ADHD treatment and academic performance: A case series

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Original Research

ADHD treatment and academic performance: A case series

J Fam Pract. 2003 August;52(8):620-626

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References

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Correspondence: 606 Haifleigh Street, PO Box 1186, Franklin, LA 70538, E-mail: Buckylou2@aol.com.

TABLE 1
Profile of participants in study of ADHD treatment and academic performance

	Participants	Nonparticipants	GPA not improved	GPA improved
Gender
Male	23	2	18	5
Female	9	1	9	0
Mean age(mo)	125 ± 30	124 ± 9.2	127 ± 32	119 ± 10
Race
White	28	3	24	4
African American	4	0	3	1
Mean GPA	2.26 ± .62	2.24 ± .54	2.26 ± .66	2.24 ± .42
Family structure
Both parents	20	2	17	3
Blended	8	1	6	2
Single parent	4	0	4	0
Parent psychopathology	8	0	7	1
Mean comorbidities	1.53	1.67	1.59	1.20
GPA, grade-point average

Results

Thirty-two of 35 students completed the study. Using a Mann-Whitney U test, no significant differences were found between these patients and those who did not complete the study (P=.80 for baseline GPA differences and P=.80 for age.)

According to follow-up information from parents and teachers, all participants exhibited short-term improvements in DSM-IV criteria for predominantly inattentive ADHD at some point during the study. Five pupils who completed the study had improved GPAs (15.6%), while the remaining 27 participants showed no change or decreased GPAs (84.4%).

Using students t tests to compare age, baseline GPAs, and number of comorbidities and χ² for parental psychopathology, no significant differences were found between students with improved GPAs and those without improvement in their GPAs (P=.61 for age, P=.93 for baseline GPA differences, P=.53 for differences in comorbidities, and P=.70 for differences in parental psychopathology; see Table 1). Using a paired sample t test on data from all 32 participants showed that the overall treatment effect was not significant (P=.176; see Table 2).

TABLE 2
Grade-point averages at baseline and at the study’s conclusion*

Student #	Baseline GPAs	Treatment GPAs	Change
1	2.29	1.59	–.70
2	3.00	2.40	–.60
3	1.80	1.25	–.55
4	2.50	1.96	–.54
5	2.50	2.00	–.50
6	1.80	1.50	–.30
7	3.50	3.22	–.28
8	2.57	2.35	–.22
9	2.43	2.29	–.14
10	3.00	2.86	–.14
11	2.25	2.12	–.13
12	2.57	2.45	–.12
13	2.47	2.37	–.10
14	2.71	2.61	–.10
15	2.20	2.10	–.10
16	2.27	2.20	–.07
17	1.66	1.59	–.07
18	1.87	1.80	–.07
19	2.43	2.36	–.07
20	.71	.67	–.04
21	2.53	2.50	–.03
22	2.10	2.07	–.03
23	.95	.92	–.03
24	2.53	2.52	–.01
25	3.29	3.29	0
26	.95	.95	0
27	2.25	2.25	0
28	2.17	2.60	+.43
29	2.66	3.09	+.43
30	2.50	3.00	+.50
31	1.57	2.12	+.55
32	2.29	2.85	+.56
Mean ± SD	2.26 ± .62	2.18 ± .65
*Post-treatment GPAs declined an average of .08 ± .32, 95% confidence interval, –.19 to .04. Paired samples test=1.385 (31 degrees of freedom) (P=.176).
GPA, grade-point average; SD, standard deviation

Discussion

Psychostimulant therapy did not significantly improve the outcome measures (GPAs) in the cohort diagnosed with predominantly inattentive ADHD and academic impairment. Additional comorbidities were diagnosed and treated, but differences among participants were not statistically significant. Short-term decreases in DSM-IV symptoms of predominantly inattentive ADHD did not translate into academic gains.

Limitations to the present study include the small sample size and lack of a control group. Thus, the findings should be considered preliminary. GPAs are not standardized scores and are sensitive to varying influences. However, the American Academy of Pediatrics notes that even when standardized instruments are used to assess stimulant treatment for ADHD, there is “frequently no association with improvements in academic achievement.”¹⁶ Only short-term gains in academic efficiency have been reported.¹⁷

The average doses employed (methylphenidate 16.7 mg/d, dextroamphetamine 11 mg/d) were smaller than the starting doses used successfully in the Multimodal Treatment Study of Children with ADHD (methylphenidate 30.5 mg/d, dextroamphetamine 15.25 mg/d).¹⁸ However, this study excluded patients with predominantly inattentive ADHD.¹⁹ The lower dosages used in the present study are compatible with the practice parameters of the American Academy of Child and Adolescent Psychiatry for ADHD without hyperactivity.²⁰

All participants in the study received educational assistance. Those students not attending resource classes qualified for accommodations and modifications under Section 504 of the Rehabilitation Act of 1973 guidelines. The small sample sizes precluded an analysis of the effects of these different educational interventions on GPAs. The input from multiple teachers and classroom settings could not be delineated. However, GPAs have the advantage of being readily accessible. In addition, the findings obtained from a community-based practice with patients and families in their natural environment support the study’s results.

How do the results of the present study correlate with the literature on predominantly inattentive ADHD, and how should clinicians incorporate these data into their evaluations of students who have inattention and academic concerns? Results from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network²¹ note that there is “a lack of standardization in the primary care evaluation of attentional problems.” Inattention is not unique to predominantly inattentive ADHD. Children and adolescents with language/learning disorders,^22-24 anxiety/depression,²⁵ and family dysfunction²⁶ are also described as inattentive.

It is difficult to define accurately what is meant by inattention in predominantly inattentive ADHD because the psychological construct of attention is not the same as that being measured behaviorally in predominantly inattentive ADHD.²⁷ In addition, the unifying theory on ADHD, which involves deficits in behavior inhibition and executive function, does not include predominantly inattentive ADHD in the definition.^28,29 The American Academy of Pediatrics concludes that with ADHD the need “to develop more valid and precise diagnostic criteria is essential.”³⁰

The present study should be considered an introductory step in the evaluation of psychostimulant treatment in predominantly inattentive ADHD. GPAs are easily obtained by busy clinicians and are time-efficient measures of treatment outcomes. Clearly, additional research, using larger groups and controls, is needed.