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1. Motor symptoms of ADHD


1. Motor symptoms of ADHD

Hyperactivity is a common symptom of ADHD, but not all people with ADHD are hyperactive. In children, hyperactivity is manifested by constant fidgeting, standing up or running around. In adults, hyperactivity decreases, but restlessness of movement and certain behaviors such as finger drumming, foot tapping or nail biting may still occur. Motor hyperactivity may decrease over time, while inner restlessness remains or becomes more visible. It is debated whether inner restlessness is a separate symptom and whether it is related to drive problems.

Hyperactivity and inner restlessness are also symptoms of stress. Stress hormones such as CRH can cause restlessness of movement. Gross motor problems such as clumsiness and coordination problems are common in ADHD-HI and ADHD-C. Fine motor problems such as poor handwriting and difficulties with fine motor tasks can also occur. It is unclear whether fine motor problems can be improved by ADHD medication.

The data from the symptom test showed that motor hyperactivity decreased with age, while restlessness and attention problems persisted.

While it has been recognized that attention problems in ADHD are primarily a motivational problem (lack of self-motivability), as intrinsically interesting topics can arouse attention while intrinsically non-interesting topics cause attention problems, it is largely unknown that this also applies to motor restlessness. A Time-lapse video showing a person with ADHD watching an intrinsically interesting and an intrinsically uninteresting videoillustrates that hyperactivity problems are also caused by motivational factors.

1.1. Hyperactivity

Motor hyperactivity is a very common symptom of ADHD. However, hyperactivity is not a mandatory symptom of ADHD. There are people with ADHD who suffer greatly from their symptoms, who were/are neither hypermotoric as children nor full of inner restlessness as adults.

1.1.1. Motor hyperactivity as an ADHD symptom

Motor hyperactivity is a characteristic of ADHD-HI and ADHD-C. Hyperactivity is less pronounced in the ADHD-I subtype (predominant attention problems).1
Hyperactivity often subsides in adolescence. The specialist literature describes that hyperactivity in adults usually turns into a form of inner restlessness. This will need to be discussed.

The fidgeting and constant movement could be understood as an internal correction of vigilance (internal basic tension) and low dopamine levels. Movement increases the dopamine level.23 People with ADHD who are forced to sit still are (even) more likely to give incorrect answers than when they are allowed to move.2 Similarly, sports before school (to act out motor restlessness) increases learning success.2

1.1.2. Manifestations of motor hyperactivity

  • for small children:
    • Extended childish defiant phase
    • Possibly with excessive, veritable, real tantrums
  • for children:
    • Constant fidgeting with hands and feet or sliding around on the chair (DSM IV/5)
    • Is often present in class and other situations where sitting is expected (DSM IV/5)
    • Frequently runs around or climbs excessively in situations where this is inappropriate (in adolescents or adults this may be limited to a subjective feeling of restlessness) (DSM IV/5)
    • Often has difficulty playing quietly or engaging quietly in leisure activities (DSM IV/5)
    • Is often “on the move” or often acts as if he/she is “driven” (DSM IV/5)
    • Often talks excessively (DSM IV/5; categorized as impulsivity in ICD-10). Speech diarrhea can also be observed in some adults
  • for adults:
    • Hyperactivity (external/physical) decreases by up to 60 % in adults4
    • Physical restlessness in adults, possibly only to a lesser extent
      • Foot tapping with high frequency (or impulse to do so, which is deliberately suppressed)5
      • Finger drumming (or impulse to do so, which is consciously suppressed)5
      • Chew nails6
      • Biting lips
      • Knot legs / wrap around chair leg to limit movement6

1.1.3. Age-related decline in motor hyperactivity

The data from the symptom test show the following changes in the age groups:

Age group Motor hyperactivity Inner restlessness Attention problems
5- 9 years (n = 9) 0.70 0.80 0.75
10 - 14 years (n = 15) 0.72 0.68 0.83
15 - 19 years (n = 48) 0.45 0.62 0.81
20 - 29 years (n = 373) 0.49 0.70 0.81
30 - 39 years (n = 492) 0.49 0.74 0.83
40 - 49 years (n = 301) 0.46 0.74 0.78
50 - 59 years (n = 158) 0.46 0.72 0.80
60 - 75 years (n = 32) 0.42 0.74 0.72
Men (n = 630) 0.52 0.73 0.81
Women (n = 823) 0.45 0.72 0.80

As at June 2020. The values given reflect the severity of the symptoms relative to each other.
Limitations of informative value:

  • There are few data sets with test persons under 20 years of age and far too few data sets with test persons under 10 years of age for a reliable statement.
  • There was no separation of ADHD-I and ADHD-HI, so the (random) ratio of ADHD-I to ADHD-HI may skew the data for small group sizes.
  • Only the data sets in which the symptom test found indications of existing ADHD were evaluated.
  • This is a non-validated online self-test (screening).

The data can be discussed in relation to the thesis that attention problems in children up to the age of 15 are not yet fully developed and that motor hyperactivity diminishes in adulthood. However, they indicate that hyperactivity does not transform into inner restlessness, but that inner restlessness also exists in children and merely recedes to a lesser extent than hyperactivity. After the regression of motor hyperactivity, inner restlessness merely appears to become more visible.

Inner restlessness could be described as the “little brother” of hyperactivity.

Inner restlessness as an independent symptom alongside hyperactivity?

An interesting consideration is whether the fact that, according to the data, inner restlessness may already exist in children due to the fact that, unlike hyperactivity, it does not appear to recede or recede only slightly, could indicate that inner restlessness could be a symptom to be distinguished from Inner restlessness / Inner drivenness
In terms of the original (possible) benefit of stress symptoms (originally = before humans became sedentary), it could have been helpful if children developed an increased willingness to move in a dangerous situation so that they could escape better together with the group in dangerous situations. Adults benefit less from hyperactivity because they are the ones who have to fight the stressors. In the fight against stressors, an increased urge to move is no longer as important as in children (who can contribute little to the fight against stressors); instead, the focus is on doing everything possible to fight the stressor and not resting until the danger has been overcome.

A parallel to this is that attention problems in adults can also decrease significantly or even remit completely (albeit less frequently or to a lesser extent than hyperactivity and impulsivity),7 without a change to a different symptom pattern being described for the latter. However, our data show at best only a very slight decrease in attention problems in adults.

It is doubtful whether Inner restlessness / Inner drivenness could possibly fit under the heading “drive problems” and represent the counterpart to lack of drive, just as distractibility (switching the focus of attention too easily) and task switching problems / hyperfocus (making it difficult to switch the focus of attention) form counterparts within the umbrella term “attention problems”. This is contradicted by the fact that lack of drive correlates strongly with ADHD-I and less with ADHD-HI, while distractibility and task switching problems correlate equally with ADHD-HI and ADHD-I.

1.1.4. Hyperactivity as a stress symptom

Hyperactivity and fidgeting are known to be typical symptoms of severe stress, as is the fact that thoughts concentrate on the stressor (circling thoughts, rumination).
Stress symptoms from the hyperactivity spectrum are:

  • Restlessness89
    Inner restlessness is a typical symptom of the approaching final state of burnout.10
  • Restlessness1112
  • Restlessness of movement13

The stress hormone CRH, which is released by the hypothalamus in the first increment of the HPA axis, directly mediates an urge to move. Increased locomotor activity is a direct effect of the stress hormone CRH.141516139

Symptoms that are directly mediated by stress hormones themselves can nevertheless also be ADHD-specific symptoms. Chronic stress such as ADHD mediate their symptoms through a lack of dopamine and noradrenaline in the brain.

1.2. Gross motor problems with ADHD

Gross motor skill problems are a symptom of ADHD.17181920 They are already present in young children and correlate with sleep problems in children. More than half of people with ADHD are said to have gross and fine motor problems.212223
Gross motor and fine motor disorders should be considered separately from motor hyperactivity.

Forms of appearance:

  • Clumsiness
    • Frequent bumping/sticking
  • Many accidents (clumsiness meets hectic pace)
    • Frequent injuries (esp. ADHD-HI)
    • Bruises
  • Coordination problems (dyscoordination)
    • E.g. learning to ride a bike at the age of 6
    • E.g. difficulty maintaining balance or standing on one leg24
  • Difficulties with force dosage

Initial data from the online symptom test (as of October 2018) suggests that gross motor problems are far more common in ADHD-HI with hyperactivity than in the ADHD-I subtype. Studies prove the connection between gross motor problems and hyperactivity/impulsivity.25

It is possible that motor problems in the form of deficits in interpersonal (automatic) (motor) synchronization contribute to the development of social problems. Interpersonal synchronization requires good motor control and is also important in the development of mother-child relationships26
Interpersonal synchronization plays an important role in the acquisition of social cognitive skills in development.2728 In ADHD, the extent of interpersonal synchronization between mother and child correlates with the level of functioning of preschool children with ADHD.29
Another hypothesis assumes a connection between impaired eye control (gaze control and gaze saccades (eye movements)) and ADHD symptoms such as attention problems and impulsivity.30

1.3. Fine motor problems with ADHD

Fine motor problems are a symptom of ADHD.193132 More than half of people with ADHD are said to have gross and fine motor problems.23
Fine motor and gross motor disorders should be considered separately from motor hyperactivity.

Forms of appearance:

  • Handwriting problems33
    • Scrawly handwriting34
    • Disproportionately increasing with dictation under time pressure35
  • Children find it difficult to color pictures neatly35
  • Precision mechanics are difficult (e.g. smooth cuts with scissors, inserting small screws)

Fine motor problems should

  • be more common with ADHD-I23
  • be about equally common in ADHD-HI and ADHD-I36

According to a review, between 28% and 67% of people with ADHD also show improvements in their fine motor skills as a result of ADHD medication.23 Our impression is that this is rather rarer.

  1. Diamond (2005): Attention-deficit disorder (attention-deficit/hyperactivity disorder without hyperactivity): A neurobiologically and behaviorally distinct disorder from attention-deficit (with hyperactivity), Development and Psychopathology 17 (2005), 807–825, S. 819

  2. Studie des MIND Institute der Universität California, zitiert nach Winkler in


  4. Barkley, Benton (2010): Das große Handbuch für Erwachsene mit ADHS

  5. Krause, Krause (2014): ADHS im Erwachsenenalter, S. 61

  6. Krause, Krause (2014): ADHS im Erwachsenenalter, S. 61

  7. Mick, Faraone, Biederman (2004): Age-dependent expression of attention-deficit/hyperactivity disorder symptoms, Psychiatr Clin N Am 27 (2004) 215–224

  8. Dr. Rolf Merkle, Diplom-Psychologe: Stress – was versteht man darunter?

  9. Gruber: Fragebögen zur Stressdiagnostik; Fragebogen 1: Streß-Folgen

  10. Prof. Dr. med. Volker Faust: Erschöpfungsdepression; Seelische Störungen erkennen, verstehen, verhindern, behandeln; PSYCHIATRIE HEUTE; Arbeitsgemeinschaft Psychosoziale Gesundheit

  11. Merkle (2013): Stress – was versteht man darunter?

  12. Hebold (2004): Stress und Stressverarbeitung bei Kindern und Jugendlichen, in: Schluchter, Tönjes, Elkins (Hrsg.), Menschenskinder! Zur Lage von Kindern in unserer Gesellschaft. Band zur Vortragsreihe des Humanökologischen Zentrums der BTU Cottbus, Seite 86

  13. Edel, Vollmöller (2006): ADHS bei Erwachsenen, Seite 113

  14. Rensing, Koch, Rippe, Rippe (2006): Mensch im Stress; Psyche, Körper Moleküle, Seite 96, Seite 151

  15. Egle, Joraschky, Lampe, Seiffge-Krenke, Cierpka (2016): Sexueller Missbrauch, Misshandlung, Vernachlässigung – Erkennung, Therapie und Prävention der Folgen früher Stresserfahrungen; 4. Aufl., S. 45

  16. Arborelius, Owens, Plotsky, Nemeroff (1999): The role of corticotropin-releasing factor in depression and anxiety disorders. J Endocrinol 1999; 160: 1–12, Seite 5 zitiert nach Egle, Joraschky, Lampe, Seiffge-Krenke, Cierpka (2016): Sexueller Missbrauch, Misshandlung, Vernachlässigung – Erkennung, Therapie und Prävention der Folgen früher Stresserfahrungen; 4. Aufl. S. 46

  17. Carte ET, Nigg JT, Hinshaw SP. (1996):Neuropsychological functioning, motor speed, and language processing in boys with and without ADHD. J Abnorm Child Psychol. 1996 Aug;24(4):481-98. doi: 10.1007/BF01441570. PMID: 8886944.

  18. Harvey WJ, Reid G, Bloom GA, Staples K, Grizenko N, Mbekou V, Ter-Stepanian M, Joober R (2009): Physical activity experiences of boys with and without ADHD. Adapt Phys Activ Q. 2009 Apr;26(2):131-50. doi: 10.1123/apaq.26.2.131. PMID: 19478346.

  19. Scharoun SM, Bryden PJ, Otipkova Z, Musalek M, Lejcarova A (2013): Motor skills in Czech children with attention-deficit/hyperactivity disorder and their neurotypical counterparts. Res Dev Disabil. 2013 Nov;34(11):4142-53. doi: 10.1016/j.ridd.2013.08.011. PMID: 24060728.

  20. Brossard-Racine M, Shevell M, Snider L, Bélanger SA, Majnemer A (2012): Motor skills of children newly diagnosed with Attention Deficit Hyperactivity Disorder prior to and following treatment with stimulant medication. Res Dev Disabil. 2012 Nov-Dec;33(6):2080-7. doi: 10.1016/j.ridd.2012.06.003. PMID: 22796639.

  21. Sweeney KL, Ryan M, Schneider H, Ferenc L, Denckla MB, Mahone EM (2018): Developmental Trajectory of Motor Deficits in Preschool Children with ADHD. Dev Neuropsychol. 2018;43(5):419-429. doi: 10.1080/87565641.2018.1466888. PMID: 29757012; PMCID: PMC5991607.

  22. Papadopoulos N, Stavropoulos V, McGinley J, Bellgrove M, Tonge B, Murphy A, Cornish K, Rinehart N (2019): Moderating Effect of Motor Proficiency on the Relationship Between ADHD Symptoms and Sleep Problems in Children With Attention Deficit Hyperactivity Disorder-Combined Type. Behav Sleep Med. 2019 Sep-Oct;17(5):646-656. doi: 10.1080/15402002.2018.1443455. PMID: 29528702.

  23. Kaiser ML, Schoemaker MM, Albaret JM, Geuze RH. What is the evidence of impaired motor skills and motor control among children with attention deficit hyperactivity disorder (ADHD)? Systematic review of the literature. Res Dev Disabil. 2015 Jan;36C:338-357. doi: 10.1016/j.ridd.2014.09.023. PMID: 25462494. REVIEW

  24. Cook, Kelshaw, Caswell, Iverson (2019): Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment. J Pediatr. 2019 Aug 30. pii: S0022-3476(19)30956-4. doi: 10.1016/j.jpeds.2019.07.048.

  25. Jansen, Philipsen, Dalin, Wiesmeier, Maurer (2018): Postural instability in adult ADHD – A pilot study. Gait Posture. 2018 Oct 17;67:284-289. doia: 10.1016/j.gaitpost.2018.10.016.

  26. Gvirts Probolovski HZ, Dahan A (2021): The Potential Role of Dopamine in Mediating Motor Function and Interpersonal Synchrony. Biomedicines. 2021 Apr 5;9(4):382. doi: 10.3390/biomedicines9040382. PMID: 33916451; PMCID: PMC8066519. REVIEW

  27. Feldman R (2015): Sensitive periods in human social development: New insights from research on oxytocin, synchrony, and high-risk parenting. Dev Psychopathol. 2015 May;27(2):369-95. doi: 10.1017/S0954579415000048. PMID: 25997760. REVIEW

  28. Feldman R (2007): Parent-infant synchrony and the construction of shared timing; physiological precursors, developmental outcomes, and risk conditions. J Child Psychol Psychiatry. 2007 Mar-Apr;48(3-4):329-54. doi: 10.1111/j.1469-7610.2006.01701.x. PMID: 17355401. REVIEW

  29. Healey DM, Gopin CB, Grossman BR, Campbell SB, Halperin JM (2010): Mother-child dyadic synchrony is associated with better functioning in hyperactive/inattentive preschool children. J Child Psychol Psychiatry. 2010 Sep;51(9):1058-66. doi: 10.1111/j.1469-7610.2010.02220.x. PMID: 20331491.

  30. Valtr L, Psotta R, Dostál D (2023): Effects of the Specific Eye Fixation Training on Fine Visuomotor Coordination in Children with Attention Deficit Hyperactivity Disorder. Children (Basel). 2023 Oct 3;10(10):1648. doi: 10.3390/children10101648. PMID: 37892311; PMCID: PMC10605083.

  31. Fenollar-Cortés J, Gallego-Martínez A, Fuentes LJ (2017): The role of inattention and hyperactivity/impulsivity in the fine motor coordination in children with ADHD. Res Dev Disabil. 2017 Oct;69:77-84. doi: 10.1016/j.ridd.2017.08.003. PMID: 28829996.

  32. Çak HT, Karaokur R, Atasavun Uysal S, Artık A, Yıldız Kabak V, Karakök B, Şahan N, Karaer Y, Karabucak B, Özusta Ş, Çengel Kültür E (2018): Dikkat Eksikliği Hiperaktivite Bozukluğu Olan Çocuklarda Motor Yeterlilik: Bilişsel Beceriler ve Belirti Şiddeti ile İlişkisi [Motor Proficiency in Children with Attention Deficit Hyperactivity Disorder: Associations with Cognitive Skills and Symptom Severity]. Turk Psikiyatri Derg. 2018 Summer;29(2):92-101. Turkish. PMID: 30215837.

  33. Puyjarinet F, Chaix Y (2023): Biotteau M. Is There a Deficit in Product and Process of Handwriting in Children with Attention Deficit Hyperactivity Disorder? A Systematic Review and Recommendations for Future Research. Children (Basel). 2023 Dec 27;11(1):31. doi: 10.3390/children11010031. PMID: 38255345; PMCID: PMC10813961. METASTUDY

  34. Mokobane M, Pillay BJ, Meyer A (2019): Fine motor deficits and attention deficit hyperactivity disorder in primary school children. S Afr J Psychiatr. 2019 Jan 22;25:1232. doi: 10.4102/sajpsychiatry.v25i0.1232. PMID: 30899581; PMCID: PMC6424539.

  35. Krause, Krause (2014): ADHS im Erwachsenenalter, S. 85

  36. Mokobane, Pillay, Meyer (2019): Fine motor deficits and attention deficit hyperactivity disorder in primary school children. S Afr J Psychiatr. 2019 Jan 22;25:1232. doi: 10.4102/sajpsychiatry.v25i0.1232. eCollection 2019.

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