Neurological Soft Signs in Patients with Attention Deficit Hyperactivity Disorder Aged 6 to 18 Years Old at a University Hospital: A Cross-sectional Study


Purpose: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children persisting into adulthood. Evidence suggests that the condition is etiologically related to delayed brain maturation. The detection of the presence of neurological soft signs can be a means to assess neuromaturation. The objective of this study was to assess the prevalence of neurological soft signs in ADHD patients and determine any correlation between the presence of neurological soft signs with age, gender, severity and type of ADHD which could give further insights into this disorder.


Methods: A cross-sectional study was conducted at the Child Neurology and Developmental Pediatrics outpatient clinic which included patients 6-18 years old diagnosed with ADHD as well as healthy controls. Patients with other neurodevelopmental conditions (intellectual disability, metabolic disorder, cerebral palsy, abnormal MRI findings), or any condition that may lead to failure to complete the given tasks such as physical handicaps were excluded. Neurological soft signs were measured by utilizing the Physical and Neurological Evaluation for Soft Signs (PANESS) scale.


Key Findings: A total of 48 patients between 6 and 18 years of age (24 ADHD patients and 24 healthy controls) were examined. Neurological soft signs were significantly higher in patients with ADHD and were present regardless of gender, type and severity of ADHD. ADHD patients performed worse on the given tasks as evidenced by higher PANESS scores. There was a weak negative correlation between neurological soft signs and age indicating that soft sign scores decrease with increasing age. There was no statistically significant difference in neurological soft sign scores between those with medication versus without treatment, except for dysrhythmia which was significantly higher in the drug-naive group.



Neurological soft signs are common in patients with ADHD and add scientific evidence to the predictive value of neurological soft signs as indicators of the severity of functional impairment in ADHD. The prevalence of neurological soft signs is much higher in children with ADHD than in controls which may have the potential to improve sensitivity in the diagnosis of ADHD.


Keywords: Neurological soft signs, ADHD, PANESS

  1. Polanczyk G, De Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry. 2007 Jun;164(6):942–8.
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. BMC Med. 2013;17:133–7.
  3. ADHD Society of the Philippines. 2000. Available from:
  4. Pasini A, D'agati E. Pathophysiology of NSS in ADHD. The World Journal of Biological Psychiatry. 2009 Jan 1;10(4-2):495–502.
  5. Dickstein DP, Garvey M, Pradella AG, Greenstein DK, Sharp WS, Castellanos FX, et al. Neurologic examination abnormalities in children with bipolar disorder or attention-deficit/hyperactivity disorder. Biological Psychiatry. 2005 Oct 1;58(7):517–24.
  6. Denckla MB. Revised neurological examination and subtle signs. Psychopharmacol Bull. 1985;21:773–9.
  7. Gidley Larson JC, Mostofsky SH, Goldberg MC, Cutting LE, Denckla MB, Mahone EM. Effects of gender and age on motor exam in typically developing children. Developmental Neuropsychology. 2007 Jul 6;32(1):543–62.
  8. Mayston MJ, Harrison LM, Stephens JA. A neurophysiological study of mirror movements in adults and children. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society. 1999 May;45(5):583–94.
  9. Patankar VC, Sangle JP, Shah HR, Dave M, Kamath RM. Neurological soft signs in children with attention deficit hyperactivity disorder. Indian Journal of Psychiatry. 2012 Apr;54(2):159.
  10. Pennington BF, Ozonoff S. Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry. 1996 Jan;37(1):51–87.
  11. Guy W. Physical and neurological examination for soft signs (PANESS). ECDEU Assessment Manual for Psychopharmacology. Revised. US: 383Á406. 1976.
  12. Cardo E, Casanovas S, Servera M. Soft neurological signs: are they of any value in the assessment and diagnosis of attention deficit hyperactivity disorder?. Revista de Neurologia. 2008;46:S51–4.
  13. Castellanos FX, Acosta MT. The neuroanatomy of attention deficit/hyperactivity disorder. Revista de Neurologia. 2004 Feb;38:S131–6.
  14. Dazzan P, Morgan KD, Chitnis X, Suckling J, Morgan C, Fearon P, et al. The structural brain correlates of neurological soft signs in healthy individuals. Cerebral Cortex. 2005 Oct 26;16(8):1225–31.
  15. Castellanos FX, Proal E. Large-scale brain systems in ADHD: beyond the prefrontal–striatal model. Trends in Cognitive Sciences. 2012 Jan 1;16(1):17–26.
  16. Cao Q, Zang Y, Sun L, Sui M, Long X, Zou Q, Wang Y. Abnormal neural activity in children with attention deficit hyperactivity disorder: a resting-state functional magnetic resonance imaging study. Neuroreport. 2006 Jul 17;17(10):1033–6.
  17. Barkley RA. Theories of attention-deficit/hyperactivity disorder. In: Handbook of Disruptive Behavior Disorders. 1999 (pp. 295–313). Springer, Boston, MA.
  18. Mostofsky SH, Newschaffer CJ, Denckla MB. Overflow movements predict impaired response inhibition in children with ADHD. Perceptual and Motor Skills. 2003 Dec;97(suppl 3):1315–31.
  19. Uslu R, Kapci EG, Oztop D. Neurological soft signs in comorbid learning and attention deficit hyperactivity disorders. Turkish Journal of Pediatrics. 2007 Jul 1;49(3):263.
  20. Meyer A, Sagvolden T. Fine motor skills in South African children with symptoms of ADHD: influence of subtype, gender, age, and hand dominance. Behavioral and Brain Functions. 2006 Dec;2(1):33.
  21. Pitcher TM, Piek JP, Hay DA. Fine and gross motor ability in males with ADHD. Developmental Medicine and Child Neurology. 2003 Aug;45(8):525–35.
  22. Dazzan P, Morgan KD, Chitnis X, Suckling J, Morgan C, Fearon P, et al. The structural brain correlates of neurological soft signs in healthy individuals. Cerebral Cortex. 2005 Oct 26;16(8):1225–31.
  23. Aziz A, Azza AN, El Sheikh MM, Mohsen NM, Khalil SA, Hassan AM. Neurological soft signs in a sample of Egyptian ADHD children and their clinical correlates. Middle East Current Psychiatry. 2016 Apr 1;23(2):51–5.
  24. Blakemore SJ, Burnett S, Dahl RE. The role of puberty in the developing adolescent brain. Human Brain Mapping. 2010 Jun;31(6):926–33.
  25. Lazarus JA, Todor JI. The role of attention in the regulation of associated movement in children. Developmental Medicine and Child Neurology. 1991 Jan;33(1):32–9.
  26. Hadders-Algra M. Developmental coordination disorder: is clumsy motor behavior caused by a lesion of the brain at early age?. Neural Plasticity. 2003;10(1-2):39–50.
  27. Gustafsson P, Svedin CG, Ericsson I, Linden C, Karlsson MK, Thernlund G. Reliability and validity of the assessment of neurological soft‐signs in children with and without attention‐deficit–hyperactivity disorder. Developmental Medicine & Child Neurology. 2010 Apr;52(4):364–70.
  28. Valdimarsdottir M, Hrafnsdottir AH, Magnusson P, Gudmundsson OO. The frequency of some factors in pregnancy and delivery for Icelandic children with ADHD. Laeknabladid. 2006 Sep;92(9):609–14.
  29. Vitiello B, Stoff D, Atkins M, Mahoney A. Soft neurological signs and impulsivity in children. Journal of Developmental and Behavioral Pediatrics. 1990 Jun ;11(3):112-5.
  30. Rubia K, Noorloos J, Smith A, Gunning B, Sergeant J. Motor timing deficits in community and clinical boys with hyperactive behavior: the effect of methylphenidate on motor timing. Journal of Abnormal Child Psychology. 2003 Jun 1;31(3):301–13.
  31. Pitzianti M, D’Agati E, Casarelli L, Pontis M, Kaunzinger I, Lange KW, et al. Neurological soft signs are associated with attentional dysfunction in children with attention deficit hyperactivity disorder. Cognitive Neuropsychiatry. 2016 Nov 1;21(6):475–93.
  32. Gidley Larson JC, Mostofsky SH, Goldberg MC, Cutting LE, Denckla MB, Mahone EM. Effects of gender and age on motor exam in typically developing children. Developmental Neuropsychology. 2007 Jul 6;32(1):543–62.

Articles related to the one you are viewing

There are currently no results to show, please try again later

CC BY: Open Access Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit