ADHD medications and school performance

By Nestor Lopez-Duran PhD

I spent most of my Sunday afternoon reviewing and editing reports of child neuropsychological evaluations. Most of them were for children who came to our clinic for a comprehensive ADHD diagnostic evaluation. At the end of these reports we always include a large number of individualized recommendations for home and school accommodations and interventions. Within this list, we often, if not always, encourage parents to consult with their pediatrician or child psychiatrist regarding the appropriateness of medication for the treatment for their childs ADHD. But such recommendation is only one of more than a dozen. In our approach to treatment, medication is one small component of a multi-pronged strategy. Why? Because medication alone is unlikely to be enough to help the child successfully navigate the multiple obstacles imposed by his/her condition. So I was not surprised when I read the results of one of the largest studies of community-based medication interventions for elementary school children with ADHD. The result? Medication alone works, but not as much as wed like.

The study was conducted by a team of researchers at the University of Cincinnati and published in Archives of Pediatrics. The researchers examined the results of the ADHD Collaborative a initiative in the greater Cincinnati region aimed to improve the adherence of ADHD treatment guidelines by local community pediatricians. The study included 785 children between 7-11 years of age treated by 158 community physicians from 47 separate practices in greater Cincinnati. The children were evaluated when they first started treatment and 3, 6, 9, and 12 months later. The researchers were interested in examining the effectiveness of the treatment in reducing ADHD symptoms and reducing functional impairment (i.e., how the children did at school, home, and with their peers).

The initial results were very promising.

As you can see above, the treatment resulted in a rapid and dramatic decrease in ADHD symptoms as reported by both parents and teacher. This is consistent with most research on the effectiveness of ADHD medications: they are very effective in reducing ADHD symptoms.

On first impression, the picture became less rosy, or better said, outright gloomy, when the authors examined the effects of the treatment on functional impairment. See for example the effect of the treatment on academic difficulties in reading, math, writing, and overall school performance:

The number of children experiencing impairment in reading, math, writing, and overall in school remained virtually identical during the entire year of the study. This suggests that the intervention did not have much of an impact on the kids school functioning. The same pattern of results was observed for the kids peer, sibling, and family relations.

Does this mean that medication for ADHD is simply ineffective? Not really. What it means is that medication alone may not have a significant impact on the childs functional domains.  It is possible that medication provides the foundation for additional interventions to work. However, there is a more relevant limitation of this study. If you compare the two graphs above, you will see that the Y axis of the first graph refers to symptoms of ADHD. In contrast, the Y axis of the second graph refers to the % of children showing impairment in those categories. Why is this significant? Because the first graph allows us to observe changes in a continuous scale of symptoms (we would see even a small change in symptoms). However, the graph below does not allow us to see the effect of the medication on the LEVEL of impairment of the children. That is, we only see that the percentage of children who show impairment did not change, but it is still possible that these children improved significantly!- albeit still performing in the impaired range. So although it is disappointing that the treatment alone did not result in a reduction of the percentage of children who had functional impairment, the picture may not be a gloomy as we think.

The reference:
Epstein, J., Langberg, J., Lichtenstein, P., Altaye, M., Brinkman, W., House, K., & Stark, L. (2010). Attention-Deficit/Hyperactivity Disorder Outcomes for Children Treated in Community-Based Pediatric Settings Archives of Pediatrics and Adolescent Medicine, 164 (2), 160-165 DOI: 10.1001/archpediatrics.2009.263