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Psychiatry Research 141 (2006) 315 – 320

www.elsevier.com/locate/psychres

Effect of methylphenidate on Stroop Color–Word task
performance in children with attention
deficit hyperactivity disorder
Daniel D. Langleben a,*, John Monterosso d, Igor Elman b, Brian Ash a,
Gary Krikorian c, Glenn Austin c,F
a
Department of Psychiatry, University of Pennsylvania School of Medicine, 3900 Chestnut Street, Philadelphia, PA 19104, United States
b
McLean Hospital, Harvard University School of Medicine, 115 Mill Street, Belmont, MA 02478, United States
c
The Community/Academia Coalition, Mountain View, CA, United States
d
Department of Psychology, University of California-Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, United States
Received 25 March 2005; received in revised form 8 September 2005; accepted 18 September 2005
Dedicated to the memory of Glenn Austin

Abstract

Attention deficit hyperactivity disorder (ADHD) is a neuropsychiatric syndrome common in the pediatric population. It is
associated with multiple nonspecific deficits on neuropsychological tests of executive function, and a beneficial response to
pharmacotherapy with methylphenidate (MPH) and other psychostimulants. The Stroop Color–Word task is used empirically as
an aid in diagnosis and treatment monitoring of ADHD; however, data on the sensitivity of the Stroop interference score to the
effects of MPH are limited. To address this issue, we studied Stroop performance in a cohort of 18 MPH-treated prepubescent
boys with ADHD and six healthy controls on and off MPH treatment conditions. MPH significantly improved performance in
both groups, with the ADHD participants consistently displaying worse scores than those of controls both on and off MPH.
These results suggest that though the diagnostic value of the Stroop task in ADHD remains controversial, it has heuristic value
for monitoring clinical responses to MPH treatment. More research is needed to ascertain the clinical significance of our
findings and to replicate this relatively small effect in a larger cohort, to determine whether MPH effects on Stroop performance
are specific to ADHD symptoms or they generalize to other forms of symptomatology.
D 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Methylphenidate; Interference; Response inhibition; Attention deficit hyperactivity disorder

* Corresponding author. TRC, 3900 Chestnut Street, Philadelphia, PA 19104, United States. Tel.: +1 215 222 3200x196; fax: +1 215 386
6770.
E-mail address: langlebe@mail.med.upenn.edu (D.D. Langleben).
F
Deceased.

0165-1781/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2005.09.007

with at least one recent placebo-controlled effect (Stroop. and the associated Stroop sive. ADHD has been associated with deficits istration to healthy subjects. sis is dependent upon clinical history. and observation. 2005). Katz et al. van Mourik et been challenged.. Nigg et al. 1997a. plicating treatment follow-up. van Mourik et al. impul. The neuropsychological mechanisms treatment follow-up instrument. 2005. 1935. 2005). not been uniform. Shallice et al. 1997. Langleben et al. further com. ADHD are highly context dependent. Due to the lack of established pathways processing word and color stimuli (Cohen psychometric or biological markers.g.. increased Stroop effect in ADHD is a deficit in sivity and inattention (American Psychiatric Associ. The difference in the acute response to with ADHD exhibit on other neuropsychological MPH between ADHD and health is quantitative tasks suggest broader core psychopathology (Rapport rather than qualitative (Rapoport et al.316 D. 2005).. Introduction naming. 2005) has is limited by the lack of pathognomonic psychomet.b). 2005)... One of the classic tasks of this type is the performance in children with ADHD are inconclu- Stroop Color–Word task. some have been experimentally demon- strated (Peterson et al. the deficits that children 2004).. symptoms of (Golden. 2002. experimental data of MPH’s effect on Stroop 2005). 2002). Thus. 1995. 2002. Nigg. Although current on a variety of neuropsychological tasks broadly hypotheses of ADHD predict that MPH should described as measures of bexecutive functioningQ reduce the Stroop interference effect in ADHD. van Veen Attention deficit hyperactivity disorder (ADHD) and Carter. van Mourik et al. the diagnosis and the treatment follow-up in ADHD Shallice et al. especially (Kipp.. 2005). Rapport et al. attentional modulation of the distributed parallel ation. 2001. cent boys with ADHD. ADHD diagno.. . 1976. though blue).. in comparison with healthy controls.. tion for Stroop’s diagnostic validity in ADHD was The purpose of the present study was to test the based on the association between cognitive effect of MPH on Stroop performance in prepubes- binterferenceQ and behavioral response inhibition.. 1976. relatively to the bcolor-matchedQ words and the specificity of the Stroop effect to ADHD has shapes (Stroop. We hypothesized that: 1) The putative basic neural mechanism mediating the MPH would reduce the Stroop interference effect in Stroop effect both in ADHD and in health was the ADHD cohort and 2) children with ADHD response competition between the relatively auto. Poldrack. 2005). Moreover. as evidenced One of the more consistent features of ADHD is by deficits in performance of tasks requiring the behavioral response to methylphenidate (MPH) intermittent withholding of response (Aron and and other psychostimulants (Solanto. it may have clinical value as a al. The accuracy of both untreated ADHD (Reeve and Schandler. the theoretical justifica. Carter et al... The primary ADHD Rucklidge and Tannock. 1980). et al. 2002. 1997a. yet the Stroop task is widely ric and biological markers and the high incidence of used empirically as an aid in clinical diagnosis psychiatric co-morbidity. MTA.. physical 1999). An influential rationale for the is characterized by locomotor hyperactivity. Bedard et al.b. The sensitivity of the Stroop effect to examination. would demonstrate a larger MPH effect than the matic word reading and the less habitual color controls. Traditionally... Seidman et al. 2002. / Psychiatry Research 141 (2006) 315–320 1.. Nigg. 1935. Weingartner et al..D. 1998. 1999. symptoms have been attributed to a core deficit in 2002. 1990. Nigg. Reeve study reporting improved inhibitory but not inter- and Schandler. 2005). (Barkley. 2002.. The ference control in children with ADHD (Scheres et Stroop binterferenceQ effect is the decrease in the al. Peterson et al. 2001. ethical considerations In addition to the deficits in behavioral response preclude controlled studies of chronic MPH admin- inhibition. the word bredQ written in analysis (van Mourik et al. Schmitz et al.. et al. 2003). 1998. 1978. A recent meta-analysis of Stroop speed of reading words that are incongruent with performance in ADHD deemed the number of the color of the ink in which they are printed and studies on the effect of MPH insufficient for the word’s meaning (e. Golden. response inhibition (Barkley. 2001. 1994). if shown to be underlying this effect are not fully understood sensitive to stimulant therapy in ADHD.. Shallice et al. however. 2001.

1–12.e.007).Q In the in a significant effect of medication ( F(1. S.and off-MPH) as the within- White Lane. two-tailed t-test).028). history of head trauma.22. ADHD diagnosis was confirmed by a multidisciplin. and the Wechsler Intelligence A post hoc paired t-test detected MPH-induced Scale for Children.8).D. revealed that following MPH administration. In able clinical response to an average of 12 weeks addition.22.07 vs.005) and the group ( F(1. (52. 56.4 F 13.25) = 6. verbal P = 0.10.and off-MPH) as the within-subject factor children assented to participate.34. participated as controls. we the medication ( F(1. Pelham scale (SNAP). on the Conners scale df = 1.99. P = 0. 1992).9.8 years. and CWS).86. df = 1. Their verbal IQ (WISC III) CS. the WS. we observed a group difference. scale. Each of these variables were modeled was slightly higher (125. ADHD. = 10).71 F 4. 2005). the morning of the session. P = 0. Methods 3. counterbalanced so that approximately half of the participants were tested off-MPH first. All as the between-subjects factor and treatment condition parents gave written informed consent and the (on.1 vs.53.89. was an overall increase (improvement) in the IntS S. (n = 6) on and off methylphenidate. 1. P = 0. For CS. the off-MPH condition was achieved P = 0. Fig.7). . 1). van Mourik et al.32. The latter results did not reach statistical IQ b 85. 1994) was subject factor.67 F 6. IL 60191. / Psychiatry Research 141 (2006) 315–320 317 2. The treatment conditions (group effect: F = 6.22. range = 8.015). Wechsler. with group (ADHD albeit not significantly ( P b 0. but not for healthy controls above the population mean (mean = 50. Nolan. perhaps by Type II error resulting from chronic medical or psychiatric disorder other than the small sample size. the Conners Teachers between group and treatment condition ( F = 0.329) (Fig. three subscores used to derive the IntS (i. The investigator performing the Stroop task was blind to the medica. or significance. and the controls received a single 10-mg dose of MPH.D. All participants were of Caucasian origin. 1. Wood Dale. df = 1.33 F 5.. there cent boys (mean age = 10.3) with ADHD. Langleben et al. = 1.048) and of group ( F(1.006) MPH dose.60. 114. P = 0. and control) as the between-subjects factor and The Stroop Color and Word Testn (Stoelting Co.019). were included in the subjects performing worse than controls across both study. who demonstrated a favor. which reflect the baseline reading and color recognition (Golden.07. premature birth.D. Swanson.68. MPH administration resulted performed twice: bon-MPHQ and boff-MPH.37. Stroop interference effect in ADHD (n = 18) and controls tion state and diagnosis of the participants. df = 1.72 vs. Results The study protocol was approved by the Stanford One-way ANOVA with group (ADHD and control) University Hospital institutional review board. ADHD cohort. (treatment effect: F = 8. There was no significant interaction ary team using clinical history. criteria were a T-score b 2 S. 50.7 F 4. P = 0. and df = 1.25) = 9. 620 treatment condition (on.25) = 8. S. by withholding MPH for 36 h and in the controls by Similarly. Third Edition (WISC) (Conners.D.. ADHD participants received their usual prescribed dose of 10 to 30 mg of MPH. For WS. Eighteen prepubes.172). Color (CS) scores.57 F 4.27.and off-MPH sessions were conducted 1 to 3 weeks apart.28. 1976. using repeated measures ANOVA. D. Six demographically matched healthy boys Secondary analyses were conducted on each of the (mean age = 10.2 years. range = 7. For the bon-MPHQ condition.D. Exclusion ipants (48. t = 2. The Stroop binterference scoreQ (IntS) was derived by correcting the raw Color–Word (CWS) score by the age-adjusted Word (WS). t = 1.2. with ADHD (range = 8–16) of MPH therapy. A higher IntS indicates less interference. P = 0.84. 1991. significant increases in the IntS for ADHD partic- 1989.4–12.25) = 4. treatment with medications other than MPH. The on. testing at least 1 week before or after the single test P = 0. the parents’ and teachers’ Swanson.

. Ernst. performance on the Stroop resulted due to the absence of a placebo pill in this task is a robust predictor of hyperactive/impulsive study. correlates of these findings (e. Weingartner et al. The off-MPH condition in the ADHD group deficiency in resistance to interference that is was 36 h after 8 to 12 weeks of MPH therapy. Volkow et al... while trying to avoid al. Langleben et al. Our results contrast with two prior studies potential clinical impact of treatment discontinuation in children with ADHD (Bedard et al. These data do not add to the (approximately 4%) improvement in Stroop response debate on the diagnostic specificity of the Stroop task interference scores of children with ADHD after or provide an indication of the expected effect size of administration of MPH. indicates that this and the absence of a healthy control group in both issue requires further investigation (Mendelson et al. 1997a. schedule in our study was also constrained by the The main effect of group on Stroop data supports inability to administer chronic MPH to the normal the hypothesis that ADHD is associated with a controls. 2005). P = 0. 2003) that did not show an improvement in argue against tolerance to the clinical effects of MPH. study hypothesis and the investigators were blind to 1991. our results neurophysiological abnormalities in ADHD (Bush et may not apply to females with ADHD. Scheres (Kimko et al. which share many phar- Methodological differences (fixed vs. 2005).25) = 23. The duration al.. indicates that the Stroop task could be a useful Therefore.. while in improved by MPH (van Mourik et al. amphetamine and cocaine.D. 2002) participants and their parents were kept blind to the and is sensitive to stimulant effects (Everett et al. 1980). This the controls it was 36 h after a single MPH dose.003).27. varied dosing) macological properties with MPH. studies and call for further elucidation of the effects of Scheres et al.064. 2003). the small sample .. Therefore.. MPH was more robust in the color than the word score.. P b 0. In our sample. 1999. This mechanism could observed a highly significant effect of medication account for the reduced interference we see in the ( F(1. classroom perfor. Our findings support the subjects’ MPH status. 1999).b. Our findings are consistent with prior reports in recruiting girls from a clinic-referred population of an increased interference effect and associated (Barkley. 1999. Discussion studies and supports the notion that color naming may be less bautomaticQ than word reading (Scheres We found a statistically significant yet modest et al.g. 2002) and with the putative of the drug discontinuation was aimed at exceeding neuropsychological mechanism of action of MPH five MPH half-lives to render our subjects free of the through enhancement of stimulus salience (Volkow et clinical effects of MPH. Inquiry into behavioral MPH on the Stroop performance. 1999). Shallice et al.. for CWS. the existence of sensitization and tolerance with d- the color and word scores improved significantly. This that there is no MPH effect beyond 36 h. 1999.. 2005). 2005). interference score with MPH. 1998). Although most clinical data et al.. To offset this issue. we inputs (Volkow et al. Nigg. A male- mance) will help assess the clinical potential of these only cohort was studied due to the difficulty involved findings. though in Bedard et al.001) and group ( F(1. future studies essentially increasing the bsignal-to-noiseQ ratio of employing a true placebo condition may be warranted the distributed parallel systems processing sensory to fully rectify this issue. Although this is not a reliable indication of the effect size.318 D. for decreased performance on this task... / Psychiatry Research 141 (2006) 315–320 effects were similarly significant. Although these argue the hypothesis that the therapeutic action of MPH is against non-specific anticipatory effects as a basis to enhance the salience of the relevant stimuli. Lastly. 2004. Our study has a number of limitations. the investigators... prior studies complicate the comparisons between 1998. the effect of 11.25) = control group after MPH. The MPH administration MPH on the Stroop interference effect. the schedules of MPH administration in the adjunct clinical measure of response to MPH and two groups are only comparable under the assumption possibly other stimulant pharmacotherapies. 2002. An conclusion is in agreement with previous reports additional potential confound is related to a possibility showing that although it may not be specific for of performance expectation bias that could have ADHD (Katz et al. the ADHD symptoms (Rucklidge and Tannock. Finally. the observation is consistent with prior 4. Swanson et al..

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