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of Child Neurology
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What is This?
Abstract
The present investigation examined the effects of methylphenidate on impulsivity in children with attention-deficit hyper-
activity disorder (ADHD). A task was designed to measure empirically the ADHD child’s proclivity to blurt out incorrect
answers before giving a final and/or correct response. Twenty-six ADHD children referred for double-blind placebo-
controlled assessment of medication responsiveness and 14 non-ADHD controls were given a visual search word-matching
task to assess impulsive responding. An analysis of covariance showed that ADHD children on methylphenidate made
fewer impulsive errors than ADHD children on placebo. The control group made fewer impulsive errors than the ADHD
children in the placebo condition, but the performance of the ADHD children on medication approximated the perfor-
mance of the children without ADHD. These preliminary findings suggest that the word-matching task may be a useful
tool for assessing impulsive responding and determining the benefits of stimulant medication on impulsivity. ( J Child Neu-
rol
1993;8:157-163).
mpulsivity is one of the primary features con- quences of an action are disregarded and there is a
Isidered to characterize children with attention- lack of tolerance for any delay in gratification, and a
deficit hyperactivity disorder (ADHD). 1,2 Although cognitive impulsivity, in which answers are given
this has been recognized for many years, there contin- without adequate consideration of alternative re-
ues to be a need for the development of methods to sponses. The Matching Familiar Figures Test (MFFT)
adequately assess ADHD symptoms such as impul- was designed to assess cognitive impulsivity.9 There
sivity, as well as different aspects of attention and have been inconsistent findings, however, with
overactivity.3 Evidence from follow-up studies has in- some reports of a fast, inaccurate response style in
dicated that the poor inhibitory control of ADHD chil- children with ADHD10 and other investigations indi-
dren persists into adolescence and adulthood.4-5 cating greater inaccuracy but no change in the MFFT
Deficits in self-regulatory behavior (and thus the re- response time. 11-13 Similarly, reports of stimulant
sulting impulsive response tendencies) have been as- treatment effects have been mixed with some re-
sociated with, and may directly produce, a number of searchers finding decreased errors but no change in
problems, including low academic achievement, peer response latency following medication,14,15 while
rejection, and delinquency.6-8 others have found a decrease in MFFT errors and an
Two classes of impulsiveness have been identi- increase in response time.l6-ls
fied : a behavioral impulsivity, in which the conse- A pattern of high MFFT errors with an absence
of concomitant fast responses in ADHD children
Received Jan 27, 1992. Received revised Aug 10, 1992. Ac-
may be indicative of reduced efficiency in cognitive
cepted for publication Aug 17, 1992.
From the Division of Neurology, The Hospital For Sick Chil- processing.l9 For example, the effects of meth-
dren, Toronto, Canada (Dr Malone), and the Department of Pedi- ylphenidate on self-paced learning has shown that
atrics, University of California, Irvine, CA (Dr Swanson). ADHD children take about the same amount of time
Address correspondence to Dr Malone, Child Development
Clinic, Division of Neurology, The Hospital For Sick Children,
on drug as on placebo but learn more on drug.20 Eye
555 University Avenue, Toronto, Ontario, M5G lX8 Canada. movements of children performing the MFFT have
157
parisons, although no apparent benefit of drug was sponses made by the child before a final response
found (ie, errors were not reduced in conjunction was given during performance of a word-matching
with the increased attentional selectivity).23 task. It was predicted that methylphenidate would
A number of other measures have been used to lead to a decrease in impulsive responses. A de-
examine deficits in response inhibition and to deter- crease in actual errors (final incorrect responses) as a
mine medication effectiveness in ADHD children. function of medication was considered a possible,
Tasks include the Continuous Performance Test,24,25 but not necessary, outcome because these errors
a
Porteus Maze Test,12 delayed reaction time task,16 may not adequately represent a primary deficit in
delayed response task26 stopping task, 21 finger the ability to exert inhibitory control. The effect of
movement detection ’28 and go-no go task.29 None medication on response time was also explored to
of these tasks, with perhaps the exception of the de- determine what, if any, change occurred. Variability
layed response task,26 have been specifically de- of mean latency was expected to decrease in ADHD
signed to measure impulsivity. Instead they have children treated with stimulant drug.16,2’
been adopted from a variety of neurologic, psycho-
logical, and psychiatric paradigms in an attempt to
investigate impulsivity in ADHD children. The Method
MFFT was designed specifically to examine an im-
pulsive response style, but it is unclear what pre- Subjects
cisely the MFFT is assessing in ADHD children. Twenty-six ADHD children, 21 boys and 5 girls ranging in
Although the pathophysiology of ADHD is un- age from 6 to 13 years (mean, 9.1 years; SD, 1.79 years),
known, various brain structures and neural systems participated in the study. Children had been referred to the
have been implicated in theories that have been of- Child Development Clinic at The Hospital For Sick Chil-
fered to help explain the variety of symptoms that dren in Toronto for inattention/hyperactivity problems. De-
constitute ADHD. Particularly relevant to a deficit of velopmental pediatricians in the clinic had identified these
children as meeting the Diagnostic and Statistical Manual of
inhibitory control is the behavioral inhibition sys- Mental Disorders, 3rd ed, revised (DSM-111-R) criteria for
tem,3° which has been suggested to be underacti- ADHD and requested that an evaluation of stimulant
vated in ADHD children.31 When activated, this medication (methylphenidate) be completed through the
double-blind assessment service offered by the clinic.
system functions to inhibit actions in response to In addition to a primary diagnosis of ADHD, a num-
frustrative nonreward situations or when circum-
ber of the children exhibited other problems often found to
stances involve conditioned stimuli for punishment, be associated with the disorder. Nine children were found
and it results in passive-avoidance or extinction. to have learning disabilities as identified by the clinic psy-
ADHD and, specifically, defective response inhibi- choeducational assessment team or by school board per-
tion have been linked to another area of the brain: sonnel. Eight children met the DSM-111-R criteria for
the right frontal lobe, particularly as involved in a oppositional disorder, two evidenced aggressive behavior,
and three demonstrated anxious behavior.
right-sided frontal-striatal system. 28,32 Several inves- Children were administered the Wechsler Intelligence
tigators have also postulated or provided evidence Scale for Children-Revised, unless it had been previously
for involvement of frontal areas in the etiology of given. A verbal or performance IQ of 80 or more was a
ADHD. 33-37 minimum requirement for inclusion in this study. The Full-
Scale IQ for participants ranged from 76 to 131 (mean,
In the present investigation, examined the
we
103.4; SD, 15.8). The Verbal IQ ranged from 80 to 131
effects of methylphenidate on a new task designed
(mean, 103.4; SD, 15.0) and the Performance IQ ranged
to measure empirically the ADHD child’s proclivity from 72 to 136 (mean, 102.5; SD, 16.2).
to blurt out incorrect answers before giving a final Eighteen of the children had been treated with meth-
and/or correct response. We attempted to design a ylphenidate previously, whereas the remaining eight sub-
naturalistic task that would closely reflect the diag- jects had no prior history of treatment with stimulant
medication. Scores from the Abbreviated Conners Rating
nostic criteria for impulsivity in ADHD children, Scale’ were available for each subject. A score of 15 or
which describe the impulsiveness of these children more is considered indicative of an ADHD diagnosis, al-
158
the teacher but not the parent, and conversely, some (n = Materials
3) were given a high rating from the parent but not the The word-matching task required the child to make a vi-
teacher. Two subjects were given ratings below 15 on both sual search in order to find the exact match of a centered
the parent- and teacher-administered Conners. However, word from among similar words scattered randomly on the
both children met DSM-111-R criteria for ADHD, showed page. An example of one of the task pages is presented in
functional impairment, and were being treated with stimu- Figure 1. The task included one practice page plus 18 test
lant medication. pages. The stimulus words were typed on 21.7 x 28.0-cm
FIGURE 1
An example of one of the test pages from the word-matching task..
159
havioral areas. The purpose of the assessment was to pro- cided to perform a between-group analysis compar-
vide information on whether current methylphenidate ing the data for the 11 ADHD children who were
therapy was appropriate or whether the child would bene- given placebo for the first test session, with the 11
fit from a more extended home trial of drug therapy. Chil- ADHD children who were given medication for the
dren were assessed in the clinic for the entire day for a
first test session, along with the data for the control
given medication (or placebo) condition. Therefore, to
overcome the short half-life of methylphenidate, morning group from test session 1. Table 1 presents the mean
and afternoon doses were given to obtain constant effects values for the dependent measures from the word-
across the day. Test data for the word-matching task were
matching task for ADHD children on placebo, ADHD
collected 2 hours following the administration of the after- children on drug, and the control group. An analysis
noon (12:00) dose of medication/placebo.
of covariance was performed on the data for each of
The placebo and medication test sessions were always
on separate days and usually separated by 1 week. The or-
the seven dependent measures with age, sex, and
der of medication and placebo conditions was randomized learning disabilities as the three covariates. The re-
so that approximately half the subjects received meth- sults showed a significant difference among the three
ylphenidate first and the remaining half received placebo groups of subjects, for impulsive errors (F[2,28] _
first. Children were tested on the fixed dose prescribed by
their physician, and the mean dosage of medication given
8.25; P < .01), regular errors (number of incorrect fi-
was 9.4 mg, with a range of 2.5 to 15 mg. The mean dosage
nal responses) (F[2,28] 4.83; P < .05), total errors
=
by weight was 0.34 mg/kg, with a range of 0.1 to 0.54 mg/ (impulsive, plus regular errors) (F[2,28] 10.36; P < =
those subjects who failed to show a positive effect and The ADHD group on placebo made the most impul-
were tested on an additional higher dose, or who exhibited
sive and regular errors and the fewest correct re-
an adverse or no response across the variety of clinic tasks
on the prescribed doses. The average dose for this sub- sponses. The ADHD group on medication and the
group was 12.01 mg (range, 7.5 to 15 mg), representing a control group made fewer impulsive and regular er-
mean dosage by weight of 0.42 mg/kg (range, 0.33 to 0.50 rors and more correct responses, with the control
mg/kg). Medication was prepared in capsule form by the group showing slightly better performance overall
hospital pharmacy and was administered at the hospital than the ADHD-medication group. Statistical control
upon the subject’s arrival in the morning (about 9:00 AM)
and at noon. for differences in task performance due to age, sex,
Control children were tested at home. They were and learning disabilities was achieved by the analysis
160
ADHD =
attention-deficit hyperactivity disorder.
*Mean (SD).
of covariance; all three covariates were significant at effects of medication on the nonspecific attention
the P < .01 level for the four dependent variables dis- problems of these children. Previous studies with
cussed below. the MFFT 14-18 found overall errors to decrease with
There were no significant differences among the drug administration. However, in those studies no
three groups for response latency (time in seconds attempt was made to break the error score into com-
to first response whether correct, incorrect, or im- ponents, as in the current study, to determine
pulsive), within-subject variability (standard devia- whether specific aspects of the error score might be
tion) of response latency, or latency for correct affected by medication.
responses. Overall response latency did not change with
In additional analyses of data for the ADHD medication. However, some evidence for a more
children, latency of impulsive responses under pla- hasty approach to the task was found for the ADHD
cebo was compared to latency for correct responses children during placebo testing. Comparison of the
under placebo (14.9 ± 9.1 seconds versus 18.89 ± reaction time for impulsive responses with the reac-
7.4 seconds). A one-tailed test revealed that impul- tion time for initial correct responses showed that
sive responses were faster than correct responses the ADHD children were faster when they made im-
(t[20] 1.74; P < .05, one-tailed test).
=
pulsive responses than when they made correct re-
sponses. Nonetheless, reaction time for correct
responses in the drug condition was not signifi-
Discussion cantly slower than reaction time for correct re-
Treatment with methylphenidate reduced impulsive sponses in the placebo condition. Thus, treatment
responding in ADHD children on the MFFT-like task with stimulant medication did not seem to slow
designed for this study. By reducing the impulsive down the thinking processes in the ADHD children.
errors, stimulant-induced improvement brought the These data suggest that when ADHD children blurt
task performance of the ADHD children closer to the out an incorrect response, they may do so without
performance of the non-ADHD children. Also, regu- losing any speed in their processing of task informa-
lar errors (incorrect final responses) were signifi- tion. Without medication, they do blurt out incorrect
cantly decreased by drug treatment. The findings of responses more often than when they are on medi-
the present study therefore demonstrated that med- cation. This suggests that medication is operating
ication has specific as well as general effects on per- via an efficiency effect’9,20 rather than a slowing-
formance. It can be concluded that the present study down effect. 16
isolated, in a more precise fashion, the particular de- Response time variability was not significantly
ficiency in inhibitory control that seems to be modi- decreased with medication. Two recent studies
fied by medication in ADHD children. It is difficult have observed decreased variability in task perfor-
to know why medication also affected general errors mance when ADHD children are given meth-
on the task, but this may be related to the beneficial
ylphenidate. The results of these studies suggest
161
162
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