Stimulants don’t help, but behavioral strategies do
Flipping through a magazine, a parent comes across a photo of a calm, smiling boy and a graphic detailing his ‘path to success in managing ADHD.’ ‘A typical school day’ for a child with ADHD, the advertisement for long-acting stimulant medication reads. The child ‘starts Concerta’ and then is able to perform better in the classroom, have more positive interactions with peers, and focus on homework. Sounds like a dream come true for parents.
As a researcher and doctoral student, my first thought was: What does the scientific evidence say about the effect of long-acting medication on homework? Answer: Nothing, yet. So, the more important question quickly became: What homework-focused treatment should we recommend for children with ADHD?
With my mentor, Dr. William Pelham, a well-known researcher in the field of ADHD functioning, assessment, and treatment, and the rest of our research lab at Florida International University, we designed a study to address this question.
The research study
The current study included 75 children with ADHD, mostly Hispanic, and evaluated whether behavioral treatment, stimulant medication, or a combination of the two was the best treatment for homework problems. Children were either assigned to receive the behavioral intervention or assigned to a waitlist control group (which means that the waitlist families didn’t receive the behavioral intervention until after the study was over). Additionally, half of the children received long-acting stimulant medication (Concerta) for three weeks while the other half of the children received placebo (a sugar pill), and then they switched.
The behavioral intervention included a brief parent skills training program in which families learned how to develop a clear and consistent homework routine, reward their child for appropriate behavior, and set smaller, more frequent goals for homework completion and accuracy. Additionally, teachers assigned homework that was appropriate for every child’s grade level and productivity, and children in the behavioral intervention had a homework completion and accuracy goal each day, such as ‘Completes 80% of homework with accuracy’.
The difference between an F- and a C-grade
Medication did not improve children’s homework completion or accuracy, other than a small effect on math homework accuracy. However, children whose parents received parent skills training completed about 10-13% more homework and earned about 8% higher accuracy. This is the difference between receiving an F and a C on homework assignments. We also looked at whether medication helped children perform even better on homework when they were already receiving the behavioral intervention, and medication didn’t lead to further improvement then either.
Based on this study, we do not recommend stimulant medication for the treatment of homework problems among children with ADHD. ADHD is a chronic disorder that requires ongoing treatment in the three main domains of daily life functioning: home, school, and peer relationships. Medication hasn’t been shown to help with important things that relate to long-term outcomes such as parenting, homework performance, and social functioning. Though medication helps children complete more work in the classroom, it hasn’t been shown to improve grades or achievement over time. This study is another in a line of studies that show behavioral intervention needs to be more readily available to families and teachers as a first-line treatment for children with ADHD.
What should pediatricians do?
Pediatricians are often the first to formally identify children with ADHD and treatment is typically prescribed in the form of stimulant medication. There is no Big Psychotherapy to contend with Big Pharma, but we urge pediatricians to let these and other research findings guide their recommendations. Behavioral treatment should be the first recommendation, specifically in the form of behavioral parent training and working with the child’s teachers to develop a behavioral intervention plan including a daily school-home note with specific behavioral goals. Examples of these can be found at http://ccf.fiu.edu/for-families/resources-for-parents/printable-information/ along with printable homework tips and fact sheets about ADHD.
What should parents do?
In addition to looking through the materials above, parents should take ownership of their child’s education and ensure that their child with ADHD is receiving the services they are entitled to in the school setting—including a 504 plan and requesting a teacher that consistently implements necessary behavioral interventions such as the daily report card found in the link above.
Link to the primary paper:
Merrill, B. M., Morrow, A. S., Altszuler, A. R., Macphee, F. L., Gnagy, E. M., Greiner, A. R.,…Pelham, W. E. (2016). Improving homework performance among children with ADHD: A randomized clinical trial. Journal of Consulting and Clinical Psychology. Advance online publication. DOI: 10.1037/ccp0000144
Brittany Merrill is a Master’s level graduate student in the Clinical Science Doctoral Program in Child and Adolescent Psychology at Florida International University. She has worked with numerous families of children with ADHD and their schools throughout her three years in the doctoral program. Her thesis examining the effects of a behavioral parent training program focused on homework problems among children with ADHD is discussed herein, and she is currently researching how off-task thought relates to the attentional functioning and classroom performance of children with ADHD. Brittany’s research can be followed here.