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Study: To help children with ADHD improve academic performance, combine medication AND behavioral treatment

Students academic performance.

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.

The Study

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.

Results

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.

Rabiner_David– 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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