The relationship between cognitive disengagement syndrome and misophonia in children with attention deficit hyperactivity disorder: the mediating role of cognitive disengagement syndrome symptoms

Abstract

Background

Misophonia is a condition characterized by a reduced tolerance to certain sounds and strong emotional, physiological, and behavioral responses. Existing research on the relationship between misophonia and psychopathologies in children remains limited. To our knowledge, the relationship between Cognitive Disengagement Syndrome (CDS), formerly known as sluggish cognitive tempo, and attention deficit hyperactivity disorder (ADHD) and misophonia has not been investigated to date. In this study, we examined the relationship between misophonia and ADHD and CDS symptoms and possible mediating factors.

Method

The study included 53 adolescents diagnosed with ADHD and a control group of 50 adolescents without ADHD. All participants underwent a semi-structured clinical interview using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version, Turkish version (K-SADS-PL). Misophonia symptoms were assessed with the Amsterdam Misophonia Scale–Revised (AMISOS-R). In contrast, CDS symptoms were measured using the Sluggish Cognitive Tempo Self-Report Scale (SCT-SR). ADHD symptom severity was evaluated using the Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), which the participants’ parents completed.

Results

AMISOS-R scores were higher in adolescents with ADHD compared to the control group. The AMISOS-R revealed significant correlations with ADHD-hyperactivity/impulsivity (r = 0.291), ADHD-inattention (r = 0.513), and SCT-SR (r = 0.661) symptoms. As a result of regression analysis, ADHD-inattention severity (β = 0.745, p < 0.001) emerged as the variable that was significant with adolescent misophonia severity, independently of other variables.The mediation test using the bootstrap method showed that the indirect coefficient for SCT-SR in the relationship between T-DSM-IV-S Inattention and AMISOS-R was significant, and consistent with partial mediation.

Conclusion

Our findings indicate that symptoms of misophonia are significantly associated with ADHD and CDS symptoms, and the importance of recognizing the comorbidity of misophonia in ADHD patients. Notably, although ADHD-inattention was associated considerably with misophonia, this association was mediated by CDS severity. Therefore, when assessing individuals with symptoms of misophonia, it is important to screen specifically for ADHD-inattention and CDS symptoms as well. Further research is needed to explore these relationships in more detail and to expand our knowledge of the underlying mechanisms.

Introduction

Misophonia is characterized by reduced tolerance to certain sounds and related stimuli and unpleasant emotional reactions, causing significant psychological distress and impairment in daily functioning [1]. These reactions are triggered by specific stimuli. Typical triggers include sounds that are often ignored by most people but can be distressing for individuals with misophonia, significantly impacting their daily lives. Examples include common everyday sounds such as nail clipping, tooth brushing, eating, breathing, sniffing, talking, sneezing, yawning, walking, gum chewing, laughing, snoring, whistling, television sounds, and coughing. Encountering these sounds can trigger negative emotions such as anger, disgust, and anxiety, as well as physiological responses like an increased heart rate [2]. These symptoms are highly distressing for individuals with misophonia, who often respond by avoiding these triggering situations. This avoidance behavior can result in functional impairments in work, school, and family or social relationships [3].

When misophonia was first described, it was discussed in the audiological literature within a broad category of disorders characterized by decreased sound tolerance (DST) [4]. However, misophonia is different from well-established disorders of DST, such as hyperacusis. Hyperacusis is characterized by a decreased tolerance to ordinary environmental sounds that are typically well-tolerated by the general population [5]. In contrast, misophonia is a neuropsychiatric disorder in which even at low amplitudes, “trigger” sounds—such as chewing, lip-smacking, tapping, sniffing, etc.—that are frequently repeated and human-produced cause excessive and inappropriate emotional reactions [6]. Importantly, both these conditions are present in individuals with normal hearing thresholds [4], ruling out peripheral hearing loss and abnormal loudness recruitment as potential causes.

Although misophonia is not currently defined in psychiatric diagnostic classification systems, it has frequently been examined in the context of obsessive-compulsive and related disorders in the past [7]. Studies conducted in adults have shown that the most common psychiatric disorders associated with misophonia are anxiety disorders and major depressive disorder, both of which are considered internalizing disorders [8, 9]. Additionally, externalizing problems have been reported to be less common among individuals with misophonia [10, 11].

There is a well-established link between ADHD and sensory sensitivity [12, 13], and some researchers refer to misophonia as a type of sensory sensitivity [14, 15]. Given these findings, emerging research has begun exploring potential links between misophonia and ADHD. ADHD was reported by 5% of adult participants with misophonia in a research study [16]. Conversely, in another study that retrospectively reviewed the medical records of misophonic adults and compared them with the records of individuals without misophonia, rates of depression and anxiety disorders were high, while the prevalence of ADHD did not appear to be significantly increased among adults with misophonia [17]. These conflicting results suggest that there is a need for further research to clarify the connections between misophonia and ADHD.

ADHD is characterized by symptoms of inattention, impulsivity, and/or hyperactivity that occur in multiple settings and lead to functional impairment [18]. Although not officially recognized as a subtype of ADHD, the relationship between Cognitive Disengagement Syndrome (CDS), formerly known as sluggish cognitive tempo (SCT), and ADHD has been explored and discussed for many years. CDS is defined as a disorder of cognitive arousal and alertness, characterized by symptoms such as hypoactivity, difficulty staying awake, low energy, apathy, daydreaming, and mental confusion [19].Evidence suggests that individuals with the inattentive presentation of ADHD have higher rates of internalizing problems, which may also be symptoms of CDS. Additionally, numerous studies have shown positive correlations between CDS and internalizing symptoms, such as anxiety, depression, and social withdrawal, in children and adolescents [20–23]. Based on previous studies highlighting the connection between misophonia and internalizing issues, our research focused on examining the relationship between misophonia and CDS, the prevalence of misophonia in individuals with ADHD, and the connection between misophonia and ADHD symptoms. While the current literature has yet to investigate potential relationships between misophonia and presentations of ADHD or cognitive disengagement syndrome (CDS), this study aimed to address this critical gap in the literature.

The high comorbidity of misophonia with psychiatric disorders suggests that misophonia shares a transdiagnostic process with other psychiatric diagnoses rather than being associated with a specific diagnosis. The high comorbidity is likely due to shared predispositions (e.g., genetics, neurobiology, behavioral patterns) and causal pathways (e.g., misophonia-related isolation causing depression and social anxiety) with psychiatric disorders. Further research should attempt to understand comorbidity in misophonia. If considered as a transdiagnostic factor, misophonia could serve as a valuable marker for understanding the development, comorbidities, and treatment approaches of other disorders.

While the relationship between misophonia symptoms and psychiatric disorders has gained significant attention recently, the limited research on misophonia in children and adolescents restricts our understanding of its prevalence, progression, and clinical associations within these age groups.

Aim.

A literature review revealed a limited number of studies investigating mental disorders in children and adolescents with misophonia. To our knowledge, no previous studies have examined the relationship between misophonia symptoms and CDS symptoms in children diagnosed with ADHD. Recent neurological studies suggest that misophonia symptoms might be linked to challenges in maintaining sustained attention [24]. It has been observed that individuals with misophonia have excessive focus on specific sounds [25] and perform poorly in paying attention to sentences during listening tasks in the presence of misophonic sounds [26]. Therefore, the primary aim of this study was to examine the prevalence of misophonia symptoms in children diagnosed with ADHD, with the hypothesis that ADHD children would display higher rates of misophonia symptoms compared to healthy controls. Second, we examined whether CDS symptoms mediate the relationship between ADHD and misophonia.

Method

Participants and procedure

This cross-sectional case-control study included 53 cases diagnosed with ADHD between the ages of 12 and 18 years who visited the Child Psychiatry Outpatient Clinics of Afyonkarahisar Health Sciences University and Aydın Adnan Menderes University between December 2023 and February 2024. All of these patients were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria after completing a semi-structured clinical interview [27, 28] with the first and second authors, who are child psychiatrists, using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL).

The control group was formed of 50 age- and gender-matched adolescents who visited the outpatient clinic with various complaints (routine checkup or counseling for issues such as puberty, school, and friendship problems). They were evaluated with K-SADS-PL and had no past or present psychiatric disorders or chronic medical disorders (such as diabetes mellitus, hypertension, rheumatic and immunological diseases, epilepsy, and genetic disorders).

The “Amsterdam Misophonia Scale-Revised” (AMISOS-R) was used to assess misophonia symptoms, and the " Sluggish Cognitive Tempo Self-Report Scale” (SCT-SR) to measure symptoms of CDS in adolescents. Participants completed the AMISOS-R and SCT-SR assessments. ADHD symptoms were evaluated using the Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), which the participants’ parents completed.

Ethics committee approval

The Ethics Committee of Afyonkarahisar University of Health Sciences granted IRB approval for the study on November 3, 2023 (No: 2023/490). Written informed consent was obtained from the families of the children who agreed to participate, and all study procedures adhered to local laws and regulations, as well as the Declaration of Helsinki [29].

Measurements

Sociodemographic data form

The Sociodemographic Data Form, developed by the researchers, collected information on the participants’ and their parents’ sociodemographic details, as well as the clinical characteristics of the participants. This form was completed by the participants.

Amsterdam misophonia scale-revised (AMISOS-R)

This scale was revised from the Amsterdam Misophonia Scale (A-MISO-S) [30, 31]. The A-MISO-S and AMISOS-R are self-report scales designed to assess the types of sounds that trigger sound-related stress, as well as the emotional and behavioral responses to these misophonic sounds. The A-MISO-S was adapted from the Yale-Brown Obsessive-Compulsive Scale (YBOCS) [32], the gold standard tool for assessing symptom severity in obsessive-compulsive disorder. Therefore, the A-MISO-S and AMISOS-R address resistance to and control over misophonia-triggering thoughts (similar to resistance to and control over obsessive thoughts assessed in the YBOCS). In the AMISOS-R, respondents first identify their specific triggers and emotional responses (yes/no). They then answer questions regarding their most disturbing trigger and typical emotional response to it. This 10-item, 5-point Likert-type scale assesses misophonia severity, with scores of 0–10 indicating normal/subclinical, 11–20 mild, 21–30 moderate, and 31–40 severe misophonia. The Turkish version was validated in 2022 by Çakıroğlu et al., who found it to be a reliable tool for assessing misophonia severity [33]. The Cronbach’s alpha coefficient of the scale calculated in our study was 0.90.

Sluggish cognitive tempo self-report scale (SCT-SR)

The main symptoms of SCT include subjective experiences such as daydreaming and mind wandering, which may be difficult to observe from the outside. Therefore, it was planned to develop a self-report scale to measure SCT symptoms. The SCT-SR, developed by Gözpınar et al., is a tool that measures SCT symptoms with 20 items. In the validation study in which 467 adolescents and 178 parents participated, it was reported that the SCT-SR is a valid and reliable tool for assessing SCT symptoms in Turkish children and adolescents aged 11 to 18 years. The item-total correlation coefficients of the final 20-item scale ranged from 0.62 to 0.81. The internal consistency of the scale was tested using the Cronbach’s alpha value, and the Cronbach’s alpha coefficient was 0.95 [34]. The Cronbach’s alpha coefficient of the scale calculated in our study was 0.93.

Turgay DSM-IV-based screening and assessment scale for attention deficit and disruptive behavior disorders (T-DSM-IV-S)

The clinical diagnosis of ADHD and its presentations were evaluated using the Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale (T-DSM-IV-S), which the participants’ parents completed. This scale was developed by Turgay [35] and adapted into Turkish by Ercan et al. [36]. The scale is based on DSM-IV diagnostic criteria and evaluates inattention (nine items), hyperactivity-impulsivity (nine items), opposition defiance (eight items), and CD (15 items). Symptoms are scored on a four-point Likert-type scale for each item: 0 = Not at all,1 = Just a little,2 = Quite a bit, and 3 = Very much. Individuals with six or more inattention symptoms but fewer than six hyperactivity-impulsivity symptoms are classified as predominantly inattentive. Conversely, participants with six or more hyperactivity-impulsivity symptoms are classified as predominantly hyperactive/impulsive. The Cronbach’s alpha coefficient of the scale calculated in our study was 0.94.

Statistical analysis

Data were analyzed using IBM SPSS Statistics (Version 21) Descriptive statistics of the sample for categorical variables were presented as numbers and percentages, and for continuous variables as the mean scores. The data’s normal distribution was assessed using the Kolmogorov-Smirnov test, histograms, and skewness-kurtosis coefficients. For group comparisons, the chi-square test was used for categorical variables, the independent samples t-test for normally distributed continuous data, and the Mann-Whitney U test for T-DSM-IV-S scores that did not follow a normal distribution. Spearman correlation analysis was conducted to assess correlations, with statistical significance set at p < 0.05.

A multivariate linear regression model using the Enter method was used to analyze the factors related to the AMISOS-R scale score. Multicollinearity was evaluated by examining tolerance and the variance inflation factor (VIF). The correlation coefficients between independent variables were not greater than > 0.8. Variables that were significantly related in bivariate analyses (p < 0.05) were included in regression analyses.

Mediation analysis was conducted to determine whether the SCT-SR score mediated the relationship between the T-DSM-IV-S Inattention score and the AMISOS-R score. The Guideline for Reporting Mediation Analyses (AGReMA) recommendations were followed in reporting the mediation analysis [37]. In the mediation analyses, in line with our hypothesis, T-DSM-IV-S Inattention was determined as the independent variable (X), whereas AMISOS-R was the dependent variable (Y). SCT-SR was identified as a potential mediator (M) (Fig. 1). In order to test whether SCT-SR has a mediating role in the effect of T-DSM-IV-S Inattention on AMISOS-R score, a regression analysis based on the bootstrap method was conducted. The analyses were conducted using the PROCESS macro V4.2 model for SPSS developed by Hayes (2018) [38]. Unstandardized coefficients (b) and their 95% confidence intervals (CI) were obtained using bootstrapping with 5,000 samples, a method appropriate for small sample sizes [39]. An indirect effect was considered statistically significant if the confidence intervals did not include zero [40].

Fig. 1.

The Mediating Role of SCT-SR in the Relationship between T-DSM-IV-S Inattention and AMISOS-R. Note: Non-standardized beta coefficients have been reported. CI = Confidence interval. R² values show the variance explained

Results

Our study included 103 adolescents, 53 in the case group and 50 in the control group. The mean age of the participants was 14.31 ± 1.79 years, with no significant difference between the groups. Fifty-two (55.8%) participants were female, and the gender ratios were similar between the groups. The sociodemographic characteristics of the participants are presented in Table 1. In the case group, 35 patients (66.0%) were on medication. Among those, 80% were using methylphenidate, 15.7% atomoxetine, 2.8% guanfacine, 14.3% antipsychotics, and 14.2% antidepressants. Additionally, 13 patients (37.1%) were on polypharmacy. Regarding diagnoses, 27 patients (50.9%) in the case group had predominantly inattention (ADHD-I), while 26 (49.1%) were diagnosed with combined (ADHD-C) presentations of ADHD. When the AMISOS-R scores of patients who used and did not use psychotropic drug were compared in the case group, no statistically significant difference was found ( p = 0.254, t = 1.154).

Table 1.

Demographic and clinical findings of the groups

	ADHD (n=53) n %	Control (n=50) n %	p-value
Age	14.03±1.70	14.60±1.86	0.132
Gender			0.695
Female	28 (52.8)	24 (48)
Male	25 (47.2)	26 (52)
Parental Status			0.527
Together	46 (86.8)	46 (92)
Separated	7 (13.2)	4 (8)
Mother Education Status			0.284
Elementary	17 (32.1)	23 (46)
High school	17 (32.1)	15 (30)
University	19 (35.8)	12 (24)
Father Education Status			0.336
Elementary	14 (26.4)	19 (38)
High school	19 (35.8)	18 (36)
University	20 (37.7)	13 (26)
Working Status of Mother			0.409
Working	21 (39.6)	15 (30)
Not working	32 (60.4)	35 (70)
Working Status of Father			0.932
Working	49 (92.5)	46 (92)
Not working	4 (7.5)	4 (8)
Income Level			0.194
0-10000 Turkish Lira	1 (1.9)	1 (2)
10000-20000 Turkish Lira	18 (34)	14 (28)
20000-30000 Turkish Lira	11 (20.7)	20 (40)
Over 30,000 Turkish Lira	23 (43.4)	15 (30)
Smoking status			0.353
Smoking	1 (1.9)	3 (6)
Not smoking	52 (98.1)	47 (94)
Presence of Chronic Disease			0.518
Yes	4 (7.5)	6 (12)
None	49 (92.5)	44 (88)

(ADHD: Attention Deficit/Hyperactivity Disorder)

When sound types and associated emotions were classified, food-related sounds were identified as the most common trigger in both groups. The most frequently reported emotion in response to misophonia sounds was irritability across both groups (Table 2).

Table 2.

Groups’ misophonia sound type and emotions felt in misophonia

	ADHD (n = 53) n %*	Control (n = 50) n %*
Sound type
None	6 (11.3)	6 (12.0)
Eating (chewing, smacking, slurping, swallowing sounds)	34 (64.1)	34 (68.0)
Breathing (smell, inhale, exhale sounds)	18 (33.9)	16 (32.0)
Throat Sounds (throat clearing – coughing)	16 (30.1)	15 (30.0)
Specific Sounds (e.g., the ‘k’ sound)	6 (11.3)	3 (6.0)
Repetitive Clicking	25 (47.1)	18 (36.0)
Rustling Sounds	15 (28.3)	5 (10.0)
Ambient Sounds	15 (28.3)	12 (24.0)
Emotion Felt
None	6 (11.3)	6 (12.0)
Restlessness	30 (56.6)	20 (40.0)
Irritability	31 (58.4)	27 (54.0)
Disgust	10 (18.8)	18 (36.0)
Other	6 (11.3)	3 (6.0)

(ADHD: Attention Deficit/Hyperactivity Disorder)

*Since participants were allowed to choose more than one option on the scales, the column percentages exceeded 100%

The comparison of T-DSM-IV-S, SCT-SR, and AMISOS-R scores between the case and control groups is shown in Table 3. Table 3 highlights the differences between groups in ADHD and CDS symptoms and misophonia severity.

Table 3.

Comparison of the two groups in terms of total scale scores

	ADHD (n = 53)	Control (n = 50)	t/Z value	p value
T-DSM-IV-S Total a	21.60 ± 9.85	7.94 ± 6.38	-6.853	< 0.001
T-DSM-IV-S a Inattention	12.71 ± 5.31	4.16 ± 3.68	-7.147	< 0.001
T-DSM-IV-S a Hyperactivity/impulsivity	8.8 ± 6.9	3.78 ± 3.74	-3.997	< 0.001
SCT-SR b	56.05 ± 16.51	42.28 ± 15.01	4.421	< 0.001
AMISOS-R b	14.30 ± 7.20	9.72 ± 6.95	3.280	0.001

(^aMann-Whitney U test, ^b Student’s t-test. Bold values represent statistically significant results. ADHD: Attention Deficit/Hyperactivity Disorder, T-DSM-IV-S: Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale, SCT-SR: Sluggish Cognitive Tempo Self-Report Scale, AMISOS-R: Amsterdam Misophonia Scale-Revised)

The relationship between AMISOS-R and other scale scores, age, and gender variables was analyzed. When participants were grouped by gender, no significant difference was observed in AMISOS-R scores between the groups (p = 0.832, t = -0.213). Similarly, the correlation analysis revealed no significant relationship between age and AMISOS-R scores (p = 0.249). However, a moderate positive correlation was identified between AMISOS-R scores and both T-DSM-IV-S Total scores and T-DSM-IV-S Inattention scores (p < 0.001, p < 0.001, respectively). There was a weak positive correlation between the T-DSM-IV-S Hyperactivity/Impulsivity scores and AMISOS-R scores (p = 0.003). Additionally, a moderate positive correlation was found between SCT-SR and AMISOS-R scores (p < 0.001) (Table 4). Table 4 highlights the significant relationship between inattention and CDS symptoms in the ADHD group and misophonia severity.

Table 4.

Correlation analysis of scales in the ADHD group

	Age	1	2	3	4	5
1. T-DSM-IV-S Total	-0.119	1.000
2. T-DSM-IV-S Inattention	-0.076	0.896*	1.000
3. T-DSM-IV-S Hyperactivity/impulsivity	-0.139	0.784*	0.458*	1.000
4. SCT-SR	0.132	0.610*	0.645*	0.332*	1.000
5. AMISOS-R	0.115	0.495*	0.513*	0.291*	0.661*	1.000

(Spearman’s correlation test. *Correlation is significant at the 0.01 level. T-DSM-IV-S: Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale, SCT-SR: Sluggish Cognitive Tempo-Self Report Scale, AMISOS-R: Amsterdam Misophonia Scale-Revised)

To test the hypothesis that higher T-DSM-IV-S Inattention and SCT-SR scores would significantly and positively impact the AMISOS-R scale score, a multivariable linear regression analysis was conducted (enter method). The model was statistically significant (F = 23.183, p < 0.001) and explained 59% of the variance in the AMISOS-R scale score, with no significant issues of autocorrelation (Durbin-Watson = 1.407). In this analysis, only the T-DSM-IV-S Inattention score was determined as the variable that was significant with the AMISOS-R score, independently of other variables. Specifically, a 1-point increase in the T-DSM-IV-S Inattention score was associated with an increase of approximately 0.833 points in the AMISOS-R score (Table 5).

Table 5.

Linear regression analysis investigating the effect of T-DSM-IV-S inattention, T-DSM-IV-S hyperactivity/impulsivity, and SCT-SR scores on AMISOS-R scores in the ADHD group

Variables	B	Std. Error	β	t	p	95% Confidence Interval
(Constant)	-0.213	2.378	-	-0.090	0.929	-4.992 to 4.565
T-DSM-IV-S Inattention	0.833	0.175	0.652	5.042	< 0.001	0.531 to 1.235
T-DSM-IV-S Hyperactivity/impulsivity	-0.195	0.147	-0.125	-1.325	0.191	-0.491 to 0.101
SCT-SR	0.077	0.055	0.176	1.386	0.172	-0.035 to 0.188
Dependent variable: AMISOS-R score R:0.766 R2:0.587 F: 23.183 p < 0.001 Durbin-Watson: 1.407 (Tests the independence of errors. No autocorrelation, value in the range of 1–3)

(T-DSM-IV-S: Turgay DSM-IV-Based Disruptive Behaviour Disorders Scale, SCT-SR: Sluggish Cognitive Tempo Self-Report Scale, AMISOS-R: Amsterdam Misophonia Scale-Revised)

It was observed that T-DSM-IV-S Inattention significantly and positively influenced SCT-SR (a path) (b = 1.79, 95% CI [1.38, 2.20], p < 0.001, t = 8.717). T-DSM-IV-S Inattention accounts for approximately 43% (R² = 0.429) of the variance in SCT-SR scores.

When examining the combined effects of the mediator variable SCT-SR (b path) and the independent variable T-DSM-IV-S Inattention (c’ path) on the outcome variable AMISOS-R score, it was observed that SCT-SR significantly and positively influenced AMISOS-R (b = 0.21, 95% CI [0.12, 0.29], p < 0.001, t = 4.937). T-DSM-IV-S Inattention was also found to have a significant effect on AMISOS-R (b = 0.27, 95% CI [0.04, 0.50], p = 0.02, t = 2.346). T-DSM-IV-S Inattention and SCT-SR together explained approximately 44% (R² = 0.441) of the variance in AMISOS-R scores.

The potential indirect effect of the T-DSM-IV-S Inattention Score on the AMISOS-R score was assessed using confidence intervals generated via the Bootstrap technique. The analysis revealed that the T-DSM-IV-S Inattention score had a significant indirect effect on the AMISOS-R score. This indicated that the SCT-SR score mediated the relationship between the T-DSM-IV-S Inattention score and the AMISOS-R score (b = 0.37, 95% CI [0.22, 0.54]). The bootstrap analysis confirmed that the lower and upper confidence interval values ​​obtained using the percentile bootstrap confidence intervals method do not include 0. The completely standardized effect size of the mediation effect was 0.32 95% CI [0.18, 0.44]. This mediation was partial and attributed to the SCT-SR Total Score (p < 0.018) (Fig. 1).

Discussion

Misophonia remains an under-researched condition, largely due to ongoing uncertainties surrounding its fundamental diagnostic criteria and underlying etiology. In this study, we investigated the relationship between symptoms of misophonia and both ADHD and CDS. In adolescents diagnosed with ADHD, symptoms of misophonia were higher than in the healthy control group. Symptoms of ADHD and CDS were positively correlated with misophonic symptoms. In the regression model, the T-DSM-IV-S Inattention score emerged as a significant variable of misophonic symptoms. To our knowledge, this is the first study in the literature to identify and predict the relationship between misophonia symptoms, CDS, and ADHD symptoms in adolescents with ADHD. Our study underscores the need to include misophonia in the evaluation of ADHD patients, adopting a multidisciplinary approach.

Clinical presentation of misophonia

Although there has been an increasing number of studies on the clinical presentation of misophonia in adults, there is still limited data on its clinical phenomenology in children. Studies examining the clinical phenomenology of misophonia in adults, including factors such as age, gender distribution, trigger types, and associated emotions, have reported that younger age and female gender are associated with a higher risk of developing misophonia [8, 10, 41]. In our study, no significant difference was observed in misophonia symptoms in terms of gender. However, as our sample was formed from a clinical population, studies involving participants from the general population may provide more generalizable findings. Notably, community-based research also includes studies that align with our findings, reporting no significant relationship between gender and misophonia symptoms [6, 42–44]. Similar to our findings, a study investigating the prevalence of misophonia in the Turkish population identified young age as a significant factor influencing the severity of misophonia symptoms [41]. A study by Rouw et al. also reported a negative correlation between age and symptom severity [45]. A survey study conducted in a large sample reported that the mean age of onset of misophonia symptoms was 12.6 years and that earlier age of onset was significantly associated with a higher level of misophonia severity [6]. On the other hand, supporting the findings of our study, numerous studies in the literature also reported no association between age and the severity of misophonia symptoms [43, 44].

Consistent with previous studies [6, 10, 16, 41], the most common misophonia triggers identified in our study included eating, breathing, and throat sounds. Other frequently reported triggers were repetitive clicking/tapping and rustling paper. Additionally, a study focusing on children and adolescents with misophonia reported that aggression was more prevalent in children, while self-harm behaviors were more common among adolescents following exposure to triggers [44]. In our study, the most common emotional responses to misophonia triggers were irritability and restlessness. Other emotional responses observed in our study included anxiety, disgust, and sadness, either in reaction to or anticipation of trigger sounds.

Psychiatric morbidity

Although the lack of formal diagnostic criteria for misophonia prevents a reliable characterization of comorbidity, the results of previous studies suggested that misophonia often co-occurs with other clinically significant psychiatric symptoms and disorders. The most common psychiatric symptoms observed in adults with misophonia have been reported as mood disturbances, anxiety, and symptoms of obsessive-compulsive disorder (OCD) or characteristics of obsessive-compulsive personality disorder [6, 16]. In adult studies, it has been reported that 50–70% of individuals diagnosed with misophonia also have a comorbid psychiatric disorder [8, 9]. The most commonly associated psychiatric conditions are anxiety disorders and major depressive disorder [8, 9]. In a clinic-based study, 28% of 575 adults with misophonia were found to have a comorbid psychiatric diagnosis, with the most common being mood disorders (10%) and anxiety disorders (9%), alongside higher-than-expected rates of ADHD (5%) [16].

ADHD and misophonia

Given the known relationship between ADHD and sensory sensitivities, previous studies have investigated the potential for higher rates of ADHD in individuals with misophonia [12, 46]. In one such study, which examined 575 adults diagnosed with misophonia from a clinical sample, it was reported that 5% of these individuals were also diagnosed with ADHD [16]. It is noteworthy that this study had participant selection criteria that primarily excluded participants with primary ADD/ADHD. In another study, which examined participants who self-identified as having misophonia through an online questionnaire, participants were asked whether they had been diagnosed with any other psychiatric disorders. It was reported that the most common psychiatric disorders among participants were depression (514, 48.4%) and anxiety disorders (463, 43.6%). ADHD was identified as one of the other common comorbid psychiatric disorders, reported by 13.1% of the participants [6]. In another online study, ADHD was found to co-occur with misophonia in 12% of adults [45]. A recent study examining the mental health profile of children with developed misophonia, using a large birth cohort to assess the rates of anxiety, depression, and ADHD, reported that the likelihood of an ADHD diagnosis in the group with developed misophonia was not significantly different from the group without misophonia. Both groups showed a similar course regarding ADHD diagnoses [17]. In the literature, most studies investigating misophonia have focused on adult populations, with relatively few studies conducted on children. In one of the rare studies conducted on children, 90 children aged 7 to 18 and their families were interviewed. The study reported that there was no significant difference between the group with misophonia and the group without misophonia in terms of neurodevelopmental disorders, including ADHD, Autism Spectrum Disorders (ASD), and dyslexia [44]. In a recent study in which 102 teenagers aged 8–17 years with misophonia were compared with 94 young people with anxiety disorders, it was reported that the severity of misophonia was associated with internalized symptoms, externalizing behaviors reported by the participants, and a lower quality of life. In this study, it was reported that at least one psychiatric disorder co-occurred with 79% of the patients with misophonia. The most common accompanying disorders were social anxiety disorder, generalized anxiety disorder, major depressive disorder, and specific phobias [10]. Currently, this study was the only one examining the relationship between misophonia and internalizing and externalizing problems. The study suggested that misophonia should be conceptualized as a disorder within the spectrum of internalizing disorders. However, it reported that diagnoses such as chronic tic disorders (13%) and ADHD (21%) were found at higher rates than would be expected in a randomly selected sample of individuals with misophonia. Therefore, the aforementioned study suggested that the observed pattern in misophonia may not be directly related to a specific diagnosis. Instead, transdiagnostic processes between these diagnoses were thought to contribute to this pattern, and the study emphasized the need to further investigate these underlying processes [10]. In a study conducted in Turkiye evaluating the prevalence of misophonia and related factors in participants over the age of 15, the prevalence of misophonia was found to be 12.8%. The study also reported that ADHD was more common in the group with misophonia (20.3%) compared to the control group (7.3%) [41].

Recent studies have suggested that ADHD (4.8%) may be associated with misophonia, potentially due to difficulties with attention regulation and shifts between visual and auditory cues [30]. In a study involving neuropsychological assessments of adults with misophonia, higher rates of behavioral impulsivity and executive dysfunctions, as well as higher rates of ADHD, were observed in the misophonia group compared to the control group. The study further suggested that difficulties in attention regulation and impulsivity may play a role in the development or expression of misophonia [24]. In another study, it was reported that participants with misophonia showed poorer selective attention than the control group. Their attention processes were impaired, especially when triggering sounds, such as chewing sounds, were selected as distracting stimuli [26]. In another study, the Attention Network Test (ANT) performance and neuropsychological functioning of individuals with misophonia were compared to a non-clinical control group under symptom-provocation conditions. The study’s results suggested that individuals with misophonia experienced difficulty in achieving and maintaining alertness during attention tasks and that these performance differences were not only a result of symptom provocation (i.e., blockade before, during, and after symptom provocation) [47]. Considering these studies, the question arises as to whether inattention plays a role in the etiology of misophonia. In our study, this question was addressed by comparing the symptoms of misophonia in the ADHD group with those in the control group. Participants had a semi-structured interview conducted by a child and adolescent psychiatrist. Individuals with other mental disorders, such as depression, anxiety disorders, and substance abuse, were excluded from the study. This approach minimized the influence of confounding secondary psychiatric conditions. It was observed that as participants’ scale scores measuring inattention symptoms increased, their misophonia scale scores also increased. Additionally, it was determined that misophonia scale scores were no different between participants with and without psychotropic medication use in the ADHD group. Future studies in this area may prioritize longitudinal evaluations in larger samples to investigate the effects of psychotropic drug treatment on misophonia symptoms in ADHD.

CDS and misophonia

CDS co-occurs with ADHD in 39–59% of clinically referred children and adolescents [22]. Studies suggested that CDS symptoms are distinct from ADHD symptoms and that CDS is highly associated with inattention (and hyperactivity to a lesser extent). Additionally, CDS symptoms have been found to differ from ADHD symptoms in terms of executive function profiles, global impairment, and comorbidity [22]. CDS has been shown to be associated with social withdrawal, internalizing disorders (i.e., anxiety, depression), academic functioning, adaptive functioning, and executive functioning in samples of youth and adults with ADHD [22, 48, 49]. In light of these results, CDS symptoms appear to contribute to unique psychosocial difficulties, including internalizing problems and social impairments, beyond the difficulties associated with ADHD.

CDS symptoms are expected to be relevant to ASD research and clinical practice due to the neurodevelopmental overlap between ASD and ADHD, the diagnostic feature of social difficulties within ASD, the propensity for internalizing disorders in ASD, and the high degree of comorbidity between ASD and ADHD as well. In a study conducted on young people with ASD, it was reported that the presence of moderate and high levels of CDS was associated with more social impairment and internalizing problems after controlling for ADHD using statistical methods [50]. A second and more recent study of CDS in ASD investigated CDS and its relations to ADHD and ASD symptomatology, executive functioning, and internalizing and externalizing symptoms in adolescents. According to the results, CDS symptoms were linked to internalizing, ASD, and ADHD symptoms, while ADHD symptoms were mostly linked to externalizing behaviors [51]. On the other hand, the phenomenological similarities in sound sensitivity in ASD and misophonia suggest a relationship between these two conditions. Recently, there has been an increasing number of studies reporting that misophonia symptoms are associated with autistic traits [14, 52].

Recent studies have shown that misophonia is positively associated with autistic traits and emotion regulation difficulties [14, 52], with studies reporting that these two factors are associated with CDS [51, 53]. In our study, a significant relationship was found between the CDS characteristics of the participants and misophonia symptoms. To identify whether symptoms of CDS might underlie the relationship between misophonia and ADHD symptoms, we conducted a mediational analysis exploring CDS symptoms as a mediator. CDS symptoms emerged as a significant mediator between misophonia and attention deficit symptoms. This suggests that attention deficit and CDS symptoms may be important factors in better understanding misophonia.

Misophonia’s association with more CDS symptoms and attention deficits may indicate symptom overlap between these conditions or shared vulnerabilities in the development of symptoms. Despite these findings, the cross-sectional design of our study makes it difficult to establish a causal relationship. We cannot conclusively determine whether misophonia symptoms are the specific cause of attention difficulties or if these difficulties reflect a long-standing weakness. Future longitudinal studies could investigate the role of attention difficulties in the development of misophonia. Nevertheless, our study is significant because it included adolescents from two distinct centers, all assessed and diagnosed using a semi-structured clinical interview. Another strength of our study is that we excluded comorbid disorders, such as anxiety and depression, in adolescents with ADHD.

Limitations

Our results should be interpreted in light of several limitations. The most significant limitation of our study was the small sample size, and we recommend conducting a replication study with a larger population to validate the findings. Another limitation of our study was its cross-sectional design. The results of regression analysis should be avoided as predictors of cause and effect due to the cross-sectional design of the study. Another limitation was that the severity of ADHD symptoms was assessed solely through a parent-reported scale, without the use of a self-report scale from the adolescents themselves.

Conclusion

This study is among the few exploring the relationship between ADHD and misophonia, paving the way for future research. Our study pioneers the investigation of the relationships between ADHD symptoms, particularly ADHD-PI symptoms, and misophonic symptoms. The results may contribute to a deeper understanding of misophonia as a transdiagnostic clinical phenomenon. Assessing CDS and ADHD symptoms in individuals with misophonia could facilitate more effective treatment planning. Further research is needed to explore these relationships in more detail and to expand our knowledge of the underlying mechanisms. Future research should privilege longitudinal assessments to shed light on the link between the ADHD symptoms and misophonic symptoms.

Abbreviations

CDS

Cognitive Disengagement Syndrome

ADHD

Attention Deficit Hyperactivity Disorder

K-SADS-PL

Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version

AMISOS-R

Amsterdam Misophonia Scale–Revised

SCT-SR

Sluggish Cognitive Tempo Self-Report Scale

T-DSM-IV-S

Turgay DSM-IV-Based Disruptive Behavioral Disorders Screening and Rating Scale

ADHD-I

Attention Deficit Hyperactivity Disorder-Inattentive

ADHD-C

Attention Deficit Hyperactivity Disorder-Combined

YBOCS

Yale-Brown Obsessive-Compulsive Scale

VIF

Variance Inflation Factor

ANT

Attention Network Test

Author contributions

H.G.G: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. B.G.O: Conceptualization, Methodology, Resources, Data collecting, Writing – original draft, Writing – review & editing. Z.H: Conceptualization, Formal analysis, Investigation, Writing – review & editing. A.S: Data collecting, Formal analysis, Investigation,. H.A: Conceptualization, Methodology, Writing – review & editing, Supervision. All authors had full access to the data, contributed to the study. All authors read and approved the final manuscript.

Funding

The authors declare that there was no financial support for this study.

Data availability

Anonymised data from the study is available to bona fide researchers on application to the corresponding author.

Declarations

Ethics approval and consent to participate

The Afyonkarahisar University of Health Sciences Ethics Committee granted IRB permission for the study on November 3, 2023 (No: 2023/490). The families of the children who agreed to participate in the study provided written informed consent, and all study methods complied with local laws and regulations as well as with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.