Effects of Methylphenidate on the Academic Performance of Children with Attention-Deficit Hyperactivity Disorder and Learning Disabilities

Medical treatment of Attention Deficit/Hyperactivity Disorder (ADHD) and children's academic performance

Attention Deficit/Hyperactivity Disorder (ADHD) is negatively associated with a range of academic achievement measures. We use Danish administrative register data to study the impact of medical treatment of ADHD on children's academic performance assessed by student grade point average (GPA). Using administrative register data on children, who begin medical treatment, we conduct a natural experiment and exploit plausible exogenous variation in medical nonresponse to estimate the effect of medical treatment on school-leaving GPA. We find significant effects of treatment on both exam and teacher evaluated GPAs: Compared to consistent treatment, part or full discontinuation of treatment has large significant negative effects reducing teacher evaluation and exam GPA with .18 and .22 standard deviations, respectively. The results demonstrate that medical treatment may mitigate the negative social consequences of ADHD. Placebo regressions indicate that a causal interpretation of our findings is plausible.

The co-occurrence of reading disorder and ADHD: epidemiology, treatment, psychosocial impact, and economic burden

The co-occurrence of reading disorder (RD) and attention-deficit/hyperactivity disorder (ADHD) has received increasing attention. This review summarizes the epidemiology, treatment strategies, psychosocial impact, and economic burden associated with the co-occurrence of these conditions. Common genetic and neuropsychological deficits may partially explain the high degree of overlap between RD and ADHD. Children who face the additive problems of both disorders are at greater risk for academic failure, psychosocial consequences, and poor long-term outcomes that persist into adulthood. However, few studies have evaluated interventions targeted to this patient population, underscoring the importance of identifying effective multimodal treatments that address the neuropsychological deficits of RD and ADHD through carefully planned clinical research.

College students with and without ADHD: comparison of self-report of medication usage, study habits, and academic achievement

OBJECTIVE

To examine the relationship between ADHD medications, study habits, and academic achievement of ADHD-diagnosed undergraduates.

METHOD

A total of 92 students with a self-reported ADHD diagnosis and a current prescription for ADHD medication were compared with 143 control students in a survey of academic performance.

RESULTS

Most ADHD students took stimulant medication and said the drugs helped them, yet believed they were worse than other students at planning and completing assignments and avoiding distractions. Although most study habits of ADHD students did not differ from controls, their high school and college GPA (grade point average), and ACT scores were significantly lower, and they withdrew from significantly more classes than did control students. Interestingly, preliminary data suggested that good study habits alone, even without stimulants, could overcome the achievement disparity of ADHD students.

CONCLUSION

As previously shown for children and adolescents, stimulant medications alone did not eliminate the academic achievement deficit of ADHD undergraduates.

What are the cognitive effects of stimulant medications? Emphasis on adults with attention-deficit/hyperactivity disorder (ADHD)

The relevant literature concerning cognitive effects of amphetamine and methylphenidate, was reviewed, with an emphasis on research conducted in adults diagnosed with attention-deficit/hyperactivity disorder. As first-line treatment for ADHD, stimulant drugs are well-known to improve attention and concentration. Yet, there is increasing evidence that (as with children and adolescents), they do not promote learning and academic achievement in adult college students with ADHD. A review of neuropsychological studies indicates that, although response latencies are reduced, performance of ADHD adults on tests of 'distractibility' and 'planning' is also not consistently improved by stimulants. Studies in non-ADHD adults suggest that stimulants do not promote acquisition of new information, might improve retention of previously acquired information, and facilitate memory consolidation, but may actually impair performance of tasks that require adaptation, flexibility and planning. It is still not clear if improvement only occurs when there is a baseline deficit. Stimulants may influence cognition by their effects on physiological arousal. Regardless, the evidence does not support the conclusion that stimulants are cognitive 'enhancers.'

Methylphenidate improves reading performance in children with attention deficit hyperactivity disorder and comorbid dyslexia: an unblinded clinical trial

Attention Deficit Hyperactivity Disorder (ADHD) and dyslexia are frequently co-occurring disorders. Although methylphenidate (MPH) is the primary treatment for ADHD, the effect on reading in children with these comorbid problems is not yet known. This study was an unblinded clinical trial to evaluate the reading performance before and after treatment with MPH. Reading performance was compared with General Linear Model repeated measures between three groups: (1) an experimental group of children with both ADHD and dyslexia (N = 24), (2) a control group of children with ADHD (N = 9) and (3) a control group of children with dyslexia (N = 10). MPH improved reading performance significantly stronger in the experimental group than in the control groups; the number of correctly read words increased to a larger extent. In conclusion, MPH proved to be an aid in the reading process of children with ADHD and comorbid dyslexia by improving the learning conditions, but MPH cannot cure the reading disorder. Future research should study the effect of MPH on reading in a double-blind clinical trial.

Placebo-controlled study examining effects of selegiline in children with attention-deficit/hyperactivity disorder

There is evidence suggesting a role for dopamine in attention-deficit/hyperactivity disorder (ADHD). Pharmacological treatments that act on the dopamine system have been successful in reducing ADHD symptoms. However, unlike traditional stimulants (i.e., methylphenidate), selegiline is a monoamine oxidase inhibitor (MAOI) that has been shown to reduce ADHD symptoms without producing undesirable side effects. In this study using a randomized, double- blind, placebo-controlled, crossover design, cognitive tasks and behavioral rating scales were administered to measure the effectiveness of selegiline in treating different symptoms of ADHD in 11 children aged 6-13. Results indicate that selegiline may target specific symptoms of ADHD including: sustained attention, the learning of novel information, hyperactivity, and peer interactions. Because the drug was not associated with negative side effects and did not specifically reduce symptoms of impulsivity, selegiline may be a preferred treatment for individuals who present with the primarily inattentive subtype of ADHD.

Effects of stimulant medication on cognitive performance of children with ADHD

The effect that treatment with stimulant medication has on the intellectual performance of children with attention deficit hyperactivity disorder (ADHD) was examined. Thirty-one children diagnosed with ADHD were given a WISC-III before any treatment was implemented. At least 1 year later, children were retested. At this time, 24 of the children were taking stimulant medications. Children receiving medications had significant increases in IQ scores, but no changes were found for those not taking medications. Changes in IQ scores were moderately related to parents' perceived efficacy of the medication and parent-reported compliance with medication but were not strongly related to changes in parent-reported ADHD symptoms.

Applying a psychoeducational perspective to ADHD

This article examines whether various cognitive abilities are associated with symptoms of ADHD. Cognitive ability is conceptualized using Cattell-Horn-Carroll (CHC) theory as measured using the Woodcock-Johnson Tests of Cognitive Ability (3rd ed.). This article also examines whether test session behavior mediates the association between cognitive ability and ADHD. Participants are children ages 6 to 12 with (n= 33) and without (n= 19) ADHD. Results show that inattentive symptoms of ADHD are significantly related to the CHC ability of processing speed above and beyond the effect of test session behavior. Symptoms of ADHD (both inattention and hyperactivity/impulsivity) are also significantly associated with visual spatial processing, but this is completely mediated by test session behavior. It is concluded that inattentive symptoms of ADHD are associated with slower processing speed and that this relationship is not explained by test session behavior.

Once-a-day Concerta methylphenidate versus three-times-daily methylphenidate in laboratory and natural settings

OBJECTIVE

Methylphenidate (MPH), the most commonly prescribed drug for attention-deficit/hyperactivity disorder (ADHD), has a short half-life, which necessitates multiple daily doses. The need for multiple doses produces problems with medication administration during school and after-school hours, and therefore with compliance. Previous long-acting stimulants and preparations have shown effects equivalent to twice-daily dosing of MPH. This study tests the efficacy and duration of action, in natural and laboratory settings, of an extended-release MPH preparation designed to last 12 hours and therefore be equivalent to 3-times-daily dosing.

METHODS

Sixty-eight children with ADHD, 6 to 12 years old, participated in a within-subject, double-blind comparison of placebo, immediate-release (IR) MPH 3 times a day (tid), and Concerta, a once-daily MPH formulation. Three dosing levels of medication were used: 5 mg IR MPH tid/18 mg Concerta once a day (qd); 10 mg IR MPH tid/36 mg Concerta qd; and 15 mg IR MPH tid/54 mg Concerta qd. All children were currently medicated with MPH at enrollment, and each child's dose level was based on that child's MPH dosing before the study. The doses of Concerta were selected to be comparable to the daily doses of MPH that each child received. To achieve the ascending rate of MPH delivery determined by initial investigations to provide the necessary continuous coverage, Concerta doses were 20% higher on a daily basis than a comparable tid regimen of IR MPH. Children received each medication condition for 7 days. The investigation was conducted in the context of a background clinical behavioral intervention in both the natural environment and the laboratory setting. Parents received behavioral parent training and teachers were taught to establish a school-home daily report card (DRC). A DRC is a list of individual target behaviors that represent a child's most salient areas of impairment. Teachers set daily goals for each child's impairment targets, and parents provided rewards at home for goal attainment. Each weekday, teachers completed the DRC, and it was used as a dependent measure of individualized medication response. Teachers and parents also completed weekly standardized ratings of behavior and treatment effectiveness. To evaluate the time course of medication effects, children spent 12 hours in a laboratory setting on Saturdays and medication effects were measured using procedures and methods adapted from our summer treatment program. Measures of classroom behavior and academic productivity/accuracy were taken in a laboratory classroom setting during which children completed independent math and reading worksheets. Measures of social behavior were taken in structured, small-group board game settings and unstructured recess settings. Measures included behavior frequency counts, academic problems completed and accuracy, independent observations, teacher and counselor ratings, and individualized behavioral target goals. Reports of adverse events, sleep quality, and appetite were collected.

RESULTS

On virtually all measures in all settings, both drug conditions were significantly different from placebo, and the 2 drugs were not different from each other. In children's regular school settings, both medications improved behavior as measured by teacher ratings and individualized target behaviors (the DRC); these effects were seen into the evening as measured by parent ratings. In the laboratory setting, effects of Concerta were equivalent to tid MPH and lasted at least through 12 hours after dosing. Concerta was significantly superior to tid MPH on 2 parent rating scores, and when asked, more parents preferred Concerta than preferred tid IR MPH or placebo. Side effects on children's sleep and appetite were similar for the 2 preparations. In the lab setting, both medications improved productivity and accuracy on arithmetic seatwork assignments, disruptive and on-task behavior, and classroom rule following. Both medications improved children's rule following and negative behavior in small group board games, as well as in unstructured recess settings. Individual target behaviors also showed significant improvement with medication across domains in the laboratory setting. Children's behavior across settings deteriorated across the laboratory day, and the primary effect of medication was to prevent this deterioration as the day wore on. Results support the use of background behavioral treatment in clinical trials of stimulant medication, and illustrate the utility of a measure of individualized daily target goals (ie, the DRC) as an objective measure of medication response in both the laboratory and natural school settings.

CONCLUSION

This investigation clearly supports the efficacy of the Concerta long-acting formulation of MPH for parents who desire to have medication benefits for their child throughout the day and early evening. (ABSTRACT TRUNCATED)

Knowledge and attitudes of high school pupils towards peers' attention deficit and learning disabilities

The purpose of this study was to investigate pupils' knowledge and attitudes in the areas of attention deficit and hyperactivity (ADHD) and learning disabilities (LD). One hundred and four high school pupils in Holon (Israel) were interviewed and anonymously completed a questionnaire on these conditions. Pupils' knowledge on the topic of ADHD was low (62%); they showed a better knowledge about LD (75%). They showed a partially tolerant attitude (62.7%) towards pupils suffering from ADHD; on the other hand, they had a somewhat more positive and perceptive attitude (74.1%) towards peers diagnosed as learning disabled. Pupils' attitudes became more perceptive with increasing age. There was no correlation between pupils' knowledge and attitude. Pupils had learned about these two handicapped conditions from various sources; TV (66.3%), newspapers (63.5%) and school (53.8%), while physicians and nurses occupied the 5th and last place. Information about these two disabilities (ADHD and LD) should be added to the curriculum and be taught by qualified specialists, as there is an obvious statistically deficient knowledge in these areas.

Testing the ability of children with attention deficit hyperactivity disorder to accurately report the effects of medication on their behavior

Children with attention deficit hyperactivity disorder (ADHD) are often treated with central nervous system stimulants, making the evaluation of medication effects an important topic for applied behavior analysts. Because assessment protocols emphasize informant reports and direct observations of child behavior, little is known about the extent to which children themselves can accurately report medication effects. Double-blind placebo-controlled procedures were used to examine whether 6 children with ADHD could recognize the effects of their medication. The children were given math worksheets to complete for 15 min during each of 14 sessions while on medication and placebo. Children completed a self-evaluation form at the end of each session, and ratings were compared to observed behavior and academic performance. Results indicated that 3 children were able to accurately report their medication status at levels greater than chance, whereas the accuracy of reports by all children was related to dosage level, differences in behavior, and the presence of adverse effects. The implications of these results for placebo-controlled research, self-monitoring of dosage levels, and accuracy training are discussed.

School psychologists: strategic allies in the contemporary practice of primary care pediatrics

Immense changes in the developmental/behavioral aspects of primary care pediatrics have resulted from revisions in special education laws, introduction of managed care, widened dissemination of information about disabilities to parents, and the changing character of American society. Challenges associated with contemporary pediatric practice can be diminished by routine collaboration with school psychologists. An alliance with school-based psychologists permits pediatricians access to children in their natural environments and potential collaboration for preventing illness and emotional/behavior problems. Further, school psychologists can provide a partner for assessing and treating both common and low-incident disorders without the constraints imposed by managed care.

Use of the School Performance Rating Scale with children treated for attention deficit hyperactivity disorder

The School Performance Rating Scale was developed to assess academic performance of children diagnosed with attention deficit hyperactivity disorder. The most frequent concern of professionals, parents, and teachers is the child's performance and achievement in school; however, assessments are seldom obtained pretest and posttest. The scale has yet to be standardized so its association with academic behavior was estimated with the ADD-H Comprehensive Teachers' Rating Scale. 24 elementary-school children were given both scales after being diagnosed and treated for ADHD, following evaluation by a multidisciplinary team at a medical university's child-development clinic. A positive correlation of .8 was found between scores on the School Performance Rating Scale and .6 with Attention and Social Skills from the ADD-H Comprehensive Teachers' Rating Scale. Standardization of the scale would allow clinicians more specific identifications.

Evaluating medication response in ADHD: cognitive, behavioral, and single-subject methodology

Although evidence supports the use of double-blind placebo medication trials to evaluate methylphenidate (MPH) effects on the core behavioral symptoms of attention-deficit/hyperactivity disorder (ADHD), few studies have demonstrated their utility in examining MPH effects on the cognitive deficits associated with ADHD. This article presents a technique for evaluating behavioral and cognitive dose-response relationships at the single-subject level of analysis. Case study results and multivariate analyses suggest that systematic evaluation of behavioral and cognitive MPH dose-response relationships could lead to more accurate MPH titration and greater long-term multimodal treatment efficacy.

School-based methylphenidate placebo protocols: methodological and practical issues

Around 1990, psychologists and educators began to notice increasing use of methylphenidate by students. Diagnosis of attention-deficit/hyperactivity disorder by family physicians and pediatricians was most commonly based on brief behavioral descriptions by parents and, infrequently, by use of rating scales. At that time, the present researchers began to explore the development of a school-based, methodologically sound, and inexpensive method of assessing the efficacy of stimulant medications, which would ensure reasonable compliance by teachers, parents, and students in monitoring the effects of medications and placebos. This article focuses on the methodological issues involved in choosing instruments to monitor behavior, once a comprehensive evaluation has suggested trials on Ritalin. Case examples illustrate problems of teacher compliance in filling out measures, supplying adequate placebos, and obtaining physician cooperation, and with the practical issue of providing adequate data without overwhelming the time and resources of participants. Emerging school-based methodologies are discussed with recommendations for future efforts.

Learning disorders with a special emphasis on reading disorders: a review of the past 10 years

OBJECTIVE

To review the past 10 years of clinical and research reports on learning disorders.

METHOD

The most common and best-researched type of learning disorder is reading disability, which is the focus of this review. A selective review of the literature from Psychological Abstracts and Index Medicus from 1985 to the present was conducted. This review focused on conceptual and methodological issues, current assessment practices, epidemiology, correlates of brain function, biological factors, predictors of reading achievement, core deficits, comorbidity reading development and instructional approaches, treatment, and outcome.

RESULTS

Definitional issues, still unresolved, bedevil the field with the debate between those for and those against discrepancy definitions of reading disabilities. Nevertheless considerable progress has been made. Phonological processing problems are now considered the main core deficit responsible for reading disabilities. Correlates of brain function and possible genetic factors are noted. Comorbidity with externalizing and internalizing disorders is described, and some theories for the overlap are identified. Studies on the comorbidity with internalizing disorders are lacking. Good assessment practice and promising approaches to remediation are identified. Unless a concurrent disorder is present, the use of medication for the treatment of reading disabilities should be considered experimental. Favorable outcomes are dependent on initial severity and a supportive home and school environment.

CONCLUSIONS

Much progress has been made in our understanding of learning disabilities, especially in reading disabilities. Resolution of definitional and conceptual issues will greatly assist research into assessment, treatment, and long-term outcome of learning disabilities with and without concurrent psychiatric disorders. Further research into the nature, extent, and correlates of comorbid learning disabilities and their treatment is much needed.

Pemoline effects on children with ADHD: a time-response by dose-response analysis on classroom measures

OBJECTIVE

To evaluate the dose-response by time-response characteristics of pemoline (Cylert) on dependent measures of behavior and academic performance in a laboratory classroom.

METHOD

After a 2-week baseline, a double-blind crossover design was used to compare placebo, 18.75 mg, 37.5 mg, 75 mg, and 112.5 mg of pemoline, q.a.m., with each dose administered for 1 week. Medication was given at 9:00 A.M., and performance was measured beginning immediately and beginning 2, 4, and 6 hours after ingestion. The dependent measures included number of math problems completed correctly, teacher-recorded rates of on-task behavior and noncompliance, and teacher ratings on an Abbreviated Conners Teacher Rating Scale.

RESULTS

There were linear effects of medication, with pemoline doses greater than 18.75 mg having an effect beginning 2 hours after ingestion and lasting through the seventh hour after ingestion.

CONCLUSIONS

Results are contrasted with widespread misbeliefs regarding pemoline's time course and efficacy.