Original Article

Alpha Psychiatry 2023;24(1):1-7

DOI: 10.5152/alphapsychiatry.2023.22976

Do Children with Attention Deficit and Hyperactivity Disorder Present with Different Spatio-Temporal Gait Parameters? An Evaluation of the Relationship Between Gait and Gross Motor Skills

Arzu Demircioğlu¹

Songül Atasavun Uysal¹

Buse Büşra Şanlı Dumankaya¹

Elif Kırdı¹

Halime Tuna Çak Esen²

Osman Dağ³

Semra Topuz¹

¹ Department of Physiotherapy and Rehabilitation, Hacettepe University Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey

² Department of Pediatric Mental Health and Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey

³ Department of Biostatistics, Hacettepe University Faculty of Medicine, Ankara, Turkey

Corresponding author: Arzu Demircioğlu ✉ arzu.demircioglu90@hotmail.com

Cite this article as: Demircioğlu A, Atasavun Uysal S, Şanlı Dumankaya BB, et al. Do children with attention deficit and hyperactivity disorder present with different spatio-temporal gait parameters? An evaluation of the relationship between gait and gross motor skills. Alpha Psychiatry. 2023;24(1):1-7.

ABSTRACT

Objective: The aim of the current study was to compare the spatio-temporal parameters of gait and gross motor skills in children with attention deficit hyperactivity disorder-combined type with those of typically developing children and to search the effect of motor skills on gait parameters in children with attention deficit hyperactivity disorder-combined type.

Method: A total of 50 children (n = 25 attention deficit hyperactivity disorder-combined type, n = 25 typically developing children) aged 5-12 years were included. Gross motor skills were evaluated using the Bruininks–Oseretsky Test Second Edition-Short Form. Spatio-temporal parameters of gait were assessed with a GAITRite® computer-based system.

Results: In the subtests of Bruininks–Oseretsky Test Second Edition-Short Form (bilateral coordination (P < .001), balance (P = .013), running speed and agility (P = .003)), lower scores were obtained by the children with attention deficit hyperactivity disorder-combined type. The swing phase of gait was found to be longer in children with attention deficit hyperactivity disorder-combined type (P = .01).

Conclusion: The current study results show that gross motor skills are affected negatively and the swing phase is prolonged in children with attention deficit hyperactivity disorder-combined type. Upper limb coordination and balance were also seen to have an effect on the velocity, step, and stride length. It is important to include an objective gait assessment as well as gross motor skills in the comprehensive clinical evaluation of children with attention deficit hyperactivity disorder-combined type.

Keywords: Attention deficit disorder with hyperactivity; child psychiatry; evaluation study; gait; motor skills

Introduction

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in childhood, characterized by clinically significant symptoms of inattention and/or hyperactivity-impulsivity, which are seen before the age of 12 years.¹ The prevalence of ADHD has been reported to be 5.29% worldwide.² Epidemiological studies in Turkey have shown the prevalence of ADHD in school-age children to be between 8.1% and 13.3%.³,⁴ Although the etiology of ADHD is unknown, some changes in the brain and other central nervous system structures of children with ADHD may explain changes in gross motor skills and spatio-temporal parameters of gait.⁵ The decrease in size of the basal ganglia,⁶ corpus callosum,⁷ cerebellum,⁸ temporal, parietal, and frontal lobes,⁹ together with a decrease in total brain volume,¹⁰ may explain the problems experienced by children with ADHD in the planning and execution of gait and motor skills.⁵ It is also known that the majority of children with ADHD experience motor skill problems and often display deficits in performing gross motor tasks. Motor skill problems such as motor decision,¹¹ motor adjustment,¹² and motor preparation problems¹³ have been demonstrated. These also include gross motor skill problems such as bilateral coordination, balance and gait disturbances, and trunk control problems.¹⁴

Gait is a highly complex movement involving the whole body. Human gait can be sub-classified into stance (from initial contact on the ground to the toe-off) and swing phase (starts with the toe-off and ends with initial contact).¹⁵ However, the number of studies evaluating gait in children with ADHD is limited and the results are conflicting.⁵ Previous studies have reported that children with ADHD walk with greater anterior pelvic angle,¹⁶ exhibit idiopathic toe-walking,¹⁷ and produce greater stride time and stride length variability.¹⁸ Another study has also found no differences in forward self-paced walking¹⁹ or when walking backward at a self-selected pace between children with and without ADHD during gait analysis.²⁰ Previous studies have shown alterations and variations in the gait parameters in children with ADHD.

Gross motor skills and gait performance are important in routine daily activities and peer relationships of school-aged children. The relationship between gait performance and gross motor skills should be evaluated and explained for each child with ADHD. Better gait function and gross motor skills may facilitate community participation and sports as they allow the child to play with peers, thereby enhancing self-esteem and quality of life.²¹

In summary, anomalies in the frontostriatal-cerebellar circuits can cause a deterioration in gross motor skills, posture, and gait control secondary to ADHD symptoms. It is thought that this close relationship may lead to a deterioration in both gross motor skills and gait in children with ADHD.²² For the reasons explained above, the aim of the present study was to compare the gross motor skills and gait parameters of children with ADHD-combined type (ADHD-CT) with those of typically developing (TD) peers and to investigate spatio-temporal gait parameters with objective gait assessment and associated gross motor skills. The hypothesis of the study was that children with ADHD would differ in terms of gross motor skills and spatio-temporal parameters of gait when compared to peers with typical development. The second hypothesis was that the gait parameters would be affected, especially by balance and bilateral coordination in children with ADHD-CT.

Methods

Participants

The current study protocol was approved by the University Research Ethics Board (decision no: 2019/28-18). The present study research protocol was explained to all children and parents and those who provided written informed consent were included.

MAIN POINTS

Gross motor skills are affected negatively in children with ADHD.

The swing phase of gait is prolonged in children with ADHD.

Upper limb coordination and balance were effective on gait in children with ADHD.

Gait and motor skill assessment is important in children with ADHD.

Children with ADHD-CT were diagnosed at the Child and Adolescent Psychiatry Outpatient Clinic. All participants were consulted to the Faculty of Physical Therapy and Rehabilitation for motor evaluation.

The children with ADHD-CT included in this study were those aged 5-12 years, as this age group has a higher rate of presentation at the clinic due to frequently experiencing motor skill problems at school. Since cerebral lateralization plays an important role in motor coordination problems, only right-handed children participated in the study to ensure homogeneity.

The inclusion criteria for children with ADHD-CT were determined as (1) ADHD-CT diagnosis according to DSM-5 diagnostic criteria, (2) age between 5 and 12 years, and (3) right-hand dominance. The exclusion criteria were defined as (1) accompanying major psychiatric and/or neurodevelopmental problem (mental retardation, autism spectrum disorder, bipolar, psychotic, and tic disorders), (2) a history of head trauma or any chronic neurological disease, (3) having additional medical illnesses requiring medication, and (4) participation in a regular exercise program or sports activity for the last 6 months.

The inclusion criteria for the typically developing children were determined as follows: (1) voluntary participation, (2) age 5-12 years, and (3) right-hand dominance.

The exclusion criteria were defined as follows: (1) diagnosed with ADHD, (2) any major psychiatric and/or neurodevelopmental problem (mental retardation, autism spectrum disorder, bipolar, psychotic, and tic disorders), (3) a history of head trauma or any chronic neurological disease, (4) having additional medical illnesses requiring medication, and (5) participation in a regular exercise program or sports activity in the last 6 months.

The TD group and ADHD-CT group were matched as closely as possible in respect of age, height, and weight. The parents of the children in the control group reported no ADHD symptoms, and examination by a physician confirmed that they did not have ADHD or any other neurodevelopmental health problems.

A total of 82 children were assessed for eligibility to participate in the study. A total of 25 children who met the inclusion criteria formed the ADHD-CT group and a TD group was formed by 25 children. The flow diagram of the composition of the research groups is given in Figure 1. The ADHD-CT group was already taking stimulant medication, namely methylphenidate (Ritalin®, Concerta,® or Medikinet®), and the medication was discontinued on the day of testing. The assessments included gross motor skills and gait performance.

Figure 1. Flow diagram for the research.

Assessment of Gross Motor Skills

The Bruininks–Oseretsky Test Second Edition-Short Form (BOT-2 SF) was used to evaluate gross motor skills. This test consists of 14 items in 8 subtests. The subtests related to gross motor skills were used in this study. The total of the bilateral coordination, balance, running speed and agility, and strength scores provides information about gross motor skills. Upper limb coordination provides information on both gross and fine motor skills. Detailed information about the subtests of BOT-2 SF is shown in Figure 2. The raw score obtained by the children from each subtest was recorded according to the test administration. Then, the raw scores were converted into points and the test results were found for each child.²³

Figure 2. Subtests of Bruininks–Oseretsky Test Second Edition-Short Form, (BOT-2 SF. BOT-2 SF).

Gharaei et al²⁴ previously conducted validity and reliability studies comparing BOT-2 (SF) with the Movement Assessment Battery for Children Test. Canonical correlation analysis results showed a significant linear relationship between the 2 motor tests (P < .001). The intra-class correlation coefficient (ICC = 0.80) was high for time reliability. The BOT-2 (SF) has been shown to have high sensitivity in addition to being a valid and reliable test.²⁴

Assessment of Gait

Gait velocity (per second in centimeters [cm/s]), cadence (step numbers per minute [steps/min]), step length (the distance from the heel of the present footprint to the heel of the previous footprint on the prior foot [cm]), stride length (the distance between the consecutive heel centers of the foot [cm]), base of support (vertical distance between the heel center and progression line of the opposite foot [cm]), swing phase (initiates with toe off and ends with heel strike [% gait cycle]), stance phase (initiates with heel contact and ends with toe off of the foot [% gait cycle]), and foot progression angle (the angle of the foot measured relative to the progression line[o]) were evaluated using the GAITRite® electronic walkway (CIR Systems Inc. Clifton, NJ, USA) located in a quiet room without windows.²⁵ Dominant side data (right side for all children) were used for analysis. All the participants walked barefoot along the walkway 3 times at a self-selected speed after the familiarization period, and then, the average of 3 trials was calculated for analysis.

The test–retest reliability of the GAITRite® electronic walkway has been investigated in a previous study that examined temporal and spatial characteristics of gait (gait velocity, step length, stride length, base of support, stance time, swing time, foot progression angle, etc.). The ICC was found to be 0.92 and high at selected walking speed in all walking measurements. The ICC of base of support was found to be 0.80. As a result of the research, the GAITRite® was determined to have good to excellent test–retest reliability.²⁶

In the study investigating the validity of GAITRite®, it was compared with the 3-dimensional motional analysis system (Vicon-512®). The ICC of gait characteristics was between 0.92 and 0.99 for both electronic walkway systems. The GAITRite® system was therefore determined to be a valid tool for measuring spatio-temporal parameters of gait.²⁵

Statistical Analysis

The participant characteristics and the outcome variables were reported with mean, standard deviation (SD), median, minimum, and maximum values. We applied Kolmogorov–Smirnov and Shapiro–Wilk normality tests for assessing the normality and conducted Levene test to test homogeneity of variances. We used independent Student’s t-test to evaluate any difference between the 2 groups in terms of continuous variables and reported mean ±standard deviation values if normality and variance homogeneity assumptions are satisfied. Otherwise, we applied Mann–Whitney U test and reported median and minimum-maximum values. We used Pearson chi-square test for the comparison of groups with respect to categorical variables when sufficient observations fell into the cells of the contingency table; otherwise, we applied Fisher exact test.

Whether variables such as age, gender, height, and weight as well as subtests scores of BOT-2 (SF) had an effect on the spatio-temporal parameters of gait was examined. Significant variables determined using the Pearson correlation coefficient or hypothesis testing process (P < .05) were entered into the multiple regression model. Linear regression models with backward selection were constructed to identify factors predicting spatio-temporal gait parameters. International Business Machines’ Statistical Package for Social Sciences Statistics for Windows v. 22.0 (IBM SPSS Corp.; Armonk, NY, USA) software was utilized for statistical analysis. A value of P < .05 was accepted as statistically significant.

In the present study, we calculated the required sample size in GPower (version 3.1) while making the design of the study. When we compared the ADHD and control groups with the Student’s t-test, we obtained a total of 52 subjects (26 in each group) by considering the power of 80%, the type I error of 5%, and Cohen’s effect size of 0.8. This study could be completed with 25 children in each group due to missing data as shown in Figure 1.

Results

The ADHD-CT group consisted of 23 boys (92%) and 2 girls (8%), and the TD group consisted of 22 boys (88%) and 3 girls (12%) (P = 1.000). There was no statistically significant difference between the ADHD-CT and TD groups in terms of age (P = .053), height (P = 0.055), and weight (P = .06). The demographic characteristics of the children are shown in Table 1.

Table 1. Demographic Characteristics of the Children

Variable | ADHD Group | TD Group | P
(n=25) | (n=25)
Gender | 23 boys, 2 girls | 22 boys, 3 girls | 1.000a
Age (months) | 104.88 (17.74) | 96.64 (10.73) | .053b
Height (cm) | 133.44 (7.46) | 129.16 (9.41) | .055b
Weight (kg) | 30, 20-46 | 26, 21-37 | .06c

a, b, cP-values are obtained via Fisher’s exact test, independent t-test, Mann–Whitney U test, respectively.

ADHD, attention deficit hyperactivity disorder; M, mean; SD, standard deviation; TD, typical developing.

In the BOT-2 (SF) subtests, a significant difference was found in favor of the TD group in bilateral coordination (P < .001), balance (P = .013), and running speed and agility (P = .003). The results of the comparisons of the BOT-2 (SF) subtests of the 2 groups are shown in Table 2.

Table 2. Comparison of Subtests in BOT-2 (SF)

Subtests of BOT-2 (Point) | ADHD Group | TD Group | P
(n = 25) | (n = 25)
Bilateral coordination (0-7) | 4, 0-7 | 7, 3-7 | <.001c
Balance (0-8) | 6, 4-8 | 8, 5-8 | .013c
Strength (0-18) | 6, 0-9 | 7, 0-11 | .564c
Running speed and agility (0-10) | 7, 0-8 | 8, 2-10 | .003c
Total gross motor skills (0-43) | 23, 10-30 | 27, 10-34 | .003c
Upper limb coordination (0-12) | 8, 2-12 | 8, 0-12 | .702c

cP-values are obtained via Mann–Whitney U test.

ADHD, attention deficit hyperactivity disorder; BOT-2 (SF), The Bruininks–Oseretsky Test-Second Edition (Short Form); M, mean; SD, standard deviation; TD, typical developing.

When the spatio-temporal parameters (velocity, cadence, step and stride length, base of support, swing-stance phase, and foot progression angle) of gait were examined, a statistically significant difference was found between the 2 groups in terms of swing (P = .01) and stance phases of the gait (P = .009). The results of the comparisons of gait parameters of the two groups are shown in Table 3.

Table 3. Comparison of Spatio-temporal Gait Parameters of Gait

Spatio-temporal Parameters of Gait | ADHD Group | TD Group | P
(n = 25) | (n = 25)
Velocity (cm/sec) | 108.06 (16.83) | 107.02 (16.55) | .826b
Cadance (step/min) | 124.60 (14.33) | 131.13 (11.36) | .08b
Step length (cm) | 52.21 (4.78) | 49.19 (6.82) | .077b
Stride length (cm) | 104.01 (10.52) | 97.44 (15.45) | .085b
Base of support (cm) | 8.13 (2.53) | 9.16 (2.10) | .124b
Swing (%GC) | 40.14 (1.42) | 39.07 (1.40) | .01b
Stance (%GC) | 59.84 (1.41) | 60.93 (1.40) | .009b
Foot progression angle (o ) | 3.29 (6.10) | 0.71 (6.07) | .141b

bP values are obtained via independent t-test.

ADHD, attention deficit hyperactivity disorder; GC, gait cycle; M, mean; SD, standard deviation; TD, typical developing.

The multiple linear regression model showed that upper limb coordination and balance had significant effects on the spatio-temporal gait parameters. The explanatory effect of upper limb coordination and balance on step length was found to be 40%. The results of multiple linear regression analysis on gross motor skills that affect the spatio-temporal gait parameters in children with ADHD-CT are given in Table 4.

Table 4. Effect of Gross Motor Skill Scores on Spatio-temporal Parameters of Gait in Children with ADHD

Dependent Variable | Predictor | B | SE | β | t | P | R²
| 83.131 | 8.608 |  | 9.658 | <.001* |
Velocity | Upper limb coordination | 3.425 | 1.114 | 0.540 | 3.076 | .005* | 0.292
| 38.684 | 4.022 |  | 9.618 | <.001* | 0.403
Step length | Upper limb coordination | 0.810 | 0.312 | 0.449 | 2.592 | .017*
Balance | 1.193 | 0.627 | 0.330 | 1.904 | .07
| 90.059 | 5.596 |  | 16.092 | <.001* |
Stride length | Upper limb coordination | 1.917 | 0.724 | 0.483 | 2.648 | .014* | 0.234

*P < .05,

B, unstandardized coefficients; β, standardized coefficients; R², coefficient of determination; SE, standard error.

Discussion

The results of the current study demonstrated that the children with ADHD-CT had significantly lower scores in the tests of balance, bilateral coordination, and running speed and agility than the TD group and the swing phase of the gait cycle was longer in children with ADHD-CT compared to the control group.

Cho et al²⁷ found that balance, running speed and agility, bilateral coordination, and strength were lower in an ADHD group whereas upper limb coordination was not significantly different between the groups. Cak et al²⁸ also found that children with ADHD have lower motor skills in running speed and agility, bilateral coordination, and strength and balance subtests of BOT-2 (SF). In another study on children with ADHD, the Movement Assessment Battery for Children-Second Edition was used to assess motor efficiency. Children with ADHD were seen to have lower performance in the balance subtest.²⁹ Consistent with previous studies, the present research results showed that children with ADHD-CT have lower performance in bilateral coordination, balance, and running speed and agility than typically developing peers.

In a study examining gait parameters in children with ADHD, average stride time, stride time variability, and gait speed were evaluated. No difference was found between children with ADHD and the control group in all 3 gait parameters.³⁰ In another study, Buderath et al³¹ investigated posture and gait parameters in children with ADHD, children with chronic surgical cerebellar lesions, and healthy children. Gait parameters were evaluated with an ultrasound-based motion analysis system (WinGait, Zebris, Germany), and no difference was found between the 3 groups in cadence, stride length, double limb support time, and stance phase during tandem and normal walking. In those studies, methylphenidate was given to children with ADHD, which could explain why the gait parameters were similar to those of peers with typical development. However, both studies suggested that future studies should be conducted without administering medication to children with ADHD. Papadopulos et al³² used the GAITRite® system to evaluate the spatio-temporal gait variables of children and reported no difference between the ADHD and TD groups in terms of velocity, base of support, double support percentage, caddence, Y-axis range, and stride length. The current study was similar to previous studies, in that no difference was determined between children with ADHD-CT and TD peers in respect of the variables of speed, step length, stride length, cadence, foot progression angle, and base of support. The swing phase was not included as one of the outcome measures in the previous studies, whereas, in the current research, the swing phase was found to be increased in children with ADHD-CT compared to the control group. Although the difference was statistically significant, it was not clinically related.

This study also examined the effects of gross motor skills on the gait parameters in children with ADHD-CT. Upper limb coordination and balance has been shown to be explanatory of gait parameters (velocity, step, and stride length). The increasing loss of balance moves the body’s center of gravity away from the base of the support surface so a larger step will help maintain the balance from a biomechanical perspective.³³ The fact that balance is descriptive of the step length of children with ADHD-CT may be related to this mechanism.

In a study evaluating quantitative gait using the inertial measurement unit, it was shown that step length is an important factor affecting bilateral coordination.³⁴ In the current study, upper limb coordination was found to be important in step and stride length. This result may have been achieved because arm swings are important during gait.

Gait is an autonomic process consisting of coordinated movements of the upper extremities, lower extremities, trunk, and pelvis.³⁵ In a previous study, deterioration in upper limb coordination has been shown to cause changes in the decrease in gait velocity, step frequency, and stride length.³⁶ In the current study, upper limb coordination was determined to have an effect on gait velocity.

This research had both strengths and limitations. One of the strengths of the present study was that objective, valid, and reliable assessment methods were used. Other strong aspects can be said to be the fact that the children with ADHD-CT did not participate in any regular sports activity or exercise program and had no additional psychiatric disorder or disease. All the children with ADHD had a diagnosis of ADHD-CT. Although the sample size of this study was larger than previous studies on this topic, the sample was too small for generalizability of the results. This also makes it impossible to understand the effect of narrower age groups and gender on the results.

It is clinically very important to evaluate gait performance and motor skills with objective methods within the multi-stage assessment in children with ADHD. When motor skill and gait problems are identified, appropriate consultations should be made within the scope of multidisciplinary treatment approaches.

Conclusion

To the best of our knowledge, this research is the first study in which an objective gait analysis method and motor skills have been examined together. The children with ADHD-CT were determined to have lower scores than TD peers, especially in gross motor skill tests such as running speed and agility, bilateral coordination, and balance. In addition, the swing phase of the children with ADHD-CT was longer than that of TD peers. The study results also demonstrated that upper limb coordination and balance have an effect on the velocity, step, and stride length of gait in children with ADHD-CT compared to TD peers.

Ethics Committee Approval: Ethical committee approval was received from the Ethics Committee of Hacettepe University (Approval no: 2019/28-18).

Informed Consent: Written informed consent was obtained from the children and their parents who participated in the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – A.D., S.A.U.; Design - A.D., S.A.U.; Supervision – S.A.U., S.T.; Materials - S.A.U., S.T.; Data Collection and/or Processing – A.D., B.B.Ş.D., E.K.; Analysis and/or Interpretation: A.D., O.D.; Literature Review – A.D., E.K., H.T.Ç.E.; Writing Manuscript – A.D., S.A.U., E.K.; Critical Review – S.A.U., H.T.Ç.E., S.T.

Acknowledgments: The authors would like to thank all the children and their parents who participated in the study.

Declaration of Interests: The authors declare that they have no competing interest.

Funding: The authors declare that this study had received no financial support.

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Received: June 13, 2022
Accepted: November 16, 2022

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