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ADHD Treatment in Community Settings - Impact on Educational Outcomes
In prior issues of Attention Research Update, detailed results from the Multi-site, Multi-modal Treatment Study for Children with ADHD (the MTA study) have been presented. The results of this groundbreaking study -- the largest and most comprehensive treatment study for ADHD ever conducted -- clearly established that carefully conducted medication therapy and intensive behavioral treatments are effective interventions for children with ADHD. The combination of medication and behavior therapy was slightly more effective overall than either treatment used in isolation, and over two-thirds of children who received combined treatment had symptom scores for ADHD and oppositional behavior that fell within the normal range after 14 months.
Although these results are encouraging, it is important to recognize that they demonstrate the success rate that is possible to achieve when medication treatment and behavior therapy are provided in a rigorous and comprehensive manner. Unfortunately, the level of care that children with ADHD receive in typical community settings may often fall short of this standard. As a result, even though a child may receive treatments with well-established efficacy, the results may fall short of what is obtained in carefully conducted research studies. For example, in the MTA study, some children were treated as usual in their communities so that the effect of the routine community treatment could be compared to the rigorously conducted treatments provided in the study. Results indicated that community-treated children did not do nearly as well -- only 25% had ADHD symptoms and oppositional behavior that fell within the normal range after 14 months. This is far lower than the 68% success rate for children who received combined treatment through the study.
Despite the wealth of information contained in MTA study results published so far, there remains one limitation: information on "real-world" academic outcomes -- a domain in which children with ADHD often struggle considerably -- has not been provided. For example, in addition to learning about treatment impact on core ADHD symptoms, or even on academic achievement as measured by standardized testing, it would be important to know how treatment impacts such important academic outcomes as receiving special education services, being expelled or suspended from school, and having to repeat a grade. These outcomes are critically important in a child's life and of great concern to parents.
What do we know about how treatment for ADHD in the community impacts important outcomes such as these?
A recently published study conducted in 3 elementary schools in southeastern Virginia provides some very important -- and alarming -- data on this critical "real-world" question (LeFever, G.B. et al. (2001). Parental perceptions of adverse educational outcomes among children diagnosed and treated for ADHD: A call for improved school/provider collaboration. Psychology in the Schools, 39, 63-71).
In this study, parents of all 1644 children in 3 schools received a survey asking whether their child had ever been diagnosed with ADHD, and, if so, what types of treatments their child was receiving. Parents also were asked how they perceived their child's performance at school, whether their child was receiving special educational services, whether their child had ever been suspended or expelled, and whether their child had ever been retained. The survey was completely anonymous and responses were obtained from over 60% of the sample. This response rate is not quite as high as one would like, but is typical of what is generally obtained in this type of survey research.
Results
How Frequently Were Children Diagnosed With ADHD?
As you may be aware, the commonly reported prevalence rate for ADHD is between 3 and 5% of the population of school-age children. In this sample, however, 17% of the students had received an ADHD diagnosis according to their parents. Rate of reported diagnosis for boys was significantly higher than for girls (28% vs. 11%). This is an enormously high rate of diagnosis -- several times higher than the commonly reported prevalence rates.
There are several possible factors that may have contributed to this high rate of diagnosis. First, it is possible that some parents reported that their child had been diagnosed with ADHD when this had not occurred, although this seems unlikely. Another possibility is that parents with a diagnosed child were more likely to return the survey because it asked specifically about a condition that their family was dealing with. This would have would have made the rate of diagnosis in this sample higher than it would have been if all parents returned the surveys. It is also possible that ADHD may be over-diagnosed in this community, as experts believe that both over- and under- diagnosis of ADHD occurs, and that this can vary from one community to the next.
Finally, these data raise questions about the accuracy of the 3-5% prevalence rate for ADHD that is generally reported and suggests that actual prevalence rates may be higher. (In this regard, it is worth noting that higher rates than the generally accepted 3-5% figure have also been reported in other studies.)
What Types Of Treatment Were Diagnosed Children Receiving?
Children diagnosed with ADHD were receiving a range of services to treat their condition. Most of the children -- 84% -- received medication to treat the disorder, although only 56% were receiving medication during the school day. More than half of the children -- 57% -- were receiving behavioral interventions. And, nearly half of the children -- 47% -- were receiving both medication and behavioral treatment. Only 27% received medication treatment alone; only 10% received behavioral treatment alone; and only 16% were receiving no treatment at all.
These results seem encouraging in that the vast majority of children diagnosed with ADHD were receiving treatments for which extensive empirical support exists -- i.e. medication and behavior therapy -- and many diagnosed children were being treated using both approaches. This is certainly consistent with treatment guidelines recently published by the American Academy of Pediatrics.
Several important differences in treatment services received by black and white students were evident. Although medication use did not differ for black and white students diagnosed with ADHD, whites were significantly more likely to receive behavioral interventions (69% vs. 43%) and were also more likely to receive combined treatment (69% vs. 31%). It is also interesting to note that among students without health insurance, none were receiving behavioral treatment. Instead, they were treated exclusively with medication. Data on treatment differences according to gender were not presented.
Adverse Educational Outcomes for Children with ADHD
Eighty-four percent of parents with ADHD children reported that ADHD affected their child's school performance and 40% believed the school was not providing adequate services to meet their child's needs. The association between ADHD and adverse education outcomes were as follows:
Children With Adhd Were About 5 Times As Likely As Other Children To Be Receiving Special Education Services;
Children With Adhd Were About 7 Times As Likely As Other Children To Have Been Suspended Or Expelled;
Children With Adhd Were About 3 Times As Likely As Other Children To Have Repeated A Grade.
(Note: Special education services should not necessarily be considered an adverse outcome as it is intended to provide additional education support and services for children with legitimate needs. Many children with ADHD also have co-occurring learning disabilities and would require special education services for this reason alone.)
These results are striking. They indicate that, despite the fact that the vast majority of ADHD children in these schools were receiving empirically supported treatments, they were still faring far worse than their peers on these important indicators of academic functioning. What is perhaps even more striking is that when the researchers compared children with ADHD who were receiving combined treatment -- the approach found to be most effective in the MTA study -- with children who were receiving no treatment at all, they found no differences in these outcomes. In other words, they found no evidence that combined treatment reduced the likelihood that a child with ADHD would require special education services, would be expelled, or would have repeated a grade.
Summary And Implications
These results are sobering. They indicate that -- at least as practiced in this community -- children receiving treatment for ADHD continued to experience adverse educational outcomes at a rate that far exceeded that of other children. In fact, there was no indication that treatment had any beneficial effect on the educational outcomes for children with ADHD that were examined.
How can this be? It is tempting to attribute these findings to something unique to this particular community and hope that it is not representative of the effectiveness of ADHD treatment services provided in other communities. Although such a possibility cannot be definitively ruled out, it does not seem to be a particularly plausible explanation. In fact, it appeared that a larger percentage of students diagnosed with ADHD in this community were receiving empirically supported treatments than is often found.
The authors suggest, correctly, I believe, that their results raise important questions regarding "treatment effectiveness as opposed to clinical efficacy". Clinical efficacy examines the benefits of a treatment in a controlled setting, such as the treatment provided in the MTA study. Treatment effectiveness, in contrast, is concerned with the actual benefits of a treatment as it is actually delivered in community settings. As the results of this study make clear, when it comes to treatments for ADHD, there may be a substantial difference between clinical efficacy and treatment effectiveness.
It would be both incorrect and potentially harmful to interpret these results as indicating that medication treatment and behavioral interventions for ADHD are not effective. In fact, we know from the MTA study -- and from other studies as well -- that when these treatments are carefully delivered, they can be very effective over a sustained period of time. Instead, careful attention needs to be directed to learning why treatment outcomes that are typically attained in community settings are so much less positive than what is possible to achieve.
There are several possible reasons for this. Regarding behavioral treatment, it is important to note that the behavioral intervention provided in the MTA study -- although effective -- is probably beyond what could ever be routinely available in most communities. It included a combination of an intensive summer camp treatment experience, extensive parent training, and an extremely rigorous classroom-based behavior management system delivered by highly trained paraprofessionals. Noted ADHD expert Dr. Russell Barkley has suggested that this form of intensive treatment is beyond what could reasonably be implemented on a large scale. Whether less intensive behavioral treatment could yield equally positive results to those obtained in the MTA study thus remains somewhat unclear.
The issues surrounding medication treatment, in contrast, do not seem nearly so difficult to surmount. In the MTA study, there were several aspects of medication treatment that, although not routinely done, may not be that difficult to consistently implement. First, children received an initial trial that included a full range of doses. Systematic feedback was obtained from parents and teachers to determine the most effective dose. Second, if a positive response was not obtained on any dose tested, another stimulant medication was tested in the same way. It was only after a child failed to show a sufficiently positive response to any dose of either 2 or 3 different stimulants that a different class of medication, such as an antidepressant, was tried. Finally, children's functioning was monitored on a monthly basis, an effort that included receiving information directly from teachers. When it was evident that a child's symptoms were no longer being managed effectively, an adjustment to either dosage or medication type was implemented in an effort to bring the child's symptoms back under better control. During the 14-month study, the majority of children receiving medication required one or more such adjustments.
Although a reasonable variant of MTA medication treatment procedures would not be difficult nor particularly time consuming to implement, there is little indication that they are routinely employed in community settings. This is truly unfortunate, because the MTA results suggest that implementing these procedures could make an important difference in treatment outcomes. For example, just making sure that physicians received regular feedback from teachers about a child's behavior and academic performance at school would be enormously helpful for deciding whether treatment was proving effective or whether adjustments to treatment were necessary.
The authors of the current study conclude by noting that one of the most important ways to increase the effectiveness of treatment for ADHD is to "...improve collaboration between physicians and school professionals" and that "taking proactive steps toward meaningful school/community collaboration is essential if we are to reduce the public health and educational crisis surrounding ADHD identification, treatment, and outcomes." One hopes that this important call-to-action will be heeded.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.