Classroom adjustments for ADHD may not be effective – Expert Reaction

“For those of us who work with children with ADHD and do research in this area, this new research study comes as no surprise. Briefly, the new study found that medication and behaviour therapy improved academic productivity and rule-following behaviour in the classroom, but common classroom accommodations (e.g., extended time on tasks) had no effect.

“Procrastination and time blindness are one of the key symptoms of ADHD. The main reason for the benefits of medication and behavioural therapy comes down to the brain chemical dopamine and the reward system of the brain. Stimulant medication such as Ritalin works to increase dopamine in the prefrontal cortex and this helps those with ADHD focus on the task at hand: right now.

“Another thing that works in a similar way as stimulant meds is a hard deadline and quick consequences of actions – so basically people with ADHD work very well under pressure (which gives them a dopamine reward hit) and do less well when there is time available to perform a task like a test or when there is a distant or inconsequential reward.”

Conflict of interest statement: “None.”

---

“Positive behaviour supports, medication, or both, are known to improve academic performance and decrease challenging behaviour for many children with ADHD. This study points out that while school-based “accommodations” (extra time, more breaks, a standing desk, or fewer distractions), are often rolled out in classrooms, there’s currently little evidence they actually help.

“Researchers often face a dilemma: carry out the experiment in a tightly controlled or artificial setting to be more confident in the results. Or, prioritise real world settings where findings might then apply more broadly, even if other factors muddy or confuse or explain the findings.

“This study leaned towards strict control. Children with low IQ or Autism alongside ADHD were excluded. It took place in a specialist American summer camp treatment classroom, where staff even counted the ratio of teacher praise to commands, to ensure it was 3:1. That’s quite far removed from a messy, complex, real world classroom with fewer resources, stretched teachers, and children with higher needs. The authors themselves recommend the study now needs to be repeated in real- world classrooms, where they expect the effects would be weaker.

“Ideally, we should also acknowledge that some accommodations do work for some children, some of the time. However, this research suggests that a blanket, Oprah-style giveaway (“You get extra time! And you get extra time!”) may not return reliable dividends, compared to behavioural approaches and/or medication.

“This study is an important ‘signal’, from a carefully designed experiment, but it needs testing in the real world.”

Conflict of interest statement: “No conflicts of interest to declare.”

---

“How can we best support children who are inattentive, impulsive and active in classrooms?”Fabiano and Pelham have authored papers about children and ADHD for decades. Some of their previous work looked at the best order for interventions. They found that starting with behavioural strategies was more effective than starting with medication. Also, that ADHD medication made things worse for children in the long term, even if it produced improvements in the short-term.

“This new crossover, randomised trial evaluated the effects of classroom adaptions on student behaviour and quiz scores. Schools in the USA offer extended time, frequent breaks, standing desks and low distraction environments to children diagnosed with ADHD. The study is also interesting for comparing general and behaviour intervention classrooms; and comparing methylphenidate extended release (like Ritalin) to placebo.

“The study was in a controlled ‘summer camp’ setting. Interestingly, classroom adaptions provided no benefit – they did not significantly improve the classroom behaviour or quiz performance of the diagnosed students in the study.

“As in their previous studies, training teachers to consistently use specific behavioural strategies improved child classroom behaviour. The strategies improved behaviour whether or not the child was also using methylphenidate drugs. Behavioural strategies have the great advantage of having no adverse effects on children. In contrast, ADHD drugs’ long list of serious adverse effects include reduced growth, a risk of psychotic symptoms, and cardiovascular problems.

“Methylphenidate also improved classroom behaviour, along with an additional benefit of better quiz results. While this echoes evidence that in the short term, drugs reduce core ADHD behaviours of inattention, impulsivity and hyperactivity in many children, it does not contradict other research which has found no long term benefit from drugs on academic, social and occupational measures. Are we targeting the right thing in ADHD research?

“The students achieved their superior classroom results with a low dose of only 0.3mg/kg, less than usually prescribed. The authors highlight the contrast with current advice which recommends “prescribing the highest tolerated stimulant dose” for children with ADHD. Indeed New Zealand’s own BPACNZ  tells prescribers that “treatment response is typically expected at doses of 0.5 – 1 mg/kg for methylphenidate”.  At the very least, our prescription patterns may benefit from review.

“Although this study found clear effects, we don’t know how much these results, produced in an American special holiday programme, can be applied to a normal classroom context in Aotearoa. Here, regular classrooms have twice as many children and half as many teachers. Here, children work on academic content for more than 1 hour per day; and don’t spend the remaining hours only doing sports, games, arts and craft.  Moreover, what difference does it make that New Zealand children can access support through Special Education without a diagnosis?”

Conflict of interest statement: “No conflicts of interest.”