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To Succeed at School, Children With ADHD Need Both Medication and Non-Medication Treatments

An impor­tant ques­tion then, for mil­lions of kids diag­nosed with ADHD and for their par­ents and edu­ca­tors, is whether long-term aca­d­e­mic func­tion­ing can improve with appro­pri­ate treat­ment.
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Aca­d­e­mic prob­lems are extremely com­mon in chil­dren with ADHD, and often the issue that leads to refer­ral for an ADHD evaluation.

Aca­d­e­mic out­comes can be mea­sured in two dif­fer­ent ways -- aca­d­e­mic achieve­ment and aca­d­­emic per­for­mance -- and both are com­pro­mised in chil­dren with ADHD. Aca­d­e­mic achieve­ment refers to the infor­ma­tion and skills that chil­dren acquire and is typ­i­cally mea­sured by stan­dard­ized tests. Aca­d­e­mic per­for­mance focuses on direct mea­sures of suc­cess at school such as grades, grade reten­tion, high school grad­u­a­tion, and col­lege enrollment.

An impor­tant ques­tion then, for mil­lions of kids diag­nosed with ADHD and for their par­ents and edu­ca­tors, is whether long-term aca­d­e­mic func­tion­ing can improve with appro­pri­ate treat­ment.

IMPORTANT NEW STUDY

A new study pub­lished online in the Jour­nal of Atten­tion Dis­or­ders (Long-term out­comes of ADHD: Aca­d­e­mic achieve­ment and per­for­mance) rep­re­sents a valu­able effort to answer that question.

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 two-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.

As a result of this search, the authors iden­ti­fied 14 stud­ies that looked at aca­d­e­mic achieve­ment out­comes and 12 that assessed per­for­mance out­comes were com­pared. 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 was 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.

MAIN STUDY FINDINGS

For achieve­ment test scores, treat­ment yielded improve­ment in 7 of 9 stud­ies (78 percent) when the com­par­i­son was with pre-treatment base­line and in 4 of 5 stud­ies (80 percent) 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 med­ica­tion, non-medication, and treat­ments that com­bined both approaches. Although the num­ber of stud­ies on which these com­par­isons were based is small, avail­able evi­dence sup­ported the value of mul­ti­modal treat­ment (e.g., the com­bi­na­tion of med­ica­tion, behav­ior ther­apy, school con­sul­ta­tion). Such treat­ment yielded ben­e­fits in 100 percent of stud­ies exam­in­ing achieve­ment out­comes and 67 percent of those exam­in­ing per­for­mance out­comes. For med­ica­tion treat­ment only the per­cent­ages were 75 percent and 33 percent respec­tively; for non-medical treat­ments, the fig­ures were 75 percent and 50 percent.

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 percent and 67 percent, respec­tively) than phar­ma­co­log­i­cal (75 percent and 33 percent) or non-pharmacological (75 percent and 50 percent) treat­ment alone."

This is con­sis­tent with the gen­er­ally held view that most youth for ADHD should receive multi-modal treat­ment as opposed to med­ica­tion or non-medication approaches alone. How­ever, as recently found in another study that exam­ined treat­ment prac­tices in a large num­ber of pedi­a­tri­cians (Study finds large gaps between research and prac­tice in ADHD diag­no­sis and treat­ment) while med­ica­tion treat­ment was rec­om­mended for over 90 percent of youth diag­nosed with ADHD, behav­ioral treat­ment was rec­om­mended fewer than 15 percent of the time. Thus, many chil­dren may not be receiv­ing mul­ti­modal treat­ment in com­mu­nity care.

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 five 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.

In the years ahead, we hope that the research needed to bet­ter address these impor­tant issues will become more avail­able. We need bet­ter data to inform deci­sions as to how to best help each child suc­ceed at school, and at home.

In the mean­time, as we will out­line in our upcom­ing online course, we need to ensure chil­dren with atten­tion deficits access appro­pri­ate non-medication treat­ments, com­ple­ment­ing the more com­mon phar­ma­co­log­i­cal ones.

Dr. David Rabiner is a child clin­i­cal psy­chol­o­gist, Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity, and founder of the Atten­tion Research Update. Alvaro Fer­nan­dez, named a Young Global Leader by the World Eco­nomic Forum, is the co-author of The Sharp­Brains Guide to Brain Fit­ness: How to Opti­mize Brain Health and Per­for­mance at Any Age.Child-Brain They have part­nered to offer the upcom­ing online course How to Nav­i­gate Con­ven­tional and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment. (May 2015; reg­is­tra­tion open)