One concern frequently expressed about stimulant medication treatment for children with ADHD is this: could the medications encourage children to discount the importance of their own efforts when they experience success, and attribute positive outcomes to the medication?

It has been argued that the use of medication could inadvertently teach children to believe they need pills to succeed, and possibly that it contributes to the development of subsequent problems with substance use/abuse. What are children's expectations about the effects of medication, and are their explanations for day-to-day successes and failures influenced by medication treatment?

These interesting questions were examined in a study published in the Journal of Consulting and Clinical Psychology (Pelham et al., (2002). Effects of methylphenidate and expectancy on children with ADHD: Behavior, academic performance, and attributions in a summer program and regular classroom settings. 70, 320-335.)

Participants were 136 boys, ranging in age from 7.6 to 12.7 years, who attended an intensive eight-week summer treatment program for ADHD that included both academic and recreational activities. One aspect of the program was a Daily Report Card system in which individualized behavioral goals were developed for each child in four different domains: classroom behavior, classroom performance, adherence to rules, and behavior with peers.

At the end of each day, children were provided feedback about whether they had reached each goal for that day. (The criteria required for the goals to be considered "met" were adjusted during the summer as the children progressed, thereby maintaining a consistent level of challenge.)

Two weeks into the summer program, participants began a trial period in which they received stimulant medication (i.e. methylphenidate). Prior to beginning this medication trial, the children were told that on some days they would receive placebo pills in an effort to learn whether the medication really helped them. They also were informed they would be told which type of pill -- real vs. placebo -- they received on a given day. They were not told, however, that on half the days the information provided about which pill they had taken would be incorrect.

Thus, on some days children were given real medication and told it was real. On other days, they were given real medication and told it was placebo. Similarly, on some days they received a placebo and were told it was real. And, on other days, they received a placebo and were told it was a placebo. The counselors and teachers who were working with the children, and providing daily ratings of their behavior, were not told whether the children had received active medication or placebo, nor what the children themselves had been told.

Measures

Several measures were collected each day to determine how well children expected to do in meeting their Daily Report Card goals, how well they actually did, and how they explained their daily successes and struggles.

First, after being told whether they had received real or "fake" medication, children were asked to predict whether they would succeed in meeting their goals that day. Ratings were made on a 1 (very poorly) to 10 (very well) scale. These ratings allowed the researchers to determine whether the children's medication-related expectations influenced their expectations for daily success.

Second, behavioral ratings were collected from the counselors and teachers, as were teacher ratings of academic performance. Teacher and counselor ratings for the Daily Report Card also were examined. These measures enabled the researchers to determine whether children's medication expectations (i.e. whether they were told they had received real medication) and actual medication condition (i.e. whether they actually received medication or placebo) influenced their behavioral and academic success during the day.

Finally, the researchers obtained children's attributions for their daily successes and failures. After being told whether they had achieved their Daily Report Card goals, participants were asked why this had occurred. For each goal, the children rated the degree to which their success or failure was attributable to: their ability, the difficulty of the goal, how hard they had tried, how much the medication helped, and how fairly teachers/counselors had treated them (or, in the peer domain, how nice the other children were.)

Each reason was rated on a 1 (really true) to 10 (not true at all) scale. These data enabled the researchers to examine how children's attributions of success or failure varied according to whether they had actually received medication and whether they believed they had received medication.

RESULTS

As anticipated, children anticipated more success meeting their goals when they were told they had received real medication than on days when they were told the medication was a placebo. The differences in success predictions were not large, however, (average predictions of 8.4 vs. 8.0 on the 1-10 scale described above), and children clearly expected to be successful even when told they had received placebo medication. Thus, even though they were somewhat more confident of succeeding when informed they had been given real medication, they were inclined to expect success regardless.

Results for the behavioral ratings were also interesting. For counselors' ratings, children were reported to do significantly better on a wide range of behaviors (e.g. following rules, interrupting, etc.) when they had received real medication than on placebo days. The same was true for teachers' behavior ratings and for the quality of the children's academic work. In regards to the Daily Report Card, children were more than 4 times as likely to achieve their classroom behavior, classroom work, and getting-along-with-counselors goals on days when they had been given medication. They also were almost 2.5 times as likely to meet their social goals with peers on the days they received real medication.

In contrast to these largely positive effects of medication, there were no significant effects for expectancy condition. This means that telling children they have received medication when they were actually given a placebo does not result in an improvement in their performance. And, telling children they were given placebo when they were actually given medication doesn't diminish the actual benefits of the medication. In other words, what really matters in terms of children's success is whether or not they received active medication, regardless of what they were told.

The last issue examined was the attributions children made for their successes and failures in achieving their Daily Report Card goals. Overall, there was little indication that boys regarded medication as an important reason for either their success or failure. When boys succeeded in meeting their goals, they consistently rated the "pill" as the least important determinant for their success. Instead, they rated their effort and ability level as far-more-important determinants of their success.

(Note: In addition to the results presented above, the researchers conducted a similar study using most of the same children, after they had completed the summer program and were back in their regular schools. The purpose of this follow up study was to determine whether results obtained in the summer treatment program would generalize to children's regular classrooms.)

This is exactly what was found. As reported above, children behaved better, experienced greater classroom success, and were more likely to meet their daily goals on medication days than on placebo days, and this was true regardless of what they had been told. In fact, behavioral differences between medication and placebo days were greater than those found during the summer program. This probably reflects the fact that there was no carefully implemented behavioral program in the regular school setting, making it more difficult for children to succeed on placebo days. Once again, there was no evidence that children regarded medication as an important reason for their success. Instead, they again rated effort and ability level as being the most crucial factors for success in achieving their Daily Report Card goals.

SUMMARY AND IMPLICATIONS

The results of this study have several interesting and important implications. First, although children may expect more success when they believe they have received medication, boys with ADHD tend to expect success even when not on meds. In fact, their expectations for success when not on meds may be overly optimistic.

On the one hand, it is encouraging that ADHD boys in this age group appear to expect positive outcomes and generally anticipate being able to accomplish their daily goals. On the other hand, these optimistic expectations could create difficulties through boys failing to recognize what may be required in order for them to succeed.

It would be interesting to know whether similarly positive expectations were found for girls with ADHD, as well as adolescents. Because adolescents with ADHD have struggled for a longer time than the boys in this study, their expectations may not be so optimistic.

Results from this study also highlight the significant benefits that many children with ADHD derive from medication treatment. Recall that during medication days, boys were far more likely to achieve their daily goals than on placebo days, even though a very carefully implemented behavioral plan was in place throughout. They also were doing better on virtually every dimension rated by counselors and teachers, including the quality of their academic work. These findings highlight that, although behavioral intervention can be an effective treatment for children with ADHD, a multi-modal approach that includes carefully monitored medication treatment is likely to be more effective for many children.

Finally, despite concerns that ADHD children treated with medication will discount their own efforts as a reason for success, and instead attribute any success they experience to medication, this does not seem likely to occur. As discussed above, boys consistently believed the most important reasons for their success were their effort level and ability, and they downplayed the role of medication. Thus, although some children treated may come to believe that medication is the primary reason for their success -- and it is important to attend to this possibility -- there was no evidence that this is a frequent occurrence. In fact, the authors raise the opposite concern, namely that boys with ADHD may minimize the role of medication treatment in their success.

The potential problem with this is that as children get older, they may decide to stop taking medication because they do not believe it is necessary for them to succeed. In fact, follow-up data from other studies have shown that a large number of adolescents who have received medication treatment for ADHD during childhood discontinue taking medication, even though many could continue to benefit from it. As a result, these teens may experience negative outcomes because they are no longer receiving a necessary treatment.

The authors suggest that providing children with a realistic understanding of the benefits of medication could be helpful in preventing this premature discontinuation. They emphasize that parents, teachers, and health professionals should be careful not to inadvertently contribute to the emergence of "negative cognitive styles" by emphasizing to children the role of medication in their daily successes and failures.

Instead, for children who respond positively to medication (and remember, not every child with ADHD does), they suggest that adults should work to "develop realistic medication attributions in children that strike a balance between a belief that they are completely dependent on medication, on the one hand, and complete denial of medication effects, on the other hand."