Hyperactivity in Adults: Inner Restlessness in ADHD

"As a child I couldn't stay in one place, but it has passed now."

This sentence is often heard in ADHD assessments. And most of the time it is not quite true. Running, climbing, getting under the table may have passed; the need to move itself usually does not go anywhere, it is drawn inward.

I was never the running child anyway, so for a long time I did not think this heading belonged to me. When I heard the word hyperactivity, I always pictured someone who turned the classroom upside down. Yet I had never asked why I was so tired at the end of a long meeting, or why I could not keep still, without fidgeting, in a quiet room.

This article is about that movement drawn inward: inner restlessness.

What happens to hyperactivity with age

Follow-up studies show that ADHD symptoms tend, in general, to decrease with age. But how much they decrease depends heavily on how "decrease" is defined.

The meta-analysis by Faraone, Biederman and Mick (2006), which combined follow-up studies, shows this clearly: counting only those who meet the full diagnostic criteria, the proportion whose picture persists at age 25 is about 15 percent. When those in partial remission are counted too, that is, those who still meet some of the criteria and are still struggling, the proportion rises to about 65 percent.

A more recent long-term follow-up study adds another detail: in most people the course of ADHD does not follow a straight line but fluctuates in periods (Sibley et al., 2022). Years that go well and years in which symptoms return can follow one another.

The part of hyperactivity that decreases is mostly outward movement. The part that stays inside takes other forms within adult life.

What it looks like in adults

In adulthood, hyperactivity is most often noticed in these forms:

• Fidgeting. Jiggling a foot, tapping fingers on the desk, playing with a pen, constantly changing position in a chair.
• Difficulty sitting for long. A meeting, a flight, the cinema, a long meal. After the first half hour, the body saying "get up."
• A constant need to be busy. Sitting idle feels uncomfortable. Looking at the phone while watching television, doing another job at the same time.
• Talking fast and a lot. Interrupting, answering without waiting for the end of the sentence.
• Thoughts in the head that do not stop. A mind that makes falling asleep harder, jumping from one subject to another.
• Being unable to rest. Making plans even on vacation, tensing up when you are supposed to "do nothing."
• Gravitating toward active jobs or hobbies. While desk work feels unbearable, working in the field, on your feet or in changing environments feels easier.

The European consensus statement stresses that in adults hyperactivity is most often experienced as a subjective inner restlessness and that this needs to be asked about in assessment (Kooij et al., 2019).

Someone who looks calm on the outside may be carrying an engine inside all the time.

What inner restlessness is like

Inner restlessness is a hard feeling to describe, because it is not tied to a visible behavior. What adults describe usually comes together in sentences like these:

• "Something inside me is working all the time."
• "I can sit, but I spend effort to sit."
• "I need to do something even in order to relax."
• "In silence the sound of my head gets louder."

Mine appears most in the evenings and in moments when I have nothing to do. The moment I finish a task, instead of resting, I look for the next one. For a long time I took this to be diligence; now I see it like this: resting does not come to me on its own, it is a skill that has to be learned.

This feeling can be confused with anxiety. The difference is often this: in anxiety the restlessness has a subject, a worry. In the inner restlessness of ADHD there is no particular subject; the body and mind seem to want to move on to the next thing all the time.

The two can also be present together. I covered this distinction separately in the article ADHD and anxiety.

Why it looks calm

Most adults learn to suppress movement through the warnings they have heard since childhood. Crossing the legs so as not to jiggle the foot in a meeting, taking notes to keep the hand busy, going to fill a glass of water instead of getting up.

This suppression often works but it is not free. The effort spent on holding movement back steals from attention and energy. Part of the extreme fatigue felt at the end of a long meeting comes from here.

For me the clearest sign of this was that I came out of a one-hour meeting more tired than from a difficult piece of work done in the same time. There was nothing in the content; the tiredness came from sitting.

This is also a kind of masking.

Arrangements that work in daily life

Instead of suppressing the need to move completely, making a controlled place for it generally gives better results.

Build movement into the work. Taking phone calls while walking, using a desk you can work at standing, choosing for reading a way of sitting that allows movement rather than a fixed chair.

Use quiet fidget tools. A small object held in the hand, a stress ball, a silent fidget tool. These tools, rather than distracting attention, channel excess movement energy into a quiet outlet. It is under the heading fidget tool in the glossary.

Break up long periods of sitting. Putting short breaks to stand up between meetings or work blocks. It is also possible to ask for this at work as an accommodation; the details are in the article ADHD at work.

Regular physical movement. A positive effect of exercise on ADHD symptoms has been reported, and it is one of the most natural outlets for inner restlessness. The framework is in the article ADHD and movement.

Set aside an unloading time for the evening. The movement in the head increases most when you lie down. Writing it out before sleep or a short walk can help slow the mind.

Moving is not inattention. Taking notes in a meeting, standing, or holding something in the hand is, for some people, a condition of listening. Forbidding movement most often does not increase attention; it makes the energy go into suppressing the movement.

What is asked in an assessment

In an adult assessment, the clinician is usually curious less about the movement itself than about the following:

• What did restlessness look like in childhood?
• How hard is it to sit for a long time?
• Is there a feeling of restlessness inside, and when does it increase?
• What is done to suppress movement?
• How does this affect work, relationships or sleep?

Studies in community samples show that adult ADHD is more common than assumed and often continues without being diagnosed (Kessler et al., 2006). The assumption that restlessness "passes" with age is one of the reasons for this being missed.

What recognizing this changes

In adulthood hyperactivity most often does not vanish, it turns inward. The running child becomes an adult who jiggles a foot, has difficulty sitting and carries an engine in the head.

Recognizing this does two things. First, it makes clear what to look at in assessment: not "can't I stay in one place" but "what does sitting cost me."

Second, it makes it possible, instead of fighting the need to move, to make a controlled place for it. For years I tried to suppress this energy, and every hour I suppressed it came out somewhere else: being unable to sleep at night, constantly starting a new job, doing something without ever stopping. Now I give it a place. I talk while walking, I break up long meetings, in the evening I put what is in my head into writing.

I still cannot sit comfortably in a quiet room. But I now know that this is not a character flaw, it is a need, and working with needs is much easier than working with flaws.