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The persistence of externalising behavioural disorders has recently been well documented (eg Brown & Borden, 1986; Barkley et al., 1990a; Taylor et al., 1991, 1996). However, the course of these disorders is likely to vary

between individuals (Lambert, Hartsough, Sassone & Sandoval, 1987) and the phenomenology of these behaviours may change over time (Wilson & Marcotte, 1996), which is significant as different behaviours and levels of comorbidity are likely to have varying impacts on the development of behaviour and educational performance. Recognising this is important if levels of educational performance are to be improved amongst young people with behavioural problems, and the appropriate treatments administered at a pertinent point in time when they will have most impact. Whilst the effects of stimulant medication on attention deficit behaviours are well reported (eg Gittelman & Kanner, 1986), the influence they exert on educational performance and classroom learning is comparatively unclear. Balthazor, Wagner & Pelham (1991) reviewed three ways in which the literature had reported that stimulant medication may be effective in improving performance and learning. Firstly, that medication may improve the child’s ability to attend more selectively to the task at hand and to filter out distracting stimuli; secondly, the medication may increase the efficiency of basic cognitive processing and, thirdly, medication may be effective by influencing nonspecific information processing mechanisms. However, whilst some studies show there may be some improvement in educational performance as a result of different interventions, including stimulant medication, behavioural management and/or additional teaching support, the findings are inconsistent.

Two early reviews of the literature indicated there was limited evidence for the success of behavioural programs alone (Cunningham & Barkley, 1978) or the efficacy of stimulant medication, which may only improve short-term manageability of the associated behaviours rather than academic performance (Barkley & Cunningham, 1978). However, both reviews concurred that these methods of treatment resulted in an overall improvement in the behaviours associated with hyperactivity resulting in better classroom demeanour and less disruption.

There are exceptions to these conclusions, and some studies have found significant improvements in educational performance using behavioural programs. For example, Allyon, Layman & Kandel (1975) found a significant improvement in mathematics and reading performance with the use of behavioural programs alone, amongst schoolchildren clinically diagnosed as “chronically hyperactive”, as well as a substantial decrease in their levels of overactivity. Cameron & Robinson (1980) used cognitive training programs designed specifically to encourage an improvement in classroom behaviour rather than general cognitive skills. As such, self-instructional and self­ management skills were introduced into the program. Overall they found a significant increase in mathematics accuracy and improved on-task behaviour in 7-8 year olds with hyperactivity.

Studies measuring the effects of behavioural programs have typically used very small sample sizes and/or long-term outcome is rarely examined. Durability of the outcome of these treatments is therefore questionable, as is their generalisability to larger samples, suggesting these programs are labour intensive, at least in the initial stages.

Other studies have reported success in improving educational performance through the use of stimulant medication. For example, Tannock, Schachar, Carr & Logan (1989) found that short-term use of methylphenidate improved accuracy on academic task performance (ie arithmetic and letter search tasks) in referred 6-11 year olds diagnosed with ADHD (DSM-III), as well as improving overt behaviours associated with the condition. Also, Balthazor et al (1991) found that stimulant medication improved performance on cognitive tasks (ie letter-matching) amongst referred boys rated as having attention deficit problems on rating scales. James, Sharp, Bastain, Lee et al (2001) also found improved outcomes in children meeting diagnostic criteria for ADHD-CT (DSM-IV), measured over an 8 week period in a randomised, double-blind, crossover study. They reported a significant increase in the number of mathematics problems attempted and solved accurately, across all three different drug groups when compared to a placebo group.

Despite the efficacy of stimulant medication, most studies still tend to measure the short-term effects. A study by Charles & Schain (1981) investigated whether or not improved outcomes would still influence academic attainment over a longer period of time. They evaluated children referred for hyperactive behaviours, who were either administered placebo or methylphenidate over a 16 week period, and followed them up four years later (aged 10-16). The authors reported that whilst the hyperactive behaviours had generally diminished over time, there were still considerable problems with educational performance. Specifically, school performance was poor, with repeated grades and special education placements, and these children were found to underachieve in mathematics and reading tests. The nature of the improvement in studies using stimulant medication is also inconclusive, in that whilst some studies may identify improvements in selective attention, others have found alterations in general indices of processing (eg Balthazor et al., 1991).

Overall, studies examining the effects of stimulant medication have used larger sample sizes and educational outcomes resembling those tasks measured in the classroom, thereby improving generalisability to other clinic samples. In a more recent review, Elia, Welsh, Gullotta & Rapoport (1993) reported that amongst children with hyperactivity and normal 10 levels, that the effects on educational performance were generally favourable, although this was not the case for children with both hyperactivity and LD. Some of the findings may have been obscured as a result of differing titration levels, which may be administered according to the measurement of behavioural rather than academic improvements (Swanson, Cantwell, Lerner, McBurnett et al., 1991). Accordingly, Tannock et al (1989) found an optimum level whereby although behaviour continued to improve with higher dosage levels, educational performance did not.

As a consequence of the variable outcomes identified by the two treatment approaches, it has been suggested that combining both medication and

behavioural therapy might provide the best possible outcome. Such studies are limited, and a study by Brown, Wynne & Medenis (1985) found no evidence that educational performance was improved in any of the groups under investigation. They compared boys with hyperactivity (aged 6-11) based on parent and teacher rating scale scores and pre-existing reading difficulties, according to four groups. The first being those on medication, the second being those receiving cognitive behavioural treatment, the third were a mixed treatment group and, the fourth, were an untreated group. At follow- up (3 months post treatment), they found that only children in the two medication groups showed improvement in levels of attention (eg impulsivity ratings, sustained attention tasks) and behavioural ratings.

These mixed findings clearly point to the need for further investigation and the consideration of early interventions. By adolescence, it appears that treatment may make little difference with regard to improving educational performance if these young people have a history of disorder, although medication continues to be relatively effective in improving behaviour. Due to the heterogeneous nature of these disruptive behavioural disorders, it is likely that children will benefit most from the combined effects of treatment involving the collaborative efforts of teachers and improved educational programmes, alongside treatment (eg medication or behavioural programs) by mental health care professionals (Hinshaw, 1992b). Fergusson et al (1997) also suggested that, because of the relationship between inattention and poor academic attainment (independently of IQ) using dimensional criteria, that children below the diagnostic threshold might also be at risk and may currently be ignored or missed. Therefore, in order to reduce the longer term risk of academic problems and the additional risks of offending behaviours that CD may induce, careful early assessments and management need to be undertaken. Support for looking at the wider picture comes from Rabiner et al (2000) who found that only 34% of children in their study with attention problems had difficulties with reading. This emphasises the limitations that could result if only children with attention problems were targeted to improve early reading skills, which might result in a number of

false positives being identified and incorrectly targeted, thereby wasting valuable resources.

2.5.9 Summary

The relationship between externalising behaviours and poor educational performance has been consistently documented in the literature. The majority of studies indicate that those with disorder perform considerably worse at school than controls without behavioural problems. Young people with externalising behavioural problems typically show impaired academic attainment (eg academic subject tasks, school grades) or poor school performance (eg repeated grades, school suspension) (Barkley et al., 1991; Wolraich et al., 1996; Gaub & Carlson, 1997b; Merrell & Tymms, 2001).

The heterogeneity of the behaviours associated with ADHD is well established and exemplified by the introduction of the different subtypes in DSM-IV (APA, 1994). The studies reviewed here not only indicate that young people with the various subtypes behave differently, but also that their performance at school is different. The most impaired group are young people with a diagnosis of ADHD-CT, as not only is their academic attainment impaired (eg Wolraich et al., 1996; Gaub & Carlson, 1997b; Merrell & Tymms, 2001), but their behaviour also has a detrimental effect on their school performance (Gaub & Carlson, 1997b). This group of young people are also more likely to have a comorbid disorder, which may exacerbate their existing symptomatology and further impair their educational performance (Gaub & Carlson, 1997b), for which they are likely to be receiving special educational needs provision (Fergusson et al., 1997). Young people with ADHD-I were also found to perform poorly on academic attainment tasks (eg reading and mathematics tests) (Wolraich et al., 1996; Merrell & Tymms, 2001).

The relationship between hyperactivity and LD is also well documented. However, not all young people with hyperactive behaviour perform badly at

school as a consequence of any associated LD. Some studies have shown that outcomes at school between young people with hyperactivity and LD are indistinguishable from one another when compared to controls (Barkley et al., 1990b; Rowe & Rowe, 1992). Despite similar IQs, young people with hyperactivity perform worse on school performance and academic attainment measures than controls (Wilson & Marcotte, 1996), and 10 fails to fully account for the relationship between ADD and impaired educational performance (Fergusson et al., 1997). Even after taking any learning difficulties into account, other studies have shown that the educational performance of young people with ADHD continues to be poor (Merrell & Tymms, 2001), all of which suggests that behaviour substantially influences poor educational performance irrespective of any associated LD.

Although cross-sectional studies generally indicate that groups with RD behave similarly to mixed groups (RD and ADHD) (eg McGee et al., 1989), others have also found that ADHD groups also perform similarly to mixed groups (eg August & Garfinkel, 1990). However, August & Garfinkel (1990) attribute the differences in cognitive deficits to underlying levels of processing. As such, the RD group appear to have a basic skill deficit (ie automisation of subskills, including rapid object naming or identification of letters), whereas the ADHD group show impaired learning (ie an inability to sustain processing). Despite the paucity of studies examining the relationship between behavioural disorders and MD, evidence from these does not clarify the underlying mechanisms, and may actually contribute to the confusion. Studies have shown that young people with ADHD-I perform worse on mathematics skill tests than those with ADHD-CT (Morgan et al., 1996) and those with ADD (no hyperactivity) perform worse than those with hyperactivity (Marshall et al., 1997).

Despite both externalising behavioural disorders having some influence in impaired educational performance, it is generally proposed that this outcome is primarily due to hyperactive behaviour (eg Frick et al., 1991; Fergusson et al., 1993), and both CD and ADHD have been shown to have separate

developmental pathways throughout adolescence. Specifically, that ADHD is related to poor educational performance and CD is linked to a rise in delinquent behaviours and later criminality (eg Fergusson et al., 1993).

Overall, studies investigating causal relationships have proven inconsistent in their findings as to whether RD is a precursor to impaired educational performance or vice-versa. Some studies have also concluded that neither predicts the other, and that common causal factors may provide the answer to both (Chadwick et al., 1999).

Educational performance has long-term effects beyond school and into further education and/or employment. This is important as studies have shown that externalising behaviours are relatively persistent, either contributing to difficulties in adulthood in terms of a lack of formal education and job instability (Maughan et al., 1985), future psychiatric disorder (eg Loeber et al., 1991) or the risk of criminality (eg Moffitt, 1993; McCabe et al.,

2001).

The effects of medication on educational performance are inconclusive, with some findings suggesting that whilst stimulant medication is successful over a short period of time (eg Tannock et al., 1989; James et al., 2001), long­ term effects appear to be more beneficial to improved behaviour alone (eg Charles & Schain, 1981). Studies looking at the influence of combined effects of medication and behavioural treatment are very limited. Conclusions in the literature indicate improved collaboration through mental health and education services, in order to identify problems earlier and formulate a multi-dimensional approach to treatment.