Can an ADHD Diagnosis Actually Harm Academic Performance?

A provocative study recently published in Sociology of Education found that diagnosing and medicating children may actually do more harm than good when children exhibit only mild symptoms of attention-deficit/hyperactivity disorder (ADHD).¹

Children in the study with less severe ADHD symptoms received similar scores on social and academic behavior to their peers diagnosed with more severe ADHD symptoms when the children in the less severe group received medication, compared with their unmedicated, but diagnosed peers.¹ This finding reinforced prior evidence that children diagnosed with less severe ADHD-related behaviors scored lower on both math and reading assessments than their peers diagnosed with more severe ADHD symptoms—even when children in the less severe category received medication.² These unexpected outcomes earned the studies some media exposure,³ largely because both claim that labeling students with mild symptoms of ADHD outweighed any benefits gained from medication.

When children reach kindergarten age, they show awareness of differences between themselves and others, thus causing them to unconsciously lower their performance on social and academic measures compared to their peers, with medication reinforcing their difference from students without a diagnosis of ADHD.⁴ By taking medication during the school day, these students increase their sense of difference and may also elicit biased treatment from teachers, undercutting any benefits offered by medications that treat ADHD symptoms.^1,2

Other studies have similarly supported the impacts of labeling on teachers’ assessments of students. Even when presented with hypothetical descriptions of students, teachers rated the intelligence, behavior and personality of students labeled with ADHD significantly less favorably than their unlabeled peers. However, in this study, teachers labeled students with ADHD who did not receive medication less favorably than students who had both ADHD and treatment labels.⁵

As researchers have discovered, studies have surprisingly variable outcomes when they focus on the impacts of ADHD diagnoses and medication on students’ learning. These highly variable outcomes stem from confounders⁵ that include demographics,^1,2,6 context,⁶ medication,⁷ dosage, length of treatment, and adherence to medication.⁸ Additionally, any research on the impacts of an ADHD diagnosis on students’ performance faces substantial confounders from teachers’ personalities, training,^7,10 and attitudes toward behaviors that deviate from social norms.^10,11

Both studies that concluded that labeling mild ADHD symptoms did more harm than good analyzed longitudinal data on nearly 10,000 US elementary school students. The Early Childhood Longitudinal Study-Kindergarten Cohort (ECLS-K) was collected by the US Department of Education’s National Center for Education Statistics from 1998 to 2008.¹² This data offered researchers opportunities to study the long term effects of ADHD diagnoses and medication on children’s academic and social performance, which can differ significantly from laboratory conditions.⁷ Nevertheless, in the ECLS-K data, children diagnosed with ADHD tended to be white, have mothers with slightly higher educational levels, and exhibit slightly lower inattentive behavior scores than their non-white peers at baseline.^1,2

The ECLS-K data may also have underrepresented shifts in the diagnosis of ADHD that occurred after both studies’ cohorts received their initial diagnoses.⁶ Driven by the No Child Left Behind Act of 2001, school districts responded to pressures to increase school rankings and test scores by having more children tested for ADHD. As a result, low income public schools in Southern states saw twice the increase in ADHD diagnoses compared to the national average, which itself doubled between 2006 and 2016.⁶

Conclusions about the impact of medications for ADHD on students’ performance may also reflect differences in dosing, administration, adherence, and medications themselves.⁸ Both studies relying on the ECLS-K data¹² failed to note medication, dosing, adherence, and the number of years students had received treatment for their mild or more severe ADHD.^1,2 Any one of these factors could easily skew students’ performance on behavioral and academic measures.^7,8

In fact, the ECLS-K data has a crucial limitation that the most recent analysis fails to acknowledge.¹ All data on ADHD medications stem from a single survey, conducted during each cohort’s fifth grade year. If children diagnosed with any form of ADHD had parents respond that a child was unmedicated for his or her diagnosis during that year only, the ECLS-K data coded that child as never taking medication, even if the child had either taken medication from kindergarten through fourth grade or from sixth through eighth grades.¹³ As a result, both studies may draw mistaken conclusions by stating that students taking medication at school experienced detrimental effects from teachers’ and peers’ labelling these students as different.⁴

Earlier longitudinal cohort studies have revealed the significant role played by the socioeconomic status of students with ADHD, medicated or not. In the National Institute of Mental Health’s Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder, students with married parents, more financial stability, and higher IQs at baseline had less severe behavioral and learning issues at the study’s outset.⁹ Improvements in parental attitudes can also exert some influence on children’s behavioral and academic performance at school.¹⁴

Most researchers’ attempts to link a variety of ADHD medications to improvements in reading or math scores have failed to demonstrate even strong associations for 4 key reasons. First, few studies include at least 1 treatment-naïve group, newly diagnosed children, or teenagers who receive medication for the first time in the study and have pretreatment baseline scores available.¹⁵ Second, most studies document significant medication-related improvements in behavior, attentiveness in class, and academic productivity,^7,14,15 but fail to show gains on standardized testing scores.¹⁶ This lack of a significant link between medication and test performance may well stem from a dearth of teacher training for students with ADHD symptoms, particularly on tests that assess a narrow range of skills.¹⁶

Third, teachers focus more intensively on student test scores to accommodate the demands of widespread standardized testing.⁶ At the same time, “teachers fail to focus on students’ learning disabilities, which is another way of thinking about ADHD,” as Atih Amanda Seif, MD, a Los Angeles-based child and adolescent psychiatrist, stated in an interview. Finally, adherence to medication among students varies widely, depending on long- or short-acting results, dosing, and side effects.⁸ Ultimately, nonadherence may be “a critical issue among teens with ADHD that likely dampens stimulant medication effectiveness,” according to a 2017 study.⁸

“We really need a long-term study, with controls—not just undiagnosed students—that follows participants from ages 7 through 18,” Dr Seif concluded, “since many students fail to exhibit symptoms of ADHD until adolescence.” Moreover, by focusing study outcomes on increases in scores on standardized tests, “we’re fixated on measures that may mask other improvements students experience from taking medication for their symptoms of ADHD.”

Despite potential flaws in these surprising studies, the findings nevertheless emphasize the importance of taking into account perceptions and stigma surrounding ADHD and other intellectual disabilities and children with behavioral challenges.^1,2 They also point to the stresses placed on teachers and parents, as well as the structure of education systems increasingly reliant on standardized assessments.

References

1. Owens J. Relationships between an ADHD Diagnosis and Future School Behaviors among Children with Mild Behavioral Problems. Sociol Education. 2020. doi.org/10.1177/0038040720909296

2. Owens J, Jackson H. Attention-deficit/hyperactivity disorder severity, diagnosis and later academic achievement in a national sample. Soc Sci Res. 2017;61:251. doi.org/10.1016/j.ssresearch.2016.06.018

3. Barshay J. Labeling kids with mild disabilities can backfire, study finds [published online March 9, 2020]. The Hechinger Report. https://hechingerreport.org/study-questions-educational-benefits-of-labeling-kids-with-mild-forms-of-adhd/

4. DeRoche C. Labels in education: the role of parents and parental cultural capital in acquiring diagnoses and educational accommodations. Can J Ed. 2015;38(4):n4.

5. Batzle CS, Weyandt LL, Janusis GM, DeVietti TL. Potential impact of ADHD with stimulant medication label on teacher expectations. J Attention Disorders. 2020;14(2):157. doi.org/10.1177/1087054709347178

6. Piper BJ, Ogden CL. Simoyan OM, et al. Trends in use of prescription stimulants in the United States and Territories, 2006 to 2016. PloS One. 2018;13(11):e0206100. doi.org/10.1371/journal.pone.0206100

7. Pelham WE, Hoza B, Pillow DR, et al. Effects of methyphenidate and expectancy on children with ADHD: Behavior, academic performance, and attributions in a summer treatment program and regular classroom settings. J Consult Clin Psychol. 2002;70(2):320. doi.org/10.1037/0022-006x.70.2.320

8. Pelham WE, Smith BH, Evans SW, et al. The effectiveness of short-and long-acting stimulant medications for adolescents with ADHD in a naturalistic secondary school setting. J Atten Disord. 2017;21(1):40. doi.org/10.1177/1087054712474688

9. Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: Prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484. doi.org/10.3410/f.1159958.620216

10. Antonak RF. Development and psychometric analysis of the Scale of Attitudes Toward Disabled Persons. J Applied Rehab Counsel. 1982;13(2):22. doi.org/10.1891/0047-2220.13.2.22

11. Brophy JE. Research on the self-fulfilling prophecy and teacher expectations. J  Edu Psych. 1983;75(5):631. doi.org/10.1037/0022-0663.75.5.631

12. Tourangeau K, Nord C, Lê T, et al. Early Childhood Longitudinal Study, Kindergarten Class of 1998–99 (ECLS-K), Combined user’s manual for the ECLS-K eighth-Grade and K–8 full sample data files and electronic codebooks (NCES 2009–004). National Center for Education Statistics, Institute of Education Sciences, US Department of Education. Washington, DC. 2009. https://nces.ed.gov/ecls/data/ECLSK_K8_Manual_part1.pdf

13. Currie J, Stabile M, Jones L. Do stimulant medications improve educational and behavioral outcomes for children with ADHD? J Health Econ. 2014;37: 58. doi.org/10.3386/w19105

14. Hechtman L, Abikoff H, Klein RG, et al. Children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment: Impact on parental practices. J Am Acad Child Adolesc Psychiatry. 2004;43(7):830. doi.org/10.1097/01.chi.0000128785.52698.19

15. Jangmo A, Stålhandske A, Chang, Z et al. Attention-deficit/hyperactivity disorder, school performance, and effect of medication. J Am Acad Child Adolesc Psychiatry. 2019;58(4):423. doi.org/10.1016/j.jaac.2018.11.014

16. Loe IM, Feldman HM. Academic and Educational Outcomes of Children With ADHD. J Ped Psychol. 2007;32(6):643. doi.org/10.1093/jpepsy/jsl054

17. Sciberras E, Roos LE, Efron D. Review of prospective longitudinal studies of children with ADHD: mental health, educational, and social outcomes. Cur Attention Disorders Rep. 2009;1(4):171. doi.org/10.1007/s12618-009-0024-1