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Does Medication Treatment Improve the Academic Performance of Adolescents with ADHD?
The efficacy of stimulant medication treatment in reducing core ADHD symptoms in children -- at least in the short-term -- has been convincingly demonstrated in a large number of studies. And, recently, results from the MTA study have provided evidence that these benefits can persist over a sustained period. Although the effectiveness of medication treatment for adolescents has not been researched as extensively, several studies showing positive results have been published.
Despite these positive findings, however, the impact of medication treatment on real-world academic outcomes remains an important gap in the ADHD treatment literature. For example, even in the MTA study, surprisingly little data on children's academic performance was collected. In this study, standardized tests of academic achievement were used as one measure of treatment outcome, and some modest benefits in reading achievement were reported. However, children's performance on individually administered achievement tests does not necessarily indicate that their day-to-day performance in the classroom has improved.
Although several studies have documented that stimulant medication treatment is associated with immediate gains in academic productivity and work quality for children, it has yet to be convincingly shown that these gains in daily academic work are associated with better long-term achievement. And, studies of the impact of medication treatment on academic performance for adolescents with ADHD are virtually non-existent. Because academic performance is an area where adolescents with ADHD are especially prone to struggle, this is an enormously important topic to investigate.
Recently, a study published in Experimental and Clinical Psychopharmacology demonstrates an impressive effort to examine this issue (Evans, S. at al., (2001). Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD. 9, 163-175.) Participants in this study were 45 (40 male and 5 female) teenagers (average age of about 14 years) who took part in an intensive eight-week summer treatment program for ADHD.
As part of the summer treatment program, all participants spent 60 minutes each day in a "class" designed to simulate a junior high school history course. Students were required to listen to a lecture and take notes, as they would in a class taken in their regular school. After class each day, there was a 30-minute study hall period during which the adolescents were given a work sheet to complete based on the material covered that day in class. . After completing the work sheet, a 15-minute creative writing assignment was required. Later in the day, students were quizzed on the material from the day's history class. To prepare for the quiz, the adolescents were provided with no materials other than their own notes.
During the summer program, participants also were involved in a double-blind, placebo-controlled medication trial that involved three different doses of methylphenidate -- 10 mg., 20 mg., and 30 mg. Medication conditions were switched on a daily basis so the researchers could examine whether adolescents' schoolwork varied depending on the dose being administered. The daily measures of academic performance included an assessment of note-taking quality during class, scores on the daily work sheet and quiz, the number of words written during the creative writing assignment, and the overall quality of the daily writing assignment. Teachers also completed behavioral ratings each day.
Two other aspects of the summer treatment program are important to note. First, prior to beginning the medication trial, participants received extensive instruction in note-taking skills, an area in which adolescents with ADHD are notoriously deficient. And, during the class, a clear set of rules for behavior was established and consistently enforced. Several contingencies were in place to encourage adolescents to follow classroom behavior rules, including monetary incentives for appropriate behavior and fines that were levied for violating class rules. Thus, this was an extremely structured and well-organized classroom, and may not have been entirely representative of a typical junior high-school class.
Results
Results of medication treatment on adolescents' academic performance were considered in two ways. First, the researchers analyzed whether there was an overall improvement in adolescents' academic and behavioral performance while taking medication. Second, they examined academic improvement on each dosage level for each adolescent. This latter analysis is especially important because it is possible to obtain significant overall differences (i.e. on average, adolescents showed better academic performance on medication vs. placebo) even though a substantial proportion of participants may not have benefited.
Group Effects
Analysis of the overall data for adolescents indicated that medication was associated with superior academic performance, as compared to placebo, in every area examined. The percentage of correct answers on the history work sheet improved from an average of 53% during placebo days to approximately 80% during the 20-mg. and 30-mg. medication days. Scores on the daily history quiz showed similar levels of improvement, with the average grade increasing from an F (47% correct) on placebo days to a C (72% correct) during the two higher-dose medication days.
Results also indicated that adolescents did a better job of note taking during medication days (i.e. they recorded a greater percentage of the main ideas covered in class, as well as details) and that both the length and quality of their daily creative writing assignments were enhanced. There also was evidence that adolescents completed significantly more homework during the medication days, compared to placebo, although the differences here were considerably smaller than for the other measures of academic performance.
For all outcome measures considered, the pattern of results indicated a large improvement from the placebo dose to the 10-mg. dose, with smaller increments of improvement from the 10-mg. dose to the 20- and 30-mg. doses. Similar results were obtained for teacher ratings of adolescents' classroom behavior.
Individual Differences
Although this evidence of overall improvement is impressive, it also is important to determine the percentage of adolescents who showed gains from medication treatment. To examine this important issue, the researchers compared the performance of each adolescent during medication and placebo conditions to see how many showed improvement that would be considered clinically meaningful. These results are presented in the table below:
The entries in the table represent the percentage of adolescents who showed deterioration, no change, moderate improvement, or large improvement in overall behavioral and academic functioning (i.e. academic performance averaged across their score on the daily history worksheet, quiz, and creative writing assignment) on each dosage relative to the next lower dosage.
For example, on the 10-mg. dose, 5% of adolescents showed a decline in academic/behavioral functioning relative to how they had performed on placebo, 40% showed no change, 40 % showed a moderate improvement compared to placebo, and 15% showed a large improvement. When the dosage was increased to 20 mg., 9% deteriorated relative to their performance on the 10-mg. dose, 48% showed no change, 39% did moderately better, and 4% did substantially better. When the dosage was increased to 30 mg., 16% declined, 61% showed no change, only 23% showed a moderate gain, and no participant showed a large gain.
Overall, these results at the individual level are also positive. It is important to emphasize, however, that not all adolescents improved on medication. For example, across all doses tested, 9% did not improve on the daily worksheet or quiz, and approximately 25% failed to improve on the creative writing task. Over one-third did not show meaningful gains in on-task behavior.
Summary And Implications
Results from this study provide clear evidence that stimulant medication treatment is associated with significant positive effects on adolescents' classroom behavior and academic performance. For example, with respect to grades, the improvements obtained on quiz scores and study hall assignments corresponded to changes from "F" to "C", a clearly meaningful change. There also was evidence of medication effects on the quality of notes taken, which would hopefully translate into longer-term improvements in academic performance.
In the context of these overall positive results, it is important to emphasize that not all adolescents showed such benefit. Depending on the outcome being considered, anywhere from 9% to 36% failed to show a meaningful improvement on any dosage tested. Furthermore, there were some adolescents whose performance declined while on medication (i.e. 5% did significantly worse on the lower dose than they had on placebo). And, as dosage was increased, there was diminished likelihood of additional gains and an increased risk of deterioration. (Note: For some children who did not benefit on any dosage of methylphenidate, it is likely that switching to a different medication would have yielded significant gains.)
Results from this study highlight the importance of carefully monitoring an adolescent's performance on the aspects of behavioral and/or academic performance one is trying to improve when evaluating the impact of medication treatment. For example, although 55% of adolescents showed moderate or large improvement on the 10-mg. dose, relative to placebo. 43% of those who did not improve on the 10-mg level were helped when the dosage increased to 20-mg. And, of those who were still not helped, an additional 23% showed gains at the highest dose tested in this study. These data demonstrate the value of testing a child across a range of doses, because many children will not show significant benefits until a certain dosage threshold is reached.
At the same time, however, increasing the dosage was associated with a significant deterioration in performance for an increasing number of participants. Thus, one cannot assume that increasing the dose when positive results have not yet been obtained will necessarily yield better results. In fact, in some cases, academic and behavioral functioning can decline. It is only by carefully monitoring behavioral and academic performance on each dosage tested that one can be more confident about optimizing the impact that medication treatment is actually having. And, even after an optimal dose for beginning treatment has been determined, it remains critically important to monitor performance over time, as it is not uncommon for medication adjustments to be necessary. (For more information on ongoing medication monitoring, click below: http://www.attention.com/library/articles/article.jsp?id=845&parentCatId=6&categoryId=37.)
In summary, results from this study provide evidence that carefully conducted medication treatment can be associated with meaningful gains in academic performance for adolescents with ADHD. As the authors note, however, one should not conclude that these gains would necessarily translate into enhanced long-term academic success. And, because their simulated classroom was significantly better structured and organized than many middle- and high-school classrooms, it is possible that the same positive results would not have been found in a regular school setting. This would be the case if, as the authors speculate, the behavioral program in place for this study is required for medication to have the beneficial effects that they found for many of the participants.
Overall, therefore, this study provides compelling evidence that medication treatment can enhance the short-term academic performance for many adolescents with ADHD. Clearly, this is an important finding. However, demonstrating that these short-term boosts translate into long-term academic success, and that such success is also obtained in more typical middle- and high-school settings, remains an essential research task.
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.