Attention Deficit Hyperactivity Disorder, Creativity, and the Effects of Methylphenidate

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Attention

Deficit

Hyperactivity

Disorder,

Creativity,

and

the

Effects

of

Methylphenidate

Jeanne B. Funk, PhD; John B. Chessare, MD, MPH; Michael T. Weaver, RN, PhD; and Anita R. Exbey, MA

ABSTRACT. Given that children with attention deficit

hyperactivity disorder (ADHD) are more impulsive than peers, this study explored whether they are correspond-ingly more creative, and whether creativity declines when impulsivity is decreased through methylphenidate (Ritalin) therapy. A repeated-measures

quasi-experimen-tal design was used to compare the performance of 19

boys with previously diagnosed ADHD and 21

compar-ison boys aged 8 through 11 on two administrations of

alternate forms of the Torrance Tests of Creative

Think-ing-Figural (nonverbal). Boys with ADHD received

pre-scribed methylphenidate only for the first session. Over-all, mean Torrance summary scores for comparison boys (mean = 115.1, SD = 16.1) were higher than for boys with

ADHD (mean = 107.6, SD = 12.7). However, the

differ-ence between means was small (7%) and did not meet the 25% criterion for a clinically significant difference. No changes in performance over time (comparison group) or

medication state (ADHD group) were observed. These

data suggest that, when measured nonverbally, the

cre-ative thinking performance of boys with ADHD is not

superior to that of peers who do not have ADHD.

Re-garding the effects of methylphenidate, prescribed

ther-apy did not influence performance on this measure of

creative thinking. Pediatrics 1993;91:816-819; attention deficit hyperactivity disorder, methylphenidate, creativity, Torrance Tests of Creative Thinking.

ABBREVIATIONS. ADHD, attention deficit hyperactivity

disor-der; ADDH, attention deficit disorder with hyperactivity; WISC-R, Wechsler Intelligence Scale for Children-Revised.

Children with attention deficit hyperactivity dison-den (ADHD) are impulsive, distractible, and disorga-nized. It has been postulated that creativity is related to a more adventurous, nonconforming, and impul-sive cognitive style.1 Therefore, some clinicians have suspected that children with ADHD may demon-stnate superior creativity. Some have proposed in-creased creativity as an actual benefit of the syn-drome and have recommended that parents be counseled accordingly.2

Methylphenidate (Ritalin) and other stimulant medications are often prescribed as one component of treatment for ADHD. One desired outcome is a

From the Department of Pediatrics, Medical College of Ohio, Toledo.

Received for publication Sep 10, 1992; accepted Dec 21, 1992.

Published in abstract form in Pediatr Res 1992;31:1OA. Presented, in part, at the Society for Behavioral Pediatrics Annual Meeting in St Louis, MO,

September 21, 1992, and published in abstract form in JDev Behav Pediatr

1992;13:306.

Reprint requests to (J.B.E) Dept of Pediatrics, Medical College of Ohio, P0 Box 10008, Toledo, OH 43699.

decrease in impulsivity. Assuming that a degree of impulsivity is an important component of creativity, as methylphenidate decreases impulsivity, is there a concomitant decline in creativity? Because there is no conclusive empirical work to either justify or allay

this concern, our study addressed two questions: (1)

Is there a measurable difference in creativity between children with ADHD and those who do not have this disorder and (2) Does prescribed methybphenidate therapy influence creativity in children with ADHD?

WHAT IS CREATIVITY?

The concept of creativity is multidimensional and

resists simple definition. For this investigation, we

chose to focus on creative thinking as the dimension potentially most susceptible to the unwanted effects of methylphenidate. Creative thinking is presumed to require spontaneity, an openness to experience, a willingness to take risks, and an ability to disregard the conventional.3 These attributes have also been associated with ADHD and impulsivity.2

IMPULSIVITY AND CREATIVE THINKING

One early study was found which specifically eval-uated hypothesized relationships between aspects of creative thinking and impulsivity. In 1968 Wand4 evaluated whether children designated impulsive by laboratory definition also demonstrated more diver-gent thinking. Divergent thinking, or the ability to produce more than one of several possible “correct” answers, is often considered to be one component of creative thinking. Groups of relatively reflective and impulsive boys were defined by using the Haptic-Visual Matching Test. This test requires an individual to manipulate wooden cutouts placed out of sight, and then to match the cutout to one of five drawings. Measures of relative impulsivity were time spent in initial exploration, latency to choice of drawing, and number of errors in matching. Using a verbal meas-une,5 Wand determined that children grouped as “im-puisive” by his specific laboratory definition were not superior to reflective children in divergent think-ing. Because this study predates current conceptual-izations of ADHD, Ward did not relate his findings to

this clinical population. He did, however,

acknowb-edge a need for further investigation of potential relationships between impulsivity and creativity.

METHYLPHENIDATE, ADHD, AND CREATIVITY

Two more recent studies examined both the

nela-tive performance of children with and without ADHD and the effects of methylphenidate on the

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performance of children with ADHD on tasks meas-uning components of creative thinking.6’7

Solanto and Wender’ administered two divergent thinking tasks6 similar to those used by Ward4 to 19 children with attention deficit disorder with hyper-activity (ADDH) and 18 control subjects. The main focus of the study was to evaluate the effects of dif-fenent dosage levels of methylphenidate on task per-fonmance. Children with ADDH were tested on four levels of methylphenidate, including a placebo. No performance difference was found between the groups in the baseline (no medication) condition. When methylphenidate was administered, the per-formance of children with ADDH was superior to their performance on placebo days. While there was no baseline difference in the performance of the two groups (when children with ADDH received no med-ication), the study design does not allow comparison

oven time of control children and those with ADDH

(only 4 control children were tested more than once).

The studies cited above4’6 suggest that, when Un-treated, impulsive children will not demonstrate su-penior ability in verbal measures of divergent think-ing. The effects of methylphenidate therapy on other dimensions of creative thinking were not explored.

Curiosity is another component of creative think-ing. Using two verbal, one nonverbal, and two mixed

measures of “curiosity,” Feidben and Ullman7 evalu-ated the performance of “hyperactive” boys with and without their prescribed dose of methylphenidate. Matched nonhyperactive control children were also tested. The groups did not differ on three of the measures, and hyperactive boys received higher scores on a mixed measure and lower scores on a verbal measure. Medication decreased the scones of hyperactive boys on the mixed measure where they were initially superior, but not below the perfor-mance level of control children on that task. Based on these results, it appears that children with hyperac-tivity do not differ from control children on most measures of curiosity and that medication has a mm-imal effect on performance on curiosity tasks. How-ever, no general conclusions can be drawn either from this study or from Ward’s4 or Solanto and Wenden’s6 study regarding the relative abilities of children with ADHD when multiple components of creative thinking are assessed, or about the effects of prescribed doses of methylphenidate on these abii-ties. Performance on nonverbal measures, which may lessen the influence of the cognitive and inter-actional problems that often accompany ADHD, also has not been thoroughly studied.

PREDICTIONS

Our study was designed to use primarily

nonven-bal criteria to address the questions of whether

ADHD is accompanied by increased creative

think-ing abilities and whether performance on a test mea-suning multiple components of creative thinking is altered by prescribed methylphenidate therapy. Given (I) only limited previous research on these specific questions, (2) the theoretical significance of impulsivity for creativity, and (3) the fundamental quality of increased impulsivity in the ADHD

pop-ubation, we predicted that boys with ADHD would

perform better on a standardized measure of multi-pie dimensions of creative thinking than comparison

(non-ADHD) boys. Regarding the second question of

medication effect, our interest was primarily in the practical question of the impact of methybphenidate therapy at the prescribed dosage bevel. With incon-clusive findings from past creativity studies, and nec-ognizing that knowledge about methylphenidate’s effects on specific cognitive functions is emerging,8’9 we chose the conservative prediction that a therapeu-tic dose of methyiphenidate would decrease penfon-mance on a standardized measure of creative think-ing.

Subjects

METHODS

Subjects were 8- to 11-year-old boys who were recruited

through mailings to parents. Names of potential subjects were

obtained through a local ADHD parent support group, the

prac-tices of hospital-based pediatricians, and from one private school.

Only boys retained in school for no more than I year were

in-cluded. To control for major intelligence deficiencies, participants

were required to achieve scaled scores of 8 or more on both the

Vocabulary and Block Design subtests of the Wechsler Intelligence Scale for Children-Revised (WISC-R),’#{176} administered individually during the first testing session by qualified examiners.

To be accepted into the ADHD group, three criteria had to be

met: the presence of ADHD must have been previously

deter-mined by physician or multidisciplinary team diagnosis, the child

must have been currently receiving methylphenidate therapy, and

there must have been elevations in Conners Hyperactivity Index

score” by parent report, based on behavior when not taking

me-thylphenidate. Comparison boys were required to have none of

the features outlined above, including current elevation on the

Conners. In most cases, the diagnosis of ADHD had been made by

a developmental pediatrician using questionnaires completed by

teachers and parents, school test results, direct parent interview,

and a child interview and physical examination. Current

meth-ylphenidate therapy was required for subjects with ADHD

be-cause one focus of the study was to examine the effects of

pre-scribed treatment with methylphenidate. The Conners score was

used as a screen, primarily to eliminate potential control subjects with behavioral features suggestive of ADHD or other significant

behavioral problems.

Accepting a 25% difference as clinically significant, a power

analysis was performed using data from a pilot study of 6 ADHD

and 5 comparison subjects. Results estimated power = .97 for

detecting a 25% difference on our measure of creative thinking

using 15 subjects per group.

Nineteen boys with ADHD and 21 comparison boys in grades

2 through 5 met all study inclusion criteria. Analysis of Conners

scores revealed a significant difference between the two groups

(t1381 - -9.08, P < .0001), with ADHD boys receiving higher

Conners T scores (mean = 78.63, SD = 14.13) than comparison

boys (mean = 44.33, SD = 9.53). No significant differences were

found between the groups on the following variables: age, grade,

performance on WISC-R subtests, parent report of learning or

behavioral problems, special class placement, socioeconomic

sta-tus (Hollingshead AB. Four Factor Index of Social Status.

Unpub-lished manuscript, 1975), or race (all were white). Methylpheni-date (Ritalin) dosage ranged from 0.14 to 1.0 mg/kg every 4 hours

(mean = 0.39 mg/kg per dose), with most receiving two doses per

day.

Procedure

Torrance Tests of Creative Thinking. The Torrance Tests of

Cre-ative Thinking’2 is a highly respected battery of verbal and

non-verbal measures of multiple components of creative thinking.’3

Reliability is adequate, and validity studies suggest that the test

does measure some important dimensions of creativity.’3 We chose

the Figural (nonverbal) version of the Torrance. This consists of

two equivalent forms (A and B), each with three 10-minute

draw-ing activities. The child is given partial line drawings and asked to at Viet Nam:AAP Sponsored on September 1, 2020

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*See Torrance and Ball’2 for detailed scoring criteria.

make original pictures and give each one a title. Then each

draw-ing is scored usmg objective criteria. The primary measure of

creative thinking is the Creativity Index, a summary score which

is calculated by averaging the standard scores (mean = 100, SD =

20) from five norm-referenced categories of specific creative abil-ities, and then adding the score (range 0 to 26) from the 13-item criterion-referenced Creative Strengths Checklist (Table 1).

Study Questionnaire. Parents of all participants completed a

background questionnaire designed for the study. In addition to

basic demographic information, we obtained medical and

educa-tional history for the child and other family members, including

information about learning and behavioral problems, grade

reten-tion, and special class placement.

Prescreening. After volunteering, parents were contacted by

telephone. More information was given about the study and a

brief interview was conducted to confirm that potential subjects

met study criteria, and then the first of two testing sessions was

scheduled. Parents of boys with ADHD were instructed to

admin-ister the prescribed methylphenidate dose 30 minutes prior to the

first of two testing sessions. Most families received reminder calls I or 2 days prior to the session.

Session 1. Written consent was obtained from parents, and boys

signed assents. The time of methylphenidate administration was

recorded for boys with ADHD and then they were weighed. All

other procedures for both sessions were identical for the two

groups. Parents completed the study questionnaire and the

Con-ners Hyperactivity Index. All testing of subjects was done

mdi-vidually. First, the WISC-R subtests were administered. Data from

boys with scores less than 8 on either subtest were not included in the final analyses and they did not participate in session 2. Next,

either Form A or Form B (counterbalanced) of the Torrance was

administered by trained examiners. The second session was then

scheduled and the boys with ADHD and their parents were

re-minded that the boys were not to take methylphenidate before the

session.

Session 2. Withholding of methylphenidate was confirmed for

boys with ADHD. All boys were given the alternate form of the

Torrance. Some boys and parents then completed questionnaires

for another project.

Data Scoring. Examiners scored WISC-R protocols. Torrance

protocols were scored by the Scholastic Testing Service. The

Ser-vice did not have any information about the purpose of the study

or about group membership.

RESULTS

The data were analyzed using a two by two

ne-peated-measunes analysis of variance, with multi-variate analysis of the repeated-measures factor.

Order of test form administration did not affect Creativity Index values (F[1, 361 = 1.20, P =

.28).

There was no difference in creative thinking scones

TABLE 1. Torrance-Figural Categories*

Creative Ability Simplified Criteria

Fluency Total number of drawings

Originality Uniqueness of subject

Abstractness of Titles Descriptive quality of title

Elaboration Number of details

Resistance to Closure Uniqueness of stimulus use

across dosage ranges (Pearson r = -.29, P = .24). The

groups performed in a comparable manner oven time (F[1, 381 = .01, P = .90), and there was no significant

change in the performance of groups over time (com-panison group) on medication state (ADHD group) (FF1, 381 = .39, P = .54). Comparison boys performed

better on the Creativity Index than did boys with

ADHD (F[1, 38] = 4.37, P = .04) (Table 2), with the

mean difference between groups approximately 7%

(Table 3).

DISCUSSION

Contrary to our prediction, multivaniate analysis revealed that comparison boys performed better than subjects with ADHD on the Torrance. If this is a reliable difference, the error in our prediction may anise from the presumption that impulsivity is fun-damental to creativity. One study14 suggests that the typically “impressionistic” cognitive approach of im-pulsive children requires less effort than the ap-pnoach of children who are more reflective. Cneativ-ity theorists, however, view the creative process as one that requires considerable effort.3 Perhaps the impressionistic cognitive approach of children with

ADHD outweighs the advantage of their increased

spontaneity, particularly in a structured test situation where a discrete creative performance is the criterion. We also recognize that any single measure will only describe a subset of the components of creative think-ing. The effects of ADHD and methylphenidate may vary with different components of the creative pro-cess.

Even though comparison boys did perform better on the Torrance than boys with ADHD, the difference of 7% is below our criterion for a clinically significant difference and probably without important practical implications. More naturalistic measures of creative thinking may be useful in determining whether dif-ficulties with structured testing situations prevent children with ADHD from fully demonstrating cre-ative potential, and perhaps in describing more util-itanian creative abilities.

Our hypothesis that the ADHD group’s penfon-mance on a nonverbal creative thinking task would be adversely affected by methybphenidate also was not supported. Boys were tested after having ne-ceived their typical methylphenidate dose, which for most was within the recommended, published range for dose by weight. Recognizing that work in the area of the specific neural effects of methylphenidate re-mains exploratory,9 one explanation is that meth-ylphenidate does not independently influence the neural activity involved with the processing

neces-Creative Strengths

Emotional Expressiveness Storytelling Articulateness

Movement or Action

Expressiveness of Titles Synthesis, Figures and Lines Visualization, Unusual and Internal Breaking Boundaries

Humor

Imagery, Richness and Colorfulness Fantasy

TABLE 2. Repeated-Measures Analysis ences in Creativity Index

of Variance:

Differ-Source Statistic F* J7

Group 1195.7+ 4.37 .04

Error 273.5t

Time .0102 0.39 .54

Time x Group .00041 0.01 .90

*dfl, 38. .F Mean square.

::Hotelling-Lawley Trace.

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TABLE 3. Creativity Index Score by Group and Time

Group Time P Time 2

Mean SD Mean SD

ADHD 107.63 12.67 108.79 13.47

Comparison 115.10 16.05 116.81 12.52

* All children with attention deficit hyperactivity disorder

(ADHD) had taken their prescribed dose of methylphenidate.

sary for nonverbal creative thinking tasks. Solanto and Wender,6 studying the effects of varying dosage

bevels on verbal divergent thinking, concluded that

methylphenidate actually sustained performance oven several trials. We propose that, considered to-gether, the results of the present study and those of Solanto and Wenden6 strongly suggest that meth-ybphenidate does not impair some dimensions of cre-ative thinking performance in children with ADHD.

The present study is limited by design issues

de-scnibed above, by the relatively restricted age group,

by

testing only white boys, and by using only one

measure of creative thinking. Our study was de-signed to address the possible effects of prescribed methylphenidate therapy, and we did not control the initial ADHD evaluation process on the child’s

dos-age of methylphenidate during testing. Although we

believe that potential expectancy effects were miti-gated by the unfamiliar nature of the task and by utilizing a professional scoring service, at this stage of the field’s development it may be preferable to use a placebo control. To clarify the role of impulsivity in

the creative process, future work should include a

specific measure of impulsivity. Finally, we must

em-phasize

that there are countless potential expressions

of creativity. Therefore, developing a comprehensive understanding of the creative abilities of children with ADHD will require additional study using a variety of creativity measures with more diverse populations.

REFERENCES

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atten-tion deficits. Pediatr Cliii North Am. 1982;29:105-120

3. Sternberg RJ, ed. The Nature of Creativity: Contemporary Psychological Perspectives. New York, NY: Cambridge University Press; 1988 4. Ward WC. Creativity in young children. Child Dcv. 1968;39:737-754 5. Wallach MA, Kogan N. Modes of Thinking in Young Children. New York,

NY: Holt Rinehart & Winston; 1965

6. Solanto MV, Wender EH. Does methylphenidate constrict cognitive functioning? IAm Acad Child Adolesc Psychiatry. 1989;28:897-902

7. Feidler NL, UlIman 0G. The effects of stimulant drugs on curiosity behaviors of hyperactive boys. IAbnorm Child Psychol. 1983;11:193-206

8. Barkley RA, DuPaul GJ, McMurray MB. Attention deficit disorder with and without hyperactivity: clinical response to three dose levels of methylphenidate. Pediatrics. 1991;87:519-531

9. Rapport MD, Kelly KL. Psychostimulant effects on learning and cogni-tive functions: findings and implications for children with attention

deficit hyperactivity disorder. Cliii Psychol Rev. 1991;11:61-92 10. Wechsler D. Manual for the Wechsler Intelligence Scale for Children-Revised.

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12. Torrance EP, Ball OE. Torrance Tests of Creative Thinking: Streamlined (Revised) Manual. Bensenville, IL: Scholastic Testing Service Inc; 1984

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14. Smith JD, Kemler Nelson DG. Is the more impulsive child a more holistic processor? A reconsideration. Child Dev. 1988;59:719-727

DIOGENES UNDERSTOOD THE NEED FOR CONCURRENT

CONTROLS

When shown the votive tablets [offerings to the gods] of sailors who escaped shipwreck “because they made their vows,” Diogenes the Cynic inquired “Where

are the portraits of those who perished in spite of their vows?”

Merton RK. The Sociology of Science. An Episodic Memoir. Carbondale, IL: Southern Illinois University

Press; 1979.

Submitted by Student

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1993;91;816

Pediatrics

Jeanne B. Funk, John B. Chessare, Michael T. Weaver and Anita R. Exley

Methylphenidate