Psychotropic drugs and learning problems--a selective review

Does methylphenidate improve academic performance? A systematic review and meta-analysis

Academic improvement is amongst the most common treatment targets when prescribing stimulants to children with ADHD. Previous reviews on stimulant-related academic improvements are inconclusive and focus on task engagement. Recent literature suggests outcome-domain-specific medication effects that are larger for productivity than for accuracy. The aims of this study are quantifying methylphenidate effects on academic productivity and accuracy for math, reading, spelling; exploring the mediating or moderating effects of symptom improvements, demographic-, design- and disorder-related variables. PubMed, EMBASE, ERIC and PsycINFO were searched for articles reporting methylphenidate effects on academic productivity and accuracy. Thirty-four studies met entry criteria. Methylphenidate improved math productivity (7.8% increase, p < .001); math accuracy (3.0% increase, p = .001); increased reading speed (SMD .47, p < .001) but not reading accuracy. None of the mediators or moderators tested affected methylphenidate efficacy. Academic improvements were small compared to symptom improvements; qualitative changes limited to math. Clinicians should take this discrepancy into account when prescribing medication for ADHD.

Risperidone Added to Psychostimulant in Children with Severe Aggression and Attention-Deficit/Hyperactivity Disorder: Lack of Effect on Attention and Short-Term Memory

OBJECTIVE

Professionals have periodically expressed concern that atypical antipsychotics may cause cognitive blunting in treated patients. In this study, we report data from a double-blind, randomized, controlled study of stimulant plus placebo versus combined stimulant and risperidone to evaluate the effects of the atypical antipsychotic on attention and short-term memory.

METHODS

A total of 165 (n = 83 combined treatment; n = 82 stimulant plus placebo) children with attention-deficit/hyperactivity disorder and severe physical aggression, aged 6-12 years, were evaluated with Conners' Continuous Performance Test (CPT-II) and the Wechsler Intelligence Scale for Children-III (WISC) Digit Span subscale at baseline, after 3 weeks of stimulant-only treatment, and after six additional weeks of randomized treatment (stimulant+placebo vs. stimulant+risperidone).

RESULTS

At 3 weeks, improvement on CPT-II performance (Commissions and Reaction Time Standard Error; p < 0.001) and on Digit Span memory performance (p < 0.006) was noted for the full sample. At study week 9, no difference in CPT-II or Digit Span performance was observed between the randomized groups (ps = 0.41 to 0.83).

CONCLUSIONS

Similar to other studies, we found no deleterious effects on attention and short-term memory associated with short-term use of risperidone. NCT00796302.

A review of atomoxetine effects in young people with developmental disabilities

This review summarizes the pharmacokinetic characteristics, pharmacodynamic properties, common side effects, and clinical advantages and disadvantages associated with atomoxetine (ATX) treatment in typically developing children and adults with ADHD. Then the clinical research to date in developmental disabilities (DD), including autism spectrum disorders (ASD), is summarized and reviewed. Of the 11 relevant reports available, only two were placebo-controlled randomized clinical trials, and both focused on a single DD population (ASD). All trials but one indicated clinical improvement in ADHD symptoms with ATX, although it was difficult to judge the magnitude and validity of reported improvement in the absence of placebo controls. Effects of ATX on co-occurring behavioral and cognitive symptoms were much less consistent. Appetite decrease, nausea, and irritability were the most common adverse events reported among children with DD; clinicians should be aware that, as with stimulants, irritability appears to occur much more commonly in persons with DD than in typically developing individuals. Splitting the dose initially, starting below the recommended starting dose, and titrating slowly may prevent or ameliorate side effects. Patience is needed for the slow build-up of benefit.

CONCLUSIONS

ATX holds promise for managing ADHD symptoms in DD, but properly controlled, randomized clinical trials of atomoxetine in intellectual disability and ASD are sorely needed. Clinicians and researchers should be vigilant for the emergence of irritability with ATX treatment. Effects of ATX on cognition in DD are virtually unstudied.

A risk-benefit assessment of pharmacotherapies for clinical depression in children and adolescents

Child and adolescent major depressive disorders are common and recurrent disorders. The prevalence of major depressive disorders is estimated to be approximately 2% in children and 4 to 8% in adolescents. Major depressive disorders in children are frequently accompanied by other psychiatric disorders, poor psychosocial outcome and a high risk of suicide and substance abuse, indicating the need for effective treatment and prevention. The use of antidepressant medications as the first line of treatment for children and adolescents with mild to moderate major depressive disorders has been questioned. However, some subgroups of patients may benefit from initial treatment with antidepressants. These subgroups may include patients who are unwilling or unable to undergo psychotherapy, have not responded to at least 8 to 12 sessions of psychotherapy, have bipolar, atypical or severe depression or have recurrent depression. Currently, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors are the first medication choice because of their efficacy, benign adverse effect profile, ease of use and low risk of death following an overdose. Further research in continuation and maintenance treatments, treatment of comorbid conditions, subtypes of depression, e.g. bipolar, atypical, seasonal, and combinations of pharmacotherapy and psychotherapy are needed. In addition, studies of the pharmacokinetics, pharmacodynamics and long term adverse effects of antidepressant medications in children and adolescents are warranted.

Pharmacologic treatment for children and adolescents with anxiety disorders

Pediatric anxiety disorders are common illnesses that, if left untreated, may induce academic, family, and interpersonal problems. Cognitive-behavioral techniques and other psychotherapeutic interventions may be adequate for the treatment of most anxiety disorders. For patients with severe symptoms or for whom psychotherapeutic approaches are not adequate, medications are indicated. Among the available medications, the SSRIs are currently the first choice; however, other medications, such as the benzodiazepines and the TCAs, may be used alone or sometimes in combination with the SSRIs. Caution with respect to medication interactions and side effects is indicated. In particular, long-term side effects in these medications have not been well studied.

CNS stimulant controversies

Controversies in the use of central nervous system stimulant medications in children with attention deficit hyperactivity disorder are discussed. Diagnostic issues, age of optimal use, side effects, effects on learning and ethical considerations are current issues. An animal model for the effects of chronic long-term high dose regimes is proposed.

Hyperactivity and inattentiveness. School assessment of stimulant treatment

The school health folders of all students receiving stimulant medication for hyperactivity/inattentiveness from five public elementary and two middle schools in Baltimore County were evaluated to 1) record pre-treatment teacher ratings of those on stimulant medication; 2) assess, using the rating scales, the initial and subsequent effectiveness of the medication; and 3) to identify treatment subgroups. Major findings were 1) three-fourths of the 176 students on stimulant medication in 1987 had pre-treatment ratings consistent with moderate to severe hyperactivity/inattentiveness; 2) over 90 percent of the students evidenced at least 50 percent improvement initially following stimulant treatment by teacher ratings; 3) 76 percent of the medicated students continued to show this level of improvement at the end of the 1987 school year; 4) medication improvement and compliance declined in middle school; 5) 15 percent of the students on stimulant medication in 1987 were inattentive but not hyperactive on baseline teacher ratings, but their degree of improvement with stimulants was equivalent to that of hyperactives; 6) in the county-run hyperkinetic clinic, the subpopulation of inattentive/non-hyperactive students on stimulants rose from 7 percent to 18 percent of the total between 1976 and 1987.

Psychophysiological effects of methylphenidate (Ritalin)

The nature and psychophysiological effects of methylphenidate whose metabolism, pharmacokinetics, and effects on human behavior are not well known are the focus of this review. Methylphenidate treatment of attention deficit disorder with hyperactivity is presented summarily.

Evaluation of the efficacy of piracetam in treating information processing, reading and writing disorders in dyslexic children

Piracetam, a new class of drug (nootropil) thought to enhance specific cognitive skills, was given in a 3300 mg daily dose to half of a group of fifty-five dyslexic boys aged 8-13 years, in a 12-week, double-blind, placebo-controlled study. The other half of the subjects received placebo. All subjects met the following criteria: normal intelligence, normal educational opportunities, no severe emotional problems, no neurological handicaps, good physical health, not taking other psychotropic medication, and scoring at least one and one half years below their mental age equivalent on the Gilmore Oral Reading Test. Non-verbal (auditory and visual) and verbal perceptual, and memory skills were examined, and reading, spelling, language and writing abilities were measured using standardized instruments. Compared to the placebo control group, individuals treated with Piracetam did not show statistically significant improvements above their baseline scores on measures of perception, memory, language, reading accuracy or comprehension, or writing accuracy. However, reading speed and numbers of words written in a timed period were significantly enhanced in subjects treated with Piracetam as compared to placebo. Effective reading and writing ability, taking both rate and accuracy into consideration, were also significantly improved in the Piracetam as compared to the placebo treatment group. The medication was well-tolerated and medical examinations showed no significant adverse reactions. These results encourage further study of Piracetam to determine more precisely the mechanism of action by which specific cognitive skills are affected.

Short term effects of methylphenidate on the cognitive, learning and academic performance of children with attention deficit disorder in the laboratory and the classroom

Sixteen children meeting diagnostic criteria for Attention Deficit Disorder with Hyperactivity (ADD-H) were tested on methylphenidate (0.3 mg/kg) and placebo on cognitive, learning, academic and behavioral measures in a double-blind study. Assessments were carried out in the laboratory and in the children's regular classrooms. Results indicate methylphenidate-induced improvements on a majority of the measures. Drug-induced changes reflected increased output, accuracy and efficiency and improved learning acquisition. There was also evidence of increased effort and self-correcting behaviours. It is argued that reviewers have underestimated the potential of stimulants to improve the performance of ADD-H children on academic, learning and cognitive tasks.

Effects of color stimulation and information on the copying performance of attention-problem adolescents

The optimal stimulation theory proposes that hyperactive children are less tolerant of lower levels of arousal than nonhyperactive children and should thus derive greater gains from stimulation added to repetitive copying tasks than do comparisons. To test this hypothesis, 16 adolescents, rating high on attention and behavior problems, were matched on the basis of age and poor handwriting performance to 16 controls. Matched pairs were randomly assigned to treatment order (high-stimulation colored letters followed in 2 weeks by low-stimulation black letters or the reverse order) and to level of information (color added to difficult letter parts or added to randomly selected letters), counterbalanced for treatment order and level of information within each order. Errors and activity were subjected to a mixed-design analysis of covariance, with IQ the covariate. The major findings indicated that attention-problem adolescents performed better with high-stimulation task stimuli than with low, relative to the opposite performance pattern of controls. Different responding was significant for experimental but not for control children.

Multimodality approaches in the treatment of attention deficit disorders

This article describes the diagnostic process and various etiologic considerations that underpin the formulation of a comprehensive treatment program for a child with attention deficit disorder and then goes on to describe treatment modalities and strategies. The authors then suggest that the coordinated use of problem-specific treatment modalities is likely to prove more therapeutic and cost-effective than a global treatment.

Hyperactivity: nature of the syndrome and its natural history

The composition of hyperactivity as a syndrome is discussed from a historical perspective, and the principal events leading to the recent emphasis on attentional characteristics of hyperactive children are summarized. Some of the major challenges to the legitimacy of hyperactivity as a valid syndrome are set forth, and after critical examination of the most influential work, it is concluded that hyperactivity has not been disproved. This is followed by a survey of the large follow-up literature dealing with the natural history of children diagnosed as hyperactive. It is noted that the manifestations of the syndrome appear to change with age but there is little indication that problems simply remit with maturity. The evidence indicates that hyperactivity, as diagnosed in the past, is often a serious disorder with long-term and far-reaching consequences for the children and their families. Multivariate studies are also discussed, as they have important implications for differential outcome. Different symptoms such as aggression, overactivity, and learning disability appear to contain unique information about current and future status, and therefore it appears useful to retain these distinctions rather than view such children as part of an undifferentiated group. It is unknown whether the recent guidelines for diagnosing Attention Deficit Disorder with Hyperactivity will alter or refine the outlook for children so identified, but this is an active area of research at present.

Effects of stimulant drugs on academic performance in hyperactive and learning disabled children

The effect of stimulant drugs upon academic performance in hyperactive (HA), learning disabled (LD), and hyperactive-learning disabled (HA-LD) children has been a matter of controversy for over a decade. Research on this topic is reviewed with attention to specific academic skills, methodological issues, relative efficacy of drug, educational, and multimodal interventions, and clinical implications. It is concluded that while stimulants may increase academic productivity, (a) the effect on standardized achievement test scores is not particularly robust; (b) individual reaction is quite variable; (c) the clinical implications for adult outcome appears to be minimal; and (d) some behavioral interventions are clearly superior. However, the number of pertinent subject, task, treatment, and setting variables is so great that a definitive answer with regard to the relationship between pharmacotherapy and academic performance is anything but close at hand.

Stimulant drug effects in developmental disorders and hyperactivity--toward a resolution of disparate findings

An attempt is made to integrate data from a variety of clinical populations and from the animal literature. Evidence is presented suggesting that mentally retarded and autistic children generally show a poor response to stimulant medication, whereas hyperactive and normal children respond beneficially. Cognitive research in mentally retarded and autistic children is reviewed, and it is suggested that both diagnostic groups suffer from attentional difficulties, the mechanisms of which may be very similar. The literature on stimulant-induced stereotypy in animals is discussed, with emphasis on the clinical implications for autism and mental retardation. An attentional model is proposed to account for type of therapeutic response to stimulant medication. This is followed by a possible method for testing the model and by specific predictions relating to subject characteristics and response.

Methylphenidate in severely retarded residents and the clinical significance of stereotypic behavior

An attempt was made to evaluate a model predicting stimulant drug response based on attentional characteristics of the participants. Twenty-eight severely and profoundly mentally retarded residents took part in a double blind, placebo controlled trial of methylphenidate (Ritalin). Methylphenidate was administered, for one week each, in a low dose of 0.3 mg/kg and a high dose of 0.6 mg/kg. The results failed to show any clinically relevant differences between placebo and active drug conditions with the exception that methylphenidate caused a significant reduction in food consumption. A variety of subject characteristics, including level of stereotypy, hyperactivity, and IQ were unrelated to drug effect. One positive finding, unrelated to drug effects, was that subdivision of the group by degree of stereotypy provided substantial clinical information about individual subjects.

Three-year multimodality treatment study of 100 hyperactive boys

We conducted a prospective study of 100 hyperactive boys admitted to a multimodality treatment program. After a comprehensive evaluation, an individualized psychotherapy plan commensurate with the child's disabilities was developed. In addition to medication, each child was enrolled in one or more indicated psychotherapeutic modalities. Since approximately 50% of our patients dropped out of treatment, groups receiving less and more treatment were compared on outcome measures. At three-year follow-up the group receiving more treatment was found to be further ahead educationally, to demonstrate less antisocial behavior, to be more attentive (as rated by their teachers), to have better adjustment at school and at home (as reported by their parents), and to be more globally improved (as rated by psychiatrists and by parents) than children in the group receiving less treatment. Outcome for the group receiving more treatment was found also to be unusually good as compared to that in other studies of hyperactive children treated for varying lengths of time and evaluated after one to five years.