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of Child Neurology

Effects of Methylphenidate on Impulsive Responding in Children With Attention-Deficit Hyperactivity

Disorder
Molly A. Malone and James M. Swanson
J Child Neurol 1993 8: 157
DOI: 10.1177/088307389300800209

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Effects of
Methylphenidate on
Impulsive Responding in Children
With Attention-Deficit
Hyperactivity Disorder
Molly A. Malone, PhD; James M. Swanson, PhD

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-
Isidered to characterize children with attention-
deficit hyperactivity disorder (ADHD). 1,2 Although
this has been recognized for many years, there contin-
ues to be a need for the development of methods to
adequately assess ADHD symptoms such as impul-
quences of an action are disregarded and there is a
lack of tolerance for any delay in gratification, and a
cognitive impulsivity, in which answers are given
without adequate consideration of alternative re-
sponses. The Matching Familiar Figures Test (MFFT)
was designed to assess cognitive impulsivity.9 There

sivity, as well as different aspects of attention and
overactivity.3 Evidence from follow-up studies has in-
dicated that the poor inhibitory control of ADHD chil-
dren persists into adolescence and adulthood.4-5
Deficits in self-regulatory behavior (and thus the re-
sulting impulsive response tendencies) have been as-
sociated with, and may directly produce, a number of
problems, including low academic achievement, peer
rejection, and delinquency.6-8
Two classes of impulsiveness have been identi-
fied : a behavioral impulsivity, in which the conse-
Received Jan 27, 1992. Received revised Aug 10, 1992. Ac-
cepted for publication Aug 17, 1992.
From the Division of Neurology, The Hospital For Sick Chil-
dren, Toronto, Canada (Dr Malone), and the Department of Pedi-
atrics, University of California, Irvine, CA (Dr Swanson).
Address correspondence to Dr Malone, Child Development
Clinic, Division of Neurology, The Hospital For Sick Children,
555 University Avenue, Toronto, Ontario, M5G lX8 Canada.
have been inconsistent findings, however, with
some reports of a fast, inaccurate response style in
children with ADHD10 and other investigations indi-
cating greater inaccuracy but no change in the MFFT
response time. 11-13 Similarly, reports of stimulant
treatment effects have been mixed with some re-
searchers finding decreased errors but no change in
response latency following medication,14,15 while
others have found a decrease in MFFT errors and an
increase in response time.l6-ls
A pattern of high MFFT errors with an absence
of concomitant fast responses in ADHD children
may be indicative of reduced efficiency in cognitive
processing.l9 For example, the effects of meth-
ylphenidate on self-paced learning has shown that
ADHD children take about the same amount of time
on drug as on placebo but learn more on drug.20 Eye
movements of children performing the MFFT have

157

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shown that impulsive children make fewer system-
aticcomparisons when matching stimuli2l and seem
to demonstrate more global search patterns.22 Hy-
peractive children tested on placebo and meth-
ylphenidate using a visual matching-to-sample task
were found to be more reflective on drug as indi-
cated by the increased number of systematic com-
parisons, although no apparent benefit of drug was
found (ie, errors were not reduced in conjunction
with the increased attentional selectivity).23
A number of other measures have been used to
examine deficits in response inhibition and to deter-
mine medication effectiveness in ADHD children.
Tasks include the Continuous Performance Test,24,25
Porteus Maze Test,12 delayed reaction time task,16
delayed response task26 stopping task, 21 finger
movement detection ’28 and go-no go task.29 None
of these tasks, with perhaps the exception of the de-
layed response task,26 have been specifically de-
signed to measure impulsivity. Instead they have
been adopted from a variety of neurologic, psycho-
logical, and psychiatric paradigms in an attempt to
investigate impulsivity in ADHD children. The
MFFT was designed specifically to examine an im-
pulsive response style, but it is unclear what pre-
cisely the MFFT is assessing in ADHD children.
Although the pathophysiology of ADHD is un-
known, various brain structures and neural systems
have been implicated in theories that have been of-
fered to help explain the variety of symptoms that
constitute ADHD. Particularly relevant to a deficit of
inhibitory control is the behavioral inhibition sys-
tem,3° which has been suggested to be underacti-
vated in ADHD children.31 When activated, this
system functions to inhibit actions in response to
frustrative nonreward situations or when circum-
stances involve conditioned stimuli for punishment,
and it results in passive-avoidance or extinction.
ADHD and, specifically, defective response inhibi-
tion have been linked to another area of the brain:
the right frontal lobe, particularly as involved in a
right-sided frontal-striatal system. 28,32 Several inves-
tigators have also postulated or provided evidence
for involvement of frontal areas in the etiology of
ADHD. 33-37
In the present investigation, examined the
we
effects of methylphenidate on a new task designed
to measure empirically the ADHD child’s proclivity
to blurt out incorrect answers before giving a final
and/or correct response. We attempted to design a
naturalistic task that would closely reflect the diag-
nostic criteria for impulsivity in ADHD children,
which describe the impulsiveness of these children
158
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manifested by responding prematurely. We wanted
to try to in a laboratory task the &dquo;jumping-
capture
the-gun&dquo; phenomenon exhibited by ADHD chil-
dren. A visual search word-matching task was
developed and used as a context to operationally de-
fine impulsive responding. Specifically, impulsive
errors were identified as all incorrect (impulsive) re-
sponses made by the child before a final response
was given during performance of a word-matching
task. It was predicted that methylphenidate would
lead to a decrease in impulsive responses. A de-
crease in actual errors (final incorrect responses) as a
function of medication was considered a possible,
but not necessary, outcome because these errors
a
may not adequately represent a primary deficit in
the ability to exert inhibitory control. The effect of
medication on response time was also explored to
determine what, if any, change occurred. Variability
of mean latency was expected to decrease in ADHD
children treated with stimulant drug.16,2’
Method
Subjects
Twenty-six ADHD children, 21 boys and 5 girls ranging in
age from 6 to 13 years (mean, 9.1 years; SD, 1.79 years),
participated in the study. Children had been referred to the
Child Development Clinic at The Hospital For Sick Chil-
dren in Toronto for inattention/hyperactivity problems. De-
velopmental pediatricians in the clinic had identified these
children as meeting the Diagnostic and Statistical Manual of
Mental Disorders, 3rd ed, revised (DSM-111-R) criteria for
ADHD and requested that an evaluation of stimulant
medication (methylphenidate) be completed through the
double-blind assessment service offered by the clinic.
In addition to a primary diagnosis of ADHD, a num-
ber of the children exhibited other problems often found to
be associated with the disorder. Nine children were found
to have learning disabilities as identified by the clinic psy-
choeducational assessment team or by school board per-
sonnel. Eight children met the DSM-111-R criteria for
oppositional disorder, two evidenced aggressive behavior,
and three demonstrated anxious behavior.
Children were administered the Wechsler Intelligence
Scale for Children-Revised, unless it had been previously
given. A verbal or performance IQ of 80 or more was a
minimum requirement for inclusion in this study. The Full-
Scale IQ for participants ranged from 76 to 131 (mean,
103.4; SD, 15.8). The Verbal IQ ranged from 80 to 131
(mean, 103.4; SD, 15.0) and the Performance IQ ranged
from 72 to 136 (mean, 102.5; SD, 16.2).
Eighteen of the children had been treated with meth-
ylphenidate previously, whereas the remaining eight sub-
jects had no prior history of treatment with stimulant
medication. Scores from the Abbreviated Conners Rating
Scale’ were available for each subject. A score of 15 or
more is considered indicative of an ADHD diagnosis, al-
though it is currently recognized that associated features of
aggression and defiance are overrepresented when this cri-
terion alone is used to select ADHD children. The mean
score of the teacher-administered Conners was 19.3 (SD,
7.6). The mean score for the parent-administered Conners
was 17.2 (SD, 7.2). The
majority of subjects (n 17) ob-
=
tained ratings of 15 or above from both the teacher and
parent. Some subjects (n 4) received a high rating from
=
the teacher but not the parent, and conversely, some (n
3) were given a high rating from the parent but not the
teacher. Two subjects were given ratings below 15 on both
the parent- and teacher-administered Conners. However,
both children met DSM-111-R criteria for ADHD, showed
functional impairment, and were being treated with stimu-
lant medication.
FIGURE 1
An example of one of the
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Fourteen non-ADHD control children, nine boys and
five in age from 6 to 11 years old (mean,
girls ranging
9.1 years; SD, 0.94 years) were also given the word-
matching task. Children were volunteers from the sur-
rounding communities. All were in the grade appropriate
for their age.
= Materials
The word-matching task required the child to make a vi-
sual search in order to find the exact match of a centered
word from among similar words scattered randomly on the
page. An example of one of the task pages is presented in
Figure 1. The task included one practice page plus 18 test
pages. The stimulus words were typed on 21.7 x 28.0-cm
test pages from the word-matching task..
159
 white paper. There were 32 words per page, including the
centered to-be-matched standard word.
All stimulus words used for the task were three-letter
words following a consonant-vowel-consonant configura-
tion. Four different words were chosen for each page shar-
ing at least one common letter and frequently two common
letters (eg, bus, but, bat, and bit). Four variations of case
were then produced for each of the four words (eg, bus,
Bus, bUs, and buS). The resulting 16 words were then sim-
ply doubled to obtain a total of 32 words per page. This
was done to increase the difficulty level of the task. That is,
increasing the number of stimulus words through which
the child must search for the answer was believed to create
a more effortful task.
The standard word, as well as being centered in the
middle of the page, was also set off by typed lines just
above and below it to make the examples readily apparent
to the child. The object of the task was to find the correct
match embedded in similar but nonmatching words, or
distractors. Alternate versions of the task were constructed
for testing under placebo and medication conditions by
varying the case of the standard word and the location of
the answer.
Procedure
ADHD children were tested in the context of a double-
blind, placebo-controlled assessment for medication re-
sponsiveness. During the clinical assessment, children
typically attended the clinic on the same weekday once per
week. Behavior was measured by various laboratory tasks
and questionnaires involving academic, cognitive, and be-
havioral areas. The purpose of the assessment was to pro-
vide information on whether current methylphenidate
therapy was appropriate or whether the child would bene-
fit from a more extended home trial of drug therapy. Chil-
dren were assessed in the clinic for the entire day for a
given medication (or placebo) condition. Therefore, to
overcome the short half-life of methylphenidate, morning
and afternoon doses were given to obtain constant effects
across the day. Test data for the word-matching task were
collected 2 hours following the administration of the after-
noon (12:00) dose of medication/placebo.
The placebo and medication test sessions were always
on separate days and usually separated by 1 week. The or-
der of medication and placebo conditions was randomized
so that approximately half the subjects received meth-
ylphenidate first and the remaining half received placebo
first. Children were tested on the fixed dose prescribed by
their physician, and the mean dosage of medication given
was 9.4 mg, with a range of 2.5 to 15 mg. The mean dosage
by weight was 0.34 mg/kg, with a range of 0.1 to 0.54 mg/
kg. A small subgroup of children (n 11) was formed by
=
those subjects who failed to show a positive effect and
were tested on an additional higher dose, or who exhibited
an adverse or no response across the variety of clinic tasks
on the prescribed doses. The average dose for this sub-
group was 12.01 mg (range, 7.5 to 15 mg), representing a
mean dosage by weight of 0.42 mg/kg (range, 0.33 to 0.50
mg/kg). Medication was prepared in capsule form by the
hospital pharmacy and was administered at the hospital
upon the subject’s arrival in the morning (about 9:00 AM)
and at noon.
Control children were tested at home. They were
160
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tested on one occasion with one version of the task and a
week later with an alternative version of the task. The 22
ADHD subjects who demonstrated a favorable response to
medication at a given (optimal) dosage level during the
clinical evaluation of medication responsiveness were in-
cluded in the favorable/optimal dose group if they im-
proved on a test battery that included the paired-associate
learning task.39
In presenting the word-matching task to subjects, the
experimenter placed each page one at a time on the desk in
front of the child. The 18 test sheets were presented to sub-
jects in a random order, but the same order was used for
each subject. Each session began with a practice page. The
child was instructed to find and point to another word that
was just the same as the word in the middle of the page.
For each of the 18 test items, the experimenter recorded all
incorrect (&dquo;impulsive&dquo;) responses given before a final re-
sponse, incorrect and correct final responses, and first re-
sponse latency. The testing time involved approximately 20
minutes for a given test session.
Results
’
There were no practice effects observed on the task for
the primary measure of impulsive errors from initial
testing (mean, 1.0) to repeat testing (mean, 1.30)
for the control
group, but a complex drug-
practice interaction effect was noticed in the ADHD
group (F[1,20] 4.51; P < .05). Therefore we de-
=
cided to perform a between-group analysis compar-
ing the data for the 11 ADHD children who were
given placebo for the first test session, with the 11
ADHD children who were given medication for the
first test session, along with the data for the control
group from test session 1. Table 1 presents the mean
values for the dependent measures from the word-
matching task for ADHD children on placebo, ADHD
children on drug, and the control group. An analysis
of covariance was performed on the data for each of
the seven dependent measures with age, sex, and
learning disabilities as the three covariates. The re-
sults showed a significant difference among the three
groups of subjects, for impulsive errors (F[2,28] _
8.25; P < .01), regular errors (number of incorrect fi-
nal responses) (F[2,28] 4.83; P < .05), total errors
=
(impulsive, plus regular errors) (F[2,28] 10.36; P < =
and correct responses (F[2,28]
.001), 4.83; P < .05).
=
The ADHD group on placebo made the most impul-
sive and regular errors and the fewest correct re-
sponses. The ADHD group on medication and the
control group made fewer impulsive and regular er-
rors and more correct responses, with the control
group showing slightly better performance overall
than the ADHD-medication group. Statistical control
for differences in task performance due to age, sex,
and learning disabilities was achieved by the analysis
 TABLE 1
Comparison of the Dependent Measures From the Word-Matching Task for
ADHD Children on Placebo, ADHD Children on Methylphendiate (Optimal
Dose) and Control Children
ADHD =
attention-deficit hyperactivity disorder.
*Mean (SD).
of covariance; all three covariates were significant at
the P < .01 level for the four dependent variables dis-
cussed below.
There were no significant differences among the
three groups for response latency (time in seconds
to first response whether correct, incorrect, or im-
pulsive), within-subject variability (standard devia-
tion) of response latency, or latency for correct
responses.
In additional analyses of data for the ADHD
children, latency of impulsive responses under pla-
cebo was compared to latency for correct responses
under placebo (14.9 ± 9.1 seconds versus 18.89 ±
7.4 seconds). A one-tailed test revealed that impul-
sive responses were faster than correct responses
(t[20] 1.74; P < .05, one-tailed test).
=
Discussion
Treatment with methylphenidate reduced impulsive
responding in ADHD children on the MFFT-like task
designed for this study. By reducing the impulsive
errors, stimulant-induced improvement brought the
task performance of the ADHD children closer to the
performance of the non-ADHD children. Also, regu-
lar errors (incorrect final responses) were signifi-
cantly decreased by drug treatment. The findings of
the present study therefore demonstrated that med-
ication has specific as well as general effects on per-
formance. It can be concluded that the present study
isolated, in a more precise fashion, the particular de-
ficiency in inhibitory control that seems to be modi-
fied by medication in ADHD children. It is difficult
to know why medication also affected general errors
on the task, but this may be related to the beneficial
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effects of medication on the nonspecific attention
problems of these children. Previous studies with
the MFFT 14-18 found overall errors to decrease with
drug administration. However, in those studies no
attempt was made to break the error score into com-
ponents, as in the current study, to determine
whether specific aspects of the error score might be
affected by medication.
Overall response latency did not change with
medication. However, some evidence for a more
hasty approach to the task was found for the ADHD
children during placebo testing. Comparison of the
reaction time for impulsive responses with the reac-
tion time for initial correct responses showed that
the ADHD children were faster when they made im-
pulsive responses than when they made correct re-
sponses. Nonetheless, reaction time for correct
responses in the drug condition was not signifi-
cantly slower than reaction time for correct re-
sponses in the placebo condition. Thus, treatment
with stimulant medication did not seem to slow
down the thinking processes in the ADHD children.
These data suggest that when ADHD children blurt
out an incorrect response, they may do so without
losing any speed in their processing of task informa-
tion. Without medication, they do blurt out incorrect
responses more often than when they are on medi-
cation. This suggests that medication is operating
via an efficiency effect’9,20 rather than a slowing-
down effect. 16
Response time variability was not significantly
decreased with medication. Two recent studies
have observed decreased variability in task perfor-
mance when ADHD children are given meth-
ylphenidate. The results of these studies suggest
161
that ADHD children perform in a more consistent
fashion on medication, perhaps because they are
better able to maintain their attentional focus on the
task for a longer period of time. In the current
study, it appeared from the analysis of covariance,
which showed that the age covariate was significant,
that variability was related more to patient age, with
young children being more variable than older chil-
dren, than to any specific effect of medication.
In a few studies,16,26 impulsivity has been evalu-
ated using a delayed response paradigm, where an-
ticipatory or premature responses are viewed as
reflecting poor impulse control. Our word-matching
task appears to tap somewhat different cognitive
processes. In this task, the child is not simply wait-
ing to make a response, but instead is engaged in an
active visual search to find the appropriate word
match. Impulsive errors on the word-matching task
are presumed to result because insufficient consider-
ation is given to alternate answers. This may be be-
cause it is somewhat effortful to continue to search
until the correct match is located.
There were not sufficient numbers of ADHD
children with a comorbid diagnosis of learning dis-
ability to examine these children as a specific group,
particularly because they did not form a homoge-
neous group with respect to learning disabilities.
Of the 22 ADHD children exhibiting a favorable
response to medication, eight were identified as
having a comorbid learning disability. Five of these
eight children showed a reading/language prob-
lem while the remaining three children demon-
strated visual-perceptual learning problems. Individ-
ual inspection of the data for these children revealed
that those ADHD children with a comorbid visual-
perceptual learning disability tended to make more
regular errors on the task than those with a comor-
bid reading/language disability, and these errors
were often of a visual-perceptual nature (eg, wet for
Wet, or cAn for caN). Children with either type of a
comorbid learning disability made fewer impulsive
errors, although medication did reduce impulsivity
when it occurred in these children as well. Statisti-
cally removing the effect of any type of comorbid
learning disability with analysis of covariance al-
lowed the significant effects of medication on task
measures to emerge more clearly for the ADHD
group without comorbid learning disability.
The word-matching task appears to be a useful
tool for assessing the effect of stimulant medication
on impulsivity in ADHD children. Data from this
task may help identify children who respond poorly
to medication, or in those who respond favorably, it
162
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may be useful in determining the appropriate dos-
age. There were no practice effects observed for the
control group with repeat testing. However, there
appears to have been some evidence of practice ef-
fects on the word-matching task for the ADHD chil-
dren during this study. Therefore, it may be
advisable to use an A-B-A (no-drug/drug/no-drug)
design to evaluate the efficacy of medication therapy
in individual patients.
Acknowledgment
Appreciation is extended to Debra Greenberg for her helpful
comments during the development of the word-matching task.
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