Study describes fluctuations, remissions seen with ADHD

Research published in 2022 novelly described attention-deficit/hyperactivity disorder (ADHD) as a condition in which symptoms can fluctuate, with intermittent periods of remission for many people. A much-awaited follow-up paper today reports that these fluctuations seem influenced by environmental factors such as whether a person goes to school or work, and has obligations to others.

At face value, however, the finding contradicts conventional thought about how everyday demands affect ADHD symptoms. 

“We did find a robust relationship, but it was the opposite of our hypothesis. We found that, in the years that people were doing better, they seemed to actually be living much more demanding lives,” said Margaret Sibley, the lead author. She is a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and a clinical psychologist at Seattle Children's Hospital.

These and other findings that characterize ADHD’s fluctuations appear in the Journal of Clinical Psychiatry. 

“This tells us that the environment and ADHD — they talk to each other,” Sibley said.  “One possible interpretation of this is that people with ADHD do best when they keep busy and have external responsibilities. Another way to interpret it, though, is that only during periods of life when symptoms have gotten under control are people able to then step up to the demands in their lives.”

Sibley and colleagues reviewed the cases of 483 patients at six sites in the United States and Canada. The patients had been part of the study for at least 16 years, starting around age 8, on average, and had been formally assessed for ADHD every two years. 

Among those patients, 63.8% experienced fluctuations. Over the 16-year span, the fluctuations were characterized by three or four periods of remission in which patients’ assessments did not indicate ADHD. These remissions first emerged in early adolescence, at about age 12, with symptoms recurring within a few years.

“We were able to identify two types of remission,” Sibley explained. “One is full remission, where a person has almost no symptoms or impairments and have completed all of their treatment. And then we identified a partial remission in which patients got better to the point that they technically no longer meet criteria for ADHD, but still have some milder problems that are meaningful in life. 

“When we look at the fluctuating group, it's a mix of people going between those three statuses of full remission, partial remission and full-fledged ADHD,” she said. 

The authors identified three other patient subgroups: 

• Stable persistent (10.8%): met criteria for ADHD every year of the study
• Stable partial remission (15.6%): displayed one classification change from persistent ADHD to partial remission, which was maintained until the study’s endpoint. 
• Recovery (9.1%): ADHD full remission that persisted for at least two consecutive assessments without being followed by an episode of recurrence.

The rich dataset, Sibley said, enabled the researchers to create a “moving image” of how people with ADHD experience the condition, in contrast to a clinical “snapshot determination” of someone’s future based on one assessment.

“If you're a doctor talking with a patient who is first getting diagnosed with ADHD, it’s a huge help for that person to hear the message that ‘You're going to have good years and you're going to have not-so-good years, but things can go really well for you if you can get the right factors in place.’ ”

The researchers emphasized the importance of identifying personal factors that contribute to periods of remission for better ADHD management.

“A person with ADHD needs to learn what factors they need to put in place in their life in order to be their best,” Sibley said. “Although the science is still unraveling which factors help people, it's easy for a patient to work with a therapist or just to consider their own lives to understand, ‘When I've had those periods of remission, when I've been doing really well, what was it that made me do well? Can I replicate that in my life?’”

The Multimodal Treatment Study of Children with ADHD was a National Institute of Mental Health (NIMH) cooperative agreement randomized clinical trial. The work was supported by cooperative agreement grants and contracts from the NIMH and the National Institute on Drug Abuse (N01MH12009, HHSN271200800003-C, HHSN271200800004-C, HHSN271200800005-C, HHSN271200800006-C; HHSN271200800007-C, HHSN271200800008-C, HHSN271200800009-C; N01 MH12012, N01 MH12011, N01 MH12007, N01 MH12004, N01 MH12010, N01 MH12008; U01 MH50461, U01 MH50477, U01 MH50467, U01 MH50453, U01 MH50440; DA039881, DA85550, DA85551, DA85552, DA85553, DA85554, DA85548, DA85549.)

The authors' conflict-of-interest statements are in the published paper, which is available upon request.

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