effects of amphetamine therapy and prescriptive tutoring

509

Effects of Amphetamine Therapy and Prescriptive Tutoring on the Behavior ond Achievement of Lower Class Hyperactive Children

W. G. Conrad, Ph.D., E. S. Dworkin, Ph.D., A. Shai, Ph.D., J. E. Tobiessen, Ed.D.

The present study had two primary objectives: (1) to evaluate the relatively long-term (4-6 months) effects of dextroamphetamine on the behavior, achievement, and perceptual<ognitive functioning of hyperkinetic children; (2) to compare the effects of dextroamphetamine and prescriptive perceptual<ognitive tutoring. Sixty-eight children matched for intelligence and degree of hyperactivity were assigned to the following groups: placebo/no tutoring; placebo/tutoring; dextroamphetamine I no tutor-ing; and dextroamphetamine/tutoring. Double-blind procedures were used in the administra-tion of medication. Results indicate that dextroamphetamine contributed to a reduction of hyperkinetic behavioral symptoms and to improvement in performance on various meas-ures of perceptual motor and cognitive develop-ment. Twice-a-week tutoring for an average of 20 weeks resulted in gains on some WISC subtests but was clearly not as effective as medication. Neither experimental condition significantly influenced academic achievement as measured by the Wide Range Achievement Test. Implications for the management and instruction of hyperkinetic children are dis-cussed.

Hyperactive children have been found to differ significantly in several respects from matched controls. Douglas, Werry, and Weiss (1965) found hyperactive children deficient in visual motor skills, perceptual speed and accuracy, and motor ability. They were also less able to deal with information in a dichotic listening situation. According to a recent investigation by Weiss et al. (1968), hyperactive children showed significantly more signs of neurological dysfunction and exhibited less sensorimotor coordination than matched controls.

Amphetamine therapy has been demon-strated to be effective in reducing the behav-ioral manifestations of hyperkinesis in children (Bradley, 1937; Bradley and Bowen, 1941; Bradley, 1950; Levy, 1959; Eisenberg et al., 1963; Conners, Eisenberg, and Barcai, 1967). Amphetamines also have been found to have a beneficial effect on Porteus Maze performance, Frostig Perceptual Quotient, Auditory Syn-thesis, and number of errors on a paired associates learning task (Conners et al., 1969).

Another approach to the remediation of children with specific learning disabilities is training in the specific area of perceptual or cognitive dysfunction (Frostig et al., 1963;

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Silver and Hagin, 1966; Silver, Hagin, and Hersh, 1967; and Llorens, 1967). The findings of these investigators support the premise that, for children with perceptual cognitive impair-ment, training in the specific area of impair-ment is needed before more traditional re-medial procedures will be most effective.

Due to the relatively short duration of medication studies, the effect of amphetamine therapy on academic achievement is not well documented. Furthermore, the relative effec-tiveness of chemotherapy and prescriptive tutoring for hyperkinetic children has not been investigated. The purpose of the present study was to evaluate the effects of chemotherapy with and without prescriptive tutoring and the effect of tutoring alone on the behavior, achievement, and test performance of hyper-kinetic children. The research was conducted by the Schenectady County Child Guidance Center in cooperation with the Schenectady City School District. The Center is a com-munity child guidance clinic serving Schen-ectady County, with a population of approxi-mately 120,000.

SELECTION OF THE SAMPLE Although the prevalence of hyperkinetic chil-dren in low income neighborhoods has not been clearly established, it is our impression from con-sultation with teachers that from 3 to 5 percent of the children from predominantly middle class schools and perhaps as high as 10 percent of the children from predominantly lower class schools are likely to be hyperkinetic. The children selected for this study were from predominantly lower class neighborhoods.

Teachers in kindergarten, first grade, and second grade in seven schools were asked in June of 1969 to rate all of their children on the Schenectady Hyperkinetic Scale (SHS), which consists of listings of symptoms of hyper-activity, distractibility, and perceptual-motor dysfunction.

From a population of 1,350 children, 262 with the highest scores on the SHS (upper 19%) were selected for further evaluation. Of the 262, the families of 105 could not be con-tacted, 18 children were already receiving med-

46

ication, and the parents of 33 refused to participate.

A comparison of the mean scores on the SHS for the 156 children who were excluded (x = 19.23) and the 106 who constituted the experimental sample (x = 20.35) revealed no significant difference between the groups.

After parental approval was obtained for the 106 children, each child was seen for an individual evaluation involving the following areas of functioning:

(1) Ability to organize events in time and objects in space.

(2) Ability to skip, jump, walk on heels and toes, balance on both left and right foot with eyes open and with eyes closed, and to perform finger to nose test with eyes closed.

(3) Ability to repeat a rhythmic pattern using both hands.

(4) Ability to follow moving target with the eyes.

(5) Perceptual Motor Skills (Bender-Gestalt and Frostig).

(6) Visual Memory (recall of Bender-Gestalt).

(7) Intelligence (WISC).

In addition, there were ratings by the exam-iner of the child's distractibility, hyperactivity, and ability to attend during the testing session.

To qualify for the program, the child must have been rated hyperactive (19th percentile or lower) by the teacher and must have shown significant evidence of perceptual-cognitive i mpairment. Significant perceptual-cognitive impairment was defined as any of the follow ing:

(1) A perceptual age on the (Bender-Gestalt (as scored by the Koppitz norms) which was one year or more below the chronological age of the child.

(2) A Frostig Perceptual Quotient of 90 or less.

(3) Thee or more errors on the Bender-Gestalt, which Koppitz found signif-icantly more often in brain-injured groups.

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511

TABLE I. Frequency and percent of sample meeting each of the five criteria.

%of

Criteria N Total

Perceptual age 1 year or more below CA 38 36

Frostig PQ of 90 or less 68 64

3 or more "Brain Injured" errors 72 68

Discrepancy between Verbal IQ and 30 28

Performance IQ = 15 or more

Variability among subscores on 81 76

WISC of 6 scaled scores or more

(4) A discrepancy between Verbal IQ and Performance IQ on the WISC of 15 points or more.

(5) Variability among subscores on the WISC of six points or more.

The number of children meeting each of the five criteria is shown in Table I.

Of the 106 children who were evaluated, 96 qualified for the program using one or more of the above criteria (see Table I). Of these, 15 families refused to continue with the study following the evaluation and another 13 families terminated later in the program, leaving 68 children in the study at its completion.

EXPERIMENTAL DESIGN The diagnostic evaluations were completed dur-ing the summer and fall of 1969 by clinical psychologists. The four groups were then matched for intelligence and degree of hyper-activity as measured by the SHS and then were assigned randomly to the following conditions:

Group A: Placebo and no prescriptive tutor-ing (N = 18)

Group B: Placebo and prescriptive tutoring (N = 17)

Group C: Dextroamphetamine and no pre-scriptive tutoring (N = 17)

Group D: Dextroamphetamine and prescrip-tive tutoring (N = 16)

The group Ns vary because some of the parents withdrew after initiation of the study. A double-blind experimental design was main-tained in which the families, teachers, and the clinicians who were involved in obtaining the measures of drug response did not know wheth-er a child was receiving amphetamine or place-bo. Experimental and control subjects were placed on 5 mg. dextroamphetamine or placebo

per day and, at weekly intervals, the daily dosage was increased by 5 mg. until undesirable side effects or maximum positive response to the medication was achieved. Most of the children were maintained on between 10 and 20 mgs. per day. Medication was provided by the Center at no cost to the family; in general, the family was given only a four weeks' supply of medicine at each visit to the Center. During the first month that medication was administer-ed, weekly reports were obtained from parents and teachers. After a maintenance dose was determined, monthly reports were obtained. Contacts were more frequent if a child did not seem to be getting the medication regularly as scheduled. Parents were "reminded" when the supply of medication was about to run out. Inconsistencies between the supply on hand and what should have been available provided clues to irregular administration of medication. To eliminate from the study children who were receiving the medication infrequently, a minimum criterion for remaining in the study for the final analysis was that the family had obtained at least a 60 days' supply of medicine from the Center.

The second independent variable was pre-scriptive tutoring twice a week. Approximately half the children receiving Dexedrine or placebo received tutoring, while the other half did not. The placebo-tutored group (Group B) received an average of 39.2 tutorial sessions, and the Dexedrine-tutored group (Group D) received an average of 39.9 tutorial sessions.

The tutors were from middle and upper-middle class backgrounds and were recruited largely through such organizations as the American Association of University Women, Junior League, and church groups. Two of the tutors had been through the training program in previous years, while 14 were new to the program. Nearly all of the tutors had a college education or equivalent training in nursing or related fields.

The training program for the tutors began with a series of twenty 90-minute lectures. The group met twice weekly during September and the first two weeks of October so that most of the course work was completed before the

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512

tutors began working with the childern late in October and early November.

The content of the course was aimed at providing a theoretical framework within which the practical approach to remediation would become meaningful. Sessions on cogni-tive development emphasized the work of Piaget; sessions on personality development stressed an ego-psychology orientation. Em-phasis was placed on those functions which underlie academic learning: reading arithmetic, writing, and spelling. The objective of training was to enable tutors to provide structured learning experiences in such functions as gross and fine motor coordination, spatial relation-ships, form constancy, temporal sequencing skills (both in the auditory and visual sphere), auditory discrimination, visual and auditory memory. Following the formal lecture series the group continued to meet throughout the school year for 90 minutes each week in group supervisory sessions.

Before a tutor began working with a child, a member of the project team staff met with her to go over the diagnostic evaluation and to plan a remedial program based on the individual child's needs. It should be clear that this research program was not an evaluation of a specific method of training.

The dependent variables under investigation were: Motor Coordination. Consisted of a judgment

of good, fair, or poor after observing the child skip, jump, stand on both right and left foot with eyes open and with eyes closed, put finger to nose with eyes closed, and walk on toes and heels.

Repeating a Motor Pattern. Consisted of an error score (0-10) of the child's ability to reproduce a tapping pattern using both hands.

Visual Tracking. Consisted of a judgment of good, fair, poor after observing a child follow a target with his eyes which included horizontal, vertical, diagonal, and circular movements approximately 18 inches from child's eyes.

Motor Acitvity. Was a judgment made by the examiner following testing which described

48

the child's behavior as (1) cannot sit in chair, (2) in and out of chair, (3) sits but fidgets, or (4) sits calmly.

Distractibiiity. Was a judgment, made by the examiner following testing, of very distrac-tible, somewhat distractible, or engrossed in task.

Hyperkinetic Score. Scores obtained on the Schenectady Hyperkinetic Scale.

Behavior Rating by Teacher. Teachers' ratings of the child's behavior, at the end of one, two, and three weeks on medication or placebo, on a four-point scale including (1) dramatic improvement in behavior, (2) definite improvement in behavior, (3) no change, and (4) worse.

Behavior Rating by Parent. Center staff con-tacted parents at the end of one, two, and three weeks on medication or placebo; on the basis of parental reports made a judg-ment on the same four-point scale used by teachers. The average of the three judgments represented the measure employed.

Spatial Orientation. Consisted of an error score on eight trials requiring the child to indicate whether an object was to the left or right of another object.

Koppitz Errors. The Bender-Gestalt was scored according to Koppitz norms and the number of errors was recorded.

Frostig I. — Eye Motor Coordination. Frostig II.— Figure Ground. Frostig I I I . - Form Constancy. Frostig IV.— Spatial Relations. Frostig V.— Position in Space. Frostig P.Q. Frostig Stars. Item six of the figure-ground

subtest of the Frostig Developmental Test of Visual Perception was scored separately as a measure of distractibiiity.

Subtests from the WISC as follows: Informa-tion, Comprehension, Arithmetic, Similar-ities, Digit Span, Picture Completion, Picture Arrangement, Block Design, Object Assembly, Coding.

WISC Verbal IQ. WISC Performance IQ. WISC Full Scale IQ. Temporal Order. Consisted of an error score on

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513

TABLE II. Mean difference scores, F ratios, and level of significance for the eight measures involving motor behavior.

Mean Differences Between Pre-Testing and Post-Testing

Variable

Motor Coordination

Repeating a Motor

Pattern

Visual Tracking

Motor Act iv i ty

Distractibil ity

Hyperkinetic Score

Behavior Rating by

Teacher

Behavior Rating by Parent

Group A

Placebo/

No Tutoring

- .17

.00

.00

- . 0 6

.22

2.28

3.00

2.94

Group B

Placebo/

Tutoring

.24

1.00

.59

.18

.35

5.59

2.77

2.77

Group C

Dextro-

amphetamine/

No Tutoring

18

.71

.18

.65

.59

9.29

2.59

2.06

Group D

Dextro-

amphetamine/

Tutoring

.25

1.50

.31

.69

.44

6.25

2.19

1.94

F Ratio

1.60

3.54

2.14

4.17

.67

2.44

5.74

10.23

P

.20

.02

.12

.01

> .50

.08

.001

.001

six trials requiring the child to order the days in the week, e.g., what day comes before Thursday, after Saturday, etc.

Bender Recall. The number of figures drawn from memory immediately following the completion of the Bender Test.

WRAT Reading. WRAT Arithmetic.

RESULTS Differences between pre-test and post-test scores on the 34 dependent variables were subjected to analysis of variance in a 2x2 factorial design. For purposes of discussion the 34 variables are presented in three categories: (1) measures relating to the child's motoric behavior, (2) measures of perceptual function-ing, and (3) measures of intellectual function-ing. The results of analyses of variance for the behavioral measures are summarized in Table I I .

Table III summarizes the results of the Scheffe' test, which was performed on those variables that had reached the .05 level of significance in the original analysis of variance.

The results in Tables II and III indicate that ratings of behavior by teachers and parents reflected a reduction of hyperactivity and

improvement in ability to attend and concen-trate for children receiving dextroamphetamine sulfate, while there was little or no change in placebo groups. Teachers perceived even greater improvement in the behavior of children who received dextroamphetamine sulfate and tutor-ing. Reduction of motor activity as perceived by the psychologist in the testing situation, and improvement in global behavior as reported by the parents, occurred only for those groups receiving dextroamphetamine sulfate. The reduction of errors in repeating a motor pattern appears to result from an interaction of tutor-ing and medication as significant differences occur only between groups A and D. This finding suggests that the reduction in hyper-activity and improved ability to attend and concentrate which characterized the children receiving dextroamphetamine sulfate enabled them to use the tutorial experience to make significant gains in repeating a motor pattern. Those children who received tutoring and place-bo and those receiving dextroamphetamine sulfate without tutoring failed to improve significantly on this measure. Although they failed to reach the .05 level, significant trends occurred in number of hyperkinetic symptoms




514

TABLE III. Scheffetest of significance for differences among groups on the eight variables which attained the .05 level on the F test.

Repeating a Motor — Pattern

Motor Activity .07 .07 -Behavior Rating, Teacher — — .001 Behavior Rating, Parent — Frostig IV — Frostig V - .025 -Frostig PQ - .005 -Information (WISC) .05 - 025

A vs. B A vs. C A vs. D B vs. C D vs. B D vs. C

.05

.005 .05 .001 .001 .01 .001 .05 - - . -

TABLE IV. Mean difference scores, F ratios, and level of significance for the nine measures of perceptual functioning.

Variable

Spatial Orientation

Koppitz Errors

Frostig I

Frostig II

Frostig III

Frostig IV

Frostig V

Frostig PQ

Frostig Stars

Mean Differences Between Pre-Testing <

Group A

Placebo/

No Tutoring

1.33

1.44

- . 5 6

- . 3 9

.06

- . 5 6

- . 3 9

-4.61

.56

Group B

Placebo/

Tutoring

1.65

2.18

- . 1 8

- . 1 8

1.29

- . 4 7

.53

2.18

.53

Group C

Dextro-

amphetamine/

No Tutoring

.71

3.06

.53

1.00

1.47

1.18

1.00

10.41

.88

and Post-Testing

Group D

Dextro-

amphetamine/

Tutoring

2.00

4.25

- . 2 5

.00

1.69

.31

.69

.69

.56

F Ratio

.23

2.62

1.18

2.02

1.31

3.85

3.86

5.77

.18

P

> .50

.07

.30

.12

.25

.02

.02

.002

> .50

on the SHS (.08), which appears to be an interaction between medication and tutoring, and visual tracking (.12), which appears to be primarily due to tutoring.

The results of the analysis of variance for measures of perceptual functioning are sum-marized in Table IV.

Significant improvement in perceptual functioning (Frostig IV, V, and PQ) was found apparently as a result of medication rather than tutoring, as might have been expected. Trends approaching the .05 level of significance were

found for Frostig II (.12) and Koppitz Errors (.07). Improvement on Frostig II scores appears also to be the result of medication; whereas reduction in Koppitz Errors appears to be an interaction of medication and tutoring.

The results of the analysis of variance for the fifteen measures of cognitive functioning and the two measures of academic achievement are presented in Table V.

Only WISC Information attains the .05 level of significance, and reference to Table II indicates that this improvement was due to

50 Journal of Learning Disabilities



515

TABLE V. Mean difference scores, F ratios, and level of significance for the fifteen measures of cognitive functioning.

Variable N

WISC Subtests Information

Comprehension

Arithmetic

Similarities Digit Span

Picture Completion

Picture Arrangement

Block Design

Object Assembly

Coding

WISC Verbal IQ

WISC Performance IQ

WISC Full Scale IQ

Temporal Order

Bender Recall

WRAT Reading

WRAT Ari thmetic

Mean Differences Between Pre-Testing

Group A

Placebo/

o Tutoring

-1.17

- .33

.28

.72

1.39

.02

.89

- .50

.67

.72

.89

2.94

2.11 1.44

.80

6.33

3.06

Group B

Placebo/

Tutoring

.88

.06

.59 - .24

.77

- . 0 6 1.41

1.29

.88

.82

2.18

6.06

4.41

2.00

.93

5.59

3.47

Group C

Dextro-

amphetamine/

No Tutoring

- . 0 6

- .29

.47

.82

2.18 .71

.41

- .06

1.06

3.35

4.53

6.88

6.24

1.53

1.00

5.29

5.41

and Post-Testing

Group D

Dextro-

amphetamine/

Tutoring

1.06

1.00 - . 3 1

- . 0 6

1.69

.06

1.75

.56

2.75

2.00 3.94

9.19

7.43

2.19

1.38 4.94

4.44

F Ratio

4.49

.67

.47

.70

.84

.24

.83

.87

1.81

2.36

.66

1.19

2.10 .44

.23

.39

2.00

P

.005

>.50

>.50

).50

>.50

>.50

>.50

>.50

.17

.07

>.50

.30

.12

>.50

>.50

>.50

.18

tutoring. The Coding subtest of the WISC (.07) and the Full Scale IQ (.12) approach signific-ance. It appears from the mean differences that improvement on the Coding subtest is due to the medication variable and that improvment in Full Scale IQ is the result of the interaction of the medication and tutoring.

In summary, differences significant at the .05 level were found on eight of 34 dependent variables, while trends approaching this level of significance were found on six more. The medication variable clearly accounted for a reduction in motor activity, improvement in behavior as rated by both parent and teachers, improvement in Spatial Relationship (Frostig IV), Position in Space (Frostig V), and Frostig PQ. Medication-related trends were found on Figure Ground Perception (Frostig II) (.12) and the Coding subtest of the WISC (.07). The tutoring variable clearly accounted for improve-ment on the Information subtest of the WISC

and a trend is observed on visual tracking (.12). The combination of medication and tutoring resulted in improvement in copying a motor pattern and trends on Koppitz Errors (.07), hyperkinetic score (.08), and increase in Full Scale IQ (.12).

DISCUSSION The most clear-cut results of this study indicate that children who received dextroamphetamine sulfate improved in their behavior and their performance on the Frostig Developmental Test of Visual Perception, while children who received a placebo made no significant gains in these areas. Children who received tutoring obtained higher scores on the Information subtest of the WISC than did children who were not tutored, but otherwise there were no statistically significant gains attributable to tutoring alone.

Although between-group differences were not




516

significant at the .05 level, several patterns of pre-test to post-test improvement are worth noting. The two tutored groups showed more improvement than the control group or the non-tutored groups on three WISC subtests: Comprehension, Picture Arrangement, and Block Design. The dextroamphetamine-tutoring group showed more improvement than all other groups on six variables: reduction of Koppitz Errors on the Bender-Gestalt; recall of Bender designs; performance on the Form Constancy subtest of the Frostig; WISC Object Assembly; Performance IQ and Full Scale IQ. The dextro-amphetamine-only group improved more than all other groups on 11 variables: Arithmetic, Similarities, Digit Span, Picture Completion, Coding, and Verbal IQ on the WISC; Eye-Motor Coordination, Figure Ground, Position in Space, and Spatial Relationships on the Frostig.

These results combined with the more con-clusive findings mentioned above suggest that tutoring contributed to gains in general know-ledge and use of such knowledge (Information, Comprehension), to understanding of temporal sequencing (Picture Arrangement), and to ability to master abstract perceptual-motor tasks (Block Design). Medication alone seemed to contribute to both improvement in behavior and improvement on portions of the WISC which are most affected by poor concentration (Arithmetic, Digit Span, Picture Completion, Coding). The fact that the dextroamph-etamine-only group did better than all other groups on four of five subtests of the Frostig is somewhat surprising in that medication and tutoring would be expected to produce more gains than medication alone. Similar effects of dextroamphetamine on Frostig performance are reported by Conners et al. (1969). Perhaps the most important implication of the influence of the medication on Frostig scores is that perfor-mance on the test seems heavily influenced by poor impulse control and distractibility, which are not in themselves visual perceptual or perceptual-motor functions. Thus, a child may appear to have a "visual perceptual problem" when in fact his perceptual-motor skills are fairly intact. The diagnostician should, there-fore, use post-medication rather than pre-medication tests results in the planning of

52

remedial activities for hyperkinetic children with apparent learning disabilities.

As indicated earlier, a major weakness in this study was the lack of control over the admin-istration of the medication. Some subjects in both dextroamphetamine groups received med-ication erratically or received smaller doses than were recommended. There also were wide variations in the length of time over which medication was administered. A post hoc an-alysis of the two medication groups revealed that four of 16 children in the medication-only group were receiving medication irregularly or not at all at the time of the post-testing, while eight of 16 children in the medication-tutoring group were receiving medication irregularly, not at all, or in arbitrarily reduced doses when they were retested. Records were kept of the num-ber of daily doses dispensed for each child to provide a measure of drug usage. The mean number of daily doses for the medication-only group was 166.44 compared with 134.13 for the medication-turoring group. The difference between the means was found to be significant at the .05 level (t = 2.U,d.f. 30). The differ-ences in regularity and duration of medication use favoring the dextroamphetamine-only group may have contributed to the fact that this group improved on more variables than any other group.

Although the effects of dextroamphetamine and tutoring on reading and arithmetic achieve-ment were primary concerns of the present study, neither treatment was found to have a significant influence on the achievement meas-ures which were used. Past experience and informal reports from classroom teachers re-garding progress made by children in the project make these findings difficult to accept. The need for a brief, easy-to-administer instru-ment resulted in the use of the Reading and Arithmetic sections of the Wide Range Achieve-ment Tests. While these tests may be useful measures of word recognition skills and know-ledge of basic arithmetic processes, they are relatively insensitive to distractibility, short-term memory problems, temporal sequencing problems, and poor hand-eye coordination, which are the areas most likely to be affected by medication or tutoring. If this study were to

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517

be repeated, criterion measures for achievement would include writing, spelling, paragraph read-ing, retention and comprehension of what was read, and number and accuracy of arithmetic problems solved in a group setting.

It should be mentioned that of the 68 children involved in the study, only three had made sufficient progress during the year to no longer meet the initial criteria for inclusion in the study. Thus, despite the impressive gains made by the children in the experimental groups, most of them still needed remedial help at the conclusion of the study. This fact highlights several important considerations re-garding the treatment of hyperkinetic children: (1) most of these children have specific learning disabilities in addition to hyperkinetic symp-toms, (2) regardless of the educational or remedial approach employed, amphetamine therapy is an important adjunct to the overall treatment of hyperkinetic children, (3) medica-tion alone is sufficient treatment only for hyperkinetic children who have no specific learning problems, and (4) more sophisticated and better controlled methods of remediation of the underlying learning disability need to be developed. — Schenectady County Child Guid-ance Center, 821 Union Street, Schenectady, N.Y. 12308

A CKNO WL EDGMEN TS This research was supported by the New York State Department of Mental Hygiene Contract No. C36725. Dexedrine was the detroamphetamine used in this research and we are grateful to Smith, Kline & French Laboratories for contributing the medication for this study. We gratefully acknowledge the contribution of Mrs. Georgia Wirth, our extraordinary secretary, Mrs. Bette Hesse, our statistical consultant, and the teach-ers and administrators of the Schenectady City School District who participated.

REFERENCES Bradley, C: The behavior of children receiving Ben-

zedrine. Amer, J. Psychiat., 1937, 94, 577-585. Bradley, C Benzedrine and Dexedrine in the treat-

ment of children's behavior disorders. Pediatrics, 1950,5,24-37.

Bradley, C, and Bo wen, M.: Amphetamine therapy for children's behavior disorders. Amer. J. Ortho-psychiat., 1941, 11, 92-103.

Conners, C. K., Eisenberg, L., and Barcai, A.: Effect of dextroamphetamine on children. Arch. Gen Psychiat., 1967, 17, 478-485.

Conners, C. K., et al.: Dextroamphetamine sulfate in

children with learning disorders. Arch. Gen. Psychiat., 1969, 21, 182-190.

Douglas, Virginia I., Werry, J. 5., and Weiss, Gabriel/: Hyperkinetic behavior in children: some findings regarding aetiology and treatment (abstract). Canad. Psychol., 1965, 6, 219.

Eisenberg, L., et al.: A psychopharmacologic experi-ment in a training school for delinquent boys: methods, problems, findings. Amer. J. Ortho-psychiat., 1963,33,431-447.

Frostig, M., et al.: Visual perceptual development and school adjustment and progress. Amer. J. Ortho-psychiat., 1963, 33, 367-368.

Levy, S.: Post-encephalitic behavior disorder - a for-gotten entity: a report of 100 cases. Amer. J. Psychiat., 1959, 115, 1062-1067.

L/orens, L.: Cognitive-perceptual-motor dysfunction and training. Paper presented at Annual Confer-ence of United Cerebral Palsy Research and Educa-tion, New Orleans, March, 1967.

Silver, A., and Hagin, R.: Maturation of perceptual functions in children with specific reading dis-ability. Reading Teacher, 1966, 19, 253-259.

Silver, A., and Hagin, R.: Reading disbility: teaching through stimulation of deficit perceptual areas. Amer. J. Orthopsychiat., 1967, 37, 744-752.

Weiss, Gabrielle, et al.: Studies on the hyperactive child - V, the effects of dextroamphetamine and chlorpromazine on behavior and intellectual func-tioning. J. Child Psychol. Psychiat., 1968, 9, 1945-156.

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