Medications Boost Academic Performance in ADHD Patients

Deborah Brauser

July 07, 2017

Individuals with attention-deficit/hyperactivity disorder (ADHD) often have problems with academic achievement, but new research suggests that medication can improve their performance.

A cohort study of more than 900 young adults from Sweden with ADHD showed that unadjusted scores on a higher education entrance examination averaged more than 13 points higher when the participants were taking ADHD medication than when they were not taking these drugs.

Although there was only a 5-point improvement in score after multiple adjustments were made for those who were taking medication, this was still significant.

Lead author Yi Lu, PhD, Department of Medical Epidemiology and Biostatistics, Karolinksa Institute, Stockholm, Sweden, told Medscape Medical News that she was "surprised at the small effect of medication on the test scores.

"Nevertheless, our results send a general message that ADHD medications can help patients with real-life educational outcomes beyond the core symptoms," said Dr Lu. "And the small effect highlights that multimodal treatment programs are needed to support people with ADHD in educational settings."

The findings were published online June 28 in JAMA Psychiatry.

Underachievement Common

"On average, individuals with ADHD earn lower school grades or standardized test scores and receive less schooling compared with peers without ADHD," write the researchers.

Because it is unclear whether ADHD medications improve academic outcomes, Dr Liu and colleagues investigated whether the drugs "might help to narrow the disadvantage and to improve academic underachievement" in these patients.

The researchers examined the Swedish National Patient Register to identify individuals who received an ADHD diagnosis from January 2006 through December 2013. They also assessed other national registers, as well as Swedish Scholastic Aptitude Test data. Scores on that test range from 1 to 200 points.

The study included a group of patients with ADHD (n = 3718) and a matched control group (n = 8371). Members in the ADHD group were significantly older than those in the control group at the time the participants took the standardized test (22.1 vs 20.6 years, respectively; P < .001).

The ADHD patients who had taken medication for their condition (n = 2745) were also significantly older than those who had never taken any medications (22.3 vs 21.6 years; P < .001). The former also had significantly higher test scores (94.1 vs 83.5; P < .001).

The main within-patient analysis included 930 ADHD patients (53% men). All were intermittent users of ADHD medications and had taken the entrance test several times, which is common in Sweden, because universities there only consider an applicant's best score.

Participants were considered to be receiving medication at the time of academic testing if they took the entrance examination in a 6-month period during which there were two records of prescriptions.

The use of ADHD medication was associated with an average increase of 13.1 test points in comparison with not using the drugs (95% confidence interval [CI], 9.7 - 16.5; P < .001). There was a 4.8-point increase after adjusting for age and "practice effects" (95% CI, 2.3 - 7.3; P < .001).

Don't Overinterpret

After sensitivity analyses, the effect size was a 0.048-point improvement on the original scale of the test scores, equivalent to 0.11 SD.

"It has been suggested that the people with greatest deficit are the ones who experience the most benefit from ADHD medication," said Dr Lu. "So the medication might have a larger effect in people with more impaired cognitive function or other severe functional impairment, but we were unable to determine that...given the test we chose."

Although men demonstrated greater improvement in test scores than women (5.7 vs 3.6, respectively), the differences were not statistically significant. There were also no significant score differences between those who used only stimulants and those who used nonstimulants or a combination of medications; or for those who did take selective serotonin reuptake inhibitors in comparison with those who did not.

The overall findings "suggest that ADHD medications may help ameliorate educationally relevant outcomes in individuals with ADHD," write the investigators. "This evidence should be considered together with the current list of risks and benefits of ADHD medication to guide clinical decisions."

"I believe clinicians should inform patients of the potential...effect when facing important academic tests," added Dr Lu.

She noted that the results should not be overinterpreted. "This study focused on people with ADHD. The risks and benefits of...medications to healthy people await further investigation."

Interpret With Caution

In an accompanying editorial, Luis Augusto Rohde, MD, PhD, ADHD Outpatient Program, Hospital de Clinicas de Porto Alegre, the Federal University of Rio Grande do Sul, Brazil, notes that although the results are encouraging, caution is needed, especially because there are "some methodological issues" in all population studies.

He pointed out that the sample might not be truly representative of those with ADHD and questioned the validity of the diagnostic assessments used.

"There are also uncertainties about the magnitude of the clinical effect because the use of medication increased test scores by a mean of 4.80 points...on a scale of 0 to 200," writes Dr Rohde.

"This uncertainty is even more relevant considering that effects were significant only for those who had average or high performance on the test."

He added that causality cannot be inferred from the findings and that taking medication could mean an individual was investing more in their health and was studying more.

"Do these methodological issues diminish clinical interest in the findings? Clearly not. Science is a construction in which we need to put 1 brick at a time in the wall of knowledge," writes Dr Rohde.

"The work done by this group of investigators provides the kind of information that we all need to stimulate compliance with pharmacologic interventions in our discussions with patients," he concludes.

The study was funded by grants from the Swedish Research Council and the National Institute of Mental Health and by an early career fellowship to Dr Lu from the Australian National Health and Medical Research Council. Dr Lu has reported no relevant financial relationships. The original article lists relevant financial relationships for the coauthors. Dr Rohde has received honoraria, has served on speakers bureaus or advisory boards, and/or has served as a consultant for Eli Lilly, Janssen-Cilag, Novartis, Medice, and Shire. He receives authorship royalties from Oxford Press and ArtMed and has received travel awards from Shire and unrestricted educational and research support from Eli Lilly, Janssen-Cilag, Novartis, and Shire.

JAMA Psychiatry. Published online June 28, 2017. Abstract, Editorial

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