Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I just keep coming back to TherapyNotes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code “testing”.
This podcast is brought to you in part by PAR.
The NEO Inventories Normative Update is now available with a new normative sample that is more representative of the current U.S. population. Visit parinc.com/neo.
Folks, welcome to The Testing Psychologist. [00:01:00] Today is a little bit of a, I suppose it’s a clinical episode. We are talking about that article in the New York Times; that ADHD article that made rounds three, four weeks ago, and caught a lot of folks’ attention.
So if you have not looked at this article, it’s worth checking out. It is pretty recent. You should be able to search New York Times or New York Times Magazine ADHD article. I will also write a link in the show notes, of course.
It dives deep into the history of ADHD and challenges some of the assumptions that we’ve had over the years about treatment for ADHD, course of ADHD, “causes” and symptom manifestation. So if you haven’t checked it out, go read it, for sure. It’s bit of a lengthy read, but you can also listen it if you have that New York Times audio [00:02:00] app. It’s about an hour long.
It was fascinating. It got a lot of discussion in The Testing Psychologist community on Facebook. I’ve heard it come up in many different environments over the last few weeks, so I thought I would dig deep and look into the article, look at it somewhat critically, and do a little analysis, but dive a little deeper into one particular aspect of the article, and that is the fluctuation of ADHD symptoms over someone’s lifetime.
And there’s some, turns out, pretty good research on that from a former podcast guest, Maggie Sibley. So we’ll check out all those things. The hope, like always, is that you walk away with some good information to apply to your practice, and that will keep you thinking about a topic that’s pretty relevant for a lot of us in the work that we do.
If you’re a practice owner and you’d like some support with building or scaling your practice, I’d love to help you out with that. That is a big part of my work, [00:03:00] and has been for the past 7 or 8 years, is consulting with folks on practice management in the testing realm. So you can go to thetestingpsychologist.com/consulting, check it out and see if any of those options look like the good way when together.
But for now, let’s get to that discussion on “that” ADHD article in the New York Times.
Testing people, let’s dig into this article. This article stirred up a lot when it came out. It has done a lot of discussion. People have a number of different reactions to this article ranging from disbelief, to questioning everything that we do, to critical analysis and challenging the structure and content of the article.
So I’ll cover [00:04:00] some of that, but I am going to dive deep into one particular aspect, and that is this aspect that they talk about as far as ADHD symptoms fluctuating over the course of someone’s life. That was particularly interesting to me.
Before we go any further, just to make it super clear, the title of the article is from New York Times Magazine, and it’s, Have We Been Thinking About ADHD All Wrong? That’s a very provocative title, and caught a lot of folks’ attention.
So what was this article all about? If you didn’t see it, I would recommend that you go check it out. So pretty easy. You can find it in the New York Times. It probably will be behind a paywall, but hopefully you can access that. I think it’s worth it.
All right, folks, so let’s talk about this article a little bit. So the article covered many different things. [00:05:00] We could go down any number of rabbit holes as far as the content of the article. I think there are lots of threads to pull on, but the one that I’m going to pull on the most is, like I said, this aspect of ADHD symptoms fluctuating throughout someone’s life, depending on environment and other factors.
But just to summarize the article a bit, for those of you who have not read it or maybe forgot some of the content. So the article titled, Have We Been Thinking About ADHD All Wrong? A very provocative title. So this is an article that centers around the MTA study, which is the Multimodal Treatment Study of ADHD. It’s one of the landmark studies in our field, started in the 1990s, followed nearly 600 kids with ADHD over more than 20 years looking at any number of factors related to their functioning.
So when I was in graduate school, the MTA study was gospel.[00:06:00] I started graduate school in 2003, finished in 2008. So this was right after some of the initial findings from the MTA study were starting to be published.
My advisor, shout out Dr. Lee Rosen at Colorado State University, my advisor was super into the MTA study and we quoted that study so often when we were talking about ADHD treatments, medication, evaluations, recommendations, things like that.
And so this article dives deep into the MTA study and cites one of the primary authors of the MTA study frequently throughout the article. And one of the central components of the original study is that medication works for ADHD, and it works [00:07:00] better than behavioral therapy, at least in the short term. That’s what the MTA study found initially.
So the short-term benefits medication, pretty well proven, but then they started to question if it holds over the long term. What they found is that long outcomes are far less clear in terms of the effectiveness of medication, with some evidence suggesting that behavioral benefits might fade, and academic gains are pretty minimal for medication, which I think a lot of us know, but this article presented it in pretty dark terms.
Some other things that came from this article, it talked about how ADHD symptoms often fluctuate over time rather than remaining stable. So it tied that in a bit to the idea that there is no biomarker for ADHD. It got into a discussion of state versus trait, [00:08:00] and how stable ADHD symptom might be. And it talked a lot about the environmental factors that influence ADHD symptom.
So, on the whole, I think the reaction to the article largely stems from the fact that it presented what I would consider a little bit of a one-sided approach to critically looking at the role of medication as an effective treatment for ADHD. I’m not going to get into a deep critique of this article. Like I said, that might be for a different podcast, and there’s plenty out there that you can read as far as the actual critique and shortcomings of the article.
But one thing that I did want to focus on that I think is pretty legitimate and dovetails nicely with a conversation that I had in part with Dr. Stephanie Nelson [00:09:00] a few weeks ago on a podcast is this idea that environmental factors influence someone’s symptom presentation.
This is one of those no-brainer ideas that seems intuitive, but I think it’s easy to forget when we’re in the throes of an evaluation. And just speaking personally, I can really get tempted into trying to write evaluation results in stone, or trying to make data make sense, or organize data into a coherent monolithic picture. And that certainly applies with ADHD evals.
I know that a lot of you have been in that situation where the data just does not line up; where a kid is behaving differently at home than at school, or differently at a soccer practice than at home, and we have to somehow make sense of all this disparate data. And then there’s the even bigger [00:10:00] challenge of how to make sense of kids who seem to be different kids when they come back for an evaluation 3, 4, 5, 8 years after their initial evaluation.
I’m at the point in my career where I have evaluated some kids three, maybe even four times at this point and it’s a very humbling process to look back at prior evaluations and realize that either kids are changing, or they’re behaving differently now than they were back then, or I just got it wrong, or maybe a combination of all those things.
So I’m throwing all this out there just to provide a little bit of context for this discussion, which is going to center around, okay, how do we make sense of the fact that symptoms can fluctuate both in the short term, like in different environments, but also in the long term, like across someone’s life into young adulthood.
[00:11:00] One of the most compelling findings from this article, or something that they presented, came from some research from Maggie Sibley. She is a previous podcast guest talking about adult ADHD. She’s fantastic. You can go look that up.Essentially, she looked at some of the data from the MTA study and published two articles dealing with the fluctuating nature of ADHD symptoms. So they tracked ADHD symptoms from childhood through young adulthood, and found that about 64% of participants followed a “fluctuating” trajectory of symptoms.
In other words, for the majority, ADHD symptoms were not stable across the course of the individual’s lives. They wax and wane. Sometimes they disappeared altogether, sometimes they returned after 2 years. And [00:12:00] looking at the data on the whole, it seemed clear. This was not a case of misdiagnosis or inconsistency. It was a legitimate pattern. It begs the question of why?
This is where Stephanie and I got into this conversation a few weeks ago on the podcast; why do symptoms fluctuate? Why do people present differently in different places? How do we address that as clinicians?
So to tackle that, I dove deeper into Dr. Sibley’s research and came up with some discussion material here for our episode. So, to understand this fluctuating pattern, we need to look at some pretty key research. 64% of people demonstrated what they would call fluctuating ADHD. So instead of the symptoms being consistently present or consistently absent, individuals experience alternating periods where their ADHD symptoms met diagnostic criteria and periods where they [00:13:00] seemed to be “in remission”.
This is an interesting term for me, that ADHD could be in remission. And so researchers in the study proposed that these ebbs and flows are not random occurrences, instead, it’s a dynamic interplay between an individual’s underlying genetic predisposition, which we know is very relevant in ADHD, and the ever-changing demands of the environment as they move through life.
So when we talk about environmental demands, the MTA study made a fascinating distinction between what they called between-person effects and within-person effects. So the between-person effect suggests that individuals who, on average, experience higher levels of environmental demands over the long term, those individuals were more likely to experience periods of full remission from their ADHD symptoms.
So think about that just for a [00:14:00] second. This will be someone who was in like a consistently challenging career, or a very active family environment, a very dynamic engaging school environment, so the idea is that it’s possible that these ongoing demands might help them develop stronger coping mechanisms or find ways to manage their attention and impulsivity more effectively over time.
I would also argue, and there’s some literature out there to support this, that just having a more engaging environment is more stimulating and plays on that need for novelty for ADHD folks. And so if this idea, the between-person effect is that on average, those who are engaged in more high-demand, high-stimulation environments over the long term are more likely to have periods of full remission from their ADHD symptoms, which the author’s defined [00:15:00] as being symptom free for 2 or maybe 2.5 years at some point between the ages of childhood and young adulthood.
Let’s take a break to hear from a featured partner.
Y’all know that I love TherapyNotes, but I am not the only one. They have a 4.9 out of 5-star rating on trustpilot.com and Google, which makes them the number one rated Electronic Health Record system available for mental health folks today. They make billing, scheduling, note-taking, and telehealth all incredibly easy. They also offer custom forms that you can send through the portal. For all the prescribers out there, TherapyNotes is proudly offering ePrescribe as well. And maybe the most important thing for me is that they have live telephone support seven days a week, so you can actually talk to a real person in a timely manner.
If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your [00:16:00] demographic data free of charge so you can get going right away. So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months absolutely free. You can go to thetestingpsychologist.com/therapynotes and enter the code “testing”. Again, totally free. No strings attached. Check it out and see why everyone is switching to TherapyNotes.
Our friends at PAR have released the NEO Inventories Normative Update. The NEO inventories measure the five major dimensions of personality and the most important facets that define each. Now with an updated normative sample that’s more representative of the current U.S. population and fewer components for easier purchasing. Visit parinc.com/neo.
Let’s get back to the podcast.
On the other hand, they also talked about this within-person effect, which tells a little different story. That sound that, [00:17:00] at any given time, when an individual’s environmental demands were higher than what was typical for that individual, they were more likely to be experiencing a spike in ADHD symptoms.
So while consistently high demands, like on average high demand environment is beneficial for some in the long run over time, a sudden spike in stress due to say a big project at work, a major life transition, they specifically noted the transition to middle school seems to be particularly influential for kids or likely to cause a spike in ADHD symptoms. Increased social pressures, these kinds of things can temporarily overwhelm someone’s ability to cope, leading to a return or worsening of ADHD symptoms.
Another critical factor that [00:18:00] they mentioned in the fluctuation of ADHD symptoms is age. So there was definitely an interplay between age and this fluctuating pattern. So the MTA study noted that the first periods of remission for many of the kids in the group tended to occur during early adolescent, which is interesting. It could relate to developmental changes in the brain, like executive functioning, coming online a little bit more, and the types of environmental demands faced during those years.
So maybe they have a spike when they transition to middle school or junior high, but then they settle in. And that higher demand environment actually helps with a reduction in ADHD symptoms. The study also found that the way environmental demands impact ADHD symptoms appears to change as individuals age.
So there’s a [00:19:00] clear interaction between age and those within-person environmental demands on the likelihood of experiencing persistent symptoms versus full remission. So the tendency for higher-than-usual demands to be associated with remission was stronger when individuals were younger. I’ll say that again: the tendency for higher-than-usual demands to be associated with remission was stronger when individuals were younger.
So this is maybe related to the structure and engagement provided by these demanding environments in childhood and early adolescence are more directly helpful in managing symptoms, but it seems like this effect went away a bit as the participants moved into their mid-20s, which suggests that the relationship between environmental demands and ADHD symptom expression gets more nuanced as we move into young adulthood.
So that’s a lot of information to [00:20:00] to take in. The takeaways for me, though, here are: the general idea that ADHD symptoms can be in remission, or they define something like partial remission, and they talk about true recovery. So I want to throw some statistics out there around some of these things.
For example, 64% of people experienced fluctuation of ADHD symptoms, including periods of remission, either full or partial, and recurrence of ADHD symptoms. You can define recovery or sustained remission as full remission of ADHD for at least two consecutive assessments. Sorry, I said 2 [00:21:00] years, but two consecutive assessments without a subsequent recurrence until the study endpoint.
This was relatively rare. Only about 9% of individuals in the study experienced recovery, or sustained remission. Interestingly, the average recovery period was 4 years, and the onset of recovery occurred in adulthood. That was fascinating.
They also defined something called stable persistence. So this pattern involves persistent ADHD at all assessment points throughout the follow-up. This was only observed in 11% of the sample, and was characterized by early and lasting risk for comorbid mood problems, elevated substance use, stable impairments, and low medication utilization.
So all that makes sense, but [00:22:00] at the extremes, so sustained remission or recovery only happened in 9% of people, stable persistence of systems only happened in about 11% of people. So a vast minority of folks experienced stable ADHD symptoms over the course of their lives.
They also defined stable partial remission, and this is something that occurred in about 15 or 16% of the sample. And this is when they changed from persistent ADHD to partial remission that was maintained until the end of the study.
This, on the whole, challenges the notion that folks outgrow ADHD. There was a prevalent theory that up to 50% of kids could outgrow ADHD by adulthood, but instead [00:23:00] it seems like a vast majority of individuals are experiencing fluctuating symptoms and impairment into young adulthood, and sustained remission or recovery is very uncommon.
I know I took a little detour there to give some statistics, some definitions, but I think it’s important to provide more context for this. Again, just to recap, there’s a lot of fluctuation in symptoms. It seems to be age-related, and there seems to be somewhat contradictory information in the sense that high stimulation or high engagement, high demand environments, can lead to lower manifestation of ADHD symptoms unless it is a spike in higher demand relative [00:24:00] to the individual.
Let’s talk about what to do about it. We can talk about how this impacts us as clinicians, and what we might do with this in our practice environments. The first thing is maybe just shifting our thinking from thinking of ADHD as a truly categorical diagnosis to more of a dimensional approach.
So when you write reports or give feedback, it’s resisting that urge to treat ADHD as a binary either it’s diagnosed or not. So you can talk about the presence, severity and variability of symptoms over time. I think families and clients understand that symptom thresholds are often arbitrary and don’t always reflect clinical reality.
I think this is something that a lot of us know, but can be easy to lose that in the moment and over time, [00:25:00] because there are a lot of compelling reasons to present more certainty in our evaluations. People like answers, people like clarity, people like to close loop, and all that applies in phases when we’re founding out about symptom fluctuation.
You can also take a developmental and longitudinal view over this whole thing. So make sure to include questions in your interviews and rating scales that look at historical symptom patterns and contextual triggers like thinking, has this individual’s attention fluctuated across school years? Did symptoms improve during structured summers but then come back during stressful transitions?
Ask about inflection points like the transition of middle school, high school, college, or into a job, things like that. So this time mapping, so to speak, can clarify what might otherwise look like disparate data. Another aspect that we can take into our practices is to [00:26:00] assess environmental demands explicitly like build in functional context when you’re evaluating “impairment”.
So that might mean asking about things like school or workplace structure, parent or teacher scaffolding, competing mental health symptom differential component, life changes, like I mentioned, and then levels of novelty, autonomy, or boredom in daily routines.
And so a way that I like to do this is even, this is very simple and very straightforward, but just asking kids like, do you feel different in different classes? Why do you feel different in different classes? Is it due to the teacher? Are you interested in that class? Are you bored in that class? Is your friend sitting next to you in that class?
I think what you would take from this is that it requires us be investigators in this process, and not just run through a symptom checklist, [00:27:00] but investigate how these symptoms might present in different environments, and ask detailed questions around that.
Another component you could take away is reframing the diagnosis in a more developmentally sensitive way. Especially for adolescents and young adults, you can communicate to them that ADHD might not necessarily be “permanent”. Let them know that symptoms can ebb and flow with age, stress and setting. It doesn’t necessarily invalidate their experience, but hopefully, empowers them to develop strategies and seek out environments that support their strengths.
The last thing that I’ll mention is when we’re talking about recommendations, you can maybe do a next steps toolkit almost versus just a diagnosis and concrete discrete recommendations. So it’s not just medication. I think we know that, but just making that very clear that you [00:28:00] can do different things based on the person’s age, stage and circumstances.
So behavioral therapy is going to be helpful. CBT is helpful for teens or adults. There are executive functioning coaching options. School accommodations can fluctuate depending on what grade they’re in, the environment and the setting of the school. So not getting locked into rote recommendations. And then psychoeducation for parents and clients that truly and concretely includes the idea of symptom fluctuation as typical and not pathological.
And then the last thing, I think a lot of us do this, is talking about check-ins or reevaluations scheduled around developmental milestones or big environmental changes like [00:29:00] that. So I think a lot of us have probably recommended getting re-eval over the years, and not necessarily known whether research supports that, but I think it absolutely does.
Just tying it all together, from all of this, we’re just seeing more and more that ADHD is a pretty complex condition. Environmental demands and age play significant roles in symptom fluctuation, but they’re not the only piece of the puzzle. Genetics are contributing significantly to the underlying vulnerability. There are also other environmental factors that are playing a role that we didn’t get into recently.
Fluctuation is a common experience. Don’t beat yourself up as a clinician if you’re having trouble reconciling some of the data. Instead of looking at disparate data as the exception and trying to make sense of it, maybe shifting to a mindset and [00:30:00] recognizing that disparate data is a little bit more the norm, at least with ADHD symptom; both short term between environments that someone’s currently living in and then long term from different age and developmental stages to others.
So if you haven’t checked out that article, definitely go look at it. It’s not the best article, I could pick apart a few things with it, but at least in the way that it sheds some light on this particular facet of ADHD, I appreciate that, to have the opportunity to dive a little deeper into this dimension of symptom fluctuation.
So thanks for checking it out and listening along with me. Thanks for going along the ride here and diving a little deeper into [00:31:00] environmental influences and symptom fluctuation in ADHD.
All right, y’all. Thank you so much for tuning in to this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes, so make sure to check those out.
If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes or Spotify or wherever you listen to your podcasts.
And if you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice development: beginner, intermediate, and advanced. We have homework, we have accountability, we have support, we have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the [00:32:00] details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call, and we will chat and figure out if a group could be a good fit for you. Thanks so much.
The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.
Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast [00:33:00] and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.
Click here to listen instead!