What are examples of inattention and hyperactivity in an 18-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Examples of Inattention and Hyperactivity in an 18-Year-Old with ADHD

In an 18-year-old, inattention manifests as difficulty sustaining focus during lectures or work tasks, frequently losing essential items like keys or phones, avoiding assignments requiring sustained mental effort, and chronic disorganization of materials and time, while hyperactivity presents as internal restlessness, excessive talking, difficulty remaining seated during meetings or classes, and impulsive decision-making rather than the overt motor hyperactivity seen in younger children. 1, 2

Inattentive Symptoms in Late Adolescence

At age 18, inattentive symptoms become more prominent and problematic than in childhood, as academic and occupational demands increase. 1

Specific manifestations include:

• Poor attention to detail resulting in careless mistakes in schoolwork, job applications, or workplace tasks 3
• Difficulty sustaining attention during college lectures, lengthy reading assignments, or extended work shifts 3
• Appearing not to listen when spoken to directly by professors, employers, or peers, even without obvious distractions 1
• Failure to follow through on multi-step tasks like completing college applications, job assignments, or household responsibilities 3
• Chronic disorganization of academic materials, work documents, personal belongings, and time management 1, 3
• Active avoidance of tasks requiring sustained mental effort, such as research papers, studying for exams, or detailed work projects 1, 3
• Frequently losing necessary items including phones, wallets, keys, textbooks, or work materials 1, 3
• Easy distractibility by external stimuli or internal thoughts during conversations, classes, or work activities 3
• Forgetfulness in daily activities like keeping appointments, returning calls, paying bills, or completing chores 3

Hyperactive-Impulsive Symptoms in Late Adolescence

A critical distinction at age 18 is that overt motor hyperactivity typically declines, but internal restlessness persists and remains functionally impairing. 1 The hyperactive presentation shifts from obvious physical activity to more subtle manifestations. 4

Specific manifestations include:

• Fidgeting, tapping, or squirming during classes, meetings, or social situations where remaining still is expected 2, 3
• Difficulty remaining seated during lectures, work meetings, or meals, with frequent need to stand or move around 2, 3
• Subjective feelings of restlessness described as being "on edge" or unable to relax, even without visible hyperactivity 1
• Difficulty engaging quietly in leisure activities, with constant need for stimulation or activity 3
• Feeling "on the go" or driven by an internal motor, with inability to sit still for extended periods 3
• Excessive talking in social situations, dominating conversations, or interrupting group discussions 3
• Blurting out answers before questions are completed in academic or work settings 3
• Inability to wait turn in conversations, lines, or group activities 3
• Intrusive behavior such as interrupting others' conversations or activities without awareness 3
• Impulsive decision-making including risky sexual behaviors, substance experimentation, reckless driving, or impulsive spending 4

Critical Diagnostic Context for Age 18

To meet diagnostic criteria at age 18, symptoms must have been present before age 12, though the individual may not have been previously diagnosed. 4, 1, 3 This requires obtaining collateral history from parents or reviewing school records to document childhood manifestations. 4

Important considerations at this age include:

• Adolescents often have poor insight into their symptoms and may underestimate their severity and resulting impairments 4
• Functional impairment must be documented in at least two settings (e.g., college/work and home, or academic and social environments) 1, 3
• Substance use must be ruled out as marijuana and other substances can mimic ADHD symptoms in this age group 4
• Comorbid conditions are common, including anxiety, depression, substance use disorders, and risky behaviors, which may overshadow or complicate the ADHD presentation 4, 1
• Trauma, toxic stress, and mood disorders must be systematically excluded as alternative explanations for attention and impulse control problems 4

Common Pitfalls in Identifying Symptoms at Age 18

The most critical error is failing to obtain information from multiple observers across different settings. 4, 1 At age 18, individuals may be living independently or have limited parental observation, making collateral information from roommates, partners, employers, or professors essential. 4

Additional pitfalls include:

• Relying solely on self-report when the patient may lack insight or may be seeking stimulant medication for performance enhancement rather than legitimate symptoms 4
• Missing the predominantly inattentive subtype, which is more common in females and lacks obvious hyperactive behaviors 5
• Failing to verify symptom onset before age 12, which is required for diagnosis even when evaluation occurs in late adolescence 4, 1, 3
• Not screening for substance use with detailed history and consideration of urine drug screening 4