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Effect of Methylphenidate on Stroop Color–Word Task Performance in Children with Attention Deficit Hyperactivity Disorder

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Effect of Methylphenidate on Stroop Color–Word Task Performance in Children with Attention Deficit Hyperactivity Disorder Psychiatry Research 141 (2006) 315–320 www.elsevier.com/locate/psychres Effect of methylphenidate on Stroop Color–Word task performance in children with attention deficit hyperactivity disorder Daniel D. Langleben a,*, John Monterosso d, Igor Elman b, Brian Ash a, Gary Krikorian c, Glenn Austin c,F a Department of Psychiatry, University of Pennsylvania School of Medicine, 3900 Chestnut Street, Philadelphia, PA 19104, United States b McLean Hospital, Harvard University School of Medicine, 115 Mill Street, Belmont, MA 02478, United States c The Community/Academia Coalition, Mountain View, CA, United States d Department of Psychology, University of California-Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, United States Received 25 March 2005; received in revised form 8 September 2005; accepted 18 September 2005 Dedicated to the memory of Glenn Austin Abstract Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric syndrome common in the pediatric population. It is associated with multiple nonspecific deficits on neuropsychological tests of executive function, and a beneficial response to pharmacotherapy with methylphenidate (MPH) and other psychostimulants. The Stroop Color–Word task is used empirically as an aid in diagnosis and treatment monitoring of ADHD; however, data on the sensitivity of the Stroop interference score to the effects of MPH are limited. To address this issue, we studied Stroop performance in a cohort of 18 MPH-treated prepubescent boys with ADHD and six healthy controls on and off MPH treatment conditions. MPH significantly improved performance in both groups, with the ADHD participants consistently displaying worse scores than those of controls both on and off MPH. These results suggest that though the diagnostic value of the Stroop task in ADHD remains controversial, it has heuristic value for monitoring clinical responses to MPH treatment. More research is needed to ascertain the clinical significance of our findings and to replicate this relatively small effect in a larger cohort, to determine whether MPH effects on Stroop performance are specific to ADHD symptoms or they generalize to other forms of symptomatology. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Methylphenidate; Interference; Response inhibition; Attention deficit hyperactivity disorder * Corresponding author. TRC, 3900 Chestnut Street, Philadelphia, PA 19104, United States. Tel.: +1 215 222 3200x196; fax: +1 215 386 6770. E-mail address: [email protected] (D.D. Langleben). F Deceased. 0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2005.09.007 316 D.D. Langleben et al. / Psychiatry Research 141 (2006) 315–320 1. Introduction naming; some have been experimentally demon- strated (Peterson et al., 1999; Nigg, 2005; van Veen Attention deficit hyperactivity disorder (ADHD) and Carter, 2005). An influential rationale for the is characterized by locomotor hyperactivity, impul- increased Stroop effect in ADHD is a deficit in sivity and inattention (American Psychiatric Associ- attentional modulation of the distributed parallel ation, 1994). Due to the lack of established pathways processing word and color stimuli (Cohen psychometric or biological markers, ADHD diagno- et al., 1990; Carter et al., 1995; Peterson et al., sis is dependent upon clinical history, physical 1999). The sensitivity of the Stroop effect to examination, and observation. The accuracy of both untreated ADHD (Reeve and Schandler, 2001; the diagnosis and the treatment follow-up in ADHD Shallice et al., 2002; van Mourik et al., 2005) has is limited by the lack of pathognomonic psychomet- not been uniform, yet the Stroop task is widely ric and biological markers and the high incidence of used empirically as an aid in clinical diagnosis psychiatric co-morbidity. Moreover, symptoms of (Golden, 1976; Seidman et al., 1997; Katz et al., ADHD are highly context dependent, further com- 1998; Bedard et al., 2002; Nigg et al., 2002; plicating treatment follow-up. The primary ADHD Rucklidge and Tannock, 2002; Schmitz et al., symptoms have been attributed to a core deficit in 2002; Shallice et al., 2002). response inhibition (Barkley, 1997a,b), as evidenced One of the more consistent features of ADHD is by deficits in performance of tasks requiring the behavioral response to methylphenidate (MPH) intermittent withholding of response (Aron and and other psychostimulants (Solanto, 1998; MTA, Poldrack, 2005); however, the deficits that children 2004). The difference in the acute response to with ADHD exhibit on other neuropsychological MPH between ADHD and health is quantitative tasks suggest broader core psychopathology (Rapport rather than qualitative (Rapoport et al., 1978; et al., 2001; Nigg, 2005). Weingartner et al., 1980); ethical considerations In addition to the deficits in behavioral response preclude controlled studies of chronic MPH admin- inhibition, ADHD has been associated with deficits istration to healthy subjects. Although current on a variety of neuropsychological tasks broadly hypotheses of ADHD predict that MPH should described as measures of bexecutive functioningQ reduce the Stroop interference effect in ADHD, (Barkley, 1997a,b; Shallice et al., 2002; Nigg, experimental data of MPH’s effect on Stroop 2005). One of the classic tasks of this type is the performance in children with ADHD are inconclu- Stroop Color–Word task, and the associated Stroop sive, with at least one recent placebo-controlled effect (Stroop, 1935; Rapport et al., 2001; Reeve study reporting improved inhibitory but not inter- and Schandler, 2001; van Mourik et al., 2005). The ference control in children with ADHD (Scheres et Stroop binterferenceQ effect is the decrease in the al., 2003). A recent meta-analysis of Stroop speed of reading words that are incongruent with performance in ADHD deemed the number of the color of the ink in which they are printed and studies on the effect of MPH insufficient for the word’s meaning (e.g. the word bredQ written in analysis (van Mourik et al., 2005). Thus, though blue), relatively to the bcolor-matchedQ words and the specificity of the Stroop effect to ADHD has shapes (Stroop, 1935; Golden, 1976; van Mourik et been challenged, it may have clinical value as a al., 2005). The neuropsychological mechanisms treatment follow-up instrument, if shown to be underlying this effect are not fully understood sensitive to stimulant therapy in ADHD, especially (Kipp, 2005). Traditionally, the theoretical justifica- in comparison with healthy controls. tion for Stroop’s diagnostic validity in ADHD was The purpose of the present study was to test the based on the association between cognitive effect of MPH on Stroop performance in prepubes- binterferenceQ and behavioral response inhibition. cent boys with ADHD. We hypothesized that: 1) The putative basic neural mechanism mediating the MPH would reduce the Stroop interference effect in Stroop effect both in ADHD and in health was the ADHD cohort and 2) children with ADHD response competition between the relatively auto- would demonstrate a larger MPH effect than the matic word reading and the less habitual color controls. D.D. Langleben et al. / Psychiatry Research 141 (2006) 315–320 317 2. Methods 3. Results The study protocol was approved by the Stanford One-way ANOVA with group (ADHD and control) University Hospital institutional review board. All as the between-subjects factor and treatment condition parents gave written informed consent and the (on- and off-MPH) as the within-subject factor children assented to participate. Eighteen prepubes- revealed that following MPH administration, there cent boys (mean age=10.2 years; range=8.1–12.9, was an overall increase (improvement) in the IntS S.D.=1.3) with ADHD, who demonstrated a favor- (treatment effect: F =8.68, df =1.22; P =0.007). In able clinical response to an average of 12 weeks addition, we observed a group difference, with ADHD (range=8–16) of MPH therapy, were included in the subjects performing worse than controls across both study. All participants were of Caucasian origin. The treatment conditions (group effect: F =6.27, df =1,22, ADHD diagnosis was confirmed by a multidisciplin- P =0.019). There was no significant interaction ary team using clinical history, the Conners Teachers between group and treatment condition ( F =0.99, scale, the parents’ and teachers’ Swanson, Nolan, and df =1,22, P =0.329) (Fig. 1). Pelham scale (SNAP), and the Wechsler Intelligence A post hoc paired t-test detected MPH-induced Scale for Children, Third Edition (WISC) (Conners, significant increases in the IntS for ADHD partic- 1989; Wechsler, 1991; Swanson, 1992). Exclusion ipants (48.57F4.07 vs. 50.71F4.84; t =2.37, criteria were a T-scoreb2 S.D. on the Conners scale df =1,34, P =0.028), but not for healthy controls above the population mean (mean=50, S.D.=10); (52.33F5.72 vs. 56.67F6.28; t =1.60, df =1.10, treatment with medications other than MPH; verbal P =0.172). The latter results did not reach statistical IQb 85; history of head trauma, premature birth, or significance, perhaps by Type II error resulting from chronic medical or psychiatric disorder other than the small sample size. ADHD. Six demographically matched healthy boys Secondary analyses were conducted on each of the (mean age=10.8 years; range=7.4–12.2, S.D. 1.7), three subscores used to derive the IntS (i.e. the WS, participated as controls. Their verbal IQ (WISC III) CS, and CWS). Each of these variables were modeled was slightly higher (125.7F4.1 vs. 114.4F13.8), using repeated measures ANOVA, with group (ADHD albeit not significantly ( P b0.07, two-tailed t-test). and control) as the between-subjects factor and The Stroop Color and Word Testn (Stoelting Co., 620 treatment condition (on- and off-MPH) as the within- White Lane, Wood Dale, IL 60191, 1994) was subject factor. For WS, MPH administration resulted performed twice: bon-MPHQ and boff-MPH.Q In the in a significant effect of medication ( F(1,25)=4.32, ADHD cohort, the off-MPH condition was achieved P =0.048) and of group ( F(1,25)=6.89, P =0.015).
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