Despite the widespread use of methylphenidate (MPH) in the treatment of children with Attention Deficit Hyperactivity Disorder (ADHD), physicians often must rely on anecdotal observations and subjective reports to titrate MPH regimens. Many double-blind placebo-controlled medication trials have demonstrated treatment efficacy; however, the development of an effective clinical protocol that is reliably sensitive to dose-response relationships and can be used in office practice remains elusive. Using a double-blind placebo clinical protocol, and rank order analysis of instruments sensitive to ADHD symptoms, the MPH response patterns of 50 children with ADHD were analyzed using repeated measures multivariate analysis of variance. Several instru ments were sensitive in predicting response, and others revealed trends in the expected direction. The rank order rating analyses revealed robust differences between active drug conditions and placebo. Using cognitive rank order ratings, linear and quadratic MPH response patterns were identified, with the best dose for each group significantly different from that obtained for all other conditions.
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References
1.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author .
2.
Barkley, R.A. (1988). Child behavior rating scales and checklists. In M. Rutter , A.H. Tuma, & I.S. Lann (Eds.), Assessment and diagnosis in child psychopathology (pp. 113-155). New York: Guilford Press.
3.
Barkley, R.A. (1994). The assessment of attention in children. In G. Reid Lyon (Ed.), Frames of reference for the assessment of learning disabilities: New views on measurement issues (pp. 69-102). Baltimore : Paul H. Brookes Publishing Co.
4.
Barkley, R.A., DuPaul, G.J. , & McMurray, M.B. ( 1991). Attention Deficit Disorder with and without hyperactivity: Clinical response to three different doses of methylphenidate. Pediatrics,87, 519-531.
5.
Barkley, R.A., Fischer, M. , Newby, R.F., & Breen, M.J. (1988). Development of a multimethod clinical protocol for assessing stimulant drug response in children with Attention Deficit Disorder. Journal of Clinical Child Psychology, 17, 14-24.
6.
Barkley, R.A., Grodzinsky, G , & DuPaul, G.J. ( 1992). Frontal lobe functions in Attention Deficit Disorder with and without hyperactivity: A review and research report. Journal of Abnormal Child Psychology, 20, 163-188.
7.
Blouin, A.G., Conners, C.K. , Seidel, W.T., & Blouin, J. (1989). The independence of hyperactivity from Conduct Disorder: Methodological considerations. Canadian Journal of Psychiatry, 34, 279-282.
8.
Brown, R.T., Jaffe, S.L. , Silverstein, J., & Magee, H. (1991). Methylphenidate and adolescents hospitalized with Conduct Disorder: Dose effects on classroom behavior, academic performance, and impulsivity. Journal of Clinical Child Psychology, 20, 282-292.
9.
Buschke, H. (1973). Selective reminding for analysis of memory and learning. Journal of Learning and Verbal Behavior, 12, 543-550.
10.
Chelune, G.J., Ferguson, W., Koon, R., & Dickey, T.O. (1986). Frontal lobe disinhibition in Attention Deficit Disorder. Child Psychiatry and Human Development,16, 221-234.
11.
Cohen, M. (1988). The revised Conners' Parent Rating Scale: Factor structure replication with a diversified clinical sample. Journal of Abnormal Child Psychology, 16, 187-196.
Conners, C.K., & Wells, K.C. (1982). Single-case designs in psychopharmacology . New Directions for Methodology of Social and Behavioral Science, 13, 61-77.
14.
Copeland, L, Wolraich, M. , Lindgren, S., Milich, R., & Woolson, R. (1987). Pediatricians' reported practices in the assessment and treatment of attention deficit disorders. Journal of Developmental and Behavioral Pediatrics, 8, 191-197.
15.
DiTraglia, J. (1991). Methylphenidate protocol: Feasibility in a pediatric practice. Clinical Pediatrics , 30, 656-660.
Douglas, V.I., Barr, R.G. , O'Neill, M.E., & Britton, B.G. (1988). Dosage effects and individual responsivity to methylphenidate in attention deficit disorder. Journal of Child Psychology and Psychiatry, 29, 453-475.
18.
Dulcan, M.K. (1985). The psychopharmacologic treatment of children and adolescents with attention deficit. Psychiatric Annals, 15, 69-87.
19.
DuPaul, G.J., & Barkley, R A. (1990). Medication therapy. In R.A. Barkley (Ed.), Attention Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (pp. 573-612). New York: Guilford.
20.
DuPaul, G.J., & Barkley, R.A. (1993). Behavioral contributions to pharmacotherapy: The utility of behavioral methodology in medication treatment of children with ADHD. Behavior Therapy, 24, 47-65.
21.
Evans, R.W., Gualtieri, C.T. , & Amara, I. (1986 ). Methylphenidate and memory: Dissociated effects in hyperactive children. Psychopharmacology, 90, 211-216.
22.
Firestone, P. (1982). Factors associated with children's adherence to stimulant medication. American Journal of Orthopsychiatry, 52, 447-457.
23.
Fischer, M. (1996, August). Use of restricted academic task in ADHD dose-response relationships. In J. Hoeppner (Chair) Developing objective methylphenidate placebo protocols for children with ADHD. Symposium conducted at the 104th Annual Convention of the American Psychological Association, Toronto, Ontario, Canada.
24.
Fischer, M., & Newby, R.F. (1991). Assessment of stimulant response in ADHD children using a refined multimethod clinical protocol. Journal of Clinical Child Psychology, 20, 232-244.
25.
Gadow, K.D. (1981). Prevalence of drug treatment for hyperactivity and other behavior disorders. In K.D. Gadow & J. Loney (Eds.), Psychosocial aspects of drug treatment for hyperactivity (pp. 325-378). Boulder, CO: Westview.
26.
Goodyear, P. & Hynd, G.W. (1992). Attention-Deficit Disorder with (ADD/H) and without (ADD/WO) hyperactivity : Behavioral and neuropsychological differentiation. Journal of Clinical Child Psychology, 21, 273-305.
27.
Gordon, M. (1991). The Gordon Diagnostic System. Boulder, CO: Clinical Diagnostic Systems.
28.
Gordon, M., & Mettelman, B.B. (1988). The assessment of attention: Standardization and reliability of a behavior-based measure. Journal of Clinical Psychology, 44, 682-690.
29.
Goyette, C H., Conners, C K., & Ulrich, R.F. ( 1978). Normative data on revised Conners' parent and teacher rating scales. Journal of Abnormal Child Psychology, 6, 221-236.
30.
Hale, J.B., & Zimmerman, L.M. (1995). Evaluating cognitive and behavioral effects of medication for children with ADHD. Communiqué , 24, 13-14.
31.
Hamlett, K.W., Pellegrini, D.S., & Conners, C.K. ( 1987). An investigation of executive processes in the problem-solving of Attention Deficit Disorder-Hyperactive children. Journal of Pediatric Psychology, 12, 227-240.
32.
Helsel, W.J., Hersen, M. , Lubetsky, M.J., & Fultz, S.A. (1989). Stimulant drug treatment of four multihandicapped children using a randomized single-case design. Journal of the Multihandicapped Person, 2, 139-154.
33.
Hudspeth, W.J., & Pribram, K.H. (1992). Psychophysiological indices of cerebral maturation. International Journal of Psychophysiology , 12, 19-29.
34.
Jacobson, N.S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19.
35.
Johnston, H.F., Witkovsky, M.T. & Fruehling, J.J. ( 1966, Second Quarter). Stimulant dosing and ADHD. Just The Facts, 3, 3-4. (Newsletter of the University of Wisconsin Child Psychopharmacology Information Service.)
36.
Koziol, L.F., & Stout, C.E. (1992). Use of a verbal fluency measure in understanding and evaluation: ADHD as an executive function disorder. Perceptual and Motor Skills, 75, 1187-1192.
37.
Leimkuhler, M.E., & Mesulaum, M.M. (1985). Reversible go no-go deficits in a case of frontal lobe tumor. Annals of Neurology , 18, 617-619.
38.
Livingston, R.L., Dykman, R.A., & Ackerman, P.T. ( 1992). Psychiatric comorbidity and response to two doses of methylphenidate in children with attention deficit disorder. Journal of Child and Adolescent Psychopharmacology, 2, 115-122.
39.
Lovejoy, M.C., & Rasmussen, N.H. (1990). The validity of vigilance tasks in differential diagnoses of children referred for attention and learning problems. Journal of Abnormal Child Psychology, 18, 671-681.
40.
May, R., Masson, M., Hunter, M., & Wells, J. (1990). NPStat 3.01 [computer software] . University of Victoria, Victoria, BC.
41.
Mayes, S.D., & Bixler, E.O. (1993). Reliability of global impressions for assessing methylphenidate effects in children with Attention-Deficit Hyperactivity Disorder. Perceptual and Motor Skills, 77, 1215-1218.
42.
McBride, M.C. (1988). An individual double-blind crossover trial for assessing methylphenidate response in children with Attention Deficit Disorder. Journal of Pediatrics, 113, 137-145.
43.
Milich, R., Roberts, M.A. , Loney, J., & Caputo, J. (1980). Differentiating practice effects and statistical regression on the Conners Hyperkinesis Index . Journal of Abnormal Child Psychology, 8, 549-552.
44.
Mirza, K.A.H., Michael, A. , & Dinan, T.G. ( 1994). Recent advances in paediatric psychopharmacology: A brief overview. Human Psychopharmacology Clinical and Experimental , 9, 13-24.
45.
Pelham, W.E. (1989). Behavioral therapy, behavioral assessment and psychostimulant medication in the treatment of attention deficit disorders: An interactive approach. In J. Swanson & L. Bloomingdale (Eds.), Attention Deficit Disorder IV: Current concepts and emerging trends in attentional and behavior disorders of childhood. New York: Pergamon.
46.
Pelham, W.E., Bender, M.E. , Caddell, J., Booth, S., & Moorer, S. (1985). Methylphenidate and children with Attention Deficit Disorder: Dose effects on classroom, academic, and social behavior. Archives of General Psychiatry, 42, 948-952.
47.
Pelham, W.E., & Hoza, J. (1987). Behavioral assessment of psychostimulant effects on ADD children in a summer day treatment program. In R. Prinz (Ed.), Advances in behavioral assessment of children and families (pp. 23-33). Greenwich, CT: JAI.
48.
Rapport, M.D. (1992). Introduction. Treating children with Attention Deficit-Hyperactivity Disorder. Behavior Modification, 16, 155-163.
49.
Rapport, M.D , DuPaul, G.J , & Kelly, K.L. ( 1989). Attention-Deficit Hyperactivity Disorder and methylphenidate: The relationship between gross body weight and drug response in children . Psychopharmacology Bulletin, 25, 285-290.
50.
Rapport, M.D., DuPaul, G.J. , Stoner, G., & Jones, J.T. (1986). Comparing classroom and clinic measures of Attention Deficit Disorder: Differential, idiosyncratic, and dose-response effects of methylphenidate. Journal of Consulting and Clinical Psychology, 54, 334-341.
51.
Rapport, M.D., & Kelly, K.L. (1993). Psychostimulant effects on learning and cognitive functioning. In: J.L. Matson (Ed.), Handbook of hyperactivity in children (pp. 97-136). Boston: Allyn & Bacon.
52.
Rapport, M.D., Stoner, G. , DuPaul, G.J., Kelly, K L., Tucker, S.B. , & Schoeler, T. ( 1988). Attention Deficit Disorder and methylphenidate: A multilevel analysis of dose-response effects on children's impulsivity across settings . American Academy of Child and Adolescent Psychiatry, 27, 60-69.
53.
Resnick, R.J., Hamer, R.M. , & Goldberg, S.C. ( 1988). Attention Deficit Disorder without Hyperactivity: A preliminary investigation. Psychotherapy in Private Practice , 6, 1-11.
54.
Richer, F., Decary, A., Lapierre, M., & Rouleau,I. (1993). Target detection deficit in frontal lobectomy. Brain and Cognition, 21, 203-211.
55.
Rudel, R.G., Denckla, M.B. , & Broman, M. ( 1978 ). Rapid silent response to repeated target symbols by dyslexic and nondyslexic children. Brain and Language, 6, 52-62.
56.
Safer, D.J., & Krager, J.M. (1988). A survey of medication treatment for hyperactive/inattentive students. Journal of the American Medical Association, 260, 2256-2258.
57.
Sargeant, J., & van der Meere, J.J. (1989). The diagnostic significance of attentional processing: Its significance for ADDH classification — A future DSM. In T. Sagvolden & T.
58.
Archer (Eds.), Attention Deficit Disorder: Clinical and basic research (pp. 151-166). Hillsdale, NJ: Erlbaum.
59.
Snow, J.H., English, R., & Lange, B. (1992). Clinical utility of the Selective Reminding Test — Children's Version . Journal of Psychoeducational Assessment, 10, 153-160.
60.
Solanto, M.V., & Conners, C.K. (1982). A dose-response and time-action analysis of autonomic and behavioral effects of methylphenidate in Attention Deficit Disorder with Hyperactivity. Psychophysiology, 19, 658-667.
61.
Speer, D.C., & Greenbaum, P.E. (1995). Five methods for computing significant individual client change and improvement rates: Support for individual growth curve approach. Journal of Consulting and Clinical Psychology , 63, 1044-1048.
62.
Sprague, R., & Sleator, E. (1977). Methylphenidate in hyperkinetic children: Differences in dose effects on learning and social behavior. Science, 198, 1274-1276.
63.
Taylor, H.G. (1985) The children's version of Buschke's Selective Reminding Test. Montreal : McGill University.
64.
Trommer, B.L., Hoeppner, J.B., Lorber, R., & Armstrong, K. (1988). The Go No-Go paradigm in Attention Deficit Disorder (ADD). Annals of Neurology, 24, 610-614.
65.
Trommer, B.L., Hoeppner, J.B., & Zecker, S.G. ( 1991). The Go No-Go Test in Attention Deficit Disorder (ADD) is sensitive to methylphenidate. Journal of Child Neurology , 6, S128-S131.
66.
Vyse, S.A. & Rapport, M.D. (1989). The effects of methylphenidate on learning in children with ADDH: The stimulus equivalence paradigm. Journal of Consulting and Clinical Psychology, 57, 425-435.
