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Anxiety Disorder: Different Types, Symptoms, and Treatment Options | Mass General Brigham

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Find information on symptoms, diagnosis, treatment, data, research, and free resources.

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Anxiety: Symptoms, types, causes, prevention, and treatment

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Anxiety is an emotion that causes increased alertness, tension, and physical signs, such as a rapid heart rate. Read on to learn more.

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Anxiety in college: What we know and how to cope - Harvard Health

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Differences in frequency between administrative and parent-reported ADHD diagnosis data of children and adolescents taking sociodemographic characteristics into account – Results from the consortium project INTEGRATE-ADHD | Northeast Lakeview College

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WorldCat Discovery helps people navigate their research journeys to find and get resources from Northeast Lakeview College and libraries worldwide.

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65 Tips and Tricks to Better Manage Adult ADHD (Without Meds) - Frida

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Learn the best ADHD tips and tricks for boosting productivity, sleep, beating procrastination, improving your mood and much more.

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4.) Making ToDo lists that don't become never done piles (mastering  

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4.) Making ToDo lists that don't become never done piles (mastering  

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5.) Time Management + Triage Method (ADHD+Anxiety) (Mastering)

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5.) Time Management + Triage Method (ADHD+Anxiety) (Mastering)

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How I Manage My Time - The Triage System

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6.) Prioritize self care (Anxiety) (Mastering)

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6.) Prioritize self care (Anxiety) (Mastering)

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Learning strategies for ADHD (mastering)

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Learning strategies for ADHD (mastering)

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Strategies/Techniques for ADHD – Disability Resources and Educational Services

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How to create a routine ADHD focused (mastering)

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How to create a routine ADHD focused (mastering)

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ADHD Coach Mande John - Learn to Thrive with ADHD

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How To Create a Routine That Works When You Have ADHD - ADHD Coach Mande John

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Do's and don'ts of helping manage anxiety (mastering)

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Do's and don'ts of helping manage anxiety (mastering)

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Everyone is born with the ability to experience anxiety. The American Psychological Association defines anxiety as an emotion characterized by feelings of tension, worried thoughts and physical changes, such as increased blood pressure and heart rate.

Anxiety is normal and will occur at various times throughout life. It is important to experience anxiety, as it helps recognize and respond to threats of danger and motivate the completion of tasks. For example, having anxiety while driving in a snowstorm is helpful because it leads to altered driving behaviors to safely arrive at the destination. Also, having anxiety before an important test is helpful because it motivates you to study. However, some people's experiences of anxiety can become excessive, ongoing and overwhelming, and lead to significant difficulty functioning in daily life. These are signs of an anxiety disorder.

Signs and symptoms of anxiety

Children and teenagers may have similar worries to adults, but also they may have excessive worries about performance at school or sporting events, fitting in, social experiences, safety, being on time, their future, natural disasters or other catastrophic events. Some signs of significant anxiety include fatigue; changes in sleep habits, such as sleeping too much or too little; irritability; anger; difficulties with concentration; lack of confidence; reassurance seeking; avoidance; and decreased grades.

The most common physical symptoms present in children and teenagers who experience significant anxiety include stomachaches and headaches. They also can experience increased heart rate, rapid breathing, restlessness or jitteriness, trembling or feeling "twitchy," dizziness, diarrhea, nausea and chest tightness or pain.

For many children, anxiety can develop as a paired association, which means the anxious symptoms become associated with something that does not typically elicit anxiety, such as a situation, event or object. For example, imagine a child being at school and experiencing a panic attack for the first time, which is the sudden onset of intense anxiety or fear that often includes a strong body response, such as increased heart rate, rapid breathing, feelings of going crazy or losing control. On this day, the child was stressed about a large presentation, but because of this panic attack, the child's brain may start to associate school with intense anxiety, especially if the child experience's another panic attack at school. Therefore, whenever the child goes to school or even thinks about going to school, the brain can perceive it as a threatening situation, which can trigger ongoing anxiety or frequent panic attacks.

Do's and don'ts to ease anxiety

Many tools can help your children work through anxiety. These are strategies licensed mental health clinicians use with people in therapy, and research has found these strategies to be beneficial in treating and managing anxiety.

If you feel confident you can use these tools with your child - excellent. However, if you do not feel confident or want more support, consider talking with your child's primary care physician who may connect you with a mental health clinician for assistance. If needed, physicians or clinicians can use additional tools not listed here.

Do:

1. Identify triggers.

A helpful first step is for you and your children to become aware of and recognize what causes them to feel intense anxiety. Once those triggers are identified, you can implement many of the tips below.

2. Validate and empathize.

Children's thoughts, emotions and experiences are real to them. No matter how you think or feel about their experiences, it is important for your children to feel heard, validated and understood. Empathize with your children, imagine what it is like to be in their shoes, and recognize and affirm that their thoughts, feelings and experiences are valid and important.

3. Challenge unhelpful thinking.

Ask your children to talk you through the thoughts they are experiencing that are unhelpful and causing them distress, such as "I am going to fail my test and then fail my class." Once you know what thoughts your children are telling themselves, you can work with them to identify more realistic, helpful thoughts. Ask questions to get them thinking about their situation differently and decrease their buy-in into their unhelpful thoughts, such as "Have you ever failed a test or class before" or "What have you done in the past to pass a test? Have you done those things now?"

These questions allow children to think through all the evidence and come to conclusions independently. Self-realization is much more powerful than parents, teachers or peers telling children they will not fail. Once your child's unhelpful thoughts have been challenged, encourage them to develop a more realistic, helpful thought, such as "Although I feel like I may fail, I have prepared for this test and will perform my best" or "Even if I fail this test, that does not mean I will fail the class." Exaggerated ideas, such as "I will for sure pass and will do amazing," are unnecessary and typically not helpful, as most children do not buy in to these unrealistic notions.

4. Practice deep breathing.

Deep belly breathing is a tool to help calm down, refocus and think clearer. It increases oxygen levels in the bloodstream and decreases heart rate, breathing rate, muscle tension and stress level. Instruct your children to place their hands on their belly and chest. Tell them the goal is to take deep breaths with their bellies, which will lead to the hand on their belly moving up and down as air enters and leaves their bodies. When the hands on their chests are moving more, that means they are breathing with their chest. Encourage them to use their bellies to breath. Instruct them to take deep breaths slowly in through the nose, hold and then out slowly through their mouth. Repeat this several times. A fun way to guide this exercise includes pretending to smell a flower, and then blow bubbles or blow out birthday candles.

5. Break down tasks.

Break down tasks into smaller steps so the overall process feels less daunting. For younger children, have random rewards throughout the process to positively reinforce their behavior. For older children, provide positive praise and encourage them to reward themselves.

6. Role-play.

If your children are worried about specific situations, role-play those feared situations to help them prepare. Examples could include ordering at a restaurant, buying a movie ticket, asking a teacher for help or inviting friends over.

7. Build overall confidence.

Have your children perform tasks around the house to contribute to the family and build confidence. Offer your children opportunities to face challenges. It is important to praise their efforts and focus less on results. If they get stuck, ask your children about skills they used to overcome similar obstacles in the past.

Don't:

8. Label emotions as bad.

Stay away from labeling their thoughts, emotions and experiences as good or bad. For example, do not say "It is bad to think you will fail." When children hear that, their thoughts are bad, they often then internalize this and think "I am bad."

9. Minimize anxiety.

Do not minimize your children's experiences and tell them to "Just do it" or "Suck it up." Their feelings of anxiety are real, and they are suffering. Although it is healthy to face things that cause anxiety, meeting children with empathy, compassion and kindness is more helpful and effective when facing feared things.

Remember, you are not alone. You and your children do not have to navigate this alone. Your child's primary care physician wants to help all children thrive.
Deirdre Paulson, Ph.D., is a psychologist in Family Medicine in Eau Claire, Wisconsin.

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Everyone is born with the ability to experience anxiety. The American Psychological Association defines anxiety as an emotion characterized by feelings of tension, worried thoughts and physical changes, such as increased blood pressure and heart rate. Anxiety is normal and will occur at various times throughout life.

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Tips for managing anxiety as a student (mastering)

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Tips for managing anxiety as a student (mastering)

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Tips For Managing Anxiety Whilst At University

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Ebook on coping with Anxiety (mastering)(NLC)

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Ebook on coping with Anxiety (mastering)(NLC)

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WorldCat Discovery helps people navigate their research journeys to find and get resources from Northeast Lakeview College and libraries worldwide.

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EVideo CBT strategies for students with Anxiety and ADHD

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EVideo CBT strategies for students with Anxiety and ADHD

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CBT strategies for kids and adolescents : supporting students with ADHD and anxiety | Northeast Lakeview College

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WorldCat Discovery helps people navigate their research journeys to find and get resources from Northeast Lakeview College and libraries worldwide.

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Technique to help attack tasks (ADHD) (mastering)

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Technique to help attack tasks (ADHD) (mastering)

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Adapting the Pomodoro Technique for Your Work Style

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Ideal for folks living with ADHD, hard workers, and disorganized pros and students alike.

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Leads to feelings of frustration + dismissal or misunderstanding from others

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#4) Women’s Experiences with ADHD & the Impacts of Diagnosis

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#4) Women’s Experiences with ADHD & the Impacts of Diagnosis

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Women With ADHD: How A Diagnosis Changed Our Lives

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#2) Parent-Reported ADHD Diagnoses in Children Since 1997

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#2) Parent-Reported ADHD Diagnoses in Children Since 1997

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Historical overview of ADHD throughout the years.

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#5) Visual Chart for Levels of Anxiety VS Level of Performance in Academics

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#5) Visual Chart for Levels of Anxiety VS Level of Performance in Academics

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I. What is anxiety?

Anxiety is your body's way of telling you that there is something in the environment in need of your attention-it is a series of biochemical changes in your brain and body, such as an increase in adrenaline (causing your heart to beat faster) and a decrease in dopamine (a brain chemical that helps to block pain). These changes result in a state of heightened attention to the source of the anxiety. High levels of anxiety cause your body to prepare to fight or run away from the perceived threat - commonly called the "fight-or-flight response."

II. How does anxiety affect academic performance?

Anxiety is not a bad thing. It is true that a high level of anxiety interferes with concentration and memory, which are critical for academic success. Without any anxiety, however, most of us would lack the motivation to study for exams, write papers, or do daily homework (especially in classes we find boring). A moderate amount of anxiety actually helps academic performance by creating motivation. The graph below illustrates the relationship between anxiety and performance.

III. What can I do to reduce my anxiety?

Academic anxiety has four components - worry, emotionality, task-generated interference, and study skills deficits. The method of reducing your anxiety depends upon which of these you are experiencing. Read the following descriptions and identify which of these are causing you problems:

Worry: Thoughts that prevent you from focusing on and successfully completing
academic work. For example, predictions of failure, self-degrading thoughts, or
preoccupation with the consequences of doing poorly. Some effective techniques
for managing this component include: using positive mental imagery, disputing
negative and self-defeating thoughts with more productive, realistic thoughts, and
self-hypnosis.

Emotionality: Biological symptoms of anxiety. For example, fast heart-beat,
sweaty palms, muscle tension. The most effective strategies for dealing with
emotionality are muscle and breathing relaxation exercises.

Task-generated interference: Behaviors related to the task at hand, but which are
unproductive and prevent successful performance. For example, constantly
checking the clock during an exam, or spending a lot of time on a test question
you cannot answer. Since these behaviors can take on many forms, the best
management technique is to work with a study skills instructor or a counselor to
identify the specific behaviors that cause problems and create a plan to reduce or
change them.

Study skills deficits: Problems with your current study methods which create
anxiety. For example, last-minute cramming resulting in not knowing answers to
test questions or poor note-taking during lecture resulting in confusion about a
major assignment. Many students experience the first three components of
academic anxiety as a result of study skills deficits. If this is the case, then your
grades will not improve unless study skills are addressed. A study skills instructor
can help you with this.

IV. What if my anxiety level is too low?

This may seem like a strange question, but if your anxiety level is too low you may be experiencing the same low level of academic performance as a student with an excessively high anxiety level (see the graph above). If you find yourself falling weeks behind on your homework, spending little or no time preparing for exams, and failing to turn in assignments, while not feeling particularly motivated to change, you may be suffering from too little anxiety. If this is the case, the best strategy is to figure out how your performance on daily coursework is related to the goals you have that you care the most about. One useful method for doing this is seeking career counseling.
Understanding Academic Anxiety

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Anxiety is your body's way of telling you that there is something in the environment in need of your attention-it is a series of biochemical changes in your brain and body, such as an increase in adrenaline (causing your heart to beat faster) and a decrease in dopamine (a brain chemical that helps to block pain).

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#6) (NLC Library) Self-Efficacy & Its Connection to Anxiety

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#6) (NLC Library) Self-Efficacy & Its Connection to Anxiety

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Relationship Between Self-Efficacy and Symptoms of Anxiety, Depression, Worry and Social Avoidance in a Normal Sample of Students

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Objective: Self-efficacy beliefs determine how people feel, think, motivate themselves and behave. Regarding to similar findings it is supposed that concept of self efficacy has a general role on mental health. The present study focused on examining…

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Information about ADHD in the Classroom & Accommodations

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Information about ADHD in the Classroom & Accommodations

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Children with attention-deficit/hyperactivity disorder (ADHD) experience more obstacles in their path to success than the average student. The symptoms of ADHD, such as inability to pay attention, difficulty sitting still, and difficulty controlling impulses, can make it hard for children with this diagnosis to do well in school.

Classroom treatment strategies for ADHD students

There are some school-based management strategies shown to be effective for ADHD students:

Behavioral classroom management

The behavioral classroom management approach encourages a student's positive behaviors in the classroom, through a reward system or a daily report card, and discourages their negative behaviors. This teacher-led approach has been shown to influence student behavior in a constructive manner, increasing academic engagement. Although tested mostly in elementary schools, behavioral classroom management has been shown to work for students of all ages.

Organizational training

Organizational training teaches children time management, planning skills, and ways to keep school materials organized in order to optimize student learning and reduce distractions. This management strategy has been tested with children and adolescents.

Teaching and supporting positive behavior‎

These two management strategies require trained staff-including teachers, counselors, or school psychologists-to follow a specific plan to teach and support positive behavior.

Special education services and accommodations

Most children with ADHD receive some school services, such as special education services and accommodations. There are two laws that govern special services and accommodations for children with disabilities:

The Individuals with Disabilities Education Act (IDEA)

Section 504 of the Rehabilitation Act of 1973

Learn more about IDEA vs Section 504
The support a child with ADHD receives at school will depend on if they meet the eligibility requirements for one of two federal plans funded by IDEA and Section 504:

What are the main differences between an IEP and a 504 Plan?‎

* IEPs: Provide individualized special education services to meet the unique needs of the child and is governed under the Federal law known as the Individuals with Disabilities Education Act (IDEA).

* 504 Plan: Provides services and changes to the learning environment to meet the needs of the child as adequately as other students and is part of Section 504 of the Rehabilitation Act.

Accommodations

IEPs and 504 Plans can offer accommodations for students to help them manage their ADHD, including the following:

Extra time on tests

Instruction and assignments tailored to the child

Positive reinforcement and feedback

Using technology to assist with tasks

Allowing breaks or time to move around

Changes to the environment to limit distraction

Extra help with staying organized

Did you know?‎

Parents of children with ADHD report receiving more services through an IEP than through a 504 plan.

There is limited information about which types of accommodations are effective for children with ADHD. However, there is evidence that setting clear expectations, providing immediate positive feedback, and communicating daily with parents through a daily report card can help.

What teachers can do to help

For teachers, helping children manage their ADHD symptoms can present a challenge. Most children with ADHD are not enrolled in special education classes but do need extra assistance on a daily basis.

Helping students with ADHD‎

CHADD's National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.

Close collaboration between the school, parents, and healthcare providers will help ensure the child gets the right support. Here are some tips for classroom success:

Communication

Give frequent feedback and attention to positive behavior.

Be sensitive to the influence of ADHD on emotions, such as self-esteem issues or difficulty regulating feelings.

Provide extra warnings before transitions and changes in routines.

Understand that children with ADHD may become deeply absorbed in activities that interest them (hyper-focus) and may need extra assistance shifting their attention.

Assignments and tasks

Make assignments clear-check with the student to see if they understand what they need to do.

Provide choices to show mastery (for example, let the student choose among written essay, oral report, online quiz, or hands-on project.

Make sure assignments are not long and repetitive. Shorter assignments that provide a little challenge without being too hard may work well.

Allow breaks-for children with ADHD, paying attention takes extra effort and can be very tiring.

Allow time to move and exercise.

Minimize distractions in the classroom.

Use organizational tools, such as a homework folder, to limit the number of things the child has to track.

Develop a plan that fits the child

Observe and talk with the student about what helps or distracts them (for example, fidget tools, limiting eye contact when listening, background music, or moving while learning can be beneficial or distracting, depending on the child).

Communicate with parents on a regular basis.

Involve the school counselor or psychologist.

Parent education and support

How to best advocate for your child‎

What every parent should know

School support and services are regulated by laws. The U.S. Department of Education has developed a "Know your rights" letter for parents and a resource guide for educators to help educators, families, students, and other interested groups better understand how these laws apply to students with ADHD so that they can get the services and education they need to be successful.

Healthcare providers also play an important part in collaborating with schools to help children get the special services they need.

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ADHD in the Classroom: Helping Children Succeed in School

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Resources for parents, teachers, and healthcare providers to help children with ADHD succeed in the school.

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(NLC Library) Effects of ADHD Medication on Academic Performance

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(NLC Library) Effects of ADHD Medication on Academic Performance

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J Am Acad Child Adolesc Psychiatry

. Author manuscript; available in PMC: 2020 Apr 1.

Abstract

Objective:

Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) are at increased risk of poor school performance and pharmacological treatment of ADHD may have beneficial effects on school performance. Conclusions from previous research have been limited by small sample sizes, outcome measures, and treatment follow-up. The current study analyzed school performance in students with ADHD compared to students without ADHD, and the association between pharmacological treatment of ADHD and school performance.

Method:

A linkage of Swedish national registers covering 657,720 students graduating from year 9 of compulsory school provided measures of school performance, electronically recorded dispensations of ADHD medication, and potentially confounding background factors such as parental socioeconomic status. Primary measures of school performance included student eligibility to upper secondary school and grade point sum.

Results:

ADHD was associated with substantially lower school performance independent of socioeconomic background factors. Treatment with ADHD medication for 3 months was positively associated with all primary outcomes, including a decreased risk of no eligibility to upper secondary school, odds ratio of 0.80, 95% confidence interval (CI) 0.76-0.84, and a higher grade point sum (range 0.0-320.0) of 9.35 points, 95% CI=7.88-10.82; standardized coefficient of 0.20.

Conclusion:

ADHD has a substantial negative impact on school performance while pharmacological treatment for ADHD is associated with higher levels in several measures of school performance. Our findings emphasize the importance of detection and treatment of ADHD at an early stage to reduce the negative impact on school performance.

Keywords: ADHD, school performance, medication, treatment

LAY SUMMARY

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with poor school performance and ADHD medication may improve school performance. Using a register linkage of Swedish students this study finds a positive association between length of medication use prior to graduation and several measures of school performance. Three months of treatment with ADHD medication was associated with an increase in the grade-point average (range 0-20) of 0.49 and treatment over three school years with an increase of 2.38 points. The strength of these associations suggest that ADHD medication may play a role in improving school performance in students with ADHD, but other educational interventions are likely needed to bridge the substantial school performance gap between students affected by ADHD and their unaffected peers.

INTRODUCTION

Approximately 5% of all school-aged children world-wide are diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD)1 and the impairments associated with ADHD persist into adulthood in many cases.2 Research suggests that ADHD is associated with poor school performance, both in childhood and later in life. Children with ADHD are at increased risk of lower scores on reading and arithmetic achievement tests, lower grade point average (GPA), grade repetition and placement in special education classes compared to controls.3-5 Adolescents with ADHD fail more grades and perform worse on standardized academic achievement tests than matched controls.6 Although the relationship between ADHD and school performance is well-researched, no study has examined this relationship in a nationwide setting using objectively measured confounders such as parental education.

Randomized controlled trials (RCTs) involving children7 and adults8 have shown that ADHD medications have beneficial short-term effects on the core symptoms of ADHD and are associated with improvements in a wide range of cognitive functions in children with ADHD, including complex reaction time, spatial recognition memory reaction time, inhibition, working memory and strategy formation.9 Research on the short-term effects of ADHD medication on different measures of school performance has found positive effects in several domains. RCTs, usually with a follow-up of 1-7 weeks,10,11 suggest positive effects on note-taking quality, quiz scores, class work productivity, and disruptive behavior,12,13 whereas more modest effects have been reported for test scores in reading and mathematics.7,14,15 Observational studies exploring short-term effects have found converging evidence.16,17 One recent study using Swedish register data found that, although of small effect, individuals (mean age 22.2 years) performed better on higher education entrance tests during medicated than unmedicated periods16 and another study in children using a similar design found that GPA was higher during stimulant adherent periods.17

Ideally, the long-term association between ADHD medication and school performance should be examined in large prospective RCTs, but since such trials are problematic (e.g., patients assigned to a long-term untreated control arm may seek out medications elsewhere) and unethical (e.g., withholding treatment with known benefits), future research in this area must rely on findings from observational designs.

Existing observational studies of the long-term association between ADHD medication and school performance have yielded inconsistent results.18-21 Although improvements in test scores during primary school have been reported,22,23 the evidence regarding GPA is mixed. A 9-year longitudinal follow-up study of children with ADHD showed an association between ADHD medication and higher GPA21 and an 8-year follow-up of the Multimodal Treatment Study of Attention Deficit Hyperactivity Disorder (MTA) reported no effects of ADHD medication on GPA.20 Imperfect assessment (e.g., parent- or self-reported) of long-term medication usage, and small and/or clinically referred samples are essential limitations of the available studies.18 Another important limitation of the aforementioned observational research is how different measures of school performance influence each other. Standardized tests can be conceptualized as examinations of academic knowledge while school grades, in addition, incorporate broader aspects of school performance such as productivity and classroom behavior.24 One review reported that the correlation between test scores and grade points is lower in students with ADHD compared to students without ADHD18, suggesting that teacher assessment differs by ADHD status. The potential role of ADHD medications in this relationship is unknown.

The current study captured the total population of students graduating from compulsory (primary and lower secondary) school in Sweden in 2008-2013, including a large sample of students diagnosed with ADHD. The aims were twofold: First, we investigated the association between ADHD and school performance. Second, we examined how ADHD medication influenced the association between ADHD and school performance in the shorter and longer term.

METHODS

Data sources

We extracted data on school performance from the Swedish National School Register (NSR) for all 657,720 students graduating from year 9 of compulsory school between 2008 and 2013. The NSR contains individual level data on final grades (FGs) from school leaving certificates and grades in standardized tests (subsequently referred to as tests) taken in Swedish, English and mathematics, information about eligibility to upper secondary school (USS), and school of graduation. Using the Longitudinal Integration Database for Health Insurance and Labor Market Studies (LISA) individual completion of USS was obtained. Individuals were linked to data on dispensed medication, including amphetamine (Anatomical Therapeutic Chemical classification system (ATC) codes: N06BA01, N06BA02), methylphenidate (N06BA04) and atomoxetine (N06BA09), using the Swedish Prescribed Drug Register (July 2005 - December 2013) and diagnosis of ADHD (International Classification of Diseases [ICD] 10: F90), in the National Patient Register (NPR). ADHD cases were defined either by a lifetime in/outpatient primary diagnosis of ADHD or at least one lifetime dispensation of ADHD medication (excluding dispensations indicated for narcolepsy; 93 individuals). Defining ADHD by a dispensed ADHD medication has been used and validated in prior research using Swedish registers.25 This study was approved by the Regional Ethical Review Board in Stockholm. In Sweden, using de-identified register data in research does not require informed consent from participants.

The Swedish school system

The Swedish primary and lower secondary school is compulsory by law and 9 years in length where each scholastic year starts in mid-August and ends in early June. FGs received upon graduation in the 9 th year determines the options available for a student to advance to USS. First, eligibility to any of the national programs in USS requires the student to pass all "core subjects" (Swedish, English and mathematics). Second, eligibility differs between vocational and higher education preparatory programs. In general, preparatory programs require a passing grade in an additional 9 subjects (passing certain subjects is necessary for some of these). Until 2011, vocational eligibility only required passing the core subjects while, 2011 and later, passing an additional 5 subjects was required (in total 8). If the number of applicants to a program exceeds the available slots, these are distributed to the highest achievers using a grade point sum, the merit value, constructed by scoring the alphabetical grade in each subject (0-20 points) and summing the student's 16 best-performing subjects (range 0-320).26 A schematic of the Swedish school system is presented in Figure 1.

FIGURE 1.

Measurement of Medication Use, Grade Conversion, and Outcome Measures in the Swedish School System from Compulsory to Upper Secondary School

Note: Medication use measured during year 7-9 (shaded circles).

In the spring semester of their final year 9, students also take three tests in each of the core subjects. Each student receives a weighted grade in each subject that reflects overall performance on the tests and teachers are supposed to take these results into account when setting FGs at the end of the scholastic year.

The national USS programs are 3 years in length. Ineligible students are admitted to one of the introductory programs that prepare the student for either the labor market or one of the national programs.

Measures of school performance

Primary outcomes of school performance included eligibility for USS and the grade point sum. Eligibility to USS was indicated by eligibility to a vocational program (i.e., the lowest requirement) and was determined using FGs as outlined above. The grade point sum is available in the NSR. For comparison with previous research, we calculated a GPA for each student by dividing the grade point sum by the number of graded subjects (range 0.0-20.0). The grade point sum can complement a GPA as its sensitivity to the number graded subjects differ. For instance, a treatment may increase subject enrollment while leaving the performance in these subjects unaffected. A measure of teacher assessed school performance (subsequently referred to as teacher assessment) was created by first converting the alphabetical grades as outlined in Figure 1, and subsequently subtracting grade points in weighted tests from the corresponding FG in each of the core subjects (range −20.0-20.0). Since the standardized tests can be considered as a more objective measurement of academic knowledge, this difference can be expected to be more sensitive to behavioral aspects of school performance. As performance in compulsory school determines the options to advance to USS, completion of USS was included in the sensitivity analyses to test whether associations between ADHD, ADHD medication, and performance in compulsory school replicated for USS completion, which was ascertained using LISA and available for students graduating 2008-2010.

Medication for ADHD

We first calculated the number of days of medication usage covered by each dispensation based on the defined daily doses dispensed and the accompanying dosage instruction when available. The extent of treatment was then calculated in months for each individual from the start of grade 7 until graduation ( Figure 1) or test while ignoring treatment status during the summer holiday (June 1 to August 15), leading to a treatment range of 0 to 29 months. Details on this procedure are found in online Supplement 1, Figure S1, and Table S1.

Covariates

Information about individual background factors (sex, immigration background, and month of birth) were obtained from the Total Population Register (TPR). Information about comorbid diagnoses of developmental disorder (ICD10: F80-F89) and behavioral disorders (ICD10: F91-98) disorder were obtained from the NPR. Parents were identified through the Multi Generation Register, linked to the TPR for information on immigration status, and linked to LISA for information on disposable income and highest educational attainment in the year of graduation. Parental educational attainment was divided into 4 levels: at most one parent USS, both parents USS, at least one parent with a (3 years or less) university education or at least one parent with 4 years of university education or more. Income was divided into quartiles calculated over the average sum of parental income between the year of the child's graduation from year 9 and the two preceding years to account for year-to-year fluctuations. When information on parental income and education was missing, information from the year closest to the child's graduation was used if available.

Analyses

The association between ADHD and school performance

To explore school performance in adolescents with ADHD compared to adolescents without ADHD we used two types of regression models. Logistic regression models were used for the binary outcome eligibility for USS. When school performance was a continuous measure (i.e., the grade point sum, GPA, and teacher assessments) we used linear regression models. To disseminate the influence of potential confounding factors, each association was estimated with and without adjustments for covariates. Individual level covariates included were month of birth (continuous, range 1-12), sex, year of graduation (6 categories), years resident in Sweden (range 0.0-16.0), age at graduation (<15.5, 15.5 to 16.5, >16.5), indicators (1 when present, 0 otherwise) of diagnosis of developmental and behavioral disorders respectively. Parental background factors included immigration status (no, one, or both parents born abroad), combined educational level, and income quartile. The adjusted model was estimated within school of graduation (i.e. a fixed-effects approach) using robust standard errors clustered on this unit.

The association between ADHD medications and school performance

We estimated the association between medication and school performance by extending the logistic (i.e., for binary outcomes) and linear (i.e., for continuous outcomes) regression models outlined above with treatment exposures. An indicator of ever being treated between the start of grade 7 and test or graduation was used to account for baseline differences between the treated and untreated groups in terms of the outcome. Months on ADHD medication (range 0.0-29.0) prior to test or graduation was entered as a continuous covariate. To account for non-linear effects, a quadratic term of months on ADHD medication was included in the models. When the quadratic term was statistically significant (p<0.05) the combined association was reported. Since estimates including non-linear effects differ according to treatment length, the estimates were scaled to 3 and 29 months to reflect treatment periods of 3 months and the entire three school years preceding graduation respectively. The relationship between the grade point sum and ADHD medication was also plotted against treatment length including estimates stratified by treatment length to assess the fit of the association.

Risk differences (RDs) and standardized coefficients (SCs)

To aid the interpretation of estimates in the logistic models, RDs were calculated for point estimates. The RD is the average difference in the probability of the outcome due to a unit change in the exposure (i.e., ADHD status or treatment length) predicted from the fitted model given the underlying covariate data.27 For continuous outcomes, SCs were calculated by multiplying the point estimate with the standard deviation of the exposure and dividing with the standard deviation of the outcome. A standard deviation increase in the exposure thus increases the outcome with a standardized coefficient (SC) standard deviations. Point estimates of RDs and SCs were provided for estimates mentioned in text, and for all outcomes in supplementary tables.

Sensitivity analyses

The sensitivity analyses focused on the association between ADHD medication and school performance. First, different treatment groups were defined according to the pattern of dispensations and stratifying the analyses on these groups. Similar to previous research17, continuous treatment was defined as a treatment extent covering the remaining 70 percent of the scholastic months following the student's first observed dispensation of ADHD medication up until the time of the outcome (test or graduation). Discontinuous treatment was defined as a treatment pattern not classifiable as continuous. Further details on the definition of these treatment groups are found in online Supplement 2, Figure S2, and Table S2. Second, we performed analyses excluding cases that did not carry a clinical diagnosis of ADHD, and third, excluding cases that were dispensed an ADHD medication prior to the 3-year period in which medication use was calculated. Fourth, we used logistic regression models to investigate whether treatment length at graduation was predictive of not completing USS within 3 years among students graduating 2008-2010.

Analyses were conducted using R version 3.4.4 (R core team, Vienna, Austria), package drgee28 for continuous outcomes and package bife27 for binary. Routines in bife were also used to calculate RDs.

RESULTS

Descriptives

Of the 657,720 students graduating in 2008 to 2013, 29,128 (4.4%) students had either received a diagnosis of ADHD and/or dispensation of ADHD medication. There were fewer females in the ADHD group (35.8%), than in the student population without ADHD (49.4%). A larger portion of students with ADHD (12.5%) graduated later than expected based on their age, compared to students without ADHD (3.8%). A comorbid diagnosis of developmental disorder was found in 14.9% of the ADHD group compared to 1.2% in the unaffected group and for behavioral disorders 15.5% in the ADHD group compared to 1.9% in the unaffected group. Parents of students with ADHD had fewer years of education and were about 6 percentiles lower in the income distribution than parents of students without ADHD. The share of females was lower in the group treated with ADHD medications prior to graduation (27.9%) than the ADHD group in general. Otherwise the differences in the ADHD group by treatment status were negligible ( Table 1).

TABLE 1.

Non-ADHD

ADHD

Treated prior to graduation

Total
628,592 (95.6)

29,128 (4.4)

16,054 (55.1)

Individual background

Birth montha

6.2 (3.4)

6.6 (3.4)

6.6 (3.4)

Family background

Parental income percentilea

50.8 (28.9)

45.0 (27.7)

45.3 (27.5)

The association between ADHD and school performance

Students with ADHD were at increased risk of not being eligible to USS, 37.6% compared to 10.7% in the student population unaffected by ADHD; adjusted odds ratio (AOR) 4.70 (95% confidence interval [CI]: 4.56; 4.85); RD=19.9%. The ADHD group received a lower grade point sum (max=320), 136.8 compared to 211.0 points among students unaffected by ADHD; adjusted grade point difference (β A) −56.40 (−57.47; −55.33); SC=−0.17. ADHD was negatively associated with teacher assessments (i.e., FG minus test) in Swedish and English, but displayed a positive association in mathematics ( Table 2). ADHD associated with significantly lower grade points (β A) in tests and FGs of core subjects (Swedish, English, and mathematics), and other subjects, ranging from −2.32 to −3.99 grade points (see Table S3, available online).

TABLE 2.

ADHD status

Estimated association with ADHD

ADHD

Non-ADHD

Unadjusted

Adjusted

Outcome

N (%)

OR (95% CI)

M (SD)

Grade point β (95% CI)

Teacher assessment

The association between ADHD medication and school performance

One treatment period (i.e., three months) significantly decreased the odds of not being eligible to USS, AOR=0.80 (0.76; 0.84), RD=−1.9%, and was associated with a higher grade point sum of β A=9.35 (7.88; 10.82) points, SC=0.20. Positive associations were observed between ADHD medication and teacher assessments (i.e., FG minus test) in all core subjects ( Table 3). Statistically significant, positive associations between ADHD medication and FGs (β A range 0.09 to 0.58) were observed for all subjects while the only significant association with tests was found for mathematics and Swedish (see Table S4, available online).

TABLE 3.

Treatment status prior to graduation

Effect over one treatment period

Effect over 3 school years

Treated

Not treated

Unadjusted

Adjusted

Unadjusted

Adjusted

N (%)

OR (95 % CI)

OR (95 % CI)

Not eligible to USS

6,347 (39.5)

4,607 (35.2)

Grade point mean (SD)

Grade point β (95% CI)

Grade point β (95% CI)

Grade point average

8.7 (4.0)

9.3 (4.1)

Grade point sum

132.7 (70.4)

141.7 (73.2)

Teacher assessment

Scaling the adjusted estimates to the maximum treatment length (29 months) amounted to a lower likelihood of not being eligible for USS of AOR=0.50 (0.39; 0.63), RD=−6.0%, and a grade point sum β A=40.84 (34.49; 47.18) points higher ( Table 3). Figure 2 illustrates the association between treatment length and the grade point sum, including the modeled trend, absolute and relative (adjusted) grade points stratified by treatment length. The model displays a close dose-response relationship with the relative grade points when extrapolating the estimated association beyond the 3-month treatment period and indicates that the effect of medication is diminishing over treatment length. This means that according to the model, the estimated difference in grade sum between, for instance, 18 and 21 months of treatment is smaller than the corresponding difference between 3 and 6 months.

FIGURE 2.

Grade Point Sum by Length of Treatment with Attention-Deficit/Hyperactivity Disorder (ADHD) Medication

Note: See Table 3 for details of the statistical model. Months in treatment (prior to graduation from compulsory school) have been rounded upwards.

Left scale: Crosses represent the means. (a) Students with ADHD not treated prior to graduation.

Right scale: Dots represent the adjusted grade point sum by treatment length relative to students with ADHD not treated prior to graduation. The black line represents the modelled change in grade point sum extrapolated over treatment length. (b) The adjusted grade point sum of students with ADHD not treated prior to graduation relative to those treated prior to graduation

Sensitivity analyses

Stratifying the analyses by treatment group (continuous or discontinuous) did not reveal any systematic differences between the groups in terms of school performance (see Table S5, available online). The associations also remained robust to the exclusion of ADHD cases without a clinical diagnosis of ADHD, and cases with a dispensed medication prior to the period over which medication use was calculated (see Table S6- 7, available online). Treatment length prior to graduation from compulsory school was predictive of completing USS within 3 years where one treatment period was significantly associated with a reduction in the odds of not completing USS, AOR=0.89 (0.87; 0.91); RD=−1.8% ( Table 3).

DISCUSSION

To our knowledge, this is the largest study to examine the associations among ADHD, medication usage, and school performance. We used a population cohort of 657,720 individuals graduating from compulsory school between 2008 and 2013. The main findings were that ADHD has a substantial negative impact on school performance that is independent of several important confounders (e.g., parental education), and that pharmacological treatment for ADHD is associated with an attenuation in this relationship. For instance, we estimated the ADHD associated risk of ineligibility for USS to 19.9 percent and the modeled risk reduction associated with the longest treatment length to −6.0 percent yielding a residual risk of 13.9 percent. Our findings thus highlight the need to detect ADHD at an early stage, and that other non-pharmacological educational interventions are likely needed if school performance in students with ADHD is to be normalized. From an educational policy perspective, it can be proposed that pharmacological treatment should at most be viewed as an aid to facilitate learning, and without the proper educational support for the affected students it appears unlikely that such treatment would translate into large gains in knowledge.

Our finding that pharmacological treatment for ADHD is positively associated with several measures of school performance is consistent with previous observational studies.17,21,22 The largest previous study (N ADHD=3543) reported an improvement in GPA of 0.11 points during stimulant adherent marking periods (≈78 days).17 Expressing this effect as a percentage of maximum GPA (4.0) would yield an effect size of 2.7%. The corresponding effect size in our study was 2.1% which indicates a weaker relationship between ADHD medication and school performance, possibly due to differences in source population (Medicaid claims versus national registers), study question (treatment adherence versus length), and school system as students in Sweden are generally not separated based on abilities (with some exceptions). Other available studies are less comparable due to differences in design, outcome measures, or substantially longer follow-ups than the three years used in our study. Of these, a small study (N ADHD=90) where participants had an average treatment duration of 5.33 years found that medicated individuals had a 0.6 point higher GPA (max=4.0) compared to unmedicated individuals.21 Concerning standardized tests, one of the larger studies (N ADHD=594) found that ADHD medication was associated with a 2.9 point higher score in mathematics and 5.4 in reading.22 Other studies have found significant positive correlations in this domain, but do not report effect sizes.19,20,29 Our findings are inconsistent with two follow-ups of the MTA-study reporting no statistically significant association between past year ADHD medication use and GPA20, and between 8-year medication use and test scores in mathematics.19 The differences could be due to several factors. First, it is unclear whether these studies addressed confounding by indication appropriately (i.e., whether ADHD medication was indicative of lower school performance). This is problematic as our results illustrate ( Figure 2) that students receiving ADHD medication prior to graduation are performing worse in terms of school performance compared to students treated later or not at all. Thus, not accounting for the baseline differences between treatment groups may bias the estimated effect of ADHD medication on school performance. Second, our results indicate that improvements in school performance diminish with increasing treatment length. It is possible that the additional gains at the 8-year follow-up are too small to detect given the sample size in the MTA-study and the low frequency of treatment naïve individuals.

Our study extends previous research on ADHD, the effect of ADHD medication, and school performance in several ways. First, by estimating how the usage of ADHD medication over several years affects school performance we show how short-term effects potentially translate to long-term effects.

Second, by including a measure of teacher assessment (the grade point difference between FGs and tests) we were able to include a more comprehensive set of school performance measures and thereby explore new aspects of how ADHD, and ADHD medication, is associated with school performance. We found that, after accounting for their test performance, students with ADHD receive a lower FG in Swedish and English, but a higher FG in mathematics, compared to students without ADHD. Consistent with previous research,18,19 these findings suggest that teacher assessment differs by ADHD status. Furthermore, research using Swedish data has revealed that differences between tests and FGs are systematically related to student background characteristics such as sex and socioeconomic status.30 Possible explanations for the negative differences (Swedish and English), and positive difference in mathematics, are that the behavioral aspects associated with ADHD, such as classroom productivity and disturbance, are taken into account by teachers as the classroom environment likely differs between languages and mathematics. If, and to what extent, this type of grading behavior exists in other educational systems is an important direction for future research on ADHD and school performance to take.

Third, the positive associations between ADHD medication and teacher assessments coupled with the absent, or small relative to FGs, associations with tests (see Table S4, available online), suggest that the main treatment related improvements are not in terms of subject knowledge as measured by standardized tests. As Swedish and English are subjects that place more focus language related skills (e.g., reading, writing) than mathematics, potentially medication affects these subjects differentially via their respective skill requirements. Such an interpretation is supported by a recent meta-analysis of the effect of methylphenidate on academic performance reporting positive effects on mathematics productivity and accuracy, but only productivity for reading.31 This highlights the importance in considering the domain (e.g., academic knowledge, classroom behavior and productivity) of school performance when assessing the potential benefits of ADHD medication.

The current study has limitations that need to be highlighted. It is not possible to determine whether students received concurrent non-pharmacological treatment or supportive measures such as teaching in a smaller group setting, help by extra personnel, or if the school specialized in teaching students with ADHD, as this information is not available in the registers. According to a report from 2016, about 5 percent of 7 th graders and 8 percent of 9 th graders in Sweden receive some form of educational support in compulsory school.32 The presence of such supportive resources is not necessarily problematic since these interventions are likely to cluster at the school level and are thus accounted for in our analyses. However, if treatment is increasing in schools in which such resources are provided over time, or other unmeasured factors correlated with treatment length are present, our estimates might be positively biased. We do find that the strongest predictor of treatment assignment and length by far is year of graduation, reflecting an increase over time in the utilization of ADHD medication, but that other measured background factors at the individual and parental level are of relatively low importance neither for the extent of treatment nor for initiating treatment earlier or individual treatment pattern (see Table S8, available online). Nonetheless, despite controlling for an important set of confounders, it must be emphasized that the non-randomized design with regards to pharmacological treatment initiation is an inherent limitation of our results that precludes a causal interpretation.

ADHD is associated with substantially lower school performance. Pharmacological treatment of ADHD is associated with higher grades, eligibility for, and completion of, USS. The strength of these associations suggest that interventions targeting school performance should be initiated early, in conjunction with medication when considered appropriate by clinicians and the relevant stakeholders, for closing the school performance gap associated with ADHD. Potential beneficial effects of medication on school performance should be carefully weighed against potential adverse effects of medication, including side-effects (e.g., disturbed sleep, appetite loss), and problems with misuse and diversion.

Supplementary Material

CLINICAL GUIDANCE:

Students with ADHD are at risk for poor school performance.

Duration of medication use is associated with higher levels of school performance.

Parents and teachers should be encouraged to monitor school performance in students with ADHD and address difficulties at an early stage.

Acknowledgments

Disclosures: H Larsson has served as a speaker for Eli-Lilly and Shire and has received research grants from Shire; all outside the submitted work. CM Bulik has served as a Scientific Advisory Board member of Shire and receives royalties from Pearson. P Lichtenstein has served as a speaker for Medice. A Jangmo, A Stålhandske, Z Chang, Q Chen, C Almqvist, B D'Onofrio, and R Kuja-Halkola report no conflicts of interest.

Funding: We acknowledge financial support from the Swedish Research Council (2013-2280) and through the Swedish Initiative for Research on Microdata in the Social and Medical Sciences (SIMSAM) framework Grant No. 340-2013-5867, and through the National Institute of Mental Health (NIMH) Grant No. 1R01MH102221.

Footnotes

Presentation information: This study was presented as an abstract at the American Professional Society of ADHD and Related Disorders Annual Meeting, Washington, D.C., January 12-14, 2018.

Twitter: New study @JAACAP finds positive association between medication for #ADHD and adolescent school performance in Sweden using large population data.

REFERENCES

Associated Data
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