Applied Neuropsychology: Child

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/hapc20

Osmotic Release Oral System-Methylphenidate

Hydrochloride (OROS-MPH) versus atomoxetine
on executive function improvement and clinical
effectiveness in ADHD: A randomized controlled
trial

Yasemin Taş Torun , Yasemen Işik Taner , Esra Güney & Elvan İseri

To cite this article: Yasemin Taş Torun , Yasemen Işik Taner , Esra Güney & Elvan İseri (2020):
Osmotic Release Oral System-Methylphenidate Hydrochloride (OROS-MPH) versus atomoxetine
on executive function improvement and clinical effectiveness in ADHD: A randomized controlled
trial, Applied Neuropsychology: Child, DOI: 10.1080/21622965.2020.1796667

To link to this article: https://doi.org/10.1080/21622965.2020.1796667

Published online: 06 Aug 2020.

Submit your article to this journal

Article views: 9

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=hapc20
APPLIED NEUROPSYCHOLOGY: CHILD
https://doi.org/10.1080/21622965.2020.1796667

Osmotic Release Oral System-Methylphenidate Hydrochloride (OROS-MPH)

versus atomoxetine on executive function improvement and clinical
effectiveness in ADHD: A randomized controlled trial
Yasemin Taş Torun , Yasemen Işik Taner €ney
, Esra Gu , and Elvan _Iseri
Child and Adolescent Psychiatry Department, Gazi University Medical Faculty, Ankara, Turkey

ABSTRACT KEYWORDS
Objectives: The aim of this study to compare the clinic efficacy and effects of osmotic release Attention deficit; executive
oral system-methylphenidate and atomoxetine on executive function in children and adolescents functions; treatment
with attention deficit hyperactivity disorder by a open-label, prospective, randomized con-
trolled trial.
Methods: The study was performed by 95 cases between ages 6 and 12 years who were diag-
nosed as attention-deficit/hyperactivity disorder (ADHD) and also 40 control individuals. In this
study, Conners’ Teacher Rating Scale (CTRS) was used in order to evaluate the efficacy of the treat-
ment. Executive functions were assessed by the performance-based neuropsychological tests and
ecological behavioral rating scales. Stroop test, cancellation test, and serial digit learning test were
applied to performance based neuropsychological tests. Behavior Rating Inventory of Executive
Function tests (BRIEFs) were used as behavioral assessment scales.
Results: Among the ADHD groups, a reduction of over 40% in the CTRS subtest scores used to
evaluate the efficacy of the treatment was considered to be an improvement, and no significant
difference was found for both drugs. Both Osmotic Release Oral System-Methylphenidate
Hydrochloride (OROS-MPH) and atomoxetine (ATX) significantly improved scores in neuropsycho-
logical tests.
Conclusion: Atomoxetine and OROS-MPH treatments have shown similar efficacy in clinical recov-
ery and improvement on executive functions. However, disturbances in executive functions
observed in children with ADHD are persistent despite treatment, when compared with the con-
trol group.

Introduction
Attention-deficit/hyperactivity disorder (ADHD) is a neuro-
psychiatric disorder characterized by attention deficit, hyper-
activity, and impulsivity symptoms that begin in childhood
(American Psychiatric Association [APA], 2013). Although
the diagnosis of ADHD is based on clinical signs of atten-
tion deficit and/or hyperactivity/impulsivity, hundreds of
experimental and theoretical studies have shown that neuro-
psychological deficiencies, especially executive functions,
play a role in this disorder (Barkley, 1997; Brown, 2006).
Executive function (EF) is an umbrella term that encom-
passes the set of higher-order processes (such as inhibitory
control, working memory, and attentional flexibility) that
govern goal-directed action and adaptive responses to novel,
complex, or ambiguous situations (Yildiz et al., 2011).
Neuropsychological tests are widely used in research into
executive functions in ADHD (Bakar et al., 2011; Homack &
Riccio, 2004; Willcutt et al., 2005). Although it is known
that there are many executive function impairments that are
closely related to the clinical presentation of ADHD,
whether these impairments persist after treatment has not
been clarified yet. There are numerous studies on the effects
of atomoxetine (ATX) (Adler et al., 2014; Brown et al.,
2011; Faraone et al., 2005; Gau & Shang, 2010; Maziade
et al., 2009; Shang & Gau, 2012; Wehmeier et al., 2011) and
methylphenidate (Biederman et al., 2011; Coghill et al.,
2014; Fallu et al., 2006; Karakaya et al., 2006; Kiriş et al.,
2013; Konrad et al., 2005; O’Driscoll et al., 2005; Yilmaz
et al., 2013; Zheng et al., 2015) on executive functions, two
of the most commonly used drugs used in ADHD treat-
ment, but comparative studies are fewer (Bedard et al., 2015;
Tasdelen et al., 2015; Ni et al., 2013; Yang et al., 2012; Yildiz
et al., 2011). The results of one of these comparative studies,
which included 26 patients aged 8–14 diagnosed with
ADHD and under treatment with Osmotic Release Oral
System-Methylphenidate Hydrochloride (OROS-MPH) or
ATX, showed significant improvement in executive func-
tions compared to pretreatment in both drugs groups. The
study also demonstrated that OROS-MPH treatment was
more effective in terms of variables such as perseveration
and interference resistance as a result of the neuropsycho-
logical test battery (Wisconsin card sorting test, visual mem-
ory test, Stroop test) (Yildiz et al., 2011). In another study

CONTACT Yasemin Taş Torun ysmn.ts@gmail.com Child and Adolescent Psychiatry Department, Gazi University Medical Faculty, Ankara, Turkey.
ß 2020 Taylor & Francis Group, LLC
2 Y. TAŞ TORUN ET AL.
with a similar design including 33 ADHD patients aged
7–12, the Wisconsin Card Sorting Test, the Visual Auditory
Number Sequence Test, and the Stroop test (VANS-B) were
performed before and after 20 weeks of followup. The con-
clusion was similar to other studies, where both drug groups
were observed to have increased test performance, but ATX
treatment was more effective in terms of the auditory, ver-
bal, and written task performances measured in VANS-B
(Tasdelen et al., 2015). Another study by Yang et al. (2012)
compared the efficacy of OROS-MPH and ATX on executive
functions in 142 children with ADHD aged 7–14. In this
study, Behavior Rating Inventory of Executive Function-
Teacher–Parents (BRIEF) scales, Rey Complex Figure Test,
Digit Span Test, Tower of Hanoi Test, verbal fluency test,
Trail-Making Test, and Stroop test were used to evaluate
executive functions. As a result, all performance-based tests
including working memory, inhibition, attention shifting,
verbal fluency, and planning were observed to be signifi-
cantly improved in the OROS-MPH group. In the ATX
group, a significant improvement was observed in working
memory and inhibition skills. BRIEF evaluations showed sig-
nificant improvement compared to baseline in both drug
groups (Yang et al., 2012). Another study compared execu-
tive functions using Cambridge Neuropsychological Test
Automated Battery (CANTAB) before and after treatment
with IR-MPH and ATX in adult ADHD patients. The study
showed that both drugs had a curative effect on executive
functions after treatment, but ATX was more effective in
terms of spatial planning (Ni et al., 2013). A follow-up study
by Bedard et al. (2015) evaluated executive functions before
and after treatment in adolescents with ADHD, it was con-
cluded that methylphenidate treatment was more effective
than ATX in terms of measurements that were carried out
using continuous performance test.
In conclusion, although the effects of drug therapies
applied in ADHD have been shown to have improvement
on many executive functions, the mechanism of this activity,
which executive function is affected, and the individual dif-
ferences regarding efficacy have not been elucidated.
The aim of this study was to compare the effects of ATX
and OROS-MPH on executive functions and evaluate their
clinical effectiveness using performance-based neuropsycho-
logical tests and ecological behavioral rating scales.
Methods
Study design and patients
This prospective, randomized, open-label, follow-up study
compared the efficacy and effects of ATX and OROS-MPH
on executive functions in children and adolescents with
ADHD. The study duration was 18 weeks. All subjects
underwent a 1–2 week screening phase to determine the per-
sistence and severity of their diagnostic and eligibility crite-
ria at entry. The patients were randomly assigned to
treatment with either ATX or OROS-MPH. All measure-
ments were performed by the two authors. The patients in
this study were 6–12 years old at their initial visit and met
diagnostic criteria for ADHD and other comorbid
psychiatric disorders as defined by Diagnostic and Statistical
Manual of Mental Disorders–Fifth Edition (DSM-5) (APA,
2013). They were assessed by clinical interviews based on
DSM-5 and the Kiddy Schedule for Affective Disorders and
Schizophrenia (K-SADS) (Kaufman et al., 1997). Patients
with seizures, bipolar disorder, psychotic illness, mental
retardation, pervasive developmental disorder, and those
who were taking concomitant psychoactive medications
were excluded from the study. Baseline measurements
included medical history, the Conners’ Teacher Rating Scale
(CTRS), a neuropsychological tests battery (Stroop test,
Cancelation test, the Serial Digit Learning Test), and the
BRIEF. The CTRS, the neuropsychological test batteries, and
the BRIEF were repeated only at week 16, while other
assessments were repeated at weeks 4, 8, and 12. The exam-
iners and teachers who completed Conners were blind to
the study drug (ATX, OROS-MPH). This study was con-
ducted in accordance with the ethical principles of the
Declaration of Helsinki and the Good Clinical Practice
guidelines established at the International Conference on
Harmonization. The study protocol was approved by the
Gazi University Ethics Committee (number: 25901600-549).
In the patient group, a total of 100 patients were random-
ized to receive ATX or OROS-MPH. Treatment was initi-
ated at a standard specified dose (ATX: 0.5 mg/kg/day;
OROS-MPH: 18 mg/day administered as a single morning
dose) for all patients and increased to 1.2 mg/kg/day for
ATX and 36–54 mg/day for OROS-MPH based on the
reports of the parents and clinicians at weeks 4 and 8. Of
the 100 subjects randomized, 95 completed the study. Three
subjects who were administered ATX and two subjects who
were administered OROS-MPH discontinued the study.
Nausea and vomiting were reported as the reasons for dis-
continuation in the ATX group, and chest pain and palpita-
tions were the reasons in the OROS-MPH group. The
dosages in the ATX group (n ¼ 46) ranged from 18 to
60 mg/day (mean ¼ 1.18 mg/kg/day), and the dosages in the
OROS-MPH group (n ¼ 49) ranged from 18 to 54 mg/day
(mean ¼ 0.94 mg/kg/day). After psychiatric examination, 40
healthy volunteers aged 6–12 were included in the study as
a control group. The controls were administered the same
neuropsychological tests battery. This was a single-blind
randomized controlled trial study with only blind raters due
to the different appearance of the medications.
The Turkish version of the Kiddy Schedule for Affective
Disorders and Schizophrenia Present and Lifetime Version
(K-SADS-PL); this scale was developed by Kaufman et al.
(1997). Turkish validation and reliability studies were per-
formed by G€ okler et al. (2004). It allows the screening of
psychiatric diagnoses in a wide spectrum. In this study, indi-
vidual interviews with children and one of their parents
were made to complete the scale. Patients diagnosed with
any psychiatric disorder other than ADHD by K-SADS-PL
were excluded.
CTRS: This scale was developed by Conners (Conners,
1969) and revised by Goyette et al. (1978). It was adapted
into Turkish, and its validation and reliability studies were
performed by Dereboy et al. (2007). The scale contains

questions regarding the hyperactivity, attention deficit, and
behavioral problems of children in school, and their teachers
are asked to grade them. In this study, this scale was used to
evaluate the efficacy of treatment.
Stroop Test: This test was developed by Stroop (1935)
and standardized for Turkish children by Kılıç et al. (2002).
The Stroop test measures selective attention (cards 2 and 4),
focused attention (cards 1 and 3), and mental flexibility and
the ability to inhibit a dominant response (card 5) by differ-
ent subtests (Kılıç et al., 2002; MacLeod, 1992). Also, card 5
is believed to provide a measure of the individual’s ability to
inhibit stimulus-bound responses and deal with interference
(Homack & Riccio, 2004). The Stroop test is closely related
to the frontal lobe and many other cerebral regions. It pro-
vides information about several cognitive processes such as
selective attention, response inhibition, interference control,
and input processing speed.
Cancelation Test (CT): This test was developed by
Mesulam in 1985 and is used to measure sustained attention
(Weintraub & Mesulam, 1985). CT has four subtests using
regular letters, regular shapes, irregular letters, and irregular
shapes. In subtests that use letters, the letter “A” needs to be
marked on the paper; and in subtests that use shapes, the
same as all the figures shown by the examiner need to be
marked. Mesulam stated that a sensory component related
to perceptual errors is a motor component related to the
detection of the stimuli and drive components that contain
emotional features. Different studies have been shown that
the test measures visual screening, response speed, and
impulsivity. It was standardized for Turkish children by
Karakas (2004).
Serial Digit Learning Test (SDLT): SDLT measures the
number of repetitions required to accurately say an index of
nine numbers and therefore the learning ability. The stand-
ardization of SDLT to Turkish culture was carried out by
Karakas (2004).
Behavior Rating Inventory of Executive Function
(BRIEF): The BRIEF is an 86-item teacher and parent ques-
tionnaire, with two summary index scores, an overall general
index score and eight scales intended to capture the basic
components of executive functioning (Gioia et al., 2000). It
has eight subdomains: inhibit, shift, emotional control, initi-
ation, working memory, plan/organize, organization of
materials, and monitor. The inhibition, shift, and emotional
control subdomains together result in an additional compos-
ite behavioral regulation index (BRI). The subdomains of
initiation, working memory, plan/organize, organization of
materials, and monitor provide a composite metacognition
index (MI). The BRI and MI results are also combined to
obtain an overall Global Executive Composite (GEC) score.
Reliability studies show high internal consistency and tes-
t–retest reliability (Gioia et al., 2002). Convergent validity
was established with other measures of inattention, impul-
sivity, and learning skills in clinical ADHD populations
(Isquith & Gioia, 2000). The standardization for the Turkish
population was carried out by Bakar et al. (2011). In this
study, we administered the parent and teacher forms of the
Behavior Rating Inventory of Executive Function (BRIEF) to
APPLIED NEUROPSYCHOLOGY: CHILD 3
evaluate executive functions in ADHD before and
after treatment.
Statistical analysis
In this study, the data obtained from the participants were
analyzed using the SPSS 21 IBM software. The variables
were investigated using visual and analytical methods
(Kolmogorov–Simirnov/Shapiro Wilks test) to determine
whether or not they are normally distributed. Descriptive
analyzes were used for sociodemographic characteristics of
the groups. Mann–Whitney U and Kruskal Wallis analysis
methods were used to determine the differences in terms of
independent variables. Descriptives analyses were presented
using means and standard deviations for pretreatment and
posttreatment scale scores of Stroop, SDLT, and Cancelation
Subtests among MPH, ATX, and Control. Levene test was
used to assess the homogeneity of the variances. If the var-
iances were homogeneoous, we used one-way analysis of
variance (ANOVA); if not, we used Welch-ANOVA to
determine the statistically significant results. An overall p-
value of less than 0.05 was considered significant. When an
overall significance was observed, pairwise post-hoc tests
were performed using the Tamhane T2 test. Then, for the
treatment efficacy, we first determine the change in scale
scores for MPH and ATX groups independently. Since the
change of scale scores after treatment was not normally dis-
tributed, Wilcoxon nonparametric tests were conducted to
compare pretreatment and posttreatment scores. For
Wilcoxon analyzes, a p-value of less than 0.05 was consid-
ered to show statistically significant results.
Results
Of the 135 participants, 95 were diagnosed with ADHD, and
the healthy group was comprised of 40 participants. A total
of 49 children in the ADHD group received methylphenid-
ate treatment, while 46 children received ATX treatment.
There was no significant difference between the groups in
terms of gender (X2 ¼ 0.379, p ¼ 0.827), hand preference
(X2 ¼ 2.271, p ¼ 0.321) or age (X2 ¼ 5.173, p ¼ 0.075). The
treatment doses used were found to be 0.94 mg/kg/day ± 0.2
in the OROS-MPH group and 1.18 mg/kg/day ± 0.08 in the
ATX group.
Pretreatment evaluation
Whether there was a difference in terms of CTRS pretreat-
ment scores in the ADHD group was determined using the
Mann-Whitney U test, and no significant difference was
observed between the groups (Table 1). The pretreatment
performance-based neuropsychological test scores of chil-
dren with ADHD (OROS-Methylphenidate and ATX group)
were compared to the control group, and the performance
scores of the patients were found to be significantly lower
than the control group. There was no significant difference
between the drug groups in terms of test performances
(Tables 2 and 3). There was no significant difference
4 Y. TAŞ TORUN ET AL.
Table 1. Pretreatment scores of CTRS.
Sequence
Subtests Group N Mean sum
CTRS-hyperactivity OROS-MPH 49 50.43 2471
Atomoxetine 46 45.41 2089
CTRS-inattention OROS-MPH 49 47.94 2349
Atomoxetine 46 48.07 2211
CTRS-behavior problems OROS-MPH 49 49.47 2424
Atomoxetine 46 46.43 2136
Notes: CTRS ¼ Conners’ Teacher Rating Scale; OROS-MPH ¼ Osmotic Release
Oral System-Methylphenidate Hydrochloride.
between the ADHD groups—except in four subtests in the
teacher evaluation form—in terms of the BRIEF pretreat-
ment scores (Mann–Whitney U test) (Table 4).
Post-treatment evaluation
Among the ADHD groups, the reduction of over 40% in the
CTRS subtest scores was considered to be an improvement,
but no significant difference was found between the drug
groups (Table 5).
Both drug groups showed significantly improved scores
in performance-based neuropsychological tests. When the
post-treatment performance of the ADHD group was com-
pared with the control group, it was observed that both
drug groups performed worse than the control group except
for the time points in the Stroop test (Table 2).
When the BRIEF pre and post-treatment scores were
evaluated in the ADHD group, there was an improvement
in many scores in both drug groups (Table 6) but no signifi-
cant difference between the groups (Table 7).
Discussion
Although there are comparative studies regarding the treat-
ment effectiveness of ATX and psychostimulant agents,
comparative data are limited regarding executive functions.
In the present study, we aimed to compare the effects of
ATX and OROS-MPH on executive functions and evaluate
their clinical effectiveness.
In this study, clinical efficacy was evaluated with the
results of CTRS in accordance with many studies in the lit-
erature (Çetin et al., 2015; Gao et al., 2006). In some studies
that comparing the efficacy of pharmacological treatment in
ADHD, methylphenidate treatment was found to be more
effective than ATX treatment (Newcorn et al., 2008; Yildiz
et al., 2011), but ATX was found to be more effective in
fewer studies (Prasad et al., 2007). In some follow-up stud-
ies, it was concluded that both drugs showed similar clinical
efficacy (Çetin et al., 2015; Kratochvil et al., 2002; Su et al.,
2016). In the present study, similar to the other studies in
the field, CTRS was applied at the end of the 4-month fol-
low-up period, before and after treatment, and there was a
significant decrease in attention deficit, hyperactivity, and
behavioral problems subscale scores in both methylphenidate
and ATX groups after treatment. In addition, no significant
difference was found in terms of the three subscale scores
when the clinical efficacy was 40% or more in CTRS scores.
Based on this result, it can be concluded that both drugs
had similar efficacy on ADHD core symptoms, attention
U p
deficit, hyperactivity, and behavioral problems.
1008 0.373
This study adopted two types of EF measures, perform-
1124 0.982 ance-based neuropsychological tests and ecological behavioral
rating scales. The performance-based neuropsychological tests
1055 0.590
were more specific for the components of EF, although they
might not reflect EF in real life, while the rating scales had
good ecological validity. Brown (2006) and Barkley & Fischer
(2011), suggested that a behavioral rating scale might be a
more sensitive indicator (Barkley & Fischer, 2011; Brown,
2006). The combined use of performance based neuropsycho-
logical tests and rating scales for EF can provide a more com-
prehensive view of medication effects on EF performance at
various levels.
In this study, Stroop, CT and SDLT were applied to per-
formance-based neuropsychological tests. BRIEF was used as
a behavioral assessment scale. The results imply that both
OROS-MPH and ATX could improve EF in children with
ADHD. In both drug groups, when the Stroop test perform-
ances before and after the treatment were evaluated separ-
ately, it was observed that, after the treatment, they
completed the test in less time and made less errors and
corrections. When the differences between the groups were
evaluated after the treatment, it was observed that both drug
groups completed the tests in a similar time to the control
group, except for the first card. It can be thought that this
difference may be due to the remember effect of the test,
which is one of the exercise cards. When the number of cor-
rections and errors was observed, it was seen that there was
no difference between each drug group and that there were
more errors and corrections in both drug groups than in the
control group (MPH ¼ ATX > control). In the literature,
there has been only one study that included a control group
with ATX and methylphenidate drug groups. Similarly to
our study, an improvement was found in interference resist-
ance in both drug groups after treatment, and the control
group showed better performance than the drug groups
(Yang et al., 2012). When all findings were evaluated, Stroop
test performances were found to be significantly impaired in
ADHD, evaluating variables such as the ability to maintain
set-up against disruptive effect, selective attention, and psy-
chomotor velocity. After treatment, an increase in test per-
formance was observed in both groups. However, despite
this increase, the ADHD group and the control group
showed similar performance on the psychomotor speed after
treatment, while the ADHD group showed worse perform-
ance on ability to maintain set-up against disruptive effect
and selective attention compared to the control group. This
finding can be interpreted that the ATX and methylphenid-
ate treatments are beneficial for impulsivity but not enough
control when there is a disturbing factor.
The cancelation test measures cognitive functions such as
visual spatial perception, visual screening, continuous atten-
tion, and response rate, especially in the parietal region
(Kılıç et al., 2002). When the performance of the groups was
compared before the treatment, the children diagnosed with
ADHD completed the subtests with regular letters, regular
Table 2. The comparison of pretreatment and posttreatment scores of STROOP and SDLT among groups and the statistics of treatment efficacy.
Pretreatment scores Postreatment Treatment efficacy
c c
MPH ATX Control Statistics MPH ATX Control Statistics Statistics for MPHd Statistics for ATXd
b b
S1- time 18.1 ± 12.6 15.9 ± 5.2 14.9 ± 3.5 F ¼ 1.78, p ¼ 0.174 13.5 ± 4.0 12.1 ± 3.0 14.9 ± 3.5 F 5 6.1, Z 5 24.15, p < 0.001 Z 5 24.86,
p 5 0.003, p < 0.001
ATX < Control
S1-error 0.0 ± 0.0 0.0 ± 0.0 0.0 ± 0.0 – 0.02 ± 0.14 0.0 ± 00 0.0 ± 0.0 – Za ¼ 1.00, p ¼ 0.31 Zc ¼ 0.00, p ¼ 1.0
S1-correction 0.08 ± 0.2 0.06 ± 0.2 0.02 ± 0.1 F ¼ 0.64, p ¼ 0.52 0.0 ± 0.0 0.04 ± 0.2 0.02 ± 0.1 – Zb 5 22.0, p 5 0.04 Zb ¼ 0.44, p ¼ 0.65
S2-time 19.4 ± 9.9 17.9 ± 6.1 16.9 ± 4.0 F ¼ 1.46, p ¼ 0.23 17.5 ± 6.4 20.2 ± 8.2 16.9 ± 4.0 F ¼ 2.91, p ¼ 0.06 Zb ¼ 1.11, p ¼ 0.26 Zb ¼ 0.82, p ¼ 0.40
S2-error 0.04 ± 0.1 0.0 ± 0.0 0.0 ± 0.0 – 0.02 ± 0.1 0.04 ± 0.2 0.0 ± 0.0 – Zb ¼ 0.57, p ¼ 0.56 Za ¼ 1.41, p ¼ 0.15
S2-correction 0.5 ± 1.1 0.1 ± 0.6 0.02 ± 0.1 F* 5 5.44, p 5 0.006, 0.1 ± 0.3 0.1 ± 0.4 0.02 ± 0.1 F ¼ 2.93, p ¼ 0.059 Zb 5 22.11, p 5 0.03 Zc ¼ 0.00, p ¼ 1.0
MPH > Control
S3-time 24.0 ± 7.8 23.2 ± 6.6 22.7 ± 5.8 F ¼ 0.38, p ¼ 0.67 21.5 ± 7.8 20.4 ± 7.2 22.7 ± 5.8 F ¼ 1.19, p ¼ 0.30 Zb ¼ 1.79, p ¼ 0.07 Zb 5 21.86, p 5 0.06
S3-error 0.1 ± 0.6 0.02 ± 0.14 0.0 ± 0.0 – 0.04 ± 0.1 0.1 ± 0.3 0.0 ± 0.0 – Zb ¼ 1.0, p ¼ 0.31 Za ¼ 1.41, p ¼ 0.15
S3-correction 1.2 ± 1.1 1.1 ± 1.4 0.07 ± 0.2 F* 5 34.18, p < 0.001, 0.4 ± 0.6 0.4 ± 0.9 0.07 ± 0.2 F* 5 7.91, p 5 0.001, Zb 5 -3.72, p < 0.001 Zb 5 2.99,
MPH > Control, MPH > Control, p 5 0.003
p < 0.001; p 5 0.005;
ATX > Control, p < 0.001 ATX > Control,
p 5 0.03
S4-time 41.1 ± 16.8 37.1 ± 8.9 30.1 ± 5.4 F* 5 15.78, p < 0.001, 29.5 ± 11.1 27.2 ± 10.4 30.1 ± 5.4 F ¼ 1.29, p ¼ 0.27 Zb 5 24.58, Zb 5 24.12,
MPH > Control, p < 0.001 p < 0.001
p < 0.001;
ATX > Control, p < 0.001
S4-error 0.2 ± 0.6 0.1 ± 0.4 0.0 ± 0.0 – 0.08 ± 0.3 0.2 ± 0.8 0.0 ± 0.0 – Zb ¼ 1.14, p ¼ 0.25 Za ¼ 0.32, p ¼ 0.74
S4-correction 3.2 ± 2.7 3.5 ± 2.8 0.1 ± 0.4 F*5 15.78, p < 0.001, 0.9 ± 1.2 1.0 ± 1.5 0.1 ± 0.4 F* 5 14.51, p < 0.001, Zb 5 24.28, Zb 5 24.59,
MPH > Control, MPH > Control, p < 0.001 p < 0.001
p < 0.001; p < 0.001;
ATX > Control, p < 0.001 ATX > Control,
p < 0.001
S5-time 58.0 ± 18.2 52.8 ± 17.6 39.6 ± 5.9 F* 5 30.14, p < 0.001, 42.5 ± 16.1 39.9 ± 12.0 39.6 ± 5.9 F ¼ 0.68, p ¼ 0.50 Zb 5 24.73, Zb 5 23.78,
MPH > Control, p < 0.001 p < 0.001
p < 0.001;
ATX > Control, p < 0.001
S5-error 2.9 ± 3.7 2.8 ± 3.1 0.0 ± 0.0 – 0.2 ± 0.5 0.2 ± 0.4 0.0 ± 0.0 – Zb 5 24.70, Zb 5 24.65,
p < 0.001 p < 0.001
S5-correction 5.8 ± 3.2 6.2 ± 2.6 0.3 ± 0.6 F* 5 16.54, p < 0.001, 1.8 ± 1.8 1.6 ± 1.6 0.3 ± 0.6 F* 5 22.67, p < 0.001, Zb 5 25.68, p < 0.001 Zb 5 25.68,
MPH > Control, MPH > Control, p < 0.001
p < 0.001; p < 0.001;
ATX > Control, p < 0.001 ATX > Control,
p < 0.001
SDLT 5.2 ± 6.6 6.6 ± 6.4 18.0 ± 2.0 F* 5 130.2, p < 0.001, 17.7 ± 5.1 14.3 ± 6.2 18.0 ± 2.0 F* 5 6.97, p 5 0.002, Za 5 25.91, p < 0.001 Zb 5 25.62,
MPH < Control, MPH > ATX, p 5 0.01; p < 0.001
p < 0.001; Control > ATX,
ATX < Control, p < 0.001 p < 0.001
Notes: SDLT ¼ Serial Digit Learning Test; MPH ¼ methylphenidate hydrochloride; ATX ¼ atomoxetine.
Statisticsc: One-Way analysis of variance (ANOVA) or Welch ANOVA was used to compare parameters between MPH, ATX, and control groups. When an overall significance was observed, pairwise pos-hoc tests were per-
formed using Tamhane’s test. Statistics value were indicated as F for One-Way ANOVA, and F for Welch ANOVA.
Statisticsd: The Wilcoxon test was used to compare the treatment efficacy by using posttreatment-pretreatment scores for MPH and ATX group, separately. Za: Z value based on negative ranks; Zb: Z value based on
positive ranks; Zc: Z value based on the sum of negative ranks equals the sum of positive ranks.
p < 0.05 is marked as bold.
APPLIED NEUROPSYCHOLOGY: CHILD
5
Table 3. The comparison of pretreatment and posttreatment scores of cancelation subtests among groups and the statistics of treatment efficacy. 6
Pretreatment scores Postreatment scores Treatment efficacy
a a
MPH ATX Control Statistics MPH ATX Control Statistics Statistics for MPHb Statistics for ATXb
b b
RL-marked 54.2 ± 5.9 57.0 ± 4.3 59.7 ± 0.7 59.2 ± 1.8 59.4 ± 1.0 59.7 ± 0.7 F ¼ 2.23, p ¼ 0.11 Z ¼ 0.63, p ¼ 0.52 Z 5 22.05, p 5 0.04
F* 5 28.3, p < 0.001, MPH < Control, p <
0.001;ATX < Control, p < 0.001; MPH < ATX,
p 5 0.02
RL- skipped 5.7 ± 5.9 2.9 ± 4.3 0.2 ± 0.7 0.7 ± 1.8 0.5 ± 1.0 0.2 ± 0.7 F ¼ 2.23, p ¼ 0.11 Zb 5 25.21, p < 0.001 Zb 5 23.78, p < 0.001
F* 5 28.3, p < 0.001, MPH > Control, p <
Y. TAŞ TORUN ET AL.

0.001; ATX > Control, p < 0.001; MPH > ATX,

p 5 0.02
RL-incorrect 0.5 ± 2.1 0.2 ± 1.6 0.0 ± 0.0 0.02 ± 0.1 0.0 ± 0.0 0.0 ± 0.0 – Zb ¼ 1.73, p ¼ 0.08 Zb ¼ 1.34, p ¼ 0.163
–
RL-error 6.3 ± 6.6 3.2 ± 4.9 0.2 ± 0.7 0.6 ± 1.6 0.5 ± 1.0 0.2 ± 0.7 F ¼ 1.64, p ¼ 0.20 Zb 5 25.23, p < 0.001 Zb 5 23.84, p < 0.001
F* 5 27.2, p < 0.001, MPH > Control, p <
0.001; ATX > Control, p < 0.001; MPH > ATX,
p 5 0.03
RL-time 221.0 ± 110.0 173.6 ± 72.7 203.0 ± 23.7 188.0 ± 74.4 170.1 ± 39.8 203.0 ± 23.7 F* 5 11.1, p < 0.001, Zb ¼ 1.48, p ¼ 0.13 Za ¼ 0.33, p ¼ 0.73
F* 5 4.17, p 5 0.001, Control > ATX, p 5 ATX < Control, p < 0.001
0.03; MPH > ATX, p 5 0.04
RS-marked 54.7 ± 7.0 57.6 ± 3.7 59.7 ± 0.6 59.3 ± 1.3 59.4 ± 1.8 59.7 ± 0.6 F ¼ 1.01, p ¼ 0.36 Za 5 25.10, p < 0.001 Za 5 23.40, p 5 0.001
F* 5 18.2, p < 0.001, MPH < Control, p <
0.001; ATX < Control, p 5 0.002;
MPH < ATX, p 5 0.04
RS-skipped 5.2 ± 7.0 2.3 ± 3.7 0.2 ± 0.6 0.6 ± 1.3 0.5 ± 1.8 0.2 ± 0.6 F ¼ 1.01, p ¼ 0.36 Zb 5 25.10, p < 0.001 Zb 5 23.40, p 5 0.001
F* 5 18.2, p < 0.001, MPH > Control, p <
0.001; ATX > Control, p 5 0.002;
MPH > ATX, p 5 0.02
RS-incorrect 1.3 ± 4.1 0.7 ± 1.8 0.0 ± 0.0 0.02 ± 0.1 0.04 ± 0.2 0.0 ± 0.0 F ¼ 0.54, p ¼ 0.57 Zb 5 23.89, p < 0.001 Zb 5 23.22, p 5 0.001
–
RS-error 6.5 ± 8.4 3.1 ± 4.8 0.2 ± 0.6 0.6 ± 1.3 0.5 ± 1.9 0.2 ± 0.6 F ¼ 1.04, p ¼ 0.35 Zb 5 25.36, p < 0.001 Zb 5 23.82, p < 0.001
F* 5 20.9, p < 0.001, MPH > Control, p <
0.001; ATX > Control, p < 0.001; MPH > ATX,
p 5 0.04
RS-time 196.8 ± 81.6 190.3 ± 78.6 192.0 ± 67.9 178.0 ± 49.8 167.0 ± 40.2 192.0 ± 67.9 F ¼ 3.04, p ¼ 0.051 Zb ¼ 1.24, p ¼ 0.21 Zb ¼ 1.26, p ¼ 0.20
F ¼ 0.25, p ¼ 0.77
IRL-marked 53.5 ± 6.6 55.1 ± 4.7 59.6 ± 0.8 58.0 ± 4.3 58.7 ± 2.5 59.6 ± 0.8 F* 5 4.79, p 5 0.01, Za 5 24.53, p < 0.001 Za 5 24.48, p < 0.001
F* 5 37.8, p < 0.001, MPH < Control, p < MPH < Control,
0.001; ATX < Control, p < 0.001 p 5 0.05;
IRL-skipped 6.4 ± 7.1 4.5 ± 4.8 0.4 ± 0.8 1.8 ± 4.2 1.1 ± 2.4 0.4 ± 0.8 F* 5 4.28, p 5 0.01, Zb 5 24.49, p < 0.001 Zb 5 24.29, p < 0.001
F* 5 32.5, p < 0.001, MPH > Control, p < MPH > Control,
0.001; ATX > Control, p < 0.001 p 5 0.05
IRL-incorrect 0.4 ± 1.8 0.3 ± 1.3 0.0 ± 0.0 0.02 ± 0.1 0.2 ± 1.3 0.0 ± 0.0 – Zb ¼ 1.93, p ¼ 0.053 Zb ¼ 1.44, p ¼ 0.14
–
IRL-error 6.8 ± 7.5 4.9 ± 5.1 0.4 ± 0.8 1.8 ± 4.2 1.3 ± 3.4 0.4 ± 0.8
F* 5 4.10, p 5 0.02, Zb 5 24.71, p < 0.001 Zb 5 24.48, p < 0.001
F* 5 34.3, p < 0.001, MPH > Control, p < MPH > Control,
0.001; ATX > Control, p < 0.001 p 5 0.06
IRL-time 245.3 ± 301.8 194.4 ± 89.2 214.4 ± 19.1 181.6 ± 53.6 191.3 ± 64.8 214.4 ± 19.1 F* 5 9.54, p < 0.001, Zb ¼ 1.61, p ¼ 0.10 Zb ¼ 0.06, p ¼ 0.95
F ¼ 1.3, p ¼ 0.26 MPH < Control,
p 5 0.001
IRS-marked 54.2 ± 6.9 56.5 ± 4.5 59.6 ± 0.9 58.4 ± 2.8 59.1 ± 2.4 59.6 ± 0.9 F* 5 4.13, p 5 0.02, Za 5 24.28, p < 0.001 Za 5 24.39, p < 0.001
F* 5 23.4, p < 0.001, MPH < Control, p < MPH < Control,
0.001; ATX < Control, p < 0.001 p 5 0.02
(continued)
 APPLIED NEUROPSYCHOLOGY: CHILD 7

Statisticsd: The Wilcoxon test was used to compare the treatment efficacy by using posttreatment-pretreatment scores for MPH and ATX group, separately. Za: Z value based on negative ranks; Zb: Z value based on posi-
Statisticsc: One-Way analysis of variance (ANOVA) or Welch ANOVA was used to compare parameters between MPH, ATX and control groups. When an overall significance was observed, pairwase pos-hoc tests were per-
figures and irregular letters in similar time with their healthy
Z 5 24.28, p < 0.001 Z 5 24.39, p < 0.001

Zb 5 24.48, p < 0.001 Zb 5 24.22, p < 0.001

Za ¼ 1.92, p ¼ 0.054
Zb 5 23.10, p 5 0.002 Zb ¼ 1.31, p ¼ 0.18
Statistics for ATXb

peers. However, it was observed that the subtest with irregu-

lar shapes was completed in a shorter time than the control
group (p < 0.05). There are studies in the literature reporting
that children with ADHD perform faster in the case of presen-
Treatment efficacy

tation of stimulants in an irregular and unfamiliar manner

b

(Landau et al., 1999). In addition, it was observed that chil-

dren with ADHD had less target markings, more targets and
Za ¼ 1.32, p ¼ 0.18
Statistics for MPHb

more wrong targets than the control group in all subtests

except the one with regular letters (p < 0.05). This finding is
consistent with other studies in the literature (Kılıç et al.,
2007; Soysal, 2007). These findings suggest that ADHD is
associated with impaired cognitive functions such as visual
b

motor sensing, visual selectivity, selection of mental activity,

suppression of inappropriate, and sustained attention. The
situation of marking false stimuli at CT is described as
162.7 ± 47.9 166.2 ± 39.0 195.6 ± 21.9 F* 5 15.0, p < 0.001,
F* 5 4.13, p 5 0.02,

F* 5 4.05, p 5 0.02,

“impulsivity,” one of the core symptoms of ADHD (Kılıç

a

MPH > Control,

MPH > Control,

MPH < Control,

Statistics

et al., 2007). In the ADHD group, the response rate was

p < 0.001
p 5 0.02

p 5 0.02

higher, but the total number of errors was also higher. It can
be thought that individuals diagnosed with ADHD are more
Postreatment scores

aggressive in daily life, but are more likely to be accident-

–

prone and clumsy individuals. When the differences between

0.4 ± 0.9

0.0 ± 0.0

0.4 ± 0.9
Control

the groups were evaluated after the treatment, it was observed

that the drug groups completed the subtests in a shorter time
compared to the control group. While there was no significant
difference between the groups in terms of the marked, skipped
0.8 ± 2.4

0.2 ± 0.7

1.1 ± 3.9
ATX

and mismarked targets, there was no significant difference

between the groups in terms of the regular/irregular letters
formed using Tamhane’s test. Statistics value were indicated as F for One-Way ANOVA, and F for Welch ANOVA.

sub-tests and the regular shapes subtest. However, the ATX

1.5 ± 2.8

0.0 ± 0.0

1.5 ± 2.8

group showed similar performance with respect to the num-

MPH

ber of targets marked in the irregular shapes subtest and the

number of skipped targets. When all the findings were eval-
uated, it was observed that children with ADHD performed
F* 5 23.4, p < 0.001, MPH > Control, p <

F* 5 24.4, p < 0.001, MPH > Control, p <

F* 5 28.9, p < 0.001, MPH < Control, p <

differently than their healthy peers in CT, which evaluated

tive ranks; Zc: Z value based on the sum of negative ranks equals the sum of positive ranks.

cognitive functions such as visual spatial perception, visual

screening, continuous attention and response rate. After the
0.001; ATX > Control, p < 0.001

0.001; ATX > Control, p < 0.001

0.001; ATX < Control, p < 0.001

treatment, visual spatial perception, visual screening, and per-

a
Statistics

forming tasks that require constant attention were observed to

be performed better than before. This increase in performance
was more prominent in the ATX group. When response rates
and mismarked targets were evaluated, it was concluded that
Pretreatment scores

Notes: MPH ¼ methylphenidate hydrochloride; ATX ¼ atomoxetine.

they made quick decisions similar to the ones before the treat-
ment, and their impulsivity persisted despite the treatment.
When the SDLT scores used to measure short-term
–

146.9 ± 58.3 195.6 ± 21.9

memory capacity and learning ability were compared, it was

0.4 ± 0.9

0.0 ± 0.0

0.4 ± 0.9
Control

observed that the pretreatment SDLT performances in both

methylphenidate and ATX groups were lower than in the
control group (p < 0.05). In the study, it was determined
3.4 ± 4.5

0.3 ± 1.7

3.8 ± 5.3

that children with ADHD had significant impairment in

ATX

short-term memory and learning capacities compared to

their healthy peers. This finding is consistent with the
p < 0.05 is marked as bold.

results of a study by Erdogan Bakar (2007) with 154 ADHD

136.3 ± 42.9
5.7 ± 6.9

0.6 ± 1.9

6.4 ± 7.4
MPH

patients and 73 healthy participants. The memory space

Table 3. Continued.

tests, including the arrays of digits, can be used as a meas-

urement tool for short-term memory capacity, but also as a
IRS-incorrect
IRS-skipped

measurement tool for attention. In ADHD, the lower per-

IRS-error

IRS-time

formance than the control group in sensitive memory subt-

ests is considered as a condition related to working memory
8 Y. TAŞ TORUN ET AL.

Table 4. Pretreament BRIEF scores.

Subtests Group N Mean Sequence sum U p
Inhibit (BRIEF-Teacher) OROS-MPH 49 41.19 2018.5 793.5 0.013
Atomoxetine 46 55.25 2541.5
Shift (BRIEF-Teacher) OROS-MPH 49 44.80 2195.0 970.0 0.241
Atomoxetine 46 51.41 2365.0
Emotional Control (BRIEF-Teacher) OROS-MPH 49 44.60 2185.5 960.5 0.214
Atomoxetine 46 51.62 2374.5
BRI (BRIEF-Teacher) OROS-MPH 49 42.33 2074.0 849.0 0.038
Atomoxetine 46 54.04 2486.0
Initiation (BRIEF-Teacher) OROS-MPH 49 42.01 2058.5 833.5 0.027
Atomoxetine 46 54.38 2501.5
Working Memory (BRIEF-Teacher) OROS-MPH 49 42.58 2086.5 861.5 0.047
Atomoxetine 46 53.77 2473.5
Plan/Organize (BRIEF-Teacher) OROS-MPH 49 47.19 2312.5 1087.5 0.768
Atomoxetine 46 48.86 2247.5
Organization of materials (BRIEF-Teacher) OROS-MPH 49 45.93 2250.5 1025.5 0.448
Atomoxetine 46 50.21 2309.5
Monitor (BRIEF-Teacher) OROS-MPH 49 48.49 2376.0 1103.0 0.858
Atomoxetine 46 47.48 2184.0
MI (BRIEF-Teacher) OROS-MPH 49 44.07 2159.5 934.5 0.152
Atomoxetine 46 52.18 2400.5
GEC (BRIEF-Teacher) OROS-MPH 49 43.38 2125.5 900.5 0.092
Atomoxetine 46 52.92 2434.5
Inhibit (BRIEF-Parents) OROS-MPH 49 51.49 2523.0 956.0 0.201
Atomoxetine 46 44.28 2037.0
Shift (BRIEF-Parents) OROS-MPH 49 49.95 2447.5 1031.5 0.474
Atomoxetine 46 45.92 2112.5
Emotional Control (BRIEF-Parents) OROS-MPH 49 50.46 2472.5 1006.5 0.368
Atomoxetine 46 45.38 2087.5
BRI (BRIEF-Parents) OROS-MPH 49 51.16 2507.0 972.0 0.248
Atomoxetine 46 44.63 2053.0
Initiation (BRIEF-Parents) OROS-MPH 49 46.72 2289.5 1064.5 0.640
Atomoxetine 46 49.36 2270.5
Working Memory (BRIEF-Parents) OROS-MPH 49 50.63 2481.0 998.0 0.335
Atomoxetine 46 45.20 2079.0
Plan/Organize (BRIEF-Parents) OROS-MPH 49 48.49 2376.0 1103.0 0.858
Atomoxetine 46 46 47.48
Organization of materials (BRIEF-Parents) OROS-MPH 49 49 53.26 869.5 0.054
Atomoxetine 46 46 42.4
Monitor (BRIEF-Parents) OROS-MPH 49 49 48.54 1100.5 0.843
Atomoxetine 46 46 47.42
MI (BRIEF-Parents) OROS-MPH 49 49 49.85 1036.5 0.500
Atomoxetine 46 46 46.03
GEC (BRIEF-Parents) OROS-MPH 49 49 50.89 985.5 0.292
Atomoxetine 46 46 44.92
Notes: BRIEF ¼ Behavior Rating Inventory of Executive Function; OROS-MPH ¼ Osmotic Release Oral System-Methylphenidate Hydrochloride; BRI ¼ behavioral regu-
lation index; MI ¼ metacognition index; GEC ¼ Global Executive Composite.
p < 0.05.

problems (Kaplan et al., 1998). When the post-treatment Table 5. Post-treatment improvement of CTRS sub-test scores in two
SDLT scores were compared with the pretreatment scores, drug groups.
both drug groups showed significant improvement com- OROS-MPH Atomoxetine
CTRS N (%) N (%) p
pared to pretreatment levels. In addition, there was no dif-
Hyperactivity HYPERACTIVITY 24 (49) 22 (47.8) 0.910
ference between the methylphenidate and ATX groups in Inattention 34 (69.4) 29 (63) 0.513
terms of pretreatment SDLT performance, but higher per- Behavior problems 27 (55.1) 27 (58.7) 0.724
formance was found in the methylphenidate group com- Notes: CTRS ¼ Conners’ Teacher Rating Scale; OROS-MPH ¼ Osmotic Release
pared to the ATX group. The performance of the Oral System-Methylphenidate Hydrochloride.
methylphenidate group was better than the control group,
but the performance of the ATX group was significantly ATX treatment was more effective in auditory-verbal-written
lower than the control group (MPH > control > ATX). tasks; however, no control group was included in the study
There is no study comparing SDLT performance before and (Tasdelen et al., 2015). In a study by Yang et al. (2012), the
after ADHD treatment in the literature. However, the task effects of ATX and methylphenidate treatments on WISC-R
used in the SDLT reveals the sequences of numbers used in number sequence subtest performance were evaluated, and
the Wechsler Adult Intelligence Scale–Revised (WISC-R) both drugs showed significant improvement in the number
test and Visual Auditory Number Sequence Test (VANST) sequence performance test compared to the pretreatment
(Kaplan et al., 1998). In a comparative study by Tasdelen levels. It was concluded that the performances of both drug
et al. (2015) on the effect of ATX and methylphenidate groups after treatment were similar to the healthy control
treatments on VANST performance, both drugs were found group. In addition, after treatment, no significant difference
to increase test performance similarly. It was concluded that was found between the two drug groups (Yang et al., 2012).
 APPLIED NEUROPSYCHOLOGY: CHILD 9

Table 6. The comparison of pretreatment and posttreatment scores of BRIEF among MPH and ATX groups and the statistics of treatment efficacy.
MPH ATX
Treatment efficacy
BRIEF subtests Pretreatment Posttreatment Treatment efficacy statistics Pretreatment Posttreatment statistics
Teacher
 Inhibit 22.9 ± 5.6 (24) 20.0 ± 4.9 (20) Zb 5 22.89, p 5 0.004 25.7 ± 4.0 (26.5) 20.5 ± 5.8 (20) Zb 5 24.34, p < 0.001
 Shift 19.4 ± 4.0 (20) 17.4 ± 3.3 (17) Zb 5 22.68, p 5 0.007 20.4 ± 3.2 (20) 17.6 ± 3.3 (18) Zb 5 24.20, p < 0.001
 Emotional Control 18.4 ± 4.9 (19) 16.9 ± 4.4 (18) Zb 5 22.34, p 5 0.01 19.7 ± 4.7 (19.5) 16.8 ± 4.1 (16) Zb 5 23.67, p < 0.001
 BRI 60.8 ± 11.6 (61) 54.4 ± 9.2 (53) Zb 5 23.63, p < 0.001 65.9 ± 8.7 (68) 54.9 ± 8.4 (55.5) Zb 5 25.06, p < 0.001
 Initiation 16.8 ± 3.2 (17) 15.2 ± 3.3 (15) Zb 5 22.46, p 5 0.01 18.1 ± 3.4 (19) 15.0 ± 3.3 (15) Zb 5 24.71, p < 0.001
 Working Memory 23.4 ± 4.1 (24) 20.7 ± 3.9 (21) Zb 5 23.95, p < 0.001 24.9 ± 4.2 (26) 20.4 ± 3.7 (21) Zb 5 25.09, p < 0.001
 Plan/Organize 23.7 ± 3.7 (23) 21.2 ± 2.9 (21) Zb 5 23.46, p 5 0.001 23.7 ± 4.3 (24) 20.3 ± 3.7 (20) Zb 5 24.40, p < 0.001
 Organization of materials 15.3 ± 4.4 (17) 15.1 ± 3.7 (15) Zb ¼ 0.20, p ¼ 0.83 16.3 ± 3.3 (16) 16.0 ± 3.6 (16) Zb ¼ 0.27, p ¼ 0.78
 Monitor 21.3 ± 4.4 (23) 19.8 ± 4.4 (19) Zb 5 22.39, p 5 0.001 21.4 ± 4.3 (21.5) 18.6 ± 3.5 (18.5) Zb 5 23.95, p < 0.001
 MI 100.6 ± 15.7 (102) 92.1 ± 11.4 (91) Zb 5 23.57, p < 0.001 104.7 ± 14.6 (107.5) 90.4 ± 10.5 (88) Zb 5 25.01, p < 0.001
 GEC 161.4 ± 24.2 (164) 146.6 ± 18.2 (147) Zb 5 23.03, p < 0.001 170.7 ± 20.5 (173.5) 145.4 ± 14.5 (147) Zb 5 25.34, p < 0.001
Parents
 Inhibit 21.6 ± 4.8 (23) 19.4 ± 3.7 (19) Zb 5 23.03, p 5 0.002 20.9 ± 4.3 (21) 19.3 ± 3.1 (19) Zb 5 22.02, p 5 0.04
 Shift 17.1 ± 3.3 (18) 14.7 ± 3.6 (15) Zb 5 24.01, p < 0.001 16.8 ± 3.3 (17.5) 15.4 ± 2.8 (16) Zb 5 22.28, p 5 0.02
 Emotional Control 21.6 ± 4.6 (22) 19.8 ± 4.1 (19) Zb 5 21.99, p 5 0.004 20.9 ± 5.1(20) 18.9 ± 3.7 (19.5) Zb 5 22.15, p 5 0.03
 BRI 60.5 ± 10.7 (62) 53.6 ± 9.4 (54) Zb 5 23.66, p < 0.001 58.7 ± 9.8 (59) 53.7 ± 6.6 (54) Zb 5 22.70, p 5 0.007
 Initiation 17.6 ± 3.2 (18) 16.4 ± 3.1 (17) Zb 5 22.50, p 5 0.01 17.8 ± 3.8 (18) 15.8 ± 2.8 (16) Zb 5 22.70, p 5 0.007
 Working Memory 22.7 ± 3.6 (23) 20.20 ± 3.6 (20) Zb 5 23.72, p < 0.001 22.0 ± 4.1 (22) 19.0 ± 2.9 (19) Zb 5 23.34, p 5 0.001
 Plan/Organize 27.5 ± 4.2 (28) 25.7 ± 5.1 (26) Zb 5 21.97, p 5 0.04 27.2 ± 5.4 (27.5) 24.7 ± 4.9 (24) Zb 5 22.24, p 5 0.02
 Organization of materials 13.9 ± 2.8 (14) 13.2 ± 3.0 (14) Zb ¼ 1.61, p ¼ 0.10 12.5 ± 3.4 (12) 12.4 ± 2.9 (12) Zb ¼ 0.50, p ¼ 0.61
 Monitor 19.1 ± 3.5 (20) 16.5 ± 3.6 (17) Zb 5 23.89, p < 0.001 18.8 ± 3.9 (20) 16.9 ± 2.9 (17) Zb 5 22.66, p 5 0.008
 MI 100.9 ± 14.6 (102) 92.0 ± 12.7 (93) Zb 5 23.53, p < 0.001 98.5 ± 16.8 (101) 88.9 ± 11.5 (89) Zb 5 23.20, p 5 0.001
 GEC 161.5 ± 23.9 (166) 145.7 ± 19.0 (148) Zb 5 24.01, p < 0.001 157.2 ± 24.5 (164) 142.6 ± 15.8 (143) Zb 5 23.57, p < 0.001
Notes: BRIEF ¼ Behavior Rating Inventory of Executive Function; MPH ¼ methylphenidate hydrochloride; ATX ¼ atomoxetine; BRI ¼ behavioral regulation index;
MI ¼ metacognition index; GEC ¼ Global Executive Composite.
Statistics: The Wilcoxon test was used to compare the treatment efficacy by using posttreatment-pretreatment scores for MPH and ATX group, separately. Za: Z
value based on negative ranks, Zb: Z value based on positive ranks, Zc: Z value based on the sum of negative ranks equals the sum of positive ranks.
p < 0.05 is marked as bold.

SDLT is also a learning test as it measures the number of
repeat sequences for the correct repetition of a given num-
ber of sequences, as well as measuring the short-term mem-
ory, similar to the WISC-R number sequence subtest and
VANS. From this, it can be said that ATX and methylphen-
idate treatments have an improving effect on both short-
term memory and learning ability compared to similar study
results, and this effect is observed more with methylphenid-
ate treatment.
In this study, the results of the BRIEF test were used as a
behavior evaluation scale. When the scale scores were com-
pared separately in the two drug groups before and after the
treatment, all BRIEF subscale scores except the suppression,
initiation, working memory, and behavioral regulation index
were similar in both groups. Considering the change in
scores before and after treatment in ADHD groups, there
was a significant decrease in all the scale scores except for
parents/teacher material organizing scores in both methyl-
phenidate and ATX groups. Significant decreases were
observed in the upper cognition index and global executive
scores in both BRIEF-parents and BRIEF-teacher forms
(Maziade et al., 2009). According to the results of a com-
parative study on ATX and methylphenidate by Yang et al.
(2012) with OROS-MPH and ATX groups, there was a
decrease in all the parents/teacher scale scores, except for
the initiation scores in the parents scale. Also, no significant
difference was observed between the two drug groups (Yang
et al., 2012). In a study by Adler et al. (2014), there was a
significant decrease in self-efficacy based on the initiation,
material organization, set change, and emotion control sub-
scale scores in adult ADHD cases after ATX treatment. In a
study comparing the results of self-report BRIEF subscale
scores and performance-based neuropsychological tests on
adult ADHD patients, it was concluded that the only pre-
dictive subtest for performance-based tests was material
organization (Grane et al., 2014). In this study, the continu-
ity in the material organization subscale scores, which
express the ability to keep the related parts of the environ-
ment in a systematic way, was noteworthy in both drug
groups, in both teacher and parent notifications.
The present study had several limitations. First, subgroups
of ADHD were not evaluated in the study. Improvement in
executive functions may vary in different subtypes of ADHD.
Second, we did not include a group that received placebo;
therefore, there might have been bias in our results regarding
a potential placebo effect when we estimated the effect of
each medication. Another limition of present study is not
having measure of impairment. Also, the study was only
18 weeks in duration; study results may not reflect the long-
term effects of treatment on executive functions.
At the same time, this study had several strengths. The
major strengths of this study were that this was the first
head-to-head study comparing OROS-methylphenidate and
ATX directly in children with ADHD, including a healthy
control group. An additional strength in this study, was that
the effects of ATX and OROS-MPH on executive functions
were evaluated using both performance-based neuropsycho-
logical tests and ecological behavioral rating scales.
In conclusion, the present study suggests that ATX and
OROS-MPH treatments have shown similar efficacy in clin-
ical recovery and improvement on executive functions.
However, disturbances in executive functions observed in
10 Y. TAŞ TORUN ET AL.

Table 7. Post-treament BRIEF scores.

Subtests Group N Mean Sequence sum U p
Inhibit (BRIEF-Teacher) OROS-MPH 49 47.83 2343.5 1118.5 0.949
Atomoxetine 46 48.18 2216.5
Shift (BRIEF-Teacher) OROS-MPH 49 46.69 2288 1063.0 0.632
Atomoxetine 46 49.39 2272
Emotional Control (BRIEF-Teacher) OROS-MPH 49 48.7 2386.5 1092.5 0.796
Atomoxetine 46 47.25 2173.5
BRI (BRIEF-Teacher) OROS-MPH 49 47.29 2317 1092.0 0.794
Atomoxetine 46 48.76 2243
Initiation (BRIEF-Teacher) OROS-MPH 49 48.62 2382.5 1096.5 0.820
Atomoxetine 46 47.34 2177.5
Working Memory (BRIEF-Teacher) OROS-MPH 49 48.76 2389 1090.0 0.781
Atomoxetine 46 47.2 2171
Plan/Organize (BRIEF-Teacher) OROS-MPH 49 51.34 2515.5 963.5 0.220
Atomoxetine 46 44.45 2044.5
Organization of materials (BRIEF-Teacher) OROS-MPH 49 44.69 2190 965.0 0.225
Atomoxetine 46 51.52 2370
Monitor (BRIEF-Teacher) OROS-MPH 49 52.02 2549 930.0 0.141
Atomoxetine 46 43.72 2011
MI (BRIEF-Teacher) OROS-MPH 49 50.03 2451.5 1027.5 0.458
Atomoxetine 46 45.84 2108.5
GEC (BRIEF-Teacher) OROS-MPH 49 48.34 2368.5 1110.5 0.902
Atomoxetine 46 47.64 2191.5
Inhibit (BRIEF-Parents) OROS-MPH 49 48.89 2395.5 1083.5 0.744
Atomoxetine 46 47.05 2164.5
Shift (BRIEF-Parents) OROS-MPH 49 45.45 2227 1002.0 0.349
Atomoxetine 46 50.72 2333
Emotional Control (BRIEF-Parents) OROS-MPH 49 50.07 2403.5 980.5 0.348
Atomoxetine 46 44.82 2061.5
BRI (BRIEF-Parents) OROS-MPH 49 48.1 2357 1122.0 0.970
Atomoxetine 46 47.89 2203
Initiation (BRIEF-Parents) OROS-MPH 49 50.73 2486 993.0 0.316
Atomoxetine 46 45.09 2074
Working Memory (BRIEF-Parents) OROS-MPH 49 52.11 2553.5 925.5 0.131
Atomoxetine 46 43.62 2006.5
Plan/Organize (BRIEF-Parents) OROS-MPH 49 50.72 2485.5 993.5 0.319
Atomoxetine 46 45.1 2074.5
Organization of materials (BRIEF-Parents) OROS-MPH 49 52.11 2553.5 925.5 0.131
Atomoxetine 46 43.62 2006.5
Monitor (BRIEF-Parents) OROS-MPH 49 46.49 2278 1053.0 0.580
Atomoxetine 46 49.61 2282
MI (BRIEF-Parents) OROS-MPH 49 51.23 2510.5 968.5 0.238
Atomoxetine 46 44.55 2049.5
GEC (BRIEF-Parents) OROS-MPH 49 50.05 2452.5 1026.5 0.454
Atomoxetine 46 45.82 2107.5
Notes: BRIEF ¼ Behavior Rating Inventory of Executive Function; OROS-MPH ¼ Osmotic Release Oral System-Methylphenidate Hydrochloride;
BRI ¼ behavioral regulation index; MI ¼ metacognition index; GEC ¼ Global Executive Composite.

children with ADHD are persistent despite treatment, when References

compared with the control group.
Adler, L., Tanaka, Y., Williams, D., Trzepacz, P. T., Goto, T., Allen,
A. J., & Upadhyaya, H. P. (2014). Executive function in adults with
attention-deficit/hyperactivity disorder during treatment with atom-
oxetine in a randomized, placebo-controlled, withdrawal study.
Acknowledgment Journal of Clinical Psychopharmacology, 34(4), 461–466.
We would like to thank the children and their families for participating American Psychiatric Association (APA). (2013). Diagnostic and statis-
in the study on a voluntary basis. The cost of the study has been paid tical manual of mental disorders (5th ed.). American Psychiatric
by the authors. Association.
Bakar, E. E. (2007). Dikkat Eksiklig i Hiperaktivite Bozuklug unun Alt
€ unt€
Tiplerine Ait Bilişsel Or€ uler. Doktora Tezi.
Bakar, E. E., Taner, Y. I., Soysal, A. S., Karakas, S., & Turgay, A.
(2011). Behavioral rating inventory and laboratory tests measure dif-
Disclosure statement ferent aspects of executive functioning in boys: A validity study.
No potential conflict of interest was reported by the author(s). Klinik Psikofarmakoloji B€
ulteni [Bulletin of Clinical
Psychopharmacology], 21(4), 302–316. https://doi.org/10.5455/bcp.
20111004014003
ORCID Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and
executive functions: Constructing a unifying theory of ADHD.
Yasemin Taş Torun http://orcid.org/0000-0002-4922-7594 Psychological Bulletin, 121(1), 65–94. https://doi.org/10.1037/0033-
Yasemen Işik Taner http://orcid.org/0000-0001-8560-5161 2909.121.1.65
Esra G€uney http://orcid.org/0000-0002-4043-8301 Barkley, R. A., & Fischer, M. (2011). Predicting impairment in major
_
Elvan Iseri http://orcid.org/0000-0002-1809-5867 life activities and occupational functioning in hyperactive children

as adults: Self-reported executive function (EF) deficits versus EF
tests. Developmental Neuropsychology, 36(2), 137–161. https://doi.
org/10.1080/87565641.2010.549877
Bedard, A. C. V., Stein, M. A., Halperin, J. M., Krone, B., Rajwan, E.,
& Newcorn, J. H. (2015). Differential impact of methylphenidate
and atomoxetine on sustained attention in youth with
attention-deficit/hyperactivity disorder. Journal of Child Psychology
and Psychiatry, 56(1), 40–48. https://doi.org/10.1111/jcpp.12272
Biederman, J., Mick, E., Fried, R., Wilner, N., Spencer, T. J., &
Faraone, S. V. (2011). Are stimulants effective in the treatment of
executive function deficits? Results from a randomized double blind
study of OROS-methylphenidate in adults with ADHD. European
Neuropsychopharmacology: The Journal of the European College of
Neuropsychopharmacology, 21(7), 508–515. https://doi.org/10.1016/j.
euroneuro.2010.11.005
Brown, T. E. (2006). Executive functions and attention deficit hyper-
activity disorder: Implications of two conflicting views. International
Journal of Disability, Development and Education, 53(1), 35–46.
https://doi.org/10.1080/10349120500510024
Brown, T. E., Holdnack, J., Saylor, K., Adler, L., Spencer, T., Williams,
D. W., Padival, A. K., Schuh, K., Trzepacz, P. T., & Kelsey, D.
(2011). Effect of atomoxetine on executive function impairments in
adults with ADHD. Journal of Attention Disorders, 15(2), 130–138.
https://doi.org/10.1177/1087054709356165
Çetin, F. H., Torun, Y. T., & Taner, Y. I. (2015). Dikkat Eksikligi
Hiperaktivite Bozuklugu Tedavisinde Atomoksetin ve Osmotik
Salinimli Metilfenidat: Etkinlik ve Yan Etki Profilinin
Degerlendirildigi Alti Aylik Izlem Çlismasi [Atomoxetine Versus
Oros Methylphenidate in Attention Deficit Hyperactivity Disorder:
A Six-Month Follow Up Study for Efficacy and Adverse Effects].
T€urkiye Klinikleri. Tip Bilimleri Dergisi, 35(2), 88.
Coghill, D., Seth, S., Pedroso, S., Usala, T., Currie, J., & Gagliano, A.
(2014). Effects of methylphenidate on cognitive functions in children
and adolescents with ADHD: Evidence from a systematic review
and a meta-analysis. Biological Psychiatry, 76(8), 603–615. https://
doi.org/10.1016/j.biopsych.2013.10.005
Conners, C. K. (1969). A teacher rating scale for use in drug studies
with children. The American Journal of Psychiatry, 126(6), 884–888.
https://doi.org/10.1176/ajp.126.6.884
Dereboy, C., Senol, S., Sener, S., & Dereboy, F. (2007). Validation of
the Turkish versions of the short-form Conners’ teacher and parent
rating scales. Turk psikiyatri dergisi [Turkish Journal of Psychiatry],
18(1), 48–58.
Fallu, A., Richard, C., Prinzo, R., & Binder, C. (2006). Does OROS-
methylphenidate improve core symptoms and deficits in executive
function? Results of an open-label trial in adults with attention def-
icit hyperactivity disorder. Current Medical Research and Opinion,
22(12), 2557–2566. https://doi.org/10.1185/030079906X154132
Faraone, S. V., Biederman, J., Spencer, T., Michelson, D., Adler, L.,
Reimherr, F., & Seidman, L. (2005). Atomoxetine and Stroop task
performance in adult attention-deficit/hyperactivity disorder. Journal
of Child and Adolescent Psychopharmacology, 15(4), 664–670. https://
doi.org/10.1089/cap.2005.15.664
Gao, H., Zhao, Y., Levine, L., & Allen, A. (2006). Determining cut-
points for clinically meaningful improvement: A receiver operating
characteristic approach. In Scientific Proceedings of the 53rd Annual
Meeting of the American Academy of Child and Adolescent
Psychiatry. American Academy of Child and Adolescent Psychiatry.
Gau, S. S. F., & Shang, C. Y. (2010). Improvement of executive func-
tions in boys with attention deficit hyperactivity disorder: An open-
label follow-up study with once-daily atomoxetine. The International
Journal of Neuropsychopharmacology, 13(2), 243–256. https://doi.org/
10.1017/S1461145709990836
Gioia, G. A., Isquith, P. K., & Guy, S. C. (2000). Construct validity of
the behavior rating inventory of executive function (BRIEF). Journal
of the International Neuropsychological Society, 6, 139.
Gioia, G. A., Isquith, P. K., Retzlaff, P. D., & Espy, K. A. (2002).
Confirmatory factor analysis of the Behavior Rating Inventory of
Executive Function (BRIEF) in a clinical sample. Child
APPLIED NEUROPSYCHOLOGY: CHILD 11
Neuropsychology, 8(4), 249–257. https://doi.org/10.1076/chin.8.4.249.
13513
G€ €
okler, B., Unal, F., Pehlivant€urk, B., K€ult€
ur, E. Ç., Akdemir, D., &
Taner, Y. (2004). Reliability and validity of schedule for affective
disorders and Schizophrenia for school age children-present and
lifetime version-Turkish version (K-SADS-PL-T)[in Turkish]. Turk
Journal of Child Adolescence Mental Health, 11, 109–116.
Goyette, C. H., Conners, C. K., & Ulrich, R. F. (1978). Normative data
on revised Conners parent and teacher rating scales. Journal of
Abnormal Child Psychology, 6(2), 221–236. https://doi.org/10.1007/
BF00919127
Grane, V. A., Endestad, T., Pinto, A. F., & Solbakk, A. K. (2014).
Attentional control and subjective executive function in treatment-
naive adults with attention deficit hyperactivity disorder. PLOS One,
9(12), e115227. https://doi.org/10.1371/journal.pone.0115227
Homack, S., & Riccio, C. A. (2004). A meta-analysis of the sensitivity
and specificity of the Stroop Color and Word Test with children.
Archives of Clinical Neuropsychology, 19(6), 725–743. https://doi.org/
10.1016/j.acn.2003.09.003
Isquith, P. K., & Gioia, G. A. (2000). BRIEF predictions of ADHD:
clinical utility of the Behavior Rating Inventory of Executive
Function for detecting ADHD subtypes in children. Archives of
Clinical Neuropsychology, 15(8), 780–781. https://doi.org/10.1093/
arclin/15.8.780a
Kaplan, B. J., Dewey, D., Crawford, S. G., & Fisher, G. C. (1998).
Deficits in long-term memory are not characteristic of ADHD.
Journal of Clinical and Experimental Neuropsychology, 20(4),
518–528. https://doi.org/10.1076/jcen.20.4.518.1477
Karakas, S. (2004). Handbook of BILNOT Battery: Studies of research
and development for neuropsychological tests. Dizayn Ofset.
Karakaya, I., Yıldız, O. € & Şişmanlar, Ş. (2006). Metilfenidatın Dikkat
Eksikligi Hiperaktivite Bozuklugu olan çocuklarda dikkat ve
y€ur€ut€ uc€ €zerine etkisi: Bir olgu serisi. Çocuk ve Gençlik Ruh
u işlevler u
Sag lıg ı Dergisi, 13(69), 75.
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P.,
Williamson, D., & Ryan, N. (1997). Schedule for affective disorders
and schizophrenia for school-age children-present and lifetime ver-
sion (K-SADS-PL): Initial reliability and validity data. Journal of the
American Academy of Child and Adolescent Psychiatry, 36(7),
980–988. https://doi.org/10.1097/00004583-199707000-00021
Kılıç, B. G., Irak, M., Koçkar, A. I., _ Şener, Ş., & Karakaş, S. (2002).
_
Işaretleme Testi T€ urk Formu’nun 6-11 Yaş Grubu Çocuklarda
Standardizasyon Çalışması. Klinik Psikiyatri Dergisi, 5(4), 213–228.
Kılıç, B., Koçkar, A., Irak, M., Şener, Ş., & Karakaş, S. (2002). The
standardization study of the Stroop test TBAG form in children
between 6 and 11 years of age. Turkish Journal of Child Adolescent
Mental Health, 9(2), 86–99.
Kiliç, B. G., Sener, S., Koçkar, A. I., & Karakaş, S. (2007).
Multicomponent attention deficits in attention deficit hyperactivity
disorder. Psychiatry and Clinical Neurosciences, 61(2), 142–148.
https://doi.org/10.1111/j.1440-1819.2007.01629.x
Kiriş, N., Tahiroglu, A. Y., Avci, A., Herg€ € Altunbaşak, Ş., &
uner, O.,
Karakaş, S. (2013). Dikkat Eksikligi Hiperaktivite Bozuklugu Olan
Çocuklarda Metilfenidatın N€oropsikolojik Işlevler _ €
Uzerine Etkisi.
Turkiye Klinikleri Journal of Medical Sciences, 33(3), 797–805.
https://doi.org/10.5336/medsci.2012-31505
Konrad, K., G€ unther, T., Heinzel-Gutenbrunner, M., & Herpertz-
Dahlmann, B. (2005). Clinical evaluation of subjective and objective
changes in motor activity and attention in children with attention-
deficit/hyperactivity disorder in a double-blind methylphenidate
trial. Journal of Child and Adolescent Psychopharmacology, 15(2),
180–190. https://doi.org/10.1089/cap.2005.15.180
Kratochvil, C. J., Heiligenstein, J. H., Dittmann, R., Spencer, T. J.,
Biederman, J., Wernicke, J., Newcorn, J. H., Casat, C., Milton, D., &
Michelson, D. (2002). Atomoxetine and methylphenidate treatment
in children with ADHD: A prospective, randomized, open-label trial.
Journal of the American Academy of Child and Adolescent
Psychiatry, 41(7), 776–784. https://doi.org/10.1097/00004583-
200207000-00008
12 Y. TAŞ TORUN ET AL.
Landau, Y. E., Gross-Tsur, V., Auerbach, J. G., Van der Meere, J., &
Shalev, R. S. (1999). Attention-deficit hyperactivity disorder and
developmental right-hemisphere syndrome: Congruence and incon-
gruence of cognitive and behavioral aspects of attention. Journal of
Child Neurology, 14(5), 299–303. https://doi.org/10.1177/
088307389901400506
MacLeod, C. M. (1992). The Stroop task: The “gold standard” of atten-
tional measures. Journal of Experimental Psychology: General, 121(1),
12–14. https://doi.org/10.1037/0096-3445.121.1.12
Maziade, M., Rouleau, N., Lee, B., Rogers, A., Davis, L., & Dickson, R.
(2009). Atomoxetine and neuropsychological function in children
with attention-deficit/hyperactivity disorder: Results of a pilot study.
Journal of Child and Adolescent Psychopharmacology, 19(6),
709–718. https://doi.org/10.1089/cap.2008.0166
Newcorn, J. H., Kratochvil, C. J., Allen, A. J., Casat, C. D., Ruff, D. D.,
Moore, R. J., & Michelson, D., Atomoxetine/Methylphenidate
Comparative Study Group (2008). Atomoxetine and osmotically
released methylphenidate for the treatment of attention deficit
hyperactivity disorder: Acute comparison and differential response.
The American Journal of Psychiatry, 165(6), 721–730. https://doi.org/
10.1176/appi.ajp.2007.05091676
Ni, H. C., Shang, C. Y., Gau, S. S. F., Lin, Y. J., Huang, H. C., & Yang,
L. K. (2013). A head-to-head randomized clinical trial of methyl-
phenidate and atomoxetine treatment for executive function in
adults with attention-deficit hyperactivity disorder. The International
Journal of Neuropsychopharmacology, 16(9), 1959–1973. https://doi.
org/10.1017/S1461145713000357
O’Driscoll, G. A., Depatie, L., Holahan, A. L. V., Savion-Lemieux, T.,
Barr, R. G., Jolicoeur, C., & Douglas, V. I. (2005). Executive func-
tions and methylphenidate response in subtypes of attention-deficit/
hyperactivity disorder. Biological Psychiatry, 57(11), 1452–1460.
https://doi.org/10.1016/j.biopsych.2005.02.029
Prasad, S., Harpin, V., Poole, L., Zeitlin, H., Jamdar, S., Puvanendran,
K., & Group, S. S., on behalf of the SUNBEAM Study Group (2007).
A multi-centre, randomised, open-label study of atomoxetine com-
pared with standard current therapy in UK children and adolescents
with attention-deficit/hyperactivity disorder (ADHD). Current
Medical Research and Opinion, 23(2), 379–394. https://doi.org/10.
1185/030079906X167309
Shang, C. Y., & Gau, S. S. F. (2012). Improving visual memory, atten-
tion, and school function with atomoxetine in boys with attention-
deficit/hyperactivity disorder. Journal of Child and Adolescent
Psychopharmacology, 22(5), 353–363. https://doi.org/10.1089/cap.
2011.0149
Soysal, S. (2007). Dikkat eksiklig i hiperaktivite bozuklug u alttiplerinde
dikkat y€ onetici işlevler ve u €st-biliş performansının oluşturdugu
€r€
ilişkiler o unt€us€
un€un incelenmesi [Doktora Tezi [Doctoral disserta-
€
tion]]. Hacettepe Universitesi, Sosyal Bilimler Enstit€ us€u, Ankara,
2007 (Thesis in Turkish).
Stroop, J. R. (1935). Studies of interference in serial verbal reactions.
Journal of Experimental Psychology, 18(6), 643–662. https://doi.org/
10.1037/h0054651
Su, Y., Yang, L., Stein, M. A., Cao, Q., & Wang, Y. (2016). Osmotic
release oral system methylphenidate versus atomoxetine for the
treatment of attention-deficit/hyperactivity disorder in Chinese
youth: 8-week comparative efficacy and 1-year follow-up. Journal of
Child and Adolescent Psychopharmacology, 26(4), 362–371. https://
doi.org/10.1089/cap.2015.0031
Tasdelen, B. I., Karakaya, E., & Oztop, D. B. (2015). Effects of
atomoxetine and osmotic release oral system-methylphenidate on
executive functions in patients with combined type attention-deficit/
hyperactivity disorder. Journal of Child and Adolescent
Psychopharmacology, 25(6), 494–500. https://doi.org/10.1089/cap.
2014.0155
Wehmeier, P. M., Schacht, A., Wolff, C., Otto, W. R., Dittmann,
R. W., & Banaschewski, T. (2011). Neuropsychological outcomes
across the day in children with attention-deficit/hyperactivity dis-
order treated with atomoxetine: Results from a placebo-controlled
study using a computer-based continuous performance test com-
bined with an infra-red motion-tracking device. Journal of Child
and Adolescent Psychopharmacology, 21(5), 433–444. https://doi.org/
10.1089/cap.2010.0142
Weintraub, S., & Mesulam, M. M. (1985). Verbal and Nonverbal
Cancellation Test. FA Davis.
Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., & Pennington,
B. F. (2005). Validity of the executive function theory of attention-
deficit/hyperactivity disorder: a meta-analytic review. Biological
Psychiatry, 57(11), 1336–1346. https://doi.org/10.1016/j.biopsych.
2005.02.006
Yang, L., Cao, Q., Shuai, L., Li, H., Chan, R. C., & Wang, Y. (2012).
Comparative study of OROS-MPH and atomoxetine on executive
function improvement in ADHD: A randomized controlled trial.
The International Journal of Neuropsychopharmacology, 15(1), 15–26.
https://doi.org/10.1017/S1461145711001490
Yildiz, O., Sismanlar, S. G., Memik, N. C., Karakaya, I., & Agaoglu, B.
(2011). Atomoxetine and methylphenidate treatment in children
with ADHD: The efficacy, tolerability and effects on executive func-
tions. Child Psychiatry and Human Development, 42(3), 257–269.
https://doi.org/10.1007/s10578-010-0212-3
Yilmaz, A., Gokcen, C., Fettahoglu, E. C., & Ozatalay, E. (2013). The
effect of methylphenidate on executive functions in children with
attention-deficit hyperactivity disorder. Klinik Psikofarmakoloji
B€ulteni-Bulletin of Clinical Psychopharmacology, 23(2), 162–170.
https://doi.org/10.5455/bcp.20121130090251
Zheng, Y., Liang, J. M., Gao, H. Y., Yang, Z. W., Jia, F. J., Liang, Y. Z.,
& Zhuo, J. M. (2015). An open-label, self-control, prospective study
on cognitive function, academic performance, and tolerability of
osmotic-release oral system methylphenidate in children with atten-
tion-deficit hyperactivity disorder. Chinese Medical Journal, 128(22),
2988.