For children with ADHD, succeeding academically is often especially difficult. In fact, numerous studies have documented that academic underachievement is one of the most frequent consequences of the disorder. 

There are a variety of reasons why this may occur.  First, traditional instructional methods during elementary school may not be conducive to promoting learning in many students with ADHD.

Second, a significant percentage of children with ADHD also have specific learning disabilities; the presence of a learning disability can make it even more difficult for a child to acquire the basic academic skills needed to succeed in school. 

Even when specific learning difficulties are not present, however, problems attending in the classroom can interfere with the acquisition of academic skills and knowledge.  This has already been clearly demonstrated in a number of published studies, and one can easily imagine that a child who struggles with attention in class would fail to master these skills as well as classmates, even when the child was equally capable intellectually.  As a result, this child would be less prepared to succeed in subsequent grades, and a downward spiral could have already begun.

One plausible approach to prevent this from occurring would be to identify children with attention difficulties during first grade, and provide them with extra assistance so that they acquire the critical skills necessary for academic success. For example, because attention problems may interfere with their mastering critical early reading skills, perhaps specialized tutoring would help them to learn things they would otherwise miss out on, and thus provide a foundation for more solid academic success.

This was the premise of a study that my colleagues and I reported last year in the Journal of Abnormal Child Psychology (Rabiner, Malone, et al.,(2004). The impact of tutoring on early reading achievement in children with and without attention problems. Journal of Abnormal Child Psychology, 32, 273-284).  Participants in this study were 581 children who were part of a larger study designed to prevent the development of serious conduct problems in children at risk for this outcome because of early behavior difficulties. 

Children randomly assigned to a treatment or control group; those in the treatment group received a comprehensive set of interventions designed to prevent the development of conduct problems.  Of particular relevance to this study was 90 minutes of individual reading instruction that they received over the entire first grade year. Children who were randomly assigned to the control group received no such assistance.

All participants completed a standardized assessment of reading ability before and after first grade.  In young children, such assessments examine the ability to recognize letters, awareness of letter-sound combinations, and to read simple words.  Children who scored poorly on this measure prior to first grade were thus starting out with evidence of difficulty in their early acquisition of important reading skills.  The assessment completed at the end of the year allowed us to determine how much progress in reading each child had made.

In addition to these reading assessments, teachers also completed a standardized behavior rating measure on each child at the end of first grade.  Among the items rates were the inattentive symptoms of ADHD.  This was not intended to provide a formal diagnosis for any child, but simply to quantify the level of attention difficulties during the year that had been observed.

As noted above, half the children received reading tutoring during first grade.  This was a fairly intensive intervention and consisted of 3 30-minute sessions per week over the entire year.  The tutoring program emphasized a phonics-based, mastery-oriented approach to the development of initial reading skills.  Tutoring was provided by paraprofessionals who had received over 40 hours of training in the program and who were closely supervised during the year.

Our particular interest in this study was to examine whether the presence of attention difficulties resulted in tutoring being less helpful, both for children with and without evidence of early reading problems.  The primary question of interest was thus whether the benefits children derived from tutoring depended on their level of attention problems.  We made the following predictions:

• Children without early reading problems but with attention problems will fall behind in reading if they do not receive tutoring; this hypothesis was based on prior findings that attention problems interfere with the acquisition of early reading skills.

• Children without early reading problems but with attention problems who receive tutoring will make adequate progress in reading during the year; this hypothesis reflected our belief that tutoring would provide these children with skills they would otherwise miss out on and enable them to keep pace with their peers.

• Children with early reading problems but without attention problems who receive tutoring will make excellent progress during the year; this hypothesis reflects the fact that this was a well validated tutoring program that would help children struggling in their early reading development.

• Children with early reading problems and attention problems who received tutoring would progress less, but would still show clear signs of progress relative to similar children who did not receive tutoring; this hypothesis reflected our belief that although attention difficulties might somewhat undercut the beneficial effects of tutoring, these benefits would still be apparent within this group.

RESULTS

Do the benefits children derived from tutoring depended on their level of attention problems?

The results we obtained indicate the answer to this question is clearly yes.  Specifically, we found that at low levels of attention difficulties, children who received tutoring had substantially higher achievement scores after first grade than children who were not tutored.  As children's attention difficulties approached the level that is often seen in ADHD, however, the beneficial affects of tutoring were substantially reduced.  Because we controlled for a number of other factors that may have influenced children's reading achievement, including IQ, parental involvement in school, there is a strong basis for concluding that attention difficulties were the critical factor in whether or not tutoring was likely to be beneficial.

What about results for our specific hypotheses?

Hypothesis 1 - Children without early reading problems but with attention problems will fall behind in reading if they do not receive tutoring;

This hypothesis was supported.  By the end of first grade, children with no early reading problems but who were inattentive during first grade had reading achievement scores that were now significantly below other children.

Hypothesis 2 - Children without early reading problems but with attention problems who receive tutoring will make adequate progress in reading during the year;

We found partial support for this hypothesis.  These children did not fall as far behind as children with attention problems who were not tutored, but they also did not make as much progress as children without attention difficulties.  In fact, if the trend we observed continued for another year, they would have fallen significantly behind.

Hypothesis 3 - Children with early reading problems but without attention problems who receive tutoring will make excellent progress during the year;

This hypothesis was strongly supported - in fact, by the end of the year, reading scores for these children were no longer significantly below average.  This provided clear evidence that the tutoring program was effective for children who entered first grade with early signs of reading difficulty, but who were not inattentive.

Hypothesis 4 - Children with early reading problems and attention problems who received tutoring would progress less, but would still show clear signs of progress relative to similar children who
                      did not receive tutoring;

The results we obtained here were quite unexpected.  To our surprise, we found that for children with both early reading difficulties and significant attention problems, there was no evidence of any benefit from tutoring.  That is, children with these characteristics were still far below average in reading at the end of first grade, regardless of whether they had been tutored.  In fact, those who were tutored did not score any higher than those who were not.


DISCUSSION

We began this study hoping to document that identifying children with attention problems during first grade, and providing these children with specialized tutoring, would enable them to make good progress in the acquisition of early reading skills. 

To our surprise and disappointment, however, this was not the case.  Although tutoring was quite helpful for students with good attention skills, children with attention difficulties were found to benefit far less.  In fact, among children with both attention problems and early reading difficulties, we found no evidence of any benefit from tutoring.

There are several reasons why these results should not be interpreted to mean that tutoring and other forms of specialized academic help are a waste of time for children with ADHD.  First, we were not working with a diagnosed population.  Second, participants in this study also had high levels of acting out behavior problems, which is not the case for many children with ADHD.  Third, our sample was restricted to first graders and it is quite possible that tutoring older children with attention difficulties would be more beneficial.  Fourth, the tutoring we provided was restricted to reading, and tutoring in other academic subjects may have been more helpful.  Fifth, and most importantly, it is possible that the specific tutoring program we used would need to be modified to provide greater benefits to students who struggle with attention difficulties.

Because of all these issues, it is definitely not the case that parents and educators should stop pursuing efforts to provide extra academic help for students with ADHD.  Doing so would represent a strong misreading of what can be concluded from this study.

What these results do clearly suggest, however, is that we cannot assume that academic interventions that are quite helpful for students with academic problems but good attention skills will prove equally helpful to students who also struggle with attention difficulties.  Thus, the results underscore the pressing need to develop and research alternative interventions that may be more effective in promoting academic success for students with attention difficulties.  In fact, an unfortunate truth in the current research literature is that there is currently no intervention for children with ADHD that has been conclusively demonstrated to promote long-term gains in academic achievement.

As a result of this study, I chose to pursue research on alternative interventions to boost academic achievement in students with attention difficulties.  Currently, I am getting a study underway in which we will test whether computerized attention training and computerized instruction in basic academic skills will help inattentive first graders make better academic progress.  The results from this study are at least 2-3 years away, and hopefully promising results from similar types of investigations will be published in the interim.  If they are, I will be sure to include them in Attention Research Update.