Symptom development in children by age and frequency

• 1. Symptom development of ADHD-HI (with hyperactivity) by age
  • 1.1. Infancy
  • 1.2. Toddler age (1 - 3 years)
  • 1.3. Preschool age (4 - 6 years)
    • 1.3.1. ADHD-I in preschool age (without hyperactivity)
    • 1.3.2. AHDS in preschool age (with hyperactivity)
  • 1.4. School time (6 to 15 years)
    • 1.4.1. ADHD-I at school age (without hyperactivity)
    • 1.4.2. ADHD-HI in school age (with hyperactivity)
  • 1.5. Adolescence (from 15 years)
  • 1.6. Adulthood
• 2. Symptom frequency and symptom intensity in ADHD
• 3. Ethnic and cultural differences

1. Symptom development of ADHD-HI (with hyperactivity) by age¶

1.1. Infancy¶

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 behavioral and temperament problems).¹

• Restlessness, hypermotor activity
  • About 60% of the children show extreme restlessness²
  • Continuous urge to move²
  • Inexhaustible energy³
  • Crawling eliminated, early walking⁴
  • Restless, unbalanced⁴
  • Game endurance shortened⁴
  • Difficulty in establishing even a calm waking state³
• Sleep
  • Unstable waking and sleeping rhythm²
  • Superficial sleep, wide awake⁴
  • Short sleeper³
  • Regulatory problems (excessive crying, sleep or feeding problems) that occurred in parallel (multiple) or persistent (persistent) at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020), and overall behavior 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.⁵
• Crying, screaming
  • Particularly frequent persistent and shrill screaming²³
  • Unquenchable crying at times⁴
  • Regulatory problems (excessive crying, sleep or feeding problems) that occurred in parallel (multiple) or persistent (persistent) at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020), and overall behavioral 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.⁵
• Feeding problems
  • Drinking problems⁴³
  • Heathy eater³
  • Frequent colics³
  • Regulatory problems (excessive crying, sleep or feeding problems) that occurred in parallel (multiple) or persistent (persistent) at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020), and overall behavioral 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.⁵
• Cleanliness education often delayed²
• Language development often delayed²
• Stroking is not enjoyed⁴
• Often skin allergies⁴
• Higher levels of negative affect (as early as 3 months of age)⁶
  • The results for positive affect did not reach statistical significance
  • Simultaneous observation of the courses of positive and negative emotionality can generate additional information
  • Negative affect correlated with ADHD symptoms in childhood only when moderate, stable, or low positive affect was present at the same time

1.2. Toddler age (1 - 3 years)¶

• Distractibility³
• Chaotic and destructive, little goal-oriented play behavior²
• Sleep problems
  • Sleep-through problems in toddlers 1 to 3 years of age were a stronger predictor of later ADHD than sleep duration.⁷
  • Sleep disorders³
  • Regulatory problems (excessive crying, sleep or feeding problems) that occurred in parallel (multiple) or persistent (persistent) at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020), and overall behavior 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.⁵
• Gross motor problems
  • Often falls over its own legs⁸
  • Mouth motor activity conspicuous⁸
    • Mouth is often open
    • Drools easily
  • Desire for violent movements³
  • Constantly on the move³
  • Motor sometimes very skillful³
• Game endurance shortens⁸
  • Often changes employment
  • Does not finish game
• Learning problems
  • No learning gain from negative experiences²
  • Learns hard to dress⁸
  • Language development delayed⁸⁹
  • Conversion problems⁸
  • Adaptation problems⁸
• Can’t wait⁸
  • Until the turn
• Sensitivity changes
  • Highly sensitive or hyposensitive to external stimuli⁸
• Novelty Seeking
  • Stimulation hunger³
  • Enormously curious³
  • Daring, increased risk of accidents³
• ADHD-HI-specific:
  • Group incompetence and disruptive behavior, outsider role²
  • Constant fidgeting and talking in between in the chair circle²
  • Strong urge to move leads to danger to self and others²
  • No awareness of danger²
  • Impulsivity
    • Impulsivity at age 2 correlated with ADHD symptoms at age 3.¹⁰
  • Emotional dysregulation
    • Aggression
      • Increased aggression²
      • Little tyrant³
      • Destruction of games and toys³
    • Anger
      • Frequent / uncontrollable tantrums²³
    • Affect spasms³
    • Affect labile, mostly pronounced defiant phase³
• ADHD-I specific:
  • Remarkably calm and well-behaved⁸
  • Overprotective, clingy, very affectionate⁸
• One metastudy found predictive power by symptoms in the first 36 months on later childhood ADHD:¹¹
  • Activity level (k = 18) in infancy and toddlerhood moderately correlated 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 in preschool age (without hyperactivity)¶

• Often anxious⁸
• Often unsafe⁸
• Learning Difficulties
  • Problems listening⁸
  • Slow comprehension⁸
  • Often believes task cannot be accomplished⁸
  • Slow language acquisition, confuses letters⁸
• Gross motor skills
  • Conspicuous mouth motor activity⁸
  • Speaks indistinctly⁸
  • Does not like to paint and tinker⁸
  • Motor problems⁸
  • Difficulty learning to swim⁸
  • Difficulty learning to ride a bike
  • Balance problems
  • Activities slowed down or over-fast⁸
• Withdrawn social behavior
  • Often plays alone⁸
  • Little contact with children of the same age⁸
  • Withdrawal tendencies in groups⁸
    • Kindergarten
    • Chair circle
  • Gets bored quickly⁸
• Often loses and forgets things⁸
• Regulatory problems (excessive crying, sleep or feeding problems) that occurred in parallel (multiple) or persistent (persistent) at 5, 20 or 56 months of age predicted increased internalizing (p = .001), externalizing (p = .020), and overall behavioral 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.⁵

1.3.2. AHDS in preschool age (with hyperactivity)¶

• Motor hyperactivity
  • Agitation⁸
  • Always on the move⁸
• Impulsivity
  • Gets excited quickly and strongly⁸
  • Reacts spontaneously and rashly⁸
  • Asks a lot⁸
    • Often does not wait for answers⁸
  • Does not follow rules⁸
    • Often forgets rules again¹²
  • Grumbles quickly⁸
• Attention problems
  • Often only become apparent at a later age (school years)
  • Can not listen for long⁸
  • Forgets quickly⁸
  • Loses a lot⁸
• Aggression
  • Often as a comorbidity
  • Especially with uncertainty⁸
• Gross motor skills
  • Conspicuous mouth motor activity¹³
  • Language problems
    • Speaks indistinctly⁸
    • Stammer⁸
    • Difficulties with some consonants
  • Does not like to paint and tinker¹³
  • Holds pens cramped⁸
  • Presses too hard⁸
  • Coloring or cutting out shapes more difficult⁸
  • Difficulty learning to swim
  • Difficulties in learning to ride a bike
  • Balance problems
• Social behavior
  • Strong sense of justice⁸
  • High ambition in sports and games⁸
  • Often wants to determine⁸
  • Eager at social services⁸
  • Quickly offended¹⁴
    • Rejection Sensitivity
• Impatience
  • With itself⁸
  • With others⁸
• Wets more often still a⁸
  • More often during the day than at night
• Sleep
  • Often fall asleep late⁸
  • Needs little sleep⁸

1.4. School time (6 to 15 years)¶

ADHD symptoms are now fully apparent.²

1.4.1. ADHD-I at school age (without hyperactivity)¶

• Emotional problems
  • Often anxious⁸
  • Often unsafe⁸
  • Does not dare to do anything⁸
  • Rejection Sensitivity
    • Easily offended⁸
    • Cries quickly⁸
    • Emotionally sensitive⁸
    • Takes criticism badly⁸
    • Feels unloved⁸
    • Feels misunderstood⁸
• Attention and learning difficulties
  • Problems listening⁸
  • Easily distractible⁸
  • Forgets a lot⁸
  • Overheard much⁸
  • Unfocused⁸
    • Unless something is of particular interest
  • Dreamy⁸
  • Slow⁸
  • Inflexible thinking⁸
  • Takes a very long time to do homework⁸
  • Can not do homework alone⁸
• Gross and fine motor problems
  • Writing problems
  • Messy coloring⁸
  • Speaks indistinctly⁸
• Social behavior
  • Is easily annoyed⁸
  • Can resist badly⁸
  • Delayed development of social maturity⁸
  • Gets bored quickly⁸
• Often loses and forgets things
• Somatization tendencies
  • Frequent headaches⁸
  • Frequent abdominal pain⁸

1.4.2. ADHD-HI in school age (with hyperactivity)¶

• Social behavior
  • Fitting in with the rest of the class very difficult²
• Aggression
  • Hits frequently, is often hit by others²
• Risk Behavior
  • Can assess dangers poorly⁸
  • 85 % of accidents on the way to school²
• Attention problems become apparent for the first time
  • Earliest at the age of 7 years
  • Until the age of 14, 15 years
• Motor hyperactivity
  • Agitation⁸
  • Always on the move⁸
  • Fidgets a lot⁸
• Gross motor skills
  • Poor force dosage⁸
• Impulsivity
  • Gets excited quickly and strongly⁸
  • Reacts spontaneously and rashly⁸
  • Interrupts others
  • Answers before question is finished⁸
  • Is often loud⁸
• High sensitivity
  • Is often sensitive to noise itself¹²
• Attention problems
  • Often only become apparent at a later age (school years)
  • Can not listen for long⁸
  • Forgets quickly⁸
  • Loses a lot⁸
  • Concentration span limited
    • Frequently switches back and forth between tasks / activities⁸
  • Often paints on the side
  • Difficulty starting homework⁸
  • Frequently interrupts homework⁸
  • Good observation skills⁸
    • Notices many things⁸
    • Can see through others well⁸
• Learning problems
  • Makes mistakes again and again
  • Does not learn from mistakes⁸
• Gross motor skills
  • Conspicuous mouth motor activity¹³
  • Language problems
    • Speaks indistinctly⁸
    • Stammer⁸
    • Difficulties with some consonants
  • Does not like to paint and tinker¹³
  • Holds pens cramped⁸
  • Presses too hard on⁸
  • Coloring or cutting out shapes more difficult⁸
  • Difficulty learning to swim
  • Difficulties in learning to ride a bike
  • Balance problems
• Emotional dysregulation
  • Rejection Sensitivity
    • Feels quickly treated unfairly⁸
• Social behavior
  • Strong sense of justice⁸
    • Altruistic behavior
  • Often wants to determine⁸
  • Gets along worse with peers than with younger or older people⁸
• Collects useless things⁸
• Sleep
  • Often fall asleep late

1.5. Adolescence (from 15 years)¶

• Motor hyperactivity decreases²
• Inner and outer restlessness⁸
• Impulsivity and decreased attention remain²
• Orientation towards marginalized social groups²
• Risk of developing a propensity for addiction²
• Willingness to engage in high-risk behavior²
• Frequent accidents²
• Performance drop under stress⁸
• Organization problems⁸
• Low determination⁸
• Crackled handwriting⁸

1.6. Adulthood¶

• Hardly any motor hyperactivity, instead inner restlessness, being driven¹⁵
• Attention problems subside somewhat
• Emotional problems / affective comorbidities increase
  • Depression
  • Anxiety disorders
• Increased risk of addiction, disorders in social behavior¹⁶
• Anxiety symptoms, alcohol problems¹⁷
• Criminal history ¹⁸
• Increased accident proneness¹⁹
• Worse professional position²⁰

2. Symptom frequency and symptom intensity in ADHD¶

The diagnosis of ADHD is not made by having a specific type of symptom that is exclusive to ADHD (categorical), but by the set of symptoms that may originate from ADHD and their intensity (dimensional).²¹²²

• In a collection of symptoms presented by Barkley²³
  • Non-affected persons on average 1 to 2 of the 18 symptoms often, i.e. about 5 %
  • ADHD sufferers often have an average of 12 of the 18 symptoms listed, or about 66%.²³
• In the online test designed by ourselves ⇒ ADHD online tests
  have
  • Subjects not affected according to their own assessment, on average 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 affected person has all symptoms “often”, and it is hardly typifiable which symptoms occur together in clusters.

The symptoms must occur over a long period of time and in several areas of life. In most cases, they first become apparent before the age of 12. However, more and more cases of late onset ADHD are being recognized, where symptoms were not severe enough in adolescence to warrant a diagnosis. This mainly affects women in their late 30s and older.
The fact that symptoms must persist for a longer period of time and in different areas of life serves to distinguish ADHD as a permanent disorder from symptoms of merely temporary (stress) exposure to stressors that exist for a limited period of time.

3. Ethnic and cultural differences¶

When adults diagnose ADHD in children, the different ethnic and cultural backgrounds should be taken into account.²⁴