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Study finds combined pharma + non-pharma treatment most beneficial to help youth with ADHD address long-term academic difficulties

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Aca­d­e­m­ic dif­fi­cul­ties are one of the most impor­tant adverse con­se­quences of ADHD, and they fre­quent­ly con­tribute to par­ents’ deci­sion to seek treat­ment for their child. Whether treat­ment con­sis­tent­ly yields a pos­i­tive impact on long-term aca­d­e­m­ic suc­cess is thus an impor­tant issue; how­ev­er, the answer to this ques­tion has been some­what con­tro­ver­sial.

A study pub­lished recent­ly in the Jour­nal of Atten­tion Dis­or­ders rep­re­sents the most com­pre­hen­sive effort to date to iden­ti­fy and syn­the­size research relat­ed to this impor­tant ques­tion.

The Study:

The authors began by iden­ti­fy­ing all stud­ies pub­lished between 1980 and 2012 that report­ed long-term aca­d­e­m­ic out­comes for youth with ADHD; this was defined as at least 2 years beyond an ini­tial base­line assess­ment. All stud­ies includ­ed a com­par­i­son group — either a nor­ma­tive com­par­i­son sam­ple or youth with ADHD who were not treat­ed — or a com­par­i­son mea­sure, e.g., a pre-treat­ment base­line mea­sure of aca­d­e­m­ic achieve­ment to which sub­se­quent achieve­ment could be com­pared.

Two impor­tant research ques­tions were addressed:

  1. How does untreat­ed ADHD affect aca­d­e­m­ic out­comes over the long-term?
  2. How does treat­ment and spe­cif­ic types of treat­ment impact long-term aca­d­e­m­ic out­comes?

Aca­d­e­m­ic out­comes were cat­e­go­rized as a) achieve­ment test out­comes or b) per­for­mance out­comes. a) Achieve­ment test out­comes refer to results of stan­dard­ized achieve­ment tests and reflect knowl­edge that chil­dren have acquired; b) Per­for­mance mea­sures address gen­er­al per­for­mance at school set­tings, e.g., school grades, years of school­ing com­plet­ed, grad­u­at­ing from high school. etc. Thus, per­for­mance out­comes are espe­cial­ly impor­tant because they reflect what stu­dents actu­al­ly accom­plish in school.

While these dif­fer­ent types of aca­d­e­m­ic out­comes are cor­re­lat­ed, they are not iden­ti­cal as one could score well on achieve­ment tests and yet earn poor grades for a vari­ety of dif­fer­ent rea­sons.

The authors iden­ti­fied 176 stud­ies between 1980 and 2012 that report­ed long-term aca­d­e­m­ic out­comes asso­ci­at­ed with treat­ed and untreat­ed ADHD. These stud­ies employed dif­fer­ent designs and com­par­i­son groups, as well as a vari­ety of dif­fer­ent aca­d­e­m­ic mea­sures. It should be not­ed that few stud­ies were ran­dom­ized-con­trolled tri­als, which is gen­er­al­ly con­sid­ered to be the gold stan­dard for eval­u­at­ing treat­ment effects. This is inevitable when exam­in­ing long-term out­comes, how­ev­er, as it is almost impos­si­ble to sus­tain ran­dom assign­ment to treat­ment or a con­trol con­di­tion over an extend­ed time peri­od.

The Results:

To exam­ine the impact of untreat­ed ADHD on aca­d­e­m­ic out­comes„ the authors con­sid­ered stud­ies com­par­ing out­comes for youth with untreat­ed ADHD to those with­out ADHD. Out­comes were con­sid­ered ‘poor­er’ when results for youth with untreat­ed ADHD were sig­nif­i­cant­ly worse; When no sig­nif­i­cant dif­fer­ence was found, out­comes were con­sid­ered ‘sim­i­lar’.

In stud­ies exam­in­ing the impact of ADHD treat­ment, out­comes were con­sid­ered to ‘improve’ when youth treat­ed for ADHD had sig­nif­i­cant­ly bet­ter out­comes than untreat­ed youth with ADHD. In stud­ies where out­comes were com­pared to a pre-treat­ment base­line, improve­ment was reflect­ed by sig­nif­i­cant gains rel­a­tive to the base­line.

Untreat­ed ADHD out­comes: Across all stud­ies and achieve­ment test out­comes, youth with untreat­ed ADHD had sig­nif­i­cant­ly low­er scores than youth with­out ADHD for 75% of the out­comes. They were also low­er for 79% of the aca­d­e­m­ic per­for­mance out­comes.

Does ADHD treat­ment help? For achieve­ment test scores, treat­ment was asso­ci­at­ed with sig­nif­i­cant improve­ment with treat­ment for rough­ly 80% of the out­comes exam­ined; this com­pares to only 25% improve­ment for untreat­ed ADHD.

For aca­d­e­m­ic per­for­mance out­comes, e.g., grades, high school grad­u­a­tion, sig­nif­i­cant improve­ment was found under 50% of the time. While low­er, the cor­re­spond­ing fig­ure for untreat­ed ADHD was only 21%.

What is the impact of dif­fer­ent types of treat­ment? For each type of treat­ment, i.e., phar­ma­co­log­i­cal, non-phar­ma­co­log­i­cal, or com­bined, improve­ment was more like­ly for achieve­ment out­comes than for per­for­mance out­comes.

Notice­ably, youth who received a com­bi­na­tion of phar­ma­co­log­ic and non-phar­ma­co­log­ic treat­ment were more like­ly to show improve­ment for both achieve­ment and per­for­mance out­comes than youth who received either treat­ment alone, or none.

Summary and implications:

Results of this research syn­the­sis under­score that untreat­ed ADHD is high­ly like­ly to com­pro­mise chil­dren’s long-term aca­d­e­m­ic achieve­ment and aca­d­e­m­ic per­for­mance. While this has been known for some time, inte­grat­ing rel­e­vant stud­ies on this issue over the past 30 years high­lights the robust­ness of this con­clu­sion.

More encour­ag­ing was the find­ing that treat­ment –both phar­ma­co­log­ic and non-phar­ma­co­log­ic– is asso­ci­at­ed with sig­nif­i­cant gains in long-term aca­d­e­m­ic out­comes. This was more like­ly for achieve­ment test out­comes than for per­for­mance out­comes, how­ev­er. In oth­er words, while chil­dren who receive treat­ment are very like­ly to ‘learn’ more, this will be less con­sis­tent­ly reflect­ed in how they actu­al­ly per­form at school.

It is also note­wor­thy that com­bined treat­ment –also referred to as mul­ti­modal treat­ment– was more like­ly to result in pos­i­tive aca­d­e­m­ic out­comes than treat­ments used in iso­la­tion. This sug­gests that most youth with ADHD will be bet­ter served by treat­ments that inte­grate med­ical and non-med­ical approach­es.

There are lim­i­ta­tions to this study that the authors high­light. Efforts to inte­grate dozens of dif­fer­ing stud­ies is chal­leng­ing and required that only gen­er­al con­clu­sions be offered. Even mak­ing gen­er­al com­par­isons between broad treat­ment approach­es, i.e., phar­ma­co­log­ic vs. non-phar­ma­co­log­ic, was lim­it­ed by the rel­a­tive­ly small num­ber of stud­ies where this com­par­i­son was made.

The authors were also unable to dis­en­tan­gle the effects of ADHD on long-term aca­d­e­m­ic out­comes from the oth­er con­di­tions that often accom­pa­ny ADHD, i.e., comor­bidi­ties such as oth­er behav­ioral and/or emo­tion­al dis­or­ders.

Despite these lim­i­ta­tions, this com­pre­hen­sive research review pro­vides a firm basis for con­clud­ing that treat­ment improves aca­d­e­m­ic out­comes for youth with ADHD, par­tic­u­lar­ly for aca­d­e­m­ic achieve­ment test mea­sures. Mak­ing sig­nif­i­cant improve­ment in long-term per­for­mance aca­d­e­m­ic per­for­mance, i.e., ‘real world’ aca­d­e­m­ic out­comes that are espe­cial­ly impor­tant, how­ev­er, is more dif­fi­cult.

– 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 the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

The Study in Context:

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