Academic and Educational Outcomes of Children With ADHD
Irene M. Loe, MD and Heidi M. Feldman, MD, PHD
Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math
standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-
based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high
school graduation and postsecondary education. Children in community samples who show symptoms of
inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor
academic and educational outcomes. Pharmacologic treatment and behavior management are associated with
reduction of the core symptoms of ADHD and increased academic productivity, but not with improved
standardized test scores or ultimate educational attainment. Future research must use conceptually based
outcome measures in prospective, longitudinal, and community-based studies to determine which
pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes
of children with ADHD.
based services; education; Academic achievement; Educational underachievement; Learning.
attention-deficit/hyperactivity disorder; behavior management; pharmacologic treatment; school-
Problems in school are a key feature of attention-deficit/
hyperactivity disorder (ADHD), often bringing the child
with ADHD to clinical attention. It is important to establish
the nature, severity, and persistence of these school
difficulties in children with ADHD. It is also critical to
learn how various treatments affect academic and educa-
tional outcomes. These findings inform clinical practice,
public health, public education, and public policy. This
review of academic and educational outcomes of ADHD is
organized around 5 questions: (1) What are the academic
and educational characteristics of children with ADHD?
(2) Are academic and educational problems transient or
persistent? (3) What are the academic characteristics of
children with symptoms of ADHD but without formal
diagnoses? (4) How do treatments affect academic and
educational outcomes? (5) How should we design future
research to determine which treatments improve academic
and educational outcomes of children with ADHD?
We used the International Classification of Functioning,
Disability,and Health (ICF)1
framework for describing the functional problems asso-
ciated with ADHD. The World Health Organization
developed the ICF to provide a systematic and compre-
hensive framework and common language for describing
and assessing functional implications of health condi-
tions, regardless of the specific disease or disorder. Use
of this model facilitates comparisons of health-related
states across conditions, studies, interventions, popula-
tions, and countries.
In the underlying ICF conceptual framework, health
conditions impact function at 3 mutually interacting
levels of analysis (Figure 1): body functions and
structures, activities of daily living, and social participa-
tion. Problems of body functions and structures are
called impairments, a more specific and narrow meaning
for the term than that used in DSM-IV.2Problems of
activities of daily living are called limitations. Problems of
social participation are called restrictions. Environmental
and personalfactors can
Treatments may address the health condition directly,
may be aimed at one or more domains within the levels
of functioning, or may be designed to change the
environment. Because of the bidirectional influences
also affect functioning.
All correspondence concerning this article should be addressed to Heidi M. Feldman, MD, PhD, Stanford University
School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA 94304. E-mail: email@example.com.
Journal of Pediatric Psychology 32(6) pp. 643–654, 2007
Advance Access publication June 14, 2007
Journal of Pediatric Psychology vol. 32 no. 6 ADHD Special Issue, reprinted by permission from Ambulatory Pediatrics, Vol. 7, Number 2 (Supplement),
Copyright ? 2007 by the Ambulatory Pediatric Association, published by Elsevier Inc.
by guest on June 1, 2013
within and among these levels of analysis, treatments
directed at one problem may indirectly improve problems
at other levels.
Figure 2 applies the ICF model to school functioning
in children with ADHD using the specific codes and
terminology of the classification system. At the level of
body functions, ADHD affects several global and specific
mental functions: intellectual function; impulse control;
sustaining and shifting attention; memory; control of
psychomotor functions; emotion regulation; higher level
cognition, including organization, time management,
cognitive flexibility, insight, judgment, and problem
solving; and sequencing complex movements. At the
level of activities, ADHD may result in limitations in at
least 2 domains relevant to this review (and other
domains addressed by other chapters in this volume):
(1) learning and applying knowledge, including reading,
writing, and calculation; and (2) general tasks and
demands, including completing single or multiple tasks,
handling one’s own behavior, and managing stress
and frustration. Here, we will differentiate between
academic underachievement, which will refer to problems
in learning and applying knowledge, including earning
poor grades and low standardized test scores, and
classwork or homework. At the level of social participa-
tion, ADHD can compromise the major life area of
education, including creating restrictions in moving in
and across educational levels, succeeding in the educa-
tional program, and ultimately leaving school to work.
Any one of these functional problems may have many
functional problems at other levels of analysis. We will
refer to the restrictions in participation as educational
problems. Environmental factors relevant to outcomes
in ADHD include general and special education services
Evolving Definitions of ADHD
The clinical criteria for ADHD have evolved over the last
25 years. Studies from the 1980s and 1990s often used
different inclusion and exclusion criteria than were used
in more recent studies. Some studies carefully differenti-
ate between children with what we now label as
subtype (ADHD-I). We will address briefly the outcomes
of the subtypes specifically. Many children with ADHD
have comorbid conditions, including anxiety, depression,
disruptive behavior disorders, tics, and learning problems.
The contributions of these co-occurring problems to the
functional outcomes of ADHD have not been well
established. Therefore, in this review, we will consider
the academic and educational outcomes of ADHD
without subdividing the population on the basis of
coexisting neurobehavioral problems in affected children.
What are the Academic and Educational
Characteristics of Children with ADHD?
Children with ADHD show significant academic under-
achievement, poor academic performance, and educa-
tional problems.3–8In terms of impairment of body
functions, children with
decreases in estimated full-scale IQ compared with
controls but score on average within the normal range.9
In terms of activity limitations, children with ADHD score
significantly lower on reading and arithmetic achievement
tests than controls.9In terms of restrictions in social
participation, children with ADHD show increases in
repeated grades, use of remedial academic services, and
placement in special education classes compared with
controls.9Children with ADHD are more likely to be
expelled, suspended, or repeat a grade compared with
Children with ADHD are 4 to 5 times more likely to
use special educational services than children without
ADHD.10,11Additionally, children with ADHD use more
ancillary services, including tutoring, remedial pull-
The literature reports conflicting data about whether
the academic and educational characteristics of ADHD-I
programs, and special
Figure 1. Conceptual model of International Classification of
Functioning, Disability, and Health.
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