New research examines the effects of behavioral, psychostimulant, and combined treatments on homework issues among children with attention-deficit/hyperactivity disorder (ADHD).
Although stimulant medication does not seem to improve homework performance among children with attention-deficit/hyperactivity disorder (ADHD), teaching parents techniques for working on their children’s homework problems is clearly effective-to the tune of an average difference between passing and failing--according to a new study.1
Helping parents and children with ADHD to address homework problems is an important issue, given academic underachievement is one of the most impairing aspects of childhood ADHD.2-5
The new finding that long-acting stimulant medication (methylphenidate HCl [Concerta]; Janssen Pharmaceuticals, Titusville, New Jersey) does not significantly improve homework quality helps to answer a previously unanswered question, and pediatricians should provide this information to parents, says the study’s senior author William E. Pelham Jr, PhD, director of the Center for Children and Families at Florida International University (FIU), Miami, and distinguished professor and chair of the Department of Psychology at FIU.
Rather, it’s the nonpharmacologic approach that positively impacts homework completion and accuracy.
“Pediatricians need to know that behavioral treatment and effective instruction are necessary to make changes in academic performance in ADHD children, and medication does not enhance the effectiveness of such interventions,” Pelham says.
This is the first study to examine the effects of behavioral, psychostimulant, and combined treatments on homework issues among children with ADHD, according to the abstract.
Researchers studied 75 children aged 5 to 12 years with ADHD who were participating in a therapeutic summer program with a classroom component. They randomly assigning the children and their families to behavioral treatment or to a control group for treatment of homework problems. The active arm did homework-focused behavioral parent training and a daily report card. They completed 6 2-hour, clinician-led group sessions in the first 2 weeks and 1 30-minute individual session the subsequent 2 weeks. To determine the effects of medication, children went through a 2-week medication titration period, then were assigned to receive medication and placebo in a crossover for 3 consecutive weeks each.
“The daily report card . . . is a communication tool between parents and teachers and is a core component of most school-based behavioral interventions for children with ADHD,” says the study’s lead author Brittany M. Merrill, MS, a doctoral student in FIU’s Department of Psychology. “In our study, teachers set realistic goals for the children’s homework-assigning an age-appropriate amount and requiring 80% completion and 100% accuracy on the assignments. Parents evaluated how the child did on homework each evening and returned the note to the teacher the next morning in the child’s homework folder. Children then received small rewards in the classroom based on homework completion at home, in addition to the rewards they received at home for finishing homework.”
Researchers analyzed the children's objective homework completion and accuracy, as well as parent-reported child homework behaviors and parenting skills.
They found medication had nonsignificant effects on homework completion and accuracy. On the other hand, children in the behavioral treatment arm achieved 10% to 13% improved homework completion and 8% improved accuracy compared with controls. This translates to the children in the behavioral treatment arm achieving an average C grade, versus an average F grade for those who didn’t get the behavioral intervention.
Combined behavioral and medication treatment did not provide additional benefit beyond that achieved with the behavioral approach and daily report card, according to the researchers.
The study’s authors tell Contemporary Pediatrics that most parents of children with ADHD will benefit from working with a behavioral therapist and/or their children’s teachers to develop a homework plan.
“Parents can begin by setting up a more consistent homework routine on their own and praising their child’s appropriate behaviors, ([such as] ‘Thank you so much for sitting down at the table’) and ignoring mildly annoying behaviors ([such as] whining),” Merrill says.
Merrill offers these specific recommendations that pediatricians can give parents:
· Work with the child’s teacher to develop ways to ensure that all needed homework materials make it home (eg, teacher checking that assignments are written in the agenda); have a “homework folder” in the child’s backpack that the parent knows to check daily; and allow the child to earn small rewards at home, such as praise for bringing homework home.
· Set up a consistent homework routine, time, and space.
· Periodically monitor the child during homework time, checking progress and praising homework completion at regular intervals, such as every 5 to 10 minutes.
· Provide a reward for homework completion within the designated time with accurate and complete performance; 1 example, video game time after homework completion.
“If a consistent routine, monitoring, and praise are not sufficient to address the homework problems, the family likely needs further support from a behavioral therapist,” Merrill says.
In addition to addressing the homework needs of children with ADHD, this study adds to decades of research indicating that stimulant medication has no beneficial effects on key mediators of long-term outcomes for children with ADHD, according to Pelham.
“Homework performance in elementary school is longitudinally related to academic outcomes in middle and high school among individuals with ADHD, and the current recommendations for improving homework performance in this population should be behavioral treatment and not stimulant medication,” Pelham says.
Merrill recommends that pediatricians steer parents to this free resource from the FIU Center for Children and Families: http://ccf.fiu.edu/for-families/resources-for-parents/printable-information/.
“The most relevant titles are ‘How to Establish a Daily Report Card,’ ‘ADHD Psychosocial Fact Sheet,’ and ‘ADHD Medication Information Sheet for Parents and Teachers,’" Merrill says.
1. Merrill BM, Morrow AS, Altszuler AR, et al. Improving homework performance among children with ADHD: a randomized clinical trial. J Consult Clin Psychol. September 12, 2016. Epub ahead of print.
2. Frazier TW, Youngstrom EA, Glutting JJ, Watkins MW. ADHD and achievement: meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. J Learn Disabil. 2007;40(1):49-65.
3. Loe IM, Feldman HM. Academic and educational outcomes of children with ADHD. J Pediatr Psychol. 2007;32(6):643-654.
4. Molina BS, Hinshaw SP, Swanson JM, et al; MTA Cooperative Group. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry. 2009;48(5):484-500.
5. Polderman TJ, Boomsma DI, Bartels M, Verhulst FC, Huizink AC. A systematic review of prospective studies on attention problems and academic achievement. Acta Psychiatr Scand. 2010;122(4):271-284.
Ms Hilton is a medical writer who has covered health and medicine for 25 years. She resides in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.