Dr. Jeremy Sharp (00:00.568)
Hello everyone and welcome to the Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.
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Dr. Jeremy Sharp (00:57.858)
Folks, welcome to the Testing Psychologist. Today is a little bit of a, I suppose it’s a clinical episode. We are talking about that article from the New York Times, that ADHD article that made the rounds three, four weeks ago and caught a lot of folks’ attention. So if you have not looked at this article, I think it’s worth checking out. It is pretty recent and you should be able to search New York Times or
New York Times Magazine ADHD article. I’ll also provide a link in the show notes, of course. But it dives deep into the history of ADHD and really challenges some of the assumptions that we’ve had over the years about treatment for ADHD, course of ADHD, causes, quote unquote, and symptom manifestation. So if you haven’t checked it out, go read it for sure.
little bit of a lengthy read, but you can also listen to it if you have that New York Times audio app, about an hour long. And yeah, it was fascinating, got a lot of discussion in the testing psychologist community on Facebook. And 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.
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. And of course, 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. Now, if you’re
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 and has been for the past seven or eight years is consulting with folks on practice management in the testing realm. So you can go to the testing.psychologist.com slash consulting and check it out and see if any of those options look like a good way to work together. But for now, let’s get to this discussion on quote unquote that ADHD art.
Dr. Jeremy Sharp (03:36.536)
people, let’s dig into this article. This article stirred up a lot when it came out. There’s been a lot of discussion. And 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 some of that, but I really want 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. So, before we go any further, just to make it super clear, the title of the article is…it’s from the New York Times or New York Times Magazine and it’s, Have We Been Thinking About ADHD All Wrong? Now, that’s very rockative title and caught a lot of folks’ attention. So,
What was this article all about? If you didn’t see it, again, I would recommend that you go check it out, of course. So, pretty easy. You can find it in the New York Times. It might be, well, it probably will be behind a paywall, but hopefully you can access that. think it is worth it. All right, folks, so let’s talk about this article a little bit. So, the article covered many different things, and 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 gonna pull on the most, I think, 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, again, titled, Have We Been Thinking About ADHD All Wrong? Very provocative title. So this is an article that
really centers around the NTA 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 two decades, looking at any number of factors related to their functioning. So when I was in grad school, the NTA study was gospel. Now, I started grad school in 2003, finished in 2008.
Dr. Jeremy Sharp (06:03.18)
So this was right around the time that, right after some of the initial findings from the MTA study were starting to be published. And yeah, my advisor, shout out Dr. Lee Rosin at Colorado State University. So my advisor was super into the MTA study and we quoted that study so often when we were talking about ADHD treatment, medication, evaluations, recommendations, things like that.
And so this article really 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, I think, of the article is that medication works for ADHD. That’s rather, sorry, a central component of the original study. Medication works. And it works better than behavioral therapy, at least in the short term.
That’s what the MTA study found initially. So the short-term benefits of medication, pretty well proven. But then they started to question if that’s true or if it holds true over the long term. And what they found is that long-term outcomes are actually far less clear in terms of effectiveness of medication with some evidence suggesting that behavioral benefits might fade and academic gains are actually pretty minimal for medication, which
I a lot of us know, but this article really presented it in pretty dark terms. Now, some other things that came from this article. It talked about how ADHD symptoms often fluctuate over time rather than remaining stable. 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.
and again 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 reactions to the article largely stem from the fact that it presented what I would consider like a little bit of a one-sided approach to critically looking at the role of medication as an effective treatment for…
Dr. Jeremy Sharp (08:29.07)
Now, 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 sort of 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 a few weeks ago on the podcast is this idea that environmental factors influence someone’s symptom presentation. Okay. Now, this is one of those no-brainer ideas that it 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, right? Or trying to make data make sense or organize data into a coherent kind of monolithic picture. And that certainly applies with ADHD evals, okay? So 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 challenge of how to make sense of kids who seem to come, seem to be different kids when they come back for an evaluation three, four, five, eight years after their initial evaluation. And I’m at the point in my career where I have evaluated some kids, I think 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 really going to center around, how do we make sense of the fact that symptoms can fluctuate both
Dr. Jeremy Sharp (10:51.03)
Now, in the short term, like in different environments, but also in the long term, across someone’s life into young adulthood. So, one of the most compelling findings from this article or something that they presented came from some research from Maggie Sibley. So, she was previous podcast guest talking about adult ADHD. was fantastic. You can go look that up.
Essentially, she looked at some of the data from the MTA study and published a couple of articles dealing with the fluctuating nature of ADHD symptoms. So, they tracked ADHD symptoms from childhood through young adulthood and essentially found that about 64 % of participants followed a, quote-unquote, fluctuating trajectory of symptoms. So, 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 a couple of years. And looking at the data on the whole, it seemed clear this was not a case of misdiagnosis or inconsistency. It was like a legitimate pattern. And it begs the question of why? This is where
I started to get in, know, Stephanie and I got into this conversation a few weeks ago on the podcast, like, why do symptoms fluctuate? Why do people present differently in different places? How do we address that as clinicians? So to tackle that, dove deeper into Dr. Sibley’s research and came up with some discussion material here for our episode. So to understand this fluctuating pattern, I think we need to look at some
some pretty key research, okay? So again, 64 % of people demonstrated what they would call fluctuating ADHD. So instead of the symptoms being consistently present or consistently absent, individuals experienced alternating periods where their ADHD symptoms met diagnostic criteria and periods where they seem to be, quote unquote, in remission. Now this is an interesting term for me that ADHD could be in remission. And so,
Dr. Jeremy Sharp (13:08.364)
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 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, experienced higher levels of environmental demands over the long term, those individuals were actually more likely to experience periods of full remission from their ADHD symptom. Hey, so think about that just for a second.
This will be someone who was in like a consistently challenging career or a very active family environment, very dynamic, engaging school environment. So the idea is that it’s possible that these ongoing demands might actually help them develop stronger coping mechanisms or find ways to manage their attention and impulsivity more effectively over time. Now I would
also argue, and there’s some literature out there to support this, that just being, just having a more engaging environment is more stimulating and plays on that need for novelty for ADHD folks. And so, if, again, this idea, the between-person effect is that on average, you know, those who are engaged in more high-demand, sort of high-stimulation environments over the long term are more likely to have periods of full remission from their ADHD symptoms, which the authors
defined, I think, as being symptom free for like two, maybe two and a half years at some point between the ages of, you know, childhood and young adulthood. Let’s take a break to hear from a featured partner. Y’all know that I love therapy notes, but I am not the only one. They have a 4.9 out of five star rating on trustpilot.com and Google, which makes them the number one rated electronic health record system available for mental health folks today.
Dr. Jeremy Sharp (15:29.868)
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which tells a little different story. that sound that at any given time when an individual’s environmental demands were higher than what was typical for that individual, they were actually 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 kind of things can temporarily overwhelm someone’s ability to cope, leading to a return or kind of worsening of ADHD.
Dr. Jeremy Sharp (17:57.506)
Now, another critical factor that they mentioned in the fluctuation of ADHD symptoms is age. So there was definitely an interplay between age and, you know, 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 adolescence, which is interesting, right?
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 kind of settle in, right? And that higher demand environment actually helps with a reduction in ADHD.
Now the study also found that the way environmental demands impact ADHD symptoms appears to change as individuals age. So again, there’s a 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.
And 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 like 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 take in. The takeaways for me though here are one, I mean just the general idea that ADHD symptoms can be in remission or, you they define something like partial remission, okay?
Dr. Jeremy Sharp (20:17.934)
and they talk about true recovery. So I want to throw some statistics out there around some of these things. okay, again, for example, 64 % of people experienced fluctuation of ADHD symptoms, including periods of remission, either full or partial, and recurrence of ADHD.
All right. Think about recovery or sustained remission as full remission of ADHD for at least two consecutive assessments. Sorry, I said two years. But two consecutive assessments without a subsequent recurrence until the study end point. This was relatively rare. So, individuals, only about 9 % of individuals in the study experience recovery or sustained remission.
And interestingly, the average recovery period was four years. All right. 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, all right, 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 again, at the extremes, so sustained remission or recovery only happened in
9 % of people, stable persistence of symptoms only happened in about 11 % of people. So, a vast minority of folks experienced stable ADHD symptoms over the course of their lives. Now, they also defined stable partial remission. And this is something that occurred in about 15 or 16 % of sample. And this is when, you know, they changed from persistent ADHD to
Dr. Jeremy Sharp (22:34.03)
partial remission that was maintained until the end of the study. So, yeah, this really, I think, on the whole challenges the notion that, you know, folks outgrow ADHD. I mean, there was kind of a prevailing theory that up to 50 % of kids could outgrow ADHD by adulthood, but instead it seems like…
vast majority of individuals are experiencing fluctuating symptoms and impairment into young adulthood and sustained remission or recovery is very uncommon. So I know I took a little detour there to give some statistics and definitions, but I think it’s important to provide more context for this. So again, just to recap.
There’s 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 to the individual. Now let’s talk about
what to actually do about it. We can talk about how this impacts us as clinicians and what we might do with this in our environments. So the first thing is maybe just shifting our thinking from, you know, thinking of ADHD as a truly categorical diagnosis to more of a dimensional approach, okay?
So when you write reports or give feedback, it’s kind of resisting that urge to treat ADHD as a binary, right? Either to diagnosed or not. So you can talk about like the presence and severity and variability of symptoms over time. Helping families and clients kind of understand that symptom thresholds are often arbitrary and don’t always reflect clinical reality. Again, I think this is something that a lot of us know, but it can be easy to lose that in the moment.
Dr. Jeremy Sharp (24:58.86)
and over time because there’s a compelling, there are a of compelling reasons to present more certainty in our evaluations. People like answers, people like clarity, people like to close loop and all of that kind of flies in the face of what we’re finding out about symptom fluctuation. Now you can also take a developmental and longitudinal view over this whole thing. make sure to include questions in your interviews and rating scales that look at
historical symptom patterns and contextual triggers. Okay, so like thinking how’s this individual’s attention fluctuated across school years? Did symptoms improve during structured summers, but then come back during stressful transitions? Ask about like inflection points, you know, like the transition to middle school or high school or college or into a job, things like that. So this kind of time mapping, so to speak, can clarify what, you know, might otherwise look like disparate data.
Another aspect that we can take into our practices is to assess environmental demands explicitly. So like build in functional context when you’re evaluating quote unquote impairment. So that might mean asking about things like school or workplace structure, parent or teacher scaffolding, competing, mental health symptoms, that differential component, life changes, like I mentioned, and then levels of novelty or 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, you know, just asking kids like, do you feel different in different classes? Why do you feel different in different classes? 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? And I think, you know, taking from this is there what you would take from this is that it
requires us to truly be investigators in this process, right, and not just run through a symptom checklist, but investigate how these symptoms might present different environments. And that’s detailed questions around that. Another component you could take away is like reframing the diagnosis in a more developmentally sensitive way. So, especially for adolescents and young adults, you can communicate to them that ADHD might not necessarily be quote unquote permanent. Like let them know that
Dr. Jeremy Sharp (27:22.328)
symptoms can ebb and flow with age and stress and setting. Doesn’t necessarily invalidate their experience, but hopefully, you know, empowers them to develop strategies and seek out environments that support their strengths. Last thing that I’ll mention is, you know, when we’re talking about recommendations, you can maybe do like next steps toolkit almost versus not, know, versus just a diagnosis and, you know, concrete
sort of discrete recommendations. So it’s not just medication. I think we know that, but just making that very clear that you can do different things based on the person’s age and stage and circumstances, you know? So behavioral therapy is gonna be helpful. CBT is helpful, right, for teens or adults. There are executive functioning coaching options.
School accommodations can fluctuate depending on what grade they’re in and the environment and 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 as logical.
And then the last thing, I think a lot of us do this, is talking about check-ins or re-evaluations scheduled around developmental milestones or big environmental changes like that. I think a lot of us have probably recommended getting re-eval over the years and not necessarily known whether research supports that. I think it absolutely does. Just tying it all together, I think…
From all of this, we’re just seeing more and more that ADHD is a pretty complex condition and environmental demands and age play significant roles in symptom fluctuation, but they’re not the only piece of the puzzle. I genetics are contributing significantly to the underlying vulnerability. There are also other environmental factors, of course, that are playing a role that we didn’t get into explicitly. But fluctuation is a common experience.
Dr. Jeremy Sharp (29:45.954)
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 recognizing that disparate data is actually a little bit more the norm, at least with ADHD symptom, both short-term, you know, between environments that someone’s currently living in and then long-term from different, you age.
developmental stages to others. So again, if you haven’t checked out that article, definitely go look at it. think that it, you know, again, 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 the dimension of symptom fluctuation. So thanks for checking it out and listening along with me. So thanks for going along the ride here and diving a little deeper into environmental influences and symptom fluctuation in ADHD. All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here.
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Dr. Jeremy Sharp (32:02.956)
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.
Dr. Jeremy Sharp (32:27.522)
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