Ritalin and other stimulants have long been touted as treatments for attention-deficit hyperactivity disorder (ADHD) in elementary-age children, curbing disruptive and defiant behavior and allowing children to focus. Now, in the first full-scale study of its kind, research finds that the drugs also help teen-agers with the condition, allowing them to focus in the classroom and concentrate on schoolwork.
In the new study, a University of Pittsburgh team led by clinical psychologist Steven W. Evans, PhD, and colleagues William E. Pelham Jr., PhD, and Bradley H. Smith, PhD, tested the effects of methylphenidate (MPH)--the drug best known by the trade name Ritalin--on adolescents enrolled in a summer treatment program for teen-agers with ADHD.
The results, published in this month's Experimental and Clinical Psychopharmacology (Vol. 9, No. 2), showed that the drug, in combination with a behavior modification intervention, improved students' performance on a range of academic measures, including note-taking, daily assignments and quiz scores, without causing major side effects.
"When they were taking stimulant medication, students were more likely not only to get schoolwork done, but to get it done more accurately than when they were taking a placebo," says Evans, now at James Madison University. "Scores improved by an average of about 17 percent--a jump that could mean two or three letter grades."
Previous research has indicated that medication benefits elementary-age children with ADHD. But until now, there has been little investigation of how such treatment affects teen-agers.
If the new findings hold true in regular classroom settings, the study authors say, the research should help parents and clinicians make decisions about treating ADHD in adolescents.
Stimulant treatment of ADHD has long been the subject of controversy, with some arguing that the drug is overprescribed and even dangerous because it can be abused. The new results provide evidence to the contrary, argues Lehigh University school psychologist George J. DuPaul, PhD, who conducts research on school-based interventions in children and adolescents with ADHD.
"The study provides additional evidence that MPH and other stimulants are a safe, effective way to manage ADHD--and that clinicians should be evaluating the effects of this medication not only in the behavioral domain, but also in the academic domain," he says.
Still, the study authors emphasize that stimulants should be only part of ADHD treatment.
"I hope our study does not result in more kids and adolescents getting medication as the sole form of treatment," says Pelham, who directs the summer treatment program, now at the State University of New YorkBuffalo. "It's pretty clear from long-term studies, at least in younger children, that medication alone is not going to do the trick."
Indeed, he suggests, "There would be a lot less controversy about medication for ADHD if people were consistently implementing both medication and evidence-based behavioral interventions."
Targeting academic performance
Evans and his colleagues found the lack of research on ADHD treatment for adolescents disturbing because, as scientists are increasingly recognizing, the disorder continues far beyond childhood.
Because problems in school are one of the hallmarks of ADHD in adolescents, Evans and his colleagues measured the effects of different doses of MPH not only on teen-agers' behavior, but also on their academic performance. They examined 45 adolescents diagnosed with ADHD and enrolled in an intensive summer treatment program, directed by Pelham, for youth with ADHD. Because ADHD affects boys more often than girls, most of the study participants were male.
Three times per day during the eight-week study, the researchers gave participants either a placebo or a 10-, 20- or 30-milligram dose of MPH (each day's third dose was half the size of the first and second dose). The students received each dose of the drug, or a placebo, for one day each week, in random order.
In addition to attending a one-hour history class four days a week, all students participated in other structured activities, such as note-taking instruction and social skills and problem-solving groups, designed to help them learn to control their behavior. The researchers evaluated students' note-taking, performance on daily quizzes, in-class worksheets and writing assignments, and how often they completed homework assignments. Evans's team also observed how often students displayed disruptive, inattentive or defiant behavior in the classroom.
Results showed that MPH, when given along with the intensive behavioral change interventions, significantly boosted students' schoolwork. About 80 percent of adolescents showed improved academic performance while taking some dose of stimulant medication.
"It's a phenomenal success," remarks Lehigh University's DuPaul. "I wish we could have that kind of success with other attempts to treat educational problems."
The research also revealed important individual differences in adolescents' response to the drug. Two-thirds of teen-agers in the study showed moderate to large improvement in academic performance while on 10 milligrams of MPH, compared with placebo.
Of those who did not improve significantly on the lowest dose, fewer than half showed substantial improvement when the dose was increased to 20 milligrams, and very few students achieved significant gains on a 30-milligram dose of the drug. In fact, some students' performance deteriorated when their dosages of MPH increased.
"That's extremely important," stresses Pelham. "There are lots of psychiatrists out there who believe that if you keep upping the dose, people will continue to get better."
Meds alone won't work
The researchers offer two caveats to their research. First, they note that, as with previous research with younger children, their study doesn't indicate whether taking stimulant medications helps students' school performance over the long term. Indeed, because it's not practical--or ethical--to conduct long-term studies in which researchers randomly assign participants to different doses of stimulant medication or a placebo--and because many young people stop taking medication during adolescence--that question is particularly difficult to answer, they note.
Second, they emphasize that although the results of the study are encouraging, it will be important to investigate how stimulant medication affects academic performance in regular school settings, where intensive behavioral interventions to combat ADHD are not the norm.
Toward that end, Pelham says, he and Smith, now at the University of South Carolina, have recently completed a study of adolescents in a regular school setting. Their results, not yet published, suggest that without intensive psychosocial interventions, the effects of stimulant medication on teen-agers' school performance and behavior are smaller.
A pilot program that Evans is instituting at a public middle school supports those findings. Preliminary results indicate that supplementing stimulant medication with a structured behavior-management program produces meaningful gains in academic achievement, reductions in disruptive behavior and improvement in social skills.
"Ultimately," suggests DuPaul, "what we will be looking at is what combination of medication and educational intervention is going to work best for a given kid. The medications make them ready to learn--now we have to capitalize on that."