Creativity in children with ADHD: Effects of medication and comparisons with normal peers

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Creativity in Children with ADHD: Effects of Medication and Comparisons with Normal Peers Wen Ten , Chien-Chih Tseng , Yu-Shu Chiang , Ching-Lin Wu , Hsueh-Chih Chen PII: DOI: Reference:

S0165-1781(19)30484-6 https://doi.org/10.1016/j.psychres.2019.112680 PSY 112680

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Psychiatry Research

Received date: Revised date: Accepted date:

23 February 2019 4 November 2019 4 November 2019

Please cite this article as: Wen Ten , Chien-Chih Tseng , Yu-Shu Chiang , Ching-Lin Wu , Hsueh-Chih Chen , Creativity in Children with ADHD: Effects of Medication and Comparisons with Normal Peers, Psychiatry Research (2019), doi: https://doi.org/10.1016/j.psychres.2019.112680

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Highlights  The current study first employed the classification scheme by Wakefield (1989) in the exploration of creativity, using different dimensions to measure the creative traits of people with ADHD and the answer is the open-ended or closed-ended creativity assessments. The result showed that the performance of unmedicated children with ADHD in the open-ended creativity assessments was better than medicated children with ADHD and typically developing children while there is no difference between groups in the close-ended creativity assessments.  Although previous evidence for creativity in children with ADHD have been mixed, this study includes medication as moderation variable and suggests that the performance of unmedicated children with ADHD in the open-ended creativity assessments was better than medicated children with ADHD and typically developing children.

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Title: Creativity in Children with ADHD: Effects of Medication and Comparisons with Normal Peers Author names and affiliations: Wen Ten12, Chien-Chih Tseng2, Yu-Shu Chiang2, Ching-Lin Wu34, Hsueh-Chih Chen245* 1

Xing De Elementary School, Taipei, Taiwan, Department of Educational Psychology and Counseling, National Taiwan Normal University, Taipei, Taiwan, 3 Program of Learning Sciences, National Taiwan Normal University, Taipei, Taiwan, 4Institute for Research Excellence in Learning Sciences, National Taiwan Normal University, Taipei, Taiwan, 5 Chinese Language and Technology Center, National Taiwan Normal University, Taipei, Taiwan 2

*Corresponding author E-mail address: [email protected] Professor, Department of Educational Psychology and Counseling, National Taiwan Normal University. Tel.: +886 2 77343782; fax: +886 2 23413865. 162 HE-PING E. RD., SEC 1, TAIPEI, TAIWAN 10610, REPUBLIC OF CHINA. Wen Ten [email protected] Chien-Chih Tseng [email protected] Yu-Shu Chiang [email protected] Ching-Lin Wu [email protected] Hsueh-Chih Chen [email protected]

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Abstract This study is to identify the performance of children with and without ADHD in open-ended and closed-ended creativity assessments, and investigate the moderating effect of medicated and unmedicated Children. The study subjects included third to sixth graders: 43 children with ADHD and 43 typically developing children. The participants with ADHD were those who were identified by local Committees of Identification, Placement and Consultation for Children with Special Needs or those who were diagnosed by medical institutions. Children with ADHD were further divided into medicated (22 participants) and unmedicated groups (21 participants) based on their current medication treatment. This study employed the New Tests of Creative Thinking to gauge the participants’ open-ended creativity, while Remote Associates Test and the Insight Test were used to assess the participants’ closed-ended creativity. Although previous evidence for creativity in children with ADHD have been mixed, this study includes medication as moderation variable and suggests that the performance of unmedicated children with ADHD in the open-ended creativity assessments was better than medicated children with ADHD and typically developing children. The study results can further explore the creativity characteristics of children with ADHD. Key words: Attention Deficit Hyperactivity Disorder, Creativity, Medication treatment of Attention Deficit Hyperactivity Disorder

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1. Introduction As described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), and elaborated by scholars from different disciplines, attention-deficiency/hyperactive disorder (ADHD) is typically characterized by inattention, hyperactivity and impulsivity. People with ADHD are described as frequently switching between activities, daydreaming and having the following struggles: staying focused on one task, paying attention to schoolwork, completing some tasks, getting organized, maintaining work performance, and self-regulating or remembering things. They are also often distracted and can disturb others (Barkley, 1990; Barkley, 2013; Fenollar Cortés, Servera, Becker, & Burns, 2014; Lahey, 1988). Some of the symptoms persist into adulthood, for example, being easily distracted, ―zoning out,‖ frequently switching between activities, and difficulty staying attentive or taking instructions (Millstein, Wilens, Biederman, & Spencer, 1997; Nigg, John, Blaskey, Huang-Pollock, Willicut, Hinshaw, & Pennington, 2002). People with ADHD, in childhood or adulthood, demonstrate symptoms of being easily distracted and frequently switch from one activity to another, and these traits are often associated with creativity. Creative people tend to have diffused attention (Mendelsohn, 1976), and this trait is associated with the characteristics of people with ADHD. Kaufman and Sternberg (2010) concluded that creativity is associated with certain personality traits, including questioning rules and disregarding social conventions. Some highly creative individuals may find it hard to receive approval at school (Gowen, Khatena, & Torrance, 1979). Davis (1992) thought creative individuals should have the personalities of keen awareness, originality, risk-taking, curiosity and attraction to complexity, which are not necessarily all innate characteristics but could be developed abilities (Nie &Zheng, 2005).

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Disinhibition theory explains creativity in relation to cortical activation, and it was found that a high level of creativity is more susceptible to disturbances and shows less-high-intensity inhibitions. Creative people are highly attracted to novel things. From the perspective of neuroscience, disinhibition theory emphasizes the arousal of cortical activities. With an increase in the intensity of cortical arousal, people’s movements become more rigid and less versatile (Martindale, 1999). Researchers using electroencephalography (EEG) indicated that a highly activated cortical system inhibits remote associates thinking, and in turn, a high level of cortical arousal lowered the chance of creativity (James & Robert, 2010). Highly creative people also find it harder to shut out disturbances (Dorfman, Martindale, Gassimova, & Vartanian, 2008; Kwaiatkowaski, Vartanian, & Martindale, 1999; Martindale et al., 1996; Vartanian, Martindale, & Kwiatkowski, 2007). Kwiatkowski et al. (1999) found that highly creative individuals were more responsive to single-goal tasks but were slower than controls in terms of responding to tasks with unclear goals. Based on the hypothesis that highly creative individuals have cognitive inhibition and attention deficiency, a study concluded that creative individuals have higher responsiveness to additional stimuli (Martindale, et al., 1996). In these studies, the creative individuals had more difficulty getting accustomed to the white noises during the tests, produced higher galvanic skin response (GSR), and had higher motivations toward new things. Dorfman, Martindale, Gassimova and Vartanian (2008) reproduced Vartanian, Martindale and Kwiatkowski’s (2007) research and had similar results that showed that creative individuals could deal with intuitive tasks more efficiently, but their responses to tasks while there were disturbances present turned out to be slower than those of the controls. Many researchers of these studies suggested possible correlations between creativity and mental illnesses. Scholars supporting this theory believe that ADHD patients have better divergent thinking (Abraham, 2014; Cramond, 1994; Fugate et al, 2013; White & Shah, 2006; White & Shah, 2011). When having trouble with top-down thinking, an individual may be more impulsive, inattentive and 5

have poor self-control, but these are characteristics associated with creativity. However, some studies have questioned this point (Aliabadi, Davari-Ashtiani, Khademi, & Arabgol, 2016; Healey & Rucklidge, 2005; Healey & Rucklidge, 2006; Healey & Rucklidge, 2008; Tucha, Tucha, Sontag, Stasik, Laufkötter, & Lange; 2011). Are the medications ADHD patients take one of the factors contributing to the inconsistency of the conclusion above? The medications used in the studies on creativity and medications included beta-blockers, caffeine as an ergogenic aid, methylphenidate (MPH, a central nervous system stimulant), etc. Some studies have suggested that medications lower the pursuit of creativity and make people’s responses more uniform (Funk et al., 1993; González - Carpio et al., 2016; Swartwood et al., 2003; Gvirts, Mayseless, Segev, Lewis, Feffer, Barne, & Shamay-Tsoory, 2016), while other studies have suggested that medications increase creative output (Berman et al., 1999; Douglas et al., 1995; Solanto & Wender, 1989). Berman, Douglas and Barr (1999) agreed that the purpose of medications is to increase attention and cognition and should consequently enhance the output of related executive functions, and the view was supported by the results of relevant studies (e.g., Bubnik, Hawk, Pelham, Waxmonsky, & Rosch, 2015; Tannock, Schachar, & Logan, 1995). Douglas, Barr, Desilets and Sherman (1995) also agreed that MPH enhances ADHD patients’ divergent thinking. On the other hand, some studies have found evidence in which medications lowered the fluency and originality in creativity (Funk, Chessare, Weaver, & Exley,1993; González-Carpio Hernández, & Serrano Selva, 2016; Swartwood, Swartwood, & Farrell, 2003). MPH and atomoxetine, a norepinephrine reuptake inhibitor (NRI), are commonly prescribed to ADHD patients in hospitals. They are different in engineering but similar in mechanisms of action and side effects (Kratochvil, Heiligenstein, Dittmann, Spencer, Biederman, Wernicke, & Michelson, 2002). Methylphenidate is a stimulant used to increase the activity of the central nervous system (Fond, Micoulaud-Franchi, Macgregor, Richieri, Miot, Lopez, & Repantis, 2015; Kalil, Gregory, & Makled, 6

2014). Some studies found that inhibitory control in children with ADHD improved under MPH compared to placebo (Schere, Oosterlaan, Swanson, Morein-Zamir, Meiran, Schut, Vlasveld, & Sergeant, 2003), while some studies found that people who took the medications showed increased levels of anxiety (Segev, Gvirts, Strouse, Mayseless, Gelbard, Lewis, & Bloch, 2016). Hsieh and Meng (2010) found evident effects of Ritalin and Concerta on behavioral issues and suggested that there were no distinct differences between the two brands. The major side effects observed were decreased appetite, depression and weight loss, which are similar to the descriptions in the relevant literature. The side effects often lead to parents’ reservations in giving medications to their children. Despite the side effects, there has not been any agreement on how medications affect creativity. In the studies that found ADHD patients’ creativity to be poorer or no different, Funk et al. (1993) ensured that the participants with ADHD took medications when they administered the Torrance Test of Creative Thinking (TTCT); Aliabadi et al. (2016) asked the participants with ADHD to take medications prior to the TTCT; and Healey and Rucklidge (2005) asked ADHD patients not to take medications the day prior to the TTCT. White and Shah (2006), by contrast, eliminated all individuals taking medications in their study and found the participants with ADHD did better in the Unusual Uses Test (UUT) than the control group. Many past studies did not have full control over the medications of the participants with ADHD or whether their conditions on the day of the test required medications. Many of the past studies that found that ADHD patients demonstrated higher creativity did not have specific control over test participants’ medications, while in most of the studies that found ADHD patients’ performance was the same or poorer than that of normal people, the majority of test participants took medications prior to the test or were asked not to take medications on the day of the test. Thus, the issue of inconsistent control over medications must be resolved. In addition, most of the previous studies explored open-ended creativity assessments and remote associates test (RAT) in adults, but none of them investigated the area of insight thinking. Creativity, in 7

addition to divergent thinking, also includes remote associates thinking and closed-ended insight thinking. Discussions of creativity often revolve around Guilford’s Structure of Intellect (Guilford, 1968) and Mednick’s theories (1962). Today, Csikszentmihalyi discusses creativity as a process involving the individual, the field and the domain, which underlines the interaction between creative output and applications of knowledge. Runco (2008) pointed out that in modern days there is an increasing emphasis on the potential for creative thought production. Using creativity or insight thinking as problem-solving skills (Smith & Smith, 2014) involves systematic analysis of problems and insight thinking. Thus, insight thinking is one of the factors in creativity to be discussed. The current study employed the classification scheme by Wakefield (1989) in the exploration of creativity, using different dimensions to measure the creative traits of people with ADHD with open-ended or closed-ended creativity assessments. Current Study. Following the analysis above, in the discussion of the creativity of children with ADHD, the study verified test participants’ medications and incorporated different forms of creativity. Additionally, based on the results of previous studies on adults and children with ADHD, the study has the following two hypotheses: H1: Unmedicated children with ADHD have better performance in open-ended creativity assessments than medicated and typically developing controls. H2: Unmedicated children with ADHD have lower performance in closed-ended creativity assessments than medicated and typically developing controls.

2. Methods 2.1.

Participants A total of 44 students with ADHD from 18 schools participated in this study—41 boys and 3 girls, 8

aged from 8 to 12. Every participant with ADHD and IQs equal to or above 70 was identified by a scale for assessing emotional disturbance (Zheng, 2001), student adaptation questionnaire (Hong, Zhang, Qiu, & Cai, 2004), personality and behavior scale (Lin, 1992), and problem behavior screening scale (Hong, Zhang, Qiu, Cai, & Meng, 2004); was recognized by the Committee of Identification, Placement and Consultation for Children with Special Needs, an organization consisting of scholars, doctors and experts; and received a diagnosis according to DSM-V criteria. The pool of participants included students with diagnosed ADHD and students having hospital-diagnosed ADHD and receiving special education services in an effort to ensure that all participants were within the target group. The study excluded suspected cases without medical diagnoses and individuals who received medical treatments but had not shown any manifestations at school. Among the 44 children diagnosed with ADHD, 22 children were currently taking medications, and 22 children were currently not taking medications. However, we considered that the effects of medications not only occur during the treatment period but also might affect brain development in some way, allowing the residual effects of medications to persist during medication withdrawal. Therefore, we carefully examined the medication history of the 22 currently unmedicated children and found that 21 children had never taken any medication; the other child had taken medications, but they had been discontinued for more than a month. To ensure a valid comparison between the children with and without ADHD, the data for this child and the matched child in the control group were excluded from this study. Therefore, the children in the unmedicated group in this study were all medication naïve. There were no significant differences in gender ratio (χ2(1, N = 43) = .410, p = .607), age (t (41)= 0.184，p = .855), or IQ (t (41)= 1.598，p = .118) between the two groups. All 21 of the unmedicated children had no history of taking medicine because their parents had worried about the side effects, such as poor appetite, weight loss, sleep loss, and agitation. The aforementioned temporarily unmedicated child had become too thin and had been losing sleep at night according to the mother; 9

thus, medication had been stopped. In the medicated group, the parents of the children with ADHD followed their doctors' advice and decided to let the children take medicine that could improve their concentration and learning ability. The medicated group all took medications, including Ritalin, Strattera and Concerta, for one month or more. Regarding the brand of medication, 10 participants took only Concerta, 6 took only Ritalin, 2 took only Strattera, 3 took both Concerta and Ritalin, and one took both Concerta and Strattera. In the process of selecting typically developing children, each participant with ADHD was age-, gender- and academic-achievement (or IQ percentile rank)-matched with a control student. The homeroom teachers of the children with ADHD were asked to recommend students in the same classes with similar levels of performance (N=9). Those without peers participating in the study were selected based on their IQ percentile ranks from the group intelligence test administered at school. The study ruled out children with other disorders, and typically developing children were paired up with ADHD children based on their IQ percentile ranks to eliminate differences in intelligence in the pairs, which resulted in a total of 43 participants: 10 third-graders, 13 fourth-graders, 6 fifth-graders and 14 sixth-graders. There were no significant differences in IQ (F (2, 83) =1.547, p =0.219) among the three groups (medicated and unmedicated children with ADHD and typically developing children). Table 1 shows the grade level, sex, IQ, and medication treatment duration and history for the three groups. Two groups of typically developing children were paired with medicated and unmedicated children with ADHD: Group 1 of the typically developing children was paired with unmedicated children with ADHD, and Group 2 of the typically developing children was paired with medicated children with ADHD. The study was reviewed and approved by the Institution Review Board (IRB) of Taipei Medical University. All participants were informed of the nature of the experiment and provided informed consent before the experiment began. 10

2.2.

Measures The Wechsler Intelligence Scale for Children (WISC) and Raven's Standard Progressive Matrices

Test (SPM) were used as the principal assessment tools. WISC-IV was administered to the children with ADHD and yielded full-scale intelligence quotient (fsiq) percentile ranks; SPM was administered among the typically developing children in the first grade and yielded perceptual reasoning percentile ranks. These results were used as the reference data in the study. The entire assessment process followed the standard operating procedure. After consent forms were received, three tests were administered in 40 minutes to each individual student and in groups before the first class began or during lunch breaks based on students’ needs and medications. Tests were administered in three different orders, a counterbalancing design, to avoid the progressive effect resulting from testing sequences. The assessments also used standardized wording in instructions. It was noted that participants with ADHD, if taking Ritalin, had to take the tests 1-2 hours after taking medications to ensure the effects of the medicine. An examiner was hired to assist with test administration. Open-Ended Assessment. The assessments of divergent thinking partly used the figural version of the New Tests of Creative Thinking (Wu, Chen, Kuo, Lin, Liu & Chen, 1998). The test measured divergent thinking by asking examinees to draw in a 10-minute time frame. From the test, one can analyze examinees’ fluency, flexibility and originality in creativity. The reliability of subscale raters is between .76 and .99, exclusive of differences in word usages. Closed-Ended Creativity Assessments. The assessments of remote associates thinking used the Chinese Word Remote Associates Test for Children (CWRAT-C) to evaluate examinees’ remote associates thinking capacity. CWRAT-C is a closed-ended test designed for third- to sixth-graders (Lo, Yu, Huang, Chen, Shih, & Lin, 2017). The reliability test showed an internal consistency index of .79 and .76 for 11

Forms A and B, respectively. The insight problem-solving process test administered to measure the criterion-related validity showed a moderate positive correlation in effect size (rs = .44, .50). The ―alternate uses of newspapers‖ test showed low to moderate effect size correlations between the discriminant validity and some indicators, while some other indicators had no correlations at all (rs is between approximately -.11 and .38). To maintain consistency throughout the study, only Form A of the two forms of the test was administered. The test had a total score of 20 points, 1 point per question, and was administered in a 15-minute time frame. Insight thinking assessment adopted the Insight Problem Test compiled and designed by Chiu and Chen (2005). The problems in this test mostly matched those listed by Weisberg (2006) for insight thinking research, with 6 types of formal problems. The insight problem-solving test must take into account any item bias as a result of prior knowledge of the problems in the test. Thus, examinees had to perform a self-check to confirm whether they had seen any of the problems before or had acquired the answers. The test, consisting of 6 problems, 1 point per question, with a total of 6 points, was administered in a 10-minute time frame. 2.3.

Procedure The entire assessment process followed the standard operating procedure. After consent forms

were received, three tests were administered in 40 minutes to each individual student and in groups before the first class began or during lunch breaks based on students’ needs and medications. Tests were administered in three different orders, a counterbalancing design, to avoid the progressive effect resulting from testing sequences. The assessments also used standardized wording in instructions. It was noted that participants with ADHD, if taking Ritalin, had to take the tests 1-2 hours after taking medications to ensure the effects of the medicine. An examiner was hired to assist with test administration. The examiner, with an MA in educational psychology, experienced with test administration and currently a schoolteacher, had sufficient knowledge of the purpose, tools and orders 12

of test administration of the study.

3. Results 3.1.

Descriptive results in the Open-Ended Assessment In the fluency results, the one-way ANOVA results of the four groups, homogeneous as

determined by the test for homogeneity of variance, showed significant differences in fluency (F(3,82) = 6.040, MSE=23.507, p=.001, η2=.181). A comparison of the four groups showed that the mean fluency of the unmedicated group (M=13.240) was higher than that of the medicated group (M =7.680), Typically Developing Group 1 (M =8.330) and Typically Developing Group 2 (M =8.270). The other three groups did not show significant differences. According to the analysis method of Cohen (1988), the effect size, .181, was a small effect. As shown in Tables 3 and 4, with intelligence as a control variable, the analyses of the two groups of children with ADHD and the two groups of typically developing children showed significant differences in the fluency results of the two ADHD groups (F(1,40)=9.480, MSE=22.835, p=.004, η2P=.192), a higher adjusted mean in the unmedicated group (M =12.762 a) than in the medicated group (M =8.136a), and no differences between the two typically developing groups (F(1,40) =.031, MSE=17.669, p=.860, η2P = .001). In the flexibility results, the one-way ANOVA results of the four groups, homogeneous as determined by the test for the homogeneity of variance, showed significant differences in flexibility (F(3,82) =4.300, MSE= 9.869, p =.007, η2= .136). A comparison of the four groups showed that the mean flexibility of the unmedicated group (M =8.330) was higher than that of the medicated group (M =4.950), Typically Developing Group 1 (M =6.330) and Typically Developing Group 2 (M =6.050). No significant differences were shown among the other three groups. According to the analysis method of Cohen (1988), the effect size, .136, was a small effect. With intelligence as a control variable, the 13

analyses of the two groups of children with ADHD and the two groups of typically developing children, as shown in Tables 3 and 4, showed significant differences in the flexibility results of the two ADHD groups (F(1,40)= 11.507, MSE=7.050, p=.000, η2P=.365), a higher adjusted mean in the unmedicated group (M =8.088 a) than in the medicated group (M =5.189 a), and no differences between the two typically developing groups (F(1,40) =.165, MSE=9.291, p =.686, η2P=.004). In the originality results, the one-way ANOVA results of the four groups, homogeneous as determined by the test for the homogeneity of variance, showed significant differences in originality (F(3,82) =14.188, MSE=26.707, p=.000, η2=.342). A comparison of the four groups showed that the mean flexibility of the unmedicated group (M =14.900) was higher than that of the medicated group (M =7.230), Typically Developing Group 1 (M =6.810) and Typically Developing Group 2 (M =5.640). The other three groups did not show significant differences. According to the analysis method of Cohen (1988), the effect size, .342, was a medium effect. With intelligence as a control variable, the analyses of the two groups of children with ADHD and the two groups of typically developing children, as shown in Tables 3 and 4, showed significant differences in the originality results of the two ADHD groups (F(1,40) =11.548, MSE=30.635, p=.000, η2P =.366), a higher adjusted mean in the unmedicated group (M =14.569 a) than in the medicated group (M =7.548 a), and no differences between the two typically developing groups (F(1,40) =1.415, MSE=19.268, p =.241, η2P =.034). 3.2.

Descriptive results in the Closed-Ended Assessment

The Remote Associate Thinking test results, as shown in Table 2, were not significantly different among the four groups (F(3,82) =2.045, MSE=16.265, p=.114, η2=.070). Further analyses with intelligence as a control variable found no differences in the RAT test results of both the ADHD groups (F(1,40) =0.061, MSE=11.183, p=.807, η2P= .002) and the two typically developing groups (F(1,40) =0.133, MSE=12.282, p=.718, η2P =.003). 14

The Insight Test results, as shown in Table 2, were not significantly different among the four groups (F(3,82) =0.007, MSE=1.192, p =.999, η2 =.002). With intelligence as a control variable, the analyses of the two groups of children with ADHD and the two groups of typically developing children did not show significant differences in the insight test results of the two ADHD groups (F(1,40) =0.674, MSE=1.084, p=.417, η2P =.017) or in those of the two typically developing groups (F(1,40) =0.001, MSE=0.926, p=.975, η2P =.000).

4. Discussion In terms of creativity, this study pioneered using the insight test to assess closed-ended creativity in children with ADHD and found that unmedicated children with ADHD did have better performance in open-ended creativity. On the other hand, no differentiations were found in the closed-ended creativity assessments. These results not only supported the disinhibition hypothesis but also suggested that creativity is domain-specific. This study measured the performance of its participants—medicated children with ADHD, unmedicated children with ADHD and typically developing children—instead of considering only the varied performance before and after medications were taken. In addition, it was confirmed that unmedicated children with ADHD had an unusual advantage in divergent thinking in relation to open-ended creativity. Last, this study provided evidence for the impact of medication treatments on children with ADHD, but the impact did not involve causal inference. The results supported Hypothesis 1. The unmedicated group had better performance in all three aspects of fluency, flexibility and originality than the medicated and typically developing groups in the divergent thinking assessment in the open-ended creativity category, while the medicated and typically developing groups did not show differences from each other. ADHD patients are easily distracted and tend to switch between tasks, which could be associated with the characteristics of highly creative 15

individuals who have diffused attention and tend to question school rules and refuse to follow social conventions. The study results indeed demonstrated the entwined correlations. The current study reached a conclusion similar to previous studies. The findings in Cramond’s research (1994) suggested that children with ADHD had superior creativity to their peers. Fugate et al. (2013) had the same findings in gifted children with ADHD. The current study further confirmed that unmedicated children with ADHD had advantages in divergent thinking, showing better performance in fluency, flexibility and originality in creativity. By contrast, medicated children with ADHD showed lower fluency and originality than unmedicated children with ADHD and typically developing controls (Funk et al., 1993; González-Carpio Hernández, & Serrano Selva, 2016; Swartwood, et al., 2003). In addition to this finding, it was found in this study that even flexibility was affected. In their investigation on participants before and after taking medications, Swartwood et al. (2003) found that medicated individuals showed less complex creative performance than unmedicated individuals. González-Carpio Hernández et al. (2016) also found that medicated students demonstrated lower fluency and originality in creativity than unmedicated students. In this study, investigations were conducted on different groups of participants and reached a similar conclusion, indicating differences between the creative performance of mediated and unmedicated individuals. Previous studies showed that ADHD patients demonstrated the same or even poorer creativity than typically developing children (Aliabadi et al., 2016; Funk et al., 1993; Healey et al., 2006). With a closer look, it was found that the two groups of participants in the study by Funk et al. (1993) were only medicated individuals with ADHD and typically developing individuals, and the study concluded there were no significant differences between the two groups. This current study had similar results but found that the medicated group and the typically developing group did not demonstrate any differences 16

in divergent thinking. However, this does not mean that unmedicated children with ADHD do not have advantages in divergent thinking. While the participants in the studies by Healy et al. (2016) and Aliabadi (2016) were asked not to take medications on the day of assessments, it was still impossible to verify the effects that medications normally had on the participants and their experiences with medication treatments. This issue remains to be resolved in future studies, but the current study had further findings after sorting through participants’ conditions after medications. The results of the study did not support Hypothesis 2. The four groups did not show any differences in the results of the RAT test and insight test that consisted of closed-ended creativity assessments. Previous studies indicated that the divergent thinking of both children and adults with ADHD was better than their convergent thinking (Abraham, 2014; Cramond, 1994; Fugate et al., 2013; White & Shah, 2006; White & Shah, 2011), and this finding is similar to what was found in the current study: the unmedicated group outperformed the typically developing and medicated groups in divergent thinking, but no differences were shown among the three groups in the RAT test and the insight test. Unmedicated children with ADHD had specificity in their creative performance. In contrast to previous studies, the current study did not find either group with ADHD to be inferior to the typically developing group in RAT. The study on adulthood ADHD by White and Shah (2006) found that unmedicated ADHD patients had lower performance in RAT, whereas Tucha et al. (2011) found that adults’ convergent thinking improved with medication treatments. The current study, however, did not find any difference among the children, and this discrepancy was speculated to originate from the variations in tests or in age (adults and children) in different studies. This remains a topic for future exploration. In conclusion, in addition to the differences in assessment tools and participant age, differentiation of medicated and unmedicated participants can be a cause of the different outcomes. Most of the 17

findings in previous studies are supported by the results of the current study. There are also traces to follow for the two opposite views on divergent thinking. The sharp distinction between the two conclusions could have come from the same speculation that children with ADHD have advantages over their peers in terms of some creative potentials. These results could be linked to the traits of children with ADHD—distraction and the tendency to switch from task to task. Overall, as shown in the study, the unmedicated children with ADHD had potential advantages in divergent thinking; no differences were shown among the unmedicated, medicated and typically developing groups in the RAT test and the insight test; the medicated group had slightly lower results on the RAT test than the typically developing group; and the analyses of the results in all three tests showed no significant differences between the medicated group and the typically developing group. Limitations The sample size of the study is relatively small (N=86) and is limited by the passiveness of whether participants took medications. The study recruited participants who met the assessment requirements. However, the study could group the participants only based on whether they took medications without differentiating medication efficacies and other effects; consequently, the effects of the medications were not identified. Additionally, the participants in the study, both children with ADHD and typically developing children, were elementary students at the time and had taken various intelligence tests at school. A group test was out of the question. The study could compare only the results of the participants who took the same types of intelligence tests. Despite the limitations, the study still made some breakthrough in some blind spots in this research area by confirming that medication as a variable did make a difference. This could be explored in more sophisticated discussions in later studies.

5. Conclusion 18

This study provided evidence for the advantages of the unmedicated children with ADHD in divergent thinking over the medicated group and the typically developing group in terms of their performance on tests of fluency, flexibility and originality in creativity. That means that the unmedicated group of children with ADHD indeed stood out in the divergent thinking assessment in relation to open-ended creativity and possibly has more promising potential in the field of art.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgments This work was financially supported by the grant MOST-108-2634-F-002-022 from Ministry of Science and Technology of Taiwan, MOST AI Biomedical Research Center, and the ―Institute for Research Excellence in Learning Sciences‖ and ―Chinese Language and Technology Center‖ of National Taiwan Normal University (NTNU) from The Featured Areas Research Center Program within the framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan.

References Ahmann, P. A., Theye, F. W., Berg, R., Linquist, A. J., Van Erem, A. J., & Campbell, L. R. (2001). Placebo-controlled evaluation of amphetamine mixture—dextroamphetamine salts and amphetamine salts (Adderall): efficacy rate and side effects. Pediatrics, 107(1), e10-e10. Ahmann, P. A., Waltonen, S. J., Theye, F. W., Olson, K. A., & Van Erem, A. J. (1993). Placebocontrolled evaluation of Ritalin side effects. Pediatrics, 91(6), 1101-1106. Aliabadi, B., Davari-Ashtiani, R., Khademi, M., & Arabgol, F. (2016). Comparison of Creativity 19

between Children with and without Attention Deficit Hyperactivity Disorder: A Case-Control Study. Iranian Journal of Psychiatry, 11(2), 99. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: Author. Banaschewski, T., Coghill, D., Santosh, P., Zuddas, A., Asherson, P., Buitelaar, J., ... & Sergeant, J. (2006). Long-acting medications for the hyperkinetic disorders. European Child & Adolescent Psychiatry, 15(8), 476-495. Banaschewski, Tobias & Coghill, David & Santosh, Paramala & Zuddas, Alessandro & Asherson, Philip & Buitelaar, Jan & Danckaerts, Marina & Döpfner, Manfred & V Faraone, Stephen & Rothenberger, Aribert & Sergeant, Joseph & Steinhausen, Hans-Christoph & J.S. Sonuga-Barke, Edmund & Taylor, Eric. (2007). Long-acting medications for the hyperkinetic disorders: A systematic review and European treatment guideline. European child & adolescent psychiatry. 15. 476-95. Barkley, McMurray, Edelbrock, & Robbins, (1990). Side effects of methylphenidate in children with attention deficit hyperactivity disorder: a systemic, placebo-controlled evaluation. Pediatrics, 86(2), 184-192. Barkley, R. A. (2013). Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: Executive functioning, impairment, and comorbidity. Journal of Clinical Child & Adolescent Psychology, 42, 161-173. Berman, T., Douglas, V. I., & Barr, R. G. (1999). Effects of methylphenidate on complex cognitive processing in Attention–Deficit/ Hyperactivity Disorder. Journal of Abnormal Psychology, 108, 90– 105. Bubnik, M. G., Hawk, L. W., Pelham, W. E., Waxmonsky, J. G., & Rosch, K. S. (2015). Reinforcement Enhances Vigilance Among Children With ADHD: Comparisons to Typically Developing 20

Children and to the Effects of Methylphenidate. Journal of Abnormal Child Psychology, 43(1), 149–161. Cramond, B. (1994). The relationship between attention–deficit hyperactivity disorder and creativity. Paper presented at the meeting of the American Educational Research Association. New Orleans, LA. Csikszentmihalyi, M., & Wolfe, R. (2014). New conceptions and research approaches to creativity: Implications of a systems perspective for creativity in education. In The systems model of creativity (pp. 161-184). Berlin: Springer Netherlands. Dorfman, L., Martindale, C., Gassimova, V., & Vartanian, O. (2008). Creativity and speed of information processing: A double dissociation involving elementary versus inhibitory cognitive tasks. Personality and Individual Differences, 44(6), 1382-1390. Douglas, V.I., Barr, R.G., Desilets, J., & Sherman, E. (1995). Do high doses of stimulants impair flexible thinking in attention-deficit hyperactivity disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 34, 877–885. Efron, D., Jarman, F., & Barker, M. (1997). Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: a double-blind, crossover trial. Pediatrics, 100(4), 662-666. Fenollar Cortés, J., Servera, M., Becker, S. P., & Burns, G. L. (2014). External validity of ADHD inattention and sluggish cognitive tempo dimensions in Spanish children with ADHD. Journal of attention disorders, 21(8), 655-666. Fond, G., Micoulaud-Franchi, J. A., Macgregor, A., Richieri, R., Miot, S., Lopez, R., & Repantis, D. (2015). Neuroenhancement in healthy adults, part I: pharmaceutical cognitive enhancement: a systematic review. Journal of Clinical Research & Bioethics, 6(2), 1-15. Fugate, C. M., Zentall, S. S., & Gentry, M. (2013). Creativity and working memory in gifted students 21

with and without characteristics of Attention Deficit Hyperactive Disorder lifting the mask. Gifted Child Quarterly, 57(4), 234-246. Funk, J. B., Chessare, J. B., Weaver, M. T., & Exley, A. R. (1993). Attention deficit hyperactivity disorder, creativity, and the effects of methylphenidate. Pediatrics, 91(4), 816-819. González-Carpio Hernández, G., & Serrano Selva, J. P. (2016). Medication and creativity in attention deficit hyperactivity disorder(ADHD). Psicothema,28(1), 20-25. Guilford, J. P. (1968). Intelligence, creativity, and their educational implications. San Diego: RR Knapp. Gvirts, H. Z., Mayseless, N., Segev, A., Lewis, D. Y., Feffer, K., Barnea, Y., & Shamay-Tsoory, S. G. (2016). Novelty-seeking trait predicts the effect of methylphenidate on creativity. Journal of Psychopharmacology, 31(5), 599-605. Healey, D. M., & Rucklidge, J. J. (2008). The relationship between ADHD and creativity. The ADHD Report, 16(3), 1-5. Healey, D., & Rucklidge, J. J. (2005). An exploration into the creative abilities of children with ADHD. Journal of Attention disorders, 8(3), 88-95. Healey, D., & Rucklidge, J. J. (2006). An investigation into the relationship among ADHD symptomatology, creativity, and neuropsychological functioning in children. Child Neuropsychology, 12(6), 421-438. Hernández. G. G. & Selva. J. P. S. (2016). Medication and creativity in Attention Deficit Hyperactivity Disorder (ADHD). Psicothema, 28(1), 20-25. Hong, L. Y., Zhang, Y. W., Qiu, Y. N., & Cai, M. F. (2004). Student Adaptation Questionnaire. Taipei, Taiwan: Ministry of Education. Hong, L. Y., Zhang, Y. W., Qiu, Y. N., Cai, M. F., & Meng Y. R. (2004). Problem Behavior Screening Scale. Taipei, Taiwan: Ministry of Education. 22

Hsieh, C. H.& Meng, Y. R. (2010). The Survey of Medication Conditions of Attention Deficit Hyperactivity Disorder Students in Elementary Schools. Special Education Forum, 9, 47-62. Kalil, K. M., Gregory, J., & Makled, M. (2014). Systematic review of risk factors associated with attention deficit hyperactivity disorder. Journal of Analytical Research in Clinical Medicine, 2, 159-166. Kaufman, J. C., & Sternberg, R. J. (Eds.). (2010). The Cambridge handbook of creativity. New York: Cambridge University Press. Kratochvil, C. J., Heiligenstein, J. H., Dittmann, R., Spencer, T. J., Biederman, J., Wernicke, J., & Michelson, D. (2002). Atomoxetine and methylphenidate treatment in children with ADHD: a prospective, randomized, open-label trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41(7), 776-784. Kwiatkowski, J., Vartanian, O., & Martindale, C. (1999). Creativity and speed of mental processing. Empirical Studies of the Arts, 17(2), 187-196. Lahey, B. B., Pelham, W. E., Schaughency, E. A., Atkins, M. S., Murphy, H. A., Hynd, G., & LorysVernon, A. (1988). Dimensions and types of attention deficit disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 27(3), 330-335. Lo, P. W., Yu, S. H., Huang, P. S., Chen, H. C., Shih, Y. L.& Lin, W. L.(2017). Assessing Children’s Closed-ended Creative Potential: The Development of Chinese Word Remote Associates Test for Children. Psychological Testing, 4(3), 237-258. Martindale, C. (1999). Biological bases of creativity. Handbook of creativity, 2, 137-152. Martindale, C., Anderson, K., Moore, K., & West, A. N. (1996). Creativity, oversensitivity, and rate of habituation. Personality and individual differences, 20(4), 423-427. Mednick, S. (1962). The associative basis of the creative process. Psychological review, 69(3), 220-232. Mendelsohn, G. A. (1976). Associative and attentional processes in creative performance. Journal 23

of Personality, 44, 341–369. Millstein, R. B., Wilens, T. E., Biederman, J., & Spencer, T. J. (1997). Presenting ADHD symptoms and subtypes in clinically referred adults with ADHD. Journal of Attention Disorders, 2(3), 159-166. Nie, Y. G., & Zheng, X. (2005). A study on the developmental characteristics of children’s and adolescent’s creative personality. Psychological Science, 2, 356–361. Nigg, J. T., John, O. P., Blaskey, L. G., Huang-Pollock, C. L., Willicut, E. G., Hinshaw, S. P., & Pennington, B. (2002). Big five dimensions and ADHD symptoms: links between personality traits and clinical symptoms. Journal of Personality and Social Psychology, 83(2), 451-469. Runco, M. A. (2008). Creativity and education. New Horizons in Education, 56, 107-115.\ Scheres, A., Oosterlaan, J., Swanson, J., Morein-Zamir, S., Meiran, N., Schut, H., Vlasveld, L., & Sergeant, J. A. (2003). The effect of methylphenidate on three forms of response inhibition in boys with AD/HD. Journal of Abnormal Child Psychology, 31(1), 105–120. Segev, A., Gvirts, H. Z., Strouse, K., Mayseless, N., Gelbard, H., Lewis, Y. D., & Bloch, Y. (2016). A possible effect of methylphenidate on state anxiety: A single dose, placebo controlled, crossover study in a control group. Psychiatry Research, 241, 232-235. Solanto, M. V., & Wender, E. H. (1989). Does methylphenidate constrict cognitive functioning? Journal of the American Academy of Child & Adolescent Psychiatry, 28(6), 897-902. Swartwood, M. O., Swartwood, J. N., & Farrell, J. (2003). Stimulant treatment of ADHD: effects on creativity and flexibility in problem solving. Creativity Research Journal, 15(4), 417-419. Tai, L. X. (1992). Personality and Behavior Scale. Taipei, Taiwan: Department of Special Education, National Taiwan Normal University. Tannock, R., Schachar, R., & Logan, G. (1995) Methylphenidate, and cognitive flexibility: Dissociated dose effects in hyperactive children. Journal of Abnormal Child Psychology, 23, 235-267. 24

Vartanian, O., Martindale, C., & Kwiatkowski, J. (2007). Creative potential, attention, and speed of information processing. Personality and Individual Differences, 43(6), 1470-1480. Waddell, C. (1998). Creativity and mental illness: is there a link? The Canadian Journal of Psychiatry, 43(2), 166-172. Wakefield, J. F. (1989). Creativity and cognition some implications for arts education. Creativity Research Journal, 2(1-2), 51-63. Weisberg, R. W. (2006). Creativity: Understanding innovation in problem solving, science, invention, and the arts. New Jersey: John Wiley & Sons. White, H. A., & Shah, P. (2006). Uninhibited imaginations: creativity in adults with attentiondeficit/hyperactivity disorder. Personality and Individual Differences, 40(6), 1121-1131. White, H. A., & Shah, P. (2011). Creative style and achievement in adults with attentiondeficit/hyperactivity disorder. Personality and Individual Differences, 50(5), 673-677. Wu, J. J., Chen, F. Y., Kuo, C. C., Lin, W. W., Lau, S. H., & Chen, Y. H. (1998). New test of creative thinking. Taipei, Taiwan: Ministry of Education. Zheng L. Y. (2001). Scale for Assessing Emotional Disturbance. Taipei, Taiwan: Psychology Publishing.

25

Table 1 The grade, sex, IQ, medicine treatment duration and history for medicated and unmedicated children with ADHD and typically developing children Medicated Children Unmedicated Children Typically Developing with ADHD(n=22) with ADHD(n=21) Children (n=43) Grade 4.62(1.07) 4.50(1.30) 4.56(1.18) Sex (% Female)

4.55%

9.52%

6.98%

IQ (in percentile rank)

39.14 (29.06)

47.81 (27.10)

52.95 (31.70)

Medicine treatment duration

Longer than 1 month.

Never took medicine

Never took medicine.

Medicine treatment history

10 participants only took Concerta, 6 only took Ritalin, 2 only took Strattera, 3 took both Concerta and Ritalin, and one took both Concerta and Strattera.

N/A

N/A

Table 2 One-Way ANOVA Results of All Four Groups ADHD Unmedicated M Fluency

13.240

SD

Typically Developing Medicated M

5.108 7.680

Group 1

Group 2

SD

M

SD

5.075

8.330

5.247 8.270

26

M

SD

3.869

F 6.040

p

.001

η2 .181

Flexibility

8.330

2.781 4.950

2.820

6.330

3.903 6.050

2.952

4.300

.007

.136

Originality

14.900

5.665 7.230

5.597

6.810

4.986 5.640

4.327

14.188

.000

.342

Remote Associates

6.000

3.715 4.950

4.705

7.480

4.262 7.500

3.306

2.045

.114

.070

Insight Thinking

0.710

0.902 0.730

1.352

0.710

1.056 0.680

0.995

0.007

.999

.002

Table 3 One-Way ANCOVA Results of the ADHD Group with Intelligence as a Control Variable ADHD Medicated

Unmedicated Intelligence (WISC-IV)

Fluency Flexibility

100.29

Originality Remote Associates

F

p

η2

8.136 a

9.480

.004

.192

8.088 a

5.189 a

11.507

.000

.365

14.569 a

7.548 a

11.548

.000

.366

5.332 a

5.592 a

0.061

.807

.002

0.583 a

0.852 a

0.674

.417

.017

Adjusted M

Intelligence (WISC-IV)

92.95

12.762 a

Adjusted M

Insight Thinking

Table 4 One-Way ANCOVA Results of the Typically Developing Group with Intelligence as a Control Variable Typically Developing Intelligence (CPM)

Fluency Flexibility Originality Remote Associates Insight Thinking

25.86

Adjusted M

8.297 a

Intelligence (CPM)

25.71

a

6.254 6.894 a 7.482 a 0.680 a

F

p

η2

8.070 a

0.031

.860

.001

a

0.165 1.415 0.133 0.001

.686 .241 .718 .975

.004 .034 .003

Adjusted M

5.876 5.301 a 7.448 a 0.573 a

27

.000