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Gender and age differences in the symptomatology of child depression

I should preface this ‘review’ by disclosing that I’m the corresponding author of this study. I don’t usually review my own work at Child-Psych but I think this particular study will be of especial interest to parents, educators, and clinicians.

Last week the Journal of Clinical Psychiatry published one of our studies that examined age and gender differences in the presentation of clinical depression among children and adolescents. The study was part of a large NIMH-funded Program Project on child depression led by my collaborator and recent mentor Maria Kovacs. For those who may not be familiar with Dr. Kovacs’ work, she is one of the world leaders in child depression research. She has been studying childhood onset depression for several decades and is the creator of the Child Depression Inventory – one of the most used child assessment instruments in the world.

During the last decade her team has been following an unusually large sample of children and adolescents diagnosed with clinical depression in Hungary. As part of that study, we recently analyzed and published data that allowed us to closely examine how depression is manifested among these children and adolescents. We were particularly interested in examining whether there were specific differences in the presentation of depression between boys and girls, as well as between younger children (as young as 7 years of age) and adolescents.

The study consisted of 559 children with a DSM-based diagnosis of major depression disorder, including 247 depressed girls and 312 depressed boys ranging in age from 7 to 15 (mean age 11). Depression diagnosis was obtained via a semi-structured clinical interview (the Interview Schedule for Children and Adolescents-Diagnostic Version). The results of this interview was then analyzed by two independent psychiatrists and diagnosis was determined using a consensus procedure. This helped us make sure that all children included in the study had a confirmed diagnosis of depression based on standard DSM-IV criteria. We then examined the individual symptoms endorsed during these interviews and attempted to identify different patterns of symptoms across different age groups as well as between boys and girls.

The results:

Below you can see the unadjusted rates of each symptom (% present) for boys and girls across all ages.

There are a few things worth mentioning. First, depressed mood and irritability were the two most common symptoms among these kids, and anhedonia was relatively less frequent (only between 40 and 50% of the sample showed this symptom). This is not consistent with the DSM-IV criteria that indicates that irritability should replace depressed mood in the diagnostic criteria of depression in children. Our analysis suggests that contrary to the DSM-IV assumption, depressed mood is extremely common among depressed children. In contrast, it is anhedonia that is less common in this population. We were also surprised at how common were thoughts of death in this group, which highlights the need for clinicians and educators to assess for suicidal ideation among depressed kids.

Below you can see the results of the changes in odds ratio for age and sex while adjusting for the intercorrelation between symptoms.

The column of the left tells you how the odds for each symptom changed per year (the odds of being present). The asterisks indicate which symptom significantly changed per year. In sum, depressed mood, hypersomnia, psychomotor retardation, fatigue, and thoughts of death, and suicidal ideation significantly increased from middle childhood to adolescence, while psychomotor agitation significantly decreased per year.

The column on the right tells us how the odds for each symptoms changed by the sex of the child. Specifically,  anhedonia, insomnia, hypersomnia, and somatic complaints were more likely to be seen in females, while psychomotor agitation was more likely to be seen in males.

In sum, this study provides an overview of the symptom presentation of depression among depressed children and adolescents. The study is compelling in that it presents an examination of symptoms among a very large sample of depressed kids. In fact, this is the largest research sample of children with a diagnosis of major depression ever examined for this purpose. The study suggests that, contrary to previous reports, depressed mood is extremely common in this population. The analysis also suggested that the presentation of depression becomes more neurovegetative with age and among females. Neurovegetative symptoms include those that reflect whole-body processes, such as sleep and motor functioning, so clinicians should be particularly attentive to these symptoms. Finally, thoughts of death and suicidal ideation were very common, also highlighting the need for more careful screening of suicidality among depressed children.]

The reference:

Ildikó Baji, Nestor L. Lopez-Duran, Maria Kovacs, Charles J. George, László Mayer, Krisztina Kapornai, Enikő Kiss, Julia Gádoros, & Ágnes Vetró (2009). Age and Sex Analyses of Somatic Complaints and Symptom Presentation of Childhood Depression in a Hungarian Clinical Sample J Clin Psychiatry

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Maternal obesity during pregnancy increases risk for ADHD Symptoms

Maternal obesity during pregnancy is not one of the usual suspects of risk factors for ADHD. Yet, it seems that there is some preliminary evidence associating maternal obesity and ADHD. The latest study showing this link was published in the last issue of the Journal of Child Psychology and Psychiatrist by Alina Rodriguez from the Uppsala University in Sweden and Imperial College in London.

1. In this new study the author first presented 4 issues that remain unresolved from previous research linking maternal obesity and ADHD
2. Since obesity is associated with distress, is it possible that it is the distress during pregnancy that increases the risk for ADHD rather than the obesity?
3. It is possible that maternal obesity and child ADHD are simply related to a common genetic factor. In such a case, it would be the genetic factor, and not the obesity that increases the risk for ADHD
4. Maternal obesity is associated with small birth weight due to fetal growth restrictions, and some studies have linked small birth size to ADHD, possibly through its effects on emotional regulation. Thus, is small birth size the possible link between maternal obesity and ADHD?
5. Maternal obesity is also associated with childhood obesity. Is it possible then than the increased risk for ADHD is due to childhood obesity?

To begin to tackle these issues, the author examined a cohort of women who were pregnant in Sweden from 1999 to 2000. The cohort for this analysis included 1,714 mother-child dyads who were evaluated when the child was 5 years of age. The Body Mass Index of the mothers was obtained during pregnancy and divided into 4 groups: underweight (15–19.99), normal weight (20–24.99),  overweight (25–29.99), and obese (+30). ADHD symptoms and emotionality  at age 5 were assessed via a questionnaires completed by both mothers and teachers. A number of covariates (or potentially explanatory factors) were also measured including maternal stress during pregnancy (divorce, financial problems, etc), socio-economic   status, smoking, the child’s own weight, and depression.

The results:

1. 37% of the mothers were classified as either overweight or obese (28% overweight and 10% obese)
2. Obese mothers were significantly more depressed than the mothers in any of the other weight categories
3. Children of obese mothers had significantly more symptoms of inattention but not hyperactivity when these symptoms were reported by the teachers. Specifically, maternal obesity was associated with a 2-fold increase in risk of teacher-rated inattention symptoms when compared to the children of normal-weight mothers. This association remained stable after controlling for the possible explanatory factors.
4. Maternal Obesity was also associated with an increased risk for negative emotion regulation difficulties as indicated by a teacher-reported emotionality questionnaire.
5. Maternal Obesity was not associated with any symptom when the symptoms were reported by the mother.

A couple of things were surprising. First, the results of the teacher-reported inattention problems were strong, which was of note given that no association was found between obesity and hyperactivity. This discrepancy between inattention and hyperactivity actually points towards a clear link between obesity and adhd (at least inattentive type). That is, since obesity was associated with inattention but not hyperactivity, it is unlikely that the original findings reflected simply an association between obesity and more general behavioral problems in childhood. Instead, the link seems to be specific to one aspect of ADHD. Second, the lack of association between obesity and maternal reported symptoms continues a pattern of findings I have previously discussed (see  for example this article on the effects of multiple daycare arrangements) that suggests that there are some limitations in the nature of maternal reports of the child behavior. In my experience working on several large scale family-based longitudinal studies, fathers and teachers reports of kids’ behaviors tend to agree with each other, but these reports do not always agree with the mother’s. It seems that mothers often see, or report, different behavioral tendencies in their children when compared to what teachers see (or report).

In sum, the study provides additional evidence linking maternal obesity to inattention problems in early childhood. This study expands previous findings by also showing that such a link can not be fully explained by a number of potential factors, such as maternal stress, depression, and socio-economic status. However, please also note that this study did not actually assessed for the presence of ADHD. That is, these kids did not undergo the comprehensive evaluation needed for an accurate diagnosis of ADHD. Instead, the study assessed ADHD-related symptoms as reported by teachers and parents. It would be interesting to see if obesity is associated with true ADHD diagnoses in this population.

The reference: Rodriguez, A. (2009). Maternal pre-pregnancy obesity and risk for inattention and negative emotionality in children Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2009.02133.x

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Depression in preschool – Not a transient developmental phase.

In the current issue of Archives of General Psychiatry, Joan Luby and her team at Washington University in St. Louis presented the findings of a powerful longitudinal study of depression in early childhood. In this new article, Dr. Luby examined the continuity and stability of early childhood depression. Specifically, her team wanted to explore whether preschool depression was a transient developmental phase or a more chronic condition. Surprisingly, this question has not been fully answered mostly because of the limited knowledge we have about early childhood depression.

The study included 306 preschool children (age 3 to 5) recruited from community sources in the St. Louis area. However, this is not a normative community sample, as the recruitment strategy was designed to recruit children at risk for depression and other psychiatric disorders (for example due to a family history of depression). This is a common and appropriate recruitment technique when the objective of the study is to examine the disease process rather than to provide normative or epidemiological information about the condition.  The participating children and their parents underwent a series assessments upon entry to the study (baseline) and then 12 (wave 1) and 24 (wave 2) months later.

The results

1. At baseline 25% (N=75) children met diagnostic criteria for major depression disorder, 26% (N=79) met criteria for other psychiatric disorder, and 47% ( N= 146) did not meet criteria for any psychiatric disorder.
2. At baseline, there was a significant difference in age among the groups, with depressed kids being more likely to be older than the kids in the other psychiatric diagnostic group. There were no gender differences between the depressed kids and the other groups.
3. At baseline, the depressed kids were more likely to have experienced more traumatic events than the non-depressed kids.
4. Below you can see the analysis of the longitudinal progression of MDD compared to other disorders.  Looking only at the top section of the draw, compared to kids without any psychiatric disorder at base line, kids with MDD were 11 times more likely to have MDD vs No disorder at follow up. Similarly, kids with MDD were 7 times more likely than kids with no disorder to have MDD vs. Psychiatric disorder at follow up. Finally kids with MDD were not more likely than the no disorder group to have another psychiatric disorder vs. no disorder. A Similar interpretation can be applied to the other two draws.



5. The researchers also examined the predictors of depression at follow up. Four factors were significant predictors of MDD at follow up:  having MDD at baseline (increased odds of 264%), having a family history of an affective disorder, having disruptive disorder at baseline, and having family income levels below $20,000.
6. Below you can also see the trajectory of MDD based on different severity at baseline. Severe MDD appears to follow a chronic trajectory. Those with less severe MDD follow two trajectories: a recovery, and a recovery-relapse trajectory. The authors could not identify any factors that would help us predict the  trajectories (e.g., chronic vs. recover) among kids with MDD.

There are two critical findings presented in this study. One is that MDD in preschool is highly stable and predictive of future MDD, specially when baseline MDD is severe (more than 50% of the kids with initial MDD continued to have MDD at follow up). Thus, it does not appear that MDD in preschool is a developmental transitional phase. Second, MDD appears to be a risk factor uniquely for MDD. That is, unlike more general ‘internalizing symptoms,’ which are predictive of a number of different disorders, the presence of MDD in preschool does not seem to be an indicator of future ‘general’ psychopathology, but instead it is mostly an indicator of future MDD. This suggests that the MDD diagnosis obtained at this age truly reflects a somewhat homogeneous disease process that is in place and is not simply a reflection of a non-specific dysregulation of emotion that could precede a number of conditions.

Luby, J., Si, X., Belden, A., Tandon, M., & Spitznagel, E. (2009). Preschool Depression: Homotypic Continuity and Course Over 24 Months Archives of General Psychiatry, 66 (8), 897-905 DOI: 10.1001/archgenpsychiatry.2009.97

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Child-Psych will be back in 2 weeks

Dear readers of Child-Psych,

Unfortunately I will have very limited internet access for approximately 2 weeks and no updates will be posted during this time. I hope to start posting again before July 15th. Thank you all for reading Child-Psych and for your patience!

Happy 4th of July!

Nestor.
www.child-psych.org

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“If I vaccinate her, my teen will have sex”: Factors affecting mothers’ rejection of HPV vaccines.

On Monday I discussed a study examining the link between parental vaccination refusal and childhood pertussis. I was most interested in discussing the process by which parents reach the decision to reject vaccine recommendations. In theory, I assume most parents reach such a decision after weighting the risk of vaccines against the risk of refusing the vaccines, and I questioned whether parents have the necessary information to properly weight these risks.

While reading the same issue of the journal Pediatrics, I came across a related study that examined the factors that predict whether a mother intended to vaccinate her daughter against HPV. I was very interested in this study because it could shed light into the decision processes behind parental refusal to vaccinate. That is, is the decision to refuse vaccination only a function of weighting risks vs. benefits? Or is such a decision also associated with other factors that may not be related to the issue of vaccine safety at all?

As background, HVP is a sexually transmitted infection that is associated with a number of serious conditions including cervical cancer. A vaccine for HPV was approved by the FDA in 2006, which has the potential to significantly decrease the prevalence of HPV-related conditions. In this new study, the authors examined 7,207 nurses who had at least 1 daughter participating in a large longitudinal study of adolescence. The authors were interested in examining what demographic and attitudinal variables were associated with intention to vaccinate their daughters against HVP.

The results:

1. Intention to vaccinate was associated with the age of the daughter. 48% of mothers of girls between 9 to 12 intended to vaccinate, compared to 86% of mothers of teens between 16 to 18 years of age.
2. Income was highly associated with intention to vaccinate with those making over $40,000 being 2 times more likely to report an intention to vaccinate their daughters than those making less than 40K
3. Having a history of HPV or HPV related disease doubled the changes of intention to vaccinate.

A number of beliefs about vaccines also predicted whether the mothers intended to vaccinate the daughters. A few interesting findings:

4. Mothers who believed that vaccinated girls would practice riskier sex were 38 times less likely to report an intention to vaccinate their daughters than mothers who did not have this belief.
5. Mothers who believed their daughters were at risk of HPV were 77 times more likely to intend to vaccinate than other mothers
6. Mothers who believed that the vaccine was the best protection against cervical cancer were 234 times more likely to intend to vaccinate their daughters than mothers who did not have this belief.

Initially these results were not that surprising. It seems clear that intention to vaccinate was highly associated with specific beliefs mothers have about the effects, nature, and potential consequences of the vaccine. What I found most interesting is that these results were based on a very unique and not highly representative sample. That is, these mothers were all nurses, and theoretically, they would be better educated than the general population about vaccines. Thus, it was very surprising that even among these highly educated mothers, the decision to vaccinate their daughters was affected by factors not necessarily directly associated with “vaccine safety” but with other ‘values’ or “beliefs” factors, such as the belief that if they vaccinated their daughters, the teens would be more likely to have risky sexual relations.

Kahn, J., Ding, L., Huang, B., Zimet, G., Rosenthal, S., & Frazier, A. (2009). Mothers’ Intention for Their Daughters and Themselves to Receive the Human Papillomavirus Vaccine: A National Study of Nurses PEDIATRICS, 123 (6), 1439-1445 DOI: 10.1542/peds.2008-1536

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Vaccination refusal increases risk of pertussis by 2,000%: Balancing the risks of vaccines and preventable diseases

Pertussis is a highly contagious and potentially deadly respiratory infection that affects mostly children in the developing world. The low prevalence of pertussis in industrialized nations is partly due to the effectiveness of the pertussis vaccine. However, several studies have indicated that the rates of pertussis in the US have significantly increased during the last decade, likely due to a parallel decrease in vaccinations, as parents have become increasingly worried about vaccine safety. But is this true? Are children of parents who decline the pertussis vaccine at higher risk for acquiring this disease?

The journal of the American Academy of Pediatrics recently published a study that examined the association between vaccination refusal and pertussis infections in Colorado. In this study, the authors conducted a case-control examination of children between 2 months and 18 years who were members of a large health plan (Kaiser Permanente Colorado). The study included 156 cases of pertussis and 595 control non-pertussis children.

The results:

1. The authors found time trend in the cases of pertussis, with a large increase in cases of pertussis after the year 2000.
2. Of the 156 children who acquired pertussis, 12% were children of parents who refused vaccination.
3. In contrast, only 0.5% of the children who did not get pertussis were children of parents who refused vaccination.
4. Among children of all ages, refusing vaccination increased the risk of pertussis infection by 2,280%!!!

And these numbers may actually be an underestimate of the real risk of vaccine refusal, since the authors found a possible bias in diagnostic practices. Specifically, parents who agreed to vaccinate their children were 2 times more likely than vaccine-refusing parents to visit the doctor for upper respiratory infections. One interpretation of this finding is that parents who accepted the vaccination are more likely to seek medical services when their kids are sick than parents who refused vaccination. If this is the case, it is likely that cases of pertussis in the unvaccinated kids may have been missed (as these kids were less likely to visit the doctor) so that the rate of pertussis among unvaccinated kids is actually higher than what was observed in this study.

In sum, this study indicated that children of parents who refused vaccination were over-represented among cases of pertussis in Colorado during the past decade and that vaccination refusal increased the risk of pertussis by more than 2000%

These findings made me think about the underlying reasons that drive some parents to refuse vaccination: the fear that by vaccinating their kids they are increasing their kids’ risk of having a severe side effect. But I’m wondering if these parents are properly weighting the risks. Specifically, I wonder how many of these parents have reliable information about both sides of the equation; so that the real and known risks of vaccination are properly weighted against the real and known risks of non-vaccination (such as a 2,000% increase in the risk of acquiring pertussis)?

Glanz, J., McClure, D., Magid, D., Daley, M., France, E., Salmon, D., & Hambidge, S. (2009). Parental Refusal of Pertussis Vaccination Is Associated With an Increased Risk of Pertussis Infection in Children PEDIATRICS, 123 (6), 1446-1451 DOI: 10.1542/peds.2008-2150

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Firesetting in childhood and adolescence: early sign of psychopathology?

This past week, police officers in Florida arrested an 18-year-old kid as prime suspect in a wave of cat killings and mutilations. The killing and torturing of animals for pleasure (excluding traditional hunting) is one of the strongest signs of serious psychopathology. Firesetting is likely a close second, with most adults and adolescents who engage in arson also have a history of childhood firesetting. But until now, most studies have not been able to accurately examine what type of firesetting is predictive of later problems? For example, some children who engage in firesetting do not engage in arson or have serious psychopathology. So what are the characteristics (severity, duration, etc) that are associated with such ‘transitional’ or ‘phase’ firesetting versus a firesetting behavior that is more chronic and potentially pathological?

In an upcoming issue of the Journal of Child Psychology and Psychiatry a team of researchers from the University of Toronto in Canada conducted a large epidemiological examination of firesetting among 3,965 Canadian children and adolescents in grades 7 to 12. The authors examined the correlates of 4 types of firesetters:

1. No history of fire setting
2. Desisters: History of firesetting but none during the past year
3. Low frequency (1-2 during past year)
4. High frequency (3+ times during the past year)

The authors then examined the following variables:

• sex
• age
• school level
• grades
• is family intact?
• welfare involvement?
• difficulty with peers
• daily smoking
• binge drinking
• cannabis use
• other illicit drug use
• delinquent behaviors
• Ritalin use
• high sensation seeking personality
• psychological distress
• suicidal ideation

The Results:

1. 72% of the sample had either never engaged in fire setting (32%) or had engaged sometime during their lives but not during the past year (40.5%)
2. 27% reported engaging in firesetting during the past 12 months.

While controlling for other variables:

3. When compared to those with no history of firesetting, the “desisters” were were more likely to be male, older, smokers, cannabis  users, high sensation seekers, and have high levels of psychological distress.
4. When compared to those with no history of firesetting, the high frequency fire setters were more likely to be male, have low parental monitoring, be binge drinkers, cannabis users, illicit drug users, have a history of delinquent behaviors, be sensation seeking, have high levels of psychological distress, and have suicidal ideation.  This profile was almost identical to the profile of low frequency firesetters.

One way to conceptualize these findings is to examine the factors that predicted high/low frequency firesetters but die no predict ‘desisters’. For example, low parental monitoring was associated with low/high frequency firesetters but not with desisters. This suggests that low parental monitor is a risk factor in more chronic firesetting behaviors and that parental monitoring may not have an impact on isolated events of firesetting that do not become chronic. Cannabis was associated with all groups, so it’s not that informative. This is not surprising given that cannabis use is very frequent among teens. However, other illicit drug use was associated with frequent fire setting only, likely reflecting the severity of behavior problems among these teens. This is supported by the finding that only the low and high frequency fire setters, and not the desisters, were more likely to have a history of delinquent behaviors.

The Reference: MacKay, S., Paglia-Boak, A., Henderson, J., Marton, P., & Adlaf, E. (2009). Epidemiology of firesetting in adolescents: mental health and substance use correlates Journal of Child Psychology and Psychiatry DOI: 10.1111/j.1469-7610.2009.02103.x

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PDAs for kids with Autism

The Journal of Autism and Developmental Disorders recently published a study examining the effectiveness of a Portable Digital Assistant (PDA) as an aid device for adolescents with autism spectrum disorders. I was surprised to read that only a couple of studies have been conducted examining the potential utility of PDAs in autism. The portability of PDAs and the ability of these devices to provide visual and auditory commands (such as video prompts), should make these devices ideal tools in the implementations of behavioral strategies that involve the presentation of prompts.

In order to evaluate the effectiveness of PDAs in autism, the authors taught 3  adolescents with ASD diagnoses to use the PDA to provide self-prompts while completing 3 cooking recipes (hamburger helper, individual sized pizza, and a ham & swiss sandwich). The 3 adolescents were selected because they met a specific inclusion criteria, which included having good fine motor skills (allowing them to manipulate the PDA), having good visual and auditory acuity, and having the cognitive skills necessary to recognize picture prompts. The adolescents were provided with a Cyrano Communication device programmed to provide picture, voice, and video prompts for each step of the cooking process.

The experiment used a multiple probe design that included the following steps for each recipe:

1. Pre-training to learn how to use the PDA
2. Cooking recipe without the PDA
3. Cooking recipe with PDA

The following figure is the results from one of the participants. Notice how the percent correct reached 100 when the PDA was used.

The authors concluded that the devices resulted in a noticeable improvement in performance for all three participants.  The results suggest that PDAs may be very effective in helping persons with ASDs successfully complete tasks, such as those required at educational and/or work setting. However, this study was conducted with 3 individuals only. More research with much larger sample sizes is necessary to help us better understand if, and in what conditions, these devices may  be effective.

The reference: Mechling, L., Gast, D., & Seid, N. (2009). Using a Personal Digital Assistant to Increase Independent Task Completion by Students with Autism Spectrum Disorder Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-009-0761-0

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ADHD medications and academic achievement in elementary school

A few weeks ago I discussed a research study that examined the effects of the medication Concerta (methylphenidate) on performance variability during cognitive tasks in children with ADHD. But does this translate to improvements in school work? Does the research support the effectiveness of ADHD meds in more tangible outcomes, such as grades or academic achievement?

Surprisingly, there is a lack of longitudinal long term research exploring the effectiveness of ADHD medication across multiple grades. Instead, most ADHD research examining academic outcomes are relatively short (within one year) or have very small sample sizes. However, in the latest issue of the Journal of the American Academy of Pediatrics, Dr. Richard Scheffler and a team from the University of California at Berkeley, reported the findings of a comprehensive long term examination of the effectiveness of ADHD medications on academic achievement.

The authors examined a representative population cohort of children entering Kindergarten in the late 1990’s. The study cohort included 11,890 children who entered Kindergarten in 1998. These children were examined yearly until the end of their 5th grade. The authors gathered information on whether the child had an ADHD diagnosis, whether the child was taking medication (more of this below), and the mathematics and reading achievement levels of all the kids during the 5 year study.

The estimation of the medication use was a bit tricky. During 5th grade, the families were asked whether the child was taking medication for ADHD at that time. If the child was not taking medication, the authors assumed that the child had not taken ADHD medication during the duration of the study. If the child was taking a medication in 5th grade, the parents were then asked to report the length of medication use, which was used to estimate past years’ use.

The authors then compared children who had been medicated to those with a diagnosis of ADHD but who had not received any medications.

The Results:

1. 9% of the sample had a life-time diagnosis of ADHD by 5th grade. This does not mean that 9% of 5th graders had ADHD. It means that by 5th grade, 9% of those who entered kindergarten in 1998 had received an ADHD diagnosis sometime during their lives.
2. 68 % of kids with ADHD had taken medication for their condition.
3. While controlling for a number of individual and family characteristics, medicated ADHD kids had significantly higher mathematics achievement scores across the different grades than the non-medicated ADHD kids. Although this difference is statistically significant, the authors reported that the gains represent the average gain expected during 0.19 school year over a 6 year period.
4. There was no difference between those medicated at a single year vs. those medicated at multiple years in their mathematics achievement scores.
5. Children who were medicated in multiple years had significantly higher reading achievement scores than the non-medicated ADHD peers. This reflects gains of 0.29 school years over 6 years.

Despite the limitations of this study regarding how medication use was estimated (retrospectively via parental report, no information on dosage, gaps in administration, etc), there is one very compelling overall finding: If we are to assume that severity of ADHD is associated with the likelihood of medication use (the more severe the more likely you are to be medicated), these findings show that medications are effective in improving academic achievement even among these ’severe’ kids. But we can’t test that hypothesis because the study did not include data about the initial severity of ADHD prior to medication use. Someone could also argue that the effects observed were not due to the medication, but instead to other untapped family characteristic that differentiated those who tried medications vs. those who did not. That is, it is possible that factors that make a family more likely to try medication for their ADHD kids contribute to the kids better long-term academic performance.
The reference: Scheffler, R., Brown, T., Fulton, B., Hinshaw, S., Levine, P., & Stone, S. (2009). Positive Association Between Attention-Deficit/ Hyperactivity Disorder Medication Use and Academic Achievement During Elementary School PEDIATRICS, 123 (5), 1273-1279 DOI: 10.1542/peds.2008-1597

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