Neuroscience Letters 766 (2022) 136349

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Neuroscience Letters
journal homepage: www.elsevier.com/locate/neulet

Manual dexterity and strength and in young adults with and without
Attention-Deficit/Hyperactivity Disorder (ADHD)
Alexandra C. Fietsam a, Jacqueline R. Tucker b, Manjeshwar Sahana Kamath a,
Cynthia Huang-Pollock c, Zheng Wang d, Kristina A. Neely a, *
a
School of Kinesiology, Auburn University, AL, United States
b
College of Medicine, The Pennsylvania State University, PA, United States
c
Department of Psychology, The Pennsylvania State University, PA, United States
d
Department of Applied Physiology and Kinesiology, University of Florida, FL, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Manual motor deficits are common in children with attention deficit/hyperactivity disorder (ADHD); however, it
ADHD is unclear whether these impairments persist into adulthood. The aim of this study was to examine manual
Manual dexterity dexterity and strength in young adults with ADHD aged 18–25 years. Sixty-one individuals with confirmed
Hand strength
ADHD and 56 adults without ADHD completed Purdue Pegboard tasks for manual dexterity and maximal hand-
Bimanual coordination
Pegboard
and pinch-grip tests for strength. In the Purdue Pegboard task, participants placed pins using the right, left, and
both-hands, respectively. In addition, participants built assemblies using pins, washers, and collars with alter­
nating hand movements. The results demonstrated that women without ADHD out-performed the other three
groups in the right-hand, bimanual, and assembly PPB tasks. Both maximal hand strength tests demonstrated that
men were stronger than women, but no differences were observed between adults with and without ADHD. The
current findings suggest that adults with ADHD may have deficits in manual dexterity and tasks requiring
bimanual coordination.

1. Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is the most com­
mon neurodevelopmental disorder affecting nearly 10% of American
children ages 4–17 years [1,2]. Children with ADHD experience diffi­
culties in fine and gross motor control that negatively impact their ac­
ademics [3], social life [4], handwriting [5,6], and tool use [7]. In
contrast, typically developing children (TDC) establish fundamental
motor skills of gait and balance at 6–7 years [8,9]. Specifically, by age of
10, motor skills have become efficient and unnecessary concomitant
movements (i.e., overflow) usually dissipate [2,9]. Conversely, children
with ADHD continue to experience deficits in coordination, balance,
speed, and rhythm [2,9–11] and overflow movements do not diminish
[11,12]. Further, compared to TDC, children with ADHD present
increased motor variability in temporal [13] and spatial [14,15] do­
mains of assessment. Children with ADHD also demonstrate difficulties
in tasks demanding manual dexterity and bimanual coordination [16].
For example, children with ADHD exhibit difficulty setting movement
parameters, such as the size of letters [17,18] and spacing between
words [5] during handwriting activities. Further, children with ADHD
also obtain lower scores during dominant, non-dominant, and bimanual
Purdue pegboard (PPB) tasks compared to non-ADHD controls [19].
Although less frequently studied, ADHD in adulthood is also asso­
ciated with motor control impairments, including inconsistent finger
tapping frequency [20,21], reduced visuomotor adaptation during
reaching [22], deficits in oculomotor control [23,24], and reduced
postural stability [25]. Recent work from our group reported that,
compared to adults without ADHD, adults with ADHD produced more
force than required in visually and memory-guided isometric grip force
tasks [26]. Similarly, in a force-variant of the classic Go/No-Go para­
digm, adults with ADHD produced more force than non-ADHD controls
on both Go and No-Go trials [27]. In other words, in both studies, adults
with ADHD were able to scale their force output to the target force
amplitude, but they produced more force than necessary to achieve the
target [26,27]. Importantly, no differences were observed for maximal
force production in adults with ADHD compared to adults without

Abbreviations: ADHD, Attention-Deficit/Hyperactivity Disorder.

* Corresponding author at: School of Kinesiology, Auburn University, 301 Wire Road, Auburn, AL 36849, United States.
E-mail address: kaneely@auburn.edu (K.A. Neely).

https://doi.org/10.1016/j.neulet.2021.136349
Received 28 March 2021; Received in revised form 8 November 2021; Accepted 9 November 2021
Available online 14 November 2021
0304-3940/© 2021 Elsevier B.V. All rights reserved.
A.C. Fietsam et al.
ADHD in either study [26,27]. Taken together, these studies suggest that
adults with ADHD have difficulty controlling force output, and/or
making error corrections during force control tasks. To our knowledge,
no previous work has examined maximal force production in adults with
ADHD.
Much of the previous work examining motor control in people with
ADHD has studied boys and men and thus few have examined sex dif­
ferences. Examining sex differences increases the sample size,
complexity, and expense of the work. However, considering sex differ­
ences in ADHD is important as the male to female ratio changes as a
function of age and ADHD subtype [28]. In children, adolescent, and
adults, the M:F ratio, across all subtypes 2.28:1, 2.56:1, and 2.15:1,
respectively [28]. Therefore, we sought to determine if sex differences
exist for manual dexterity in adults with and without ADHD. We
anticipated that males would be stronger than females, but did not
anticipate sex differences in manual dexterity.
The goal of the current work was twofold. First, we aimed to deter­
mine whether differences exist in manual dexterity and maximal hand
strength for adults with ADHD, compared to age- and sex- matched non-
ADHD controls. Second, we evaluated whether sex differences exist
within each of these groups. Maximal hand- and pinch- grip strength was
examined as well as manual dexterity via the Purdue Pegboard (PPB)
task [29]. The PPB requires multisensory integration, as well as control
of fingertip forces. Based on our previous work describing perceived
sensory differences [30] and differences in force output [26,27], we
anticipated that adults with ADHD would have difficulty with the PPB
task as evidenced by fewer completions compared to adults without
ADHD. Moreover, based on our previous work [26,27], we did not
anticipate group differences in maximal hand strength. Although we did
not expect differences, we included this task to eliminate strength as a
possible explanation for abnormal dexterity.
2. Methods
2.1. Participants
Participants, aged 18–25 years, were recruited from print, radio, and
television advertisements in State College, Pennsylvania and the sur­
rounding area. Exclusion criteria included a history of seizures, epilepsy,
meningitis, encephalitis, autism spectrum disorder, concussion that
resulted in loss of consciousness for more than 10 minutes, or previous
diagnosis 10 min, or previous diagnosis of a disorder involving psy­
chosis. An explanation of the study was provided to all participants
before they completed a written informed consent. The Institutional
Review Board at the Pennsylvania State University approved all pro­
cedures, which were consistent with the Declaration of Helsinki. The
data reported here are a subset of a larger dataset. All participants
received monetary compensation.
2.2. Diagnostic groups
Diagnosis was confirmed using Conners’ Adult ADHD Diagnostic
Interview (CAADID; Multi-Health Systems Inc.). Individuals with ADHD
(n = 61, 40 female) showed five or more symptoms of inattention or
hyperactivity, and these symptoms impaired everyday life in at least two
settings, such as family and work. Individuals without ADHD (n = 56, 39
female) reported less than three total symptoms and less-than or equal-
to two symptoms of inattention or hyperactivity.
Adults taking a psychostimulant completed the laboratory session
after a 24-hour washout period. No participants were taking medica­
tions known to affect motor control at the time of testing, including
antipsychotics, stimulants, or anticonvulsants [31].
2.3. Procedures
Prior to the laboratory session, using a Qualtrics web interface, all
2
Neuroscience Letters 766 (2022) 136349
participants completed a brief medical history and long form of the
Connors Adult ADHD Rating Scales (CAARS) [32]. Handedness was
assessed using the Edinburgh Handedness Inventory [33]. The 10-item
inventory asks participants to indicate which hand they would use to
complete common tasks, such as striking a match, throwing, or using
scissors. Handedness is determined using a laterality quotient (LQ = (R-
L)/(R + L) * 100), where a score of 100 reflected complete right-hand
dominance, and a score of − 100 reflected complete left-hand domi­
nance. Only individuals who were right-hand-dominant were included
in the current study.
During the laboratory session, participants completed the CAADID
semi-structured interview (Multi-Health Systems Inc.), which was
updated in accordance with the DSM-5 criteria [34]. IQ was assessed
using the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV).
Full-scale intelligence quotient (FSIQ) score was derived for each
participant [35]. Participants then completed grip and pinch strength
testing and the PPB tasks [36].
2.4. Purdue pegboard tasks
Participants completed the PPB [36] to quantify manual dexterity.
The right hand, left hand, and bimanual trials were 30 s in duration,
while assembly trials were 60 s. In the first three conditions, participants
were instructed to place as many pins as possible in a row of small holes
in three conditions. In the right hand trials, pins were retrieved from the
right-most well and placed in the right column of holes. In the left hand
trials, pins were retrieved from the left-most well and placed in the left
column of holes. In the bimanual trials, the right and left hands worked
in tandem, retrieving pins from the right and left wells, respectively, and
placing them in corresponding right and left columns. The last set of
trials required coordination of the hands to complete “assemblies.” In
these trials, participants placed a pin with their right hand, then a
washer with their left, followed by a collar with their right, and a final
washer with their left. This series of placements constituted one “as­
sembly.” In all four conditions (i.e., right hand, left hand, bimanual, and
assemblies), participants were instructed not to retrieve a pin if it was
dropped, but instead to get another pin and continue with the task. The
task was recorded by counting the number of pins successfully placed or
assemblies completed. A total of four scores were obtained: pins placed
with the right hand, pins placed with the left hand, pins placed with both
hands (bimanual condition), and completed assemblies. In addition, the
number of dropped pins were recorded for each condition. Participants
completed three trials in each condition, and an average was calculated
for number of pins placed and number of pin drops for each condition.
2.5. Maximum hand and pinch strength tests
Participants’ maximum voluntary contraction (MVC) was obtained
with pinch-grip (Lafayette Hydraulic Pinch Gauge, Model J00111,
Lafayette, IN) and a hand-grip dynamometers (Lafayette Hydraulic
Pinch Gauge, Model J00105 Lafayette, IN). In the pinch-grip trials,
participants completed the task with the elbow bent to approximately
90◦ while seated and with the forearm supported by the arm rests of the
chair. The thumb was placed on the bottom of the grip while the index
finger was placed on the top. In the hand-grip trials, participants
completed the task with the arm fully extended while seated. Partici­
pants squeezed as hard as possible with each hand to produce MVC of a
hand for each grip maneuver. Three 3-second trials were administered
for each hand during each grip maneuver. Participants alternated be­
tween left and right hands, providing at least a minute break between
each trial. MVC was derived by taking the average of peak force of three
trials.
2.6. Statistical analysis
The groups were age- and sex- matched, leading to the following
A.C. Fietsam et al. Neuroscience Letters 766 (2022) 136349

final sample sizes: non-ADHD men (n = 17), men with ADHD (n = 21),
non-ADHD women (n = 39), women with ADHD (n = 40). Differences in
group demographics were tested using multivariate analysis of variance
(MANOVA). The Shapiro-Wilk’s test for normality was significant for
nine of the 12 dependent variables associated with the PPB, maximal
hand-strength, and maximal pinch-strength tasks. Therefore, group
differences were examined using the Kruskal-Wallis H-test, followed by
pairwise comparisons in which the significance values were adjusted by
the Bonferroni correction for multiple tests.

3. Results

3.1. Participants
Table 1 reports the results of a multivariate analysis of variance
(MANOVA) for age, FSIQ, and three symptom-rating scores from the
CAADID. As anticipated, no group differences were observed for age or
FSIQ, all p-values > 0.05. However, adults with ADHD reported more
symptoms of inattention and hyperactivity/impulsivity, and more total
symptoms than adults without ADHD, all p-values < 0.001.
3.2. Manual dexterity
A Kruskal-Wallace H-test was performed to examine the number of
completions and the number of pin drops on the PPB. The results
demonstrated a difference between groups for the number of comple­
tions in the right-hand, H(3) = 16.49, p = .001, left-hand, H(3) = 8.42, p
= .038, both-hands, H(3) = 17.23, p = .001, and assembly, H(3) =
22.62, p < .001, conditions. As shown in Fig. 1, pairwise comparisons
adjusted by the Bonferroni correction for multiple tests revealed that
women without ADHD achieved more completions in the right-hand,
both-hands, and assembly conditions, compared to men and women
with ADHD, and men without ADHD. Pairwise comparisons for the
number of completions in the left-hand condition were not significant
when adjusted by the Bonferroni correction. The Kruskal-Wallace H-test
demonstrated no differences between groups for the number of pin
drops, all p-values > 0.098.
3.3. Manual strength
A Kruskal-Wallace H-test was performed to examine maximum hand-
and pinch- grip strength between groups. The results demonstrated a
Table 1
Participant characteristics.
Variables Group Significant Group
Differences
Control ADHD
Fig. 1. Women without ADHD (W-CTRL) achieved more completions than
women with ADHD (W-ADHD), and men with (M-ADHD) and without (M-
CTRL) ADHD for the right-hand, both-hands, and assembly conditions. Signif­
icance values for all pairwise comparisons were adjusted by the Bonferroni
correction. Error bars represent standard deviation.
difference between groups for the right hand-grip, H(3) 60.25, p < .001,
left hand-grip, H(3) = 58.57, p < .001, right pinch-grip, H(3) = 20.89, p
< .001, and left pinch-grip, H(3) = 26.67, p < .001. As shown in Fig. 2,
pairwise comparisons adjusted by the Bonferroni correction for multiple
tests revealed sex differences, such that men were generally stronger
than women. Specifically, for the right hand-grip, men with ADHD
(99.7 ± 20.2 N) and men without ADHD (94.3 ± 21.9 N) were stronger
than women with ADHD (55.2 ± 11.6 N) and women without ADHD
(64.6 ± 14.1 N). Similarly, for the left hand-grip, men with ADHD (93.4
± 23.4 N) and men without ADHD (90.2 ± 18.7 N) were stronger than
women with ADHD (52.3 ± 11.6 N) and women without ADHD (61.0 ±
15.8 N). For the right pinch-grip, men with ADHD (10.8 ± 3.3 N) and
men without ADHD (10.5 ± 2.9 N) were stronger than women with
ADHD (7.5 ± 2.7 N), but not women without ADHD (9.0 ± 2.2 N). Last,
for the left pinch-grip, men with ADHD (10.2 ± 3.0 N) and men without
ADHD (10.2 ± 2.1 N) were stronger than women with ADHD (7.1 ± 2.3
N) and women without ADHD (7.9 ± 2.0 N).
4. Discussion
The current work examined whether manual dexterity and maximal
hand strength differed for adults with ADHD compared to non-ADHD
controls, and within these groups, for women compared to men. We
report two findings. First, in terms of manual dexterity, women without
ADHD achieved more completions in the right-hand, both-hands, and
assembly conditions, compared to men and women with ADHD, and
men without ADHD. Second, men (with and without ADHD) were
generally stronger than women in both the hand-grip and pinch-grip

Sample size (Females) 56 (39) 61 (40) ADHD = CTRL,

χ2 (1, N = 117) =
0.22, p = .639
Age, years 21.16 20.69 ADHD = CTRL,
(1.87) (1.72) F(1, 113) = 0.21, p
= .652
FSIQ 109.27 108.30 ADHD = CTRL,
(10.54) (11.27) F(1, 113) = 0.11, p
= .747
CAADID
Number of inattention 0.09 6.43 ADHD > CTRL,
symptoms endorsed in (0.39) (2.33) F(1, 113) =
adulthood 339.34, p < .001
Number of hyperactive/ 0.05 5.20 ADHD > CTRL,
impulsive symptoms endorsed (0.30) (2.14) F(1, 113) =
in adulthood 268.49, p < .001
Total number of symptoms 0.14 11.62 ADHD > CTRL, Fig. 2. Men with (M-ADHD) and without (M-CTRL) ADHD were stronger than
endorsed in adulthood (0.48) (3.29) F(1, 113) =
women with (W-ADHD) and without (W-CTRL) ADHD in the left pinch-grip, left
570.72, p < .001
hand-grip, and right hand-grip tasks. Significance values for all pairwise com­
Note: Values are means and standard deviations (in parentheses), with the parisons were adjusted by the Bonferroni correction. Error bars represent
exception of sample size. standard deviation.

3
A.C. Fietsam et al.
tests.
Successful performance on the PPB task requires the performer to
precisely control fingertip forces, filter out unnecessary sensory input,
and correctly integrate sensory feedback in order to quickly and accu­
rately place pins, washers, and collars. In the current study, women
without ADHD performed better than women with ADHD, and both men
with and without ADHD. These findings suggest that adults with ADHD
may have difficulty with manual dexterity tasks. Three possible expla­
nations to this finding include poor regulation of fingertip forces,
inappropriate sensory filtering, and/or difficulties with sensorimotor
integration in adults with ADHD. The pins used in the PPB task are small
(one inch in length) and necessitate finely graded forces at the fingertips
in order to meticulously pick up, manipulate, and place. Control over
fingertip forces depends on the participant’s ability to store a memory
representation about the object’s physical properties, which were ob­
tained during early lifting and handling of the object [37–39]. Previous
research indicates that children with ADHD have difficulties with
parametric control of fingertip forces during precision grift and lift tasks
[40]. Further, studies have demonstrated that individuals with ADHD
exhibit an inability to filter sensory input [41] and increased moment-to-
moment neural variability on cognitive tasks [42] compared to non-
ADHD controls. Particularly, several studies have reported that neural
activity is not appropriately suppressed in individuals with ADHD,
resulting in more variable task performance due to neural interference
[43–45]. As the PPB task does not isolate motor and sensory compo­
nents, the current study cannot determine if the findings are due to
motor deficits, sensory deficits, or difficulties with sensorimotor inte­
gration. Further, sex differences were revealed such that women out­
performed men, which is consistent with a plethora of work [29,46–53].
For example, Schmidt et al. (2000) report that when tasked with placing
25 pins in the PPB, women completed the task faster than men with both
their preferred and non-preferred hand [54]. These differences in
manual dexterity suggests that future work examining fine motor con­
trol should account for sex in experimental design.
Grip strength is correlated with overall strength [55] and body
composition [56] and may provide insight to functional ability [57,58].
Indeed, accurate and predictable force is necessary for the successful
completion of many activities of daily living, including eating, hand­
writing, self-care, and other functional fine motor tasks. The current
results demonstrated that adults with ADHD do not have deficits in
maximal hand strength and that men were stronger than women.
Therefore, force production deficits in adults with ADHD are not likely
due to strength deficits, but rather difficulty with force regulation or
sensorimotor integration. Further, the finding that men are stronger
than women, regardless of diagnostic group, is consistent with norma­
tive data [59–61] and is a reminder that studies that examine maximal
force production should include sex as a factor in the experimental
design.
5. Conclusions
The results demonstrated that young adults with ADHD may have
deficits in manual dexterity, but not manual strength. Women without
ADHD outperformed men and women with ADHD in the right-hand,
both-hands, and assembly conditions of the PPB. This finding suggests
a deficit in fine motor control, manual/bimanual dexterity, and/or
bimanual coordination. The PPB is a functional task that relies on
multiple mechanisms, such as visuospatial skill, sensory integration,
force regulation, and movement speed. Future studies might aim to
parse these components to elucidate the neural mechanisms driving
performance differences. Such work may determine that tasks of manual
dexterity can be objective and quantitative measures for diagnosis,
prognosis, or response to treatment.
The present work also demonstrates a need to examine sex differ­
ences between categorical groups. This poses a challenge for study
recruitment and highlights the need for larger sample sizes and more
4
Neuroscience Letters 766 (2022) 136349
complex statistical models that allow for the relaxation of assumptions
such as equal group size and equal group variances. This is particularly
important in the study of clinical populations with variability in
behavior.
Funding sources:
• This work was supported, in part, by a Young Investigator Award
(#25004) from the Brain & Behavior Research Foundation to KAN.
• This work was supported, in part by an NIA R21 Exploratory/
Developmental Grant (AG 065621) and the University of Florida
Clinical and Translational Science Institute (CTSI) Pilot Award
(UL1TR001427) to ZW.
• This publication was supported, in part, by Grant UL1 TR002014 and
KL2 TR002015 from the National Center for Advancing Translational
Sciences (NCATS).
• The content is solely the responsibility of the authors and does not
necessarily represent the official views of the funding agencies listed
above.
CRediT authorship contribution statement
Alexandra C. Fietsam: Data curation, Writing – original draft.
Jacqueline R. Tucker: Investigation. Manjeshwar Sahana Kamath:
Writing – review & editing. Cynthia Huang-Pollock: Conceptualiza­
tion, Methodology. Zheng Wang: Writing – review & editing. Kristina
A. Neely: Conceptualization, Methodology, Formal analysis, Visualiza­
tion, Supervision, Project administration, Funding acquisition.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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