Postural and gait performance in children with attention deficit/hyperactivity disorder

doi:10.1016/j.gaitpost.2008.08.016

Gait & Posture

Volume 29, Issue 2, February 2009, Pages 249-254

https://doi.org/10.1016/j.gaitpost.2008.08.016 Get rights and content

Abstract

Up to 50% of children and adolescents with attention deficit/hyperactivity disorder (ADHD) exhibit motor abnormalities including altered balance. Results from brain imaging studies indicate that these balance deficits could be of cerebellar origin as ADHD children may show atrophy in those regions of the cerebellum associated with gait and balance control. To address this question, this study investigated postural and gait abilities in ADHD children and compared their static and dynamic balance with children with known lesions in the cerebellum.

Children diagnosed with ADHD according to DSM IV-TR diagnostic criteria were compared with children with chronic surgical cerebellar lesions and age-matched controls. A movement coordination test was used to assess differences in motor development. Postural and gait abilities were assessed using posturography, treadmill walking and a paced stepping task. Volumes of the cerebellum and the cerebrum were assessed on the basis of 3D magnetic resonance images (MRI).

Children with cerebellar lesions showed significant performance decrements in all tasks compared with the controls, particularly in the movement coordination test and paced stepping task. During dynamic posturography ADHD-participants showed mild balance problems which correlated with findings in cerebellar children. ADHD children showed abnormalities in a backward walking task and minor abnormalities in the paced stepping test. They did not differ in treadmill walking from the controls.

These findings support the notion that cerebellar dysfunction may contribute to the postural deficits seen in ADHD children. However, the observed abnormalities were minor. It needs to be examined whether balance problems become more pronounced in ADHD children exhibiting more prominent signs of clumsiness.

Introduction

Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by inattentiveness, motor hyperactivity and impulsivity. ADHD is estimated to affect between 3% and 5% of children of primary school age [1]. According to the established clinical criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR), there are three types of ADHD [2]: the predominantly hyperactive, the predominantly inattentive and the combined type. Although its aetiology remains unclear, its strong familial nature points to a genetic origin [3]. Besides behavioural deficits, approximately 50% of the children suffering from ADHD are reported to also show ‘clumsiness’, i.e. motor performance below the age norm [4], [5].

Several studies suggest a strong association between developmental coordination disorder (DCD) and ADHD [6], [7], [8]. Although DSM IV-TR does not link DCD with ADHD, the disorders co-exist in about 50% of cases [9], [10], [11]. A shared, additive genetic component has been suggested between ADHD and DCD. Despite a large number of neuroimaging and neuropsychological studies on this subject, the neural basis of ADHD is unknown. Converging data suggest that ADHD symptoms may be secondary to abnormalities in fronto-striatal-cerebellar circuits [12].

Brain regions like basal ganglia and frontal lobes may reveal altered volumes in ADHD children [12]. There are further results from MRI studies showing volume reduction of the cerebellar vermis [13], [14], [15], [16]. The cerebellar vermis is known to be crucial for postural and gait control [17]. Thus, the postural and gait disturbances in ADHD children may resemble those of ataxic patients with cerebellar disorders. However, no previous study has compared balance function in these two groups.

Consequently, this study set out to investigate the scale of postural and gait abnormalities present in ADHD and to examine whether those abnormalities are comparable to the postural deficits of children with cerebellar lesions. In order to examine motor development, participants performed a movement coordination test [18] and postural control was assessed using static and dynamic posturography. Gait abilities were investigated using gait analysis including treadmill walking. In addition, paced stepping was examined because movement timing is another important function of the cerebellum [19]. Finally, volumes of the cerebellum and the cerebrum were assessed based on 3D MRI.

Section snippets

Participants

Ten boys with ADHD (mean age 12.3 ± 1.3 years; ADHD-group) treated as outpatients at the local Department of Child and Adolescent Psychiatry were tested. Seven children with chronic surgical cerebellar lesions following astrocytoma resection (mean age 12.3 years ± 2.5; four boys; CER-group) were selected from the database of the local Department of Neurosurgery, and eleven healthy control children (mean age 12.1 years ± 1.8; nine boys; CON-group) were recruited from the families of hospital staff and

Brain MRI analysis

Absolute cerebellar and cerebral volume did not differ between ADHD-participants and controls (p > 0.13). ADHD-participants were found to have a significantly larger cerebellar volume normalized with respect to TICV compared with controls (p < 0.001). Cerebellar volumes normalized with respect to body height, TCV normalized with respect to TICV, and TCV normalized with respect to body height did not, however, differ between groups (p > 0.079; Table 1).

Fig. 1 shows the lesion sites of the seven

Discussion

In this study, few motor abnormalities were observed in children with ADHD. In the movement coordination test, ADHD-participants scored significantly lower only when walking backwards on a beam. Otherwise, performance in all four subtests was within the normal range.

In ADHD-participants balance disorders in stance and gait appear to be minor. Abnormalities were most prominent in the most difficult conditions of dynamic posturography. In these conditions subjects had to rely primarily on

Conflict of interest

None.

Acknowledgments

Supported by IFORES (D/107-20180; D/107-20170). The authors thank K. Sekotill and B. Decker for their help in data acquisition.

References (29)

P. Heiser et al.
Molecular genetic aspects of attention-deficit/hyperactivity disorder
Neurosci Biobehav Rev
(2004)
T.A. Blondis
Motor disorders and attention-deficit/hyperactivity disorder
Pediatr Clin North Am
(1999)
J.A. Sergeant et al.
ADHD and DCD: a relationship in need of research
Hum Mov Sci
(2006)
L.J. Seidman et al.
Structural brain imaging of attention-deficit/hyperactivity disorder
Biol Psychiatry
(2005)
R.B. Ivry et al.
The neural representation of time
Curr Opin Neurobiol
(2004)
P. Trouillas et al.
International cooperative ataxia rating scale for pharmacological assessment of the cerebellar syndrome. The ataxia neuropharmacology committee of the World Federation of Neurology
J Neurol Sci
(1997)
A. Dimitrova et al.
MRI atlas of the human cerebellar nuclei
Neuroimage
(2002)
T. Raberger et al.
On the automaticity/cerebellar deficit hypothesis of dyslexia: balancing and continuous rapid naming in dyslexic and ADHD children
Neuropsychologia
(2003)
P. Szatmari et al.
Ontario child health study: prevalence of attention deficit disorder with hyperactivity
J Child Psychol Psychiatry
(1989)
DSM-IV-TR: Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Press...

C. Karatekin et al.

A preliminary study of motor problems in children with attention-deficit/hyperactivity disorder

Percept Mot Skills

(2003)

R.C. Tervo et al.

Children with ADHD and motor dysfunction compared with children with ADHD only

Dev Med Child Neurol

(2002)

M. Landgren et al.

Deficits in attention, motor control and perception (DAMP): a simplified school entry examination

Acta Paediatr

(2000)

J.P. Piek et al.

Motor coordination and kinaesthesis in boys with attention deficit–hyperactivity disorder

Dev Med Child Neurol

(1999)

Cited by (100)

Gait in children with and without ADHD: A systematic literature review
2023, Gait and Posture
There is increasing speculation whether Attention-Deficit/Hyperactivity Disorder (ADHD) has phenotypic or secondary motor symptoms. Some evidence suggests even fundamental motor skills such as walking can differ in ADHD, however, the evidence is limited and has not been reviewed. Therefore, we conducted a systematic review to summarize the findings regarding gait in ADHD compared to typically developing children in (1) normal (i.e., self-paced), (2) paced or complex (i.e., walking backwards), and (3) dual-task contexts.
Following a thorough literature search and application of stringent exclusion criteria, a total of 12 studies were included in this review. All studies examined normal walking with a variety of gait parameters in children (age range: 5–18), however, selected parameters and group differences were often inconsistent.
In self-paced walking, studies reporting gait with coefficients of variance (CVs) indicated several between-group differences, whereas averages of gait variables were the same for those with ADHD and typically developing children. Paced or complex walking contexts often differed between ADHD and typically developing groups, favoring the ADHD group in some cases, but primarily the typically developing participants. Finally, walking contexts with dual-tasks showed more frequent performance losses in the ADHD group.
Children with ADHD seem to have specific patterns of gait variability compared to typically developing children, particularly in complex walking contexts and at faster paces. The influence of age, medication, and method of gait normalization may have influenced the results of studies. Overall, this review highlights the potential for a unique gait profile in children with ADHD.
Effect of psychostimulant medications on functional balance performance in persons with Attention-Deficit/Hyperactivity Disorder: A systematic review
2023, Gait and Posture
Balance impairments are highly prevalent and underscreened in individuals with Attention-deficit/hyperactivity disorder (ADHD). Psychostimulant medications, used to treat ADHD symptoms, may improve balance performance in this population as demonstrated by a growing literature; however, there has not been a systematic investigation to understand the effects of psychostimulant medications on balance performance in individuals with ADHD. This systematic review examined the existing evidence to determine if psychostimulant medications improve balance performance in this population.
We searched PubMed, CINAHL, SPORTDiscus, Scopus, Embase and Cochrane in March 2021 and in January 2022 to locate articles relevant to the topic. Two reviewers evaluated the methodological quality of included articles using the Study Quality Assessment Tools and the PEDro scale. The reviewers rated articles for the level of evidence based on the American Academy of Neurology (AAN) criteria. The reviewers further offered recommendations for research and clinical practice based on the strength of the reviewed articles using the AAN criteria. Additionally, the reviewers gleaned important characteristics from each article, such as study design, balance domain and study results.
Nine articles addressed the role of psychostimulant medications on balance outcomes. These articles included two Class II studies, two Class III studies and five Class IV studies. Based on study quality, this systematic review indicated low confidence in the use of psychostimulant medications for improving balance performance based on AAN criteria.
Psychostimulant medications trends to enhance balance performance in individuals with ADHD. However, the lack of well-designed studies and heterogeneity of balance measures warrant additional research.
Effect of psychostimulant medications on static balance performance in adults with attention deficit hyperactivity disorder: Within-subjects repeated-measure study
2023, Human Movement Science
This study examined the effect of psychostimulant medications nPS) on balance and functional motor performance in adults with attention-deficit/hyperactivity disorder (ADHD).
Participants completed two sessions (off-medication and on-medication) in a within-subjects repeated-measure study design. There was a minimum of seven days between the two sessions. During both sessions, participants stood for 30 s per condition on a force platform. The conditions were: feet-apart with 1) eyes-open and 2) eyes-closed; feet-together with 3) eyes-open and 4) eyes-closed. Participants performed three trials of timed up and go (TUG) and lateral step-up test (LSUT) during both sessions. Outcome measures were sway area (SA [cm²]), average sway velocity (SV [cm/s]), TUG average time (s), and average number of LSUT repetitions. Data were analyzed using multivariate repeated measures analysis of variance and paired t-tests for examining PS effects on balance (SA and SV) and functional motor performance (TUG and LSUT), respectively.
The sample included 45 adults (35 females; mean age = 28.4 ± 6.3 years). The repeated-measures MANOVA indicated that PS was associated with better SA [F(1,44) = 9.6; p = 0.003;η_p² = 0.18] but not with SV [F(1,44) = 1.0; p = 0.319;η_p² = 0.02]. PS was associated with significantly better SA with decreasing base-of-support [F(1,44) = 9.9; p = 0.003;η_p² = 0.18]. Additionally, PS use was associated with better TUG [t(1,44) = 2.65; p = 0.014;Cohen's d = 0.39] but not LSUT performances [t(1,44) = −0.68; p = 0.499;Cohen's d = −0.10].
PS was associated with better SA and TUG in adults with ADHD. Further studies are needed to investigate the effects of PS on balance performance using rigorous designs in this population.
Healthcare providers should screen for PS status and balance when treating adults with ADHD to enhance safe motor performance.
Gait control in children with attention-deficit/hyperactivity disorder
2020, Human Movement Science
The current profile of gait control in children with ADHD is incomplete and predominately based on children walking forward at a self-selected pace. There are no studies of potential gait deficits in this clinical population when walking in different directions in combination with varying rates of stepping that are freely selected and entrained to an external stimulus. The purpose of the current study was to address this lack of information by assessing gait of children aged 7–17 years with (n = 17) and without (n = 26) ADHD. Participants walked forward and backward along an electronically instrumented carpet at a self-selected stepping rate and in synchrony to a metronome that dictated an increased and decreased stepping rate. Using repeated measures analysis of covariance (ANCOVA) to assess spatiotemporal gait parameters, results showed that children with ADHD exhibited a significantly exaggerated, toes ‘turned out,’ foot position for all walking conditions compared to typically developing children. When walking backward, children with ADHD produced an increased step width, higher stepping cadence, and increased velocity. Additionally, coefficient of variation ratios indicated that children with ADHD produced greater variability of velocity, cadence, and step time for all walking conditions, and greater variability for stride length when walking at an increased stepping rate. Results were interpreted in terms of clinical significance and practical ramifications that inform rehabilitation specialists in designing therapies that ameliorate the reported gait deficits.
Balance and the brain: A review of structural brain correlates of postural balance and balance training in humans
2019, Gait and Posture
Background: Balance challenges are associated with not only the aging process but also a wide variety of psychiatric and neurological disorders. However, relatively little is known regarding the neural basis of balance and the effects of balance interventions on the brain.
Research question: This review synthesizes the existing literature to answer the question: What are the key brain structures associated with balance?
Methods: This review examined 37 studies that assessed brain structures in relation to balance assessment or intervention. These studies provided 234 findings implicating 71 brain structures. The frequency of implication for each structure was examined based upon specific methodological parameters, including study design (assessment/intervention), type of balance measured (static/dynamic), population (clinical/non-clinical), and imaging analysis technique (region of interest [ROI]/voxel-based morphometry [VBM]).
Results: Although a number of structures were associated with balance across the brain, the most frequently implicated structures included the cerebellum, basal ganglia, thalamus, hippocampus, inferior parietal cortex, and frontal lobe regions. Findings in the cerebellum and brainstem were most common in studies with clinical populations, studies that used an ROI approach, and studies that measured dynamic balance. Findings in the frontal, occipital, and parietal regions were also more common in studies that measured dynamic compared to static balance.
Significance: While balance appears to be a whole-brain phenomenon, a subset of structures appear to play a key role in balance and are likely implicated in balance disorders. Some of these structures (i.e., the cerebellum, basal ganglia and thalamus) have a well-appreciated role in balance, whereas other regions (i.e., hippocampus and inferior parietal cortex) are not commonly thought to be associated with balance and therefore may provide alternative explanations for the neural basis of balance. Key avenues for future research include understanding the roles of all regions involved in balance across the lifespan and in different clinical populations.
Wearable-based electronics to objectively support diagnosis of motor impairments in school-aged children
2019, Journal of Biomechanics
Citation Excerpt :
DCD results 6% in prevalence worldwide (Smits-engelsman, 2011); ADHD is different among countries, but averages 5% in prevalence (Sayal et al., 2017). Interestingly, DCD and ADHD are frequently combined, their comorbidity as high as 50% (Buderath et al., 2009; Goulardins et al., 2015; Kaiser et al., 2015), their relationship remaining pretty unknown (Sergeant et al., 2006). Moreover, both disorders have been linked to psychological problems, reduced academic performance, and reading and spelling difficulties, thus the idea of a single etiology has been suggested (Dewey and Bernier, 2016; Kaplan et al., 1998).
Developmental coordination disorder (DCD) and attention-deficit hyperactivity disorder (ADHD) are neuro-developmental disorders, starting in childhood, which can affect the planning of movements and the coordination.
We investigated how and in which measure a system based on wearable inertial measurement units (IMUs) can provide an objective support to the diagnosis of motor impairments in school-aged children.
The IMUs measured linear and rotational movements of 37 schoolchildren, 7−10yo, 17 patients and 20 control subjects, during the execution of motor exercises, performed under medical and psychiatric supervision, to assess different aspects of the motor coordination.
The measured motor parameters showed a high degree of significance in discriminating the ADHD/DCD patients from the healthy subjects, pointing out which motor tasks are worth focusing on. So, medical doctors have a novel key lecture to state a diagnosis, gaining in objectivity with respect to the standard procedures which mainly involve subjective human judgment.
Differently to other works, we propose a novel approach in terms of number of used IMUs and of performed motor tasks. Moreover, we demonstrate the meaningful parameters to be considered as more discriminant in supporting the medical diagnosis.

View all citing articles on Scopus

View full text

Postural and gait performance in children with attention deficit/hyperactivity disorder

Abstract

Introduction

Section snippets

Participants

Brain MRI analysis

Discussion

Conflict of interest

Acknowledgments

Neurosci Biobehav Rev

Pediatr Clin North Am

Hum Mov Sci

Biol Psychiatry

Curr Opin Neurobiol

J Neurol Sci

Neuroimage

Neuropsychologia

Ontario child health study: prevalence of attention deficit disorder with hyperactivity

J Child Psychol Psychiatry

A preliminary study of motor problems in children with attention-deficit/hyperactivity disorder

Percept Mot Skills

Children with ADHD and motor dysfunction compared with children with ADHD only

Dev Med Child Neurol

Deficits in attention, motor control and perception (DAMP): a simplified school entry examination

Acta Paediatr

Motor coordination and kinaesthesis in boys with attention deficit–hyperactivity disorder

Dev Med Child Neurol