Stimulants Don’t Improve Academic Performance in Kids with ADHD
興奮劑無助於改善 ADHD 兒童的學業表現
“Efforts to improve learning in children with ADHD should focus on obtaining effective academic instruction rather than stimulant medication.”
“改善 ADHD 兒童學習的努力應該側重於提供有效的學術指導，而非依賴興奮劑藥物。”
By Peter Simons – June 6, 2022
彼得·西蒙斯 撰 – 2022 年 6 月 6 日
A new study found that stimulant drugs did not help kids with ADHD perform better on their schoolwork. Although the drugs improved children’s behavior in class, they did not do any better academically when they were taking the drugs than when they were not.
“There was no detectable effect of medication on learning the material taught during instruction,” the researchers write. “Children learned the same amount of subject-area and vocabulary content whether they were taking [Ritalin] or placebo during the instructional period.”
The study, published in the Journal of Consulting and Clinical Psychology, was led by William E. Pelham, Jr. at Florida International University. It also included researchers from the University of California, San Diego; the University of California, Irvine; Florida State University; and Penn State College of Medicine.
一項新的研究發現，興奮劑藥物並沒有幫助患有 ADHD 的兒童在學業上表現得更好。儘管這些藥物改善了孩子們在課堂上的行為，但他們在服藥時的學業表現與未服藥時並沒有差異。
“藥物對於教學過程中所教授內容的學習沒有可檢測的效果，”研究人員寫道。“無論孩子在教學期間服用的是利他林（Ritalin）還是安慰劑，他們在學科內容和詞彙學習上所學到的量是一樣的。”
這項研究發表於《諮詢與臨床心理學期刊》（Journal of Consulting and Clinical Psychology），由佛羅里達國際大學的小威廉·E·佩勒姆（William E. Pelham, Jr.）主導，並包括來自加州大學聖地亞哥分校、加州大學爾灣分校、佛羅里達州立大學以及賓州州立醫學院的研究人員。
The researchers recruited 173 children (between the ages of 7 and 12) who met DSM-5 criteria for ADHD and were involved in a therapeutic summer camp. The study was designed so that one group of kids would receive the stimulant Ritalin (methylphenidate) for three weeks (while the other group received a placebo). Then the groups would switch—with the first group now being put on the placebo and the second group taking Ritalin for three weeks.
With this design, the researchers could compare how the same students did on placebo versus the stimulant drug. In addition, having the two groups switch helps to account for other effects, such as withdrawal effects and the effects of time (such as whether all students were more fidgety earlier—or later—in the program, for instance).
This study is unique because studies of the effects of stimulants don’t assess actual school performance. (The researchers write that this is the first study of its kind.) Instead, studies usually focus on behavior (whether kids are better at sitting still in a classroom, for instance) as rated by teachers or parents. Yet academic performance is one of the critical reasons parents want their kids to take drugs.
研究人員招募了 173 名年齡在 7 至 12 歲之間、符合 DSM-5 ADHD 診斷標準的兒童，這些兒童參加了一個治療性夏令營。該研究的設計是讓其中一組孩子在三週內服用興奮劑利他林（Ritalin，哌甲酯），而另一組服用安慰劑。之後，這兩組會互換——第一組轉為服用安慰劑，而第二組則服用利他林三週。
通過這樣的設計，研究人員可以比較相同學生在服用安慰劑與興奮劑藥物時的表現差異。此外，讓兩組學生互換服藥有助於考慮其他影響因素，例如戒斷效應以及時間效應（例如，是否所有學生在夏令營的早期或晚期都更加煩躁不安）。
這項研究獨特之處在於，它評估了興奮劑對實際學校表現的影響。（研究人員指出，這是首個此類研究。）通常，這類研究集中在行為評估上（例如，孩子是否能在教室裡坐得住），這些評估由老師或家長進行。然而，學業表現正是家長希望讓孩子服用藥物的關鍵原因之一。
The researchers write:
“Although it has been believed for decades that medication effects on academic seatwork productivity and classroom behavior would translate into improved learning of new academic material, we found no such translation.”
They add, “Medication had no detectable impact on how much children learned from academic units of science, social studies, and vocabulary.”
The researchers did find that, when taking the drug, kids were able to complete about one to two more math problems per minute and “committed” about two fewer “rule violations” per hour.
The researchers note that students on the drug also did a tiny bit better on their tests—by 1.7 to 3 points on a 100-point scale. However, they add that this improvement is smaller than the improvement kids see if they get a good night’s sleep before a test.
In conclusion, the researchers write that parents and pediatricians believe that stimulants will lead to academic improvement and that academic achievement is a primary goal for ADHD treatment. The researchers suggest that if this is the goal, stimulants should not be prescribed. Instead, academic instruction and support should be improved:
研究人員寫道：
“儘管幾十年來人們相信藥物對學業作業效率和課堂行為的影響會轉化為學習新學業內容的改善，但我們並未發現這種轉化。”
他們補充道：“藥物對於孩子們從科學、社會研究和詞彙學習單元中學習多少內容，沒有可檢測的影響。”
研究人員確實發現，服藥後，孩子們每分鐘能多完成一到兩個數學題目，並且每小時會少違反大約兩條規則。
研究人員指出，服用藥物的學生在測試中的成績也略有提高——在 100 分制的測試中提高了 1.7 到 3 分。然而，他們補充說，這一改進比孩子們在考試前獲得良好睡眠後看到的改進還要小。
總結來說，研究人員寫道，家長和兒科醫生相信興奮劑會帶來學業進步，並且學業成就是 ADHD 治療的主要目標。研究人員建議，如果這是目標，那麼不應該開興奮劑。相反，應該改善學術指導和支持：
“Our failure to find an effect of stimulant medication on the learning of individual academic curriculum units raises questions about how stimulant medication would lead to improved academic achievement over time. This is important given that many parents and pediatricians believe that medication will improve academic achievement; parents are more likely to pursue medication (vs. other treatment options) when they identify academic achievement as a primary goal for treatment. The current findings suggest this emphasis may be misguided: Efforts to improve learning in children with ADHD should focus on obtaining effective academic instruction and support (e.g., Individualized Educational Plans) rather than the use of stimulant medication.”
“我們未能發現興奮劑藥物對個別學業課程單元學習的影響，這讓人質疑興奮劑藥物如何隨著時間的推移導致學業成就的改善。這一點非常重要，因為許多家長和兒科醫生相信藥物會提高學業成就；當家長將學業成就視為治療的主要目標時，他們更有可能選擇藥物治療（而不是其他治療選項）。目前的研究結果表明，這種重視可能是錯誤的：改善 ADHD 兒童學習的努力應該側重於提供有效的學術指導和支持（例如，個別教育計劃），而不是使用興奮劑藥物。”
One caveat to this study is that it involved short (25-minute) lessons each day, delivered in a small-group setting, so it is unclear how the results would generalize to a standard, full-length schoolday in a larger classroom. Additionally, the short-term follow-up of the study (three weeks on the drug) makes it unclear if a longer duration of use would be more—or less—effective.
The most well-regarded and highly cited study of childhood ADHD, the NIMH’s MTA study, found promising initial results on ADHD symptoms and behavior, which were published widely in the mass media and led to the belief that stimulants were extremely effective for ADHD treatment. However, later results of the MTA study were dismal: the three-year follow-up found that those receiving treatment were no better off than those who did not, while the six-to-eight-year follow-up found that those who received medication did no better than those who did not. By that follow-up, none of the treatments had been successful: the children who received treatment still scored worse than the normative comparison group on 91% of the measures they tested.
Another recent study found that taking stimulants made kids more than 18 times more likely to experience depression. However, once the kids stopped taking the drug, their risk of depression dropped back down to that of their healthy peers. Similar studies have supported this effect.
本研究的一個限制是，它每天只涉及短暫的（25分鐘）課程，並且是在小組環境中進行的，因此不清楚這些結果能否推廣到更大班級的標準全天校課。此外，研究的短期跟蹤（服藥三週）也無法確定更長時間的使用是否會更有效，或是效果更差。
最受推崇且引用最多的兒童 ADHD 研究，即美國國家精神衛生研究所（NIMH）的 MTA 研究，最初在 ADHD 症狀和行為方面顯示出令人鼓舞的結果，這些結果被廣泛報導，並促使人們相信興奮劑對 ADHD 治療非常有效。然而，MTA 研究的後續結果卻令人沮喪：三年後的跟進發現，接受治療的孩子與未接受治療的孩子沒有任何差別；而在六到八年的跟進中，發現接受藥物治療的孩子並不比未接受治療的孩子更好。在那次跟進中，沒有任何治療顯示出成功：接受治療的孩子在所測試的91%的指標上仍然比正常對照組表現更差。
另一項最近的研究發現，服用興奮劑的孩子患抑鬱症的風險是其他孩子的18倍以上。然而，一旦孩子停止服用藥物，他們的抑鬱風險就會回到與健康同齡人相同的水平。其他類似的研究也支持這一效應。
Pelham III, W. E., Altszuler, A. R., Merrill, B. M., Raiker, J. S., Macphee, F. L., Ramos, M., . . . & Pelham Jr, W. E. (2022). The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study. Journal of Consulting and Clinical Psychology, 90(5), 367-380. (Link)
Editor’s Note: The description of the six-to-eight year results of the MTA study was edited for clarity.
Pelham III, W. E., Altszuler, A. R., Merrill, B. M., Raiker, J. S., Macphee, F. L., Ramos, M., . . . & Pelham Jr, W. E. (2022). The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study. Journal of Consulting and Clinical Psychology, 90(5), 367-380.
編者註：為了更清晰的表述，對 MTA 研究六到八年結果的描述進行了編輯。