TYPE Perspective

PUBLISHED 22 January 2025

DOI 10.3389/fnins.2025.1453025

Can attention-deficit/
OPEN ACCESS hyperactivity disorder
be considered a form of
EDITED BY
Masaya Tachibana,
Osaka University, Japan

REVIEWED BY
Anders Rasmussen,
cerebellar dysfunction?
Lund University, Sweden
Manabu Saito,
Hirosaki University, Japan
Valeria Isaac 1*, Vladimir Lopez 2 and Maria Josefina Escobar 1
*CORRESPONDENCE
1
Center for Social and Cognitive Neuroscience, School of Psychology, Universidad Adolfo Ibáñez,
Valeria Isaac Santiago, Chile, 2 Escuela de Psicología, Facultad de Ciencias Sociales, Pontificia Universidad Católica
[email protected] de Chile, Santiago, Chile

RECEIVED 24 June 2024

ACCEPTED 02 January 2025
Attention-deficit/hyperactivity disorder (ADHD) is a heterogenous disorder, commonly
PUBLISHED 22 January 2025
described for presenting difficulties in sustained attention, response inhibition, and
CITATION
Isaac V, Lopez V and Escobar MJ (2025) Can
organizing goal-oriented behaviors. However, along with its traditionally described
attention-deficit/hyperactivity disorder executive dysfunction, more than half of the children diagnosed with ADHD have
be considered a form of cerebellar been reported to show difficulties with gross and fine motor skills, albeit motor
dysfunction?
Front. Neurosci. 19:1453025.
impairments in ADHD continue to be a neglected area of clinical attention. The
doi: 10.3389/fnins.2025.1453025 rapidly growing field of the clinical cognitive neuroscience of the cerebellum has
COPYRIGHT
begun to relate cerebro-cerebellar circuits to neurodevelopmental disorders. While
© 2025 Isaac, Lopez and Escobar. This is an the cerebellum’s role in motor function, such as balance, motor coordination, and
open-access article distributed under the execution, is well recognized, ongoing research has evidenced its additional and
terms of the Creative Commons Attribution
License (CC BY). The use, distribution or fundamental role in neurocognitive development and executive function, including
reproduction in other forums is permitted, attention and social cognition, which are all areas of impairment commonly found
provided the original author(s) and the in ADHD. Interestingly, neuroimaging studies have consistently shown differences in
copyright owner(s) are credited and that the
original publication in this journal is cited, in cerebellar volume and functional connectivity between ADHD and typically developing
accordance with accepted academic children. Furthermore, methylphenidate is known to act at the cerebellar level, as
practice. No use, distribution or reproduction intrinsic cerebellar dopaminergic systems involved in attention and motor function
is permitted which does not comply with
these terms. have been identified. This article reviews some of the main findings linking cerebellar
dysfunction to ADHD behavioral symptoms and incorporates the cerebellum as a
possible neurological basis and differentiating indicator within the condition. We suggest
considering more rigorous assessments in future ADHD studies, including cerebellar-
associated skill evaluations to correlate with symptom severity and other detected
outcomes, such as executive dysfunction, and study possible associative patterns
that may serve as more objective measures for this diagnosis.

KEYWORDS

attention-deficit/hyperactivity disorder, development, motor impairment, cerebellar

dysfunction, cortico-cerebellar network

1 Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent conditions
in pediatric psychopathology, estimated to affect approximately 3 to 9.5% of the global
population (Polanczyk et al., 2007; Thomas et al., 2015), predominantly affecting school-aged
children. Its characteristic symptoms, inattention, hyperactivity, and impulsivity (American
Psychiatric Association, 2022) are often explained due to impairments in neuropsychological
executive functions such as response inhibition, working memory, and inhibitory control
(Barkley, 1997; Martinussen et al., 2005; Willcutt et al., 2005). Another prominent feature of
ADHD is that it is often accompanied by a high percentage of comorbid disorders across the

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Isaac et al. 10.3389/fnins.2025.1453025

lifespan. In adulthood, between 65 and 89% of patients with ADHD et al., 2011; Mostofsky et al., 1998), and functional cerebellar
suffer from one or more additional psychiatric disorders, such as dysconnectivity (Feng et al., 2023; Tomasi and Volkow, 2012; Wang
mood and anxiety disorders, substance use disorders, and personality et al., 2022).
disorders (Sobanski, 2006). In younger populations, ADHD is The cerebellum is considered a vital component in the human
frequently associated with psychiatric comorbidities, including brain that has traditionally been studied for its central role in motor
learning disorders, conduct disorders, anxiety, and depression (Kessler movement regulation and balance control. It is known to integrate
et al., 2006). ADHD has been frequently associated with motor different sensory inputs such as visual, vestibular, and somatosensory
deficiencies, with 45–70% of children diagnosed with ADHD reported information responsible for motor coordinated movements, postural
to show difficulties in both gross and fine motor skills (Kaiser et al., control, and the planning of sequenced actions (Horak and
2015; Pitcher et al., 2003; Sayal et al., 2018). Balance and bilateral Macpherson, 1996), contributing to the quality of movement in
coordination (including manual dexterity) are the most commonly conjunction with the prefrontal cortex (PFC) and basal ganglia
reported areas of motor function impairment (Buderath et al., 2009; (Welniarz et al., 2021). The cerebellum is also known to play a pivotal
Fliers et al., 2008; Ghanizadeh, 2010; Goulardins et al., 2013; Karaokur role in fine motor such as bilateral manual dexterity (Soteropoulos and
et al., 2017; Konicarova et al., 2014). Baker, 2008), speech articulation (Salman and Tsai, 2016), and the
Historically, ADHD has been associated with disturbances in the realization of coordinated eye movements including the control of
maturation of executive function (EF) due to frontostriatal and fixed eye movements through projections from the frontal eye field
frontoparietal dopamine-signaling deficits (Aboitiz et al., 2014), while (Pretegiani et al., 2018). While the cerebellum is often described as a
motor disturbances were not initially considered part of its diagnostic structure mainly involved in motor coordination, it has a well-
criteria. Past hypotheses explaining the motor difficulties often found established role in numerous facets of cognitive, emotional, and
in individuals with ADHD have taken two main approaches: The first behavioral functioning (Koziol et al., 2014) which are all areas
attributes these motor difficulties to the basic symptomatic triad of reported as dysfunctional in ADHD. To date, there is enough evidence
ADHD, influenced by inattention (Ghanizadeh, 2010) and/or to sustain that the cerebellum could be playing a central role in ADHD
impulsivity (Tseng et al., 2004). The severity of inattentiveness score outcomes and symptomatic behaviors, particularly in children. In this
has been found to correlate with and predict poor motor performance, study, we will review some main findings that link the cerebellum
such as coordination problems (Fliers et al., 2008), as well as deficits directly to all symptoms commonly reported in ADHD.
in fine motor skills or writing (Ghanizadeh, 2010; Kaiser et al., 2015).
Piek et al. (2004) explored the link between inattention, motor ability,
and aspects of EF in children with ADHD (6–15 years of age) and 2 Evidence for cerebellar involvement
reported strong correlations between poor motor coordination and in all reported ADHD symptoms
inattention but weaker correlations with EF, despite the fact that
research has established an undisputed association between EF and 2.1 Cognitive performance and executive
ADHD (Willcutt et al., 2005). Tseng et al. (2004) found that measures functioning
of sustained attention, along with additional impulse control, were
good concurrent predictors of fine and gross motor skills in 6- to One of the most currently accepted hypotheses of the underlying
11-year-olds with ADHD, with attention and impulse control being physiopathology in ADHD is the deficit in dopamine-signaling
the two best predictors of fine motor skill performance. mechanisms, associated with genetic factors encoding for dopamine
The second hypothesis explaining motor problems in ADHD receptor DRD4 and dopamine transporter DAT1, affecting PFC, basal
suggests these may be secondary to a comorbidity, particularly ganglia, thalamus, and amygdala circuits, which participate in EF,
developmental coordination disorder (DCD), defined as severe suggesting a reduction of executive control associated with
impairment in learning and execution of coordinated motor skills abnormalities in frontoparietal and frontostriatal network function
(American Psychiatric Association, 2022), where an estimated 50% of (Antshel et al., 2014) which would directly impact working memory,
children diagnosed with ADHD have been found to meet the criteria the ability to sustain attention to goal-directed tasks, and self-regulate
for DCD (Montes-Montes et al., 2021). Notwithstanding, even when social–emotional behaviors. Studies using neuropsychological
ADHD children do not meet the criteria of DCD, they continue to measures reported that overall cognitive abilities are significantly
show weaker motor skills than typically developing children when lower among ADHD subjects, including significant impairment in all
evaluated (Klupp et al., 2021; Manicolo et al., 2016; Poblano EF tasks (Frazier et al., 2004).
et al., 2014). While the cerebellum’s role in motor function is well recognized,
A few decades ago, a line of research emerged suggesting a substantial portion of the cerebellum is associated with non-motor
cerebellar dysfunction to ADHD symptoms after Castellanos et al. functions connected to different large-scale networks in the neocortex,
reported significantly smaller cerebellar hemispheric volumes in including frontal and parietal regions typically involved in high-order
ADHD children using quantitative brain magnetic resonance imaging cognitive processing, providing the means through which association
(Castellanos, 2002; Castellanos et al., 1996). Following neuroimaging areas and the cerebellum may influence each other’s operation
studies describing structural differences in the brain of ADHD (Ramnani, 2012). Resting-state functional connectivity MRI studies
children when compared to typical peers continued to establish show that cerebral networks involved in movement, attention, and
atypical cerebellar volume as one of the most consistent findings in the limbic valence, as well as frontoparietal and default systems associated
neuroimaging literature on ADHD (Pereira-Sanchez and Castellanos, with creativity and imagination, map onto the cerebellum with
2021; Valera et al., 2007) particularly with gray matter reductions in topographic specificity (Buckner et al., 2011). The dorsal attention,
the posterior-inferior lobules, VIII to X (Berquin et al., 1998; Bledsoe ventral attention, frontoparietal, default mode, and salience networks

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map onto focal areas within the posterior lobe of the cerebellum. proprioceptive inputs. Cerebellar circuitry regulates static and
Lobules VI and Crus I are engaged in language and verbal working dynamic parameters playing a key role in establishing balance stability
memory; lobule VI in spatial tasks; lobules VI, Crus I, and VIIB are and steady gait (Dijkstra et al., 2020). Postural instability and sway
activated by executive functions such as working memory, planning, abnormalities are commonly reported in children with ADHD, and
organizing, and strategy formation; and vermal lobules VI and VII are studies have previously shown a relationship between postural control
involved in emotional processing. Language is heavily right lateralized alterations and the cerebellum in ADHD (Hove et al., 2015). During
and spatial functions left-lateralized, reflecting crossed cerebro- static balance assessments, ADHD-diagnosed children show impaired
cerebellar projections (Schmahmann, 2019). Studies have postural control evidenced in an increased sway of their center of
demonstrated the close relationship between cerebellar function and pressure (Cheng and Wang, 2007) and significantly smaller loss of
working memory (Stein, 2021), attention modulation (Mannarelli stability area (Isaac et al., 2017) than their typical peers. In dynamic
et al., 2019), and higher order executive functioning (Pretegiani et al., motor control, existing evidence in relation to gait (Bucci et al., 2016;
2018) through cortico-cerebellar circuits (Zhu et al., 2023), including Buderath et al., 2009; Kim et al., 2017; Shum and Pang, 2009) shows
bilateral projections between the neocerebellum and dorsolateral PFC that children with ADHD walk with less consistency of speed
(Habas, 2021) as well as the basal ganglia (Caligiore et al., 2017). These (Meachon et al., 2023), less rhythmic and less automatic gait (Leitner
cortico-cerebellar networks have been described as critical during et al., 2007), greater variability of cadence and step time, and greater
participation in tasks that are difficult and novel, especially those variability for stride length when walking at an increased stepping rate
requiring unpredictable and quick adjustments, demanding sustained (Simmons et al., 2020).
attention (Diamond, 2000), directed visual attention and working Cerebellar involvement in complex manual tasks has also been
memory processes (Brissenden and Somers, 2019), and during social documented (Kühn et al., 2012; Rau et al., 2024), including studies of
interactions (Li et al., 2023). neural correlates in handwriting during childhood (Palmis et al., 2021;
Studies with patients with cerebellar lesions have been found to Zhang et al., 2022). Regarding upper extremity motor control, children
show deficits in the ability to shift attention (Akshoomoff and with ADHD have been found to show less fluidity in arm movement
Courchesne, 1994) and direct goal-oriented behavior (Beuriat et al., (Van and Thomas, 2002), reduced coordination in manual dexterity
2022; Botez et al., 1989). Cerebellar symptoms have also been (Brossard-Racine et al., 2012), and slower performance in fine motor
associated with difficulties in spatial working memory in children and tasks (Scharoun et al., 2013). Studies further find that children with
adolescents with ADHD (Ferrin and Vance, 2012). Therefore, the ADHD have less legible handwriting (Mokobane et al., 2019; Shen
cortico-cerebellar network allows the cerebellum not only to et al., 2012), with a tendency to be less accurate in keeping letter size
contribute to the coordination of movements, as once thought, but within boundaries, spacing, and alignment (Tucha and Lange, 2001).
also to the modulation and integration of all higher cortical functions, In addition to gross and fine motor, poor eye movement
including those compromised in ADHD. performance has frequently been reported in children with ADHD
(Goto et al., 2010) when compared to typically developing children.
Children with ADHD show a larger number of errors during anti-
2.2 Motor performance saccade tasks as well as frequent intrusive saccades during smooth
pursuit and fixation (Fried et al., 2014; Maron et al., 2021), less precise
Children with ADHD have consistently shown poor performance and stable movements during visual tracking (Munoz et al., 2003;
on motor skill tests when compared to typically developing children Slaats-Willemse et al., 2005), and need more time to complete
(Brossard-Racine et al., 2012; Goulardins et al., 2013), particularly in oculomotor tasks than those without ADHD (Sherigar et al., 2023).
activities requiring fluent coordinated movements (Fliers et al., 2008; The cerebellum, in particular, is a structure of utmost importance in
Kaiser et al., 2015), handwriting (Brossard-Racine et al., 2011), optimizing goal-directed eye movements such as saccadic and smooth
bimanual coordination (Piek et al., 1999), and gait, balance, and pursuit eye movements to stabilize the images of moving targets (Prsa
postural control (Buderath et al., 2009; Mao et al., 2014; Simmons and Their, 2022). Animal and human studies evidenced that damage
et al., 2020). All of these areas of motor performance are directly to specific parts of the cerebellum causes imprecise visually guided eye
associated with cerebellar function. Even DCD, a common movements and smooth pursuit deficits, such as those of the flocculus/
comorbidity to ADHD, that specifically impairs a child’s ability to paraflocculus or those of the vermis including lobule VI, VII, the
coordinate movement and learn motor skills to perform everyday uvula, and the deep cerebellar nuclei (Baier et al., 2009).
activities, has also been associated with cerebellar dysfunction (Gill Timing of motor actions is another aspect that has been found to
et al., 2022; Mariën et al., 2010). The cerebellum has been considered be impaired in ADHD (Zelaznik et al., 2012), showing slower timing
essential during motor learning and is strongly implicated in detecting of movements and greater variability between sequences of actions
and correcting motor errors (Popa et al., 2016). These motor errors are (Chen et al., 2013; Noreika et al., 2013; Shiels Rosch et al., 2013; Slater
defined as the discrepancy between the predicted consequences of and Tate, 2018), especially when movements require more planning
motor commands and the sensory feedback, which are encoded in the and complex motor coordination (Kaiser et al., 2015). Along with the
cerebellar cortex in the context of a forward internal model that motor cortices and basal ganglia, the cerebellum plays a key role in
generates predictions about the upcoming movement and drives regulating the timing of self-initiated movements and predicting the
learning and adaptation. Cerebellar Purkinje cells have been found not timing of periodic events (Tanaka et al., 2021) which allows for the
only to drive motor learning but also to expand the capacity of motor execution of synchronized movements such as spontaneous dance and
circuits (Nguyen-Vu et al., 2013). clapping to music (Bo et al., 2008). The cerebellum appears to enable
The cerebellum is responsible for the complex integration of these controls by linking sensory inputs and motor timing, particularly
multiple postural information coming from vestibular, visual, and in the range from a few hundred milliseconds to a second (Mauk and

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Buonomano, 2004). Abnormalities in reproducing temporal durations, using encoded internal models that reproduce the dynamic properties
with intervals as brief as 400 ms, have been documented in children of the body involving sequencing and planning of action, to automate
and adolescents with ADHD, showing impairments in duration and fine-tune not only voluntary motor processes but also cognitive
discrimination, and the precision and reliability with which they processes (Ito, 2008) in collaboration with the cortex, such as related
reproduced the intervals (Toplak et al., 2006). Castellanos and ToM processes based on the prediction of sequential events. A
Tannock (2002) proposed a temporal processing candidate previous meta-analysis by Van Overwalle et al. (2014) of fMRI studies
endophenotype for ADHD linked to deficits in time estimation, found robust clusters of activation in the cerebellum recruited during
emphasizing that intra-individual variability in task performance is social-cognitive processes that overlap with cerebellar non-social
“the most striking clinical characteristic in ADHD.” These authors functions such as motor functions, emotions, executive control, and
further state that temporal variability in symptom expression in language. Therefore, in addition to balance and motor coordination
ADHD is linked to cerebellar dysfunction. Timing deficits in ADHD functions, non-motor behaviors, including cognition and social
are furthermore supported by functional neuroimaging studies that behavior, appear to be equally affected by deficits in
show dysfunctions in the key inferior fronto-striato-cerebellar and cerebellar networks.
frontoparietal networks that mediate timing functions (Noreika
et al., 2013).
2.4 Autonomic and arousal regulation

2.3 Social cognition One theoretical model developed to explain ADHD

etiopathogenesis is the state-regulation theory introduced by Sanders
In addition to executive dysfunction and motor impairment, it is (1983), which suggests that a decreased ability to regulate brain
widely acknowledged that social functioning and social cognition are arousal may contribute to the higher-level cognitive deficits in
also altered in children (Arango-Tobón et al., 2023) and adults with ADHD. Arousal state regulation in the brain is related to the release
ADHD (Morellini et al., 2022). These alterations often lead to socially of the catecholamine norepinephrine (NE) and dopamine in the PFC
inappropriate responses, resulting in alterations in their adaptive (Arnsten and Li, 2004). NE has marked effects on PFC function, and
behavior. Social cognition impairments in ADHD have been observed small changes in the autonomic arousal systems can markedly alter
in the domains of theory of mind (ToM) (Parke et al., 2021), the connectivity of PFC networks impacting EF and cognitive
demonstrated by inferior performance in understanding intentional performance (Arnsten and Pliszka, 2011). Autonomic dysregulated
behaviors (Mary et al., 2016; Mohammadzadeh et al., 2016), empathy functions would directly impact brain arousal through locus coeruleus
and emotional intelligence. Children with ADHD have shown poorer (LC) connectivity and NE pathways, coordinated by the central
performance in tasks measuring emotional prosody (especially in autonomic network (CAN), altering the overall efficiency of cognitive
perceiving emotionally angry statements) and intermodal skills (Kis performance (Diamond, 2005) leading to both executive dysfunction
et al., 2017; Uekermann et al., 2010), as well as recognizing facial and hyperactivity symptoms (Sergeant, 2000). Neurophysiological
emotions, with the most significant impairments observed in negative studies measuring activity from the autonomic sympathetic nervous
emotions such as anger and fear (Bora and Pantelis, 2016). system (such as heart rate, electrodermal responses, and pupillary
Schmahmann and Sherman (1998) introduced the cerebellar dilatation) have evidenced dysfunction in individuals with ADHD,
cognitive affective syndrome (CCAS), characterized by disturbances more often in the direction of sympathetic hypo-arousal than hyper-
in executive function, visual–spatial processing, linguistic skills, and arousal, particularly at rest and during tasks requiring response
regulation of affect, linking this syndrome with cerebellar posterior regulation and sustained attention (Bellato et al., 2020).
lobe lesions (Schmahmann, 2019). Since then, studies evidencing Cerebellar structures were associated with autonomic
cerebellar involvement in the regulation of affective reactions as well cardiovascular functions by early experiments, which showed that
as in forming the association between sensory stimuli and their stimulation of the cerebellar vermis interferes with autonomic
emotional values have increased to the point where cerebellar reactions, by limiting blood pressure oscillations and inducing
functional topography for emotional and social processing has hyperventilation (Moruzzi, 1940; Nisimaru, 2004). Further studies
become well-established (D’Agata and Orsi, 2022). found anatomical connections between the fastigial nucleus and the
The cerebellar vermis, which is the principal target of limbic hypothalamus suggesting cerebellar vermis involvement in autonomic
connections (Berntson and Torello, 1982), has been implicated in the and emotional regulatory functions (Snider, 1950). Later studies
modulation of emotions (Stoodley and Schmahmann, 2010), and confirmed the existence of a prominent NE pathway from the
lobules VI and VII (crus I–II), in the posterolateral cerebellar brainstem nucleus LC to all regions of the cerebellar cortex and deep
hemisphere, have been implicated in social cognition that involves cerebellar nuclei (Olson and Fuxe, 1971), recognizing the cerebellum
more complex cognitive processes such as empathy (Sokolov, 2018). as a key region of the CAN (Benarroch, 1993) and demonstrating
An increasing amount of evidence has confirmed that the cerebellum neuromodulatory effects of NE on the spontaneous and evoked
is actively involved in emotional recognition specifically processing discharge of Purkinje neurons (Freedman et al., 1977). NE is capable
facial expressions of negative emotion (Ferrucci et al., 2012), of producing a relative or absolute enhancement of stimulus-driven
particularly in fear-related processes, possibly due to reciprocal activity in the primary output cells of the cerebellar cortex, whereby
cerebellar connections with the amygdala (Turner et al., 2007). Purkinje cells exhibiting little or no response to peripheral stimuli
Recent studies have highlighted the function of the cerebellum in become responsive to such inputs in the presence of NE (Moises et al.,
supporting social cognition and interaction, through function-specific 1990). This evidence indicates that NE can produce a spectrum of
mentalizing and somatomotor processes (Van Overwalle et al., 2015) effects on the spontaneous and evoked discharge of Purkinje neurons,

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all of which serve to regulate the responsiveness of these cells to be directly impaired in ADHD but influenced by other circuits which
synaptically driven inputs (Waterhouse and Navarra, 2019). The net may be altering the optimal development and performance of
outcome of LC-NE regulation of cerebellar circuit operations may higher-order cognitive functions. The human brain does not mature
be that voluntary and reflex motor activities, cognitive operations, and in a uniform manner, and the cerebellum has been shown to be one
emotive responses are optimized with respect to ongoing goal-directed of the first structures to start cellular differentiation. Between 20 and
behaviors and unexpected environmental challenges (Predale et al., 40 weeks of gestation, the cerebellum undergoes an exuberant period
2023) which allows for organized and adapted behavior in a stable and of growth (Clouchoux et al., 2012), with a rapid development period
predictable way. Interestingly, one of the most striking clinical in the third trimester of pregnancy and in the first postnatal year.
characteristics described by clinicians of ADHD in addition to the This growth pattern strongly suggests the presence of a critical
frequent lapses of attention is the high prevalence of intra-individual period for cerebellar development, making it especially vulnerable
variability and inconsistency in performance (Castellanos and to genetic and environmental stressors disrupting development
Tannock, 2002), which may possibly be related to cerebellar (Limperopoulos et al., 2005). Research findings suggest that the
dysfunction in modulating emotional signals and behavior through cerebellum plays a critical role in motor, cognitive, and social–
extensive cerebello-cortical and cerebello-subcortical circuits. behavioral development, possibly via modulatory effects on the
Recent data are leading to profound changes in our understanding developing cerebral cortex, guiding the maturation of remote
of cerebro-cerebellar circuits, which are now considered essential for non-motor neural circuitry and influencing cognitive learning
the functional regulation of various neocortex areas, including PFC (Gaiser et al., 2024). Cerebellar damage can cause a striking volume
cognitive circuits, as well as of the hypothalamus and autonomic reduction in the opposite hemisphere of the cerebrum
network, and the limbic system (Rudolph et al., 2023). (Limperopoulos et al., 2005), suggesting that the cerebellum may
have a direct influence on cortical maturation (Olson et al., 2023).
These findings hint that early in development, the rapid growth of
3 Could the cerebellum be a the cerebellum may be joined to PFC growth and activity and thus
neurological basis for ADHD? could be a key node in various neurodevelopmental disorders, as
already suggested for autism spectrum disorder (Wang et al., 2014)
Considering the evidence that the cerebellum works as an and possibly for ADHD.
integrated system with the cortex (including prefrontal and parietal In clinical pharmaceutical treatment guidelines, methylphenidate
areas), the basal ganglia, and the thalamus in a variety of functions— hydrochloride (MPH) is recommended as a first-line medication for
from the motor to cognitive tasks of varying complexity (Caligiore ADHD. The exact mechanism of action of MPH is not completely
et al., 2017)—and that these areas play a critical role in attention, understood, but they are presumed to act through the dopaminergic
behavior organization, affect regulation, motor planning, and and adrenergic pathways of the frontostriatal circuits in the brain by
coordination (Cortese, 2012; Rudolph et al., 2023), we suggest that blocking the reuptake of dopamine into the presynaptic cleft (Nair and
symptoms commonly reported in ADHD, such as executive function Moss Baylor, 2009). However, dopamine networks are not limited to
variability, balance and motor coordination impairments, difficulties frontostriatal networks. Along with the dense cerebellar connections
in emotional and arousal regulation, and social adaptation problems, to the frontal cortex and basal ganglia, an independent dopaminergic
can largely be explained by cortico-cerebellar network deficiencies. network exists within the cerebellum (Li et al., 2023), with high
Furthermore, common psychiatric comorbidities associated with concentrations of dopamine transporters found particularly in the
ADHD have also been related to cerebellar dysfunction. Anxiety posterior-inferior vermis (Flace et al., 2021; Melchitzky and Lewis,
disorders, being considered the most frequent and associated with 2000). Nonetheless, the effects of MPH modulating cerebellar function
worse clinical presentation of ADHD symptoms (Quenneville et al., in ADHD have been documented (Czerniak et al., 2013; Inci Kenar
2022), have been linked to abnormalities in cerebellar vermis activity et al., 2017), leading to suggest that behavioral and even motor
and vermis-amygdala connectivity (Chin and Augustine, 2023). Mood modifications in children with ADHD taking MPH may be explained
disorders and externalizing disorders, such as oppositional defiant through outcomes that involve the cerebellum (Brossard-Racine et al.,
disorder and personality disorders, are also highly prevalent 2012; Bucci et al., 2016).
comorbidities in ADHD (Katzman et al., 2017) that have been linked Research relating ADHD and cerebellar function so far has shown
to cerebellar dysfunction, where studies in patients with cerebellar a high correlation between cerebellar volume reduction and ADHD
lesions have shown states of depression, maniac, and personality symptoms, suggesting a specific contribution of the cerebellum in the
alterations (Lupo et al., 2019) suggesting that the cerebellum should etiology of this disorder (Stoodley, 2016). Goetz et al. (2017) associated
be considered a key structure involved in the regulation of mood impaired balance, reaction times, and cerebellar dysfunction in
and emotion. children with ADHD and found correlations between poor dynamic
Another important aspect to consider is that the current DSM-5 balance and reaction time consistency, concluding that impaired
classifies ADHD a neurodevelopmental condition (American balance control and cognitive functioning might share a common
Psychiatric Association, 2022), as its symptoms exhibit normative dysfunction at the cerebellar level in ADHD. Similarly, Bledsoe et al.
change over time (Martel et al., 2016). Studies show typical cortical (2011) studied correlations between ADHD symptomatology and
development patterns in ADHD, but these are delayed by as much as reductions in cerebellar vermis, finding that a large portion of the
2–3 years, depending on the specific cortical region. This delay in variance in reported ADHD behavior was predicted by reduced
both cortical thickness and surface area suggests a global volume in posterior-inferior cerebellar vermis, suggesting the vermis
perturbation in the mechanisms that guide cortical maturation of the cerebellum may be a specific structure related to symptoms of
(Shaw et al., 2007, 2012). Therefore, higher-order networks may not hyperactivity and impulsivity and in the modulation of attention.

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As mentioned, several lines of research confirm the involvement diagnosis but serve as a quantitative determination of endophenotypes
of cerebellar structures and circuits in all areas of ADHD diagnostic that can lead to more targeted and efficient treatment programs.
outcomes. This new appreciation of cerebellar incorporation into
circuits that subserve cognition and emotion mandates a deeper
understanding of the cerebellum, beyond the motor domain, and its Data availability statement
impact on neurodevelopmental disorders such as ADHD, providing
potential for novel cerebellar-based approaches to diagnosis The original contributions presented in the study are included in
and therapy. the article/supplementary material, further inquiries can be directed
to the corresponding author.

4 Conclusion
Author contributions
The ADHD is a highly complex and heterogeneous disorder in
terms of its multidimensional outcomes, multi-factorial etiological VI: Conceptualization, Writing – original draft, Writing – review
risk factors, diverse neurocognitive impairments, and comorbid & editing. VL: Writing – review & editing. ME: Writing – review &
problems (Nigg et al., 2020). A large number of controversial results editing.
continue to exist within the study of ADHD biological and
performance markers, as it is based exclusively on behavioral
symptoms where the bottom-line issue of heterogeneity and variable Funding
severity has not been directly addressed.
Several lines of research confirm the involvement of the The author(s) declare that financial support was received for the
cerebellum in ADHD symptoms and behaviors, considering the research, authorship, and/or publication of this article. This study was
cerebellum as a key factor in guiding the maturation of remote supported by grants from Agencia Nacional de Investigación y
non-motor neural circuitry and influencing cognitive development. Desarrollo (ANID) in Chile (folio 21231682) and funds from the
Evidence has indicated that the development of the cerebellum occurs Research Department of Adolfo Ibañez University.
very early in life and is more dependent upon environmental factors
than most other brain regions (Giedd et al., 2007), and sensitive-
period disruption of cerebellar-brain communication may have an Conflict of interest
impact on higher cognitive functions.
Future considerations should focus more specifically on the The authors declare that the research was conducted in the
multidimensional assessment of functions associated with specific absence of any commercial or financial relationships that could
cerebellar areas or circuits through neuropsychological evaluations be construed as a potential conflict of interest.
linked to neuroimaging studies, and assessment of functions that The author(s) declared that they were an editorial board member
particularly nurture cerebellar growth such as vestibular and of Frontiers, at the time of submission. This had no impact on the peer
proprioceptive afferences, to establish correlations that might elucidate review process and the final decision.
patterns of symptom expression. We suggest evaluating all areas
involved in cerebellar function through motor, sensory, cognitive, and
social performance, linked to neuroimaging results, to explore Publisher’s note
possible correlations that may be indicative of cerebellar-based ADHD
endophenotypes and be used as indicators to monitor All claims expressed in this article are solely those of the authors
treatment response. and do not necessarily represent those of their affiliated organizations,
Future studies should focus on assessing the large spectrum of or those of the publisher, the editors and the reviewers. Any product
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