Study: To help children with ADHD improve academic performance, combine medication AND behavioral treatment
Academic problems are extremely common in children with ADHD and often the issue that leads to referral for an ADHD evaluation. Unfortunately, the significant academic struggles that many children with ADHD experience can undermine their long-term success in areas that extend far beyond formal schooling.
Given these facts, an important question is whether long-term academic functioning in youth with ADHD improves with treatment? Because this is such a fundamentally important question, and ADHD is the most well-researched mental health condition in children, one might think that the answer is clearly established. For a variety of reasons — perhaps the most important of which is the inherent difficulty of conducting long-term treatment studies — this is not the case.
Prior studies have looked at academic outcomes in 2 different ways — academic achievement and academic performance. Achievement refers to the information and skills that children acquire and is typically measured by standardized academic achievement tests. Academic performance focuses on direct measures of success at school such as grades, grade retention, high school graduation, and college enrollment. Thus, achievement measures focus on what children demonstrate they have learned on a one-time test. Performance measures, in contrast, reflect how children actually perform in school over an extended period. Both types of outcomes are compromised in children with ADHD.
The impact of ADHD treatment on achievement and performance outcomes remains controversial. Some studies have found that while ADHD treatment clearly improves classroom behavior, the impact on academic functioning is less evident. In other studies, there is evidence that treatment improves some aspects of academic performance but not achievement. Other researchers have questioned whether medication or behavioral treatment has positive long-term effects on either type of academic outcome.
A new study published recently online in the Journal of Attention Disorders [Long-term outcomes of ADHD: Academic achievement and performance] represents a valuable effort to organize relevant studies on this issue so that broad conclusions about how ADHD treatment affects long-term academic outcomes can be made.
The authors began by conducting a systematic literature search to identify all potentially relevant studies. Specifically, they looked for all studies published in peer reviewed journals between 1980 and 2012 that examined academic outcomes associated with treatment over at least a 2‑year period. Some of these studies compared academic outcomes in treated and non-treated children, others had no comparison group but looked at achievement and/or performance measures before and after treatment, while others compared outcomes between treated youth and youth without ADHD.
Ultimately, the authors identified 14 studies that looked at academic achievement outcomes and 12 that assessed performance outcomes were compared — there was some overlap in these studies. To create a common outcome metric across multiple studies that used varying methods, studies were grouped into those that showed treatment benefits and those that did not. They then simply counted the number of studies where evidence of treatment benefits were found.
For studies that compared treated vs. untreated youth, or academic functioning before and after treatment, benefit was defined as a statistically significant gain associated with treatment. Where treated youth were compared to youth without ADHD, benefit was assumed when academic outcomes for youth with ADHD were not significantly worse than for non-ADHD controls.
For achievement test scores, treatment yielded improvement in 7 of 9 studies (78%) when the comparison was with pre-treatment baseline and in 4 of 5 studies (80%) when treated and untreated youth were compared.
For academic performance outcomes, improvement was found in 1 of 2 studies that used pre- vs. post-treatment comparisons and in 4 of 10 studies comparing treated and non-treated youth.
Overall, therefore, there was greater evidence of treatment benefits on achievement outcomes than on performance outcomes.
The authors also examined how treatment outcomes varied for medical, non-medical, and treatments that combined both approaches, i.e., multimodal treatment. Although the number of studies on which these comparisons were based is small, available evidence supported the value of multimodal treatment. Such treatment yielded benefits in 100% of studies examining achievement outcomes and 67% of those examining performance outcomes. For medication treatment only the percentages were 75% and 33% respectively; for non-medical treatments, the figures were 75% and 50%.
Finally, there were 5 studies where achievement and performance outcomes were compared between children treated for ADHD and youth without ADHD. Even with treatment, outcomes were significantly worse for ADHD youth 4 of 5 studies that looked at achievement outcomes and 3 of 5 that looked at performance outcomes.
Summary and Implications
The overall message from this summary of research examining how treatment affects long-term academic outcomes in youth with ADHD is positive. Many studies found improvement with ADHD treatment for both achievement and performance outcomes, with evidence suggesting that treatment has more consistently positive impacts on achievement than on performance. As the study notes, “More achievement test and academic performance outcomes improved with multimodal (100% and 67%, respectively) than pharmacological (75% and 33%) or non-pharmacological (75% and 50%) treatment alone.”
One interesting finding — although based on a limited number of studies — was the indication that better academic outcomes were more likely when medical and non-medical approaches were combined. This is consistent with the generally held view that most youth for ADHD should receive multi-modal treatment as opposed to medical or non-medical approaches alone. However, as I recently noted (Study finds large gaps between research and practice in ADHD diagnosis and treatment) a study that examined treatment practices in a large number of pediatricians found that while medication treatment was recommended for over 90% of youth diagnosed with ADHD, behavioral treatment was recommended fewer than 15% of the time. Thus, many children may not be receiving multimodal treatment in community care.
While the overall message from this study is basically positive, results from studies that compare youth treated for ADHD with non-ADHD controls indicate that treatment generally does not ‘normalize’ academic outcomes in ADHD youth. Thus, while treated youth may generally be doing better than they would have without treatment, treatment often does not bring them up to the level of their peers.
It is important to place these findings in the context of the limited data base on which they were drawn. First, despite systematically searching the relevant research over a 32-year period, the authors identified only 5 studies that specifically compared long-term academic outcomes in treated vs. non-treated youth. And, these studies were not necessarily randomized-controlled trials which makes it impossible to conclude that positive outcomes associated with treatment can be attributed specifically to treatment itself. This will be an ongoing limitation in the research base as conducting long-term randomized-controlled trials in which treatment is denied to a group of ADHD youth for a sustained period is not something that could be ethically done.
It is also the case that the authors’ analysis only indicates that treated youth generally have better long-term academic outcomes. However, the magnitude of treatment benefits was not discussed. There is an important difference between statistical significance and clinical significance, and whether treatment tended to produce gains that parents and educators would consider educationally meaningful is not known. It is unclear to me why the authors did not incorporate such analysis into their paper and this issue was not addressed in their discussion.
Thus, while this study makes a nice contribution by summarizing the relevant literature in a way that enables at least broad conclusions about the impact of ADHD treatment on long-term academic outcomes, it also highlights that a number of significant questions on this important issue remain. The authors conclude by noting that despite the number of studies that have been conducted, there remains a lack of data to guide “…(a) educators as to how to best manage individual children, (b) management at the school system level, and, © the formation of policy at the national level. To this I would add that data-based decisions about the course of action most likely to improve long-term academic outcomes for individual children are also difficult to make based on the available research base.
In the years ahead, one hopes that the research needed to better address these important issues will become more available.
– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. He publishes Attention Research Update, an online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD, and teaches the online course How to Navigate Conventional and Complementary ADHD Treatments for Healthy Brain Development.
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