April 27, 2009— -- Watching her son Ian wiggle and play with his fingers while the rest of his kindergarten class sat quietly in the library listening to their teacher read aloud, Rachel Hastings, 46, had an epiphany.
"It was a moment that told me that his inability to sit still was beyond his capability," Hastings said.
Soon after, her son was diagnosed with attention deficit hyperactive disorder (ADHD), a condition characterized by poor concentration, hyperactivity, impulsivity and impulsiveness. Because the condition can be associated with learning disorders as well, children with ADHD often have difficulty performing well in school.
Hastings sought treatment and opted to put her son on medication for ADHD as a way for him to control his inability to sit still during class. Within a week, Ian's teacher told Hastings how differently he was behaving.
"There was a clear benefit," Hastings said. "Before, even though he was learning to some degree, he still couldn't sit."
And there may be even greater academic benefits for children like Ian as they grow up. Grade schoolers who take medication for their ADHD can improve their long-term academic success, particularly in math and reading comprehension, compared to children with ADHD who do not take medication, according to a new study published today in the journal Pediatrics.
Using data from the U.S. Education Department's Early Childhood Longitudinal Study, researchers compared standardized math and reading scores of nearly 600 children over six years, beginning in kindergarten at age 5. Out of the 7 percent of this nationally representative group that was diagnosed with ADHD, 57 percent began taking medication.
Over time, the children with ADHD who took medication for it scored 2.9 points higher in standardized math tests and 5.4 points higher on standardized reading tests than their unmedicated peers with ADHD.
"For many decades we've known that the medications used to treat ADHD help in about 80 percent of cases with attention, impulse control and problem behavior," said Stephen Hinshaw, a professor and chairman of the Department of Psychology at the University of California at Berkeley and one of the authors of the study. "What's not been known is whether the medication has significant impact on learning and achievement in school."
Normal academic progress at a young age is important for later academic success. Falling behind by failing to learn basic math, reading, reasoning or play skills can make it difficult to catch up to peers as a child gets older.
In this way, the behavioral symptoms children with ADHD display when they are young -- inattentiveness, constant moving, daydreaming -- can translate to performance problems as they progress in school and academic requirements become more sophisticated.
"If we find in first and second grade a child who is having significant problems associating symbols with sounds or reading basic sight words, the common assumption may be to wait a couple of years," Hinshaw said. "Now in fourth grade, they are reading at a first grade level. That has been costly."
Hinshaw stressed that it is not necessary to teach every three-year-old to read or to medicate all children who progress slowly in school. Rather, early detection and treatment of ADHD based on a child's history and class observations for the classic symptoms, coupled with significant academic struggles, can significantly impact their future academic success.
The study has the potential to quiet some of the controversy surrounding ADHD, both as a diagnosis and for the way it is treated. There are camps of experts and parents who believe an ADHD diagnosis is simply a label for a child who is lazy, unmotivated or developing slowly.
Others are not convinced that medication is the proper treatment for people with ADHD, suggesting behavioral therapy and tutoring as alternatives.
A federal study from the 1990s called the Multimodal Treatment Study of Children with ADHD (MTA) generated controversy earlier this year when some suggested that the results showed that treating ADHD with medication had almost no beneficial effects over eight years.
"There is a resistance to medicating your child," said Richard Scheffler, professor of health economics and public policy at UC Berkeley's School of Public Health and another author on the study. "And some think you need to get the old ruler out."
In fact, the MTA study showed that, during 14 months of controlled trials with ADHD medications, talk therapy and routine medical care, those who received drugs showed fewer symptoms of ADHD than their peers. Data collected during follow up studies showed tapering in the beneficial effects of ADHD medication because the patients were released from the confines of a controlled trial into community care where there was less oversight.
"Absence of evidence is not evidence of absence," said L. Eugene Arnold, professor emeritus of psychiatry at Ohio State University and one of the authors of the MTA study. "To deny that there is a problem does not seem to be the sensible approach."
And the MTA study proved this principle. In one group of same-sex children, all in the same school and classroom, those with ADHD showed decreased symptoms in a follow up study eight years later, but they were still not as advanced as their peers, both behaviorally and academically.
By contrast, Hinshaw said that children with ADHD gained about one fifth of a school year almost immediately after starting medication. The children gained even more in reading skills -- about a third of a school year -- but those skills took a year longer to acquire because they are more complicated and require practice.
"The one thing that works for attention deficit is medicine, like it or not," said Dr. Gary Trock, director of Pediatric Neurology at Beaumont Hospital in Royal Oak, Mich. But Trock added that for most, a combination of behavioral therapy or tutoring and other one-on-one assistance produced the best outcomes.
Though it is difficult to compare the results of a controlled study to one that pulls data from the natural population, Arnold said that the Berkeley study findings were even more unusual because of where the data came from.
In the general population, a child receiving treatment for ADHD is likely in worse condition than someone who does not need treatment or needs less aggressive treatment.
"The fact that [these kids] made gains over kids who didn't get medications is interesting," Hinshaw said.
Will Drugs Work Over Time?
The researchers did admit potential problems with their data set because they could not control the parameters for who took medication for ADHD and how.
For example, people who were being treated for ADHD may have had more motivated parents.
In addition, black and Hispanic communities typically are under diagnosed with ADHD despite equivalent incidence of the condition, affecting about 3 to 7 percent of school age children in the United States.
Also, medication can be cost-prohibitive for low income families or those without access to health insurance.
And Hinshaw's findings are not a silver bullet technique for treating children with ADHD.
"Neither in reading nor in math were the gains associated with starting medications big enough to catch kids with ADHD up to kids without ADHD," he said.
Hinshaw said the study will continue, and he and his colleagues hope to follow up with their subjects as they go through middle and high school to see if medication will benefit those with ADHD as academic skills become more sophisticated.