Postural Sway: How ADHD and Anxiety May Manifest in the Body

By definition, postural sway is the horizontal movement around a person’s center of gravity while standing (1, 2).

“Postural sway is the subconscious maintenance of posture through movements around our center of gravity,” says Alli Cost, MSOT, OTR-L, an occupational therapist and director of education for Foundation Training.

“It’s one’s ability to control their body while standing still (i.e., balance),” adds Michael Shipper, a certified personal trainer and owner of Empowered Sports and Fitness, which provides inclusive movement opportunities for athletes of all ages and abilities.

A person with greater postural sway will have more movement while standing, which may look like they’re gently moving from side to side or in small circles, even though their feet are flat on the ground.

Perhaps an easier way to understand postural sway is to feel it for yourself. Start standing with your feet hip-distance apart, and focus your eyes on something directly in front of you. Then close your eyes.

While standing “still,” you will likely feel very small, reflexive movements around your center of gravity — perhaps side to side or front to back — as your body maintains your balance.

Cost notes, “For some folks, postural sway is a collection of micro-movements that seem imperceptible. For others, it is like they are riding stormy ocean waves. [It’s] the result of our muscular system and sensory system attempting to adapt [to changing stimuli].”

Everyone experiences postural sway to some degree. But in some cases, greater postural sway can be an indication of poor balance and coordination. It may be related to natural aging, neuromuscular disorders, anxiety, or ADHD (1, 4, 5).

Summary

“Postural sway” is a term used to describe the unconscious, small movements that happen around the body’s center of gravity in order to maintain balance. It is your body’s natural adaptation to changing stimuli. It may be noticeable or unnoticeable. Those with poor balance and coordination exhibit greater postural sway.

“There is no one defining measure that causes postural sway, but rather a multitude of factors relating to the nervous system,” says Shipper.

Our nervous system is constantly interpreting input received from various sensory systems in the body and adapts accordingly. Cost explains that our body’s response to sensory input is reflexive, so we aren’t always aware of it.

“Can you imagine if you had to ‘think through’ every sense you encountered?” she says.

But to fully understand postural sway, we must broaden our understanding of the senses beyond just the five you learn about in grade school.

“Rather than thinking of the senses as [functions of] the nose, mouth, skin, ears, and eyes, understand that the sensory system is the brain [as a whole]. It does receive input from those five sensory organs, but not exclusively,” Cost explains.

Other significant sources of sensory input are considered somatosensory systems. They are:

• interoceptive awareness (internal feedback your body sends your brain about how it feels)
• the vestibular system (the organ in your inner ear that helps control balance)
• proprioception (your body’s spatial awareness relating to its location and movement)

Combined, these sensory systems of the body provide a roadmap for your brain, helping you navigate, understand, and predict the world around you.

Collectively, the input you receive from all of these systems is called sensory integration. Sometimes, the input coming in from all of the somatosensory systems integrates (connects) cohesively. Other times, however, they misinform each other.

Postural sway is one of the ways our body responds to sensory input, and its severity depends on how well the somatosensory systems are integrating.

“Together all the systems coordinate in order to allow us to maintain balance. The more balance one has, the less postural sway is present,” says Shipper.

“Postural sway becomes something notable only when we have difficulty recognizing, interpreting, or regulating our response to input — basically, when the muscular system and sensory system are struggling to find homeostasis,” Cost says.

Summary

To maintain balance, our body relies on our muscular and sensory systems. When the brain isn’t processing information efficiently from either of these systems, it can lead to greater postural sway and poorer balance.

Research over the past decade has shown a correlation between lack of motor control and ADHD, which may lead to increased postural sway (6, 7, 8).

“In children, excessive postural sway is often related to development disabilities, and in adults, [it’s] from a decline in muscle and neurological function,” says Cost.

However, “just because an individual has ADHD, it doesn’t mean that postural sway will be present. Each individual is different and for that reason, must be handled with care, and [receive] customized treatment,” Shipper says.

In children

ADHD affects approximately 5% of children — and of these, up to 50% experience difficultly with motor control and balance (9).

“ADHD has a significant impact on the sensory system; therefore, it impacts how a person can adapt,” says Cost.

“Defined by hyperactivity, impulsivity, and inattention that negatively impact a person’s ability to function, those with ADHD [have difficulty matching] their internal processing with external expectations,” she explains.

Cost continues, “To complicate matters, we live in a world where we keep children in ‘containers,’ like seats, while demanding they remain still to learn. But the body learns and adapts through movement, with ADHD impacted children needing additional movement opportunities.

“You can’t access sensory self-regulation until you are physically stable. These kids are hungry for more input to teach and tell the body it is stable but are told to sit still.

“So, they present with being fidgety, clumsy, or not following directions to ‘stay in line’ when they are simply doing their best to find a way to stay attuned. Dysfunctional vestibular processing can [result in] reduced attention.”

Fortunately, research suggests that physical activity programs focusing on balance training and motor control can lead to significant improvements in executive function. That’s why it’s recommended as an adjunct therapy for children with ADHD (10).

In adults

Studies have shown that balance-related challenges associated with ADHD may extend to adulthood. In fact, many adults with ADHD describe themselves as being “naturally clumsy” or “accident-prone” (11, 12).

Interestingly, there appears to be a connection between cerebellum volume in the brain and postural sway.

One study found increased gray matter volume in the posterior cerebellum was linked with greater postural sway. The cerebellum is the lower lobe of the brain responsible for motor control and coordination (12).

The study found that adults with ADHD had significantly greater postural sway and gray matter volume in the cerebellum (lobules VIII and IX) than the control group (12).

This study suggests that ADHD is not solely behavior-related but connected to physical differences in brain matter.

The incidence of ADHD is approximately 2.8% in adults and approximately 5% in children. This suggests a person may outgrow symptoms of ADHD or, at minimum, some of the challenges they faced as children (9, 13).

“Adults, on the other hand, often have ‘outgrown’ the hyperactivity but continue to [deal] with restlessness and impulsiveness; along with their sensory and muscular systems still striving to get and organize input,” says Cost.

In some cases, “[they] can improve upon these deficits through practiced movements relating to fine and gross motor skills as well as regular exercise routines,” says Shipper.

He notes, “It’s best to implement these techniques during childhood as opposed to adolescence or adulthood because over time our nervous system gradually loses the ability to integrate information as quickly through our vestibular, somatosensory, and visual systems.”

Summary

Some children and adults with ADHD may exhibit greater postural sway and poor balance.

Anxiety has also been linked to increased postural sway in both adults and children.

“Anxiety is distress of the unknown, internalized into a physiological response. When we cannot trust our bodies or feel in control of them, we respond to the world (inside and outside) with a disorganized approach to the demands of the environment,” says Cost.

She adds, “This creates a want or demand for more input to confirm safety, such as visual input. Individuals with anxiety are more dependent on visual input to maintain their balance, expanding their base of support, and the corresponding postural sway field they move around in.”

“We cannot separate our mental health from our physical experience or response to the world,” she says.

In children

Though less studied, children with increased anxiety tend to exhibit greater postural sway. In fact, an older study found that children with anxiety had less stable balance and required greater focus to keep themselves balanced (14).

This can have negative effects, such as decreased engagement in physical activity and social interaction with their peers. To make matters worse, their anxiety may increase in these situations due to fear of judgment or potential injury (15).

“An example of this would be a child at the playground. Some children avoid climbing, running, jumping, and socially interacting with other children due to anxiety. Being unsure of how their body moves in space can have a direct impact on their mindset and, subsequently, overall performance,” says Shipper.

“In my experience, the difference I see in children versus adults is that adults have the ability to recognize and express their anxiety. Children, on the other hand, have more difficulty vocalizing their feelings.

“In relation to postural sway, the information remains the same. As we advance in age there is a greater chance of postural sway. A child that goes untreated for physical and emotional developmental delays may have a more difficult time adapting to their environment over time.”

In adults

Anxiety and balance have a reciprocal relationship, especially in older adults or adults with motor control issues.

Increased anxiety can potentially lead to issues with greater postural sway. It’s thought that anxiety may lead to balance dysfunction, due to changes in the brain’s ability to regulate balance and motor control (16, 17).

What’s more, fear of falling or having difficulty with day-to-day activities can lead to worsened anxiety (17).

In fact, one study found that preoccupation with one’s balance can actually worsen their balance and increase postural sway. Contrarily, if a person was distracted from focusing on their balance, it improved stability (18).

Another study found that as fear and anxiety increased over a perceived threat (i.e., falling when standing on an elevated platform), the frequency of postural sway also increased (19).

Interestingly, nonanxious individuals experienced enhanced adaptive balance control (i.e., body stiffening) and less postural sway in order to maintain their center of gravity (19).

Therefore, finding effective strategies to reduce anxiety and improve balance are equally important.

Summary

Those with anxiety are at a higher risk of poor balance and increased postural sway. In turn, this may worsen their anxiety due to fear of injury, falling, or potential embarrassment.

Because children begin to develop gross motor skills in infancy, developing good somatosensory awareness early on is key in preventing severe postural sway later on.

Several features to look out for in a child with poor postural control and stability are:

• slumping while sitting in a chair or standing upright
• leaning their head on their hand or desk when writing
• leaning on furniture or other people
• difficulty with motor activities that require strength (e.g., riding a bike, swimming, walking)
• difficulty with balance
• fidgeting in their seat and having difficulty paying attention
• poor fine motor skills, such as using pencils and scissors
• difficulty with dressing skills and other self-care activities, which require a stable posture

Still, even for adults who demonstrate severe postural sway, there are methods to treat the sensory processing challenges that may be part of the root cause.

“Treatment approaches should address both the physical and sensory systems. Professionally, I have found Foundation Training integrated with sensory self-regulation methods like meditation and breathing techniques have been the most effective,” says Cost.

“Foundation Training provides an effective approach to establish postures and patterns of muscular engagement that place the [center of gravity] in the pelvis, increase body awareness, and regain effective breathing patterns,” Cost adds.

Shipper also says that “incorporating exercise and movement in a child’s everyday life” is important. “Focusing on key areas such as the core, back, legs, hips, and shoulders are great ways to improve upon body control.”

Since postural sway and balance issues are multifactorial, it’s best to seek out a healthcare professional for personalized recommendations.

Summary

If you suspect you have poor balance or postural sway, speak with your healthcare professional, who can recommend specific exercises and activities.

If you or your child are experiencing increased postural sway or other balance-related issues, it’s best to consult a qualified healthcare professional. Ideally, seek out the advice of one or more of the following:

• pediatrician or family physician
• primary care provider or general practitioner
• occupational therapist or physical therapist
• child psychologist or behaviorist
• other fitness specialists (e.g., personal trainer who specializes in inclusive fitness)

Cost adds, “The important thing is to find a practitioner who takes an integrative approach, understanding that postural sway is not just a balance issue but part of a broader relationship between the brain and the body.”

“Most occupational therapists have training in sensory self-regulation but there are many certified Foundation Training instructors who are themselves holistic practitioners in other fields,” she says.

Summary

Improving postural sway and balance may require a multidisciplinary approach. Therefore, speak with your primary healthcare provider who may recommend you visit one or more specialists.

Balance plays an important role in our everyday activities.

Research has shown that those with neurological disorders, such as anxiety and ADHD, may be at an increased risk of poor motor control and balance, which can sometimes manifest as greater postural sway.

If you suspect that you or your child have balance issues, it’s important to work with a trained professional who may recommend certain exercises and other therapies to build better strength and coordination and help the body process sensory input in an efficient way.