A systematic review of prospective studies on attention problems and academic achievement

T. J. C. Polderman1,2,3, D. I. Boomsma1, M. Bartels1, F. C. Verhulst2, A. C. Huizink2,3,4
Article first published online: 11 MAY 2010

DOI: 10.1111/j.1600-0447.2010.01568.x

© 2010 John Wiley & Sons A/S
Issue
Acta Psychiatrica Scandinavica
Volume 122, Issue 4, pages 271–284, October 2010
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How to CiteAuthor InformationPublication History
Keywords:
attention deficit disorder with hyperactivity;educational status;child;longitudinal studies

Abstract
Polderman TJC, Boomsma DI, Bartels M, Verhulst FC, Huizink AC. A systematic review of prospective studies on attention problems and academic achievement.

Objective:  Our aim was to provide an overview of prospective studies that have addressed the association between attention problems (AP, i.e. symptoms of hyperactivity and inattentiveness) and academic achievement (AA).

Method:  We conducted a systematic search in the literature. Normal population studies and clinical studies were included. The methodological quality of each study was evaluated by objective criteria. A best evidence synthesis was used to determine the strengths of the association.

Results:  Sixteen studies were included. We found convincing evidence for a negative association between AP and AA. After controlling for intelligence, comorbidity, and socioeconomic status (SES), the association between the hyperactive symptoms of AP and AA was non-significant in two studies.

Conclusion:  Children with AP are at risk for lower AA and subsequent adverse outcomes later in life. Interventions in affected children should focus on their behavioural and educational development.

Summations
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 Attention problems (i.e. symptoms of hyperactivity and inattentiveness) predict academic problems, varying from grade repetition and need for special education, to lower scores on achievement tests.
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 After correcting for IQ, SES and comorbid disorders, especially the negative relation between inattentiveness and AA is strong.
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 Low AA is a salient adverse outcome; behavioural as well as cognitive (teacher mediated) interventions are advisable in affected children.
Considerations
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 Prospective studies on the relation between AP and AA are relatively limited and study characteristics vary considerably. However, the direction of the effect is largely the same in all studies.
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 The association between AP and covarying factors (i.e. comorbid disorders, IQ and SES), and their joined influence on AA, should be examined in future studies.

Introduction
Children with attention problems (AP) are characterized by symptoms of inattentive, hyperactive and impulsive behaviour. Children with severe symptoms are diagnosed as having attention deficit hyperactivity disorder (ADHD), which is a highly prevalent disorder during childhood (1). ADHD has a high impact on families with affected children and poses enormous burden on society in terms of financial costs and adverse outcomes later in life (2). It is assumed that symptoms of inattentive, hyperactive and impulsive behaviour are normally distributed in the population, with ADHD positioned at the extreme end of this distribution(3–5). In this review we will use the term AP to refer to these behavioural symptoms, including the disorder ADHD.

Several studies reported an association between impaired cognitive functioning and AP in children, for example deficits in inhibition and working memory (6–11), motor flexibility (12, 13) and selective and sustained attention (14–16). However, others found the evidence for impaired cognitive functioning less convincing (17–20), and emphasized the neuro-cognitive heterogeneity among affected children (21–23).

More compelling seems the negative relation between AP and IQ performance. Friedman et al. (8) investigated in a large sample the relation between AP at several time points during childhood (age 7, 8, 9, 10, 11, 12, 13 and 14), and IQ scores at age 16, and found longitudinal correlations between −0.21 and −0.27. Similarly, Polderman et al. (24) reported significant longitudinal correlations between AP measured by teachers and parents at age 5, and IQ scores at age 12 (r = −0.30/−0.31). In cross-sectional designs across childhood, correlations between AP and IQ show the same pattern with a correlation of −0.30 in 5-year-old children (25), of −0.26 in 9-year-old children and of −0.34 in 12-year-old children (26). A review by Frazier et al. (27) indicated that, IQ performance is significantly lower among persons with ADHD compared with normal controls.

An interesting question is whether impaired cognitive functioning as assessed with neuropsychological assessments, or IQ tests, is also reflected in academic and educational achievement of children with AP. Educational achievement is an important predictor of socio economic status (SES) later in life, and wellbeing and health in adulthood (28). As about 5% of the world population is suffering from ADHD (1) the long-term educational outcomes of these children are highly relevant. Only one previous review (29) conducted a review and meta-analysis on ADHD and achievement. Based on calculated effect sizes of all relevant studies published between 1990 and 2006, they determined the strength of the association between ADHD and academic achievement (AA). The results of their analyses were based on 72 studies and revealed that affected subjects had a significant lower achievement then non-affected subjects.

The aim of the current review is to provide a review of studies that have addressed the prospective relationship between AP and AA during childhood. In contrast to cross-sectional studies as reviewed previously (29), the use of prospective studies enables to address the predictive validity of AP. Thus, these studies can determine whether AP predict academic deficits over periods in the future. Prospective studies on this topic are limited and the assessment of AP and AA vary enormously across studies. To ensure a valid and objective conclusion about the prospective association between AP and AA we performed a quality assessment for the included studies. Studies were evaluated with objective criteria as proposed by Hayden et al. (30). Based on the quality assessments, a best evidence synthesis (31) provided the strength of the prospective association between AP and AA.

In an attempt to provide an overview of the pure association between AP and AA, we excluded studies that focused on medical intervention and comorbidity. A substantial amount of children with ADHD use a medical stimulant as treatment (32), such as methylphenidate or amphetamine, to reduce their symptoms of hyperactivity and attention deficit. There is evidence that this positively influences their academic performance (33–35). Also, children with ADHD often show comorbid disorders like dyslexia (36), oppositional deviant problems (ODD), conduct disorder (CD), or anxiety (37, 38) which may lead to additional problems in educational achievement (39). Studies aiming to investigate the combination of AP with a particular comorbid disorder, were excluded from this review. Thus, for example, a study on AA for which children were recruited with ADHD and conduct disorder specifically, was excluded from this review. However, studies focusing solely on AP but including some subjects having a comorbid disorder were included in the review, as the co-occurrence is the rule rather than the exception.

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