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Greetings:
Below you will find a preview of the December issue of
ADHD RESEARCH UPDATE that was recently sent out to
subscribers.
The preview contains the full text of one of the articles
from this month's issue, along with a listing of the other
studies that were reviewed this month. The article included
in this month's preview is an interesting study of how
ADHD may affect children's performance in mathematics.
SPECIAL HOLIDAY SUBSCRIPTION SAVINGS OFFER
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ADHD RESEARCH UPDATE. If you subscribe prior to 12/31/99,
you can do so for only $14.95 for a one-year subscription.
Additional information on this can be found below at
the end of the preview.
FREE GIFT
I'd like to offer you a free gift for the holiday that
I think you will find quite valuable.
I have developed a system that makes it easy for parents
to monitor how their child is doing at school and to
determine when changes to their child's treatment may
be necessary.
This is usually included as a bonus for new subscribers, but
I'd be happy to send it to you regardless of whether you
choose to become a regular subscriber at this time.
To receive the ADHD Monitoring System just click on this
email link mailto:[EMAIL PROTECTED] and hit send.
The system will be sent to you immediately.
This can be enormously helpful to you and I hope that you
will request it and use it. It works best with children
in elementary school rather than for middle school and
high school students.
Please feel free to forward this information to others you know
who may be interested in it.
I hope you are doing well. Best wishes for a safe and happy
holiday season!
Sincerely,
David Rabiner, Ph.D.
Duke University
P.S. If you sent me a question after the last mailing I apologize
if I have not answered. As this list has grown, I now receive
over 100 questions after each mailing and am no longer able to
keep up with replying. I am working on setting up a regular
chat each month where your questions can be discussed and will
have information for you about this shortly.
***************************************************
ADHD RESEARCH UPDATE - Preview of December issue
***************************************************
In this issue...
* Math performance in children with ADHD: What are the
difficulties and does stimulant medication help?
REPRINTED IN FULL BELOW
Here are the titles of the other articles in this month's
issue...
* Self-reported depression in mothers of children with
ADHD
* Sensitivity to reward in children with ADHD - Implications
for behavioral management
* Long-term outcomes for children who are persistently
hyperactive, oppositional, or aggressive
____________________________________________________________
* MATH PERFORMANCE IN CHILDREN WITH ADHD:
WHAT ARE THE DIFFICULTIES AND DOES STIMULANT
MEDICATION HELP?
This is one of the more interesting studies I have seen
in some time. It is based on the fact that performance
difficulties in math for children with ADHD have been
well documented in prior reports, and that children with
attentional deficits but not hyperactivity (i.e. those
children diagnosed with ADHD, Predominantly Inattentive Type,
are at greatest risk for these problems. Although this is
not true for all children with ADHD, children with ADHD
do tend to perform more poorly in math than other children.
Several explanations for the math difficulties in children
with attentional problems have been proposed. One
has to do with failure in "automization" - i.e. the ability
to perform basic math calculations in their head. This
difficulty has been attributed to deficits that many
children with ADHD have in "working memory".
For example, imagine trying to add up 3 different numbers
in your head - 67, 123, and 42. Working memory can be
thought of as that aspect of memory that allows you to
keep these numbers, and the sum you derive for each column,
in your head so that you can accurately calculate the
answer. If you have difficulty keeping the numbers straight
in the first place, there is no way that you can do the
arithmetic manipulations required to get the correct
sum.
Other researchers have suggested that children with ADHD
have difficulty "automatically" recalling math facts like
the multiplication tables because they do not do the
repetitive drilling required to learn them so well that
their answers become "automatic". Most parents who have
tried to help their child with ADHD learn his or her
multiplication tables can attest to how frustrating it
is getting their child to do the drilling that is required.
Although the cause of math difficulty in children with
ADHD is unclear at this time, and is likely to reflect
different factors for different children, it is generally
hoped that reducing the behavioral symptoms of ADHD
(i.e. reducing distractibility, fidgeting, etc.) will
ameliorate a child's difficulties. Thus, there is now
good evidence that treatment with stimulant medication
not only improves the behavior for the majority of
children with ADHD, but that it also enhances their
academic performance, at least in the short term.
Some have argued, however, that the impact of stimulant
medication on academic performance is primarily in the
area of productivity - i.e. how much work a child completes
- rather than improving the actual quality of the work.
It has also been argued that stimulant medication has
only a limited effect, if any, on underlying cognitive
abilities such as working memory and thus does not really
effect a child's difficulties in learning.
The current study (Benedetto-Nasho, E., & Tannock, R.
(1999). Math computation, error patterns and stimulant
medication effects in children with ADHD. Journal of
Attention Disorders, 3, 121-134.) was designed to carefully
evaluate how the math computational skills of children
with ADHD compared to non-ADHD peers. In addition to
comparing how the computational skills of children with
and without ADHD, the authors were also interested in
carefully examining how stimulant medication effected
the computational skills of the ADHD children.
Participants in this study were 15 children with a confirmed
diagnosis of ADHD (13 boys and 2 girls) and 15 comparison
children without ADHD. All participants were between 7
and 11 years old. The authors were careful to match the
two groups of children on IQ, parent education level, and
even results on a standardized test of achievement in math.
This matching was done to insure that any differences in
computational skills between the groups that were detected
could not be attributed to differences in intellectual ability
or parent educational status, or to traditional measures
of academic achievement in math.
There were two portions to the study. In the first portion,
children in each group were instructed to work independently
on a computation work sheet containing problems selected to
be sufficiently challenging for their skill level. Both
addition and subtraction problems were included and the
testing time lasted for 10 minutes. Children completed the
work sheets independently with an adult examiner in the
room at all times. Children with ADHD were not on medication
during this test session.
In the second portion of the study, children with ADHD
completed equivalent worksheets over 3 successive days.
For these test sessions, they had received either a placebo,
10 mg of methylphenidate (i.e. the generic form or Ritalin),
or 20 mg of methylphenidate 90 minutes prior to the testing.
Neither the child nor the examiner was aware of what the
child had received.
Three different scores were computed for each child's
performance on the math worksheets. A productivity score
reflected the number of problems attempted divided by the
number of items available; an accuracy score reflected the
percentage of problems attempted that were answered correctly;
and an efficiency score was calculated by dividing the number
of problems answered correctly by the total number of problems
on the worksheet. Separate scores for these variables were
computed for the addition and subtraction items.
In addition to these performance indicators, ratings were also
made of children's behavior during the test (i.e. inattention,
fidgeting, getting out of seat, on-task performance, and finger
counting). The authors also completed a detailed analysis of
the types of errors that children made (i.e. careless errors
such as adding instead of subtracting vs. errors that indicated
a lack of basic understanding of borrowing or carrying).
RESULTS
The first set of results compared children with and without ADHD
when the ADHD children were not receiving medication. As
expected, children with ADHD attempted significantly fewer items.
On average, the ADHD children attempted about 20% of the items
while the comparison children attempted about 45% (Note: the
worksheets were set up to contain more problems than children
could complete in the 10-minute period.)
The accuracy results differed for addition and subtraction. On
the addition items no accuracy differences were found between the
groups. For the subtraction items, however, children with ADHD
made substantially more errors. Efficiency scores for the children
with ADHD were lower for both the addition and subtraction items.
The behavioral ratings and error analyses were also interesting.
During the 10-minute test period, children with ADHD were rated
as being more inattentive and displayed more fidgeting. They were
out of their seat more often and spent less time on-task. What
was particularly interesting is that they also spent much more
time using finger counting to solve problems rather than being
able to do the calculations in their head. Thus, even though
the 2 groups were equivalent in IQ and results on a traditional
test of math achievement, the children with ADHD were still
forced to rely on this less developed way of solving computational
problems. (These ratings were completed, of course, by raters
who did not know whether or not the child being rated had been
diagnosed with ADHD.)
The only difference in error patterns were found for the subtraction
items. On these problems, children with ADHD consistently made
errors that showed a misunderstanding of borrowing. The form
this error generally took was subtracting the smaller number
from the larger number, irrespective of its position in the
problem (e.g. for the problem 17-9, subtracting the 7 from the
9 rather than the 9 from the 7).
THE EFFECT OF MEDICATION
The second part of the study involved comparing the performance
of children with ADHD in the 3 different medication conditions:
placebo, 10 mg methylphenidate, and 20 mg methylphenidate.
What effect, if any, did medication have on their performance?
Several aspects of these results were striking to me. The first
has to do with the importance of attending to placebo effects.
Although the authors did not make direct comparisons of ADHD
children in the placebo and baseline condition (by baseline, I
am referring to their performance in the first part of the study
above) several differences were apparent. Specifically, it
appeared that children displayed less inattentive behavior
in the placebo condition, and, surprisingly, improved their
accuracy scores on subtraction problems from 38% to 64%.
They also more than doubled the number of addition problems
that they attempted.
These placebo results underscore the importance of conducting
careful, placebo-controlled trials when evaluating a child's
response to medication. Apparently, placebo effects may
extend not just to teacher ratings of children's behavior, but
even to more "objective" indices of academic performance
like the number of worksheet problems a child attempts and
the accuracy of their answers. Of course, these results were
obtained based on only a 10-minute sample of test taking
behavior. Whether they would extend for a significantly longer
period of time is unknown.
Medication was also found to result in some clear
performance changes above and beyond any placebo effects.
In the behavioral realm, medication yield significant
reductions - relative to the placebo condition - in
fidgeting, inattention, and finger counting. In all 3 of
these areas, in fact, the children with ADHD on meds
were no longer any different from the non-ADHD comparison
children. The finger counting results are especially
interesting as they indicate that medication enabled
the children with ADHD to consistently utilize the more
sophisticated computational strategy of solving problems
in their head.
In terms of the performance measures, the main finding was
that medication improved productivity scores overall (i.e.
on medication, the children with ADHD attempted more
problems than in the placebo condition), and that efficiency
scores in subtraction were also higher. Even so, however,
productivity and efficiency scores (i.e. number problems
correct divided by total number of problems) were still more
than 50% lower than scores for the comparison children.
Accuracy scores did not change, however, nor did the types
of errors that children with ADHD made.
SUMMARY AND IMPLICATIONS
Several results from this study seem important to me. First
and foremost, the results clearly indicate that many children
with ADHD will underperform their peers on typical
math assignments even when they are just as bright and do
just as well on traditional standardized achievement tests.
The exact reasons for this are unclear, and the authors did
not specifically address this issue in the discussion of
their results. It seems to me, however that at least several
different things may contribute to this. First, when not on
medication, they complete substantially fewer problems and
often rely on finger counting to solve basic calculation
problems. In addition, many of the children with ADHD do
not seem to understand the concept of borrowing very well.
Although medication helped in decreasing finger counting
and improving productivity, even when on meds they attempted
fewer subtraction problems than other children and continued
to make more errors with borrowing.
Two things seem important here. First, these data clearly
suggest the need for many children with ADHD to either
receive additional time to complete math assignments - especially
tests - or, to reduce the number of problems they must complete.
These are both accommodations that can be part of a child's
504 plan or IEP (see http://www.helpforadd.com/rights.htm for
a discussion of these possibilities).
Second, the findings suggest that teachers be made aware of
the specific difficulties that children with ADHD are likely
to have in math computation. The children in this study
consistently made errors on subtraction problems that reflected
an incomplete understanding of borrowing. The authors suggest
that this may occur because borrowing places greater demands
on working memory and attention. In any case, paying careful
attention to the errors consistently made by an individual
child can thus reveal important gaps in the child's knowledge
of arithmetic operations that need to be remedied.
Finally, although medication was shown to provide some important
benefits to math computation performance, the difficulties
experienced by the children with ADHD were certainly not
fully remedied. This underscores the important need to clearly
identify the academic difficulties a child is having even
after benefits from medication may have been provided, and to
then make sure these remaining difficulties are being specifically
targeted in the child's educational program.
As always, the results of any single study require replication,
so please keep this in mind. This was a very instructive paper,
however, and I hope it will lead to follow up research that
will provide even more understanding of these important issues.
Reprint requests to:
Dr. Rosemary Tannock
Brain and Behavior Research Program (Psychiatry)
The Hospital for Sick Children
555 University Ave.
Toronto, Ontario
Canada M5G 1X8
Note: As a new feature in the newsletter, I now include the
address of the lead author so you can send for a complete
reprint of studies that you are particularly interested in.
This is a great way to build your own personal collection
of research papers that are most relevant to your own
child's situation.
______________________________________________________________________
"IS KEEPING UP WITH NEW RESEARCH ABOUT HELPING CHILDREN WITH ADHD
SUCCEED IMPORTANT TO YOU? HAVE YOU FOUND IT DIFFICULT TO FIND
THIS INFORMATION IN A CONVENIENT AND RELIABLE MANNER?"
Dear Parent:
Most parents I have worked with answer "Yes!" to both of these
questions.
That is why I began publishing ADHD RESEARCH UPDATE over 2 years
ago - to provide parents like yourself with convenient access
to the latest published research about the best ways to help
children with ADHD succeed.
The reason for subscribing to ADHD RESEARCH UPDATE is simple:
"As a subscriber, you will receive extensive coverage of new
research on ADHD that will help you to better understand how
ADHD can affect your child's development and how you can
help your child to succeed."
Please take a moment to visit my subscription page at
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to learn about the full benefits of subscribing.
Remember, if you subscribe prior to 12/31/99 you will receive
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off the regular rate.
Parents from around the world have found that ADHD RESEARCH UPDATE
is a valuable resource for them. I am confident that you will as
well and encourage you to become a regular subscriber.
Best wishes,
David Rabiner, Ph.D.
Licensed Psychologist
Duke University
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