566076

research-article2015
JADXXX10.1177/1087054714566076Journal of Attention DisordersArnold et al.

Article
Journal of Attention Disorders

Long-Term Outcomes of ADHD:

2020, Vol. 24(1) 73­–85
© The Author(s) 2015
Article reuse guidelines:
Academic Achievement and Performance sagepub.com/journals-permissions
DOI: 10.1177/1087054714566076
https://doi.org/10.1177/1087054714566076
journals.sagepub.com/home/jad

L. Eugene Arnold1, Paul Hodgkins2,3, Jennifer Kahle4,

Manisha Madhoo5, and Geoff Kewley6

Abstract
Objective: The aim of this study was to synthesize published data regarding long-term effects of ADHD on information
learned (measured via achievement tests) and success within the school environment (academic performance). Method:
A systematic search identified 176 studies (1980-2012) of long-term (≥2 years) academic outcomes with ADHD. Results:
Achievement test outcomes (79%) and academic performance outcomes (75%) were worse in individuals with untreated
ADHD compared with non-ADHD controls, also when IQ difference was controlled (72% and 81%, respectively).
Improvement in both outcome groups was associated with treatment, more often for achievement test scores (79%) than
academic performance (42%), also when IQ was controlled (100% and 57%, respectively). More achievement test and
academic performance outcomes improved with multimodal (100% and 67%, respectively) than pharmacological (75% and
33%) or non-pharmacological (75% and 50%) treatment alone. Conclusion: ADHD adversely affects long-term academic
outcomes. A greater proportion of achievement test outcomes improved with treatment compared with academic
performance. Both improved most consistently with multimodal treatment. (J. of Att. Dis. 2020; 24(1) 73-85)

Keywords
systematic review, ADHD, treatment, academic, functional outcomes

Introduction social skills. Grades assigned by teachers can be subject to

ADHD is increasingly recognized as a serious psychiatric
condition with long-term impact (National Institutes of
Health, 2010). Although commonly diagnosed in child-
hood, ADHD can persist into adolescence and adulthood
(American Psychiatric Association [APA], 2013) and
adversely affect functional outcomes (Shaw et al., 2012).
Academic difficulties are a common problem in ADHD and
are often the reason for a child’s initial referral for clinical
evaluation (Loe & Feldman, 2007). Problems with school-
work can be a key contributor to future functional impair-
ments. Previous studies have categorized academic outcome
types as either related to information and skills learned
(academic achievement, most accurately measured using
standardized academic achievement tests) or success within
the school setting (academic performance, such as grades,
years of schooling completed, grade retention, and college
enrollment; Langberg et al., 2011). The two outcome types
are often considered separately because success in school
requires a wide variety of skills beyond learning informa-
tion (Raggi & Chronis, 2006). For example, successful
homework completion or a college application submission
requires both organizational and time-management skills,
and successful participation in group projects requires
bias, which may be affected by a student’s social skills.
Both types of academic outcomes are thought to be
adversely impacted by ADHD (Barnard-Brak & Brak,
2011; Currie, Stabile, & Jones, 2013; Langberg et al., 2011;
Loe & Feldman, 2007).
Academic function can be negatively impacted by a vari-
ety of disabilities, including ADHD, and higher cognitive
skills are consistently related to increased academic func-
tion (Wagner, Newman, Cameto, & Levine, 2006).
Cognitive skills, however, can be impaired by the core symp-
toms of ADHD: inattention, hyperactivity-impulsiveness, or
a combination of these. Many studies have shown that early
1
Ohio State University, Columbus, USA
2
Global Health Economics & Outcomes Research, Shire, Wayne, PA,
USA
3
Vertex Pharmaceuticals, Boston, MA, USA
4
BPS International, San Diego, CA, USA
5
Behavioural Health Medical Strategy, Shire, Wayne, PA, USA
6
Learning Assessment & Neurocare Centre, West Sussex, UK
Corresponding Author:
Jennifer Kahle, BPS International, 3830 Valley Centre #705 PMB503, San
Diego, CA 92130, USA.
Email: jkahle@bpsintl.com
74
attention difficulties are associated with future reading,
math, and school performance difficulties (Fergusson &
Horwood, 1995; Fergusson, Horwood, & Lynskey, 1993;
Fergusson, Lynskey, & Horwood, 1997). Working memory
impairments (Bental & Tirosh, 2007; Jeffries & Everatt,
2004; McGrath et al., 2011; Sonuga-Barke, Dalen, Daley, &
Remington, 2002), inattention (Breslau et al., 2010), and
hyperactivity (Merrell & Tymms, 2001; Weithorn &
Marcus, 1985) may all contribute to the deficits in achieve-
ment test scores and school success observed in students
with ADHD. Moreover, learning disorders (language, read-
ing, and math) are common comorbidities of ADHD
(DuPaul, Gormley, & Laracy, 2013; Fitzgerald & Kewley,
2005; Kewley, 1999), and these may also affect academic
outcomes in an additive manner.
On average, children with ADHD score lower on
achievement tests compared with healthy peers (Frazier,
Youngstrom, Glutting, & Watkins, 2007), a problem that
can persist into adolescence (Fischer, Barkley, Edelbrock,
& Smallish, 1990; Massetti et al., 2008). An 8-year longitu-
dinal study showed that ADHD diagnosis at 4 to 6 years of
age predicted lower reading, spelling, and math standard-
ized achievement test scores in adolescence after control-
ling for IQ (Massetti et al., 2008). Children diagnosed with
Inattentive Type ADHD in childhood had lower achieve-
ment scores in adolescence compared with either children
diagnosed with Combined Type ADHD or control compari-
son children (Massetti et al., 2008). On average, children
with ADHD earn lower grades compared with peers (Frazier
et al., 2007). ADHD symptoms in adolescence are also
highly predictive of performance in school (Birchwood &
Daley, 2012). Despite these performance problems, many
children and adolescents with ADHD perform well enough
to gain admittance into college: 2% to 8% of college stu-
dents in the United States report clinically significant symp-
toms of ADHD (DuPaul, Weyandt, O’Dell, & Varejao,
2009). There is evidence, however, that this group still
struggles to complete higher degrees when untreated
(Banks, Guyer, & Guyer, 1995; Murphy & Barkley, 1996).
The effect of ADHD treatment on both types of aca-
demic outcomes (achievement tests and performance in
school) remains controversial. One study (Langberg et al.,
2010) utilizing data from the Multimodal Treatment Study
of Children with ADHD (MTA study) concluded that school
performance (homework completion and accuracy) is
enhanced by treatment. A large literature review suggested
that while classroom behavior improves with treatment, the
effect on academic outcomes is not clear (Raggi & Chronis,
2006). One non-systematic literature review concluded that
treatment increases academic productivity (note-taking,
quiz and worksheet scores, amount of written language,
homework completion) but does not improve standardized
test scores or ultimate educational attainment (Loe &
Feldman, 2007). A recent report (non-peer-reviewed)
Journal of Attention Disorders 24(1)
concluded that neither type of outcome improves with treat-
ment (Currie et al., 2013).
The specific inclusion criteria of a systematic review can
reduce the number of studies meeting inclusion criteria
making it difficult to draw conclusions from the few out-
comes reported. A review in 2013 concluded that there was
a paucity of information regarding treatment effects on
long-term ADHD outcomes (Parker, Wales, Chalhoub, &
Harpin, 2013). This review included studies that followed
the participants for at least a year after a randomized con-
trolled trial of a treatment. Eight relevant studies published
between 1982 and 2012 were found; half of them utilized
data from the MTA study. The authors conclude that of the
few academic outcomes identified, improvement with treat-
ment was reported for both academic performance and for a
test of reading fluency. Another systematic review identi-
fied nine studies (Langberg & Becker, 2012) that met their
inclusion criteria: studies published since 2000 that reported
any of three types of academic outcomes (achievement test
scores, grades, or grade retention/dropout) and followed
students for 3 or more years. The authors concluded that
while a statistically significant improvement in achieve-
ment scores was reported with pharmacological treatment,
the educational significance was questionable, and the
effects of treatment on grades or grade retention/dropout
were less conclusive. However, a systematic review with
broader inclusion criteria found 119 studies published from
1980 to 2010 reporting long-term (2 years or more) aca-
demic outcomes (Shaw et al., 2012). Academic outcomes
were the second most frequently studied long-term outcome
of ADHD, second to drug use/addictive behaviors.
Academic outcomes were one of nine areas of functional
outcomes summarized in this review. Of the treatment
results identified in these studies, 71% reported improve-
ment of academic outcomes with treatment, but different
academic outcomes were not analyzed separately.
There is a current need for a wide-scale, systematic search
and integrated summary of this evidence base to further
understand how different long-term academic outcomes
(achievement test scores and academic performance) are
affected by ADHD and the potential benefit of treatment for
these outcomes. The objective of this systematic literature
review was to provide a comprehensive synthesis of the long-
term (defined as 2 years or more) academic outcomes reported
over the last three decades in studies of individuals with
treated and untreated ADHD using broad inclusion criteria to
capture many studies. Of particular focus was the comparison
of achievement test outcomes and academic performance out-
comes. Specific research questions included the following:
Research Question 1: Considering the two general cat-
egories of achievement test scores and academic perfor-
mance, how does untreated ADHD affect academic
outcomes over the long term (2 years or more)?
Arnold et al.
Research Question 2: How do treatment and specific
aspects of treatment (treatment types, age at initiation of
treatment) impact long-term academic outcomes?
Research Question 3: What specific measures of aca-
demic outcomes have been studied, and how are they
affected by untreated ADHD and treatment for ADHD?
Research Question 4: How do outcomes reported in
studies that adjust or control for IQ or learning disorders
compare with those reported in studies overall?
Research Question 5: Because policy may differ glob-
ally, how are grade retention and school expulsion
affected by untreated ADHD and ADHD treatment,
comparing among major world regions?
Method
Systematic review search methodology (Cochrane guide-
lines) was used to identify articles for analysis (Higgins &
Green, 2009). Twelve literature databases were searched in
four search waves; the last search was performed in March
2013 (full search details in Supplemental File 1). Inclusion
was agreed on by two researchers based initially on the title
and abstract of the studies; all discrepancies were resolved
upon review of the full text of the studies. Inclusion criteria
were designed to capture a wide range of studies. They
required that articles be primary, peer-reviewed, English-
language studies of treated or untreated ADHD published
January 1, 1980, through December 31, 2012, that reported
long-term academic outcomes of 2 years or more and
included a comparison group (e.g., non-ADHD controls or
individuals with untreated ADHD) or a comparison measure
(e.g., pre-treatment baseline). Inclusion criteria required that
ADHD be the primary condition of study (not secondary to
autism, for example). Longitudinal studies must have had
prospective follow-up or retrospective measures of 2 years
or more, and cross-sectional study participants were all 10
years old or older. Considering the Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR;
APA, 2000) criterion that symptoms exist before age 7, 10
years of age was chosen as the threshold for cross-sectional
studies to conservatively allow at least 2 years to pass before
measures were taken. Meta-analyses, literature reviews,
case studies, and studies in which all participants were
younger than 2 years of age were excluded. Data regarding
study characteristics, participant characteristics, and out-
comes were extracted manually from each study by one
researcher and checked by a second researcher. Outcomes
associated with untreated ADHD and with all treatments that
were intended by the authors of each study to address ADHD
were extracted. Results adjusted for comorbidities (e.g., sta-
tistical adjustment, separate analysis) were used in the pres-
ent analysis whenever possible.
Specific academic measures reported in each study were
categorized into one of two outcome groups: either
75
achievement test scores or academic performance.
Achievement test outcomes included results on standardized
tests such as the Wide Range Achievement Test (WRAT)
and American College Testing (ACT). Academic perfor-
mance outcomes included such indicators of success within
the school environment as grades, grade retention, high
school completion, and college attendance. Grade retention
and school expulsions were compared across world regions,
as we anticipated that these outcomes may differ regionally.
Outcomes were classified in a dichotomous manner,
based on statistical significance reported in each study.
Untreated ADHD outcomes were categorized as “poorer”
than non-ADHD controls if a result was reported as statisti-
cally significantly worse than non-ADHD controls, and
“similar” if statistical significance was not achieved.
Outcomes were categorized to “improve” with treatment if
a statistically significant improvement was associated with
treatment compared with either pre-treatment baseline or
untreated individuals with ADHD. If treatment effects did not
reach statistical significance compared with pre-treatment
baseline or untreated individuals with ADHD, or were sig-
nificantly poorer than the pre-treatment baseline or
untreated individuals with ADHD, then the outcome was
summarized to have “no benefit” with treatment. Results of
studies of individuals with treated ADHD compared with
only non-ADHD controls were considered separately and
only for sub-analyses for which the number of studies was
small. This was done because results from studies utilizing
two types of comparisons (untreated or pre-treatment mea-
sures and measures for non-ADHD controls) show that
ADHD treatment often improves outcomes, but not always
to a non-ADHD level (Molina et al., 2009; Scheffler et al.,
2009). Studies that utilize only non-ADHD controls to
assess affects of ADHD treatment will not demonstrate
improvements that are less than complete “normalization,”
thus, results from these studies must be considered in light
of this limitation. For studies with only non-ADHD con-
trols, treatment was considered to “improve” outcomes if
treated ADHD and non-ADHD control outcomes were not
statistically significantly different, and to have “no benefit”
if treated ADHD outcomes were statistically significantly
worse than non-ADHD control outcomes. A further analy-
sis was conducted examining improvement by treatment
type with treatments categorized as pharmacological, non-
pharmacological, or multimodal (i.e., combination of phar-
macological and non-pharmacological treatment).
The impact of ADHD and ADHD treatment on academic
outcomes was also analyzed in the subsets of studies that
controlled for or excluded individuals with low IQ or learn-
ing disorders. In addition, differences in outcomes with dif-
ferent ages of initiation of treatment were examined by
comparing two groups of studies: those with a young age of
initiation (maximum age of initiation ≤ 9 years) versus
starting later (minimum age of initiation ≥ 10 years).
76 Journal of Attention Disorders 24(1)

Table 1. Study Characteristics.

Untreated ADHD Treated ADHD

Combined Combined
Number of studies sample size Number of studies sample size
Academic total 131 616,472a 66 115,196b
Types of Comparison
Non-ADHD controls 120 531,426 44 35,754
Untreated ADHD controls — — 13 14,384
Between treatment types — — 6 1,580
Baseline (duration in years: range, M ± SD) 5 (2-9, 4.0 ± 2.9) 76,533 11 (2-9, 3.6 ± 2.2) 82,966
ADHD as a covariate (duration in years: range, M ± SD) 8 (4-15, 9.4 ± 4.1) 8,756 5 (4-15, 8.1 ± 4.2) 4,066
Study design
Prospective longitudinal (duration in years: range, M ± SD) 55 (2-33, 9.8 ± 6.6) 65,807 48 (2-21, 7.2 ± 5.0) 105,310
Retrospective longitudinal (duration in years: range, M ± SD) 38 (3-51, 26.5 ± 12.2) 18,003 11 (3-35,11.7 ± 10.2) 6,693
Cross-sectional 29 465,059 9 15,159
a
Nine studies had a sample size of more than 5,000.
b
Three studies had a sample size of more than 5,000.

Results
Search Results and Study Characteristics
A total of 9,314 citations were identified in the systematic
search; 5,368 after removal of duplicates and records not
meeting basic criteria. In the initial screen of titles and
abstracts, 4,881 citations were excluded. A secondary screen
of the full text of the articles excluded another 311, leaving
176 studies reporting long-term academic outcomes of treated
and untreated ADHD for inclusion in the present analysis (full
citation list in Supplemental File 2). These studies included a
wide variety of experimental designs and comparison groups
(Table 1). Two studies utilized two different types of controls.
One study was both prospective longitudinal and cross-sec-
tional; another was both retrospective longitudinal and cross-
sectional. All studies with a baseline comparison and all but
one of the regression studies were prospective longitudinal
studies. Studies of untreated and treated ADHD counted sepa-
rately add up to 197 and not 176 because some studies reported
outcomes from both treated and untreated populations. Only
three of the studies randomized participants to receive treat-
ment or no treatment, and maintained these conditions until
the long-term follow-up measures.
There were many specific measures reported in these
studies. These were grouped into the two main categories of
achievement test and academic performance outcomes.
There were several subcategories within the main categories
(Table 2). There were more outcomes than studies because
more than one outcome was often reported in a single study.
Untreated ADHD Outcomes
Achievement test scores and academic performance were
compared between individuals with untreated ADHD and
non-ADHD controls (see Figure 1 and Table 3). Some stud-
ies reported both types of outcomes. This analysis did not
include those studies that only compared follow-up mea-
sures with study-start baseline or analyzed ADHD in a mul-
tifactor statistical analysis, because there were too few of
these types of studies (n = 11). A high proportion (75%-
79%) of both achievement test and academic performance
outcomes were reported to be poorer than non-ADHD con-
trols for individuals with untreated ADHD.
Treated ADHD Outcomes
Improvement with treatment was more often reported for
achievement test scores than for academic performance
(Table 3). The proportion of achievement test or academic
performance outcomes that improved was comparable
regardless of the controls utilized in each study. For achieve-
ment test scores, improvement with treatment was demon-
strated for 78% of the outcomes (7 of 9) when the
comparison was with pre-treatment baseline and 80% of the
outcomes (4 of 5) when the comparison was with untreated
individuals with ADHD. For academic performance,
improvement with treatment was demonstrated for 50% of
the outcomes (1 of 2) when the comparison was with pre-
treatment baseline and 40% of the outcomes (4 of 10) when
the comparison was with untreated individuals with ADHD.
For each of the treatment types (pharmacological, non-
pharmacological, and multimodal treatment), a higher pro-
portion of achievement test outcomes were reported to
improve with treatment compared with academic perfor-
mance outcomes (Figure 1). Although the number of studies
and outcomes was small, the highest proportion of improved
outcomes was associated with multimodal treatment for both
achievement test and academic performance outcomes.
Arnold et al. 77

Table 2. Types and Numbers of Measures Grouped Into and the measurement of IQ are complex (Butterworth &
the Achievement Test and Academic Performance Outcome Kovas, 2013), however, and the treatment of IQ as a covari-
Categories. ate in studies of ADHD may not be appropriate (Dennis
No. of outcomes et al., 2009). IQ was controlled for in 44% of the studies
Achievement test scores reported included in this review; thus, we compared the overall
results with results from the subset of studies that either
Language achievement test scores
excluded individuals with low IQ (69 studies), used con-
Reading 68
trols individually matched for IQ (1 study), and/or adjusted
Spelling 24
statistically for IQ (17 studies). IQ was a covariate in
Writing 7
Mixed measures 7
ANOVA in 10 studies, a factor in regression analyses in 6
Math achievement test scores 51 studies, a factor in a correlation analysis in 1 study, and con-
Information tests 2 trolled for with no further details provided in 1 study. One
Merged achievement test scores 5 study used two methods of adjustment. In 53 studies, the IQ
considered to be “low IQ” for exclusion was specified: IQ <
No. of outcomes 50 in 1 study, IQ < 70 in 6 studies, IQ < 75 in 2 studies, IQ
Academic performance reported
< 80 in 31 studies, IQ < 85 in 10 studies, IQ < 100 in 1
Grades study, and IQ < 120 in 2 studies. The latter two were studies
GPAa 20 specifically of individuals with high IQ. Exclusion criteria
Number of failing grades 7 were less specific in 16 other studies that excluded partici-
Class rank 2 pants based on “low intelligence,” “below normal IQ,”
Mixed measures 9 “mental retardation,” or similar criteria.
Length of education In the studies that excluded low IQ or statistically
Number of years completedb 52 adjusted for IQ, outcomes were similar to the overall results
Graduated/dropped out of high school 32 for individuals with untreated ADHD (Table 3). In the stud-
Degrees completed 20 ies of treated individuals, however, the proportion of studies
Attended college 17 that excluded low IQ or statistically adjusted for IQ report-
Mixed measures 5
ing improvement with treatment was greater than in the
Deviation from normal course of schooling
overall data set for both achievement test and academic per-
Repeated grades 40
formance outcomes.
GEDc versus graduating high school 5
Three studies identified in our search evaluated the aca-
Withdrawal from classes 2
Missed year at school 1
demic outcomes in individuals with ADHD with high IQ or
Lower level education with high academic attainment. (a) A study of individuals
Remedial classes 19 with ADHD with high IQ (≥120) reported that they had sig-
Type of schoold 5 nificantly poorer achievement scores in math but not in read-
Mixed measures 9 ing or grade retention rates compared with non-ADHD
Merged academic performance measures 15 controls, matched as a group for IQ, gender, and socioeco-
nomic status (Antshel et al., 2009). Treatment status was not
a
GPA = grade point average (average of all final grades earned over a specified in that study. (b) A study examining outcomes of
specific period).
b
“Number of years completed” also includes measurements reported as individuals with treated ADHD with high IQ (≥120) also
“education level achieved.” found math achievement scores poorer than non-ADHD
c
GED = General Educational Development test (by which to earn a high controls, but no significant difference in reading achieve-
school equivalency credential). ment scores or grade retention rates compared with non-
d
“Type of school” includes “being in high school, vocational school, or
an apprenticeship”; “qualifying for upper secondary school”; “specialized ADHD controls matched as a group for IQ and age (Antshel
professional training”; and “being in junior college (vs. a 4-year college).” et al., 2008). (c) A third study (Banks et al., 1995) reported
that 29% of a group of medical students who were in danger
of not graduating and physicians who had failed to pass the
Medical Board Exam were diagnosed with ADHD (com-
pared with 4.4% prevalence of ADHD in the general adult
Assessing the Impact of Controlling for IQ
population in the United States; Kessler et al., 2006). In the
It has been reported that individuals with ADHD have a same study, the individuals with ADHD scored the lowest on
normal distribution of IQ scores, but with a lower mean the Medical College Admission Test (MCAT; M subtest
than non-ADHD controls (Biederman et al., 2009; score: 6.024); lower than two learning disability subgroups
Laasonen, Lehtinen, Leppamaki, Tani, & Hokkanen, 2010). (M subtest score for reading learning disability group: 6.539;
The relationships between ADHD, learning disorders, IQ, M subtest score for visual/spatial learning disability group:
78 Journal of Attention Disorders 24(1)

Figure 1. Untreated outcomes and impact of different treatment modalities.

Note. Left-hand bar of each outcome group indicates proportion of achievement test and academic performance outcomes similar to non-ADHD con-
trols (dark shade) and poorer than non-ADHD controls (light shade) for individuals with untreated ADHD. Remaining bars indicate improved results
(dark shade) or no benefit (light shade) with treatment reported for each type of measure compared with untreated ADHD (either pre-treatment
baseline or untreated group of individuals with ADHD). Numbers in bars indicate the number of outcomes for each bar. Pharm = pharmacological
treatment; Non-pharm = non-pharmacological treatment; MMT = multimodal treatment.

7.167; population mean for the same year: 8.287). Treatment
history of the individuals was not reported.
Specific Measures Underlying Achievement Test
and Academic Performance Outcomes
We also examined the outcomes of each subcategory of spe-
cific measures that comprised the two large achievement
test and academic performance categories. Within the
achievement test category, math and reading achievement
test scores were each reported to be poorer proportionally
more often for individuals with untreated ADHD compared
with non-ADHD controls (Figure 2A), while writing skills
were reported to be similar for individuals with and without
ADHD. Among the specific measures within academic per-
formance outcomes, measures of length of schooling or
type of schooling were consistently reported to be poorer
proportionally more often for individuals with untreated
ADHD compared with non-ADHD controls. The results for
the other two types of specific measures of academic per-
formance (grades and deviation from normal course of
schooling) were less consistent. Two studies reported a bet-
ter result for individuals with ADHD compared with non-
ADHD controls; a higher percentage of individuals with
ADHD held a higher education degree (Park et al., 2011)
and more individuals with ADHD completed the General
Educational Development (GED) exam than non-ADHD
controls (Klein et al., 2012). These results were included in
the “similar” total for graphic presentation because they
were the only results of this kind.
Examination of specific measures underlying achieve-
ment test outcomes for individuals with treated ADHD
showed a greater proportion of studies reporting improve-
ment in reading and math associated with treatment for
ADHD (Figure 2B). Two studies reported achievement test
score outcomes (reading, spelling, and information) that
were worse than pre-treatment baseline scores with non-
pharmacological intervention (Tymms & Merrell, 2006) or
multimodal treatment (Satterfield, Satterfield, & Cantwell,
1981). These results were included in the “no benefit” cat-
egory for graphic presentation. Within academic perfor-
mance outcomes, grade point average was reported to
improve with treatment in a higher proportion of studies.
Numbers of results reported for other measures were low,
making it difficult to draw conclusions.
When we examined specific measures of achievement
test outcomes with untreated ADHD restricted to studies
that statistically adjusted for IQ or excluded individuals
with low IQ, the results for math, reading, and spelling were
very similar to those observed when all studies were
Arnold et al. 79

Table 3. Long-Term Achievement Test and Academic Performance Outcomes With and Without ADHD Treatment.

Achievement test scores Academic performance

Untreated outcomes Comparison Similar/total outcomes (%) Similar/total outcomes (%)

Overall Non-ADHD 10/47 (21) 22/89 (25)
IQ controlled/adjusteda Non-ADHD 7/25 (28) 6/32 (19)
Learning disorders controlled/adjusteda Non-ADHD 3/6 (50) 0/3 (0)
Grade retention
The United States Non-ADHD 6/19 (32)
Europe Non-ADHD 1/3 (33)
Expulsion (Northern America) Non-ADHD 7/11 (64)
Treated outcomes Comparison Benefitb/total outcomes (%) Benefitb/total outcomes (%)
Overall Untreated ADHDc 11/14 (79) 5/12 (42)
IQ controlled Untreated ADHD 5/5 (100) 4/7 (57)
Learning disorders controlled Untreated ADHD 1/1 (100) —
Non-ADHD 1/5 (20) 2/5 (40)
Grade retention
The United States Untreated ADHD 1/3 (33)
Non-ADHD 4/14 (29)
Europe Non-ADHD 0/1 (0)
China Non-ADHD 0/1 (0)
Expulsion (Northern America) Untreated ADHD 0/1 (0)
Non-ADHD 4/5 (80)
Age of treatment initiation
Younger (≤9 years) Untreated ADHD 5/8 (63) —
Non-ADHD — 1/1 (100)
Older (≥10 years) Untreated ADHD — 2/5 (40)
Non-ADHD 1/2 (50) 1/2 (50)

Note. Northern America included the United States and Canada, but not Mexico.
a
IQ and learning disorders controlled for by excluding individuals with low IQ or learning disorders or adjusted statistically for IQ or learning disor-
ders.
b
“Benefit” includes both significant improvement compared with untreated ADHD and outcomes similar to non-ADHD controls (i.e., not statistically
significantly different from non-ADHD controls).
c
“Untreated ADHD” includes comparisons either with pre-treatment baseline or with a group of individuals with untreated ADHD.

included regardless of control for IQ (Figure 2A). All stud-
ies of writing skills controlled for IQ. For academic perfor-
mance outcomes, the proportion of poorer results was
generally higher among all specific measures in studies that
controlled for IQ, especially the proportion reported for the
three measures of grades and remedial classes. The propor-
tion of poorer results for repeated grades was similar in all
studies and those that controlled for IQ. Numbers of results
reported for most measures were low, however, making it
difficult to draw conclusions.
The results of specific measures for both achievement
test and academic performance outcomes in individuals
with treated ADHD were generally similar with and without
control of IQ (Figure 2B), with one notable exception. The
proportion (83%) of reports of improved math scores asso-
ciated with ADHD treatment increased in studies that con-
trolled for IQ, indicating a measure for which improvement
with ADHD treatment was more evident in studies that
adjusted for IQ.
Assessing the Impact of Learning Disorders
Eleven studies statistically adjusted for learning disorders
and 2 studies excluded individuals with learning disorders.
Results from this subset of studies were consistent with the
overall results for both untreated and treated ADHD out-
comes (Table 3).
Grade Retention and School Expulsions
Policy regarding grade retention may differ across world
regions. Thus, it is of interest to compare grade retention
outcomes of ADHD regionally. Such outcomes were evalu-
ated in a total of 39 studies; the majority was from the
80 Journal of Attention Disorders 24(1)

Figure 2. Impact of ADHD and treatment on achievement test and academic performance outcome measures: (A) untreated
individuals—bars indicate proportion of similar (blue, dark shade) and poorer (orange, light shade) results reported for each type
of measure for individuals with untreated ADHD compared with non-ADHD controls; and (B) treated individuals—bars indicate
proportion of improved results (blue) or results showing no benefit (orange) with treatment reported for each type of measure
compared with untreated ADHD (either pre-treatment baseline or untreated group of individuals with ADHD).
Note. Numbers in bars indicate the number of results for each bar. GPA = grade point average (average of final grades earned within a certain period);
GED = General Educational Development Test (by which to earn a high school equivalency credential).
Arnold et al.
United States. Overall, there were no striking geographic
differences in grade retention results (Table 3), although the
lower number of studies in regions other than the United
States limited the ability to make meaningful comparisons.
School expulsions were addressed in 18 studies from
Northern America (Table 3) and 1 study from the United
Kingdom. The study from the United Kingdom was a study
of all girls and showed no significant difference in school
expulsions between individuals with and without ADHD
(Young, Chadwick, Heptinstall, Taylor, & Sonuga-Barke,
2005). Four of these studies demonstrated that conduct dis-
order and not ADHD was significantly associated with
school expulsion. Note that this analysis was restricted to
reported school expulsion and did not include school sus-
pension rates.
Effect of Treatment Initiation Age
The effect of age of treatment initiation on academic out-
comes was examined by comparing younger (≤9 years max-
imum in range) and older (≥10 years minimum in range)
ages of initiation. There were seven studies of younger ages
of treatment initiation (youngest initiation age in this group
of studies = 1 year, mid-range of group = 5.5 years old). For
older ages of initiation, there were five studies with a mini-
mum treatment initiation age ≥10 years (oldest initiation
age in this group of studies = 19 years, mid-range of group
= 14.5 years old). The proportion of improved outcomes
was similar to the overall results, for those analysis groups
containing more than one or two studies (Table 3).
Discussion
Although both long-term achievement test and academic
performance outcomes are adversely affected in individuals
with untreated ADHD, many studies demonstrated improve-
ment associated with ADHD treatment for both types of
outcomes. A greater proportion of achievement test out-
comes (79%) compared with academic performance out-
comes (42%) were reported to improve with treatment.
With each type of treatment (non-pharmacological, phar-
macological, and multimodal treatment), a higher propor-
tion of achievement test outcomes showed improvement
with treatment compared with academic performance out-
comes. The high proportion of improved achievement test
outcomes associated with treatment is surprising; given a
recent report that neither type of outcome improves with
treatment (Currie et al., 2013) and the prevailing clinical
wisdom that academic performance (Langberg et al., 2010)
(homework completion and accuracy) is enhanced by treat-
ment, especially by stimulants, without much change in
achievement test scores (Raggi & Chronis, 2006). One non-
systematic review of the literature concluded that, in gen-
eral, medication and behavior management increase
81
academic productivity (note-taking, quiz and worksheet
scores, amount of written language, homework completion)
but do not improve standardized test scores or ultimate edu-
cational attainment (Loe & Feldman, 2007). The results of
the present systematic review show that there is a large evi-
dence base demonstrating that ADHD treatment improves
long-term academic outcomes, particularly achievement
test outcomes. This difference in conclusions is likely due
to the larger number of studies in the current analysis, the
longer time frame (shorter term studies may not have
allowed enough time for the improvement in achievement
test scores to develop), the added strength of the systematic
approach toward study inclusion, and the systematic con-
sideration of the comparison for each result presented (non-
ADHD controls, untreated individuals with ADHD, or
pre-treatment baseline). The present findings, of course,
could also be confounded by comparing tests without treat-
ment (either an untreated group or pre-treatment tests) with
tests on/after treatment, so that the reported increases in
achievement test scores are due to improvement in exam-
taking ability. Alternatively, the discrepancy may reflect the
complexity and multifactorial nature of school success,
which requires success in a wide range of areas, including
learning information but also working well with teachers,
successfully working on group projects with classmates,
being organized, and completing homework and college
applications, for example. In this context, it is notable that
multimodal treatment, addressing numerous targets, was
most consistently reported to improve both achievement
test and academic performance outcomes.
Analysis of the subset of studies that excluded individuals
with low IQ or statistical adjustment for IQ did not substan-
tially alter the percentage of outcomes that were found to be
poorer in individuals with ADHD compared with non-ADHD
controls. Thus, the difference is not likely to be an artifact of
IQ difference or inappropriate adjustment for IQ. The propor-
tion of outcomes improved with treatment, however, was
greater in this subset of studies than in the overall data set for
both achievement test and academic performance outcomes.
The results presented here indicate that both achieve-
ment test and academic performance outcomes may
improve with treatment and that beneficial outcomes were
most consistently associated with multimodal treatment.
The ultimate goals of education and treatment of ADHD are
similar: to promote the success of the child in their future
life. This includes learning information and language and
math skills, and also learning how to successfully navigate
the adult world, including situations such as co-worker,
employer, and customer interactions; organization of
records; time management; and meeting deadlines. Further
research is required to determine which specific types of
treatment and educational strategies are most effective for
which types of outcomes, thus allowing individual treat-
ment plans to be tailored to patient needs.
82
This analysis also shows that more research is needed on
the impact of ADHD management strategies on the long-term
academic outcomes of ADHD. Although there are many stud-
ies in the field, there is a lack of data to guide (a) educators as
to how best to manage individual children, (b) management at
the school system level, and (c) the formation of policy at the
national level. There is a need for further research on the
impact of coexisting conditions on academic outcomes in
ADHD (with and without treatment), particularly disruptive
behavior disorders and specific learning disorders.
Study Limitations and Bias
In the interest of comprehensiveness, studies with widely
varied characteristics were included, for example, different
study designs, control groups, population types and num-
bers, follow-up intervals, diagnosis criteria, and treatment
types. Integration of such diverse information required that
conclusions be maintained at a general level. Some of the
included studies of treatment effects had the design limita-
tion of using pre-treatment baseline as the comparison
rather than including an untreated comparison group. Many
things aside from treatment, including maturation, history,
placebo response, rater bias, practice effect on assessment
instruments, and regression to the mean, may have contrib-
uted to observed improvement from baseline to follow-up.
Only articles published in English and listed in electronic
databases were included. These two inclusion criteria can
introduce bias and limit the number of studies identified. To
reduce English-language bias, we searched for abstracts in
other languages also translated into English, then identified
the English-language publication of the studies. We searched
12 different databases to minimize the electronic database
limitation, but held to the systematic review guideline of not
including studies identified outside the electronic search, to
minimize researcher bias in inclusion.
The number of studies available to address the more spe-
cific questions was also a limitation. Although there was a
large evidence base available to examine the key compari-
sons of achievement test and academic performance out-
comes in individuals with untreated ADHD and overall
treatment effects, evidence was more limited to address
questions such as regional differences, results of specific
measures, and the effects of specific treatments.
A final limitation of this type of study is the inability to
distinguish effects of ADHD on academic outcomes indepen-
dently from the effects of comorbidities. The influence of
comorbidities on the long-term outcomes associated with
ADHD is a complex issue, especially in the consideration of
the effects of treatment on these long-term outcomes. Many
comorbidities are associated with ADHD including depres-
sion, bipolar disorder, conduct disorders, anxiety disorders,
substance abuse, sleep problems, and learning disabilities.
The presence of comorbidities may influence the effect of
Journal of Attention Disorders 24(1)
treatment (Hodgkins, Caci, Young, Kahle, & Arnold, 2013),
although many of the studies either excluded participants with
particular comorbidities or controlled for comorbidities
through methods such as regression analysis or comparison of
outcomes of individuals with ADHD with or without the
comorbidity. Outcomes adjusted for comorbidities by some
method were used in the present analysis whenever possible.
Conclusion
•• Long-term academic outcomes are adversely affected
by ADHD; both achievement test scores and aca-
demic performance.
•• Improvement with treatment was reported for a high
proportion of achievement test outcomes (79%).
•• Improved outcomes for both achievement test and
academic performance outcomes were most consis-
tently associated with multimodal treatment (100%
and 67%, respectively).
•• The proportion of outcomes reported to improve
with treatment was high (100% for achievement test
and 57% for academic performance outcomes) in
studies that controlled for IQ or excluded partici-
pants with low IQ, similar to overall results.
Authors’ Note
Although Shire was involved in the topic concept and fact-checking
of information, the content of this article, the ultimate interpreta-
tion, and the decision to submit it for publication in Journal of
Attention Disorders were made by the authors independently. A
portion of this work was presented previously as a poster (Hodgkins
et al., ESCAP, Dublin Ireland, July 6-10, 2013, No. 207).
Acknowledgments
The authors thank Keira Kim (BPS International) for extensive data
extraction, Dr. Stephan Miller (BPS International) for writing sup-
port, Dr. Alisa Woods (BPS International) for writing early drafts,
and Dr. Amina Elsner (Shire) for helpful comments on this article.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: L. E. Arnold: none; P. Hodgkins was an employee of Shire
and held stock/stock options at the time this work was performed;
J. Kahle: Owner of BPS International, which received funding
from Shire to perform this and previous work; M. Madhoo:
Employee of Shire and holds stock/stock options; G Kewley:
none. Dr. Arnold has received research funding from Curemark,
Lilly, Forest, and Shire; advisory board honoraria from Astra-
Zeneca, Biomarin, Noven, Otsuka, Roche, Seaside Therapeutics,
and Shire; consulting fees from Tris Pharma, Gowlings, and
Pfizer; and travel support from Noven (nothing for contributing to
this article). Dr. Kewley has participated on a committee spon-
sored by Shire (nothing for contributing to this article).
Arnold et al.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This work was supported by Shire Development LLC, Wayne,
Pennsylvania.
Supplemental Material
The online supplemental material is available at http://jad.sagepub
.com/supplemental.
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Arnold et al.
Author Biographies
L. Eugene Arnold, MEd, MD, is a professor emeritus of psychia-
try at Ohio State University (OSU), where he was formerly direc-
tor of the division of child and adolescent psychiatry and vice
chair of psychiatry. He graduated from OSU College of Medicine
magna cum laude, interned at University of Oregon, took residen-
cies at Johns Hopkins, where he earned the MEd, and served in the
U.S. Public Health Service. He is a co-investigator in the OSU
Research Unit on Pediatric Psychopharmacology. He has 45 years
of experience in child psychiatric research, including the multisite
National Institute of Mental Health Multimodal Treatment Study
of Children with ADHD (“the MTA”), for which he continues as
executive secretary and current chair of the steering committee.
For his work on the MTA, he received the National Institutes of
Health Director’s Award. He has a particular interest in alternative
and complementary treatments for ADHD. His publications
include 9 books, 65+ chapters, and 250+ articles.
Paul Hodgkins graduated with a PhD in neuropharmacology from
Aston University, Birmingham, the United Kingdom, and com-
pleted an MSc in health economics and management at the
University of Sheffield, the United Kingdom. Currently, he is the
vice president of the Global Health Economics and Outcomes
Research Department at Vertex Pharmaceuticals and also holds an
honorary senior lecturer position at the School of Health and
Related Research, University of Sheffield, the United Kingdom.
His global drug development experience includes leading teams
responsible for regulatory and market-access clinical trials, regu-
latory approval of drugs, and outcomes research, as well as phar-
macoeconomic evaluations and health technology assessments.
He has published extensively in the field of psychiatry, outcomes
research, and health economics authoring approximately 100 peer-
reviewed articles.
Jennifer Kahle received her doctorate in neuroscience from the
University of California, Irvine, and in 1995 founded BPS
International, a biomedical/scientific writing and analysis company,
currently based in San Diego. In this capacity, she has managed
thousands of projects involving the analysis of raw and published
data and writing of a broad range of scientific, technical, and medi-
cal content for scientists, physicians, pharmaceuticals, bio-techs,
research institutes, and instrumentation and computer hardware
companies. These projects have included large-scale systematic
reviews, cost-of-illness analyses, consumer education web content
and video script, sales instructional materials, product monographs,
scientific/clinical articles, invited chapters, continuing medical edu-
cation reviews, internal reports, Food and Drug Administration
85
submissions, technical manuals, and advertising/marketing materi-
als. She has also authored 23 peer-reviewed articles.
Manisha Madhoo, MD, is a Clinical & Medical Affairs director
at Shire Pharmaceuticals. She has more than 12 years of experi-
ence in pharmaceuticals across scientific, clinical, and medical
organizations in various neuropsychiatric indications—
Alzheimer’s, schizophrenia, major depressive disorder, ADHD,
autism, Fragile X, and multiple sclerosis. She has led and managed
multiple teams globally (J&J and Shire) including with the World
Health Organization. In the last few years, she has served as a key
advisor to small emerging and medical innovation companies such
as MRI Center of Tampa, Oldsmar Assisted Living Care, Florida
Real Estate Investment Trusts (REITs), Microclinic, and Global
Medical Education. In her spare time, she collaborates and advises
the Tanzanian Ministry of Health on emerging medical partner-
ship in Africa. She is a neurologist who completed her undergrad-
uate degree from St. Joseph’s University and MD from the
University of Pennsylvania. She continues to practice and teach in
her personal time. She has authored 20+ abstracts and publications
in scientific journals. She has pivotal leadership roles within mul-
tiple medical organizations—American Academy of Neurology,
American Academy of Child and Adolescent Psychiatry, American
Neuropsychiatric Association, International Society for CNS
Clinical Trials and Methodology, and American Society for
Experimental NeuroTherapeutics.
Geoff Kewley, FRCPCH, is a consultant pediatrician specializing
in the management of children with neurodevelopmental, behav-
ioral, and learning difficulties, especially ADHD and related
issues. He, having also trained as a physician, is able to have
involvement in assessing and managing adults with neurodevelop-
mental problems including ADHD. In 1993, after 16 years as a
consultant pediatrician in Australia and 4 as a consultant pediatri-
cian in the National Health Service in the United Kingdom, he
established the Learning Assessment and Neurocare Centre in
Horsham, West Sussex, from concern at the lack of availability of
effective services for such conditions. He chairs the George Still
Forum: the Royal College of Paediatrics and Child Health special
interest group on ADHD and related neurodevelopmental difficul-
ties. He has been very involved in encouraging appropriate,
evidence-based professional awareness and in lecturing and writ-
ing widely on the conditions. He places great emphasis on the
importance of understanding the reality of the challenges faced by
children with ADHD and their families and in working toward
more appropriate service provision for children’s mental health
and educational services.