Pediatr Drugs

DOI 10.1007/s40272-015-0144-2

REVIEW ARTICLE

Impact of Attention-Deficit Hyperactivity Disorder on School

Performance: What are the Effects of Medication?
Raman Baweja1 • Richard E. Mattison1 • James G. Waxmonsky1

Ó Springer International Publishing Switzerland 2015

Abstract Attention-deficit hyperactivity disorder (ADHD) be needed to maximize academic performance for the many
affects an estimated 5–7 % of schoolchildren worldwide. youth with ADHD and prominent impairments in school
School functioning and academic achievement are fre- performance.
quently impaired by ADHD and represent one of the main
reasons children start ADHD medication. Multiple potential
causal pathways exist between ADHD and impaired school
performance. In this review, we decompose school perfor- Key Points
mance into three components and assess the impact of
ADHD and its treatments on academic performance Children with attention-deficit hyperactivity disorder
(assessed by grade point average [GPA], time on-task, per- (ADHD) often have impairment in their school
centage of work completed as well as percent completed performance.
correctly), academic skills (as measured by achievement School performance is one of the main reasons
tests and cognitive measures), and academic enablers (such children start ADHD medication.
as study skills, motivation, engagement, classroom behavior
and interpersonal skills). Most studies examined only the The evidence for the positive impact of ADHD
short-term effects of medication on school performance. In medications on school performance is encouraging
these, ADHD medications have been observed to improve with best support for improvements in classroom
some aspects of school performance, with the largest impact behaviors and seatwork productivity.
on measures of academic performance such as seatwork In a subset of children, these benefits may translate
productivity and on-task performance. In a subset of chil- into detectable improvements in grade point average
dren, these benefits may translate into detectable improve- (GPA) and achievement testing. However, limited
ments in GPA and achievement testing. However, limited data exist to support whether these changes are
data exists to support whether these changes are sustained sustained over years.
over years. Optimizing medication effects requires periodic
reassessment of school performance, necessitating a col-
laborative effort involving patients, parents, school staff and
prescribers. Even with systematic reassessment, behavioral- 1 Introduction
based treatments and additional school-based services may
Attention-deficit hyperactivity disorder (ADHD) affects an
estimated 5–7 % of schoolchildren worldwide [1, 2]. In the
& Raman Baweja United States, 5 % of school-aged youth were prescribed
[email protected] medication for ADHD [3]. Elevated rates of use in the US
1 may be in part due to primary care physicians being the
Department of Psychiatry, Penn State University College
of Medicine, 500 University Drive, H073, Hershey, predominant prescribers of ADHD medications for chil-
PA 17033-0850, USA dren [4] with over 4 % of all pediatric primary care visits
R. Baweja et al.

ending with a prescription of a psychotropic medication Studies show that children with ADHD have a lower IQ in
[5]. Use of psychotropic medication is significantly lower comparison to their peers [15, 31], which has been posited to
in Britain where CNS stimulants are predominantly pre- account for some of the academic impairment associated
scribed by mental health specialists [6]. with the disorder. In a study by Duric and Elgen, one-third of
Symptom characteristics of ADHD include hyperactiv- clinically referred children with ICD-10 criteria of ADHD
ity, impulsivity, and inattention, all of which can affect had low IQ, defined as \85 on the Wechsler Intelligence
performance in school. Not surprisingly, ADHD con- Scale for Children IV [32]. Another study among adolescents
tributes to increased risk for problems in education, thus from Europe reported that around 21 % of ADHD youth had
conferring a substantial burden on healthcare and educa- a co-morbid diagnosis of Intellectual Disability as defined by
tional systems worldwide [7–10]. School functioning and IQ \ 85 [33]. However, multiple studies have found that the
academic achievement are frequently and in many cases associations with ADHD and academic underachievement
profoundly impaired by ADHD. These impairments have persist after adjusting for IQ [24, 25, 34, 35].
been shown to affect a child’s quality of life not only in the Learning disorders (LD) are more common in youth
short-term [11], but also long-term [9, 12]. Furthermore, with ADHD, serving as another cause of academic under-
untreated children with ADHD also impose significant achievement. Estimates of comorbid LD among children
costs on their classmates by disrupting learning and with ADHD vary depending on the definition used, though
diverting teacher resources in the classroom setting [13]. at least 20–25 % of children appear affected [36]. How-
ever, academic underperformance in children with ADHD
has been reported above and beyond the potential effects of
2 Impact of ADHD on School Performance comorbid LD [37], suggesting that poor academic out-
comes with ADHD may also be due to inattention [36],
Children with ADHD have been shown in numerous studies executive dysfunction [38], or the associated disruptive
to be at significantly greater risk for poor school perfor- behavior problems [39] seen in ADHD.
mance [14]. On average, children with ADHD receive
lower grades than children without ADHD [15] and are at
increased risk for failing grades [16] and low-test scores 3 Casual Pathways Between ADHD and School
[17, 18]. For example, ADHD youth are roughly three times Impairment
more likely to be retained a grade [19, 20], nearly 15 times
more likely to receive special education services [21] and Presence of multiple potential causal pathways between
less than half as likely to graduate from high school [20] ADHD and impaired school performance can make it
compared with their peers. The Multimodal Treatment challenging to identify exactly how ADHD is impacting
study of ADHD (MTA), one of the largest treatment trials of academics for individual students. It has been hypothesized
ADHD to date, found that 35.5 % of children with ADHD that ADHD has both a direct cognitive as well as an
attended special education classes [22]. indirect behavioral effect on scholastic achievement. Core
Long-term prospective studies of children with ADHD symptoms and related deficits of ADHD have both been
have revealed that these impairments persist into adoles- theorized to contribute to impaired school performance.
cence [12, 23]. For example, an 8-year longitudinal study Inattention may contribute to distraction from assigned
showed that ADHD diagnosis at 4–6 years of age predicted tasks, failure to listen to instructions, off-task behaviors
lower reading and math achievement test scores in adoles- within the classroom, and losing or failing to complete
cence [24]. Similarly, Mannuzza and colleagues found that assignments [40]. An association between academic
ADHD youth completed significantly less schooling than impairments and the intensity of inattentive symptomatol-
controls when followed up 15–21 years later [25]. Another ogy has been suggested. Studies have shown that early
large longitudinal population based follow-up study from attentional difficulties are associated with future reading
England showed that every one-point increase in inattention and math scores, and school underperformance [16, 41]. A
symptoms at age 7 was associated with incrementally worse study examining the academic achievement of 125 ADHD
academic outcomes at age 16 as measured by standardized youth over 8 years found that the inattentive subtype had
achievement tests. In boys, ADHD was associated with the lowest scores in reading, spelling, and mathematics
more than double the likelihood of not achieving acceptable versus controls and the other ADHD subtypes. While dif-
scores across the range of subjects tested [26]. The chronic ferences remained after adjusting for IQ and other con-
educational underachievement associated with ADHD has founds, the very small number of inattentive subtype cases
been demonstrated to have long-term implications for (14) limits the interpretation of these intriguing results [24].
children’s future health, socioeconomic, and employment Hyperactivity in children with ADHD may lead to prob-
outcomes [9, 11, 27–30]. lems staying seated, fidgeting, and negative teacher
Impact of ADHD on School Performance

attributions of behavior in the classroom [42]. Impulsivity

may further contribute to poor performance on multiple-
choice tests and on long-term assignments, and may pre-
vent youth from waiting long enough to consider alterna-
tive information [42].
Despite these associations, ADHD symptom severity has
been found to be a better predictor of behavior than of actual
school performance, at least for ADHD students in special
education [43]. Poor academic progress was more related to
the nature of their academic problems rather than their
ADHD or other behavioral problems. In the MTA, the impact
of attentional impairments on school grades was mediated by
impaired performance in the classroom and during home-
work. Improving attentional deficits with medication did not
translate into improvements in these realms for the majority Fig. 1 Components of school performance. GPA grade point average
of youth [44]. These results suggest that interventions should
target more than just ADHD symptoms in order to achieve
meaningful gains in academic functioning. functioning. It is not surprising that the concept of school
There is substantial evidence supporting an association performance has been measured in a variety of ways,
between ADHD and impairments in various neurocognitive making comparisons across studies somewhat difficult. For
functions including executive processes such as behavioral the purposes of this review we will break down school
inhibition, response inhibition, working memory (WM), performance into three components [44, 54]: academic
attentional set shifting, and planning, as well as non-ex- performance (assessed by grade point average [GPA], time
ecutive deficits such as basic storage aspects of memory, on-task, percentage of work completed, as well as percent
timing, reaction time, and reaction time variability, as well completed correctly), academic skills (as measured by
as motivational factors such as delay aversion and decision achievement tests and cognitive measures), and academic
making [45]. Deficits in executive functioning predict enablers (such as study skills, motivation, engagement,
impaired school functioning. Among ADHD youth, those classroom behavior, and interpersonal skills) [55]. These
with greater impairments in executive functioning have the components are often considered separately because suc-
worst academic outcomes [46]. There is a particularly well cess in school requires a wide variety of skills beyond
documented association between impairment of executive learning information [49]. For example, successful home-
functioning such as WM, and academic achievement in work completion may require both organizational and
literacy, mathematics, and science [47], as well as impact time-management skills (enablers), knowledge of the req-
on homework completion [34, 48, 49]. Impairments in WM uisite material (academic performance), as well as tapping
have been found to be significant predictors of impairments WM and attention (academic skills) (Fig. 1).
in language skills in ADHD youth, even when controlling
for other potential mediating factors [50]. Practically,
children with ADHD often struggle in completing home- 5 Trends in Medication Prescription Rates
work, either forgetting to record their assignments or
recording them inaccurately. Even when done, they com- While the use of CNS stimulants in school-aged children
plete assignments inaccurately or forget to turn them in, has stabilized as of late [56], rates have increased sub-
with particular difficulties in completion of long-term stantially in adolescents. ADHD medications are now the
projects [48, 49, 51, 52]. Homework completion is a major most commonly prescribed medication class in adolescents
component of academic functioning in children and [57] with academic functioning being the primary treat-
accounts for approximately 20 % of the total time which ment target in many cases. Parents preferentially lean
students invest in overall academics [53]. toward medication options when trying to address aca-
demic concerns [58] despite no clear evidence that they are
more effective than behavioral interventions. Recent shifts
4 Dimensions of School Performance in government policies regarding public education may be
driving this trend in the US. Federal testing mandates for
School performance is a broad term with many synonyms, school such as No Child Left Behind (NCLB) laws have
such as academic performance, academic competence, been associated with increased ADHD diagnoses [59].
academic achievement, academic impairment or academic Further indicators of this trend are the increased use of
R. Baweja et al.

ADHD medications during the school year compared with Existing literature was ascertained in the English lan-
over the summer. The largest differences in school-year guage, published between 1981 and May 2015, using
versus summer stimulant use occur among families in the searches of MEDLINE and PsycInfo for the following
upper socioeconomic strata in states with the greatest categories: school performance, Attention Deficit Hyper-
accountability pressure (i.e., standardized testing) [60]. activity Disorder, children, adolescence, MPH, ampheta-
mine (AMPH), non-stimulant, pharmacotherapy, drugs,
CNS stimulants, and medication. Relevant data from peer-
6 Why Medications Should Impact Academics reviewed scientific presentations were also included. This
narrative review will address the effects of ADHD medi-
Given the increased use of ADHD medications to address cations (CNS stimulants and non-stimulants) on the three
school performance, it is imperative that clinicians have a identified domains of school performance: academic per-
thorough understanding of the capacity of ADHD medi- formance, academic skills, and academic enablers. Table 1
cations to enhance school functioning. Pharmacological provides a summary of the selected reviewed studies on
treatments for ADHD may target school functioning school performance.
through multiple pathways. They have been found to reli-
ably reduce impulsive and off-task behaviors in numerous
randomized controlled trials [61, 62]. In addition, they can 7 Measurement Approaches for Assessing ADHD
reduce impairments in a variety of executive functions, Medication Effectiveness on School
including WM [45]. Some of the first reviews on this topic Performance
found little evidence of meaningful medication effects on
GPA or achievement scores [63, 64]. Another review, Studies to date have utilized a range of settings and mea-
which assessed long-term academic functioning with sures to assess the impact of treatment of ADHD on chil-
medication use, showed improvement in standardized dren’s school performance. Common settings for such
achievement scores, while evidence for long-term studies include children’s natural classrooms or a con-
improvements in school grades and grade retention was trolled environment classroom called the analog classroom.
less compelling. Moreover, authors also questioned the The latter has been widely used in FDA approval studies
magnitude of achievement score improvements and the for new ADHD medications as it offers a controlled
educational significance of these improvements [54]. Most environment; however, it is not clear to what degree
recently, Arnold and colleagues reported greater improve- treatment effects in the analog classroom translate to nat-
ment in achievement scores and academic performance uralistic school settings.
with multimodal interventions than with either medication Measures of school performance are wide ranging.
or behavioral treatment alone [65]. Teacher ratings of ADHD symptoms and disruptive
The goal of this narrative review is to synthesize the behaviors using standardized rating scales such as the
extant literature for prescribing clinicians to aide them in ADHD Rating Scale (ADHD-RS) [69] or Conners Global
making treatment decisions regarding the role of medica- Teacher Index [70] have been commonly employed. Some
tion treatment in addressing school functioning for youth teacher-completed rating scales also attempt to measure
with ADHD. The review will also discuss findings relevant impairments in academic performance, such as the Aca-
to the assessment of school functioning in ADHD youth. demic Performance Rating Scale (APRS) [71]. The
As the focus is on treatment effects readily detectable in Swanson, Kotkin, Agler, M-Flynn and Pelham Scale
the school setting, only studies employing measures of (SKAMP) [72] is a ten-item measure assessing ADHD-
actual school performance will be included. Unfortunately, related behaviors in the classroom context encompassing
improvement in objectively measured neuropsychological multiple domains including on-task and out-of-seat
batteries appears to be only mildly predictive of medication behaviors, initiation of work, interactions with peers and
response in youth with ADHD [66]. For example, Froeh- staff, quietness, work completion and accuracy, attention
lich and colleagues observed that methylphenidate (MPH)- and transitions.
induced improvements in neuropsychological functioning Many studies utilize measures of seatwork completion
were not predictive of MPH’s capacity to improve seat- and productivity defined as the percentage of a child’s
work productivity [67]. Instead, time on-task was a sig- assigned seatwork that they completed in a preset time
nificant mediator. Therefore, studies examining the period, or seatwork accuracy defined as the percentage of a
neurocognitive effects of ADHD medications that do not child’s assigned seatwork that they answered correctly.
employ outcomes measured in the school will not be dis- Most typically, mathematics is the measured domain using
cussed. These effects have been thoroughly reviewed the Permanent Product Measure of Performance (PERMP)
elsewhere [45, 68]. [73]. The PERMP is a 10-minute arithmetic test using
Table 1 Summary of the selected reviewed studies that focused on school performance
Study No. Setting Design Duration Medication and daily School performance Main results Limitations
dose range domains

Academic performance
Pelham et al. 22 STP Placebo-controlled 5 weeks IR-MPH 10 mg bid Seatwork Both IR-MPH and SR-MPH Small sample size
[80] double-blind, SR-MPH 20 mg daily productivity led to significant Analog setting
within-subject trial Seatwork accuracy improvement in on-task
behavior, seatwork Short duration
On-task behavior productivity and accuracy
Timed reading/math No differences between
(attempted and % dosage formulations
correct)
Chacko et al. 36 STP Within-subject, 6 weeks IR-MPH 0.3 mg/kg vs Seatwork Significant improvement in Small sample size
Impact of ADHD on School Performance

[82] placebo- 0.6 mg/kg bid productivity on-task behavior, seatwork Short-term study
controlled, Seatwork accuracy productivity, but not
double-blind, daily seatwork accuracy Analog setting
crossover design On-task behavior Concurrent BT
No clinically appreciable
differences between dose,
except for on-task behavior
Dopfner 79 Analog Randomized, 2.5 weeks ER-MPH up to 1 mg/kg PERMP (seatwork Significant improvement in Small sample size
et al. [84] classroom placebo- daily productivity and seatwork productivity and Short-term study
controlled, IR-MPH up to 1 mg/kg in accuracy) accuracy
double-blind, Analog setting
2 divided doses No difference in IR vs ER
crossover, except seatwork accuracy at
multicenter study 15:30 with MPH compared
with ER-MPH
Biederman 57 Analog Multicenter, 18 days ER mixed AMPH Salt PERMP (number Significant increase from Small sample size
et al. [97] classroom randomized, (10–30 mg/d) vs ATX attempted and baseline in the M number of Analog setting
double-blind, (0.5–1.2 mg/kg/day) correct) math problems attempted
parallel-group, and answered correctly in Short duration
forced dose both groups
titration Participants on ER mixed
AMP Salt attempted
significantly greater
numbers of problems
compared with participants
on ATX
Brams et al. 86 Laboratory Randomized, 2 weeks ER Dex-MPH 20 mg Seatwork Significant improvement in Small sample size
[99] classroom placebo-controlled q.a.m. productivity and Math Test-Attempted and Analog setting
double-blind, accuracy Math Test-Correct scores
crossover, Short duration
multicenter study
Table 1 continued
Study No. Setting Design Duration Medication and daily School performance Main results Limitations
dose range domains

Marcus and 3543 Natural Community; 5 years; Grades Medication use variable School transcripts Stimulant-adherent marking Retrospective
Durkin classroom naturalistic, 1–8 represents the number for school grades periods were associated observational study
[103] setting retrospective of marking period days and GPA with significantly higher Only examined
observational with a stimulant GPAs (M = 2.18 for Medicaid-covered
study prescription Considered adherent and M = 1.99 for youth
stimulant adherent nonadherent). Significant
if [70 % of days on association between
medication adherence and GPA over
time. Small effect size
(d = 0.15) and a 0.108
higher GPA
Academic skills
Barbaresi 370 Natural Population based Median age at last Medication variables Statewide Average daily dose Retrospective study
et al. [19] classroom birth cohort; follow- examined include achievement test significantly associated No direct assessment
setting community; up = 18.4 years duration (months), scores with last reading score of diagnosis
naturalistic average daily dose, age Absenteeism Medicated participants 1.8
of onset, and any times less likely to have
treatment (yes/no) Grade retention
been retained
Decreased school
absenteeism
MTA 579 (MTA Natural Parallel group, 14 months Med group: M dose IR- Standardized Reading: Combined group Only ADHD combined
Cooperative study) classroom randomized MPH 37.7 mg/day in 3 achievement test outperforms BT and CC, type
Group setting intervention divided doses (WIAT) while Med did not Lack of no-treatment
14-month Combined group: M dose Combined not better than control arm
results IR-MPH 31.2 mg/day Med
[109] Primarily IR-MPH was
in 3 divided doses Math and spelling: no half-strength dose in
CC group: M dose IR- significant difference afternoon
MPH 22.6 mg/day in between groups Participants were in
average 2.3 divided different grade levels
doses at entry
Scheffler 594 (ECLS-K) Natural Naturalistic 5 times between Medicated vs Standardized Math: medicated 2.9 points Parent-reported ADHD
et al [112] data set classroom kindergarten and unmedicated achievement test higher (p = 0.04) than diagnosis and
5th grade unmedicated, a 0.19 school medication status
year difference
Reading: medicated 5.4
points higher (p \ 0.01)
than unmedicated, a 0.29
school year difference
Difference for reading only
significant when comparing
participants with [2 years
medicated to participants
with \2 years
R. Baweja et al.
Table 1 continued
Study No. Setting Design Duration Medication and daily School performance Main results Limitations
dose range domains

Academic enablers
Pelham et al. 68 Regular and Within-subject, 3 weeks IR-MPH (5–15 mg) tid Teacher-rated scale Significant reductions in Small sample size
[86] analog placebo- ER-MPH (18–54 mg) (IOWA Conners teacher-rated scale Short-term study
classroom controlled, q.a.m. Rating Scale) No clinically appreciable
crossover design DRC differences between IR and
AMPH in both settings
Greenhill 97 Regular Multicenter, 7 weeks ER Dex-MPH (5–30 mg) Teacher-rated scale Significant and large Small study
et al. [115] classroom randomized, q.a.m., M dose 24 mg (CADS-T) reductions in teacher rating Short duration
double-blind, scales
No objective indices of
Impact of ADHD on School Performance

placebo-
controlled, academic
parallel-group functioning

Weiss et al. 153 Regular Randomized, 7 weeks ATX 1.2–1.8 mg/kg/day Teacher-rated scale Statistically significant Small sample size
[117] classroom placebo-controlled (ADHDRS-IV- reductions in teacher rating Short-term study
Teacher) scales
High rate of placebo
response
Multiple domains (academic performance and academic enablers)
Pelham et al. 21 Regular Within-subject, 6 weeks IR-MPH bid vs IR-MPH Seatwork Significant improvement in Small sample size
[77] classroom placebo- q.a.m. vs mixed AMPH productivity seatwork productivity, on- Short-term study
controlled, Salt q.a.m. Seatwork accuracy task behavior and teacher
crossover design rating scales but not
On-task behavior seatwork accuracy
Teacher-rated scale No clinically appreciable
differences between drugs
Pelham et al. 25 STP Within-subject, 6 weeks IR-MPH 10 mg or Seatwork Significant improvement in Small sample size
[78] placebo- 17.5 mg bid productivity seatwork productivity, on- Short-term study
controlled, Mixed AMPH Salt Seatwork accuracy task behavior and teacher
crossover design 7.5 mg or 12.5 mg bid rating scales, but not
On-task behavior seatwork accuracy
Teacher-rated scale No clinically appreciable
differences between drugs
Pelham et al. 36 STP Placebo-controlled, 8 days MPH transdermal system Seatwork Significant improvement in Small sample size
[85] double-blind, (0.45, 0.9, and 1.8 mg/ productivity seatwork productivity and STP
within-subject h) Seatwork accuracy teacher-rated behavior, but
trial, 3 sites not accuracy; the highest Short duration
Teacher-rated scale dose produced limited
incremental benefit
compared with medium
dose
Table 1 continued
Study No. Setting Design Duration Medication and daily School performance Main results Limitations
dose range domains

Multiple domains (academic performance and academic skills)

Molina et al. 436 (MTA Natural Randomized 8 years; M age at Medication use was Standardized Medication use positively Infrequent
[29] study) classroom intervention follow- defined as medicated achievement test associated with math retrospective
setting changing to up = 16.8 years over 50 % of days in (WIAT) standardized achievement assessment of
naturalistic the past year School transcripts scores at the 8-year medication over an
observation for school grades assessment but not with extended time period
and retention reading Variability with the
No association with GPA or measurement of
grade retention grades across schools
Powers et al. ADHD Natural Clinic; naturalistic M = 9.13 years; Medicated sample: Standardized Medicated performs better Retrospective
[102] group = 90, classroom M age at follow- M duration of achievement test than unmedicated on assessment of
Control up = 18.4 years medication was (WIAT-II) reading and math medication use
group = 80 5.33 years School transcripts achievement scores Presence of
Parents interviewed Medicated youth significantly psychosocial and
about grade higher GPA (2.0) compared educational
retention with unmedicated (1.4) interventions
No significant differences on potentially
grade retention confounding results
Wietecha 267 Natural Randomized, 8 weeks acute ATX 0.8 or 1.4 mg/ Standardized Significant improvements Lack of a placebo
et al. [104] classroom double-blind, treatment, kg/day achievement test over time in total control group
26 sites followed by (Woodcock achievement scores as well
40 weeks Johnson-III Tests as reading and writing
maintenance of Achievement) scores in acute phase
phase GPA (school record Improvement in math grades
review) at end of maintenance
phase with low but not high
dose

AMPH amphetamine, ATX atomoxetine, ADHD attention-deficit/hyperactivity disorder, ADHDRS-IV-Teacher Attention-Deficit/Hyperactivity Disorder Rating Scale-IV—Teacher version, bid two times
daily, BT behavioral treatment, CADS-T Conners ADHD/DSM-IV Scale—Teacher version, CC community care, DRC daily report card, Dex-MPH dexmethylphenidate, ECLS-K Early Childhood
Longitudinal Study—Kindergarten Class of 1998–1999, ER extended release, GPA grade point average, IR immediate release, MTA Multimodal Treatment Study of Children with ADHD (MTA
Cooperative Group, 1999), M mean, Med medication arm, MPH methylphenidate, PERMP Permanent Product Measure of Performance, q.a.m. once in the morning, STP summer treatment program, SR
sustained release, tid three times daily, WIAT Wechsler Individual Achievement Test
R. Baweja et al.
Impact of ADHD on School Performance

problems set to the individual’s own level of math have found significant improvements in productivity [80,
achievement, so that it is primarily a measure of seatwork 84–89], but there is no clear evidence for dose-dependent
productivity versus achievement. Observational measures effects with ER preparations.
include on-task behavior (the length of time during Studies of AMPH have shown significant improvements
observed intervals that the child was focused on the task at in the amount of academic work completed with roughly
hand), out-of-seat behavior (the amount of observed comparable results for IR and ER products [90–94]. In a
intervals that the child spent away from their assigned seat study of lisdexamfetamine and ER mixed AMPH salts
or work area) and number of classroom rule violations. among 52 children aged 6–12 years, significant improve-
Results from achievement tests and changes in a student’s ment was found with both medications over placebo on the
actual GPA have also been employed to assess the impact PERMP [90]. Likewise, both IR-AMPH and ER mixed
of ADHD medications. While offering more clinically AMPH salts produced similar improvements over placebo
meaningful results of school performance than the PERMP in seatwork productivity on the PERMP [95]. Insufficient
or teacher rating scales, it is important to recognize that a studies have compared effects across different doses of
host of factors contribute to these naturalistic markers of AMPH to be able to determine if increasing dose
school performance, making it challenging to isolate the strengthens effects.
specific effects of an individual treatment such as Seatwork productivity is one realm where comparative
medication. studies between different agents have been assessed. In a
study set at a therapeutic summer camp for elementary
school children with ADHD, both IR-MPH and mixed
8 Effect of Medications on Academic Performance AMPH salts showed improvement in productivity and on-
task behavior as compared with placebo [78]. In another
8.1 On-Task Behavior study comparing IR-MPH and mixed AMPH salts, earlier
peak effects and a shorter therapeutic duration of action
Studies have demonstrated significant improvements in on- occurred with MPH versus mixed AMPH salts [96]. Sev-
task behavior with both immediate release MPH (IR- eral studies have compared the efficacy of different ER-
MPH), and immediate release AMPH (IR-AMPH). A MPH formulations over the course of a 12-h analog
meta-analysis of primarily IR-MPH studies also supports classroom day. While the overall effect is generally com-
the dose-dependent effects of MPH for improving on-task parable between agents, formulation has an impact on the
behavior as rated by direct observation in the classroom, timing of peak drug effects [88, 89]. In a post-hoc subgroup
with higher doses (0.6 mg/kg/dose or 17.5–20 mg fixed analysis of an 18-day randomized controlled trial in school-
dose) producing small (3 %) but statistically significant age girls with ADHD, treatment with ER mixed AMPH
improvements over a lower dose (0.3 mg/kg/dose or 10 mg salts was significantly more effective than atomoxetine in
fixed dose) [74]. Higher doses of IR-MPH were found to terms of ratings of classroom behavior, attention, and
substantially increase on-task behavior. Specifically, a academic productivity (SKAMP) [97]. However, the
20-mg dose improved the percentage of on-task behavior timeframe of assessment may have limited the efficacy of
more than a 5-mg dose [75, 76]. Similar gains with IR- atomoxetine given its delayed therapeutic onset [98]. Other
AMPH for on-task behavior have been seen with a mean than this one comparative study, there has been very little
increase between 8–10 % for on-task behavior compared investigation into the effects of non-stimulants for seat-
with placebo [77, 78]. Studies have also demonstrated work productivity.
significant improvement with both extended-release for-
mulations [79, 80]. 8.3 Seatwork Accuracy

8.2 Seatwork Productivity Most studies examining seatwork productivity have also
examined seatwork accuracy. Studies show improvement
Studies that have examined low-dose (0.15–0.3 mg/kg or in seat accuracy with IR-MPH and ER-MPH on the
10 mg fixed dose) and high-dose (0.6 mg/kg or PEMRP [84, 87, 99, 100] and other measures [76, 80, 94,
17.5–20 mg fixed dose) IR-MPH have consistently repor- 101]. However, PERMP results are not as consistent as
ted significant improvement in seatwork productivity [81– those seen for seatwork productivity, possibly due to the
83]. While some studies have observed dose-dependent smaller inter-subject variance in seatwork accuracy versus
effects, a prior meta-analysis did not find clear evidence productivity [67]. Early works assessing effects of MPH on
that increasing dose reliably enhances response [74]. this domain found higher doses (20 mg) to significantly
Multiple studies that examined oral and transdermal increase accuracy [76]. In support of these initial obser-
extended-release methylphenidate (ER-MPH) preparations vations, a recent meta-analysis showed no significant effect
R. Baweja et al.

of low-dose, predominantly IR-MPH (0.3 mg/kg or 10 mg treatments on parent-rated homework problems. The MTA
fixed-dose) compared with placebo on children’s seatwork randomly assigned participants to community care (where
accuracy [74]. their pediatrician prescribed ADHD medication in most
ER mixed AMPH salts significantly increased both the instances), or to study-based medication treatment (pre-
number of PERMP questions attempted and the number dominantly with IR-MPH dosed three times a day),
correct in multiple studies [90, 95]. Older AMPH formu- behavioral therapy, or a combination of the two. Compared
lations have also been found effective. Significant with community care, all three treatment groups of the
improvements were seen in arithmetic and reading accu- MTA study showed significantly greater decreases in
racy with dextroamphetamine (d-AMPH) [91], although problems related to inattention and avoidance during
Pelham and colleagues did not find an effect for ER-AMPH homework completion. However, only participants who
on a measure of reading accuracy [94]. Few studies of received the behavioral therapy component (behavioral and
AMPH have been sufficiently powered to compare effects combined arms) showed a sustained effect on homework
across doses, but Swanson and colleagues reported that productivity and non-adherence to homework rules over
increasing the dose of IR-AMPH had a significant effect on time. Impressively, group differences were detectable a
PERMP-attempted and correct scores [96]. No clinically year after study treatments had ended [106].
appreciable differences between IR and ER versions of A population-based birth cohort study examined the
AMPH or between MPH and AMPH have been reliably impact of medication use on school attendance and reten-
observed in this domain [77, 78, 92]. tion. Children who were treated with stimulants had lower
rates of school absenteeism and were less likely to be
8.4 Grade-Point Average (GPA) retained; however, the proportion of school dropout was
similar between children with ADHD who were and were
Compared with the prior domains, there are relatively few not treated with stimulants [107]. In an ecological study set
studies examining the impact of pharmacological treatment in Quebec following a change in provincial medical
of ADHD on GPA. In the MTA study, past-year medica- insurance laws, a significant increase in the usage of
tion use was not associated with GPA at the 8-year ADHD medication was not associated with any evidence of
assessment [29]. In another study, 90 children with ADHD improved academic functioning in children with elevated
symptoms were re-evaluated an average of 9 years later. ADHD symptoms [108]. Outcomes ranged from grade
Children who were treated with psychostimulant medica- retention and high school graduation to standardized math
tion achieved a higher GPA than those not treated (GPA scores.
2.0 vs 1.4). However, treated probands did not fare as well
as the never-ADHD comparison group (2.4) [102]. In a
study of ADHD youth from an urban school district, 9 Effect of Medications on Academic Skills
stimulant adherence was found to be low (18.6 %) in ele-
mentary and middle school students, though it was asso- 9.1 Achievement Testing
ciated with a marginal improvement in GPA. Mean GPA
was significantly higher during stimulant-adherent (2.18) Effects of ADHD medications on achievement scores have
than stimulant-nonadherent (1.99) marking periods [103]. been measured using a variety of standardized tests. The
Using atomoxetine, Wietecha and colleagues reported a MTA study assessed academic functioning as measured by
statistically significant improvement in math grades at the reading, math and spelling from the Wechsler Individual
end of the maintenance treatment period (40-week assess- Achievement Test (WIAT). Following 14 months of ran-
ment) with low-dose (0.8 mg/kg/day) but not with high- domized treatment, combined treatment was found to have
dose atomoxetine (1.4 mg/kg/day). The mean change in improved reading achievement scores compared with the
math grade was from C to B-. However, no significant behavioral treatment and community care arms (in which
improvement occurred in English, science and social the majority of participants used CNS stimulants). While
studies grades with any dose of atomoxetine [104]. Pelham combined treatment did not significantly differ from the
and colleagues observed statistically nonsignificant medication arm, medication alone did not outperform the
increases versus placebo in GPA (1.6–1.9) with IR-MPH behavioral or community care arms [109]. However, this
and pemoline [105]. effect had dissipated by the 24-month assessment [110,
111]. The loss of treatment benefits was partially attributed
8.5 Other Domains to the fact that approximately half of the children in the
‘non-medicated group’ were receiving psychostimulant
Langberg and colleagues utilized data from the federally treatment at the time of the 36-month follow-up, suggesting
funded MTA study to examine the impact of the MTA that the treatment groups were no longer distinct [110].
Impact of ADHD on School Performance

There were no significant improvements in mathematics or 10 Effect of Medications on Academic Enablers

spelling scores at any time point [109]. However, past-year
medication use was positively associated with math stan- 10.1 Teacher Ratings of Classroom Behavior
dardized achievement scores at the 8-year follow-up in
MTA [29]. There is a sizable literature documenting that both stimu-
Other studies have found statistically significant but lant and nonstimulant medications lead to reductions in
relatively mild improvements in achievement, with the teacher-rated ADHD symptoms and associated disruptive
precise nature of the gains varying across studies. In a behaviors. For example, in 97 youth on a mean dose of
population-based birth cohort, stimulant treatment of chil- 24 mg of ER dexmethylphenidate, Greenhill and col-
dren with ADHD was associated with improved reading leagues observed significant and large reductions in tea-
achievement [19]. Powers and colleagues found that chil- cher-rated Conners scores versus placebo over 7 weeks of
dren with ADHD symptoms who were treated with psy- treatment [115]. In a 3-week, double-blind crossover trial
chostimulant medication scored better on word reading, in 68 children, similar reductions were noted with both ER-
pseudoword decoding, and numerical operations from the MPH and IR-MPH [86]. Multiple other studies of IR-MPH
WIAT-II than those not treated with psychostimulants. have observed comparable effects [77, 78, 81, 84, 85].
However, treated probands did not fare as well as the Ahmann and colleagues observed significant effects with
never-ADHD comparison group [102]. Scheffler and col- low (0.15 mg/kg/dose) and high doses (0.3 mg/kg/dose) of
leagues [112] used data from the Early Childhood Longi- IR-AMPH on teacher-rated Conners scales among 154
tudinal Study—Kindergarten (ECLS-K) to examine the children. Treatment effects increased with dose [116]. In an
effect of medication on achievement scores in 594 children analog classroom study of the ER and IR versions of mixed
with ADHD. Children with ADHD who took medication AMPH salts, both medications were associated with sig-
had higher math and reading scores on achievement tests nificant improvements in teacher ratings on the SKAMP,
developed by ECLS-K staff than unmedicated children with higher doses of the ER formulation associated with
with ADHD; however, they still lagged behind their non- the longest therapeutic duration [95].
ADHD peers [112]. A population-based birth cohort that Weiss and colleagues completed a randomized, placebo-
included 370 youth with ADHD who were followed from controlled study of atomoxetine dosed between 1.2 and
school entry through high school graduation showed a 1.8 mg/kg day in 153 children aged 8–12 years with
modest positive correlation between average daily stimu- ADHD. Participants’ own teachers completed weekly rat-
lant dose and reading scores 12.8 years later [107]. In a ings for the 7 weeks of the study. Despite a higher than
study among 121 boys with average treatment duration of expected placebo response, statistically significant reduc-
30.4 months, treatment with MPH was associated with tions of moderate effect in teacher-rated ADHD symptoms
significantly higher reading scores, and longer treatment were observed [117]. Likewise, Waxmonsky and col-
duration was associated with improved math scores [113]. leagues noted improvements in teacher ratings of ADHD
A national registry study from Iceland showed medicated symptoms, disruptive behaviors and classroom functioning
ADHD youth had slower decline in achievement scores in an open-label study comparing atomoxetine alone with
than unmedicated youth [114]. In summary, the most atomoxetine plus a low-dose, school-based behavior
support is for improvement in reading scores with long- intervention. However, no significant differences emerged
term usage of CNS stimulants, although it does not appear between groups in teacher-rated outcomes [118].
that medication alone reliably normalizes achievement
scores in ADHD youth. 10.2 Other Domains
There is even less data for nonstimulants. In one of the
only nonstimulant studies, Wietecha and colleagues com- There has been little investigation of medication effects in
pared the effects of two different doses of atomoxetine over this domain outside of changes in classroom behaviors.
8 weeks and found significant improvements over time in One small study of IR-MPH (maximum dose: 30 mg in
total achievement scores as well as reading and written a.m., 30 mg at noon, and 15 mg in p.m.), and pemoline
language scores on the Woodcock Johnson III. No effect on (maximum daily dose of 112.5 mg every a.m.) asked the
math scores was observed and results were limited by the participating adolescents’ own teachers to rate changes in
lack of a control arm. Forty weeks later, approximately half note-taking habits, preparation for class, and turning in
of the acute gains in total achievement score had eroded, assignments on time, in addition to standard ratings of
with a trend for better reading scores in the higher (1.4 mg/ ADHD symptom severity. IR-MPH, but not pemoline, led
kg/day), but not the lower dose group (0.8 mg/kg/day) to statistically significant improvements in note-taking
[104]. habits when compared with placebo. There was a trend
R. Baweja et al.

(p \ 0.10) for both medications leading to improvement in advance planning and preparation. Third, medication
classroom preparation and on-time work completion [105]. response can be highly variable across individuals with
ADHD [61], so not all children will experience comparable
degrees of improvement.
11 Synthesizing the Literature: What We Know As this review has shown, limitations with the employed
About the Overall Effects of Medication methodology have compromised our knowledge about
on School Performance medication’s capacity for improving school performance.
Most drug trials follow children only for a short time—
The evidence for the positive impact of ADHD medica- often less than a school marking period. Ethical constraints
tions on school performance is encouraging but mixed, and preclude the possibility of long-term randomized control
more substantial for acute versus long-term indices of studies using inert control treatments, which is the most
academic performance. The strongest data exists for the common comparator in pharmaceutical industry-funded
capacity for CNS stimulants to improve teacher ratings of studies. It is problematic to have children assigned to no or
student behavior. Reductions in disruptive behaviors may non-optimal treatment groups for extended periods of time
result in children spending more time in the classroom and when approved, readily available treatments exist. The
lead to more effort toward academically oriented activities. federally funded MTA study was least burdened by these
However, it is unclear how much improvement in behavior restrictions using an active comparator of community
translates to improved academic performance as teacher treatment and providing study treatment for up to
ratings of behavioral improvements are not robustly cor- 14 months within the randomized cells. Still, the commu-
related with other outcome measures [66]. Consistent and nity treatment employed a substantively lower dose of
sizable increases in seatwork productivity have also been medication than study-based treatments, and initially
observed with pharmacological treatment of ADHD. In determined group distinctions in treatment usage quickly
fact, measures of therapeutic effect on these indices in evaporated when the study transitioned to a naturalistic
analog classroom studies have become an efficacy bench- follow-up phase. For example, approximately half of the
mark in the FDA approval process for new ADHD medi- children in the ‘behavior-only’ group had received treat-
cations [73]. ment with stimulant medication by the 36-month assess-
There is emerging evidence of positive impact of med- ment point [110]. Not surprisingly, initial group differences
ications on GPA, as well as for reading and math in ADHD symptom control favoring medication arms over
achievement. Even when long-term benefits are noted, they non-medication ones were not seen at these follow-up
may be of questionable clinical significance (e.g., small assessments. At the very least, these results suggest that
increases in GPA) that fail to eradicate the difference systematic medication or behavioral treatments do not
between ADHD and non-ADHD youth [54, 103]. More- sustain their effects once families transition to typical care,
over, Schachter and colleagues have raised a concern that which is often of much lower intensity [125]. In addition,
the positive short-run effects on attention and behavior may without the protection of randomization, potential con-
be over-estimated given publication bias towards positive founding associations between treatment uptake and dis-
findings [119]. ease severity may arise. In the 8-year follow-up of the
There are several factors that likely diminish the thera- MTA study, students with ADHD receiving special edu-
peutic efficacy of ADHD medications on GPA and cation services had taken stimulants for approximately
achievement scores. First, chronic adherence to these 40 % more days than students not receiving these services
medications is poor, with a mean duration of use less than [22]; yet, few would theorize a causal association between
an academic year [120]. In one study, improved GPA was the two. It is much more likely that greater impairment
found only amongst adherent versus nonadherent youth drives a need for more intensive pharmacological and
[103]. Second, the high comorbidity of ADHD with LD educational interventions.
[121, 122] creates multiple barriers to academic success in In addition to inadequate duration, the majority of
ADHD youth, as ADHD medications do not reliably ADHD treatment trials employing direct school-based
impact the academic deficits seen with LD [123]. While outcomes have been conducted in the US, which may limit
ADHD medications improve seatwork productivity, they the generalizability of findings. Furthermore, many studies
have not proven effective for enhancing deficits in orga- on school performance have been conducted in analog
nization and study skills. These aspects become increas- class settings where investigators can control most aspects
ingly critical in high school [102, 124] as the depth and of the learning environment, from classroom size to the
mass of testable information increases dramatically, as well level of behavioral supports. The latter is particularly rel-
as the need to complete large-scale projects that require evant, as a high level of classroom support has been found
Impact of ADHD on School Performance

to reduce the observed effectiveness of medication [83]. 12 Practical Steps for Healthcare Professionals
Hence, it may be harder to detect medication effects in a to Monitor School Performance
special education classroom with six students than in a
larger, regular education classroom. Conversely, robust According to international guidelines, a comprehensive
results observed in analog classrooms on a specific measure treatment plan that can include pharmacological and psy-
of academic performance such as timed math tests may not chosocial interventions, along with psychological, behav-
translate at all to a crowded, inner-city public school ioral and educational supports, should be developed for the
classroom with limited resources and a high number of treatment of ADHD [61, 130]. The healthcare team should,
children with an appreciable number of social stressors. with parental consent, try to include the teacher in attempts
Thus, it is not surprising that others have observed reduced to develop a comprehensive care plan [130].
effects of ADHD medication on academic functioning in The first step to successful intervention is obtaining
naturalistic versus laboratory settings [105]. accurate information about the level of ADHD symptoms
Medication is not alone in this regard. Similar assump- at school, as well the students’ current functioning in the
tions about commonly used behavior interventions, such as classroom. It has been recommended that health profes-
extended time for testing, have also not been supported sionals should get input from teachers using standardized
when systematically studied [126]. Yet, it is important to scales to aide diagnosis and treatment [130]. Obtaining this
recognize that multiple evidenced-based behavioral inter- information can be a challenge, especially for middle and
ventions do exist for improving school performance in high school students. Whenever possible, direct feedback
ADHD youth. A school-based daily report card (DRC) has from school that assesses both symptom severity and
been found to be an effective intervention either as a stand- functional impairments are preferred over second-hand
alone measure or when combined with medication [83, reports from parents [131, 132]. Several comparable
127]. It is a relatively inexpensive intervention that can be symptom measures exist, including the National Initiative
widely implemented as an initial school-based intervention for Children’s Healthcare Quality Vanderbilt Assessment
for most ADHD youth. More recent work in both ele- Scale, which is part of the American Academy of Pedi-
mentary school children and adolescents has found that atrics ADHD toolkit [133]. Few scales move beyond
behavioral treatments emphasizing organizational and symptoms to measure impairment, which is a better pre-
study skills training can improve school performance [124, dictor of long-term outcome than symptom severity [134].
128]. Similar to medication, little is known about the long- One such measure is the Impairment Rating Scale (IRS), a
term impact of evidenced-based behavioral therapies due to 5-item visual analog scale that evaluates the child’s prob-
many of the same methodological barriers impeding the lem level and need for treatment in developmentally
assessment of medication treatments over an extended time important areas such as peer relationships, teacher rela-
period. tionships, academic performance, classroom behavior, and
Despite the limitations of medication and behavioral self-esteem [135]. The APRS is a 19-item scale that was
treatments as stand-alone interventions for academic per- developed to reflect teachers’ perceptions of children’s
formance, there has only been limited work examining the academic performance and abilities in classroom settings.
effects of combined treatments in ADHD youth. Multisite It includes items directed toward work performance in
studies examining this issue, (the MTA and Montreal various subject areas, academic success, behavioral control
studies) found relatively small and inconsistent effects of in academic situations and attention to assignments [71].
adding behavior therapy to stimulants for academic per- The SKAMP is a ten-item measure assessing ADHD-re-
formance [109, 110, 129]. Likewise, small non-significant lated behaviors in the classroom context encompassing
effects were seen at school when behavior therapy was multiple domains [72].
added to nonstimulant treatment [118]. In a study by In addition to ratings of impairment, direct measures of
Fabiano and colleagues, the relative impact of each treat- academic productivity are quite useful, such as GPA.
ment individually depended on the presence of the other Increasingly, schools post grades as well as other academic
(e.g. smaller medication effects seen in the presence of indices (such as number of missing assignments) on elec-
intensive behavioral treatments), suggesting the need to tronic portals that can be securely and easily accessed by
carefully assess the level of behavioral and educational parents before meeting with the healthcare professionals.
supports in the classroom when estimating the potential Grade portal data may provide valuable information on
impact of medication [83]. The failure to systematically do treatment effects, especially for middle and high school
so may explain the disappointing effects of combined students with multiple teachers, thereby limiting reliance
therapy reported in studies examining effects in naturalistic on teacher rating scales, which were primarily design to
classroom settings. assess behavior. For younger students, teachers may send
R. Baweja et al.

home a daily note or use a daily point system. These While the primary-care clinician is unlikely to provide
communications can be easily adapted into a DRC that counseling treatments, it is important for prescribers to
tracks specific behaviors (e.g., number of prompts needed know when to refer for psychiatric consultation and
to stay on-task or percent of work completed in class), behavioral services. Obvious red flags include failing
which can serve as excellent indices of daily school func- grades, grade retention, and school suspensions. However,
tioning [136]. More information on how to develop a DRC delaying treatment until then is not ideal. Any child who
can be found at http://ccf.buffalo.edu/pdf/school_daily_ continues to exhibit impairments in school performance
report_card.pdf. after trials of two or more different ADHD medications at
The second step for monitoring is reassessment. Reg- typically therapeutic doses should be considered for a
ular patient contact is necessary to adjust suboptimal further diagnostic review that includes assessment of
treatments and discontinue ineffective ones. The National school functioning, medication tolerability, and treatment
Committee for Quality Assurance (NCQA) guidelines adherence [130]. Specialty referral and a multimodal
recommend a visit within 30 days of starting medication treatment intervention that includes school-based services
as well as two subsequent follow-up visits in the next should also be considered.
9 months [137]. Unfortunately, many children with There is no need to delay behavioral treatments until
ADHD are not seen on a sufficiently regular basis by their after medication has been initiated if local resources are
medication prescribers to adjust treatment when responses available. The addition of relatively low-intensity school-
are suboptimal [138]. Children and adolescents have a based interventions, such as a DRC, to a low dose of a CNS
limited capacity to assess their own impairment, and stimulant (0.15 mg/kg MPH) has been found to be as
medication response varies widely from one child to effective as high-dose medication (0.6 mg/kg) for
another [139]. Therefore, structured feedback on medica- improving seatwork productivity and classroom behavior
tion effects should be gathered from parents and schools [83]. As some side effects with CNS stimulants may be
whenever possible, and it should not be assumed that dose dependent, combining two relatively low-intensity
benefits seen in one realm will manifest in all realms. interventions may improve treatment tolerability. There-
Brief measures are sufficient to reassess the impact of fore, it may be advisable to consider behavioral services
medication changes, such as the 10-item IOWA Conners before maximizing the medication dose.
Rating Scale [39, 130, 134]. The IRS [135] or APRS [71] Deficits in organizational and study skills, as well as
can be completed in less than 10 minutes, making them other domains of executive functioning, often persist after
feasible for follow-up assessments as well as initial diag- improvements in attention and impulse control have been
nostic determinations. DRCs can also be used as a means observed [142]. Therefore, it should not be assumed that
of tracking the efficacy of a medication, as well as directly deficits in these domains have normalized in visibly
improving school functioning by linking incentives at asymptomatic adolescents. Even improvements in neu-
school and home to performance on the DRC. ropsychological tests from ADHD medication have limited
When examining change in symptoms and impairment, correlation with improved academic functioning [67].
it is important to consider the time of year and academic Therefore, improvement on these tests should not be
environment. Unfortunately, students tend to exhibit a assumed to lead to enhanced school functioning. Instead,
variable level of symptoms and impairment in different direct evidence of performance improvements should be
classrooms [140]. Therefore, in middle and high school collected (grades, teacher reports, direct observations, etc).
subjects, it is not safe to assume that good functioning in Even achievement tests have limited correlations with GPA
one class translates to other subjects. The demands of a [44].
new school year may lead to significant additional A number of evidence-based behavioral treatments exist
impairment while other students may show dramatic that have been found to improve study habits and organi-
improvement over time [141]. Therefore, it is essential to zational skills in youth with ADHD [124, 128]. School-
re-evaluate functioning and ADHD symptom severity at based services such as those provided through a 504 plan or
least annually. However, teachers may be hesitant to rate Individualized Educational Program (IEP) should also be
problematic behaviors in students they have just begun to considered for any child struggling in school with aca-
work with, so it may be advisable to delay assessment at demics or behavior. In some states, initial referral for
least until after the first month of the school year. Symptom school-based services must be initiated by a medical pro-
exacerbations as winter and summer breaks approach are fessional. Therefore, it is important for healthcare profes-
also not uncommon. These declines are often temporary as sionals to be aware of the educational supports that a child
student motivation for school may improve after returning is currently receiving, and parents should be queried
from an extended break. annually for any change in these supports.
Impact of ADHD on School Performance

13 Conclusions 5. Olfson M, Kroenke K, Wang S, Blanco C. Trends in office-

based mental health care provided by psychiatrists and primary
care physicians. J Clin Psychiatry. 2014;75(3):247–53.
This review has highlighted the strengths and weaknesses 6. Sayal K, Ford T, Goodman R. Trends in recognition of and
of ADHD medications on school performance in ADHD service use for attention-deficit hyperactivity disorder in Britain,
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the classroom and seatwork productivity. In a subset of 8. Pelham WE, Foster EM, Robb JA. The economic impact of
attention-deficit/hyperactivity disorder in children and adoles-
children, these benefits may translate into detectable
cents. J Pediatr Psychol. 2007;32(6):711–27.
improvements in GPA and achievement scores. Limited 9. Barkley RA. Major life activity and health outcomes associated
data supports whether these changes are sustained over with attention-deficit/hyperactivity disorder. J Clin Psychiatry.
years, as few studies have systematically assessed this. 2002;63(Suppl 12):10–5.
10. Biederman J, Faraone SV. The effects of attention-deficit/hy-
Likewise, little is known about which students are most
peractivity disorder on employment and household income.
likely to experience sustained improvements in school MedGenMed. 2006;8(3):12.
performance from medication treatment. These findings 11. Klassen AF, Miller A, Fine S. Health-related quality of life in
highlight the need for continued investigation into the children and adolescents who have a diagnosis of attention-
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effects of ADHD treatments on school performance.
12. Mannuzza S, Klein RG, Bessler A, Malloy P, LaPadula M.
It is clear that optimizing medication effects requires Adult outcome of hyperactive boys. Educational achievement,
periodic reassessment of school performance, necessitating occupational rank, and psychiatric status. Arch Gen Psychiatry.
a collaborative effort involving patients, parents, school 1993;50(7):565–76.
13. Aizer A, National Bureau of Economic Research. Peer effects
staff, and prescribers. Even with systematic reassessment
and human capital accumulation the externalities of ADD.
and optimization of medication effects, behavioral-based NBER Working Paper No. 14354, 2008.
treatments and additional school-based services may be 14. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The ado-
needed to maximize academic performance for many youth lescent outcome of hyperactive children diagnosed by research
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with ADHD and prominent impairments in school
Child Adolesc Psychiatry. 1990;29(4):546–57.
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and achievement: meta-analysis of the child, adolescent, and
Compliance with Ethical Standards adult literatures and a concomitant study with college students.
J Learn Disabil. 2007;40(1):49–65.
Funding None. 16. Fergusson DM, Lynskey MT, Horwood LJ. Attentional diffi-
culties in middle childhood and psychosocial outcomes in young
Conflict of interest Dr. R. Baweja has no conflicts of interest or adulthood. J Child Psychol Psychiatry. 1997;38(6):633–44.
financial ties to report. Dr. R. Mattison has no conflicts of interest or 17. Purvis KL, Tannock R. Phonological processing, not inhibitory
financial ties to report. In the past 3 years, Dr. J. Waxmonsky has control, differentiates ADHD and reading disability. J Am Acad
received research funding from NIMH, Shire Pharmaceuticals, and Child Adolesc Psychiatry. 2000;39(4):485–94.
Janssen (drug donation); served on the advisory board for Noven and 18. Semrud-Clikeman M, Guy K, Griffin JD, Hynd GW. Rapid
Ironshore Pharmaceuticals; and served as a speaker for CME talks naming deficits in children and adolescents with reading dis-
provided by Quintiles. abilities and attention deficit hyperactivity disorder. Brain Lang.
2000;74(1):70–83.
19. Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen
SJ. Modifiers of long-term school outcomes for children with
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