelty, urgency, or passion.”

“I have never been able to make use of the three things that organize and motivate everyone else: importance, rewards, and consequences.”

2. Emotional Hyperarousal

People with ADHD have passionate thoughts and emotions that are more intense than those of the average person. Their highs are higher and their lows are lower. This means they may experience both happiness and criticism more powerfully than their peers and loved ones do.

Mood disorders are characterized by moods that have taken on a life of their own, separate from the events of the person’s life, and often last for more than two weeks. Moods created by ADHD are almost always triggered by events and perceptions, and resolve very quickly. They are normal moods in every way except for their intensity.

3. Rejection Sensitivity

Rejection sensitive dysphoria (RSD) is an intense vulnerability to the perception – not necessarily the reality – of being rejected, teased, or criticized by important people in your life. RSD causes extreme emotional pain that may also be triggered by a sense of failure, or falling short – failing to meet either your own high standards or others’ expectations.

It is a primitive reaction that people with ADHD often struggle to describe. They say, “I can’t find the words to tell you what it feels like, but I can hardly stand it.” Often, people experience RSD as physical pain, like they’ve been stabbed or struck right in the center of their chest.

Often, this intense emotional reaction is hidden from other people. People experiencing it don’t want to talk about it because of the shame they feel over their lack of control, or because they don’t want people to know about this intense vulnerability.

The question that can help identify RSD is, “For your entire life, have you always been much more sensitive than other people you know to rejection, teasing, criticism, or your own perception that you have failed?”

When a person internalizes the emotional response of RSD, it can look like sudden development of a mood disorder. He or she may be saddled with a reputation as a “head case” who needs to be “talked off the ledge.” When the emotional response of RSD is externalized, it can look like a flash of rage. Half of people who are mandated by courts to receive anger-management training had previously unrecognized ADHD.

Some people avoid rejection by becoming people pleasers. Others just opt out altogether, and choose not to try because making any effort is so anxiety-provoking.

98-99% of adolescents and adults with ADHD acknowledge experiencing RSD. For 30%, RSD is the most impairing aspect of their ADHD, in part because it does not respond to therapy.

Alpha-agonist medications, like guanfacine and clonidine, can help treat it. Only about one in three people experience relief from either medication, but 60% experience robust benefits when both are tried. When successfully treated, people with RSD report feeling “at peace,” or like they have “emotional armor.” They still see the same things happening that would have previously wounded them, but now it bounces off without injury. They also report that, rather than three or four simultaneous thoughts, they now have just one thought at a time.

  • Attention and focus struggles.
  • Executive functioning deficits. Executive functioning is the brain’s ability to activate, organize, integrate and manage other functions. Executive functioning allows you to think about goals and the consequences for your actions, plan accordingly, evaluate your progress, and shift plans as necessary. It keeps you on track, allowing you to resist and filter out distractions around you.
  • Impulsivity, or self-regulation impairment. Self-regulation requires one to use executive functioning mental abilities and emotions to achieve a goal. Simply put, self-regulation is what allows one to stay on track to get the things done.
  • Motivational issues. Lack of motivation is seen as one of the most impairing aspects of ADHD. A person can know they need to do something, but they have no sense of urgency and therefore no compelling urge to initiate something that needs to be done.
  • Emotional restraint. Many people with ADHD will report that they are unable to control their emotions and will experience hyper-inflated emotional responses and be emotionally reactive.
  • Hyperactivity. Some people with ADHD experience restlessness and impatience.

Russell A. Barkley, Ph.D., a noted researcher and leader in the field of ADHD, defines the heart of the issue as intending to accomplish a task but getting derailed or distracted by something else. The result is that the task does not get done on time or at all.

Major Characteristics of ADHD

The three predominant features of this disorder include:

  1. Poor sustained attention or persistence of effort to tasks.
    This problem often arises when the individual is assigned boring, tedious, protracted, or repetitive activities that lack intrinsic appeal to the person. They often fail to show the same level of persistence, motivation, and will power of others their age when uninteresting yet important tasks must be performed. They often report becoming easily bored with such tasks and consequently shift from one uncompleted activity to another without completing these activities. They may also have problems with completing routine assignments without direct supervision.
  2. Poor self-control or impulse control, and the capacity to delay gratification.
    This is often noted in the individual’s inability to resist distractions while concentrating or working; work for larger, longer-term rewards rather than opting for smaller, more immediate ones; stop and think before acting; wait one’s turn while playing games; pay attention when conversing with others; wait in line; or stop their responses when it becomes evident that their actions are no longer effective.
  3. Restlessness And Excessive Movement.
    Some individuals with ADHD are noted to be excessively fidgety, restless, and “on the go.” They display excessive movement, such as wriggling their feet and legs, tapping things, rocking while seated, or shifting their posture or position while performing relatively boring tasks.
    Younger children with the disorder may show excessive running, climbing, and other gross motor activity. While this tends to decline with age, even teenagers with ADHD are more restless and fidgety than their peers. In adults with the disorder, this restlessness may be more subjective than outwardly observable, although with some adults they remain outwardly restless or appear unable to remain still.

Additional Characteristics of ADHD:

People with ADHD may also have difficulties in the following areas of functioning.

  • Working Memory

    “Working memory” refers to the capacity to hold information in mind that will be used to guide one’s actions, either now or at a later time. It is essential for remembering to do things in the near future. Those with ADHD often have difficulties with working memory and are described as forgetful, unable to keep important information in mind, and disorganized in their thinking. They may often be described as acting without hindsight or forethought, and being less able to anticipate and prepare for future events as well as others—all of which seems to be dependent on working memory.

  • Time Awareness

    Recently, research suggests that those with ADHD cannot sense or use time as adequately as others in their daily activities. They are often late for appointments and deadlines, unprepared for upcoming activities, and less able to pursue long-term goals and plans as well as others. Since young children don’t have many time-specific responsibilities, this is more noticeable in older children and adults with the disorder.

  • Rule Following

    Recent research suggests that children with ADHD are significantly delayed in the development of “internal language,” which is the private voice inside one’s mind that we employ to converse with ourselves, contemplate events, and direct or command our own behavior. This private speech is absolutely essential to the normal development of contemplation, reflection, and self-regulation. Its delay in those with ADHD contributes to significant problems with their ability to follow through on rules and instructions, to read and follow directions carefully, to follow through on their own plans, rules, and “do-lists,” and even to act in accordance with legal and moral principles. When combined with their difficulties with working memory, this problem results in significant interference with reading comprehension—especially of complex, uninteresting, or extended reading assignments.

  • Emotional, Motivational, and Arousal Regulation

    Children and adults with ADHD often have problems inhibiting their normal, healthy emotional reactions and are more likely to publicly manifest the emotions they experience than would someone else. They seem less able to “internalize” their feelings, to keep them to themselves, and even to moderate them as others do. Consequently, they may be more likely to appear less emotionally mature, more reactive with their feelings, quick-tempered, and easily frustrated by events.

    People with ADHD may have a harder time generating intrinsic motivation for tasks that have no immediate payoff or appeal. This incapacity to create private motivation or drive often makes them appear to lack willpower or self-discipline, as they cannot stay with things that do not provide immediate reward, stimulation, or interest to them. Their motivation remains dependent on the immediate environment for how hard and how long they will work.

    On a related note, people with ADHD may have more difficulty regulating their general level of arousal to meet situational demands. They find it difficult to activate or arouse themselves to initiate work that must be done, often complain of being unable to stay alert or even awake in boring situations, and frequently seem to be “in a fog” when they should be more alert, focused, and actively engaged in a task.

  • Problem Solving and Flexibility

    When encountering an obstacle to a goal, individuals must be capable of quickly generating a variety of options, considering their respective outcomes, and selecting which seems most likely to surmount the obstacle.

    People with ADHD find such hurdles more difficult to surmount, often giving up their goals in the face of obstacles and not taking the time to think through other options that could help them succeed. They appear less flexible in approaching situations, more likely to respond automatically or on impulse, and less creative at overcoming the roadblocks to their goals. These problems may even be evident in the speech and writing, as they are less able to quickly assemble their ideas into a more organized, coherent explanation of their thoughts.

  • Consistency of Work Performance

    Substantial variation in in work performance is particularly typical of those with the impulsive subset of ADHD. There are wide swings in the quality, quantity, and even speed of their work, failing to maintain a relatively even pattern of productivity and accuracy. Sometimes the person ADHD can complete their work quickly and correctly; others times, tasks are performed poorly, inaccurately, and quite erratically. Indeed, some researchers see this pattern of high variability in work-related activities to be as much a hallmark of the disorder as is the poor inhibition and inattention described above.

3 Subtypes of ADHD (as recognized by the DSM-5 manual, 2013)

  1. Predominantly Hyperactive-Impulsive Presentation (DSM-5 314.01, F90.2)
    • Fidgets with hands or feet; squirms in chair
    • Has difficulty remaining seated
    • Runs about or climbs excessively (if a child)
    • Difficulty in engaging in activities quietly
    • Acts as if driven by a motor
    • Talks excessively
    • Blurts out answers before questions are completed
    • Difficulty in waiting or taking turns
    • Interrupts or intrudes upon others

  2. Predominantly Inattentive Presentation (DSM-5 314.00, F90.0)
    • Fails to give close attention to details or makes careless mistakes
    • Has difficulty sustaining attention and does not appear to listen
    • Struggles to follow through on instructions
    • Has difficulty with organization
    • Avoids or dislikes tasks requiring sustained mental effort
    • Loses things
    • Is easily distracted
    • Is forgetful in daily activities

  3. Combined Presentation (DSM 5 314.01, F90.2)
    • Has both sets of the above symptoms of inattention and hyperactive/ impulsive symptoms

Research on those with the Combined Type suggests that they are likely to develop their hyperactive and/or impulsive symptoms first, usually during the preschool years, when they may be diagnosed as having the predominantly hyperactive-impulsive type. Most of these cases will eventually progress to difficulties with attention span, persistence, and distractibility (Combined Type).

There is considerably less research on the predominantly inattentive type of ADHD, or what used to be referred to as attention deficit disorder without hyperactivity. But the predominantly inattentive type of ADHD appears to be associated with more daydreaming, passiveness, sluggishness, and difficulties with focused or selective attention (filtering important from unimportant information), slow processing of information, mental fogginess and confusion, social quietness or apprehensiveness, hypo-activity, and inconsistent retrieval of information from memory.

It is also considerably less likely to be associated with impulsiveness (by definition) as well as oppositional/defiant behavior, conduct problems, or delinquency. Should further research continue to demonstrate such differences, there would be good reason to view this subtype as actually a separate and distinct disorder from that of ADHD.

FAQs about ADHD Symptoms

When do symptoms first present?
The symptoms of ADHD appear to arise, on average, between 3 and 6 years of age, particularly for the subtypes of ADHD associated with hyperactive and impulsive behavior. Others may not develop their symptoms until somewhat later in childhood. But certainly the vast majority of those with the disorder have had some symptoms since before the age of 13. Those who have the predominately intensive type of ADHD, not associated with impulsiveness, appear to develop their attention problems somewhat later, often in middle or later childhood.

Can I develop ADHD as an adult?
Regardless of subtype, ADHD is believed to be one of childhood onset, suggesting that should these symptoms develop for the first time in adulthood, other mental disorders rather than ADHD should be suspected.

Can symptoms present in some situations and not others?
Yes. The major symptoms of ADHD are likely to change markedly as a consequence of the nature of the situation. Research suggests that those with ADHD behave better in one-to-one situations, when doing tasks that they enjoy or find interesting, when there is some immediate payoff for behaving well, when they are supervised, earlier in the day rather than later, and, for children, when they are with their fathers compared to their mothers.

Conversely, those with ADHD may manifest more of their symptoms when they must perform boring work, in group settings, when they must work independently of supervision, when their work must be done later in the day, and when they are with their mothers.

Do ADHD symptoms improve with age?
ADHD symptoms are often developmentally stable, though the level of absolute symptoms does decline with age. Those with ADHD will show improved behavior but won’t necessarily catch up to their peer group. This seems to leave them chronically “behind” others of their age in their capacity to inhibit behavior, sustain attention, control distractibility, and regulate their activity level. Research suggests that among those children clinically diagnosed with the disorder in childhood, 50 to 80 percent will continue to meet the criteria for the diagnosis in adolescence. Whether or not they have the full syndrome in adulthood, at least 50 to 70 percent may continue to manifest some symptoms that are causing them some impairment in their adult life.

It has been estimated that anywhere from 15 to 50 percent of those with ADHD ultimately “outgrow” the disorder. However, these figures come from follow-up studies in which the current and more rigorous diagnostic criteria for the disorder were not used. When more appropriate and modern criteria are employed, probably only 20 to 35 percent of children with the disorder no longer have any symptoms resulting in impairment in their adult life. The fact that different studies reflect such a wide range of statistics suggests that ADHD is still not fully understood. There is now research suggesting there are seven different subtypes of ADHD.

Sluggish Cognitive Tempo (SCT) is relatively unknown in the general population and is often mistaken for ADHD, so little is understood about it. Hopefully, over time, research will help us be able to distinguish it—if, in fact, it is a separate disorder from ADHD or just another subtype of ADHD. There is some consideration to use the term "concentration deficit disorder" (CDD) instead of SCT.

SCT is a descriptive term for a cluster of symptoms that some researchers believe comprises a novel psychiatric disorder. Although definitions for this proposed disorder are still being developed, some mental health professionals have characterized those affected as individuals with an attention disorder that is distinct from ADHD. SCT is proposed to be a similar disorder to the predominantly inattentive presentation of ADHD but importantly distinct from it. One problem is that some individuals who actually have SCT are now mistakenly diagnosed with the inattentive presentation. Some experts think that SCT and ADHD differ in the kind of inattention that they produce: While those with ADHD can engage their attention but fail to sustain it over time, people with SCT seem to have difficulty with engaging their attention to a specific task. Accordingly, the attention style in SCT may be more halting and sluggish, whereas in ADHD it is jumpy and flighty.

What other issues are regularly associated with ADHD?
Over the course of their lives, 50 percent or more of those with ADHD experience a greater risk for developing oppositional and defiant behavior (ODD); 25 to 45 percent experience conduct problems (CD) and antisocial difficulties; 25 to 40 percent experience learning disabilities; and 25 percent experience low self-esteem and depression.

It can be fairly assumed that the disorders of ODD, CD, and anti-social difficulties can be attributed to the brain’s impairment to self-regulate, or “put the brakes on” thoughts, emotions, and behaviors. This puts the person with ADHD at high risk for constantly intruding, interrupting and “boundary blasting” into another person’s space. This then causes a cascading effect of negative interactions, which then cause negative consequences. Over years, this script of constant negative feedback can affect the person’s self-esteem, leading to depression.

Approximately 5 to 15 percent of those with ADHD may develop more serious mental disorders, such as manic-depression or bipolar disorder. Between 10 and 20 percent may develop antisocial personality disorder by adulthood, which often results in substance abuse. Overall, approximately 10 to 25 percent develop difficulties with dependence or abuse of legal (alcohol, tobacco) or illegal substances (marijuana, cocaine, illicit use of prescription drugs, etc.), with this risk being greatest among those who had conduct disorder or delinquency as adolescents.

Despite these risks, half or more of those with ADHD do not develop these associated difficulties or disorders. However, the majority of those with ADHD certainly experienced problems with school performance, with as many as 30 to 50 percent having been retained in their school grade at least once, and 25 to 36 percent never completing high school.

As adults, those with ADHD are likely to be under-educated, relative to their intellectual ability and family educational background. They are also likely to experience difficulties with work adjustment and may be under-employed in their occupations relative to their intelligence, educational, and family backgrounds. They tend to change their jobs more often than others do, sometimes out of boredom or because of interpersonal problems in the workplace. They also tend to have a greater turnover of friendships and dating relationships and seem more prone to marital discord and even divorce. Difficulties with speeding while driving are relatively commonplace, as are more traffic citations for this behavior, and, in some cases, more motor vehicle accidents.

What do symptoms look like at different ages?
ADHD symptoms may impact teens and adults differently than they do children. ADHD symptoms in adults may be more subtle and difficult to recognize, but is estimated that 4.7% of adults are affected by ADHD.

People of different ages can show the same symptoms in different ways. In children ages 6 to 12, you may notice the child with ADHD is easily distracted, has difficulty organizing homework, makes careless errors, doesn’t complete work, is disruptive in class, blurts out answers before the question is complete, interrupts, is unwilling to complete chores, fails to wait in line, and is often out of his or her seat. Children with the inattention disorder may appear to be quiet and orderly but are daydreaming and distracted; children with the hyperactive component may be deemed “boyish” or “defiant” or “in need of more discipline.”

Adolescents with ADHD (ages 13 to 17) may display inner restlessness, difficulty initiating and completing projects, disorganization, poor follow-through, forgetfulness, poor time management, inability to work independently, and social difficulties. The hyperactive component may be lesser than in earlier ages.

Adults with ADHD may display impaired attention and focus, disorganization, failure to plan ahead, difficulty initiating and completing projects, inability to stay on task, inability to judge the amount of time it will take to complete a task, forgetfulness, and impulsiveness. They may appear “scatter-brained” and may have problems with social interactions.

If you suspect that you, your spouse, or your child may have ADHD, the most important first step is to get an accurate diagnosis. None of the information on this page is intended to be a substitute for professional help. If you want to talk in more depth about the assessment process for ADHD at NPS, please call our office at (815) 477-4727 or contact us to schedule an appointment.

 

 

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