Children with Attention Deficit Hyperactivity Disorder Have Impaired

Balance Function: Involvement of Somatosensory, Visual, and Vestibular

Systems
Selina B. M. Shum, MSc and Marco Y. C. Pang, PhD

Objectives To compare standing balance performance and sensory organization of balance control in children
with attention deficit hyperactivity disorder (combined type) (ADHD-C) and typically developing children.
Study design School-aged children (n = 43) with ADHD-C and 50 age- and sex-matched typically developing
children participated in the study. Sensory organization of standing balance was evaluated using the Sensory Or-
ganization Test (SOT). In addition to the composite equilibrium score, somatosensory, vestibular, and visual ratios,
which were indicators of the ability of the child to use information from the respective sensory systems to maintain
balance, were computed. Multivariate analysis of covariance (MANCOVA) was used to compare the outcome vari-
ables between the 2 groups while controlling for physical activity level.
Results MANCOVA revealed that children with ADHD-C had significantly lower composite equilibrium scores (P <
.001) and somatosensory (P = .029), vestibular (P = .037), and visual ratios (P = .001) than control children, by 10.3%,
2.1%, 15.6%, and 16.0%, respectively.
Conclusions Children with ADHD-C had significant deficits in standing balance performance in all conditions that
included a disruption of sensory signals. The visual system tends to be more involved in contributing to the balance
deficits in children with ADHD-C than the somatosensory and vestibular systems. (J Pediatr 2009;155:245-9).

A
ttention deficit hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood,
affecting approximately 3% to 9% of typically-developing children.1 Apart from the classic symptoms of inatten-
tion, impulsivity, and hyperactivity, mounting evidence from behavioral and electrophysiological studies has
shown that many children with ADHD sustain deficiencies in sensory processing.2-4 In addition, neuroimaging studies
in children with ADHD have also revealed abnormalities not only in brain regions important for executive function
such as the prefrontal cortex5-7 but also in areas that are integral to sensorimotor control, particularly the cerebellum
and basal ganglia.8-11 These factors may underlie the suboptimal motor performance previously reported in some children
with ADHD.8,12-16
Balance control is an important sensorimotor function that may be compromised in the ADHD population because it
requires the ability to integrate inputs from various sensory systems (ie, somatosensory, visual, vestibular) and to utilize the
integrated sensory signals in generating coordinated motor actions to maintain body equilibrium.17 Studying balance perfor-
mance in children with ADHD is important, as impairments in balance ability may interfere with activity and partcipation18
and may increase the risk of injuries.19
To date, only 2 studies have examined sensory contributions to balance function in children with ADHD.20,21 Although
both studies found that the sway velocity of the center of pressure (COP) was significantly higher in the ADHD group
than in the control group in various testing conditions (eg, standing with the eyes closed, standing on a foam pad),
the extent to which different sensory systems contribute to the balance deficits in these children remains elusive. More-
over, no information on the ADHD subtypes (ie, predominantly hyperactive-impulsive, predominantly inattentive, com-
bined) and comorbidities [eg, developmental coordination disorder (DCD)] was provided. Because these factors may
influence the nature and severity of sensorimotor deficits,12,13,22 it would be important to use a homogeneous sample
of children with ADHD.

ADHD Attention deficit hyperactivity disorder

ADHD-C Attention deficit hyperactivity disorder (combined type)
COP Center of pressure
DCD Developmental coordination disorder From the Department of Rehabilitation Sciences, Hong
ICF International Classification of Functioning, Disability and Health Kong Polytechnic University, Hong Kong, China

MANCOVA Multivariate analysis of covariance The authors declare no conflicts of interest.

SOT Sensory Organization Test 0022-3476/$ - see front matter. Copyright Ó 2009 Mosby Inc.
All rights reserved. 10.1016/j.jpeds.2009.02.032

245
THE JOURNAL OF PEDIATRICS  www.jpeds.com
The objectives of this cross-sectional case-control study
were to compare standing balance ability and sensory organi-
zation of standing balance control between school-aged chil-
dren with ADHD (combined type; ADHD-C) and age- and
sex-matched typically developing children and to identify
which sensory system(s) may contribute to balance deficits
in children with ADHD-C.
Methods
Children with ADHD were recruited from the Central Kow-
loon Child Assessment Centre, which is a major institution
that provides assessment service for children in Hong
Kong. Children who had recently been diagnosed with
ADHD after a formal multidisciplinary evaluation at the
Child Assessment Centre were screened by the research
team to determine whether the following eligibility criteria
were fulfilled. The inclusion criteria were (1) a formal diag-
nosis of ADHD-C made by a pediatrician, child psychologist,
or child psychiatrist, according to the ADHD criteria of
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR),23 (2) age between 6 and 12 years, and (3)
studying in a regular education framework. Individuals
were excluded from the study if they had any of the following:
(1) a history of neurological conditions (eg, cerebral palsy)
and other movement disorders (eg, tic disorders, athetosis,
chorea, dystonia), (2) mental retardation, (3) autistic disor-
der, and (4) significant musculoskeletal or cardiopulmonary
conditions that may influence balance performance (eg,
amputations, bone fractures, heart disease). Additionally,
children were excluded if they had a diagnosis of DCD
because they also demonstrate deficits in sensory organiza-
tion of balance control24 and may thus confound our results.
The screening of DCD during the multidisciplinary assess-
ment was based on the diagnostic criteria described in
DSM-IV-TR.23 To warrant a diagnosis of DCD, the child
had to demonstrate motor coordination substantially below
that expected of the child’s age (ie, gross motor composite
score <42 as measured by the Bruininks-Oseretsky Test of
Motor Proficiency)25 which interfered with activities of daily
living and academic performance. Each child also underwent
a neurological screening performed by a pediatrician to rule
out other causes of motor deficits before a diagnosis of
DCD was made. In addition, typically developing children,
matched to the ADHD group by age and sex, were recruited
from the community. They had to fulfill the same inclusion
and exclusion criteria set above, except that they did not
have any history of ADHD. Ethics approval was obtained
from the Hong Kong Polytechnic University. The study was
explained in detail to each child and his or her parent. Written
informed consent was obtained from the parent if he or she
agreed to participate in the study. As stipulated by the ethics
committee, any child aged 7 years or more was also required
to sign on the consent form before participating in the study.
Forty-nine children with ADHD-C and 50 typically develop-
ing children volunteered for the study. However, 6 children
246
Vol. 155, No. 2
with ADHD-C did not fulfill the eligibility criteria and were
thus excluded. As a result, a total of 43 children with
ADHD-C and 50 typically developing children participated
in the study. Subject characteristics are described in Table I.
The 2 groups of children did not differ significantly on phys-
ical activity level and other demographic variables.
All data collection was performed by an experienced pedi-
atric physiotherapist between February 2007 and July 2008.
Children who were taking prescribed medications for
ADHD (ie, methylphenidate, atomoxetine) were instructed
not to take the medication on the day of testing. All proce-
dures were conducted in accordance with the Declaration
of Helsinki. Relevant information such as medical history
and medications was obtained by interviewing the parent.
During the same interview, the physical activity level of
each child was estimated by asking the parent the type of
extracurricular physical activity that his or her child was
most actively engaged in during a typical week within the
past year. The physical activity level [in metabolic equivalent
(MET) hours per week] was calculated, based on the intensity
(light, moderate, hard), duration (hours) and frequency
(times per week) of the activity as provided by the parent,
as well as the assigned MET value of the activity according
to the Compendium of Energy Expenditures for Youth devel-
oped by Ridley et al.26 This compendium was modeled after
the Adult Compendium of Physical Activities27 and contains
a list of more than 200 activities commonly performed by
children and their associated MET values.26
Body height (m) and weight (kg) of each child were mea-
sured by a mechanical scale equipped with a height rod
(420KL Physician Scale, Health-O-Meter, Bridgeview, Illi-
nois). The Sensory Organization Test (SOT) was used to
evaluate the contributions of different sensory systems to
standing balance control.28 The test is a common research
tool in the evaluation of sensory organization of balance con-
trol and has been previously used by other researchers in
studying balance performance in children.29 The system
used (SMART BalanceMaster, NeuroCom International,
Inc, Clackamas, Oregon) consists of a dynamic 18  18
inch dual forceplate that provides data on the movement of
the COP and a visual surround. The forceplate and visual sur-
round could tilt in response to the child’s anteroposterior
body sway in certain testing conditions (ie, sway-referenced),
thereby disrupting the information delivered from the
somatosensory and visual systems so that the vestibular sys-
tem could be isolated.28 During the SOT, each child was
asked to stand upright at the appointed position on the plat-
form for 20 seconds and try to keep his or her body as stable
as possible under 6 different test conditions. The details of
each condition are described in Table II. A practice trial
for each condition was given before the actual recording. A
total of 3 trials were conducted for each condition. In each
trial, the system compared the child’s sway with the theoret-
ical limits of stability and generate an equilibrium score, with
a higher equilibrium score indicating better standing stabil-
ity. If the child had a fall, a score of 0 was given for that trial.
A composite equilibrium score is also generated by the
Shum and Pang
August 2009 ORIGINAL ARTICLES

Table I. Subject characteristics Table II. The six test conditions of the Sensory
Control group Organization Test
ADHD group (n = 43) (n = 50) P value Sensory
Age, y 8.8  1.1 8.8  1.5 .984 signals Useful sensory
Sex (boys/girls), n 28/15 31/19 .756 Condition Description disrupted signals available
Height, m 1.31  0.07 1.30  0.10 .576 1 Eyes open, None Somatosensory,
Weight, kg 30.8  5.9 28.2  6.9 .060 fixed platform visual, vestibular
On medications for treating 8 — — 2 Eyes closed, Visual signals Somatosensory,
ADHD fixed platform removed vestibular
Methylphenidate, n 7 — — 3 Eyes open, Conflicting visual Somatosensory,
Atomoxetine, n 1 — — fixed platform, signals vestibular
Type of extracurricular sway-referenced
physical activities surround
Badminton, n 0 3 — 4 Eyes open, Conflicting somato- Visual, vestibular
Basketball, n 3 6 — sway-referenced sensory signals
Camping, n 3 3 — platform
Dancing, n 3 4 — 5 Eyes closed, Visual signals Vestibular
Drawing, n 3 0 — sway-referenced removed and
Ice skating, n 0 1 — platform conflicting
Kickboxing/martial arts, n 6 7 — somatosensory
Piano playing, n 2 5 — signals
Soccer, n 2 7 — 6 Eyes open, Conflicting visual Vestibular
Swimming, n 10 5 — sway-referenced and
Table tennis, n 1 0 — platform somatosensory
Violin playing, n 5 5 — and surround signals
No extracurricular 9 8 —
physical activity
Physical activity level 6.2  5.6 6.5  4.8 0.799
(MET hours per week)

system, after taking into account the equilibrium scores at-
tained in all 6 different test conditions.28 The SMART Balan-
ceMaster system also performed sensory ratio analysis, which
yielded 4 different ratios, namely, the somatosensory, vestib-
ular, visual and preference ratios (Table III).
Descriptive statistics were used to describe all relevant vari-
ables. Normality of data was checked using the Kolmogorov-
Smirnov test. Independent t tests and c2 tests were used to
compare the continuous (ie, age, height, weight, physical
activity level) and categorical demographic variables (ie,
sex), respectively, between the ADHD-C group and the con-
trol children. To compare balance performance between the
2 groups while accounting for the possible confounding ef-
fect of physical activity, a single multivariate analysis of co-
variance (MANCOVA) incorporating all primary outcomes
(ie, SOT-derived equilibrium scores and sensory ratios)
was performed, with group (ie, ADHD-C versus control chil-
dren) as the fixed factor and physical activity level as the co-
variate. The results from this analysis showed the effects of
group on all primary outcomes simultaneously as well as
the corresponding Bonferroni-adjusted P values, thus avoid-
ing the increased probability of type I errors associated with
multiple comparisons. Partial eta-squared (partial h2), which
is the standardized measure of effect size within the context of
MANCOVA,30 was also presented for each primary outcome.
By convention, partial h2 values of 0.01, 0.06, and 0.14 are
considered to be small, medium, and large, respectively.30
A significance level of .05 was set for all statistical tests
(2-tailed). All statistical analyses were performed using the
Statistical Package for Social Sciences 16.0 software (SPSS
Inc, Chicago, Illinois).
Children with Attention Deficit Hyperactivity Disorder Have Impaired Balance Function: Involvement of Somatosensory,
Visual, and Vestibular Systems
Results
MANCOVA revealed an overall significant difference in bal-
ance performance between the two groups (Wilk’s l = 3.156,
P = .001). When each individual primary outcome was con-
sidered, the between-group difference remained significant
for all the test conditions, except condition 1 (Table IV).
The composite equilibrium score was also significantly lower
in the ADHD-C group than the control group by 10.3%
(P < .001). In addition, the somatosensory, vestibular, and
visual ratios were all significantly lower in the ADHD-C
group than the control group by 2.1% (P = .029), 15.6%
(P = .037), and 16.0% (P = .001), respectively. The preference
ratio, on the other hand, showed no significant between-
group difference (P = .857). For those primary outcomes
that showed significant between-group differences, the par-
tial h2 values ranged from 0.048 to 0.148, indicating medium
to large effect sizes (Table IV).
Discussion
Children with ADHD-C have significantly poorer balance
performance than control children, after adjusting for physi-
cal activity level. It is noteworthy that children with ADHD-C
do not have particular problems in simple static standing bal-
ance when information from all 3 sensory systems is available
(ie, condition 1 of SOT). However, when sensory information
from one of the systems is removed or distorted, balance def-
icits would emerge in these more challenging conditions.
Typically developing children should be able to utilize
somatosensory information effectively for maintaining bal-
ance well before school age, at around 3 to 4 years.29 In this
247
THE JOURNAL OF PEDIATRICS  www.jpeds.com Vol. 155, No. 2

Table III. Sensory ratio analysis Table IV. Results from the Sensory Organization Test
Sensory ratio* Description Computation ADHD group Control group Effect
(n = 43) (n = 50) P value size†
Somatosensory The ability of the child Condition 2
to use somatosensory Condition 1 Equilibrium score
information for maintaining for each test
balance. Condition 1 90.3  3.1 90.6  4.0 .704 .002
Visual The ability of the child Condition 4 Condition 2 86.1  3.6 88.1  4.3 .022* .057
to use visual information for Condition 1 Condition 3 85.4  5.0 87.6  4.5 .032* .050
maintaining balance. Condition 4 57.1  16.5 68.3  15.0 .001* .116
Vestibular The ability of the child Condition 5 Condition 5 34.5  16.2 40.9  13.2 .036* .048
to use vestibular Condition 1 Condition 6 34.0  15.2 43.0  17.2 .010* .071
information for maintaining Composite equilibrium 57.2  8.8 63.8  7.3 <.001* .148
balance. score
Preference The extent to which the child Condition 3 + 6 Sensory ratio analysis
relies on visual information Condition 2 + 5 Somatosensory ratio 0.95  0.04 0.97  0.04 .029* .052
to maintain balance, even Visual ratio 0.63  0.18 0.75  0.16 .001* .115
though the visual Vestibular ratio 0.38  0.18 0.45  0.14 .037* .048
information is incorrect. Preference ratio 1.02  0.17 1.02  0.16 .857 <.001
*The sensory ratios were generated automatically by the SMART BalanceMaster system; *Significant between-group difference (P < .05).
computational formulas are shown. †Effect sizes were calculated in partial eta-squared values (partial h2).

study, we showed that the somatosensory system may con-

tribute to the observed balance impairment in children
with ADHD-C, as indicated by the significantly lower
somatosensory ratio in the ADHD-C group. However, the
deficit is relatively minor, as reflected by the modest
between-group difference in somatosensory ratio (2.1%).
The possible involvement of the somatosensory system in
balance dysfunction in children with ADHD is not entirely
surprising, as evidence from behavioral and electrophysio-
logical studies has suggested that children with ADHD may
have altered somatosensory function, including reduced tac-
tile discrimination, and impaired modulation of kinesthetic
information.2-4
The vestibular system not only senses head position and
movement but also plays an important role in gaze stabiliza-
tion.17 A properly functioning vestibular system is thus crit-
ical in balance control. In the current study, we found that
children with ADHD-C have decreased ability to use vestib-
ular information to maintain balance, as reflected by the sig-
nificantly lower vestibular ratio. Wang et al21 also found that
in children with ADHD, a significant correlation exists be-
tween sway velocity during standing on a foam pad with
the eyes closed (similar to condition 5 in our study) and ves-
tibular dysfunction as measured by the sensory integration
check scale, again highlighting the possible involvement of
the vestibular system in balance dysfunctions. Interestingly,
Yochman et al4 did not find any significant deficits in vestib-
ular processing and modulation in preschool children with
ADHD. However, balance performance was not examined
in their study. The link between the vestibular and visual sys-
tems (ie, gaze stabilization) was also not explored. Moreover,
it is possible that deficits in vestibular processing in children
with ADHD may not be as apparent in preschool age, as the
vestibular system is the last to reach full functional matura-
tion in balance control (around 15 years of age).29
Deficits in visual information processing and visual-motor
integration in children with ADHD have been previously
reported.3,4 In this study, we found that children with
248
ADHD-C had substantial difficulty with maintaining balance
when they were forced to rely more on the visual information
when somatosensory signals are disrupted (ie, condition 4).
Indeed, the visual system may be the most involved system
in contributing to the balance deficits among children with
ADHD-C, as the visual ratio showed the greatest between-
group difference (16.0%, large effect size of 0.115) when
compared with the somatosensory and vestibular ratios
(Table IV). This finding may also reveal that children with
ADHD-C could not successfully compensate by utilizing
visual information for maintaining balance. Had they been
able to compensate by using the visual inputs, the visual ratio
would have sustained less deficit than the somatosensory and
vestibular ratios. The lack of excessive reliance on visual infor-
mation for balance control is also reflected by the insignificant
between-group difference in the preference ratio (Table IV).
Although we have identified significant balance deficits in
children with ADHD-C, some important questions arise.
How are the balance deficits related to the behavioral symp-
toms of ADHD (ie, impulsivity, hyperactivity, inattention)?
What are the possible neural substrates for the observed bal-
ance dysfunctions? Neuroimaging studies have provided
some insights into these areas.5-11
Unusual activity in the prefrontal cortex, an area impor-
tant for executive functions such as moderating socially
acceptable behaviors and decision-making, has been reported
in some individuals with ADHD.5-8 Interestingly, abnormal-
ities (eg, reduced size, decreased blood flow) in the cerebel-
lum and caudate nucleus have also been found in some
children with ADHD.8-10 Both of these brain structures
have extensive interconnections with the prefrontal cor-
tex.8,17 Thus, dysfunction in one component of this neural
circuitry may affect functioning of other parts of the system.8
Although the prefrontal cortex has been thought to con-
tribute to the behavioral symptoms observed in ADHD,8,9
its intimate connections with the cerebellum and the caudate
nucleus may partly explain the coexistence of sensorimotor
Shum and Pang
August 2009
deficits and behavioral symptoms in children with ADHD.8,9
The cerebellum, in particular, receives extensive inputs from
the somatosensory, vestibular, and visual systems and plays
a major role in regulating balance.17 Thus, the suboptimal
functioning of the cerebellum may provide an explanation
for our finding that all 3 sensory ratios are significantly lower
in children with ADHD-C than in control children.8,16
It is reasonable to postulate that balance dysfunction has
an important impact on activity, particularly in situations
that demand higher balance ability (eg, walking on uneven
terrain, stairs management in school, sports activities).
When coupled with ADHD-related symptoms (inattention,
impulsivity, hyperactivity), poor balance may further
increase the risk of injuries during these activities. Hence,
balance function and the relative contribution of the sensory
systems should be an essential component of assessment of
children with ADHD-C to direct treatment.
There are several limitations in this study. First, a conve-
nience sample was used, and self-selection bias may be
involved. For example, parents who were more concerned
about the children’s balance ability might be more willing
to join this study. Second, only a small proportion of the chil-
dren were receiving medications for ADHD. The sample
might reflect a group of children with a milder expression
of ADHD. It would be interesting to further explore the bal-
ance performance in children who are taking medications for
treatment of ADHD. Finally, how the balance deficits affect
activity and participation was not examined, and this impor-
tant area awaits further research. n
Submitted for publication Sep 19, 2008; last revision received Dec 30, 2008;
accepted Feb 13, 2009.
Reprint requests: Dr Marco Y.C. Pang, Department of Rehabilitation Sciences,
Hong Kong Polytechnic University, Kowloon, Hong Kong. E-mail: rsmpang@
inet.polyu.edu.hk.
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