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ARTICLES: Richard M. Scheffler, Timothy T. Brown, Brent D. Fulton, Stephen P. Hinshaw, Peter Levine, and Susan Stone Positive Association Between Attention-Deficit/ Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School Pediatrics 2009; 123: 1273-1279 [Abstract] [Full text] [PDF]

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ADHD med effect

John F DiTraglia   (4 May 2009)

Methodology & strength of conclusions

Kevin P Young   (10 May 2009)

Brain wave therapy works much like Ritalin except for the side effects

Álvaro M. Dias   (1 July 2009)

ADHD med effect 4 May 2009
John F DiTraglia, Pediatrics Southern Ohio Medical Center Send letter to journal: Re: ADHD med effect jditrag{at}zoomnet.net John F DiTraglia	There are two ways that medication could have improved scores in the study of Scheffler et al. By improving academic achievement over time, or by improving attention and diligence at the time of the achievement test. I think the improving scores over time argues for at least some of the former effect. Do you have data to check the latter effect. Where all of the kids taking their medication at the time of the tests? Conflict of Interest: None declared
Methodology & strength of conclusions 10 May 2009
Kevin P Young, Doctoral Student Fairleigh Dickinson University Ph.D. Program in Clinical Psychology Send letter to journal: Re: Methodology & strength of conclusions 02_kyoung{at}stagweb.fairfield.edu Kevin P Young	I request consideration of several topics that relate to the strength of the relationship found between stimulant use and improved school performance.    It seems like more information is needed concerning differences between the ADHD-medicated and ADHD-non-medicated groups.  While it's stated that the regression controls for “all” time-invariant differences between groups, what “all” includes is unclear.  Critically, we lack information regarding co-morbid diagnoses, exposure to psychosocial interventions, and non-random regional differences.  It's possible that medicated children were more likely to receive psychosocial or behavioral interventions. In this case, the relative contribution of each to academic gains would be important to consider.  Similarly, likelihood of obtaining a prescription may differ by region[1], and this may correlate with regional differences in curriculum trends, which may moderate differences in test scores.    As both groups still perform worse than controls, I wonder if the differences in test scores are clinically meaningful, and not just statistically significant?  Additionally, the assertion that score differences relate to months of education implies that learning occurs in a linear and universal way that is not affected by teacher style or district curriculum.  The notion that measures of “grade-level” are meaningful is also controversial[2].  Moreover, one has to weigh these modest academic gains against the potential physical costs of prolonged exposure to stimulant medications. Data were not presented regarding physical growth, cardiac functioning, illicit drug use, etc.   While noted as a “critical limitation”, the use of parent report of diagnosis warrants reexamination.  594 clinicians/physicians, with different credentials and training in childhood psychopathology, using different assessment techniques, were responsible for diagnosing the “ADHD” sample. As diagnosis varies by setting, training and adherence to DSM criteria[3,4], the sample may be quite heterogeneous, again lessening certainty in results.    Finally, the study design was correlational, not experimental.  Thus, a causal link cannot be assumed, as there were numerous uncontrolled variables that could have impacted outcome.  Perhaps readers would have benefited from a discussion that more frankly represents the necessarily equivocal nature of findings that come from a data set with the aforementioned limitations.   References:   1 Stevens, J., Harman, J.S., Kelleher, K. (2004).  Ethnic and regional differences in primary care visits for attention-deficit hyperactivity disorder. Journal of Developmental & Behavioral Pediatrics. 25(5), 318-325.   2 For a review see discussion at http://alpha.fdu.edu/psychology/oat_cereal.htm   3 Chan, E., Hopkins, M., Perrin, J., Herrerias, C., & Homer, C. (2005) Diagnostic practices for attention deficit hyperactivity disorder: A national survey of primary care physicians.  Ambulatory Pediatrics, 5(4), 201-208.   4 Olsen, B., Rosenbaum, P., Dosa, N., & Roizen, N. (2009). Improving guideline adherence for the diagnosis of ADHD in an ambulatory pediatric setting.  Ambulatory Pediatrics 5(3), 138-142. Conflict of Interest: None declared
Brain wave therapy works much like Ritalin except for the side effects 1 July 2009
Álvaro M. Dias, Researcher, Doctorial Candidate University of São Paulo Send letter to journal: Re: Brain wave therapy works much like Ritalin except for the side effects alvaromd{at}usp.br Álvaro M. Dias	I read the article presented by Scheffler et al [1] with great interest, and would like to add some considerations about what I assume to be one of the article’s fundamental ‘Take Home Message’, the perspective that stimulants work for ADD. Among the current hot topics in neuroscience and psychiatry, the enhancement of mental functions plays a prominent role which can be methodologically separated in two different approaches: enhancing the mental skills of persons with some kind of impairment, like ADD; and raising the upper range of normal or even gifted individuals. Interestingly, methylphenidate and close related stimulants are major players in both fields, thus turning the debate about their intake into a contemporary issue. In that sense, many studies approach their uses and effects as if they also were some kind of novelty, despite the fact that the keywords “Ritalin and (attention deficit disorder or ADD)” retrieve 2499 publications in Pubmed (06/24/2009). Contrary to that, it would also be important to explore some of the less discussed perspectives; e.g. it would be interesting to define a cost/benefit algorithm wherein one could account for the moderate increases in academic performance found by the authors [1] in relation to possible side effects of these drugs. Just to name a few, it is worth noting that post treatment with methylphenidate may be associated with cognitive impairments [2]; injections of methylphenidate in young rodents produce life-long effects on their locomotor system [3]; long term use may increase the retention of contextual fear [4], increasing the risk of psychological dysfunctions; several case reports suggest associations with neuroticism and even lack of creativity. Stimulants may be the most trusted available tools for the treatment of ADD but they are far from ideal. It is important for society that medical discourse emphasize their insufficience, pushing for better drugs, and stressing the strategic use of associated non-pharmacological alternatives, including Neurofeedback, which seems to be as effective as Ritalin [5], without Ritalin’s worst side effect: the perspective that enhancement can be achieved without personal effort, which seems to be one of the goals of the reconceptualization in course. References 1. Scheffler, R.M., et al., Positive Association Between Attention- Deficit/ Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School. Pediatrics, 2009. 123(5): p. 1273-1279. 2. LeBlanc-Duchin, D. and H.K. Taukulis, Chronic oral methylphenidate induces post-treatment impairment in recognition and spatial memory in adult rats. Neurobiol Learn Mem, 2009. 91(3): p. 218-25. 3. Lee, M.J., et al., Does repetitive Ritalin injection produce long term effects on SD female adolescent rats? Neuropharmacology, 2009. 4. Bethancourt, J.A., Z.Z. Camarena, and G.B. Britton, Exposure to oral methylphenidate from adolescence through young adulthood produces transient effects on hippocampal-sensitive memory in rats. Behav Brain Res, 2009. 202(1): p. 50-7. 5. Rossiter, T., The effectiveness of neurofeedback and stimulant drugs in treating AD/HD: part II. Replication. Appl Psychophysiol Biofeedback, 2004. 29(4): p. 233-43. Conflict of Interest: None declared