Good day, everyone! Russ Sparkley back again. It's a cold day here in Richmond, so I'm dressed in flannel.
I'm off to do another Bounty paper towel commercial. After this commentary, I want to talk about an article that showed up in the news this week. It was posted over at psypost.
org; you can see it here on your screen. It's an article about surprising ad research that finds greater life demands linked to reduced symptoms. It's actually a pretty good article, and I've put it over in the description for this commentary, but I'm not going to spend much time on the article itself.
You can go read it; it's pretty well written. Instead, I want to go to the actual research paper that it describes, which is right here, appearing in the Journal of Clinical Psychiatry just recently, and done by Margaret Sible and colleagues. Maggie's a friend and colleague of mine, and she has followed up with over 480 children that were originally seen in the Multimodal Treatment Study of ADHD back when they were kids.
They were in four groups back then: they were assigned to either get community-based treatment or they were assigned to get one of several treatments provided in the Multimodal Treatment Study. These individuals were then followed for a period of about 16 years or so into their mid-20s. So, it's a study that's fairly similar to my own earlier Milwaukee Longitudinal Study, where we followed about 158 children with ADHD over time to about age 27.
This paper is significant for a number of reasons, not the least of which is it helps us understand some of the earlier follow-up studies, like mine, that found high rates of recovery from ADHD at certain ages. However, as Maggie shows in this paper, that may have obscured what was a very fluctuating course of symptoms for many of the individuals. In the paper, Maggie goes on to show these four graphs.
Down here in the first of the graphs, in the upper left corner, is the fluctuating pattern of symptoms—quite dramatic. By the way, the different lines reflect different sources of information: parent reports, teacher reports, and self-reports. They also break it down by the symptom dimension as well, so it’s a little confusing—a little bit busy—but you can see that the upper left graph shows a fluctuating course.
The next graph to its right is the recovery course, with people reporting recovery usually in late adolescence into adulthood. Then we have the persistent course, which remains high throughout most, if not all, of the follow-up period. Finally, we have the partial remission course, and those are individuals who recovered to some extent but went on to continue to have higher than normal symptoms of the disorder.
I'm going to redraw these for you over in my PowerPoint slide so we can talk a little bit about these findings. Now, as I bring up my PowerPoint here, I also want to explain to you a very important point, and that is that the persistence of the disorder into adulthood depends on several factors that were found in my study and a few earlier ones. First, the source of the information: my study found that by age 21, if you interviewed the children growing up with ADHD using a diagnostic interview, only about 4% reported enough symptoms to be diagnosed with ADHD in adulthood.
However, if we interviewed their parents at that same follow-up period at age 21, the rate of disorder was 10 times higher—about 46% at that age met all criteria for the disorder. That's just to illustrate that it really depends on who you ask. It also shows that people growing up with ADHD, particularly during childhood, adolescence, and even early adulthood, underreport their number and severity of symptoms relative to other people who know them well—in this case, their parents.
The reliability of their reporting of their symptoms doesn't begin to approach that of typical people until they get into their late 20s and usually early 30s, when we can begin to sort of take their word for it, if you will. So, part of the problem in earlier studies that claimed high rates of recovery from the disorder is that they interviewed the children growing up with the disorder at the outcome, and of course that results in a marked reduction in the number of people with the disorder. So, it matters who you ask, and it also matters what diagnostic criteria you use.
We used the old DSM-IV criteria, which didn't make any adjustments of the symptoms for adults; it was six out of nine symptoms on either symptom list that got you into the disorder category. As you know, DSM-5 said that you only needed five symptoms to have ADHD if you were an adult. By the way, as I've said in other videos, that number should really be four, but the DSM committee didn't want to drop it that far.
Nonetheless, Maggie’s study is using the DSM-5 criteria at outcome. In any case, let's take a look at what she found, remembering that it does depend on who you ask, when you ask, and of course, as I've said, what criteria you’re using. But it's a very large study, so let’s see what they found.
At the top bar here, in the top graph, you see the persistently high ADHD symptoms. These are people whose ADHD was high in childhood and remained high and diagnosable into adulthood—about 11% of the sample. Next, on the second graph, or the second line, you see those who showed a single reduction at some point, usually in mid-adolescence, and then continued to have still relatively high symptoms.
But at a reduced level, that's about 15% of Maggie's sample. One-third are those who fully recovered (full remission), and that was about 9%, who went on to have one large reduction, usually in early to mid-adolescence, and then were no longer diagnosable after that—fully recovered. Finally, the majority of children in this study (64%) showed a markedly fluctuating course, moving out of the diagnostic criteria, which is the blue dotted line you see along the bottom here, at one follow-up point, only to move back into the diagnostic category at another follow-up, and then move out of it again at the next follow-up, and then back in—showing two to three or more transitions in and out of the disorder category over time.
So, a very markedly fluctuating course. So, you can see here, it would depend on when you interviewed these families as to whether or not these individuals would be considered recovered or not, and that they'd move back into the disorder at the next follow-up period. A fluctuating course was typical of most children in this study, suggesting that they might remit for short periods of time, but they never persistently recover, moving back and forth in and out of the disorder and in and out of high levels of symptoms over time.
Now, the study found that those with the fluctuating course often showed their lowest levels of symptoms at periods where there were relatively high demands being placed on them—quite the opposite of what the authors and I would have expected. We would have expected people to be more symptomatic during high-demand periods in their life, and less during low demands. In fact, they found just the opposite.
Now, before you go on to leap to the conclusion that, um, people with ADHD do better in high-demand situations, perhaps they do, but really this is just a correlation. So, it could also be the other way around—that when people had relatively lower levels of symptoms, they took on more demands in their life, and as their symptoms increased over time, they then went back to lower-level demand activities. So, you could use either explanation.
Overall, the study is very important, I think, in showing that a very small minority of people with ADHD fully recover from the disorder; that 90% or more will continue to have high levels of symptoms and even full disorder into adulthood, but that they may show a fluctuating course over time. And that's very important because it helps to explain why earlier studies may have found such a high rate of recovery among their children. It, in part, depended on who they asked, but as we see here, it is in part dependent on when you asked.
Had you followed them up again, they might well have had the disorder back again. So, I hope you appreciate the study. I think it's a very interesting study, and my congratulations to the authors for this, I think, important and very well-done project.
If you want to read more about it, I've cited the study in the description, but it's going to be difficult to get because it's behind a paywall. You can write to Dr Sibl; her address is on that journal web page, or you can just go over to cost. org and read the U-Trade Media review of this paper.
All right, everybody, thanks for joining me today. I hope you found this to be a very informative video and research report. I certainly did, and I look forward to seeing you later in the week on my channel again.
So, as always, everybody, thanks for joining me. Live well, be well, and take care.
