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Predicting stimulant effectiveness in hyperactive children with a repeatable neuropsychological battery: A preliminary study
Prog . Amro-Psychopharmacol. Pergamon Press Ltd. 1981.
vo1.5, pp. 65-68 Printed in Great Britain.
PREDICTING CHILDR.BN
0364-7722/81/0301-0065.$05.00/O
STIMULANT BPPEcTM?lNBss IN HYPmAcTIvB WITH A REPEATABLE NEUROPSYCHOLOGICAL BAlTERYz A PRELIMIN ABY STUDY
BARRY E. GOLINKO, PHILLIP Lafayette
M. RENNICK AND RONALD F. LEWIS
Clinic/Wayne Detroit,
(Final
form,
State Mi.
University
USA
November
1980)
Abstract 1.
A double blind assessment of change on neuropsychological tests was used to determine whether psychostimlant medication would improve a particular hyperactive child's performance on tasks requiring attention and learning.
2.
Thirteen hyperactive children perceptual-motor tasks under sulfate; high dose; placebo.
3.
A ranking system was used to determine the comparative efficacy of doses in term overall performance on the battery. Results showed that d-amphetamine was more effective than placebo for 11 of the 13 children.
4.
The advantages of the assessment method for the physician, in terms of titrating quickly and in continuing to monitor dose effectiveness in long-term follow-up, discussed.
Keywords: battery
prediction,
were tested on a repeatable battery of cognitiveeach of three conditions: low dose of dextroamphetamlne
dextroamphetamine,
hyperactive
children,
repeatable
of
doses were
neuropsychology
Introduction In prescribing stimulant medication for hyperactive children, it is useful for the physician to have a predictor of drug effectiveness prior to an extended clinical trial. Most objective measures devised for this purpose, viz., electroencephalographic (Satterfield et al., 1972), electrophysiological (Knapp et al., 1973), behavioral (Barcai, 1971). are not widely used clinically due to practical considerations. Biochemical procedures have not been successful either, since investigators have not been able to study brain monoamine levels in hyperactive children (Sroufe, 1975). Given findings indicating that the performance of hyperactive children on cognitive tasks is consistently affected by single doses of stimulant medication (Swanson and Kinsbourne, 1976), the current authors were encouraged to develop a behavioral--pharmacological procedure utilizing a Repeatable Cognitive-Perceptual-Motor (RCPM) neuropsychological test battery to predict response to stimulant medication. This preliminary study demonstrates the sensitivity of the battery to high and low doses of dextroamphetamine sulfate (Dexedrine) relative to placebo in hyperactive children who are known positive responders to stimulant medication. Since a control group of hyperactive children who do not improve under stimulant medication was not available, the study results have no bearing on the predictive validity of the battery.
66
B.
E.
Golinko
6 L itl.
Methods Subjects Thirteen children, previously diagnosed as hyperactive criteria (Golinko, 1978), who (according to parent and treated with stimulant medication, served as subjects. 3 females was 8 years, 10 months, and their mean WISC-R Caucasian except for one black male.
according to detailed and quantified teacher reports) were successfully The mean age of the 10 males and All children were IQ was 103.
Procedure The tasks chosen (c-f., Table 1) measure functions which hyperactive children are known to improve on when given stimulants (Bradley, 1937), viz., attention span, sustained concentration, and visual-motor coordination. The tasks also sample more complex skills, including language usage and visuo-spatial memory. Prior studies using the RCPM have shown that it is sensitive to the effects of psychoactive substances (summarized in Lewis and Rennick. 1979).
Table Subtests
of
the
Repeatable, used
in
Cognitive-Perceptual-Motor the present study
Subtest A.
B.
C. D. E.
1
Dependent
Visual Discrimination 1. Visual Search (VISS) Critical Flicker Fusion (CFF) 2. Perceptual-Motor Skills Keyed Pegboard (PEGS) 3. 4. Trails B/Color FOI-D (TR/CF)b 5. Digit Symbol/Coding (D+ISY/COD)c 6. Reaction Time (RTME) Immediate Memory and Attention Digit Span (DISP) 7. Language Skills Color Naming (CRAM) 8. Vigilance Discriminant Reaction Time 9. @MT)
total total time total total time
Battery
Measure(s)
time errors
in
minutes
in
seconds for each hand time in seconds; errors number of correct responses in milliseconds
Total
number
total
time
time
(RCPM)a
in
of in
digits seconds;
errors
in
naming
milliseconds
a Descriptions of RCPM subtests, mental studies, are presented b Color Form is the alternate
in
instructions Lewis and
form
of
of
Digit
for Rennick
Trails
administration, (1979).
and
data
B for
children
under
9 years.
for
children
under
8 years.
from
experi-
C
Coding
is
the
alternate
form
To minimize practice effects baseline testings (drug-free) to determine the effectiveness
Symbol
on the battery, the paradigm calls for on the RCPM, followed one week later by of d-amphetamine compared to placebo.
A double-blind crossover comparison of placebo is designed for each child. The recommendation for a starting dose for a the low dose. Before testing there is a reach peak blood levels. Testing sessions Wednesday, and Friday, allowing one drug-free
three testing
initial under
doses
two dosages (low and high) of d-amphetamine and low dose of d-amphetamine represents a physician's particular child, and the high dose is double one-hour waiting period to permit the dose to (lasting about one hour) take place on Monday, day between sessions.
Stimulant
Data
effectiveness
in
hyperactive
children
67
analysis
Analysis pre-determined procedure compared,
of
RCPM test data is performed for each child individually criteria of change in performance on RCPM subtests is a two-stage ranking system wherein scores under dose first for each RCPM subtest, and then for all subtests
and for all conditions combined.
uses the children. are
same The
For each subtest, a minimum criterion (established from prior clinical use of the RCPM) is set which represents a minimum difference in scores necessary to conclude that one dose is more effective than another. These criteria of change are used to determine the best, middle, and worst performance on each subtest across dose conditions for each child. Thus, the best score three scores for each child are compared with one another for each subtest: is ranked as 1, the middle score as 2, the worst score as 3. A summary score, computed performance across all nine summary score for a condition dose condition. The criterion points since this requires scores on at least four of
by summing the ranks within each dose condition, reflects subtests under each dose condition. Accordingly, a lower reflects better overall performance on the battery under of "significant difference" in summary scores is set at that performance on the more effective dose reflects better the subtests.
that 3
The summary score for the placebo day (P) is first compared to that for the low dose day If the difference between P and L is greater than or equal to criterion, then the low CL). dose is considered effective. The same 3 point criterion and comparison procedures with placebo are used to determine the effectiveness of the high dose.
Results This type of analysis revealed thdt d-amphetamine (either or both dosages) dose was effective; for the other 10
11 of the 13 compared to children, both
Discussion
and
children placebo. doses
(85%) performed For one child, were effective.
Test data could also provide useful information strengths and weaknesses in RCPII measured abilities. samples diverse abilities it is not only a source but also a means of monitoring progress in specific attempted.
the
under high
Conclusion
While the sensitivity of the RCPM to stimulant effects in hyperactive shown, demonstration of its ability to predict long-term changes in awaits utilization of a systematic follow-up to establish criterion the RCPM could provide responders and non-responders. Potentially, of two doses of stimulants information in determining which, if either, benefit a child, prior to the routine administration of drug. This the physician would expedite treatment because it would provide direct medication effectiveness. Since measures used are repeatable, the procedure been on a maintenance dose for shortor long-term efficacy. This procedure, which investigates drug from the present study.
better only
may be periods tolerance
to
children has been cognition and behavior groups of stimulant empirical, objective is likely to immediate feedback to evidence of
performed after the to determine continued was employed with
child
has dose 6 children
the teacher concerning the child's Because the RCPM is repeatable and of pertinent remedial recommendations areas in which remediation has been
B.
E.
Golinko
et
68
al.
Acknowledgements
We thank the Lafayette Sandra Maria Forbes for
Clinic typing
staff for their help the final manuscript.
in
conducting
this
study
and
Ma.
References BARCAI, A. (1971). Predicting the response of children The clinical problems to dextroamphetamine sulfate. 47: 73-80. The behavior of children receiving BGLEY, C. (1937). 577-585.
with learning interview and benzedrine.
and behavior the finger Amer.
J.
twitch
Psych.
test. -94:
COLINKO, B.E. (1978). Hyperactivity: Operationalization of traits using a structured behavioral interview--a pilot study. J. Ped. Psych. 1: 35-44. Predicting amphetamine KNOPP, w., ARNOLD, L.E., ANDRAS, R.L. and SMELTZER, D.J. (1973). response in hyperkinetic children by electronic pupillography. Pharmakopsych. Neuropsycho. 5: X8-166. LEWIS, R.F. and RENNICK, P.M. (1979). Manual for the Repeatable Cognitive-Perceptual-Motor Battery. Axon, Grosse Pointe, Michigan. LESSER, L.I. and PODOSIN, R.L. (1972). Physiological SATTERFIELD, J.H., CANTWELL, D.P., 1418-1424. studies of the hyperkinetic child--I. Amer. J. Psych. 128: Drug treatment of children with behxor problems. In Review of SROUFE, A.L. (1975). University of Chicago Press, Chicago. Child Development and Research, F. Horowitz (ed), SWANSON, J.M. and KINSBOURNE, M. (1976). Stimulant related state-dependent learning in hyperactive children. Science. 1354-1357. -192: Inquiries
and
reprint
requests
should
Barry E. Golinko, Ph.D. The Brookdale Hospital Medical Center Dept. of Pediatrics, Comp Care'Program 9620 Church Avenue Brooklyn, New York 11212 USA
be
addressed
to:
vo1.5, pp. 65-68 Printed in Great Britain.
PREDICTING CHILDR.BN
0364-7722/81/0301-0065.$05.00/O
STIMULANT BPPEcTM?lNBss IN HYPmAcTIvB WITH A REPEATABLE NEUROPSYCHOLOGICAL BAlTERYz A PRELIMIN ABY STUDY
BARRY E. GOLINKO, PHILLIP Lafayette
M. RENNICK AND RONALD F. LEWIS
Clinic/Wayne Detroit,
(Final
form,
State Mi.
University
USA
November
1980)
Abstract 1.
A double blind assessment of change on neuropsychological tests was used to determine whether psychostimlant medication would improve a particular hyperactive child's performance on tasks requiring attention and learning.
2.
Thirteen hyperactive children perceptual-motor tasks under sulfate; high dose; placebo.
3.
A ranking system was used to determine the comparative efficacy of doses in term overall performance on the battery. Results showed that d-amphetamine was more effective than placebo for 11 of the 13 children.
4.
The advantages of the assessment method for the physician, in terms of titrating quickly and in continuing to monitor dose effectiveness in long-term follow-up, discussed.
Keywords: battery
prediction,
were tested on a repeatable battery of cognitiveeach of three conditions: low dose of dextroamphetamlne
dextroamphetamine,
hyperactive
children,
repeatable
of
doses were
neuropsychology
Introduction In prescribing stimulant medication for hyperactive children, it is useful for the physician to have a predictor of drug effectiveness prior to an extended clinical trial. Most objective measures devised for this purpose, viz., electroencephalographic (Satterfield et al., 1972), electrophysiological (Knapp et al., 1973), behavioral (Barcai, 1971). are not widely used clinically due to practical considerations. Biochemical procedures have not been successful either, since investigators have not been able to study brain monoamine levels in hyperactive children (Sroufe, 1975). Given findings indicating that the performance of hyperactive children on cognitive tasks is consistently affected by single doses of stimulant medication (Swanson and Kinsbourne, 1976), the current authors were encouraged to develop a behavioral--pharmacological procedure utilizing a Repeatable Cognitive-Perceptual-Motor (RCPM) neuropsychological test battery to predict response to stimulant medication. This preliminary study demonstrates the sensitivity of the battery to high and low doses of dextroamphetamine sulfate (Dexedrine) relative to placebo in hyperactive children who are known positive responders to stimulant medication. Since a control group of hyperactive children who do not improve under stimulant medication was not available, the study results have no bearing on the predictive validity of the battery.
66
B.
E.
Golinko
6 L itl.
Methods Subjects Thirteen children, previously diagnosed as hyperactive criteria (Golinko, 1978), who (according to parent and treated with stimulant medication, served as subjects. 3 females was 8 years, 10 months, and their mean WISC-R Caucasian except for one black male.
according to detailed and quantified teacher reports) were successfully The mean age of the 10 males and All children were IQ was 103.
Procedure The tasks chosen (c-f., Table 1) measure functions which hyperactive children are known to improve on when given stimulants (Bradley, 1937), viz., attention span, sustained concentration, and visual-motor coordination. The tasks also sample more complex skills, including language usage and visuo-spatial memory. Prior studies using the RCPM have shown that it is sensitive to the effects of psychoactive substances (summarized in Lewis and Rennick. 1979).
Table Subtests
of
the
Repeatable, used
in
Cognitive-Perceptual-Motor the present study
Subtest A.
B.
C. D. E.
1
Dependent
Visual Discrimination 1. Visual Search (VISS) Critical Flicker Fusion (CFF) 2. Perceptual-Motor Skills Keyed Pegboard (PEGS) 3. 4. Trails B/Color FOI-D (TR/CF)b 5. Digit Symbol/Coding (D+ISY/COD)c 6. Reaction Time (RTME) Immediate Memory and Attention Digit Span (DISP) 7. Language Skills Color Naming (CRAM) 8. Vigilance Discriminant Reaction Time 9. @MT)
total total time total total time
Battery
Measure(s)
time errors
in
minutes
in
seconds for each hand time in seconds; errors number of correct responses in milliseconds
Total
number
total
time
time
(RCPM)a
in
of in
digits seconds;
errors
in
naming
milliseconds
a Descriptions of RCPM subtests, mental studies, are presented b Color Form is the alternate
in
instructions Lewis and
form
of
of
Digit
for Rennick
Trails
administration, (1979).
and
data
B for
children
under
9 years.
for
children
under
8 years.
from
experi-
C
Coding
is
the
alternate
form
To minimize practice effects baseline testings (drug-free) to determine the effectiveness
Symbol
on the battery, the paradigm calls for on the RCPM, followed one week later by of d-amphetamine compared to placebo.
A double-blind crossover comparison of placebo is designed for each child. The recommendation for a starting dose for a the low dose. Before testing there is a reach peak blood levels. Testing sessions Wednesday, and Friday, allowing one drug-free
three testing
initial under
doses
two dosages (low and high) of d-amphetamine and low dose of d-amphetamine represents a physician's particular child, and the high dose is double one-hour waiting period to permit the dose to (lasting about one hour) take place on Monday, day between sessions.
Stimulant
Data
effectiveness
in
hyperactive
children
67
analysis
Analysis pre-determined procedure compared,
of
RCPM test data is performed for each child individually criteria of change in performance on RCPM subtests is a two-stage ranking system wherein scores under dose first for each RCPM subtest, and then for all subtests
and for all conditions combined.
uses the children. are
same The
For each subtest, a minimum criterion (established from prior clinical use of the RCPM) is set which represents a minimum difference in scores necessary to conclude that one dose is more effective than another. These criteria of change are used to determine the best, middle, and worst performance on each subtest across dose conditions for each child. Thus, the best score three scores for each child are compared with one another for each subtest: is ranked as 1, the middle score as 2, the worst score as 3. A summary score, computed performance across all nine summary score for a condition dose condition. The criterion points since this requires scores on at least four of
by summing the ranks within each dose condition, reflects subtests under each dose condition. Accordingly, a lower reflects better overall performance on the battery under of "significant difference" in summary scores is set at that performance on the more effective dose reflects better the subtests.
that 3
The summary score for the placebo day (P) is first compared to that for the low dose day If the difference between P and L is greater than or equal to criterion, then the low CL). dose is considered effective. The same 3 point criterion and comparison procedures with placebo are used to determine the effectiveness of the high dose.
Results This type of analysis revealed thdt d-amphetamine (either or both dosages) dose was effective; for the other 10
11 of the 13 compared to children, both
Discussion
and
children placebo. doses
(85%) performed For one child, were effective.
Test data could also provide useful information strengths and weaknesses in RCPII measured abilities. samples diverse abilities it is not only a source but also a means of monitoring progress in specific attempted.
the
under high
Conclusion
While the sensitivity of the RCPM to stimulant effects in hyperactive shown, demonstration of its ability to predict long-term changes in awaits utilization of a systematic follow-up to establish criterion the RCPM could provide responders and non-responders. Potentially, of two doses of stimulants information in determining which, if either, benefit a child, prior to the routine administration of drug. This the physician would expedite treatment because it would provide direct medication effectiveness. Since measures used are repeatable, the procedure been on a maintenance dose for shortor long-term efficacy. This procedure, which investigates drug from the present study.
better only
may be periods tolerance
to
children has been cognition and behavior groups of stimulant empirical, objective is likely to immediate feedback to evidence of
performed after the to determine continued was employed with
child
has dose 6 children
the teacher concerning the child's Because the RCPM is repeatable and of pertinent remedial recommendations areas in which remediation has been
B.
E.
Golinko
et
68
al.
Acknowledgements
We thank the Lafayette Sandra Maria Forbes for
Clinic typing
staff for their help the final manuscript.
in
conducting
this
study
and
Ma.
References BARCAI, A. (1971). Predicting the response of children The clinical problems to dextroamphetamine sulfate. 47: 73-80. The behavior of children receiving BGLEY, C. (1937). 577-585.
with learning interview and benzedrine.
and behavior the finger Amer.
J.
twitch
Psych.
test. -94:
COLINKO, B.E. (1978). Hyperactivity: Operationalization of traits using a structured behavioral interview--a pilot study. J. Ped. Psych. 1: 35-44. Predicting amphetamine KNOPP, w., ARNOLD, L.E., ANDRAS, R.L. and SMELTZER, D.J. (1973). response in hyperkinetic children by electronic pupillography. Pharmakopsych. Neuropsycho. 5: X8-166. LEWIS, R.F. and RENNICK, P.M. (1979). Manual for the Repeatable Cognitive-Perceptual-Motor Battery. Axon, Grosse Pointe, Michigan. LESSER, L.I. and PODOSIN, R.L. (1972). Physiological SATTERFIELD, J.H., CANTWELL, D.P., 1418-1424. studies of the hyperkinetic child--I. Amer. J. Psych. 128: Drug treatment of children with behxor problems. In Review of SROUFE, A.L. (1975). University of Chicago Press, Chicago. Child Development and Research, F. Horowitz (ed), SWANSON, J.M. and KINSBOURNE, M. (1976). Stimulant related state-dependent learning in hyperactive children. Science. 1354-1357. -192: Inquiries
and
reprint
requests
should
Barry E. Golinko, Ph.D. The Brookdale Hospital Medical Center Dept. of Pediatrics, Comp Care'Program 9620 Church Avenue Brooklyn, New York 11212 USA
be
addressed
to: