effects of ritalin on academic achievement from first to fifth grade

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Effects of Ritalin on AcademicAchievement from First to FifthGradeWilliam Frankenberger & Christie CannonPublished online: 21 Jul 2010.

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International Journal of Disability, Development and Education, Vol. 46, No. 2, 1999

Effects of Ritalin on Academic

Achievement from First to Fifth Grade

W ILLIAM FRANKENBERGER & CHRISTIE CANNON

Human Development Centre, 172 Human Sciences and Services Building, University

of Wisconsin ± Eau Claire, Eau Claire, WI 54702, USA

ABSTRACT This study was a continuation of the Alto and Frankenberger (1995) study

that reported the effects of Ritalin on academic achievement from ® rst to second grade. The

objectives of the current study were to identify the long-term effects of Ritalin on cognitive

ability and academic achievement. A retrospective/longitudinal design was utilised in the

study with dependent measures being scores from the Iowa Test of Basic Skills (ITBS). The

study included 13 experimental subjects who were identi ® ed with AD/HD and placed on

Ritalin between ® rst and second grade. For each experimental child, a contrast child

without AD/HD was matched based on gender, Verbal IQ score, and family structure.

Results of the study revealed that generally, the Ritalin group’ s cognitive and achievement

scores were lower before medication and the groups tended to continue to diverge after

medication was administered. Dosage levels for the children in the Ritalin group tended to

be increased over time and few of the children in general education classes received

supplementary educational programs.

Characteristics of Children with AD/HD

The hyperactive child syndrome has been discussed in the medical research

for many years and is, therefore, not a new disorder (Shorter, 1997). The hyper-

active child is often described as a relatively dif ® cult child from birth who may have

had irregular sleep patterns and presented a constant challenge to parents.

Many parents have commented that their child never learned to walk, but moved

directly from crawling to running. However, the diagnostic criteria for Attention-

De® cit/Hyperactivity Disorder (AD/HD) have evolved over the past several years to

not only include ª hyperactiveº children but also children with ª inattentiveº charac-

teristics. The inattentive child has dif® culties with sustained attention if the child

® nds the task to be uninteresting. Barkley (1976) proposed that this selective

inattention was more a motivation de® cit than an attention de® cit because affected

children could concentrate on tasks such as video games for extended periods of

time.

ISSN 1034-912X (print)/ISSN 1465-346X (online)/99/020199-23 Ó 1999 Taylor & Francis Ltd

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200 W. Frankenberger & C. Cannon

According to the American Psychiatric Association’ s Diagnostic and Statistical

Manual of Mental Disorders (4th ed., 1994), Attention-De® cit/Hyperactivity Disorder

(AD/HD) is characterised by a persistent pattern of inattention and/or hyperactivity-

impulsivity that is more extreme than would be expected for an individual of a

comparable developmental level. Some symptoms of the disorder must have been

evident before the age of seven and the symptoms must be exhibited in two or more

of the individual’ s social settings (e.g., school, home, or work). These symptoms

generate problems with peers, teachers, and parents, as well as problems with

academic achievement. There are currently three subtypes of AD/HD: AD/HD

Combined Type, AD/HD Predominantly Inattentive Type, and AD/HD Predomi-

nantly Hyperactive Type.

Increase in the Use of Stimulant Medication to Treat AD/HD

In 1988, Safer and Krager predicted that by the early 1990s over one million US

children would be receiving Ritalin for treatment of Attention-De® cit/Hyperactivity

Disorder (AD/HD). In fact, Safer and Krager underestimated the growth in use

of Ritalin as nearly three million children now use Ritalin to cope with AD/HD and

the number is rising (Read, 1995). According to DSM-IV (1994), 3 to 5% of

school-aged children are expected to have AD/HD and presumably a

smaller percent would be expected to be receiving stimulant medication because,

as Barkley (1977) stated, stimulant medication was not effective in approximately

25% of the children with AD/HD. However, the number of school-aged children

receiving stimulant medication is already approaching the 5% rate (Kohls,

Fuhrer, & Frankenberger, 1997). Frankenberger, Lozar, and Dallas (1990), in

a national survey of school districts, found that approximately 1.5% of all

public elementary age school children in the US were identi® ed as having AD/HD

and concomitantly receiving stimulant medication. Comparison of these two

studies reveals that the increase in school-aged children receiving stimulant

medication from 1988 to the present is approximately 330%. According to Zirpoli

(1995), ª it seems that what was once a rare disability has become the latest

educational fad. In some schools, half the male students are labeled ADD. Schools

are turning into pharmacies as students line up to get their next Ritalin pillº (p. 9A).

Gibbs (1998) reported that the production of Ritalin increased more than

700% from 1990 to 1997 and 90% of the medication was consumed in the United

States. In fact, Runnheim, Frankenberger, and Hazelkorn (1996) reported a

300% increase from 1987 until 1995 in the use of stimulant medication to treat

children in classrooms for emotionally disturbed (ED). In their survey, they found

that approximately 40% of children in elementary ED classes were identi® ed as

having AD/HD and were being treated with stimulant medication. Over a similar

time span, Aspenson, Snider, and Frankenberger (1996) found approximately a

300% increase in treatment for children in learning disabilities programs in a

national study.

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Effects of Ritalin 201

Stimulant Medication for Treatment of AD/HD

Typically, AD/HD is most frequently identi® ed in children during the middle

elementary school grades (Frankenberger, Lozar, & Dallas, 1990), however, there

has been a trend to diagnose and treat preschool children (Rosenberg, 1987).

Children who have been diagnosed as having AD/HD are frequently prescribed one

of three stimulant medications to treat their disorder: Ritalin, Dexedrine, or Cylert

(Methylphenidate, Dextoamphetamine, or Pemoline). In fact, Frankenberger et al.

(1990) found that Ritalin was utilised as the stimulant medication of choice in 94%

of the cases. Because stimulants are currently considered by many physicians and

educators as the intervention of choice with children diagnosed as AD/HD, it is

important to consider how the stimulant medication is affecting children be-

haviourally as well as cognitively and academically.

Basically, there are two reasons for prescribing stimulant medication to treat

children with one of the three types of AD/HD delineated above. First, because most

children diagnosed with AD/HD are inattentive, an intervention that increased

attention to academic tasks and reduced impulsivity should provide treated children

with an opportunity to learn more ef® ciently and thus improve achievement rates

over time. Second, children who exhibit hyperactive and impulsive characteristics

may be disruptive in the classroom and interfere with their own as well as other

children’ s ability to remain on task and learn new material. Obviously, a treatment

that reduced behaviours that are considered maladaptive in the classroom would be

bene® cial. The question that must be addressed is whether stimulant medication

accomplishes one or both of the treatment goals delineated above.

Effects of Stimulant Medication on Cognitive Functioning

Researchers have obtained con¯ icting results when investigating the effects of Ritalin

on cognition. The cognitive tests used in the majority of the studies were laboratory

measures, including Paired-Associated Learning Task (PAL), Short-term Memory

Task, Continuous Performance Test, Matching Familiar Figures Test, or Raven’ s

Coloured Progressive Matrices Test. Barkley (1977) suggested that stimulant drug

therapy did not produce signi® cant changes in basic intellectual or cognitive abili-

ties. Abikoff and Gittelman (1985) in a 16-week study that included cognitive

training along with stimulant medication did not ® nd an improvement in cognitive

functioning as a result of medication. Conversely, Kupietz, Winsberg, Richardson,

Maitinsky, and Mendall (1988) observed improved cognitive performances on the

PAL after 27 weeks. Their 6-month study revealed that error decreased on the PAL

when treatment included remedial reading instruction and stimulant drug treat-

ment. However, Kupietz et al. concluded that the remedial instruction was more

important than the medication in reducing the reading disability de® cits. In a

comprehensive review of 84 studies, Rapport and Kelly (1991) also found that

stimulant medication frequently improved short-term cognitive functioning on labo-

ratory tasks in children. However, overall the research examining the effects of

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Ritalin on laboratory tasks is inconclusive and effects of stimulant medication on

school-related tasks is unknown.

Effects of Stimulant Medication on Achievement

Again, there have been con¯ icting results when researchers have attempted to

identify the long-term effects of stimulant medication on achievement. In fact very

few studies have examined the effects of stimulant medication on achievement for

more than six months. Barkley and Cunningham’ s (1978) review of the literature

provided little support for the idea that stimulant medication had consistent positive

effects on academic achievement test scores. They suggested that the effects of

Ritalin were most effective for controlling hyperactive classroom behaviours on a

short-term basis. Another study by Charles and Schain (1981), evaluated a group of

stimulant-medicated hyperactive children for 16 weeks and four years later. After

four years, 81% of the children were no longer taking Ritalin. The researchers found

de® cits in several academic areas: teacher reports, failed grades, and scores on the

Wide Range Achievement Test (WRAT) (Gadow, 1983) and the Peabody Individ-

ual Achievement Test (PIAT) (Dunn & Markwardt, 1970). Some bene® cial effects

of Ritalin were seen at the beginning, but receiving medication did not seem to

positively affect long-term academic achievement.

Stimulant therapy may ª increase academic productivity,º but does not seem to

affect scores on standardised achievement tests such as the WRAT. Conversely,

Pelham et al. (1993) report that Ritalin had robust, bene® cial short-term effects on

academic performance. These positive effects were generally observed when com-

bined with other treatments. Most of these studies did not ® nd long-term positive

effects of Ritalin on academic performance.

Satter® eld, Satter ® eld, and Cantwell (1980) conducted a 2-year study evaluating

61 boys with AD/HD on several variables including academic performance. On the

PIAT, these boys displayed signi® cant de® cits in all areas. However, the students

were statistically less behind the following year in all areas, except spelling, after

treatment with Ritalin. In contrast, Alto and Frankenberger (1995) found initial

de® cits in achievement scores of children with AD/HD in Word Analysis, Reading,

Basic Composite, and Complete Composite on the Iowa Test of Basic Skills (ITBS)

that were not reduced after four to eight months of treatment with Ritalin.

Since many children with AD/HD exhibit reading dif® culties, several studies have

examined the effects of Ritalin on reading achievement. Many children with AD/HD

display de® cits in reading abilities before and after being placed on Ritalin (Weber,

Frankenberger, & Heilman, 1992). Aman and Werry (1982) found no evidence to

support short- or long-term effects of Ritalin on reading skills or achievement. Some

success was found by Gittelman, Klein, and Feingold (1983) who reported that

Ritalin had occasional, ¯ eeting effects on reading performance. However, the

long-term effects on basic reading skills and achievement were not signi® cant. Other

researchers have found a positive correlation between Ritalin and reading achieve-

ment. A group of children with a dual diagnosis of AD/HD and Developmental

Reading Disorder (DRD) were assessed periodically for six months. The partici-

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pants were given several achievement and reading tests and randomly placed in one

of four groups (.30 mg/kg, .50 mg/kg, .70 mg/kg, and placebo). These researchers

found that Ritalin treatment had a positive effect on reading achievement. They

suggest that this improvement was related to the degree of reduction of negative

behaviours associated with AD/HD (Richardson, Kupietz, & Martinsky, 1986).

Balthazor, Wagner, and Pelham (1991) found that .30 mg/kg Ritalin improved

performance on a classroom reading comprehension task. However, the researchers

could not isolate the speci® c abilities that were improved that were required for

completion of the task. Again it should be noted that the studies ® nding improve-

ments in reading were generally of a duration of less than six months.

Satter® eld, Satter® eld, and Cantwell (1980) conducted a 2-year study and re-

ported positive effects of Ritalin on academic achievement. However, this study’ s

pre-and post-treatment evaluation conditions were not similar. In addition, Charles

and Schain (1981) conducted a 4-year follow-up study and found bene® cial effects

of stimulants occurring within the ® rst months of treatment, whereas the long-term

effects on academic achievement were unclear.

A more recent study investigated the effects of Ritalin on the academic achieve-

ment of 22 children with AD/HD compared to 22 contrast children (Weber et al.,

1992). Data were obtained from group achievement tests and statistically analysed

to compare achievement gains between groups (Ritalin vs Control) and

within groups (before and after use). Their results indicated that Ritalin did not

appear to improve academic achievement even after one to two years of treatment.

They found that AD/HD children tended to be poorer readers both before and after

they were placed on Ritalin. Interestingly, the AD/HD subjects experienced

a signi® cant drop in Mathematics, Reading, Listening, and overall achievement the

year prior to receiving Ritalin. This drop occurred most often between ® rst

and second grade. Similarly , Alto and Frankenberger (1995) completed a longitudi-

nal study of the affects of stimulant medication on achievement. They found

that even when children were matched on verbal cognitive scores, the Ritalin group

had lower achievement in the four achievement areas being measured (Reading,

Word Analysis, Basic Composite, and Complete Composite) both before and

after being placed on the medication. Their ® ndings suggest that Ritalin did not

result in signi® cant increases in the children’ s academic achievement. Rather, the

initial drops in achievement stabilised somewhat after receiving the stimulant medi-

cation.

In contrast to the more recent studies cited above, Kavale (1982) reported the

results of a meta-analysis of 135 studies investigating the effects of Ritalin on

academic achievement where he found moderate positive effects favouring the

drug-treated group. The results revealed an average 15 percentile rank increase in

achievement for those treated with Ritalin. According to Kavale’ s review, children

receiving stimulant medication experienced a moderate positive gain (10%) on the

WRAT and a large achievement gain (24%) on the Iowa Test of Basic Skills (ITBS)

(Lindquist & Hieronymus, 1964). On the WRAT, the Ritalin subjects demonstrated

moderate positive gains on the Reading and Spelling subtests. The results supported

the notion that AD/HD students who are having dif ® culty with those academic areas

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which require more attention, can signi® cantly improve their achievement scores

through drug intervention.

Kavale pointed out that in former experimental investigations the achievement

test most often used was the WRAT. The WRAT contains relatively few items for

each grade level and, therefore, may not be sensitive to treatment effects in

short-term studies (Barkley & Cunningham, 1978; Gadow, 1983). Group achieve-

ment tests are typically utilised to determine the ef® cacy of school-based programs

and have been successfully used to assess the effectiveness of Ritalin for enhancing

achievement (Kavale, 1982; Rie, Rie, Stewart, & Ambuel, 1976a, 1976b; Weber et

al., 1992). These tests are more comprehensive and provide a continuous measure-

ment of growth in the fundamental skills such as Vocabulary, Reading, Word

Analysis, Listening, Mathematics, and Composite scores (Basic and Complete). In

addition, the ITBS in particular has been shown to have high reliability and

reasonable content validity (Linn, 1989). Therefore, when determining long-term

effects of Ritalin on a child’ s academic achievement over a span of a year these

particular school achievement tests would provide more useful information (Sattler,

1988).

Effects of Stimulant Medication on Behaviour

Researchers have examined stimulant treatment on the behaviour of children both

alone and in combination with different types of behavioural interventions. A

founding study by Barkley (1976) estimated that 75% of hyperactive children

bene® t from psychostimulants, but that other methods need to be used in conjunc-

tion with medication to fully meet the needs of children with AD/HD. A study by

Pelham et al. (1993) assessed the separate and combined effects of Ritalin and

behaviour modi® cation on boys with AD/HD. They found signi® cant positive effects

on ratings of classroom behaviour and measures of academic performance with both

interventions; with the mean effect size of Ritalin (.3 mg/kg, .6 mg/kg) being twice

that of behaviour modi® cation alone. The addition of either dose of Ritalin resulted

in improvement in classroom behaviour and academic performance beyond behav-

iour modi® cation alone. However, Chase and Clement (1985) found that self-re-

inforcement was better than Ritalin. They studied the effects of Ritalin and

self-reinforcement alone and in combination. The results indicated that the combi-

nation of the two was the most effective on daily measures of academic performance

which was measured by the number of accurately completed answers to reading

questions.

The use of cognitive training is another popular intervention that is used to treat

children with AD/HD. Researchers explored the use of cognitive training with

children diagnosed with AD/HD who required a maintenance level of medication.

They found no differences between the control group and experimental group in

reasoning, problem-solving, and learning (Abikoff & Gittelman, 1985). Brown,

Borden, Wynne, Schleser, and Clingerman (1986) supported the previous ® ndings

that the combination of Ritalin and cognitive therapy was no more effective than

Ritalin alone. However, they also found that the effects of the stimulant medication

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quickly dissipated after the drug was discontinued. Many of their participants had

stopped taking Ritalin which consequently may have affected the results.

In summary, there is evidence in the literature that stimulant medications such as

Ritalin have positive short-term effects on achievement and behaviour. The evidence

for short-term control of maladaptive and disruptive behaviours appears to be

stronger than for enhancement of academic achievement. However, there is also

evidence that the medication looses some of its initial ef® cacy when used as a

long-term treatment, and long-term stimulant treatment is the current trend in

medicine.

This study addressed the effects of Ritalin on academic achievement by following

a group of children with AD/HD from ® rst to ® fth grade. Records were obtained for

the children from ® rst through ® fth grade. In particular, this study was designed to

address: (a) differences in academic achievement between children diagnosed with

AD/HD and receiving treatment with stimulant medication and a matched contrast

group of children; (b) differences in measures of cognitive ability; (c) when the

differences between the groups occurred (e.g., ® rst vs ® fth grade); (d) changes in

achievement rate for children after treatment with stimulant medication in selected

achievement areas from the ITBS (Language Total, Reading, Math Total, Vocabu-

lary, and Complete Composite); and (e) changes in dosage level over time and type

of concomitant intervention (if any) used to manage behaviour.

Method

Participants

The participants in this study were 26 children aged 9 to 11 who had IQs of 80 or

higher in ® rst grade who were identi® ed in an earlier study (Alto & Frankenberger,

1995). These students attended elementary schools within a midwestern school

district in the US with approximately 4,000 students in Grades K to 6.

The Ritalin group consisted of 13 children who were identi® ed with AD/HD

(predominately hyperactive type) by the school district via the following steps:

referral, assessment by the school psychologist, referral to a pediatrician or neurol-

ogist who specialised in the disorder, and typically placebo trials and titration of

stimulant medication.

The group consisted of nine males and four females with nine of the Ritalin group

in general education, three received learning disabilities services and one received

learning disabilities and emotional disabilities services. The children began treat-

ment with Ritalin after they took their ® rst grade achievement tests, but before

November 1 of second grade. The Ritalin group in this study consisted of 13 of the

original 17 students who participated in Alto and Frankenberger’ s (1995) study.

Available data were collected from 13 children from the same Contrast group of

17 children examined in the previous study (Alto & Frankenberger, 1995). A

Contrast subject without AD/HD was matched with each experimental child be-

tween ® rst and second grade based on the following criteria: (a) similar education

placement (same classroom, same type of program), (b) same sex, (c) identical

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family structure (single parent household vs two parent household Ð both biological

parents or one biological parent present), and (d) similar Verbal IQ test scores (with

1 / 2 6 points). Of the 13 children in the Contrast group, 11 were in regular

education and two received learning disabilities support services.

The groups were matched using ® rst grade Verbal scores on the Cognitive

Abilities portion of the Iowa Test of Basic Skills (ITBS). There were no signi® cant

differences in mean scores between the two groups with the Ritalin group’ s ® rst

grade Verbal mean score being 108.7 and the Contrast group’ s mean score 113.8.

Instrument

The following information was collected from school records for all children: (a)

® rst, second, and ® fth grade achievement test scores from the ITBS, including

Reading, Vocabulary, Math Total, Language Total, and Complete Composite

scores, (b) ® rst, second, and ® fth grade cognitive test scores from the ITBS (Verbal,

Nonverbal, and Quantitative Reasoning), (c) date of birth, (d) sex, (e) current age,

and (f) family structure. All scores for the ITBS were recorded as normal curve

equivalents.

In addition to ITBS scores, the following data were collected for children in the

Ritalin group from the school nurse’ s records: (a) date when medication was ® rst

administered (between ® rst and second grade), and (b) current dosage level of

medication at the time of achievement testing.

Procedures

A retrospective/longitudinal design was utilised including measurements of achieve-

ment and cognitive ability from the ITBS over the time period from ® rst, to second,

to ® fth grade achievement testing. Data were collected by the researchers or Pupil

Services Personnel and entered on a data collection form which was designed to

provide information about the two groups of children (Ritalin and Contrast). First

grade achievement scores for both the experimental and Contrast groups were

collected retrospectively during the Fall of 1992. Second grade achievement scores

were collected for both groups as they became available during the Spring of 1993

and ® fth grade achievement scores were collected during the Spring semester of

1996.

Results

Demographic Information for Children Identi ® ed as Having AD/HD

Of the original 17 pairs of subjects included in the Alto and Frankenberger (1995)

study, 14 pairs were still in the participating school district during ® fth grade.

However, one of the children in the Ritalin group went off medication shortly after

taking his second grade achievement test. Therefore, data from 13 pairs of children

were available for the current study.

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TABLE I. Means table for cognitive verbal scores for each group

Count M SD SE

Contrast, ® rst 10 113.800 11.163 3.530

Contrast, second 10 111.000 10.593 3.350

Contrast, ® fth 10 107.900 8.937 2.826

Ritalin, ® rst 10 108.700 11.567 3.658

Ritalin, second 10 110.800 13.726 4.341

Ritalin, ® fth 10 94.800 12.461 3.941

Note. Drug (Ritalin vs Contrast) F(1, 9) 5 5.526, p , .05

Grade (® rst, second, ® fth) F(1, 9) 5 14.216, p , .001

Interaction (Drug 3 Grade) F(1, 9) 5 4.572, p , .05

Effects of Ritalin on Cognitive Abilities

A 2 (Ritalin vs Contrast) by 3 (® rst vs second vs ® fth grade) within subjects ANOVA

was employed to determine whether Ritalin in¯ uenced the rate of learning

of children receiving medication compared to the Contrast group over a relatively

long time period (minimum 3.5 years). The mean cognitive scores for the Ritalin

and Contrast groups during their ® rst, second, and ® fth grade testing were exam-

ined. The mean Cognitive Verbal scores for each group are presented in Table I.

The within subjects ANOVA revealed a signi® cant group by grade effect that

indicated a difference in learning rate for the Ritalin vs the Contrast group. The

means for the two groups were essentially identical for the second grade testing but

dropped off for the Ritalin group in ® fth grade. The interaction plot for the

Cognitive Verbal data is presented in Figure 1.

FIG. 1. Interaction Plot for Cognitive Verbal Data Grades 1, 2, and 5.

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In the Cognitive Quantitative area, the ANOVA revealed a signi® cant groups

(Ritalin vs Contrast) main effect with the Ritalin group scoring lower in the area of

Quantitative ability from ® rst grade through ® fth grade. The mean Cognitive

Quantitative scores from the ITBS from ® rst to ® fth grade are presented in Table II.

The differences between the mean scores for the ® rst (t 5 2.467, df 5 10, p , .01)

and second graders (t 5 3.741, df 5 11, p , .01) were signi® cant while the means

for the ® fth graders were not signi® cant. It should be noted that some students did

not take all portions of the ITBS for varying reasons and incomplete paired data cells

were eliminated from the evaluations resulting in differing degrees of freedom from

one year to the next. The interaction plot for the Cognitive Quantitative portion of

the ITBS is presented in Figure 2.

TABLE II. Means table for cognitive quantitative scores

Count M SD SE

Contrast, ® rst 10 115.900 18.947 5.992

Contrast, second 10 114.200 9.830 3.108

Contrast, ® fth 10 110.900 10.651 3.368

Ritalin, ® rst 10 99.800 20.351 6.436

Ritalin, second 10 98.100 12.897 4.078

Ritalin, ® fth 10 96.600 18.518 5.856


FIG. 2. Interaction Plot for Cognitive Quantitative Data Grades 1, 2, and 5.

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The means for the Cognitive Nonverbal portion of the ITBS are presented in

Table III. No signi® cant between group differences were obtained before ® fth grade

when the Ritalin group performed signi® cantly lower than the Contrast group

(t 5 2.796, df 5 12, p , .05). The interaction plot for the Cognitive Nonverbal

subtest is presented in Figure 3.

Effects of Ritalin on Achievement Skills

A 2 (Ritalin vs Control) by 3(® rst vs second vs ® fth grade) within subjects ANOVA

was also employed to determine whether Ritalin in¯ uenced the learning rate of

children receiving medication compared to the Contrast group. The mean ITBS

achievement scores for the Ritalin group during their ® rst, second, and ® fth grade

testing were examined. These mean achievement scores were compared to the

TABLE III. Means table for cognitive nonverbal scores

Count M SD SE

Contrast, ® rst 10 111.000 16.713 5.285

Contrast, second 10 108.200 19.037 6.020

Contrast, ® fth 10 112.400 8.154 2.579

Ritalin, ® rst 10 103.700 19.408 6.137

Ritalin, second 10 105.400 14.431 4.564

Ritalin, ® fth 10 97.100 13.988 4.423

FIG. 3. Interaction Plot for Cognitive Nonverbal Data Grades 1, 2, and 5.

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Contrast group’ s ® rst, second, and ® fth grade mean achievement scores. This

analysis was completed for the following categories of achievement skills: Language

Total, Reading, Vocabulary, Math Total, and Complete Composite. Again, varia-

tions in degrees of freedom among the achievement areas are due to the fact that

some of the children did not take all the parts of the ITBS during each of the three

years.

The mean scores for the Language Total sections of the ITBS are presented in

Table IV. A review of Table IV reveals that the groups started out with similar mean

scores in ® rst grade and then diverged from that point. By ® fth grade, the Ritalin

group scored signi® cantly lower on this portion of the ITBS (t 5 2.4, df 5 12, p

, .05). The divergence of the two groups is clearly apparent in the interaction plot

presented in Figure 4.

On the Reading portion of the ITBS, a similar pro® le emerged. The mean scores

for the two groups are presented in Table V.

TABLE IV. Means table for language total scores

Count M SD SE

Contrast, ® rst 12 58.833 17.658 5.097

Contrast, second 12 62.917 26.370 7.612

Contrast, ® fth 12 62.167 21.131 6.100

Ritalin, ® rst 12 56.167 11.280 3.256

Ritalin, second 12 52.167 15.050 4.345

Ritalin, ® fth 12 42.333 19.118 5.519

Note. Grade (® rst vs second) F(1, 16) 5 56.04, p , .0001

FIG. 4. Interaction Plot for Language Total Data Grades 1, 2, and 5.

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The within subjects ANOVA revealed a signi® cant grade effect re¯ ecting lower

normal curve equivalence scores over time for the two groups. However, an

examination of the interaction plot for the two groups (Figure 5) again reveals a

trend toward divergence with the achievement differences reaching a maximum in

® fth grade.

Means for the Math Total analysis are presented in Table VI. The ANOVA revealed

a signi® cant group effect indicating that the children in the Ritalin group scored

signi® cantly lower than the Contrast children. this signi® cant difference in

group mean scores was evident at the ® rst (t 5 3.303, df 5 12, p , .01), second

(t 5 2.579, df 5 12, p , .05), and ® fth (t 5 2.479, df 5 12, p , .05) grades. The

interaction plot, presented in Figure 6, reveals that the children receiving

TABLE V. Means table for reading scores

Count M SD SE

Contrast, ® rst 12 62.500 18.981 5.479

Contrast, second 12 56.917 27.434 7.920

Contrast, ® fth 12 56.083 15.728 4.540

Ritalin, ® rst 12 557.417 14.132 4.080

Ritalin, second 12 50.250 20.055 5.789

Ritalin, ® fth 12 45.583 16.855 4.866

Note. Grade (® rst, second, ® fth) F(1, 11) 5 4.273, p , .05

FIG. 5. Interaction Plot for Reading Data Grades 1, 2, and 5.

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TABLE VI. Means table for math total scores

Count M SD SE

Contrast, ® rst 13 62.538 17.270 4.790

Contrast, second 13 56.462 17.338 4.809

Contrast, ® fth 13 63.615 16.414 4.552

Ritalin, ® rst 13 42.000 21.645 6.003

Ritalin, second 13 38.923 15.408 4.273

Ritalin, ® fth 13 44.615 21.608 5.993

Note. Grade (Ritalin vs Contrast) F(1, 12) 5 13.963, p , .003

FIG. 6. Interaction Plot for Math Total Grades 1, 2, and 5.

Ritalin had signi® cant Math de® cits, when compared to the Contrast group, before

receiving treatment and those de® cits remained but did not appear to exacerbate

over time.

The group means for the Vocabulary section of the ITBS are presented in Table

VII. Again it appears that the groups started out with similar scores in ® rst grade and

diverged from that point. This trend is evident in the interaction plot presented in

Figure 7.

However, due to variability within the groups on the Vocabulary section of the

ITBS, no signi® cant group differences at any age level were obtained. Finally, the

Complete Composite score on the ITBS re¯ ects a child’ s summative performance in

all achievement areas. The group mean scores on this section of the test are

presented in Table VIII.

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The mean group differences observed in both ® rst and second grade approached

but did not reach signi® cance. However, the larger difference obtained for the ® fth

grade Complete Composite score revealed that, at that time, the children in the

Ritalin group were achieving at a level signi® cantly below the Contrast group

(t 5 2.712, df 5 12, p , .05). The difference between the two groups at the time of

the ® fth grade testing is readily observable in Figure 8.

Dosage Levels and Behavioural Programs

Thirteen of the 14 remaining children in the Ritalin group were still taking stimulant

medication in ® fth grade. Based on the information that was available at the end of

® fth grade, all but one of the children had dosage increases over the 4-year period.

Of the 13 children in the Ritalin group, three were receiving counselling and two

students had a speci® c behaviour management plan for noncompliant behaviour. In

addition, three children were in special educational programming. Otherwise, no

other interventions were documented in their cumulative folders.

TABLE VII. Means table for vocabulary scores

Count M SD SE

Contrast, ® rst 12 55.417 13.173 3.803

Contrast, second 12 55.167 17.857 5.155

Contrast, ® fth 12 53.417 14.438 4.168

Ritalin, ® rst 12 54.250 17.003 4.908

Ritalin, second 12 47.750 10.805 3.119

Ritalin, ® fth 12 47.147 21.155 6.107

FIG. 7. Interaction Plot for Vocabulary Grades 1, 2, and 5.

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TABLE VIII. Means table for complete composite scores

Count M SD SE

Contrast, ® rst 12 60.083 14.081 4.065

Contrast, second 12 56.583 20.3152 5.817

Contrast, ® fth 12 60.000 17.184 4.960

Ritalin, ® rst 12 51.583 11.634 3.359

Ritalin, second 12 48.333 15.078 4.353

Ritalin, ® fth 12 44.000 13.618 3.931


FIG. 8. Interaction Plot for complete Composite Grades, 1, 2, and 5.

Discussion

This study was designed to identify cognitive and achievement differences between

children diagnosed with AD/HD and a matched group of children without AD/HD

in an ecologically valid setting. Results of the study are important because the

etiology and treatment of AD/HD continue to be ambiguous, yet this disorder is so

widespread that as many as 1 in 20 elementary level children in the US is currently

receiving stimulant medication for treatment of AD/HD. In 1995, AD/HD overtook

LD in terms of incidence in elementary-aged children (Shorter, 1997).

The symptoms associated with AD/HD (impulsiveness, hyperactivity, and dis-

tractibility) frequently generate problems with peer, teacher, and parent relations as

well as with academic achievement. Stimulant medications continue to be the most

widely used type of pharmacological interventions with behavioural and educational

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interventions being much less frequently employed (Alto & Frankenberger, 1995).

Stimulant medication such as Ritalin and Dexedrine are administered to children in

an effort to improve attention to educational tasks and reduce distractibility and

disruptive behaviour. By controlling symptoms of AD/HD, they are generally

purported to improve academic functioning, however, this assertion has not been

consistently supported empirically . At least, long-term positive effects of stimulants

on achievement have not been established.

Demographic Information for Children Identi ® ed as Having AD/HD

Of the 13 children in the Ritalin group, 31% received special education services by

the time they were in ® fth grade, whereas only 20% of the Contrast group received

these services. Other studies have also found that AD/HD often co-exists with other

disabilities (McKinney, Montague, & Hocutt, 1993). In fact, Runnheim et al.

(1996) found that 40% of children in elementary ED classrooms were being treated

for AD/HD with stimulant medication and Aspenson et al. (1996) reported that

23% of children in LD classrooms were also diagnosed with AD/HD.

It should also be noted that 5 of the 13 children in the stimulant group were

receiving special intervention programs aimed at reducing the affects of their

AD/HD-related behaviour. The proportion of children who had supplementary

programs designed to directly address their AD/HD symptoms is higher than in past

studies (Alto & Frankenberger, 1995; Weber et al., 1992).

Another trend that is important to mention is that dosage levels tended to increase

over the time of the study. When ® rst placed on the medication, most of the children

were receiving either 5 mg or 10 mg twice per day. By the spring of their ® fth grade

year, they were generally receiving dosages of 15 mg to 20 mg twice per day. These

increases are signi® cant in that any increase in dosage level carries a concomitant

risk of increased side effects.

Effects of Ritalin on Cognitive Abilities

The Ritalin and Control groups were matched in ® rst grade on Verbal scores on the

Cognitive Abilities Test of the ITBS. The interaction plot for Cognitive Verbal

scores revealed a small group difference in ® rst grade and almost no difference

between the groups in second grade. In essence, it appeared that the children in the

Ritalin group were catching up with the children in the Contrast group. However,

by ® fth grade, the Ritalin group’ s Verbal scores dropped signi® cantly compared to

the Contrast group. This pattern was also observed in the nonverbal section of the

Cognitive Abilities Test. There were no signi® cant nonverbal abilities differences

between the two groups in ® rst and second grade; however, in ® fth grade the

Contrast group’ s scores improved, while the Ritalin group’ s performance declined

and there was a signi® cant difference between the two groups.

On the Quantitative section of the Cognitive Abilities Test a different pattern

emerged. Children in the Ritalin group scored signi® cantly lower than the Contrast

group on both the ® rst and second tests but the group differences were not

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signi® cant at the ® fth level grade level. Overall, based on the data, the Ritalin

group’ s performance declined signi® cantly from second to ® fth grade on the Verbal

and Nonverbal sections of the Cognitive Abilities Test but there appeared to be a

slight recovery from initially large de® cits for the Ritalin group on the Quantitative

portion of the test. Other researchers have reported improvement in IQ scores on the

Wechsler Intelligence Scale for Children-Revised (WISC-R) (Wechsler, 1974) and

laboratory tests of cognitive ability in short-term (six month) studies but long-term

effects are unknown (Gittelman et al., 1983; Kupeitz et al., 1988; Rapport & Kelly,

1991).

Effects of Ritalin on Achievement Skills

In the achievement areas of Language, Reading, and Composite long-term achieve-

ment patterns were quite similar. In each case, the groups diverged more over time

with the largest group differences occurring at ® fth grade. In other words, the

children with AD/HD who were receiving stimulant medication were not catching

up to the Contrast group but were instead falling further and further behind. This

pattern was very similar to the pattern that was described above on the Verbal and

Nonverbal portions of the Cognitive Abilities section of the ITBS. A similar but less

clear pattern of divergence was observed for the Vocabulary section of the tests but

the achievement curves for the two groups on the Math Total section of the test

remained parallel from ® rst to ® fth grade. On the Math Total section of the ITBS,

children in the Ritalin group performed at a signi® cantly lower achievement level

beginning in ® rst grade and continuing through second and ® fth grade testing.

These ® ndings are in direct contrast to Kavale’ s (1982) report of children demon-

strating a 24% achievement gain on the ITBS.

In the area of achievement, reading achievement has received the greatest amount

of research. This is probably due to the fact that reading is such an important skill

for children in the early grades. In fact, the majority of children with early academic

dif® culties have problems learning to read. If strategies could be developed to

remediate early reading problems, many more children would have an opportunity

to achieve successfully. Unfortunately, results of the current study do not indicate

that treatment of AD/HS with stimulant medication is an ef® cacious treatment of

reading problems in children. Cannon (1995) reported that the Ritalin group

performed signi® cantly lower than the Contrast group on the Wisconsin Third

Grade Reading Test even though these children had been receiving Ritalin for

almost two years. Similar results regarding the relationship between Ritalin and

reading achievement were reported by Weber et al. (1992) and Aman and Werry

(1982). Gittelman et al. (1983) found occasional, ¯ eeting effects on reading per-

formance, but found no long-term effects. However, other researchers have reported

that Ritalin treatment did have a positive effects on reading achievement (Balthazor

et al., 1991).

In the present study, children received stimulant medication for between 3.4 and

4 years. If the stimulant medication had a robust effect on academic achievement it

should have been re¯ ected in a relative improvement in the Ritalin group’ s mean

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achievement scores. In fact, just the opposite effect occurred; the Ritalin group’ s

achievement appeared to deviate further below the Contrast group’ s over time in

several achievement and cognitive areas. This occurred despite the fact that the

children tended to receive higher doses of the medication over the same time

interval. If there is any evidence that the stimulant medication enhanced the learning

rate of the children with AD/HD, it was between ® rst and second grade where the

interaction plots revealed smaller differences and in some cases (Cognitive Verbal

and Nonverbal) a recovery on the part of the treated children. These ® ndings are in

line with those of Weber et al. (1992) who reported that children receiving stimulant

medication to treat AD/HD had large initial achievement de® cits that were stabilised

during the ® rst year of treatment with stimulant medication. However, they did not

observe subsequent increases in achievement level on the part of the treated

children. In summary, there does appear to be evidence of some short-term treat-

ment bene® ts for children who receive stimulant medication, but long-term bene® ts

are not apparent.

Possible Reasons for Lack of Ef® cacy of Stimulants over Time

Results of the present study do not support long-term stimulant therapy to amelio-

rate academic de® cits. In fact, the results of this study appear counterintuitive

because there is evidence that stimulant medication reduces the attentional and

behavioural concomitants of AD/HD in school settings (Barkley, 1977). If these

interfering symptoms are controlled it seems reasonable that children would learn

more over time. In fact, teachers often report that children behave much better and

produce better quality work after receiving the stimulant medication. However, the

history of the US military ’ s assessment of stimulant medication with civilians

working in arms factories during World War II and members of the Armed Forces

reveals the same type of effect evidenced in the current study. In essence, use of

stimulant medication resulted in short-term gains and long-term problems whether

in attempts to improve production in war-related industries or increase vigilance in

air crews. After a period of time the target effects of the medication were overshad-

owed by the side effects some of which were related to lack of sleep (McKim, 1997).

Perhaps the most frequent side effect of stimulants like Ritalin is a disruption in

normal sleep patterns. In fact, Barkley (1976) reported that sleep disturbance was

the most frequent side effect of the medication. According to McKim (1997) studies

have shown that stimulant medications cause insomnia and suppress REM sleep.

The stimulants are characterised by a marked REM rebound after withdrawal and

there is an increased percent of time spent in REM for a period of one to two

months (Oswald & Thacore, 1963). This medication induced reduction in REM

sleep may be important because there is compelling evidence linking REM sleep and

learning in animals (Hennevin, Hars, & Bloch, 1989; Smith & Wong, 1991).

Perhaps long-term treatment with stimulant medication would interfere with

achievement by disrupting REM sleep in children. This possibility should be

investigated in light of the fact that many preschool children are currently being

treated with stimulants and young children characteristically spend a high pro-

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portion of time in REM sleep. In addition, the current trend in medical practice is

to treat children at an early age and continue the treatment inde® nitely. If, as the

current study suggests, long-term treatment with stimulant medication may not

effectively ameliorate achievement de® cits, the doctrine of early and extended

treatment with stimulants may need to be reexamined.

Implications

Results of this study suggest certain implications. First, treatment with stimulant

medication does not appear to remediate the children’ s achievement de® cits over the

period from ® rst to ® fth grade. Considering the complexity and dif® culty involved

in remediating academic de® cits in any child, it is not surprising that stand-alone

medication would represent an inadequate means of treating signi® cant achievement

de® cits in children. At the very least, children with academic dif ® culties need a well

planned educational intervention program that directly addresses their speci® c

de® cits and includes an individualised, integrated plan that may include educational,

behavioural, psychological, and pharmacological interventions. The majority of the

children in the Ritalin group, who were in general education classrooms, had no

supplementary programs.

Second, teachers and other professionals should be very thoughtful in their

recommendations to parents. Research by Runnheim et al. (1996) revealed that

teachers were the professionals who most frequently made the initial referral for

suspected AD/HD. Parents are often told that by placing their child on stimulant

medication they will be helping their child academically when the data do not

support that claim. Medication may be an effective supplement to educational

interventions but there is evidence that its ef® cacy has been oversold by many

individuals. If teachers suggest stimulant medication, they need to have evidence

that the medication is likely to be effective for a particular child but many teachers

have abdicated their professional judgment to the medical ® eld. An article by Reid,

Vasa, Maag, and Wright (1994), suggests that because AD/HD is viewed as a

medical concern, educators and other professionals view assessment and interven-

tion as out of their realm of competency. However, most of the symptoms of

AD/HD predominantly interfere with social interactions and work performance in

the school setting. Therefore, school personnel should play an integral part in the

assessment and treatment of AD/HD. Again, communication between the school,

home, and physician’ s of® ce is one of the best ways to implement an effective

treatment plan that may include curricular modi® cations, behaviour management,

self-monitoring, cognitive therapy, as well as pharmacological treatment, if necess-

ary, to help children with AD/HD obtain success in school.

Limitations

The current study has several limitations that must be considered when interpreting

the results. First, it was not feasible for the researchers to randomly assign children

with diagnosed but untreated AD/HD to treatment and placebo conditions. This

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lack of random assignment is important, because even though the Ritalin group

tended to fall further behind the Contrast group over time, we do not know how the

achievement levels of the Ritalin group would have responded without medication.

Perhaps the Ritalin group’ s achievement scores were higher than they would have

been without the medication.

Second, the current study included a relatively small sample size. Only 13 of the

original 17 pairs of children were available for study from ® rst to ® fth grade.

Longitudinal studies employing larger sample sizes are certainly warranted.

Finally, the type and severity of AD/HD may be important determinants of the

stimulant medication’ s effectiveness in ameliorating achievement de® cits. The chil-

dren in the present study had AD/HD of the predominantly hyperactive type but

there was no attempt to measure the severity of an individual’ s symptoms. However,

it should be noted that only one of the 14 children who were originally diagnosed

with AD/HD and placed on stimulant medication after ® rst grade was taken off

medication before the end of ® fth grade.

Author Note

This research was supported by a grant from the UW-Eau Claire University

Research and Creative Activities program. The authors would like to express their

appreciation to the participating public school district’ s Department of Pupil Ser-

vices for their assistance with this research. The authors would also like to thank

Stephanie Doherty and Kelly Gonske for their help with the preparation of this

manuscript.

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effects of ritalin on academic achievement from first to fifth grade

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