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Academic Underperformance in Children with ADHD. Is Medication the Solution?
Abstract and Figures
1st aim: quantify the effects of MPH on academic performance assessed in terms of both productivity and accuracy while distinguishing between core academic subjects (math, reading and spelling). Key findings: MPH has small to medium sized positive effects on math accuracy and math productivity (Chapters 2,
3 and 6) and reading speed (Chapter 2). MPH has no effect on reading accuracy and spelling (Chapters 2 and 3). Overall academic effects of MPH are small compared to behavioral effects and limited to math (Chapters 2 and 3).
2nd aim: unravel the mechanism behind MPH-effects on academic performance, thereby distinguishing between academic productivity and academic accuracy for math, reading and spelling. Key findings: Children with ADHD have cognitive impairments (visuospatial working memory and lapses of attention), and are less intrinsically motivated for math (Chapter 4). MPH has large effects on ADHD symptoms (Chapter 3). There are no effects of MPH on cognition and motivation (Chapter 4). The only evidence for mediating variables influencing MPH-effects on academic performance relates to improvements in ADHD symptoms (parent-rated) and improvements in parent reports of their child’s perceived competence. These effects are specific for MPH effect on math productivity (Chapters 3 and 4). Evidence for moderating variables affecting MPH effects on academic performance is limited to math ability: Children with below-average math performance profit more from MPH treatment than children with above-average math performance (Chapter 3).
3rd aim: quantify the effects of MPH on feedback learning in children with ADHD and the interaction between MPH and reward on math performance in children with ADHD. Key findings: Children with ADHD show intact acquisition of stimulus-reward associations and reversal learning compared to TD controls (Chapter 5). Children with ADHD are impaired when acquired knowledge needs to be applied in novel contexts (Chapter 5) MPH treatment improves learning of stimulusreward associations and shows potential (trend effect) to improve generalization of knowledge (Chapter 5). Parents of children with ADHD report differential responses of their children to punishment and reward, compared to parents of TD controls (Chapter 4). Children with ADHD and TD controls profit equally from positive feedback and reward, resulting in better math performance (Chapter 6). MPH treatment does not affect the ability to profit from feedback and reward on a math task (Chapter 6).
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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.
Objective:
This study investigated whether improvements in working memory, reaction time, lapses of attention, interference control, academic motivation, and perceived competence mediated effects of methylphenidate on math performance.
Method:
Sixty-three children (ADHD diagnosis; methylphenidate treatment; age 8-13; IQ > 70) were randomly allocated to a 7-day methylphenidate or placebo treatment in this double-blind placebo-controlled crossover study and compared with 67 controls. Data were collected at schools and analyzed using mixed-model analysis. Methylphenidate was hypothesized to improve all measures; all measures were evaluated as potential mediators of methylphenidate-related math improvements.
Results:
Controls mostly outperformed the ADHD group. Methylphenidate did not affect measures of cognitive functioning ( p = .082-.641) or academic motivation ( p = .199-.865). Methylphenidate improved parent ratings of their child's self-perceived competence ( p < .01), which mediated methylphenidate efficacy on math productivity.
Conclusion:
These results question the necessity of improvements in specific cognitive and motivational deficits associated with ADHD for medication-related academic improvement. They also stimulate further study of perceived competence as a mediator.
Recent research highlights the potential benefits of practice without feedback on learner’s strategy knowledge. However, most prior work has been conducted in one-on-one settings with short retention intervals. We compared the effects of mathematics practice with and without correct-answer feedback on immediate and 1-week delayed performance in a classroom setting. In a randomized experiment, 243 second- and third-grade children received strategy instruction and then practiced solving relevant problems in small groups within their classroom. During practice, children received immediate feedback (after each problem), summative feedback (after all the problems in the set), or no feedback. During the practice task, immediate feedback led to the best performance. However, practice without feedback led to higher levels of mastery on the 1-week knowledge retention test. Thus, instructional practices that seem less effective at first can, for some children, ultimately result in more desirable learning.
Comprehensive Meta‐Analysis (CMA) is a computer program for meta‐analysis that was developed with funding from the National Institutes of Health in the United States. CMA features a spreadsheet view and a menu‐driven interface. As such, it allows a researcher to enter data and perform a simple analysis in a matter of minutes. At the same time, it offers a wide array of advanced features, including the ability to plot the distribution of true effects, to compare the effect size in subgroups of studies, to run meta‐regression, to estimate the potential impact of publication bias, and to produce high‐resolution plots. The program's website, http://www.Meta‐Analysis.com , features PDFs and videos that explain how to perform, interpret, and report a meta‐analysis.
Objective:
This phase 3, laboratory classroom study assessed the efficacy and safety of methylphenidate hydrochloride extended-release chewable tablets (MPH ERCT) compared with placebo in children with attention-deficit/hyperactivity disorder (ADHD).
Methods:
Following a 6-week, open-label, dose-optimization period, children 6-12 years of age (n = 90) with ADHD were randomly assigned to double-blind MPH ERCT at the final optimized dose (20-60 mg/day) or placebo. After 1 week of double-blind treatment, efficacy was assessed predose and 0.75, 2, 4, 8, 10, 12, and 13 hours postdose in a laboratory classroom setting. The primary efficacy measure was the average of postdose Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP) Rating Scale-Combined scores, analyzed using a mixed-model, repeated-measures analysis. Secondary efficacy measures included Permanent Product Measure of Performance (PERMP) total number of problems attempted and total number of problems correct. Safety assessments included adverse event (AE) monitoring and the Columbia-Suicide Severity Rating Scale (C-SSRS).
Results:
MPH ERCT treatment statistically significantly reduced the average of all postdose SKAMP-Combined scores versus placebo (least-squares mean difference [95% confidence interval], -7.0 [-10.9, -3.1]; p < 0.001). Statistically significant treatment differences in SKAMP-Combined scores were observed at 2 hours postdose through 8 hours postdose (p-values <0.001). Statistically significant differences between MPH ERCT and placebo in PERMP total number of problems attempted and total number of problems correct were observed at 0.75 hours postdose through 8 hours postdose (p-values ≤0.049). Common AEs in the open-label period (≥5%) were decreased appetite, upper abdominal pain, mood swings, irritability, insomnia, upper respiratory tract infection (URTI), dysgeusia, and headache; URTI was the only AE reported by >1 subject receiving MPH ERCT in the double-blind period (placebo: URTI, contusion, wound, and initial insomnia). No suicidal ideation or behavior was reported on the C-SSRS at baseline or at any postbaseline assessment.
Conclusions:
MPH ERCT 20-60 mg significantly improved ADHD symptoms compared with placebo at 2 hours postdose through at least 8 hours postdose. MPH ERCT was generally safe and well tolerated, with a safety profile consistent with other MPH ER formulations. ClinicalTrials.gov Identifier: NCT01654250. www.clinicaltrials.gov/ct2/show/NCT01654250 .
I: Background.- 1. An Introduction.- 2. Conceptualizations of Intrinsic Motivation and Self-Determination.- II: Self-Determination Theory.- 3. Cognitive Evaluation Theory: Perceived Causality and Perceived Competence.- 4. Cognitive Evaluation Theory: Interpersonal Communication and Intrapersonal Regulation.- 5. Toward an Organismic Integration Theory: Motivation and Development.- 6. Causality Orientations Theory: Personality Influences on Motivation.- III: Alternative Approaches.- 7. Operant and Attributional Theories.- 8. Information-Processing Theories.- IV: Applications and Implications.- 9. Education.- 10. Psychotherapy.- 11. Work.- 12. Sports.- References.- Author Index.
Background:
Although numerous studies report positive effects of methylphenidate on academic performance, the mechanism behind these improvements remains unclear. This study investigates the effects of methylphenidate on academic performance in children with attention-deficit/hyperactivity disorder (ADHD) and the mediating and moderating influence of ADHD severity, academic performance, and ADHD symptom improvement.
Methods:
Sixty-three children with ADHD participated in a double-blind placebo-controlled crossover study comparing the effects of long-acting methylphenidate and placebo. Dependent variables were math, reading, and spelling performance. The ADHD group performance was compared with a group of 67 typically developing children.
Results:
Methylphenidate improved math productivity and accuracy in children with ADHD. The effect of methylphenidate on math productivity was partly explained by parent-rated symptom improvement, with greater efficacy for children showing more symptom improvement. Further, children showing below-average math performance while on placebo profited more from methylphenidate than children showing above-average math performance.
Conclusions:
The results from this study indicate positive effects of methylphenidate on academic performance, although these were limited to math abilities. In light of these results, expectations of parents, teachers, and treating physicians about the immediate effects of methylphenidate on academic improvement should be tempered. Moreover, our results implicate that positive effects of methylphenidate on math performance are in part due directly to effects on math ability and in part due to reductions in ADHD symptoms.
