Attention-Deficit Hyperactivity Disordered Boys' Evaluations of And

Journal of Abnormal Psychology Copyright 1989 by the American Psychological Association, Inc. 1989, Vol. 98, No. 3, 280-284 0021-843X/89/$00.75

Attention-Deficit Hyperactivity Disordered Boys' Evaluations of and Attributions for Task Performance on Medication Versus Placebo

R i c h a r d M i l i c h B a r b a r a G . L i c h t University of Kentucky Florida State University

Debra A. Murphy and William E. Pelham Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania

The present study examined the effects of stimulant medication on the self-evaluations of and attributions for task performance of 26 attention-deficit hyperactivity disordered boys. Each boy performed a continuous performance task twice, once while on medication and once while on placebo. Immediately following the completion of the task, the boys were asked a series of questions concerning their self-evaluations of, and attributions for, their performance. Two findings of note were obtained. First, medication, compared with placebo, increased the correspondence between the boys' self-evaluations and their performance. Second, the boys did not use medication as a frequent explanation for their performance, as others have predicted. In fact, the boys picked medication as an explanation for their successes significantly less often than either effort or ability.

Stimulant medication is the most common intervention for attention-deficit hyperactivity disorder (ADHD), with up to 90% of children diagnosed with this disorder receiving a medication trial at some point in time (Gadow, 1979). The wide- spread use of this intervention is understandable, given evidence that stimulant medication significantly improves both the classroom and social behavior of ADHD children (Pelham, 1986). Although there is a general consensus concerning the im- mediate, positive impact of medication on the behavior of ADHD children, several authors (e.g., Bugental, Whalen, & Henker, 1977; Whalen & Henker, 1976) have expressed concern that successful treatment with stimulant medication may have a delayed, adverse effect on children's self-perceptions. It has been argued that drug treatment may lead children to attribute their behavior to external factors (e.g., the drug) and view their own efforts or abilities as playing a relatively minor role. This belief may lead children to respond passively, so that while taking medication they may rely on the drug to focus their attention and efforts. When the medication is discontinued, they may feel like they are left with no way to control their own behavior (Rosen, O'Leary, & Conway, 1985).

Some case studies (e.g., Rosen et al., 1985) and indirect evidence suggest that medication may have these negative effects. Amirkhan (1982) found that teachers and students attributed the successes of hypothetical medicated ADHD children primarily to medication and those of hypothetical unmedicated ADHD children primarily to high effort. Henker and Whalen (1980) reported that when medicated ADHD children were questioned about their problems on a generallevel, the children indicated that their problems were physiologically based and that the drug helped them control their behavior. However, we

Correspondence concerning this article should be addressed to Rich- ard Milich, Department of Psychology, University of Kentucky, Lexing- ton, Kentucky 40506.

280

do not know how these children perceive their own behavior in the context of performing specific tasks. As Henker and Whalen acknowledged,

When we query them about behavior achievements and improve- ments in a context suggesting neither hyperactivity nor medication, they express the same volitional attributions as do most middle class youngsters: "It depends on how hard you try" or "You can do it if you really want to." (p. 155)

It actually is possible that medication treatment may have some positive cognitive-motivational consequences. Specifi- cally, Pelham, Milich, and Walker (1986) examined the effects of stimulant medication on ADHD children's learning of non- sense spelling words. Half of the children had medication on the 1st day and placebo on the 2nd, while the other half had the reverse order. The results revealed a significant Drug × Order interaction, such that when placebo preceded medication, placebo performance was significantly worse than medication performance; however, when medication preceded placebo, performance in the two conditions was not significantly different. One explanation for this finding is that children receiving medication on the first day had a significantly increased chance that their first exposure to the task was successful. This led them to approach the task on the second (i.e., placebo) day with relatively high expectancies of success, which led to increased effort, and thus enhanced their performance.

Because Pelham et al. (1986) did not assess children's expectancies, we cannot say whether the medication-induced success actually did enhance expectancies. If we are to understand the cognitive-motivational consequences of medication, an impor- tant first step is to determine whether the medication-induced successes are perceptible to the children. The present study was designed to address this and related issues.

Attention-deficit hyperactivity disordered boys performed a task once on medication and once on placebo. Following the task, they were asked about their self-evaluations of and attribu-

ADHD BOYS' SELF-EVALUATIONS 281

tions for their performance. We hypothesized that both task performance and self-evaluations o f performance would be better under medication than under placebo. Furthermore, because evaluating one's performance involves cognitive judg- ments, children's self-evaluations should be more highly related to their actual performance under drug than under placebo. O f particular interest concerning the children's causal attr ibutions was the overall degree to which the boys believed task outcomes were the result o f their efforts relative to medication.

M e t h o d

Subjects

Participants were 26 boys with behavior and learning problems who had been referred to the 1987 Summer Treatment Program at Western Psychiatric Institute and Clinic. On the basis of a structured parent interview, all boys met the criteria for a Diagnostic and StatisticalManual of Mental Disorders (DSM-m-R; American Psychiatric Association, 1987) diagnosis of ADHD. The boys averaged 11.0 positive symptoms out of the total of ! 4. On the basis of the interview, 20 boys also obtained a DSM-m-R diagnosis ofoppositional defiant disorder, and 8 boys, a diagnosis of conduct disorder. Teacher and parent ratings corroborated these diagnoses. On the lnattention/Overactivity scale of the IOWA Conners (Loney & Milich, 1982) the boys received an average rating of 1 i.2, whereas on the abbreviated Conners teacher and parent rating scales they averaged 18.9 and 19.8, respectively.t The boys ranged in age from 7.1 to 11.8 years, with a mean of 8.8 (SD = 1.3). They had a mean Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974) Full Scale IQ of 104.3, ranging from 71 to 129.

Procedure

The study consisted of a placebo-controlled, double-blind evaluation of the effects of stimulant medication on the boys' evaluations of and attributions for their performance on a continuous performance test (CPT), a laboratory measure of sustained attention, impulsivity, or both. Each boy performed the task once while on placebo and once while on medication. Half of the boys received medication for the first session and placebo for the second, whereas for the other boys the order was reversed. Immediately following the task, boys were asked a series of questions concerning their perceptions of their own performance.

Medication procedure. The boys received on each day, in opaque gela- tin capsule form, either 0.3 mg/kg methylpbenidate or an identical- looking placebo prepared by the research pharmacy. This dose ofmeth- ylphenidate is the most common dosage in current use in research and clinical settings when the purpose is to improve children's performance on cognitive tasks (Pelham, 1986). All of the children were participating in clinical medication assessments in the summer treatment program, and they had been receiving methylphenidate and placebo with order randomized for several weeks prior to this study. The parents were in- structed to tell their sons that they would be receiving different types of medication, although the placebo trials were not to be mentioned. All appropriate procedures had been followed to obtain consent (see Pel- ham & Hoza, 1987). Medication was given at 8:00 a.m. and 11:30 a.m., and testing was always undertaken within 1-3 hr following capsule in- gestion. Sessions were conducted in either the morning or afternoon with the same boy participating at the same time for both sessions.

Experimental task. In order to investigate whether ADHD children perceived their performances as better under medication than placebo, it was necessary to employ a task that would show superior performance under medication. A CPT task was chosen because it is considered the standard laboratory measure of sustained attention (Douglas, 1983), and it has consistently shown a dramatic medication effect (Pelham,

1986). The task was administered on Apple II microcomputers (Lind- gren & Lyons, 1984). Letters of different colors flashed on the screen at intervals of 900 ms. The boys were required to press the space bar each time they saw an orange H followed by a blue T. The task lasted approxi- mately 14 min, and consisted of 900 letters, 180 of which were targets. Measures derived from the CPT were errors of omission--failing to press the space bar when a target appeared--and errors of commission-pressing the space bar in the absence ofthe target.

Self-evaluation and attribution questionnaire. The questionnaire as- sessed seven dimensions: (a) how well they thought they performed on the task, (b) how easy they felt it was to pay attention, (c) how hard they felt they tried, (d) how hard they thought the task was, (e) their affective reaction to the task (e.g., how much they liked the task), (f) their expectancies for future success on the task, and (g) how much they felt their medication helped them on the task. The questions developed to assess these dimensions were similar to those used in research on children's achievement-related beliefs (e.g., Diener & Dweck, 1980; Dweck, Goetz, & Strauss, 1980). For example, the boys were asked to rate their performance on a 10-point scale ranging from I did very well ( 1 ) to I did very poorly (10). In order to increase the reliability of the assessments, whenever possible, two separate questions were asked to assess each dimension. These two questions were averaged to yield a single score for that dimension.

Because children's causal attributions vary as a function of whether they are explaining successes or failures (Bar-Tal & Darom, 1979), it was necessary to determine whether the boys viewed their performance as an overall good or bad job. The child was then asked six forced-choice attribution questions to determine why he thought he did a good (or bad)job. The attributionai choices for a good job were effort ("You tried hard"), ability ("You're good at this task"), task ("The task is easy for kids your age"), and medication ("The pill you took today helped you"). Attributions were pitted against one another in random order, with all possible pairwise comparisons being presented. Thus, the child could pick each attribution between zero and three times. Licht, Kistner, Oz- karagoz, Shapiro, and Clausen (1985) showed that this format could be used reliably by children with learning problems. All questions were read to the children by a trained research assistant to ensure that children's responses were not affected by any reading difficulties.

Resu l t s

It was first necessary to determine whether medication significantly improved the boys' CPT performance compared with placebo. A 2 (medication) × 2 (order) analysis o f variance (ANOVA) for errors o f omission produced a significant main effect for medication, F(1, 24) = 27.9, p < .001, but no significant main effect for order, F(1, 24) < l ; nor was there a significant Medication × Order interaction ( F < l). The means o f tbe omission errors for the medicat ion and placebo sessions were 16.3 (SD = 14.7) and 27.5 (SD = 20.7), respectively. For the commission errors there was a significant main effect for medication, F ( l , 24) = I 1.7,p < .002, but no significant main effect for order (F < 1); nor was there a significant Medication × Or- der interaction (F < 1). The mean errors o f commission for the medicat ion and placebo conditions were 27.2 (SD = 46.1 ) and 65.4 (SD = 94.4), respectively.

Table 1 presents the results o f the correlated t tests comparing the boys' self-evaluations on medication versus placebo. In re-

The scores on the Conners parent and teacher rating scales were most likely attenuated somewhat because several of the boys were on medication at the time when the ratings were completed.

282 MILICH, LICHT, MURPHY, AND PELHAM

Table 1 Correlated t- Tests Between Drug and Placebo Condit ions

Drug Placebo

Variable M SD M SD r ~ t

Self-evaluations How well they thought they did 9.60 2.5 9.54 2.4 .83 0.21 How easy they felt it was to pay

attention 8.38 2.7 8.23 2.8 .53 0.30 How hard they felt they tried 9.83 2.3 9.50 2.4 .83 1.19 How hard they thought the task

was 5.15 3.9 4.07 3.7 .74 2.02 How much they liked the task 8.25 2.8 7.92 3.2 .91 1.22 How well they thought they

would do in the future 9.71 2.4 9.73 2.2 .96 0.14 How much they thought the

pill helped 6.30 3.9 5.57 4.2 .70 I. 17

Attributions for success Effort 2.58 0.8 2.29 1.0 .41 1.43 Task 1.04 0.8 1.54 0.8 .29 2.50 Ability 1.58 0.7 1.58 0.7 .39 0.00 Medication 0.79 1.0 0.58 1.0 .65 1.23

a Correlation between the drug and placebo data.

sponse to the question of whether they did a good or bad job, only 2 of the 26 boys indicated on either day that they did a bad job. These two boys were dropped from the analyses involving attributions. As is evident in Table 1, none of the comparisons was significant. Two of the analyses were marginally significant (p < . 1), although in a counterintuitive direction. The boys were more likely to attribute their perceived good performance to the ease of the task when they were on placebo than when they were on medication, and they reported that the task was harder on medication than on placebo.

A different picture emerged when we examined the relations between the boys' performance and their self-evaluations within the drug and placebo conditions. Within each condition, correlations were calculated between performance (i.e., error score) and self-evaluations. In order to decrease the number of analyses, the two error scores were standardized and then averaged to produce one score summarizing overall performance. The correlations for the two error scores for the medication and placebo conditions were .44 (p < .05) and .32 (p < .06), respectively. 2 As is evident in Table 2, different patterns of relations emerged for drug and placebo conditions. Four of the seven correlations for the drug condition were significant. The better the performance on the task (i.e., the fewer errors), the more likely boys were to report that they did well, that it was easy to pay attention, that they tried hard, and that they would do well again if they repeated the task. In contrast, none of the correlations was significant for the placebo condition. In a test of the difference between dependent correlations, two of the correlations for the medication days were significantly greater than comparable correlations for placebo days: for "easy to pay attention," t(23) = 2.2, p < .05; for "trying hard," t(23) = 3.6, p < .01. Thus, medication increased the correspondence between the boys' performance and their self-evaluations.

In terms of the boys' attributions for their performance, only one result approached significance. On medication, the better

the boys did on the CPT, the more likely they were to attribute their success to their ability (p = .07).

The next set of analyses concerned the relative importance of the four attributional factors for explaining the boys' successes. For both medication and placebo days, the rank order, from most to least often chosen, was effort, ability, task, and medication. For the medication condition, all possible paired comparisons (i.e., correlated t tests) were significant, except for the comparison of task with medication. For the placebo condition, all possible paired comparisons were significant, except for the comparison of ability with task. Thus, regardless of medication condition, effort was seen by the boys as the primary determi- nant of their successes, whereas medication was viewed as being relatively unimportant.

Because children's attributions vary as a function of age (Kistner, Osborne, & LeVerrier, 1988), it was possible that older children might view the importance of medication differently than younger children. To assess this, we correlated the children's ages with their attributions on medication and on placebo. The only notable correlations were in the medication condition. There was a significant tendency for older boys to attribute their successes to medication less often than younger boys, r(22) = - .35 , p < .05, and there was a trend for older boys to attribute their successes to ability more often than younger boys, r(22) = .31, p < .06. No correlations were significant for the placebo condition, although there was a trend for the older boys to make fewer attributions to the pill, r(22) = - .28, p < .09. These results are consistent with Henker and Whalen's (1980) report that older ADHD children were less likely than

2 As a further check on averaging the two error scores, the relation between performance and the self-evaluation measures was examined separately for both the omission and commission scores. All conclu- sions remained the same. Copies of the results for the two error scores separately are available from Richard Milich.

ADHD BOYS' SELF-EVALUATIONS 283

Table 2 Correlations Between Task Errors and Self-Evaluations for Drug and Placebo Conditions

Variable Drug Placebo

Self-evaluations How well they thought they did -.34* -.25 How easy they felt it was to pay attention a -.48** - . 10 How hard they felt they tried a -.47* - . 18 How hard they thought the task was .23 .09 How much they liked the task -.29 -.32 How well they thought they would do in the

future -.35* -.28 How much they thought the pill helped .02 .05

Attributions for success Effort .24 .01 Task -.04 .09 Ability -.30 .05 Medication .05 - . 12

Note. A negative correlation means that the better the performance, the higher the score was on that dimension. a Correlation for drug data was significantly greater than corresponding value for placebo data. *p < .05. **p < .01.

younger ones to view medication as a primary solution to their problem.

Discussion

Contrary to expectations, no significant differences were obtained when comparing ADHD boys' mean self-evaluation and attribution responses under medication and placebo conditions, even though the children performed significantly better on medication than placebo. However, differential patterns of correlations were obtained within the two conditions. For medication, several significant correlations were obtained between children's performance and their self-evaluations. The better the boys' performance on the task, the more likely they were to report that they did well, that they tried hard, that it was easy to pay attention, and that they would do well again if they repeated the task. No significant correlations between performance and self-evaluations were obtained for the placebo condition.

These findings suggest that one of the effects of medication, compared with placebo, is to increase the correspondence between performance and self-evaluations. There are several plausible and not necessarily incompatible explanations for this ob- servation. First, medication may have led to better attending behavior so that the boys were more aware of how well they were doing on the CPT. Second, the medication may have led to more reflective responding by the boys, so that they responded more carefully when presented with self-evaluation questions. Finally, consistent with a concept raised by Douglas (1983), when taking medication, the boys may have been more invested in the task so that they were more concerned with having their responses to the self-evaluation questions accurately reflect their performance. The nature of the present study did not al- low for a determination of which, if any, of these mechanisms

was operative. It is possible that several of these factors were operating simultaneously to produce the increased correspondence between performance and self-evaluation on medication. Whatever the explanation, the present results suggest that, while on medication, ADHD children may be better able and/ or more motivated to monitor their own behavior and thereby better determine the appropriateness of their responses and task strategies.

We did not obtain the Drug × Medication interaction Pel- ham et al. (1986) reported (i.e., that placebo performance was better when the placebo day followed than when it preceded the medication day). One interpretation of their interaction was that medication-induced successes led them to approach the task on the 2rid day with relatively high expectancies of success. In light of the present finding that self-evaluations were not higher under medication than under placebo, it is plausible that the Pelham et al. findings were due to other factors. However, it is also plausible that Pelham et al.'s findings were due to enhanced expectations from the medication-induced success, but that procedural differences prevented subjects in the present study from having higher self-evaluations under medication. Specifically, Pelham et al. gave accuracy feedback to the subjects after each response (i.e., after each attempt at spelling a word). In the present study, no performance feedback was given, and the nature of the CPT task was such that it may have been especially difficult to ascertain how well one was doing. Perhaps subjects in the present study would have shown higher self-evaluations and future expectations under medication than under placebo if they had been given some performance feedback during the session or ifa different task had been used that more readily allowed them to ascertain how they were performing.

Contrary to much speculation in the field, no evidence was found to support the notion that medication produces predom- inantly external, medication-related explanations for performance. If anything, the results were in the opposite direction. For both the medication and placebo conditions, medication was chosen less often than each of the other three attributions for the boys' good performances. In addition, on medication there was a trend for a relation between performance and ability attributions, such that the better the boys did, the more likely they were to attribute this good performance to their ability.

The present study was conducted as part of an intensive day- treatment program for ADHD children involving randomized, double-blind, placebo-controlled medication trials. As such, the children were unaware of the fact that they were receiving placebo trials intermittently. However, it is possible that some of the children suspected such differences in the capsules they took. It is also conceivable that these suspicions caused the children to decrease the degree to which they attributed their success to medication. However, it is not clear how such knowledge of the placebo trial could have produced the differential patterns of correlations seen in Table 2.

The present study represents a first step in examining the effects of stimulant medication on the cognitive-motivational functioning of ADHD children. On the basis of the present results, some future studies seem appropriate. First, the present study compared medication and placebo conditions, but a no- medication condition was not used. Thus, this study examined

284 MILICH, LICHT, MURPHY, AND PELHAM

the direct effect of medication on performance and self-evaluations. Because the boys believed that they were on medication during both sessions, the present results did not address whether there are self-evaluation differences associated with knowing whether one is receiving medication.

In summary, the present study is one of the first to examine systematically the effects of medication treatment on cognitive- motivational factors among ADHD boys. Much of what has been written to date has relied on case studies and speculation rather than systematic investigation. The present results are generally inconsistent with what is routinely believed about medication's effects and suggest that further systematic investi- gations are needed. The current study found no evidence for negative cognitive-motivational consequences of medication treatment, and in fact suggested the possibility of certain positive effects.

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Received May 26, 1988 Revision received September 8, 1988

Accepted January 4, 1989 •

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Attention-Deficit Hyperactivity Disordered Boys' Evaluations of And