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Stimulant Adherence and Academic Performance in Urban Youth With Attention-Deficit/Hyperactivity Disorder

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Objective

This analysis assessed whether stimulant adherence was associated with improvement in academic grade point average (GPA) among children diagnosed with and treated for attention-deficit/hyperactivity disorder (ADHD).

Method

Medicaid claims were merged with academic records from Philadelphia public schools of Medicaid-eligible children in first through eighth grades who were diagnosed with ADHD and who had filled one or more stimulant prescription. Students diagnosed with mental retardation, autism, or speech, hearing, visual, or language impairments were excluded. Marking periods were scored for GPA (range: 0–4.0) based on English, mathematics, social studies, and science grades and for stimulant adherence (medication possession ratio ≥ 0.70). Random and fixed-effects models estimated the effects of stimulant adherence on GPA, between all adherent and nonadherent marking periods in aggregate and within individual student's marking periods, respectively.

Results

A total of 3,543 students contributed 29,992 marking periods, of which 18.6% were adherent. Mean GPA was significantly higher during stimulant-adherent (2.18) than stimulant-nonadherent (1.99) marking periods in aggregate (p < .0001). The regression coefficient representing within-student association between stimulant adherence and GPA over time was 0.108 (p < .0001), indicating that adherence was associated with a 0.108 increase in GPA. In stratified analyses, analogous coefficients were 0.106 for boys, 0.111 for girls, 0.078 for elementary students, and 0.118 for middle school students (all p < .0001). The association was stronger among students with (0.139) than without (0.088) comorbid disruptive behavior disorders (both p < .0001).

Conclusions

Stimulant adherence, although found to be low among urban elementary and middle school students diagnosed with ADHD, was associated with a marginal improvement in GPA.

Section snippets

Study Design Overview

Children diagnosed with ADHD and treated with stimulants were identified from Medicaid claims and linked to Philadelphia school system academic and administrative records. The unit of analysis was the student marking period. The school year in the Philadelphia school system is partitioned into three marking periods (fall, winter, and summer). Although the timing and duration of these marking periods varies from year to year, the average marking period includes 47 school days, 19 weekend days,

Student Sample

Roughly three-fourths of the selected students were boys. A majority of the sample were African American in race/ethnicity and eligible for Medicaid because of low income. Comorbid clinical diagnoses of disruptive behavior disorders, mood or anxiety disorders, and specific learning disabilities were common. The overall mean stimulant MPR, at the person level, was 0.31 and the mean GPA was 2.00 (Table 1).

Stimulant Use

A total of 3,543 students contributed 29,982 marking periods to the analysis. Mean stimulant

Discussion

In this retrospective observational analysis using two methodological approaches, stimulant adherence was associated with higher academic grades for urban children with a clinical diagnosis of ADHD who had initiated stimulant treatment. The projected effect of adherence on academic performance was more pronounced in students with comorbid disruptive behavior disorders than in those without these disorders and in students who had not received stimulants during the 3-month period before the first

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    This project was funded by Ortho-McNeil Janssen Scientific Affairs, LLC.

    This article is discussed in an editorial by Dr. Brady G. Case on page 435.

    Disclosure: Dr. Marcus has received grant support from Ortho-McNeil Janssen, and has served as a consultant to Eli Lilly and Co., Bristol-Myers Squibb, and AstraZeneca. Mr. Durkin holds stock in Johnson and Johnson.

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