EFFECTS

THE

AND

OF

LEARNING

C. KEITH

IN

CONNERS,

DISTURBED

PH.D.,

Stimulant
drugs have been recommended
for the treatment
of behavior
disorders
in
children
for several
decades(
1-5). Despite
this long period
of use and numerous
clinical reports,
there have been relatively
few
controlled
studies
on these
agents.
Their
effects
have

on
not

there
is
explanation
In a
training
able to

specific
psychological
been
adequately

functions
explored
and

as yet no completely
of their action.
recent
double-blind
school
for delinquents,
demonstrate,
on two

measures,

statistically

satisfactory
study
we

at a
were

independent

significant

improve-

ment in behavior
among
children
receiving
dextroamphetamine(6).
As a further
step
in the accumulation
of behavioral
data on
the psychopharmacologic
actions
of stimulant drugs,
we undertook
the present
study
of methyiphenidate,
an agent
which
has
been
reported
to be effective
in clinical
trials(7,
8).
METHOD

Subjects:
The subjects
children
in two residential
Institution
A, a Welfare

for this

study

Prior

experience

were

care institutions.
department
group

foster
home,
serves
children
judged
unsuitable
for care
in individual
homes.

with

such

to be
foster
children

(9) led to the expectation
that this group
would
include
a large
percentage
of disturbed
children.
Institution
B, a psychiatric
treatment
center,
serves
disturbed
children
who can be managed
in an open setting.
None
were
diagnosed
as brain-damaged,
defective
or overfly
psychotic.
The children
ranged
in age from 7 to 15
1 Read
at the 119th
annual
meeting
of The
American
Psychiatric
Association,
St. Louis, Mo.,
May 6-10,
1963.
The medication
and placebo
for the study were

supplied
through
the courtesy
of CIBA
Inc. This
study
was supported
by a grant
from the Psychopharmacology
Section
of NIMH,
MY-2583.
2Depts.
of Psychiatry
and
Pediatrics,
Johns
Hopkins
University
School
of Medicine,
and
Chil-

dren’s
Home,

Psychiatric
Service,
The
Johns
Hopkins
Hospital.
458

ON

METHYLPHENIDATE

Harriet

Lane; 

AND

LEON

SYMPTOMATOLOGy
CHILDREN1

EISENBERC,

M.D.2

with
a mean
age of 11.9 and a
standard
deviation
of 1.8. There
were
53
boys and 28 girls, with 8 children
of each
sex Negro.
years,

General

Design

&

Test

Measures:

The

verbal
scale
of the Wechsler
Intelligence
Scale
for Children
(W.I.S.C.),
with
the
digit span substituted
for the vocabulary,
was administered
individually
to each child.
On the basis of the I.Q. distribution,
the
children
were
divided
into 3 intelligence
groups:
low
(65-79),
mid
(80-91),
and
high
(94-135).
Half
of each
intelligence
group
was
or a placebo

The
tered

The
dose
daily
dose
days.
equal

randomly
sub-group.

medication
was
on a double-blind
children
on drug
of 10 mg.
and
of 30
The
and

designated
coded
basis

as a drug
and
for

adminis10 days.

were
begun
of methylphenidate

at a
twice

were
gradually
increased
to a
mg. twice
a day for the final 5
children
on placebo
received
an
increasing
number
of tablets
of

an inert substance.
There
were no adverse
reactions
of magnitude
sufficient
to necessitate
discontinuation
of medication.
All
children
took the medication
regularly
under the careful
supervision
of house parents.
The cottage
parents
of group
A and the
child
care workers
48-item
symptom

of group
inventory(6)

B filled
on

out a
each

child before
treatment
began
and again on
the last day of medication.
This
inventory
required
a judgment
of symptom
severity
on a scale that ranged
from 0 to +3.
The
Children’s
Manifest
Anxiety
Scale
(GMAS)
(10),
the General
Anxiety
Scale
for Children
(GASC)
(11),
and a 19-item
Impulsivity
Scale( 12)
were
administered
individually
to each child before
treatment
was begun.
Three learning
tasks were given
to each
child,
one before
and two after
treatment.
Porteus
Mazes( 13) and a tremorgraph
test were given after treatment.
A brief
interview
concerning
subjective
effects
of the medication
and a short questionnaire
about
side effects
were
given
to

19631

C. KEITH

CONNERS,

AND

in Table

1.
TABLE

Summary of Experimental

SYMPTOM
DIFFERENCE
SCORE

1

Design and Test Procedures

Low (65-79)

High (94.135)

WISC
Symptom ratings
CMAS
GASC
Impulsivity Scale
DigitSymbol
Learning
*

Three

subjects

*

13
13
13
13
13
13

Total
PRE#{149}DRUG
MEASURES

78

*

POST-DRUG MEASURES

Digit.Letter Paired Associate Learning
Symptom Ratings
Interview regarding side effects
Tremorgraph
Porteus Maze Test
DigitSymbol Learning (alternate form)

were held as a reserve

and are not counted

RESULTS

Comparability
of Treatment
Groups
on
Pre-Treatment
Measures:
The
mean
age,
I.Q.
and
initial
symptom
scores
of the
drug
and
placebo
groups
were
virtually
identical.
No significant
differences
were
obtained
on anxiety,
impulsivity
or learning

prior to treatment
to active
or inert

for the groups
medication.

Symptom
Change
After
Treatment:
A
total weighted
symptom
score was obtained
for each child by multiplying
each symptom
by its severity
and summing
the total. The
initial
score was subtracted
from the final to

compute
a difference
score.
Table
2 compares
difference
scores
for the drug
and
placebo
groups.
The overall
change
indicates
a significant
improvement
in the
drug
group
(p < .026 with a one tail test
since the direction
of change
was predicted). While
the group
as a whole
demon-

OnetaiIed

strated

In analyses requiring equal numbers in all groups. Three
other subjects completed only part of the testing and are
excluded except where their remaining scores can be validly
retained.

measures
assigned

P

10.47

Placebo group (N = 32)

N

Drug
Placebo
Drug
Placebo
Drug
Placebo

Mid (80-91)

Drug group (N = 32)

STAND.
ERROR

2.71

BASIC DESIGN
TREATMENT

WISC VERBAL l.Q.

459

EISENBERC

TABLE 2
Difference Scores Between InItial and Final Symptom
Ratings for Children Receiving 10-Day Treatment of
Methylphenidate or Placebo

and
raters,
respectively,
on the
day of treatment.
The basic design
of the study,
together
with
the
preand
post-drug
measures,
children

last

is shown

LEON

<.026*

5.16

hypothesis.

this

moderately

significant

difference

in behavior,
examination
of individual
protocols revealed
large individual
differences
in responsiveness
to the drug.
It should
be noted
that
one
of the
cottage
parents
in group
A failed
to complete

the

post-drug

ratings

for

her

children

so that the findings
are based
on 64 of the
original
sample
of 78. However,
a second
group of raters was available
from the night
shift
in institution
B; these
ratings
confirmed the findings,
with a mean difference
score of 10.5 (p < .06; N = 22) in favor of
the drug treated
children.
Each item of the symptom
inventory
was
examined
in the

drug

separately
and

for

differential

placebo

groups.

change

Table

3

TABLE 3
Changes in Individual Symptoms at 20% Level or Better
After Drug Treatment
SYMPTOMS WHICH IMPROVED

CHI’

Leads into trouble
Demanding
Disobedient
Lying
Listless & apathetic
Childish or immature
Quarrelsome (disturbs other children)

6.13
5.74
4.27
4.15
2.00
1.77
1.70

<.02
<.02
<.05
<.05
<.20
<.20
<.20

P

5.86
3.00
1.70

<.02
<.10
<.20

SYMPTOMS WHICH WORSENED

Nailbiting
Stomach aches
Anxious, fearful

lists
20%

the items
level
of

which
discriminated
at the
probability
or better.
The
largest
changes
appear
to occur on outwardly-directed
symptoms
which
would
be disturbing
to caretakers.
It is of interest
that

three symptoms
and fearful-anxious)

(nailbiting,
were

stomach
aches
reported
as worse

460

EFFECTS

OF

METHYLPHENIDATE

ON

in the drug
group
at the 20% level or better.
Although
the extent
of these changes
is not
sufficient
to place high reliability
in them,
they suggest
the possibility
of an increase
in anxiety
from
the medication.

Learning

and

Maze

Performance:

institution

the

Porteus
better
subjects

Maze
scores
performance
(Table
4),

A.

tributable

These

findings
in age,

to differences

are
I.Q.,

not
atrace or

sex. They
are consistent
with
clinical
observations
made
by those
who tested
the
children.
An additional
finding
is the higher
“lie” score
on both
anxiety
scales
for the
group
B cases
(p < .10)
which
may
indicate that they were more defensive
in re-

On

both the paired-associate
learning
tests and
on the Porteus
Mazes,
the drug group demonstrated
significantly
better
scores.
On the
learning
tasks,
however,
analyses
of covariance
indicated
that
errors
were
significantly
reduced
(p < .05) only in the
last block of learning
trials. This effect was
more marked
among
the B cottage
children,
i.e.,
those
who
were
presumably
sicker.
Moreover,
significantly
drug-treated

F November

SYMPTOMATOLOGY

porting
anxiety
symptoms.
Thus,
the anxiety
scales
may not be an adequate
measure
of
the actual
level
of anxiety
in these
more
disturbed
children.
Side
Effects
and
Subjective
Response:
The children
were
questioned
individually

regarding

problems

of sleep,

fatigue,

anor-

exia,
nervousness,
dizziness,
ataxia,
bowel
problems
and
bladder
problems.
Only
appetite
was
significantly
affected
by
the

showed
by
the
an effect

TABLE 4
Porteus Maze Test QuotientScores for Drug and Placebo Groups
DRUG

Low lQ (N = 28)

11.88

Mid lQ (N = 24)
Hi lQ (N = 27)
Total (N = 79)

11.08
12.42
11.79

PLACEBO

ST. ERROR

9.04
12.61

1.07
1.20
.798

10.42

.636

9.60

which

drug,

I.Q.

also
suggested
an interaction
with
That is, the children
of low and average I.Q. displayed
greater
gains from drug
therapy
than did those of high I.Q. These
results
are reported
and analyzed
in greater
detail
in a separate
report(
14).
Anxiety
and ImpuL9ivity
Scaks:
In view
of the large individual
differences
in symptom improvement
scores
noted
earlier,
we
examined
the
anxiety
and
impulsivity
scales
to determine
whether
variance
on
these initial
measures
might
account
for dif-

reporting

ferential

responsiveness.

However,

we

were

unable
to find any correlation
between
initial status
on these
instruments
and any
measures
of improvement.
Their
failure
to
relate
to initial
symptom
scores
indicates
that they
are
measuring
attributes
of the
children
different
from those registered
by
the

symptom
inventory.
It is, however,
of some

interest
more
disturbed
children
(those
tion B) scored
higher
on the
scale
(p < .001) and lower
on
scales
(p < .005) than the foster

that the
in instituimpulsivity
the anxiety
children
in

with

T

2.13
1.70

<.05
<.10
n.s.

2.15

<.05

<1

30 of the drug
subjects
(79%)
some loss of appetite
as opposed

to only 3 placebo
the
drug-treated
difficulty
going
to
placebo
group
had
ilar
results
were
parents’
report
of
questions
regarding

calmer
changes
stitution

P

subjects
(7.3%).
Seven
of
children
reported
some
sleep,
while
none
in the
any such problem.
Simobtained
from
cottage
side effects.
A series
of
general
improvement,

behavior,
adverse
effects
and mood
were
asked
of the raters
in inA. When
a +1 was assigned
for a

positive
effect
and a -1
for a negative
effect, the total
score
for the drug
group
was
significantly
better
than
for
the
placebo
group
(p < .05).
Similar
questions
were
asked
of the children
from both institutions,
with the drug
group reporting
“feeling
happier”
since
taking
medication
(p < .036),
but
not differing
from
the placebo
group
on the total score.
DISCUSSION

The

ventory,

difference

as well

scores

as the

on the

more

symptom

global

in-

judg-

‘:r

T:

-

C.

KEITH

CONNERS,

AND

ments asked
for statistically

of the raters, provide
evidence
significant
improvement
following
treatment
with
methylphenidate
for
the children
in both institutions.
Such rating
methods
are, however,
subject
to rater
bias.
The high incidence
of side effects
(70%)
in
the drug group leads to the possibility
that,
although
the medication
was
coded and administered
“blind,”
the raters
might
have
been able to recognize
those on active drug
on the basis of the side effects.
this as the
are two sets

Against

findings
same

scales

explanation
of data.

discriminated

medication

subjects

in an earlier

amphetamine

when

for
First,

study

subjective

the
the

on active

with

dextro-

complaints

were

fewer( 6). Moreover,
an independent
measure
in that study,
peer ratings
by the
children,
was in agreement
with
the symptom scores.
Second,
we have independent
evidence
in this study of some objective
improvement
in the drug
treated
subjects
on
two learning
tasks and on the Porteus
Maze.
This increases
our confidence
in ascribing
the difference
registered
on the symptom
inventory
to the effects of the drug.
The findings
in the present
study are thus
in accord
with
clinical
impressions
reported
in the literature(7,
8). They
are also in
agreement
with those from our concurrent
study
of methylphenidate,
phenobarbital
and placebo
in the outpatient
treatment
of
hyperkinetic
and defective
children,
a study
in which
improvement
worsening

the

in

stimulant

produced

and
the
symptoms(

sedative

reliable
reliable

15).

The learning
test and Porteus
Maze
results are of particular
interest
in indicating
improved
performance
on the drug,
with
a suggestion
on the Porteus
Maze
of a
drug-intelligence
interaction.
The multiplicity of factors
that can influence
learning
precludes
any firm explanation
of these
findings,
but they do offer an avenue
for a
more
detailed
exploration
of the psychopharmacologic
action
of methylphenidate.
It is tempting
to relate
the improvement
in
Porteus
Maze
performance
to a decrease
in impulsivity,
since impulsivity
in a subject
will interfere
with his performance.
We ‘had expected
that methylphenidate
might

high

provide

maximal

on impulsivity

benefit

and

to the

low on anxiety

child

and

LEON

481

EISENBERG

a contrary
effect on the youngthe opposite
rating.
The failure
of
the anxiety
and impulsivity
scales employed
in this study to correlate
with maze scores

might

have

ster

with

or

learning

scores

might

reflect

either

the

inadequacy
of the scales or the incorrectness
of ‘the hypothesis.
There is at least the suggestion
that
the anxiety
and impulsivity
scales
are not measuring
what they purport
to measure
from
their
lack of correlation
with the symptom
inventory
on which
we
were
able to detect
improvement
in behavior.
The
mines

available
literature
and methyiphenidate

on the amphetareveals
little

directly
applicable
to children,
save for the
previously
mentioned
therapeutic
trials(
1-5,
7,8)
in which
the emphasis
has been on the

paradoxical
duced

decrease

by

these

in

agents

hyperkinesis

classed

(15).
In the one clinical
elucidation
of physiological
action,
Laufer
and
his
investigated

mine

the

study

directed

at

mechanisms

of

coworkers(
16, 17)
of dextroamphetathe threshold
to photoof the EEC
in children
impulse
disorders.
The
thresholds
than
a com-

effect

in modifying

metrazol
activation
with
hyperldnetic
patients
had lower

parison
children.

pro-

as stimulants

group of non-hyperkinetic
disturbed
Following
the administration
of

“clinically
mine,
the
significant
olds and

efficaceous
doses”
of amphetahyperkinetic
children
displayed
a
increase
in photometrazol
thresh-

achieved
the range
characteristic
for the comparison
group.
The authors
suggest that the drug, “perhaps
by raising
the
level of synaptic
resistance,”
alters the functions
of the diencephalon
and
reticular
activating

system,

a tenable

but

unproved

hypothesis.
Weiss
and
Laties(
18)
have
provided
complete
review
of the effects
of amphetamines
on performance
in adult
subjects.

They

conclude

that

decrease
reaction
and
coordination,
havior,
counteract
mood.
Although

problem
either

performance

solving
normal

can:

time,
improve
steadiness
enhance
monitoring
befatigue,
and
elevate
amphetamines
appear
to

hasten
the acquisition
ing, there is no evidence
intellectual

amphetamines

a

or

subjects

of simple
that

they

conditionimprove

(as measured
intelligence
tests)
or mental

defectives,

by
in

462

EFFECTS

OF

METHYLPHENIDATE

despite
early
claims
based
upon
uncontrolled
studies.
However,
it should
be noted
that there have been few attempts
to meas-

ure

new

the

drugs

learning

as opposed

on already

problem

solving

acquired

to effects
knowledge

for

of
or

capacity.

results
must be viewed
cautiously
in
of the influence
of species,
age, sex,
environmental
context
and
method
of
measurement
on activity
levels( 19).
Prefrontal
lesions in monkeys
appear
to release
hyperkinetic
behavior
which is appreciably
reduced
by either
amphetamine
or methylphenidate(20).
At the same time, cortical
lesions
have
been
shown
to lower
convulsive
thresholds
to amphetamines(21).
In
the rat, cortical
lesions
did not alter activity
level per se but instead
sensitized
the animal
to amphetamine-induced
hyperidnesis
(22).
It should
be noted
that in the animal
species
studied,
just as in the human,
there
is a wide
range
of individual
variation(23).
In general,
it is the animals
with
the most
active
pre-drug
condition
who
display
the
greatest
response
to drugs(
19).
in impulsivity

(as

measured

by the Porteus
Maze)
and in aggressive
behavior
(as measured
by symptom
ratings)
registered
in our patients
is compatible
with
the
hypothesis
that
hances
the action
of

systems

(24).

The

methylphenidate
eninhibitory
controlling

same

explain
the improvement
stemming
from
suppression
ity.
However,
a second

creased
alerting-is
we are to judge
performance
on

mechanism
might
in learning
as
of

distractibil-

mechanism-inprobably
active
here if
from
reports
of human
stimulants(
18) and from

the remarkably
alert
attitudes
of primates
whose
spontaneous
pacing
has
been
decreased
by
these
agents
as opposed
to
tranquilizers(20).

However,
the available
evidence
is both
too limited
and too contradictory
to permit
any firm conclusions
on the mode by which,
and
the loci at which,
sympathomimetic
amines
action.

their

further

study

an

adequate

it

F November

of the

theory

is perhaps

cautionary

The
view

decrease

SYMPTOMATOLOGY

ical functions
influenced
formation
which
will

Animal
studies
on the action of stimulants
have
centered
mostly
on their
effects
on
motor
behavior,
either
in the intact
animal
or in the experimentally
brain-damaged
one.

The

ON

exert
their
psychopharmacologic
The present
findings,
in addition
to
clinical
significance,
offer
an avenue

point

specffic

by these
be

psycholog-

drugs,

necessary

can be constructed.
worthwhile
to make
that

while

in-

before

the

some

evidence
in the present
study
attests
to statistically
significant
changes
in our patients,
the wide
individual
differences
in responsiveness
and
the consequent
smallness
of the
overall
changes
indicates
that
the
practical
or
clinical
significance
of the drug
methylphenidate
must still be determined
for care-

fully
wide

selected
clinical
populations
over a
range
of conditions
and drug dosage.
Future
studies
of the personality
and other
factors influencing
drug responsiveness
need
to be done before blanket
endorsements
can
be given for general
clinical
use.
SuMuw
This
study
investigated
the
effects
of
methylphenidate
administered
double-blind
over a 10-day
period
to two groups
of emotionally
disturbed
children
(total
N = 81).
Symptom
ratings
by house parents
and child
care workers
were
obtained
before
treat-

ment and on the last day of treatment.
Total
symptom
scores were improved
in the drug
group
Changes
mostly

at

a

in
with

statistically
individual
outwardly

significant
level.
symptoms
occurred
directed
symptoms

such
hints
only

as “leads into trouble,”
and there were
that anxiety
showed
an increase.
The
adverse
side effect was a high report
(70%)
of appetite
loss in the drug
group.

Objective
performance
ment
in the

measures
of learning
also shOwed
reliable
drug group,
minimizing

sibility
that
rater biases.
itial

level

and maze
improve-

the posdue to
of inimpulsivity
were
improvement
in

symptom
changes
were
Questionnaire
measures
of anxiety

and

not related
to symptomatic
the drug
group,
and some
doubt
as
validity
of these instruments
for the
children
studied
was raised
by the
The results
agree
with previous
studies

activation
The wide

and

are

interpreted

to the
type of
results.
clinical
as reflecting
an

of inhibitory
controlling
systems.
individual
variation
in response
to

the drug
indicates
further
research
on individual
difference
factors
is required,
as
well
as caution
in the application
of the
drug
in clinical
situations.

19631

C.

KEITH

CONNERS,

BIBLIOGRAPHY
1. Bradley,
C.: Am. J. Psychiat.,
94: 577,
1937.
2. Bradley,
C., and
Bowen,
M.:
Am.
J.
Orthopsychiat.,
11: 92, 1941.
3. Bender,
L., and Cottington,
F.:
Am. J.
Psychiat.,
99: 116, 1942.
4. Bradley,
C. : Pediatrics,
5: 24, 1950.
5. Pasamanick,
B.: Arch. Neurol.
Psychiat.,
65: 752, 1951.
6. Eisenberg,
L., et at.: Am. J. Orthopsychiat.,
33: 431, 1963.
7. Knobel,
Mauricio,
and
Lytton,
George
J.:
Dis. Nerv. Syst., 20: Aug. 1958.
8. Knobel,
Mauricio,
et at.: A.M.A.
Arch.
Gen. Psychiat.,
1: 310, 1959.
9. Eisenberg,
L.:
Am.
J. Orthopsychiat.,
32: 5, 1962.
10. Castaneda,
A., et at.: Child Devel., 27:
317, 1956.
11. Sarason,
S. B., et at.: Anxiety
in Elementary
School
Children:
A Report
of Research.
New York:
J. Wiley,
1960.
12. Sutton-Smith,
B., and
Rosenberg,
B.
C.: J. Genet.
Psychol.,
95: 211, 1959.
13. Porteus,
S. D.:
The
Maze
Test
and
Clinical
Psychology.
Palo Alto:
Pacific
Books,
1959.
14. Conners,
C. K., et a!.: The Effects
of
Methylphenidate
on Paired
Associate
Learning
and Porteus
Maze
Performance
in Disturbed
Children.
Submitted.
15. Whitehouse,
D.,
et at.:
A Double
Blind
Study
of Phenobarbital,
Methyiphenidate and Placebo
in Hyperkinetic
Children.
To
be published.
16. Laufer,
M. W., et at.:
Electroenceph.
Clin. Neurophysiol.,
6: 1, 1954.
17. Laufer,
M. W.,
et a!.:
Psychosom.
Med.,
19: 38, 1957.
18. Weiss,
B., and Laties,
V. G.:
Pharmacol. Rev., 14: 1, 1962.
19. Irwin,
S.: Rev. Canad.
Biol., 20: 239,
1961.
20. Davis,
G. D.:
Am. J. Physiol.,
188:
619, 1957.
21. Blum,
R. A., et at.: Arch.
Neurol.
Psychiat.,
64: 685, 1950.
22. Adler,
M. W.:
J. Pharmacol.
Exp.
Therap.,

134:

214,

1961.

23. Cole,
J., and Glees,
P.:
J. Ment.
Sci.,
103: 406, 1957.
24. Eisenberg,
L.:
Behavioral
Manifestations of Cerebral
Damages
in Childhood.
To
be published.

DISCUSSION
JOEL

This

P.
study

ZRULL,

has

M.D.
what

can

(Ann Arbor,
be called

Mich.)
the new

AND

LEON

EISENBERG

463

look in methods
of assessing
the effects
of
drugs
on human
behavior
(and
in this
case
specifically
the behavior
of children).
In the
past,
most have
been
content
with
assessing
the effects
of a drug
by a clinical
evaluation
of the person’s
behavior
while
on the drug
(by the doctor
alone).
It is becoming
increasingly
apparent
that
this is not entirely
reliable
nor does it give an adequate
estimate
of the drug’s
potentiality.
The method
employed
here allows a wider view of the drug’s
effects
as well as an inherent
cross
validation
of the individual
tests.
No doubt
one of the most important
distinctions this type of study points
up is that when
trying
to alter behavior
with a drug it is the
behavior
in the every day setting
that is to be
affected
and not the behaviOr
in the doctor’s
office. There
is now a tendency
to use other
than strictly
medical
techniques
to determine
qualitatively
and quantitatively
the effects
in
the clinical
trials
of drugs.
This
method
11lustrates
the use of personnel
other than physicians
to rate
these
children
(possibly
akin
to using parents
or school
teachers
on an outpatient
basis)
and using
psychological
testing
to its greatest
advantage
(i.e.,
selectively
to
suit what
the hypothetical
results
might
be).
The effectiveness
of studies
with drugs will be
extended
when
more thorough
evaluations
on
outpatients
are undertaken.
The use of personnel
such as parents,
school
teachers,
psychologists
as well as the physician
will allow a
sampling
of the
child’s
behavior
in many
areas.
Besides
this the attitudinal
changes
in
the parents
and
teachers
produced
by the
child
taking
a drug
will
be available
for
evaluation.
This has proved
very interesting
in
our studies,
and seems
to bear
a great
deal
on drug effectiveness.
One of the most
appealing
advantages
in
using central
nervous
system
stimulants
in behavior
disorder
children
and
in particular
those
with
learning
difficulties,
since
a great
share
of them
have
these
difficulties,
is the
fact that one is not depressing
the children
with
a sedative
type
drug.
This
particular
action
itself
is worthy
of a good
deal
of
study.
The whole
area of concern
over what
drug
effects
there
are on learning
processes
and developmental
processes
can be hopefully
alleviated
or consolidated
by studies
such
as
this.
The fact that these children
tended
to show
more
fearfulness
as their
hyperactivity
and
impulsivity
decreased
seems
understandable
if
one takes
these
latter
types
of symptoms
as
releases
for anxiety
that were
then
removed.
This brings
one to wonder
generally
what the

464

EFFECTS

OF

METHYLPHENIDATE

hyperkinetic
syndrome
is. Considering
that it
is seen cross-cutting
the range
of classification
it could
be hypothesized
to have
as its origin
something
common
to all these
disorders.
No
doubt
anxiety
underlies
it to a great
degree.
It has been
our finding
that no matter
what
produces
the anxiety,
that is, neurotic
conifict,
showering
impulses,
or difficulty
in aligning
perceptions,
the
resultant
hyperkinetic
syndrome
can respond
to a CNS
stimulant.
In
spite of this, many
of the children
we studied
proved
amenable
to the drug
at one time
and then
not at another.
Besides
this,
two
children
with
the same
diagnosis
might
not
both
be helped
by the CNS
stimulant.
This
speaks
for the necessity
of building
new symptom
rating
scales
or methods
of assessing
symptoms,
through
studies
such
as these.
Some
factor
other
than
the type
of anxiety
seemingly
controls
whether
there
will be a
response
or not.
The question
of alerting
versus
inhibitory
activity
of the CNS
stimulants
is intriguing
and not adequately
studied.
The possibility
of
both mechanisms
operating
is not out of the
question.
The alerting
theory
is appealing
because
of what
one knows
of the action
in
adults-it
is obvious
that they are made
more
active
and
stimulated
by the
drugs.
Along
with this, of course,
the ability
to be aware
of and to blot out unnecessary
stimuli,
which

ON

SYMPTOMATOLOGY

[November

to some extent
implies
the inhibitory
activity,
can cut down
on the need to react impulsively
to each stimulus
and thus results
in less hyperactivity
as well as increased
efficiency
in psychic functioning.
A greater
awareness
of one’s
surroundings
allows
the
individual
to view
them
as less hostile
and thus
the need
for
aggressive
behavior
is decreased.
This
same
alerting
may be involved
in the apparent
increase
in learning
capacities
noted
in the
paper.
The
authors
are correct,
however,
in
their statement
that the evidence
is too limited
to permit
firm conclusions.
Many
might
argue
that
10 days
is hardly
enough
to determine
whether
the effects
seen
are
strictly
drug effect. However,
with methylphenidate
as well as the amphetamines
a very
short period
is all that is necessary
to build up
blood
levels
sufficient
to cause
physiologic
changes.
The study
itself
has
adequately
allowed
for the placebo
effect
of taking
a pill.
It has been our own finding,
however,
that on
lower dosages
on an outpatient
basis all drugs
that are given first are reacted
to the same as a
placebo.
Only later
can one discern
the true
drug
effect.
There
is a further
consideration
which
might
eliminate
matching
problems
in
the groups,
that of using
the subjects
as their
own controls
by giving
the drugs
and placebo
in a cross-over
pattern.