ADHD Atten Def Hyp Disord (2009) 1:310 DOI 10.

1007/s12402-009-0002-6

ORIGINAL ARTICLE

Reective and impulsive reactions in ADHD subtypes

C. Schwenck S. Schmiedeler Y. Zenglein T. Renner M. Romanos T. Jans W. Schneider A. Warnke

Received: 21 May 2008 / Accepted: 18 March 2009 / Published online: 7 April 2009 Springer-Verlag 2009

Abstract Research on different subtypes of attention decit hyperactivity disorder (ADHD) yielded inconsistent results regarding the nature of cognitive decits. Whereas some studies report signicant differences between subtypes, others fail to report these differences. In fact, the majority of studies in the eld of ADHD does not differentiate between subtypes at all. The present study adopted the cognitive task of negating valence to compare the DSM-dened ADHD combined subtype (ADHD-C; n = 25), the inattentive subtype (ADHD-I; n = 25) and the control group (n = 30). As a main result, children with ADHD-C showed signicant impairments compared to children with ADHD-I and the control group on conscious responsesdriven by executive function, as well as on unconscious associative tasks. Medical treatment with stimulants positively inuenced cognitive performance, although to a different extent for subgroups. The results are discussed in the context of current theories of ADHD and imply indications for further research in this eld. Keywords ADHD Subtypes Executive functioning Stimulant treatment

Introduction Attention decit hyperactivity disorder (ADHD) is characterized by a cluster of symptoms consisting of inattention, hyperactivity and impulsivity. Following the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, APA 2000) ADHD can be divided into three subtypes: the predominantly inattentive subtype (ADHD-I), the predominantly hyperactive/impulsive subtype (ADHDH) and the combined subtype (ADHD-C). Originally, all three subtypes were dened to belong to the same entity of ADHD. However, doubts about this assumption can be derived from basic psychological theories of ADHD as well as from present psychological research. In his wellknown model of executive functioning decits in ADHD, Barkley (1997) only discusses the subtypes ADHD-H and ADHD-C, but not ADHD-I. In comparison, the more recent motivation-oriented model of ADHD hypothesized by Sonuga-Barke (2003, 2005; Sonuga-Barke et al. 2003; Solanto et al. 2001) also includes the triad of symptoms in ADHD, but fails to explain the varying intensity of symptoms in the different subtypes. Neuropsychological research on cognitive impairments in ADHD subtypes resulted in inconsistent ndings, sometimes yielding signicant differences between subtypes, sometimes failing to nd such differences. The following table presents some of the studies on different aspects of cognitive functioning in ADHD subtypes and their results. The studies presented in Table 1 focused on fundamental aspects of cognitive functioning, such as response inhibition, attention or memory. Though the same aspects of cognitive functioning were taken into account in the respective studies, there is no unambiguous support for the differentiation of ADHD subgroups based on these

C. Schwenck (&) T. Renner M. Romanos T. Jans A. Warnke Department of Child and Adolescent Psychiatry, University of Wurzburg, Fuchsleinstrae 15, 97080 Wurzburg, Germany e-mail: schwenck@kjp.uni-wuerzburg.de S. Schmiedeler Y. Zenglein W. Schneider Department of Educational and Developmental Psychology, University of Wurzburg, Wurzburg, Germany

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4 Table 1 Studies of subtype differences in executive functions References Nigg et al. (2002) Milich et al. (2001) ODriscoll et al. (2005) Johnson et al. (1999) Lockwood et al. (2001) Gross-Tsur et al. (2006) Scheres et al. (2004) Chhabildas et al. (2001) Geurts et al. (2005) Murphy et al. (2001) Aspect of cognitive function under examination Response inhibition Attention Motor planning, response inhibition Memory Selective attention CPT Inhibition, planning, set-shifting, working memory, verbal uency Processing speed, vigilance, inhibition Behavioral inhibition, sustained attention, executive functions Verbal working memory, attention, inhibition, interference control, nonverbal working memory

C. Schwenck et al.

Difference between ADHD subtypes? ADHD-C \ ADHD-I ADHD-C [ ADHD-I ADHD-C \ ADHD-I ADHD-C [ ADHD-I ADHD-C \ ADHD-I ADHD-C = ADHD-I ADHD-C = ADHD-I ADHD-C = ADHD-I ADHD-C = ADHD-I ADHD-C = ADHD-I

domains. Results of recent studies on cognitive functioning in ADHD subtypes require clarication and replication: despite diagnostic criteria, Clarke et al. (2007) found a greater severity on inattentive symptoms in children with ADHD-C compared to those with ADHD-I in their study. Furthermore, a majority of studies on ADHD does not differentiate between subtypes at all or focuses on only one subtype (e.g. Boonstra et al. 2005; Evans et al. 2001). Medical treatment with stimulants has been shown to have a positive inuence on cognitive functioning in most of the studies conducted, though most studies do not report whether treatments have different effects depending on the subtypes (Evans et al. 2001; Huang et al. 2007) and intra- as well as inter-individual variability in medication response was found (Pietrzak et al. 2006; Zeeuw et al. 2008). Human cognition and behavior can be driven by reective and impulsive processes to a varying extent. Dual-system models that describe these processes (e.g. the Reective-Impulsive Model by Strack and Deutsch 2004; see also Deutsch et al. 2006) assume reective processes to be responsible for reasoning and executive functioning. They work slowly and depend on attentive capacity. On the other hand, impulsive processes work in an associative way of automatically activating linked representations and do not require attentive capacity. Both systems interact, compete and inuence each other. The dominant behavioral reaction depends on the capacity and selective attention directed to a special target (Strack et al. 2006). Up to now, reective and impulsive reactions were compared only in studies on healthy adults. One paradigm used to get a closer insight on the differences of these forms of cognitive functions compares the reactions on negated versus afrmed targets. Mentally negating a statement is a prime example of reective processing.

Negations presuppose propositional representation, where the meaning of the negated construct (e.g. this is not bad) is maintained in the working memory while the meaning of the negated proposition (e.g. this is good) is construed. Such maintenance and construal processes require executive control and attentive capacity (Miller and Cohen 2001), and that the process cannot be conducted in an associative way of activation (e.g. Deutsch et al. 2006; Mayo et al. 2004). In a series of experiments with a nonclinical population of students, Deutsch et al. (2006) showed higher reaction times and error rates in the evaluation of negated than afrmed targets. Although this effect has never been replicated in younger age groups, it can be assumed that reaction times and error rates differ for children depending on the qualier of a target, too. Since ADHD is associated with a reduced attentive capacity, children of all ADHD-subtypes should show a greater difference between reactions to afrmed and negated targets in comparison to normal control groups. Furthermore, ADHD-C is not only dened by a lack of attentive capacity, but additionally by a pronounced impulsivity that is not due to ADHD-I. Taking this subtype difference into account, it can be expected that children with ADHD-I show lower reactions times and error rates than those with ADHD-C on a task comparing reactions to negated versus afrmed targets. Since the research paradigm of negations considers both, attentive capacity and impulsivity, the current study aims at investigating and comparing ADHD subtypes and a nonclinical control group by applying the paradigm to these groups. It was assumed that children with ADHD should show signicant impairments in reacting to negated targets compared to the non-clinical control group. The difference between afrmed and negated reactions should be highest for ADHD-C, followed by ADHD-I and control subjects.

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Medical treatment should diminish this difference to a comparable performance of ADHD and control subjects.

Materials and methods Subjects In total, 90 boys participated in the study. There were 25 subjects with ADHD-C, 25 with ADHD-I, and 40 boys served as a non-clinical control group. Ten boys from the control group were excluded from data analyses because their parents reported substantial attention decits on two parent rating scales (CBCL, FBB-HKS; description as seen below). Therefore, results for 80 subjects, all aged from 8 to 14 years (mean age 11.03, SD = 1.75 years), are shown in the following. All of them had IQ scores of [85 on either the Wechsler Intelligence Scale for Children, third edition (Hamburg-Wechsler Intelligenztest fur Kinder, HAWIK-III; Tewes et al. 2002) or the Kaufmann-Assessment-Battery for Children (K-ABC; Melchers and Preu 2003). There were no signicant group differences for either age [F(2,77) = 0.67, P = 0.52] or IQ [F(2,77) = 0.87, P = 0.42]. Table 2 shows age and IQ of each group. Subjects with ADHD were recruited from the Department of Child and Adolescent Psychiatry, University of Wurzburg, and a local medical practice of Child and Adolescent Psychiatry in Wurzburg. They had been assessed by mental health professionals unafliated with the project and were divided into their ADHD-subtype using standard criteria (DSM-IV). The assessment consisted of a clinical examination and psychological tests. Furthermore, observational information of the childrens behavior, objective tests as well as self-, school and parent reports were considered for the diagnosis. The control group was recruited by an ad in the local newspaper; only boys who did not score above the cut-off on two parent rating scales [Fremdbeurteilungsbogen-HKS (FBB-HKS), Dopfner et al. 2000; Child Behavior Checklist (CBCL/418), 1998] were considered for further calculations. The FBB-HKS (Observer Rating Scale for ADHD) consists of 20 items containing symptoms of inattention, hyperactivity and impulsivity based on the diagnostic criteria of DSM-IV and ICD-10 (e.g. Has difculties organizing his
Table 2 Mean age in months and IQ (SD) of each group Group ADHD-C (n = 25) ADHD-I (n = 25) CG (n = 30) Total CG control group Age in months 128.76 (21.43) 135.64 (19.22) 132.53 (22.19) 132.32 (20.97) IQ 109.4 (11.53) 109.0 (13.81) 113.0 (12.43) 110.61 (12.59)

tasks and activities). Observers (in this study parents) are supposed to rate each item on a 03 point scale. Answers with 2 or 3 points are evaluated as critical and the cut-off for each nine-item-cluster of symptoms (inattention; hyperactivity/impulsivity) lies at six critically answered items. The Child Behavior Checklist is a parent-report questionnaire on which the child is rated on various behavioral and emotional problems. One of its subscales assesses attention problems. All children with ADHD were continuously taking stimulant medication with documented positive and sufcient clinical response. In the condition without treatment, subjects stopped medication at least 24 h prior to testing. All subjects agreed to participate in the study and written informed consent was obtained in all cases. The study was approved by the local Ethics Committee of the University of Wurzburg. Task Subjects performed a computerized task (according to Deutsch et al. 2006, adapted for children), in which they had to evaluate afrmed (e.g. a friend) and negated (e.g. no friend) positive (e.g. ice-cream) and negative (e.g. danger) words by pressing appropriate keys. For wordpairs with positive valence (e.g. a friend or no danger), subjects had to press the key S, which was marked with a happy smiley, and for a word-pairs with negative valence (e.g. no friend or a danger) the key L, that was marked with a sad smiley. Children were instructed to press the key as quickly and as accurately as possible. Altogether they had to react to 400 word pairs that were presented in blocks of 80 pairs, with 30 s breaks between blocks. Every word was presented equally often in afrmed and negated versions. Word pairs were presented in the following way: 700 ms before the presentation of the rst target, a warningsignal (XXX) appeared, followed by a black screen for 200 ms. Then the target words were presented in yellow letters on a black background (30 pt. Arial). If subjects reacted correctly, the next target appeared 700 ms later. If their reaction was incorrect, they received feedback (error! negative right-positive left). If subjects reacted too slowly ([3,000 ms) or too fast (\150 ms) they were requested to react faster/more slowly. There was a practice block with 30 word-pairs before the rst test block that was not evaluated for further calculations. All subjects with ADHD were tested twice within 12 weeks, once with medication (Methylphenidate 0.5 1.0 mg/kg) and once without. Medication was balanced between trials. For control of learning effects, half of the children of the control group were also tested twice. Since there were no signicant differences between the rst and the second trial for any dependent variable in the control group,

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data of the rst trial were used for further analyses. There were two sets of words (set 1: friend, cinema, birthday, summer, party, trouble, dirt, illness, pain and fear and set 2: ice-cream, schools out today because of the heat, holidays, happiness, present, conict, danger, violence, house arrest and stomach ache). Sets were balanced over the two trials for all subjects. Statistical analyses

(total, afrmed, negated) 9 medication (with, without) for the three dependent variables reaction times (in ms), standard deviations of reaction times and error rates (in %). Descriptively strong effects for the factors qualier and medication can be seen, whereas the group factor shows differences for the ADHD-C children compared to those of the two other groups. In the following section dependent measures are compared statistically for group differences. Comparisons afrmed versus negated targets

Data were preprocessed with the programme Media-Lab. From the resulting matrix a total error score and error scores for afrmed and negated targets were calculated. Next, trials in which the subjects classied targets either as incorrectly, too slowly ([3,000 ms) or too fast (\300 ms) were excluded from the data, and reaction times as well as standard deviations of reaction times were calculated both for the total number as well as for the afrmed and negated targets. For statistical analyses an alpha level of 0.05 was applied. Between group differences and within group differences as for the factor qualier were tested with analyses of variance (MANOVA/repeated measures MANOVA). For differences between groups on the variable qualier a mixed model analyses of variances with repeated measure on the qualier were conducted. Effect sizes (g2) were calculated and t tests (LSD) were conducted for post hoc tests where indicated.

To prove the negation effect for our sample of children, we compared afrmed with negated targets as to the dependent variables. As can be seen in Table 4, subjects produced more errors and reacted more slowly to negated than to afrmed targets. There were no signicant differences as to the standard deviations of reaction times. ADHD without medication compared to the control group Mixed model analyses of variances with repeated measure on the qualier were conducted for the dependent variables of the three experimental groups. As for error percentage, there was a signicant main effect for the factor qualier [F(1,77) = 67.96, P \ 0.001, g2 = 0.47], but no signicant interaction for qualier 9 group [F(2,77) = 0.07, P = 0.935, g2 = 0.00]. The between groups comparison showed signicant group differences [F(2,77) = 4.99, P \ 0.01, g2 = 0.12]. Subsequent post-hoc t-tests showed that subjects with ADHD-C made more errors than the group ADHD-I (P \ 0.01) as well as the control group (P \ 0.05), which can be seen in Fig. 1. No difference was found between ADHD-I and the control group (P = 0.44).

Results Descriptive results on groups, qualier and medication For a descriptive overview, Table 3 presents means (SD) for the factors group (ADHD-I, ADHD-C, CG) 9 qualier

Table 3 Mean (SD) reaction times (RT; in ms), standard deviations of reaction times (SD-RT) and error rates (ER; in %) of all experimental conditions Group Medication Measure RT Qualier Total Afrmed Negated SD-RT Total Afrmed Negated ER Total Afrmed Negated CG control group 1323 (241) 1272 (233) 1376 (251) 374 (95) 368 (103) 361 (95) 8.88 (6.48) 6.14 (5.35) 11.56 (8.01) 1337 (233) 1293 (225) 1385 (241) 413 (98) 419 (95) 411 (97) 11.37 (8.81) 8.68 (7.46) 14.02 (11.00) 1426 (261) 1384 (251) 1471 (275) 393 (77) 392 (76) 388 (81) 13.88 (10.82) 12.12 (11.16) 15.58 (10.87) 1477 (288) 1428 (272) 1530 (308) 460 (136) 453 (134) 459 (143) 20.79 (14.71) 18.37 (15.05) 23.18 (14.83) 1389 (281) 1347 (280) 1435 (285) 422 (104) 418 (99) 420 (115) 13.66 (8.98) 11.20 (8.40) 16.11 (10.06) ADHD-I With Without ADHD-C With Without CG

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Reective and impulsive reactions Table 4 Comparison of afrmed and negated targets as to RT (in ms), SD-RT and ER (in %) Afrmed targets Negated targets t M RT ER 1335 9.91 SD 258 95 8.90 M 1428 391 14.52 SD 271 101 9.83 -15.34 \0.001 0.75 0.60 0.553 0.00 -9.57 \0.001 0.54 RT SDRT ER P g2

7 Table 5 Inuence of medication on dependent variables (RT in ms; ER in %) Medication M 1374 384 11.38 SD 254 86 9.18 No medication M 1407 436 16.08 SD 268 120 12.91 -1.19 -4.25 -3.78 0.24 \0.001 \0.001 0.03 0.28 0.24 t P g2

SDRT 394

RT reaction time, SDRT standard deviations of reaction times, ER error rates

RT reaction time, SDRT standard deviations of reaction times, ER error rates

25 CG 20

error-rates without medication

ADHD-I ADHD-C

15 10 5 0
1 qualifier 2

medication than without medical treatment. Reaction times did not differ as a function of medical treatment. Conducted mixed model analyses of variances with repeated measure on the medication variable did not reveal any signicant group 9 medication interactions. Although the group 9 medication [F(1,48) = 3.30, P = 0.08, g2 = 0.06] interaction for error rates was short of being signicant, there was a trend, indicating that subjects with ADHD-C tended to prot higher from medical treatment than children with ADHD-I. This interaction trend is shown in Fig. 2. Comparisons for the ADHD with medication and control groups Conducted ANOVAS did not show any group differences for the dependent variables error rates, reaction time or standard deviations of reaction times (Table 6). When analyses were carried out separately for afrmed and negated targets, there was a signicant group difference for error rates [F(2,77) = 3.55, P \ 0.05, g2 = 0.08] of afrmed but not of negated targets. Post-hoc tests revealed that subjects in the ADHD-I group produced less errors (M = 6.14, SD = 5.35) than subjects in the ADHDC group (M = 12.12, SD = 11.16) and the control group

Fig. 1 Error rates (in %) for ADHD-C, ADHD-I (without medication) and controls (CG) CG control group, 1 afrmed, 2 negated

As for reaction times there was a signicant main effect for the factor qualier [F(1,77) = 189.99, P \ 0.001, g2 = 0.71]. Neither the interaction qualier 9 group [F(2,77) = 0.40, P = 0.67, g2 = 0.01] nor the between group comparison for group [F(2,77) = 1.73, P = 0.18, g2 = 0.04] showed any signicant differences. As for differences in standard deviations of the reaction times, mixed model analyses of variance did not yield any signicant effects for qualier [F(1,77) = 0.00, P = 0.95, g2 = 0.00], interaction qualier 9 group [F(2,77) = 0.56, P = 0.58, g2 = 0.01] and group [F(2,77) = 1.03, P = 0.36, g2 = 0.03]. Comparisons ADHD without medication: ADHD with medication Repeated measures MANOVAs were carried out to compare performance with and without medication in subjects with ADHD. As can be seen in Table 5, there were signicant differences in error percentage with subjects producing less errors with medication than without. Furthermore, standard deviations of reaction times differed signicantly. Children reacted more constantly with

error %

Fig. 2 Error rates (in %) in dependence of medication for ADHD-C and ADHD-I

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8 Table 6 Inuence of medication on dependent variables (RT in ms; ER in %) CG M RT ER 1389 SD 281 104 ADHD-I M SD ADHD-C M 1426 393 SD 261 77 0.99 0.38 0.03 1.80 0.17 0.05 F P g2

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1323 241 375 95

SDRT 422

13.66 8.98 8.88

6.48 13.88 10.82 2.57 0.08 0.06

CG control group, RT reaction time, SDRT standard deviations of reaction times, ER error rates

(M = 11.20, SD = 8.40), while the two latter groups did not differ signicantly.

Discussion This study investigated cognitive functioning in ADHD children as a result of variation in subtypes and medical treatment with a research paradigm which compared reactions to afrmed versus negated targets (Deutsch et al. 2006). To our knowledge, for the rst time, this research paradigm was applied to a sample of children. To differentiate and further investigate ADHD subtypes, their neurocognitive functioning and inuence of pharmacological treatment on their performance, part of the children tested was a clinical sample. Because the applied paradigm of negations accounts for both, reective processes inuenced by attentive capacity and impulsive processes aggravated by a heightened impulsivity, it seems particularly apt to discriminate between ADHD subtypes. We were able to replicate the ndings by Deutsch et al. (2006) concerning the negation effect in a sample of children with large effect sizes. We found signicantly higher error rates and reaction times for negated compared to afrmed targets across all investigated subjects. On average, children of our sample reacted 93 ms faster following afrmed than negated targets and conducted 4.61% less mistakes. Thus, it can be concluded that the applied paradigm is capable to assess cognitive reasoning dependent on executive functioning with automatic associative derived reactions in different age groups. Both, children and adults require more attentive capacity to evaluate negated compared to afrmed stimuli. Without stimulant treatment, subjects with ADHD-C produced higher error rates than children with ADHD-I and control groups. Displaying a medium effect size, the nding was independent of the qualier of the target, since no signicant interaction between the group variable and qualier was found. Surprisingly, no differences between children with ADHD-I and the control group were found. On the one hand, this result replicates ndings (ODriscoll

et al. 2005; Nigg et al. 2002) of higher impulsivity in children with ADHD-C compared with ADHD-I and control subjects. On the other hand, the expected difference between subjects with ADHD-I and normal control subjects, due to attentive limitations of children with ADHD-I, was not found. One possible explanation for this novel result may be due to limitations of the study: Children with ADHD-C only might have performed worse because of their high impulsivity. Non-naturalistic laboratory testing may not imply sufcient distraction from the task to evoke differences in performance due to limited attentive capacity. Future research should induce an additional condition distraction to further explore the inuence of distraction on the performance of children that do not react impulsively but have less attentive capacity. At the same time our results might indicate that environmental conditions (e.g. quiet home work situation) have a greater effect on children with ADHD-I than on those with ADHD-C. Another explanation of our results may be derived from recent research (Clarke et al. 2007) that indicated a greater severity of inattentive symptoms in children with ADHD-C compared to ADHD-I. Other studies (Nigg et al. 2005; Doyle et al. 2005) conclude that only a subset of children with ADHD has a decit in a given neurocognitive mechanism and that a huge variability exists within as well as between subgroups. Reective and impulsive reactions measured in our study may represent neurocognitive mechanisms impaired in children with ADHD-C but not in ADHD-I. Medical treatment with stimulants positively inuenced cognitive performance of children with ADHD, thereby agreeing with prior research (Evans et al. 2001; Huang et al. 2007). Medication resulted in increased accuracy, and subjects reacted more constantly as indicated the standard deviations of reaction times. However, contrary to prior research (Alderson et al. 2007) no inuence of medication on reaction times was found. Interestingly, there was a trend to greater prot for children with ADHD-C than for ADHD-I children. When medicated, no signicant differences in cognitive performances between children with ADHD and non-clinical controls were detected. Differentiated for the factor qualier, children with ADHD-I displayed better performance for afrmed targets compared to those with ADHD-C and control subjects on error rates. It can be concluded, that stimulant treatment in a cognitive enhancing way positively inuences information processing even in elds that were not obviously impaired previously. Effectiveness of medical treatment on performance in the negation task therefore does not allow diagnostic conclusions. However, in our study no objective measures of response to stimulant treatment was conducted, thus, single non-responders might have confounded

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9 Acknowledgment The authors thank Prof. Dr. Strack and Dr. Deutsch for their inspiring advice and their friendly support as to the programming of the task.

our results, since a huge inter- and intra-individual variability in medication response was found in past research (Pietrzak et al. 2006; Zeeuw et al. 2008). We expected to nd an interaction effect for the factors group and qualier, indicating that children with ADHD perform worse on the negated targets than on the afrmed ones compared to a control group. However, we were unable to nd an interaction effect for any of our measures. Compared to control subjects, children with ADHD-C showed general decits in categorizing the valence of the targets, yet they did not show a specic impairment on negated compared to afrmed targets. This absence of differential impairments for negated targets again may be caused by the non-naturalistic setting of the study as discussed above. It can be concluded that under the actual conditions participants had enough cognitive and attentive capacity to solve the task of reacting to afrmed as well as to negated targets at least partially by using reective processes. The cognitive load, induced by the task itself, might not have been demanding enough to exhaust the capacity of the reective system and underline the dominance of the impulsive system. General limitations primarily lie in the small sample size that may have resulted in small statistical power. Some of the identied trends may have achieved statistical signicance with a larger sample of participants. Furthermore the mean IQ of our sample was 111, which may indicate a selective sample. Though there were no between group differences regarding the IQ, the high intelligence of the sample may have inuenced the results. In conclusion, in the current study for the rst time reactions to afrmed versus negated targets were investigated in children with ADHD versus normal control subjects. Findings from healthy adult population showing that a larger cognitive capacity was necessary for the reaction to negated that to afrmed stimuli, were replicated for a younger sample. A general decit in categorizing the valence of a target in children with ADHD compared to normal control subjects was also detected, indicating an impairment in reective as well as in impulsive reactions. Furthermore we found differences in the ADHD- subtypes, indicating that children with ADHD-C make more errors than children with ADHD-I. This may be indication for qualitative differences in cognitive stimulus processing between subgroups of ADHD and not merely quantitative differences in impairments. Stimulant treatment diminished these differences with ADHD-C subjects tending to show a larger prot from medication than subjects with ADHD-I. Therefore, subtype differentiation should be carefully taken into consideration by future research on the eld of cognitive functioning in ADHD and the medical treatment of this disorder.

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