The efficacy of stimulant medication treatment in reducing core ADHD symptoms in children -- at least in the short-term -- has been convincingly demonstrated in a large number of studies.  And, recently, results from the MTA study have provided evidence that these benefits can persist over a sustained period.  Although the effectiveness of medication treatment for adolescents has not been researched as extensively, several studies showing positive results have been published.
 
Despite these positive findings, however, the impact of medication treatment on real-world academic outcomes remains an important gap in the ADHD treatment literature.  For example, even in the MTA study, surprisingly little data on children's academic performance was collected.   In this study, standardized tests of academic achievement were used as one measure of treatment outcome, and some modest benefits in reading achievement were reported.  However, children's performance on individually administered achievement tests does not necessarily indicate that their day-to-day performance in the classroom has improved.
 
Although several studies have documented that stimulant medication treatment is associated with immediate gains in academic productivity and work quality for children, it has yet to be convincingly shown that these gains in daily academic work are associated with better long-term achievement.  And, studies of the impact of medication treatment on academic performance for adolescents with ADHD are virtually non-existent.  Because academic performance is an area where adolescents with ADHD are especially prone to struggle, this is an enormously important topic to investigate.
 
Recently, a study published in Experimental and Clinical Psychopharmacology demonstrates an impressive effort to examine this issue (Evans, S. at al., (2001). Dose-response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD. 9, 163-175.)  Participants in this study were 45 (40 male and 5 female) teenagers (average age of about 14 years) who took part in an intensive eight-week summer treatment program for ADHD.
 
As part of the summer treatment program, all participants spent 60 minutes each day in a "class" designed to simulate a junior high school history course.  Students were required to listen to a lecture and take notes, as they would in a class taken in their regular school.  After class each day, there was a 30-minute study hall period during which the adolescents were given a work sheet to complete based on the material covered that day in class. .  After completing the work sheet, a 15-minute creative writing assignment was required. Later in the day, students were quizzed on the material from the day's history class.  To prepare for the quiz, the adolescents were provided with no materials other than their own notes.
 
During the summer program, participants also were involved in a double-blind, placebo-controlled medication trial that involved three different doses of methylphenidate -- 10 mg., 20 mg., and 30 mg.  Medication conditions were switched on a daily basis so the researchers could examine whether adolescents' schoolwork varied depending on the dose being administered.  The daily measures of academic performance included an assessment of note-taking quality during class, scores on the daily work sheet and quiz, the number of words written during the creative writing assignment, and the overall quality of the daily writing assignment.  Teachers also completed behavioral ratings each day.
 
Two other aspects of the summer treatment program are important to note.  First, prior to beginning the medication trial, participants received extensive instruction in note-taking skills, an area in which adolescents with ADHD are notoriously deficient.  And, during the class, a clear set of rules for behavior was established and consistently enforced.  Several contingencies were in place to encourage adolescents to follow classroom behavior rules, including monetary incentives for appropriate behavior and fines that were levied for violating class rules. Thus, this was an extremely structured and well-organized classroom, and may not have been entirely representative of a typical junior high-school class.

RESULTS
 
Results of medication treatment on adolescents' academic performance were considered in two ways.  First, the researchers analyzed whether there was an overall improvement in adolescents' academic and behavioral performance while taking medication.  Second, they examined academic improvement on each dosage level for each adolescent.  This latter analysis is especially important because it is possible to obtain significant overall differences (i.e. on average, adolescents showed better academic performance on medication vs. placebo) even though a substantial proportion of participants may not have benefited.

 
Group Effects
 
Analysis of the overall data for adolescents indicated that medication was associated with superior academic performance, as compared to placebo, in every area examined.  The percentage of correct answers on the history work sheet improved from an average of 53% during placebo days to approximately 80% during the 20-mg. and 30-mg. medication days.  Scores on the daily history quiz showed similar levels of improvement, with the average grade increasing from an F (47% correct) on placebo days to a C (72% correct) during the two higher-dose medication days.
 
Results also indicated that adolescents did a better job of note taking during medication days (i.e. they recorded a greater percentage of the main ideas covered in class, as well as details) and that both the length and quality of their daily creative writing assignments were enhanced.  There also was evidence that adolescents completed significantly more homework during the medication days, compared to placebo, although the differences here were considerably smaller than for the other measures of academic performance.
 
For all outcome measures considered, the pattern of results indicated a large improvement from the placebo dose to the 10-mg. dose, with smaller increments of improvement from the 10-mg. dose to the 20- and 30-mg. doses.  Similar results were obtained for teacher ratings of adolescents' classroom behavior.

 
Individual Differences
 
Although this evidence of overall improvement is impressive, it also is important to determine the percentage of adolescents who showed gains from medication treatment.  To examine this important issue, the researchers compared the performance of each adolescent during medication and placebo conditions to see how many showed improvement that would be considered clinically meaningful.  These results are presented in the table below:

 
Dose            Deteriorate    No change    Moderate gain    Large gain
 
10 mg                5                    40                    40                    15
20 mg                9                    48                    39                      4
30 mg              16                    61                    23                      0
 
The entries in the table represent the percentage of adolescents who showed deterioration, no change, moderate improvement, or large improvement in overall behavioral and academic functioning (i.e. academic performance averaged across their score on the daily history worksheet, quiz, and creative writing assignment) on each dosage relative to the next lower dosage.
 
For example, on the 10-mg. dose, 5% of adolescents showed a decline in academic/behavioral functioning relative to how they had performed on placebo, 40% showed no change, 40 % showed a moderate improvement compared to placebo, and 15% showed a large improvement.  When the dosage was increased to 20 mg., 9% deteriorated relative to their performance on the 10-mg. dose, 48% showed no change, 39% did moderately better, and 4% did substantially better.  When the dosage was increased to 30 mg., 16% declined, 61% showed no change, only 23% showed a moderate gain, and no participant showed a large gain.
 
Overall, these results at the individual level are also positive.  It is important to emphasize, however, that not all adolescents improved on medication.  For example, across all doses tested, 9% did not improve on the daily worksheet or quiz, and approximately 25% failed to improve on the creative writing task.  Over one-third did not show meaningful gains in on-task behavior.

 
SUMMARY AND IMPLICATIONS
 
Results from this study provide clear evidence that stimulant medication treatment is associated with significant positive effects on adolescents' classroom behavior and academic performance.  For example, with respect to grades, the improvements obtained on quiz scores and study hall assignments corresponded to changes from "F" to "C", a clearly meaningful change.  There also was evidence of medication effects on the quality of notes taken, which would hopefully translate into longer-term improvements in academic performance.
 
In the context of these overall positive results, it is important to emphasize that not all adolescents showed such benefit.  Depending on the outcome being considered, anywhere from 9% to 36% failed to show a meaningful improvement on any dosage tested.  Furthermore, there were some adolescents whose performance declined while on medication (i.e. 5% did significantly worse on the lower dose than they had on placebo).  And, as dosage was increased, there was diminished likelihood of additional gains and an increased risk of deterioration.  (Note: For some children who did not benefit on any dosage of methylphenidate, it is likely that switching to a different medication would have yielded significant gains.)
 
Results from this study highlight the importance of carefully monitoring an adolescent's performance on the aspects of behavioral and/or academic performance one is trying to improve when evaluating the impact of medication treatment.  For example, although 55% of adolescents showed moderate or large improvement on the 10-mg. dose, relative to placebo. 43% of those who did not improve on the 10-mg level were helped when the dosage increased to 20-mg.  And, of those who were still not helped, an additional 23% showed gains at the highest dose tested in this study.  These data demonstrate the value of testing a child across a range of doses, because many children will not show significant benefits until a certain dosage threshold is reached.
 
At the same time, however, increasing the dosage was associated with a significant deterioration in performance for an increasing number of participants.  Thus, one cannot assume that increasing the dose when positive results have not yet been obtained will necessarily yield better results.  In fact, in some cases, academic and behavioral functioning can decline. It is only by carefully monitoring behavioral and academic performance on each dosage tested that one can be more confident about optimizing the impact that medication treatment is actually having.  And, even after an optimal dose for beginning treatment has been determined, it remains critically important to monitor performance over time, as it is not uncommon for medication adjustments to be necessary. (For more information on ongoing medication monitoring, click below:
http://www.attention.com/library/articles/article.jsp?id=845&parentCatId=6&categoryId=37.)
 
In summary, results from this study provide evidence that carefully conducted medication treatment can be associated with meaningful gains in academic performance for adolescents with ADHD.  As the authors note, however, one should not conclude that these gains would necessarily translate into enhanced long-term academic success.  And, because their simulated classroom was significantly better structured and organized than many middle- and high-school classrooms, it is possible that the same positive results would not have been found in a regular school setting.  This would be the case if, as the authors speculate, the behavioral program in place for this study is required for medication to have the beneficial effects that they found for many of the participants.
 
Overall, therefore, this study provides compelling evidence that medication treatment can enhance the short-term academic performance for many adolescents with ADHD.  Clearly, this is an important finding.  However, demonstrating that these short-term boosts translate into long-term academic success, and that such success is also obtained in more typical middle- and high-school settings, remains an essential research task.

Researchers who have examined the impact of an ADHD child on family functioning consistently have reported resulting difficulties in family relationships.  This is not true for all families with an ADHD child, of course, and does not mean that children with ADHD cannot enjoy terrifically positive relationships within their family.
 
On average, however, there exists greater difficulty in family relationships when there is a child with ADHD involved.   In large part, this may reflect the added stress families experience while trying to meet the increased needs of a child with ADHD, especially when that child has an accompanying behavior disorder.  Also, because ADHD tends to run in families, the child's parent often has ADHD as well, and this can make it difficult for the parent to consistently apply helpful behavior management strategies.
 
Because stress levels do tend to be higher in families with an ADHD child, one wonders about the impact this may have on siblings.  Sibling relationships play an important role in children's development and can exert significant influence on socialization and peer relationships.  Although very little research on the impact of siblings ADHD on siblings has been conducted, at least one published study indicates that there can be significant difficulties in this experience:

It is reasonable to hypothesize that such difficulties could have a negative impact on the sibling's adjustment and social relationships outside the family.
 
Unfortunately, research on the family relationships and psychosocial adjustment of children with an ADHD sibling is sparse.  It is possible that high levels of conflict in the relationship between parents and a child with ADHD would be associated with greater conflict in parents' relationships with their other children.  This could occur for several different reasons.  First, parents may be stressed from the challenges of raising a child with ADHD and this could "spill over" into their relationships with their other children.
 
Second, because the relationship between a child with ADHD and his/her sibling may tend to involve more conflict than most sibling relationships, parents would have to intervene more frequently in sibling conflicts.  This also could have a negative impact on parent-child relationships.
 
Finally, a child may "model" how their sibling with ADHD interacts with parents, and thereby engage in behaviors that increase the level of conflict in his/her own relationship with parents.  This may be especially true for younger siblings who learn social interaction skills by observing their older brothers and sisters.  Because a child's functioning at school is critically impacted by the quality of his/her family relationships, one would expect that siblings of children with ADHD might experience adjustment difficulties outside the family.  This was the hypothesis investigated in an interesting study published recently in the Journal of Attention Disorders (Smith, A.J. et al. (2002). Psychosocial adjustment and peer competence of siblings of children with ADHD. 5, 165-175.) (Note: the Journal of Attention Disorders is the only peer-reviewed journal focusing exclusively on ADHD and related learning and behavior disorders.  You can learn more about this excellent resource at http://www.mhs.com).
 
Participants in this study were 30 boys with ADHD, their mothers, and their younger siblings.  The average age of the boys with ADHD was 10.4; the age of the siblings averaged 7.9.  Among the 30 siblings who participated, sixteen were males and 14 were females.  None of the siblings met diagnostic criteria for ADHD.  The majority of participants were from middle-class families.
 
First, the mothers completed a behavior rating scale -- the Child Behavior Checklist -- on their child with ADHD and also completed a questionnaire to assess their perception of the quality of their relationship with each child (i.e. the child with ADHD and the sibling).  The focus of the questionnaire was to assess perceived conflict between mothers and their children.
 
Then, the children with ADHD completed the Sibling Relationship Questionnaire to assess their perception of the quality of their relationship with their siblings.  The items on this measure tapped two domains of the sibling relationship -- the degree of warmth/closeness and the degree of conflict.
 
As discussed above, the main focus of this study was to examine the adjustment outside the family for children having an older sibling with ADHD.  To examine this, the researchers asked the teachers of these siblings to complete two different measures.  One measure -- the Behavioral Assessment System for Children -- provided an overall measure of the children's psychosocial adjustments in the classroom.  The second -- the Taxonomy of Problem Situations -- provided more specific information on siblings' social competence with peers.

RESULTS
 
There were a number of interesting results reported by the authors.  First, as expected, the severity of the ADHD child's behavior problems as reported by the mother was strongly associated with the level of conflict between the mother and that child, and between that child and his sibling.  In addition, mothers who reported more conflict in their relationship with their ADHD child also reported greater levels of conflict in their relationship with the sibling.  Thus, as predicted, there was a clear indication that high levels of conflict between parents and their child with ADHD "spills over" to adversely impact their relationship with their other children.
 
What about the adjustment of ADHD siblings in the classroom?
 
Here, the results were quite unexpected.  Recall that the authors had predicted high levels of conflict within the family would be associated with poorer adjustment and peer competence among the siblings.  Contrary to this prediction, however, higher levels of conflict in the family were found to be associated with significantly more positive adjustment and higher levels of social competency among the siblings of ADHD children.  More specifically, the greater the amount of conflict mothers reported with their ADHD child, the more competent and well adjusted the siblings were found to be by their teachers.
 

SUMMARY AND IMPLICATIONS
 
This study presents an interesting set of results.  As expected, mothers who experienced greater conflict with their ADHD child also reported greater conflict with their other children.  These results are important as they suggest that the stress associated with parenting a child with ADHD can have an adverse impact on a mother's relationships with her other children.  Although a variety of explanations may exist for why this could occur, it highlights the importance of parents carefully attending to the quality of their relationships with all of their children, and working hard to make sure that struggles with one child do not undermine their relationships with their other children.
 
This can be a challenge for parents, particularly when the efforts to help a child with ADHD succeed can consume so much time and energy.  Finding a way to preserve individual time with other children in the family is one strategy that can be quite helpful in developing and maintaining positive relations between parents and their other children -- even though this may be very difficult to manage at times.  Siblings of an ADHD child may come to resent how little time and energy parents may seem to have left for them after dealing with the demands of the ADHD child, which is one reason why putting aside special individual time for each child in the family can be so important for parents to do.
 
As discussed earlier, the authors had expected that higher levels of conflict between mothers and their child with ADHD would be associated with poorer adjustment and social competence in the younger siblings.   The results, however, were quite the opposite.  This is certainly an unexpected finding and the authors offer several speculations as to why this may have been the case.
 
First, they suggest that siblings of children with ADHD may learn good social coping skills as a result of their interactions with-- and perhaps responsibilities for -- the ADHD sibling.  In other words, perhaps the difficulties these siblings experience in their daily interactions with their ADHD brother helps them develop and refine their ability to get along with others.  This is a plausible and interesting conjecture.
 
A second possibility suggested by the authors is that some siblings who observe their mothers' conflicted interactions with their brothers who have ADHD, and who also experience difficulty with their brothers, may "overcompensate" by demonstrating good adjustment and social competence outside the family.  The idea here is that these children try extra hard to succeed in school so they do not create any additional difficulties and stresses for their parents.  (It is possible that this would put these youngsters under additional stress to be the "good child", but this was not examined in the current study.)
 
Although the reason(s) for these interesting findings cannot be determined from this study alone, they do point to the need for additional research in this area.  It is encouraging to learn that younger siblings of an ADHD child may be able to thrive socially despite significant conflict in the family. But because the sample size for this study was relatively small, these results would ideally be replicated with a larger sample before they could be confidently accepted.  Studies based on small samples that generate unanticipated findings are not always replicated, and this is important to bear in mind.
 
In addition, even if these results were replicated, the finding that greater conflict between an ADHD child and his or her mother predicts greater social competence in younger siblings is not necessarily positive.  After all, high levels of social competence and adjustment in a younger sibling should not have to depend on extensive conflict between his ADHD sibling and parents.  Instead, we should seek to learn why that experience may  promote better social adjustment in siblings, and then figure out how to accomplish this in the absence of high conflict levels between the older ADHD child and parents.
 
One hopes that additional studies of how a child with ADHD can influence family dynamics, and how to maximize the adjustment and competence among all family members, will be available shortly.  This is an interesting and important area, and one in which research has only begun to scratch the surface.