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Middle East Current Psychiatry
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Vestibular and balance dysfunction in attention deficit hyperactivity disorder and cognitive disengagement syndrome risk groups

Middle East Current Psychiatry volume 32, Article number: 12 (2025) Cite this article

Abstract

Background

In the past, cognitive disengagement syndrome (CDS) and attention deficit hyperactivity disorder (ADHD) were considered similar concepts. However, many differences have recently been identified between the two disorders, and they have been separated from each other. This study aims to investigate balance and vestibular function in individuals at high risk for ADHD and CDS.

Materials and methods

This study involved 60 college students. Participants were given the Adult ADHD Self-Report Scale and the Adult Concentration Inventory. Using the applied indices, participants with high and low risk for CDS and ADHD were identified. Every participant underwent static posturography, the video head impulse test (vHIT), and cervical vestibular myogenic-evoked potentials (cVEMP).

Results

People with low and high risk for CDS did not differ in terms of static posturography or cVEMP (p > 0.05). Similarly, no differences were found in ADHD (p > 0.05). While right ear lateral vHIT responses were worse in individuals with high-risk CDS (p > 0.05), bilateral posterior vHIT rates were worse in individuals with high-risk ADHD (p > 0.05).

Conclusion

The fact that individuals at high risk for CDS and ADHD show different vestibular involvement strengthens the fact that there are different clinical pictures.

Introduction

Prior to its recent recognition as a distinct disorder, sluggish cognitive tempo (SCT) was thought to be a subtype of attention deficit hyperactivity disorder (ADHD). It is a clinical condition marked by symptoms like mental fog and confusion, slowed behavior and thinking, daydreaming, sluggishness, and fatigue [1,2,3,4,5]. In recent discussions, SCT has been perceived as stigmatizing, thus prompting the suggestion for the usage of cognitive disengagement syndrome (CDS) [6]. In the etiology of CDS, prenatal alcohol exposure, prenatal and postnatal tobacco exposure [7, 8], low socioeconomic status, maternal low educational level [1, 9, 10], negative emotional environment, and high emotional expression within the family [11] have been identified as influential factors. Unlike ADHD, genetic involvement is more moderate and may be caused more by environmental factors [12, 13], the 7-repeat allele in the DRD4 gene is more frequent in CDS [14], thyroid-stimulating hormone levels were found to be more associated with CDS [4], and the theta/delta wave ratio in the frontal region in ADHD was found to be unrelated to CDS [15].

If we evaluate CDS and ADHD in terms of clinical characteristics, while problems such as impulsivity, hyperactivity, conduct, and substance use disorders are common in ADHD, anxiety, introversion, shyness, and social problems occur in CDS [1, 3, 16, 17]. Considering all these factors, the view that CDS is a different clinical picture than ADHD is strengthened.

The relationship between ADHD and the cerebellum has been the subject of some research. Both the cerebellum and ADHD have been linked to abnormalities in the cerebellum [18], shrinkage in the posterior-inferior cerebellar lobules [19], and disruption in the cerebello-thalamo-prefrontal brain circuit. It has been proposed that balance issues in ADHD could be caused by cerebellar impairment [20].

In order to maintain balance, the central nervous system integrates information from the vestibular, visual, and proprioceptive sensory systems and relays it to the skeletal and muscular systems [21]. In addition to increasing the risk of injury, balance disorders might limit participation and activity [22, 23]. Thus, it has been underlined how important it is to look into balance systems in ADHD, which includes issues like excessive movement and inattention. The limbic system and other brain components are linked to the vestibular system’s intricate functioning. It has been proposed that the vestibular system affects executive and attentional functioning [24], and vestibular diseases may be linked to social behavioral problems [25,26,27] or emotional symptoms including depression and anxiety [28, 29]. Especially in combined type ADHD, there are studies investigating balance and the vestibular system, suggesting that ADHD may affect vestibular functions [30,31,32]. However, we have not come across any studies investigating balance and the vestibular system in individuals with CDS in the literature. According to our hypothesis, CDS, considered as two clinical entities similar to ADHD but distinct, may also impact vestibular functions.

This study looks at vestibular function and balance in people who are at high risk for both CDS and ADHD. The video head impulse test (vHIT) and cervical vestibular-evoked myogenic potentials (cVEMP) were used in our study to thoroughly examine vestibular end organs, while static posturography was used to evaluate overall balance.

Material and methods

Ethical situation

All participants included in the study provided written and verbal consent. Karabuk University Ethics Committee granted ethical approval with meeting number 2024/04 and date of 29 March 24.

Participants and procedures

The sample size for this study was calculated using the G*Power 3.1 software. Power analysis indicated that a total sample size of 58 participants was required to achieve 85% power, a 5% type I error rate, and an effect size of 0.7315658 [31].

This study was conducted on healthy university students. The study did not include participants with neurological, orthopedic, mental, or systemic conditions. This led to the inclusion of 60 healthy university students in the study.

To assess the CDS status of the participants, the Adult Concentration Inventory (ACI) was utilized [33]. The ACI, which has been validated and shown to be reliable in Turkish by Karakaya et al. (2021), consists of 16 questions. Participants can respond to each question with “never,” “sometimes,” “often,” or “very often.” A higher score indicates an increased risk of CDS [34].

The Turkish version of the Adult ADHD Self-Report Scale (ASRS v1.1), which was first created by Kessler et al. (2005) [35], was used to assess the participants’ ADHD status [36]. “Never,” “rarely,” “sometimes,” “frequently,” and “very often” are among 18 possible answers for the ASRS questions. An increased risk of ADHD is indicated by a higher score.

The assessment of the vestibular system and balance

For vestibular-evoked myogenic potential (cVEMP) testing, the Neuro-Audio (Neurosoft, Ivanovo, Russia, Version 1.0.104.1) auditory-evoked potentials device was used. Participants were instructed to turn their necks toward the contralateral ear from which the recording was taken and maintain muscle contraction at the desired region while looking at the computer screen. The test was performed with the patient seated, the electrode areas cleaned with abrasive gel, the active electrode placed on the upper 1/3 of the sternocleidomastoid muscle, the reference electrode placed on the sternoclavicular joint, and the ground electrode placed on the forehead. The electrode impedance was checked, and all electrodes were placed to have an impedance of less than 10 Ω. A 500-Hz tone-burst stimulus at 100 dB was used in the test. If no wave was formed or if the asymmetry ratio between ears exceeded 40%, the test was considered abnormal.

The vHIT was conducted using SYNAPSYS (Ulmer, France). The same person performed every vHIT procedure. The test was conducted in a room with good lighting. The patient and the vHIT camera were positioned 90 cm apart. The patient was seated on a chair that could be rotated and adjusted. The patient was instructed to tilt their head 20° to the side and gaze at a fixed spot before suddenly rotating quickly from side to side in order to evaluate the lateral canal function. The patient was told to look to the right or left of the point and rotate their head 35 to 45° in the same direction for the left anterior right posterior (LARP) and right anterior left posterior (RALP) planes. At least five head impulses in each plane and direction were administered to the patients.

The study employed static posturography to assess the participants’ balancing abilities. Five distinct circumstances were tested using the Bertec force platform (Bertec Corporation, OH, USA). The limit of stability (LoS) is the first requirement. Eyes open on a firm surface, eyes closed on a firm surface, eyes open on a foam surface, and eyes closed on a foam surface are the additional requirements.

Statistical analysis

Statistical analyses were performed using IBM SPSS 21 software. The Shapiro–Wilk test was conducted to assess the normality of data distribution. For normally distributed data, the results were expressed as mean ± standard deviation, whereas for non-normally distributed data, the results were presented as median (min–max). Fisher’s exact test was used for gender comparisons between groups. The Mann–Whitney U-test was applied for numerical comparisons when at least one variable did not follow a normal distribution, while the independent samples T-test was used for normally distributed data. Spearman’s correlation test was utilized to evaluate relationships between variables. A p-value of less than 0.05 was considered statistically significant.

Results

The study included 60 individuals, with a median ACI score of 18 (range: 6–36) and an average score of 18.75 ± 7.10. Based on the median ACI value, participants were categorized into two groups: those with high risk for cognitive disengagement syndrome (H-CDS) and those with low risk (L-CDS). In total, 46.7% (28 individuals) were assigned to the H-CDS group, while 53.3% (32 individuals) were assigned to the L-CDS group. Similarly, the median ASRS score was 21.50 (range: 7–53), with an average score of 24.00 ± 11.21. Participants were divided into high ADHD risk (H-ADHD) and low ADHD risk (L-ADHD) groups based on the median ASRS score. As a result, each group included an equal number of participants (50%, n = 30). A moderate positive relationship was observed between the ACI and ASRS scores (r = 0.4, p = 0.002).

Age, gender, smoking status, and alcohol use did not significantly differ between the CDS and ADHD groups (p > 0.05). A thorough summary of the demographic traits of the individuals in both groups is given in Table 1.

Table 1 Age, gender, smoking, and alcohol use according to CDS and ADHD groups
Full size table

Out of the cVEMP results, 45 individuals demonstrated normal responses, 15 had abnormal responses, 10 showed no bilateral responses, and 5 exhibited asymmetric responses. The comparison of cVEMP results between the CDS and ADHD groups revealed no significant differences (p > 0.05). Figure 1 illustrates the cVEMP results based on the CDS and ADHD groups.

Fig. 1
figure 1

cVEMP results according to CDS and ADHD groups

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In the vHIT findings, there were no differences in anterior and posterior semicircular canal (SSC) gains for both ears between the CDS groups (p > 0.05). In contrast to the L-CDS group, the H-CDS group’s lateral SSC gain in the right ear was considerably smaller (p < 0.05). There was a low-level negative correlation between right ear lateral SSC gain and CDS (p = 0.025, r =  − 0.29, Fig. 2A). There were no discernible variations between the anterior and lateral SSC increases in either ear for the ADHD groups (p > 0.05). However, the H-ADHD group’s posterior SSC increases in both ears were fewer than those of the L-ADHD group (p < 0.05). There was a moderate negative correlation between right and left posterior SSC gains and ADHD (p = 0.002, r =  − 0.39; p = 0.007, r =  − 0.34, Fig. 2B and C, respectively).The vHIT gains for the CDS and ADHD groups are compiled in Table 2.

Fig. 2
figure 2

A Relationship between CDS score and right lateral SCC gain. B Relationship between ADHD and right posterior SCC gain. C Relationship between ADHD and left posterior SCC gain

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Table 2 vHIT gains according to CDS and ADHD groups
Full size table

There was no significant difference in the static posturography results between the CDS and ADHD groups (p > 0.05). The static posturography results for the CDS and ADHD groups are shown in Table 3.

Table 3 Static posturography findings according to CDS and ADHD groups
Full size table

Discussion

In our study, we investigated vestibular system findings in individuals at high risk for both CDS and ADHD. There was no difference in static posturography and cVEMP findings between both CDS and ADHD groups. However, vHIT findings were worse in individuals at high risk for both ADHD and CDS compared to those at low risk.

Afferent signals are sent to the central nervous system by the vestibular system in cooperation with other sensory systems, and the central nervous system processes these signals to determine equilibrium [37]. Additionally, through cortical and subcortical projections in the frontal and parietal lobes, the vestibular system aids in the regulation of attention, decision-making, and other higher cognitive tasks [38]. Some studies have found evidence of the relationship between vestibular function and memory and executive functions [28, 39, 40]. In a study conducted by Mulligan (1995), it was found that children with ADHD have more vestibular system problems [41]. In another study investigating the vestibular system and balance in children with ADHD, it was recorded that there was greater oscillation of the center of gravity while performing cognitive tasks such as auditory memory. This study demonstrated that children with ADHD have difficulty maintaining balance while performing certain cognitive tasks [42]. In another study, it was suggested that children with ADHD exhibit poor static postural control, and that this performance could be a reflection of a form of sensory integration disorder [43]. Studies on balance skills in people with ADHD have been published in the literature. When people with ADHD undergo static posturography, it has been discovered that they have more balance issues than people in good health, which puts them at greater risk of falling [31, 44, 45]. In the maintenance of balance and prevention of falls, along with peripheral and central balance structures, musculoskeletal system and cognitive skills are also important. In our study, there was no difference in static balance skills between groups at high and low risk for ADHD. Since the participants in our study were young university students, these individuals were physically and cognitively healthy. Therefore, a possible vestibular disorder due to ADHD may have been compensated by other balance systems in these individuals. Hence, there may not have been a difference in static posturography testing in these individuals. Evaluating the overall balance skills of individuals with ADHD under challenging dynamic conditions or in situations that challenge cognitive attention capacity, such as dual tasking, may provide better insights into how ADHD affects overall balance skills.

cVEMP is a vestibulo-collic reflex reaction that starts in the saccule and travels to the lateral vestibular nucleus, accessory nerve, and sternocleidomastoid (SCM) muscle via the inferior vestibular nerve pathway. Regarding cVEMP results in people with ADHD, there is no agreement in the literature. Bilateral cVEMP responses were lower in people with ADHD than in healthy people, according to a study looking into cVEMP findings in this population [31]. Unlike this investigation, Lotfi et al. found no difference in cVEMP between healthy people and those with ADHD [46]. No significant differences in cVEMP responses were observed between individuals with high and low ADHD risk, aligning with the findings reported by Lotfi et al. The vestibular end organs within the inner ear are responsible for detecting different planes of motion. Otolith organs, such as the saccule and utricle, regulate linear movements along the horizontal and vertical axes, while angular movements are detected by the semicircular canals, each aligned with its respective axis. In addition to saccular dysfunction, impairments in the efferent branch of the vestibulo-collic pathway can also influence cVEMP responses, which are associated with the tonic contraction of the sternocleidomastoid (SCM) muscle [47]. The absence of a cVEMP difference in our study suggests that saccular function remains unaffected in individuals with ADHD.

vHIT is a rapid, practical, and physiological test that evaluates the vestibulo-ocular reflex (VOR) between the eyes. Therefore, it is commonly preferred for assessing the semicircular canals (SCCs). In a study utilizing HIT, it was observed that children with ADHD exhibited more HIT pathologies compared to typically developing children. It was observed that individuals with ADHD were more affected in their vertical semicircular canal (SCC) gains compared to lateral SCC gains [30]. In a study by Korkmaz et al. (2024), in which 38 children with ADHD were compared to 40 healthy controls, it was found that the functional head impulse test (fHIT) results showed poorer performance in the lateral, anterior, and posterior SSCs [48]. Similarly, in our study, individuals at high risk for ADHD had poorer posterior SCC gains compared to those at low risk for ADHD. In this regard, it can be said that there is a disturbance in the vestibular system in ADHD, and this disturbance is predominantly in the vertical SCCs. As the researchers have suggested, fHIT may potentially be used as a biomarker for neurodevelopmental disorders, including ADHD, in the future (17).

Research in the field of CDS has notably increased in the past 20 years. We did not come across any studies in the literature investigating balance or the vestibular system in individuals with CDS. Our study is the first to contribute to the literature in this regard. It is noted that while ADHD and CDS may affect cognitive functions similarly, they are distinct clinical disorders [6]. Similarities are expected in the etiology, symptoms, and clinical course of disorders affecting similar functions. Similarly to ADHD, in our study, no difference was found in static posturography and cVEMP between individuals at high and low risk for CDS. However, in the evaluation with vHIT, while there was no difference in vertical SCCs between groups, individuals at high risk for CDS had poorer right ear lateral SCC gains compared to low-risk individuals. Vestibular disorders observed in individuals with CDS may affect their cognitive functions and could potentially contribute to the severity of CDS. Additionally, the involvement of the vestibular system in both ADHD and CDS groups, albeit with different SCCs affected, strengthens the hypothesis that these are distinct clinical conditions.

Individuals with vestibular disorders require more cognitive resources to maintain their balance, and due to increased cognitive competition, their cognitive functions may decrease [45, 49, 50]. In this respect, the vestibular disorders identified in individuals at high risk for both ADHD and CDS in our study may exacerbate their inattention. Similarly, treatments targeting vestibular disorders may be beneficial in reducing cognitive impairments in these clinical conditions. Further studies are required to explore the connection between the vestibular system and conditions such as ADHD and CDS in more detail.

Our study has some limitations. First, since CDS has not yet been classified as a diagnostic category, the fact that its clinical symptoms are defined solely by self-report scales should be considered a limitation of our study. Additionally, the use of self-report scales for ADHD, the lack of clinical assessment of the ADHD diagnosis, and the failure to specify the types of ADHD are also among the limitations.

Another limitation is that the groups showing ADHD and CDS symptoms were not analyzed separately in terms of high-risk groups. In our sample, individuals exhibiting symptoms associated with both of these disorders were included in the study. This may be a limitation in terms of providing a more detailed understanding of the effects of ADHD and CDS on the vestibular system. To further investigate this, we aimed to strengthen our study by conducting a correlation analysis to assess the relationship between the vestibular system and these disorders.

Our study was conducted on university students with high academic performance, and the imbalance in gender distribution, particularly the higher number of female participants, may be a limitation in terms of the generalizability of the results and their applicability to males. We acknowledge this limitation and believe that future research, conducted with more balanced gender distribution, direct diagnosis, and assessment of symptom severity using larger and representative samples, will make significant contributions to the literature.

Conclusion

Being the first to examine the connection between the vestibular system and CDS and ADHD, our study is extremely important. Our results suggest that disorders like CDS and ADHD, which are linked to cognitive functioning, affect the semicircular canals (SCC). Additionally, our results demonstrate different vestibular impacts in CDS and ADHD. Therefore, our study may significantly contribute to the literature by revealing the differences between these two disorders and enriching our understanding in this field.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

Our profound appreciation goes out to everyone who helped with this study. We also like to thank Karabuk University for supplying the facilities and resources that we needed. Our deepest appreciation goes to our study participants, whose willingness to contribute made this research possible. Finally, we would like to thank the editorial and peer-review teams for their valuable suggestions and guidance during the preparation of this manuscript.

Funding

The study was not funded by any specific grant or funding agency, and no external funding body was involved in the design of the study, data collection, analysis, interpretation, or the writing of the manuscript.

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Authors and Affiliations

  1. Department of Psychiatry, Faculty of Medicine, Karabuk University, Karabuk, Turkey

    Zuhal Koc Apaydın & Nefise Demir

  2. Department of Audiometry, Karabük University, Karabuk, Turkey

    Emre Soylemez

Authors
  1. Zuhal Koc Apaydın
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  2. Emre Soylemez
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  3. Nefise Demir
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Contributions

Conception; ZKA, ES, ND. Design; ZKA, ES, ND. Supervision; ZKA, ES. Fundings; ZKA, ES, ND. Materials; ZKA, ES. Data Collection; ZKA, ES, ND. Analysis; ZKA, ES. Literature Review; ZKA, ES, ND. Writing: ZKA, ES. Critical Review; ZKA, ES.

Corresponding author

Correspondence to Zuhal Koc Apaydın.

Ethics declarations

Ethics approval and consent to participate

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Karabuk University Ethics Committee granted ethical approval with meeting number 2024/04 and date of 29 March 24. Written informed consent for the study was obtained from the participants.

Consent for publication

This section is not applicable as the study does not include any identifiable personal data from individual participants.

Competing interests

The authors declare no competing interests.

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Koc Apaydın, Z., Soylemez, E. & Demir, N. Vestibular and balance dysfunction in attention deficit hyperactivity disorder and cognitive disengagement syndrome risk groups. Middle East Curr Psychiatry 32, 12 (2025). https://doi.org/10.1186/s43045-025-00505-1

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