For decades, many physicians, parents and teachers have believed that stimulant medications help children with ADHD learn because they are able to focus and behave better when medicated.
After all, an estimated 6.1 million children in the U.S. are diagnosed with attention-deficit/hyperactivity disorder, and more than 90% are prescribed stimulant medication as the main form of treatment in school settings.
However, in a peer-reviewed study that several colleagues and I published in the Journal of Consulting and Clinical Psychology, we found medication has no detectable effect on how much children with ADHD learn in the classroom. At least that’s the case when learning – defined as the acquisition of performable skills or knowledge through instruction – is measured in terms of tests meant to assess improvements in a student’s current academic knowledge or skills over time.
Compared to their peers, children with ADHD exhibit more off-task, disruptive classroom behavior, earn lower grades and score lower on tests. They are more likely to receive special education services and be retained for a grade, and less likely to finish high school and enter college – two educational milestones that are associated with significant increases in earnings.
Just as children with ADHD have more difficulty than peers in school, adults with a history of ADHD have a hard time keeping a steady job.
Measurements of learning
In this study, funded by the National Institute of Mental Health, we evaluated 173 children between the ages of 7 and 12. They were all participants in our Summer Treatment Program, a comprehensive eight-week summer camp for children with ADHD and related behavioral, emotional and learning challenges.
Children got grade-level instruction in vocabulary, science and social studies. The classes were led by certified teachers. The children received medication the first half of summer and a placebo during the other half. They were tested at the start of each academic instruction block, which lasted approximately three weeks. They then took the same test at the end to determine how much they learned.
Contrary to the conventional wisdom under which parents and teachers have long operated, we found children learned the same amount of science, social studies and vocabulary content whether they were taking medication or a placebo.
Yes. We were shocked by this finding, too.
Many published studies show medication helps children focus and behave better in the classroom. The theory has been that if stimulant medication helps a child stay on task with their schoolwork and improve their behavior in class, then it should also improve their learning.
In our study, medication helped children complete more schoolwork and improve their classroom behavior, as expected. When taking medication, children completed 37% more arithmetic problems per minute and exhibited 53% fewer classroom rule violations per hour.
Unfortunately, completing more schoolwork and behaving better in the classroom did not lead to higher grades on tests, which heavily determine overall class grades. These results support the findings of other research that has found there is no long-term beneficial effect of medication on standardized test scores.
This is an important finding because stimulant medication is by far the most common treatment for children with ADHD, and the majority receive only medication. Other treatments available for children with ADHD include behavior therapy, including training for parents and a combination of therapy and medication.
A new understanding
Nearly 40 years ago, my research laboratory published the very first study that looked at the effects of stimulant medication on learning for children with ADHD in the classroom setting. At the time, we measured learning by how quickly and accurately children completed worksheets and how they behaved in the classroom.
Researchers in my lab found that medicated children focused more and behaved better, and we assumed medication helped them learn more. Since then, stimulant medications have been the most common treatment for ADHD.
Having published nearly 500 scientific studies on the subject over the last 40 years, we have learned a lot about the most effective treatments for children with ADHD.
ADHD is not something children will outgrow
Our most recent National Institute of Mental Health long-running study found that an adult with a history of childhood ADHD is expected to earn US$1.25 million less than adults without a history of ADHD over their lifetime, potentially reaching retirement with up to 75% lower net worth.
In that study, we found that people with ADHD fared worse in just about every aspect of work and financial well-being. This included income, savings, employment status and dependence on parents or other adults.
Nearly half of the adults with childhood ADHD were regularly receiving money from parents, other adults or the government.
To improve long-term financial outcomes and reduce dependence on parents and government, those with ADHD may benefit from educational supports and interventions that help them finish high school and earn a bachelor’s degree.
Since the children in our study were ages 7-12 years old, we don’t know if our findings would extend to adolescents or adults with ADHD. As children grow older, how they learn changes: Adolescents or young adults may acquire knowledge more so from independent studying than from classroom teaching. So it’s important to determine whether medication helps when learning outside the classroom.
How to help children with ADHD thrive
There are ways for children to improve academic achievement with effective classroom strategies alone, rather than just being on medication to begin with. Behavioral and academic strategies that significantly help youth with ADHD include parent training and classroom-based management tools like a daily report card. A child with ADHD can also receive effective behavioral services in school that are specific to academic achievement, such as 504 and individualized education plans, also known as IEPs, for students in special education.
Our previous research has found that behavioral therapy – when used first – is less expensive and more effective than medication in treating children with ADHD. Stimulants are most effective as a supplemental, second-line treatment option for those who need it and at lower doses than typically prescribed. In other words, medication should only be added if children still need additional support after the behavioral and academic interventions have been tried.
Additionally, in 2020, the Society for Developmental and Behavioral Pediatrics published new clinical guidelines that strongly recommend behavioral intervention as the first-line treatment for youth with ADHD and medication as a second-line treatment, if necessary.
So while it’s true that medication helps with focus and behavior, so do behavioral and academic strategies in the classroom. And just because a child seems to be more focused and behaving better in the classroom doesn’t mean they will get better grades. What we have found time and time again is that behavioral intervention is best for children with ADHD because they, their teachers and their parents learn skills and strategies that will help them succeed at school, at home and in relationships long term.
To give children with ADHD the best chance to thrive, I believe families, medical professionals and educators should focus on behavioral and academic interventions first and add medication only if needed.
William E. Pelham, Jr. receives funding from organizations including but not limited to the National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), Institute of Education Sciences (IES), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute of Child Health and Human Development (NICHD).
He has served as a consultant/advisor to numerous federal agencies including the National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), Centers for Disease Control and Prevention (CDC) and organizations including the American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry (AACAP), American Psychological Association (APA), Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), The National Institute for Children's Health Quality (NICHQ) and the Society for Developmental and Behavioral Pediatrics (SDBP).