COMMENTARY

Stimulant Medications for ADHD and Academic Performance

William T. Basco, Jr., MD, FAAP

Disclosures

August 10, 2009

Positive Association Between Attention-Deficit/Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School

Scheffler RM, Brown TT, Fulton BD, Hinshaw SP, Levine P, Stone S
Pediatrics. 2009;123:1273-1279

Summary

Although much data support the thesis that use of stimulant medications for attention-deficit/hyperactivity disorder (ADHD) can impart short-term improvements in school performance, the authors of this study point out that these results come from drug trials that are of relatively brief duration. It is logical to expect that the children in those trials would experience ongoing benefit from use of stimulant medications, but most previous trials were not designed to obtain such data.

This study by Scheffler and colleagues used data from more than 500 children followed as part of the Early Childhood Longitudinal Study. Participants from the nationally representative sample were enrolled in kindergarten during the 1998-1999 school year in the United States. The children were tested at 5 points: the beginning and end of kindergarten and again in the spring of their first-, third-, and fifth-grade years. At 4 of the assessment points, parents provided information on whether ADHD had been diagnosed in their child. In addition, data on whether the children had ever been treated with medication to treat ADHD and duration of that treatment were obtained at the fifth-grade evaluation.

The authors used a regression method that accounted for the participants' sex, race, and intelligence, as well as educational environment at home and school. The variable of interest was whether the participant was receiving medication for ADHD. The authors also sought to assess the effect of prolonged ADHD treatment by completing subanalyses for children who were medicated for 2 or more periods between each testing.

The authors compared the academic performance of the treated children with that of untreated children at each testing node. In the original cohort, ADHD was diagnosed in 1195 children. Of these, 594 children had complete weight data and medication data and had been tested at a minimum of 2 testing nodes. By the fifth-grade assessment, ADHD had been diagnosed in 9.4% of all participants in the trial.

The children who were medicated at least 1 period gained 2.9 points more in mathematics performance between the first and final testing than those unmedicated, corresponding to a "gain" of 0.19 school-year. For reading performance, a benefit was seen only for children medicated for at least 2 periods, with a gain of 5.4 points above the unmedicated children and corresponding to approximately 0.29 school-year. Despite the improvement over unmedicated children with ADHD, the performance of the medicated children with ADHD lagged their peers without ADHD.

The authors conclude that children with ADHD who are medicated perform better than unmedicated children with ADHD, but when it came to measures of reading performance, the benefit was present only if children were treated for longer periods; treated children still lagged peers without ADHD.

Viewpoint

These data do not provide the same clarity as would those from long-term randomized trials of medication for ADHD, but the beneficial effects demonstrated by short-term trials make longer randomized trials unethical. It is difficult to judge the "clinical" significance of these gains. It would have been useful to see outcomes that have a clearer import, such as grade retention rates. The study could not control for factors that might affect parental choice for treating ADHD, and it could not measure access to care to obtain treatment for ADHD; both are among many factors that may be associated with academic performance. Even so, few such longitudinal trials exist, and the positive association between medication treatment for ADHD and better academic performance at least suggests no academic harm in medicating children.

Abstract

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