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Hand Movements in Children with ADHD Hold Clues to Understanding and

Predicting Symptom Severity

Two new research studies find involuntary movements in the hands and fingers are measurable markers
offering insights into the neurobiology of ADHD

For Immediate Release: February 14, 2011

(Baltimore, MD) — Two research studies published today in Neurology®, the medical journal of the
American Academy of Neurology, found markers for measuring the ability of children with Attention Deficit
Hyperactivity Disorder (ADHD) to control impulsive movements, which may reveal insights into the
neurobiology of ADHD, inform prognosis and guide treatments.

In one of two studies conducted by researchers at the Kennedy Krieger Institute in Baltimore, MD and the
Cincinnati Children’s Hospital Medical Center, children with ADHD performed a finger-tapping task. Any
unintentional “overflow” movements occurring on the opposite hand were noted. Children with ADHD
showed more than twice the amount of overflow than typically developing children. This is the first time
that scientists have been able to quantify the degree to which ADHD is associated with a failure in motor

The single most common child behavioral diagnosis, ADHD is a highly prevalent developmental disorder
characterized by inattentiveness, hyperactivity and impulsivity. The approximately 2 million affected
children often fall behind their peers in development of motor control, motor overflow (unintentional
movement) and balance. The inability to control or inhibit voluntary actions is suspected to contribute to
the core diagnostic features of excessive hyperactivity, impulsivity and off-task (distractible) behavior.

“Despite its prevalence, there is a lack of understanding about the neurobiological basis of ADHD,” said
Dr. Stewart Mostofsky, the study’s senior author and Director of the Laboratory for Neurocognitive and
Imaging Research at the Kennedy Krieger Institute. “A critical obstacle in ADHD is the lack of quantitative
measures of brain function that would provide a basis for more accurate diagnosis and effective

In the study, researchers looked at 50 right-handed children — 25 with ADHD and 25 typically developing,
ages 8-12 years. Each subject completed five tasks of sequential finger-tapping on each hand. In this
exercise, the children tapped each finger to the thumb of the same hand, in sequence. The tapping hand
alternated between left-handed finger sequencing and right-handed finger sequencing. Excessive mirror
overflow, defined as unintentional and unnecessary movements occurring in the same muscles on the
opposite side of the body, were measured using video and a device that recorded finger position. These
methods provided precise quantification of the amount of overflow movement, a major advance over prior
studies that relied on qualitiative scales. During left-handed finger tapping, children with ADHD showed
more than twice as much mirror overflow than typically developing children. The differences were
particularly prominent for boys with ADHD who showed nearly four times as much mirror overflow than
typically developing boys on one of the two measures used in the study.

“This study used quantitative measures to support past qualitative findings that motor overflow persists to
a greater degree in children with ADHD than in typically developing peers,” said Dr. Mostofsky. “The
findings reveal that even at an unconscious level, these children are struggling with controlling and
inhibiting unwanted actions and behavior. Studying motor control weakness gives us a window to
understanding the similar challenges that children with ADHD face in controlling more complex behavior,
which can lead to improved diagnosis and treatment.”

In a second study, the researchers investigated motor control in children with ADHD further by measuring
activity within the motor cortex, the part of the brain that controls voluntary movement. Researchers used
Transcranial Magnetic Stimulation (TMS) to apply mild magnetic pulses for brief durations to trigger
muscle activity in the hand, causing hand twitches. Researchers performed 60 trials, with single or paired
pulses to measure the level of muscle activity and monitored the resulting brain activity, called short
interval cortical inhibition (SICI). Overall, children with ADHD showed a substantial decrease in SICI, with
significantly less inhibition of motor activity during the paired pulse stimulation compared to typically
developing children. The degree of inhibition in children with ADHD, measured by SICI, was 40 percent
less than typically developing children. Furthermore, within the ADHD group, less motor inhibition
(decreased SICI) correlated with more severe symptoms. The measure of SICI not only predicted motor
impairment in ADHD children but also robustly predicted their behavioral symptoms as reported by
parents. The findings suggest that reduced SICI may be a critical biomarker of ADHD.

“The neurobiological underpinnings of motor delays and behavioral symptoms in ADHD are not well
understood,” said Dr. Donald Gilbert, study author and Director of the Transcranial Magnetic Stimulation
Laboratory at the Cincinnati Children’s Hospital Medical Center. “However, our study provides more insight into
the physiological measures of this disorder. We found SICI to be an important biomarker for predicting
ADHD symptoms and severity, and it is a highly quantifiable and reproducible measure. This offers a
foundation for determining which children are at higher risk for severe and ongoing symptoms as they
grow older.”

These studies were principally supported by grants from the National Institutes of Health.

About the Kennedy Krieger Institute

Internationally recognized for improving the lives of children and adolescents with disorders and injuries of
the brain and spinal cord, the Kennedy Krieger Institute in Baltimore, MD serves more than 16,000
individuals each year through inpatient and outpatient clinics, home and community services and school-
based programs. Kennedy Krieger provides a wide range of services for children with developmental
concerns mild to severe, and is home to a team of investigators who are contributing to the understanding
of how disorders develop while pioneering new interventions and earlier diagnosis. For more information
on Kennedy Krieger Institute, visit www.kennedykrieger.org.

About the Cincinnati Children’s Hospital Medical Center

Cincinnati Children’s Hospital Medical Center is one of just eight children’s hospitals named to the Honor
Roll in U.S. News and World Report’s 2010-11 Best Children’s Hospitals. It is ranked #1 for digestive
disorders and highly ranked for its expertise in pulmonology, cancer, neonatology, heart and heart surgery,
neurology and neurosurgery, diabetes and endocrinology, orthopedics, kidney disorders and urology.
Cincinnati Children’s is one of the top two recipients of pediatric research grants from the National
Institutes of Health. It is internationally recognized for quality and transformation work by Leapfrog, The
Joint Commission, the Institute for Healthcare Improvement, the federal Agency for Healthcare Research
and Quality, and by hospitals and health organizations it works with globally. Additional information can be
found at www.cincinnatichildrens.org.

Media Contacts

Colleen Butz